Presentation title here

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Presentation title here"

Transcription

1 Presentation Provider toolbox title here Sylvia Strickland, MBA, Provider Reimbursement Presentation title here Bridgette Ampey, CPC, Code Review Jorri Smith, Network Innovation & Education priorityhealth.com 0 Agenda Today, we re going to review the tools we offer that can help us work together as efficiently as possible. Feel free to ask questions throughout. We ll also make time at the end to address questions. Provider reimbursement Sylvia Strickland, MBA, Provider Reimbursement Analyst I 1

2 Provider Helpline: General Website: priorityhealth.com/provider Viewing prior authorizations You must have a web account and auth inquiry as a tool in your profile. If you re the requesting provider as well as the servicing (ie. orthopedic surgeon for a knee arthroscopy), an authorization will be entered into our system under both the facility where this will take place and the surgeon performing. If you re a referring provider only and the service will be performed by someone else, you will not be able to view the authorization on our provider portal. You must call our provider helpline for a status. Mid-level provider billing Surgical assist or facility rounding Mid-levels employed by a physician group may contract and bill Priority Health directly for surgical assist or facility rounding. All office-based services need to be billed under the supervising participating physician. Reimbursement and coding Most services reimbursed at 85% of the professional fee schedule Some services paid at 100% of the physician fee schedule Primary care designation Mid-level providers who are credentialed and contracted by Priority Health as primary care providers should bill us directly. These services are paid at 100% of the physician fee schedule. 2

3 Past filing limit Correction timelines Follow-up is required within one year of the date of service, including resolving all claim discrepancies. Corrected or augmented information received after that date will automatically deny. Negligence by the provider's staff does not justify an exception to the policy. Medicaid claims must be processed within 45 days of when we receive them to comply with the Timelines of Claims Payment Public Act 187. We ll notify you in writing of any problems or defects with your claim within 30 days; you ll have 30 days to correct and resubmit the claim. When another payer makes or recovers payment near or after our filing limit, you have 90 days from the date on the EOB to submit the claim to us. Corrected claim submission Corrected claim submission changes for Oct. 1, 2014 To comply with contract language regarding claim submission, effective Oct. 01, 2014, we will no longer accept requests for reprocessing claims by , reports or Excel files. If a claim was denied or paid incorrectly as the result of the way the claim was originally billed (i.e. billing error, improper billing), the provider must submit a corrected or voided claim. Find complete information on how to submit a corrected claim in the Provider Manual at priorityhealth.com. Denial reasons Billing error Claim resubmitted with a frequency 5 or 7, original claim adjusted and new claim paid Disenrollment retroactive Coverage terminated, member did not elect COBRA coverage Priority Health is secondary Claim submitted without primary carrier explanation of benefits Claim reprocessed: Work related injury Information provided confirming workers comp coverage Claim reprocessed: Auto insurance primary Information provided confirming auto coverage Claim reconsidered following Code Review Notes do not support charge billed 3

4 Coding and clinical edits Bridgette Ampey, Medical Coding Coordinator Clinical edits Priority Health clinical edits decisions are based on multiple criterion that may include: Medicare edits such as Medically Unlikely Edits (MUE) or National Correct Coding Initiative (NCCI edits) CMS guidelines CPT or ICD-9 guidelines Standard clinical practices and recommendations from medical societies Clinical edits are applied to all claims submitted by facilities or professionals, in and out of network, for all Priority Health medical plans, including Medicaid and Medicare, self-funded and fully funded. Providers often assume that if there s no NCCI edit for the code combination they submitted, then Priority Health should pay both codes. However, the claim may generate a clinical edit from any of the other sources of our clinical edit database. Changes for Modifier 59 Modifier 59: Used to describe a circumstance when services commonly bundled should be considered separate and distinct Different encounters Different anatomical sites Different practitioner Distinct services Commonly abused or misused Frequently requires medical records to validate accurate use 4

5 Modifier 59 continued New modifiers effective Jan. 1, 2015: XE Separate encounter XS Separate anatomical structure (separate organ/structure) XP Separate practitioner XU Unusual non-overlapping service CPT guidelines require use of most descriptive modifier MLN Matters Number MM8863 outlines changes for these modifiers Additional resource: ers/modifier-59.shtml Modifier 25 Modifier 25 is used to identify a significant, separately identifiable service Documentation must meet all requirements for reporting an E/M service In many cases, E/M services are inherent to procedures or services performed on the same date Problem oriented E/M services and preventive medicine When should these be coded together? Do these need to be documented separately? Do chronic conditions or health problems support separate E/M? Additional resource: modifier-25.shtml Medicare LCD & NCD edits Provide benefit, limit and frequency criteria for both medically necessary and non-covered services Commonly driven by CPT/HCPCS, modifiers and/or diagnosis codes GA modifier GY modifier Medical documentation must support services rendered and coded Priority Health supplemental services CMS website contains listing of all policies For more information on NCDs and LCDs, visit priorityhealth.com/provider/ manual/billing-andpayment/edits/medicare-lcds 5

6 Edit Checker Enter data pre-claim submission for edit scrubbing or verify edit criteria between code pair(s) Edit Checker can mirror how a claims submitted will process for criteria outlined below: Age Gender Unbundling and bundling Frequency Medicare LCD & NCD Criteria Inappropriate modifier use Remember to input all criteria to obtain accurate data missing or incorrect data can impact claim processing Gender Claim type (Medicare, HMO, Medicaid, etc.) This information does not guarantee coverage or payment by the patient's plan. Edit Checker Coding and clinical edit appeals To dispute a coding or clinical edit denial, please include the following: Priority Health Provider Appeal form Supporting medical documentation Any supporting coding documentation Clear and concise explanation as to why an appeal is submitted 6

7 Coding and clinical edit appeals Common reasons appeals are upheld: No supporting documentation submitted Insufficient documentation Unsigned medical records or medical records not authenticated Submitting wrong documentation Appeals should not be submitted simply because a code combination allows for a modifier or to verify editing is correct priorityhealth.com/provider/manual/billing-andpayment/reviews-appeals/standard-process Network innovation and education Jorri Smith, Senior Administrator ICD-9 to ICD-10 Support Free ICD-10 webinar series starting March 2015 Resources and webinar registration available at priorityhealth.com/provider/ news-and-education/icd-10 7

8 Billable codes outlined on our Provider Center priorityhealth.com/ provider/manual/ billing-and-payment/services/ phone-and-e-visits 8

9 Thank you! Who has the first question? 9

Payment Policy. Evaluation and Management

Payment Policy. Evaluation and Management Purpose Payment Policy Evaluation and Management The purpose of this payment policy is to define how Health New England (HNE) reimburses for Evaluation and Management Services. Applicable Plans Definitions

More information

Claims Procedures. H.2 At a Glance. H.4 Submission Guidelines. H.9 Claims Documentation. H.17 Codes and Modifiers. H.

Claims Procedures. H.2 At a Glance. H.4 Submission Guidelines. H.9 Claims Documentation. H.17 Codes and Modifiers. H. H.2 At a Glance H.4 Submission Guidelines H.9 Claims Documentation H.17 Codes and Modifiers H.22 Reimbursement H.25 Denials and Appeals At a Glance pledges to provide accurate and efficient claims processing.

More information

Unlisted Procedure Codes Frequently Asked Questions

Unlisted Procedure Codes Frequently Asked Questions Unlisted Procedure Codes Frequently Asked Questions Use of an unlisted code is common when a physician performs a new procedure or utilizes new technology when no other CPT code adequately describes the

More information

Zimmer Payer Coverage Approval Process Guide

Zimmer Payer Coverage Approval Process Guide Zimmer Payer Coverage Approval Process Guide Market Access You ve Got Questions. We ve Got Answers. INSURANCE VERIFICATION PROCESS ELIGIBILITY AND BENEFITS VERIFICATION Understanding and verifying a patient

More information

Appendix A Denial Management and Negotiation Hearing Screening

Appendix A Denial Management and Negotiation Hearing Screening Appendix A Denial Management and Negotiation Hearing Screening Ideally, hearing screenings should be covered benefits that are separately payable by the health plan. While health plan benefits may include

More information

HOW TO PREVENT AND MANAGE MEDICAL CLAIM DENIALS TO INCREASE REVENUE

HOW TO PREVENT AND MANAGE MEDICAL CLAIM DENIALS TO INCREASE REVENUE Billing & Reimbursement Revenue Cycle Management HOW TO PREVENT AND MANAGE MEDICAL CLAIM DENIALS TO INCREASE REVENUE Billing and Reimbursement for Physician Offices, Ambulatory Surgery Centers and Hospitals

More information

Office Managers Association at Presbyterian Hospital of Plano

Office Managers Association at Presbyterian Hospital of Plano Office Managers Association at Presbyterian Hospital of Plano Update your charge slips annually Team approach Pain management example Grace period discontinued! New CPT, HCPCS and ICD-9 codes Changed definitions

More information

Molina Healthcare of Washington, Inc. CLAIMS

Molina Healthcare of Washington, Inc. CLAIMS CLAIMS As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your reference:

More information

Instructions for submitting Claim Reconsideration Requests

Instructions for submitting Claim Reconsideration Requests Instructions for submitting Claim Reconsideration Requests A Claim Reconsideration Request is typically the quickest way to address any concern you have with how we processed your claim. With a Claim Reconsideration

More information

Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service

Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service Manual: Policy Title: Reimbursement Policy Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service Section: Modifiers Subsection: None Date of Origin: 1/1/2000 Policy Number: RPM027 Last Updated:

More information

Importance of Auditing

Importance of Auditing Medicare 201: Practitioner Importance of Auditing EY Fraud Investigation and Dispute Services Jennifer Shimek, Senior Manager Gretchen Segado, Manager Agenda Importance of Auditing National and Local Coding

More information

Section 9. Claims Claim Submission Molina Healthcare PO Box 22815 Long Beach, CA 90801

Section 9. Claims Claim Submission Molina Healthcare PO Box 22815 Long Beach, CA 90801 Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your

More information

SECTION 4. A. Balance Billing Policies. B. Claim Form

SECTION 4. A. Balance Billing Policies. B. Claim Form SECTION 4 Participating Physicians, hospitals and ancillary providers shall be entitled to payment for covered services that are provided to a DMC Care member. Payment is made at the established and prevailing

More information

Modifier Magic 4/13/2015. Modifiers. Anatomical Modifiers. April 15, 2015 MMBA

Modifier Magic 4/13/2015. Modifiers. Anatomical Modifiers. April 15, 2015 MMBA Modifier Magic April 15, 2015 MMBA Modifiers Modifiers should be reported to bypass a clinical edit ONLY if the criteria for the use for the modifiers is met and supporting documentation is included in

More information

Glossary of Frequently Used Billing and Coding Terms

Glossary of Frequently Used Billing and Coding Terms Glossary of Frequently Used Billing and Coding Terms Accountable Care Organization (ACO) Accounts Receivable Reports All Inclusive Fees Allowances and Adjustments Capitation Payments Care Coordination

More information

There are two levels of modifiers: Level 1 (CPT) and Level II (CMS, also known as HCPCS).

There are two levels of modifiers: Level 1 (CPT) and Level II (CMS, also known as HCPCS). PROVIDER BILLING GUIDELINES Modifiers Modifiers are two digit or alphanumeric characters that are appended to CPT and HCPCS codes. The modifier allows the provider to indicate that a procedure was affected

More information

Co$tly Coding Errors AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES

Co$tly Coding Errors AMERICAN ACADEMY OF OPHTHALMOLOGY AMERICAN ACADEMY OF OPHTHALMIC EXECUTIVES Co$tly Coding Errors Financial Disclosure Sue Vicchrilli, COT, OCS AAO Director, Coding & Reimbursement has no financial interests or relationships relative to this live activity to disclose. Error #1

More information

CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030

CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030 CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030 Missing service provider zip code (box 32) 031 Missing pickup

More information

Pre-Employment Test for Business Office Staff Answer Key

Pre-Employment Test for Business Office Staff Answer Key P a g e 1 Pre-Employment Test for Business Office Staff Answer Key 1. Mr. Walker owes $83.25. His health plan requires a 20% coinsurance. How much does he owe? Answer: $16.65 2. Scenario: Your practice

More information

Class Action Settlement Recap

Class Action Settlement Recap Class Action Settlement Recap Enhancements to Claim Payment Policy, Processing and Payment Disclosure, and an Appeals Process for Class Action Settlement Providers The following enhancements are effective

More information

Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities

Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities Question 1: When will the ICD-10 Ombudsman be in place? (revised 09/22/2015)

More information

Billing Guidelines Manual for Contracted Professional HMO Claims Submission

Billing Guidelines Manual for Contracted Professional HMO Claims Submission Billing Guidelines Manual for Contracted Professional HMO Claims Submission The Centers for Medicare and Medicaid Services (CMS) 1500 claim form is the acceptable standard for paper billing of professional

More information

Medicare Coding and Billing Part 1

Medicare Coding and Billing Part 1 Medicare Coding and Billing Part 1 Medicare Fee ScheduleMedicare has released next year s fee schedule There is a 27% cut in fees. This will be in effect until Congress takes action to delay it again.

More information

Region V Training Project 3rd Party Billing Practices for Title X Clinics Outline October 13, 2011

Region V Training Project 3rd Party Billing Practices for Title X Clinics Outline October 13, 2011 1 Region V Training Project 3rd Party Billing Practices for Title X Clinics Outline October 13, 2011 The "Affordable Care Act" is coming on-line and has significant implications for the provision of Reproductive

More information

Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities

Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities Question 1: When will the ICD-10 Ombudsman be in place? Answer 1: The

More information

Compensation and Claims Processing

Compensation and Claims Processing Compensation and Claims Processing Compensation The network rate for eligible outpatient visits is reimbursed to you at the lesser of (1) your customary charge, less any applicable co-payments, coinsurance

More information

Duplicate Claims Verify claims receipt with BCBSNM prior to resubmitting to prevent denials.

Duplicate Claims Verify claims receipt with BCBSNM prior to resubmitting to prevent denials. Claims Submission Electronically : Use Payer ID 00790 For information on electronic filing of claims, contact Availity at 1-800-282-4548. Paper claims must be submitted on the Standard CMS-1500 (Physician/Professional

More information

Common Billing Mistakes Costing Your ASC Money and Correct Modifier & Revenue Code Usage for ASC Claims

Common Billing Mistakes Costing Your ASC Money and Correct Modifier & Revenue Code Usage for ASC Claims Common Billing Mistakes Costing Your ASC Money and Correct Modifier & Revenue Code Usage for ASC Claims October 2013 Beckers 20 th Annual ASC Conference Presenter: Stephanie Ellis, R.N., CPC, Speaker Ellis

More information

Chapter 6 Policies and Procedures Unit 1: Other Party Liability

Chapter 6 Policies and Procedures Unit 1: Other Party Liability Chapter 6 Policies and Procedures Unit 1: Other Party Liability In This Unit Topic See Page Unit 1: Other Party Liability Coordination of Benefits 2 Frequently Asked Questions About COB 5 6.1 Coordination

More information

CLAIMS AND BILLING INSTRUCTIONAL MANUAL

CLAIMS AND BILLING INSTRUCTIONAL MANUAL CLAIMS AND BILLING INSTRUCTIONAL MANUAL 2007 TABLE OF ONTENTS Paper Claims and Block Grant Submission Requirements... 3 State Requirements for Claims Turnaround Time... 12 Claims Appeal Process... 13 Third

More information

Financial Disclosure. Modifiers Getting It Right! Modifiers. Modifiers. Medicare Expected Frequency. Common Modifiers Used Only with Office Visits

Financial Disclosure. Modifiers Getting It Right! Modifiers. Modifiers. Medicare Expected Frequency. Common Modifiers Used Only with Office Visits Financial Disclosure Modifiers Getting It Right! Donna McCune is a consultant for Corcoran Consulting Group and acknowledges a financial interest in the subject matter of this presentation. Donna McCune,

More information

Is Unspecified Sometimes the Correct Option?

Is Unspecified Sometimes the Correct Option? Corpectomy or ACDF? March 3, 2016 Our orthopaedic spine surgeon recently attended a presentation sponsored by a vendor other than your firm. The surgeon returned to the office and was told that he could

More information

! Claims and Billing Guidelines

! Claims and Billing Guidelines ! Claims and Billing Guidelines Electronic Claims Clearinghouses and Vendors 16.1 Electronic Billing 16.2 Institutional Claims and Billing Guidelines 16.3 Professional Claims and Billing Guidelines 16.4

More information

CLAIM FORM REQUIREMENTS

CLAIM FORM REQUIREMENTS CLAIM FORM REQUIREMENTS When billing for services, please pay attention to the following points: Submit claims on a current CMS 1500 or UB04 form. Please include the following information: 1. Patient s

More information

Chapter 8 Billing on the CMS 1500 Claim Form

Chapter 8 Billing on the CMS 1500 Claim Form 8 Billing on the CMS 1500 Claim form INTRODUCTION The CMS 1500 claim form is used to bill for non-facility services, including professional services, freestanding surgery centers, transportation, durable

More information

Provider Appeals and Billing Disputes

Provider Appeals and Billing Disputes Provider Appeals and Billing Disputes UniCare Billing Dispute Internal Review Process A claim appeal is a formal written request from a physician or provider for reconsideration of a claim already processed

More information

Online Claim Entry UB-04. Presented by: Xerox State Healthcare, LLC Provider Relations

Online Claim Entry UB-04. Presented by: Xerox State Healthcare, LLC Provider Relations Online Claim Entry UB-04 Presented by: Xerox State Healthcare, LLC Provider Relations Resources When online use: Ask Service Representative HIPAA.Desk.NM@xerox.com NMPRSupport@xerox.com Call Center 505-246-0710

More information

CODE AUDITING RULES. SAMPLE Medical Policy Rationale

CODE AUDITING RULES. SAMPLE Medical Policy Rationale CODE AUDITING RULES As part of Coventry Health Care of Missouri, Inc s commitment to improve business processes, we are implemented a new payment policy program that applies to claims processed on August

More information

Provider Adjustment, Time limit & Medicare Override Job Aid

Provider Adjustment, Time limit & Medicare Override Job Aid Provider Adjustment, Time limit & Medicare Override Job Aid Contents Overview... 1 Medicaid Resolution Inquiry Form... 1 Medicare Overrides... 3 Time Limit Overrides... 3 Adjusting a Claim through the

More information

Billing an NP's Service Under a Physician's Provider Number

Billing an NP's Service Under a Physician's Provider Number 660 N Central Expressway, Ste 240 Plano, TX 75074 469-246-4500 (Local) 800-880-7900 (Toll-free) FAX: 972-233-1215 info@odellsearch.com Selection from: Billing For Nurse Practitioner Services -- Update

More information

Corporate Reimbursement Policy

Corporate Reimbursement Policy Corporate Reimbursement Policy File Name: Origination: Last Review: Next Review: modifier_guidelines 1/2000 8/2015 8/2016 Description Policy A modifier enables a provider to report that a service or procedure

More information

1) There are 0 indicator edits, which are never correctly reported together;

1) There are 0 indicator edits, which are never correctly reported together; Medical Coverage Policy Coding and Guidelines sad EFFECTIVE DATE: 11/15/2011 POLICY LAST UPDATED: 11/1/2013 OVERVIEW This Policy provides an overview of coding and guidelines as they pertain to claims

More information

CERT: Documentation of Clinical Diagnostic Tests

CERT: Documentation of Clinical Diagnostic Tests CERT: Documentation of Clinical Diagnostic Tests May 29, 2014 Cahaba Government Benefit Administrators, LLC Provider Outreach and Education Disclaimer This resource is not a legal document. The presentation

More information

MediRegs Coding Suite

MediRegs Coding Suite MediRegs Coding Suite Specialized health care solutions to accelerate coding compliance and ensure accurate and timely reimbursement MediRegs Coding Suite from Wolters Kluwer Law & Business is a web-based

More information

Evaluation & Management Provider Compliance Summary Documentation Compliance Criteria for Evaluation & Management (E&M) Services

Evaluation & Management Provider Compliance Summary Documentation Compliance Criteria for Evaluation & Management (E&M) Services Evaluation & Management Provider Compliance Summary Documentation Compliance Criteria for Evaluation & Management (E&M) Services Date: April 23, 2012 Source Information: Medicare Policy Purpose The United

More information

Comprehensive Health Insurance Billing Coding Reimbursement

Comprehensive Health Insurance Billing Coding Reimbursement Comprehensive Health Insurance Billing Coding Reimbursement SECOND EDITION CHAPTER 17 Refunds, Follow-up, and Appeals Key Terms and Abbreviations administrative law judge (ALJ) hearing documentation Employee

More information

Early Intervention Central Billing Office. Provider Insurance Billing Procedures

Early Intervention Central Billing Office. Provider Insurance Billing Procedures Early Intervention Central Billing Office Provider Insurance Billing Procedures May 2013 Provider Insurance Billing Procedures Provider Registration Each provider choosing to opt out of billing for one,

More information

CARE1ST PROVIDER FORUM

CARE1ST PROVIDER FORUM CARE1ST PROVIDER FORUM March 2015 1 Agenda RAFFLE!! Website Overview PCP role in Dental Health Developmental Screenings Credentialing Controlled Substances Prior Authorization Claims Claim Disputes and

More information

Teamwork Leads to Getting Claims Paid

Teamwork Leads to Getting Claims Paid Teamwork Leads to Getting Claims Paid Linda R Georgian, COE Administrator Inland Eye Institute Medical Group, Inc. Financial Disclosure Both presenters acknowledges a financial interest in the subject

More information

Best Practices: Physician Billing/Coding for Hospice & Palliative Care

Best Practices: Physician Billing/Coding for Hospice & Palliative Care Best Practices: Physician Billing/Coding for Hospice & Palliative Care Presented by: Christopher P. Acevedo, CHC, CPC Objectives Describe the circumstances that allow physician visits to be separately

More information

Revenue Cycle Management Process

Revenue Cycle Management Process OVERVIEW It is important for everyone involved in the billing cycle process to be familiar with how each step of the encounter provides opportunities to assure successful and compliant billing. The purpose

More information

Chapter 5. Billing on the CMS 1500 Claim Form

Chapter 5. Billing on the CMS 1500 Claim Form Chapter 5 Billing on the CMS 1500 Claim Form This Page Intentionally Left Blank Fee-For-Service Provider Manual April 2012 Billing on the UB-04 Claim Form Chapter: 5 Page: 5-2 INTRODUCTION The CMS 1500

More information

WELLCARE CLAIM PAYMENT POLICIES

WELLCARE CLAIM PAYMENT POLICIES WellCare and Harmony Health Plan s claim payment policies are based on publicly distributed guidelines from established industry sources such as the Centers for Medicare and Medicaid Services (CMS), the

More information

Basic Medical Record Documentation

Basic Medical Record Documentation Basic Medical Record Documentation Presented by Cahaba Government Benefit Administrators, LLC P rovider O u t reach and Education September 19, 2013 1 Disclaimers This resource is not a legal document.

More information

Status Active. Reimbursement Policy Section: General Coding Section Policy Number: RP-General Coding-001.002 Modifier Effective Date: July, 2016

Status Active. Reimbursement Policy Section: General Coding Section Policy Number: RP-General Coding-001.002 Modifier Effective Date: July, 2016 Status Active Reimbursement Policy Section: General Coding Section Policy Number: RP-General Coding-001.002 Modifier Effective Date: July, 2016 Modifier Policy Description: This policy addresses reimbursement

More information

My Coding Connection, LLC 618-530-1196. 24 Unrelated E/M by the same physician during a postoperative period

My Coding Connection, LLC 618-530-1196. 24 Unrelated E/M by the same physician during a postoperative period MODIFIERS Rachel Coon, CCS-P, CPC, CPC-P, CPMA, CPC-I, CEMC, ICD-10 My Coding Connection, LLC 618-530-1196 GLOBAL PACKAGE MODIFIERS 24 Unrelated E/M by the same physician during a postoperative period

More information

Molina Healthcare of Ohio, Inc. PO Box 22712 Long Beach, CA 90801

Molina Healthcare of Ohio, Inc. PO Box 22712 Long Beach, CA 90801 Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your

More information

Physician Fee Schedule BCBSRI follows CMS Physician Fee Schedule (PFS) Relative Value Units (RVU) for details relating to

Physician Fee Schedule BCBSRI follows CMS Physician Fee Schedule (PFS) Relative Value Units (RVU) for details relating to Policy Coding and Guidelines EFFECTIVE DATE: 09 01 2015 POLICY LAST UPDATED: 09 02 2015 OVERVIEW This Policy provides an overview of coding and guidelines as they pertain to claims submitted to Blue Cross

More information

Frequently Asked Questions About Your Hospital Bills

Frequently Asked Questions About Your Hospital Bills Frequently Asked Questions About Your Hospital Bills The Registration Process Why do I have to verify my address each time? Though address and telephone numbers remain constant for approximately 70% of

More information

COM Compliance Policy No. 3

COM Compliance Policy No. 3 COM Compliance Policy No. 3 THE UNIVERSITY OF ILLINOIS AT CHICAGO NO.: 3 UIC College of Medicine DATE: 8/5/10 Chicago, Illinois PAGE: 1of 7 UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE CODING AND DOCUMENTATION

More information

The Changing Face of Medical Necessity under ICD-10

The Changing Face of Medical Necessity under ICD-10 The Changing Face of Medical Necessity under ICD-0 Sponsored by 95 N. Fine Ave #04 Fresno CA 93720-565 Phone: (559) 25-5038 Fax: (559) 25-5836 www.californiahia.org Program Handouts Monday, June 8, 205

More information

INSURANCE BILLING & COLLECTIONS PROCEDURES

INSURANCE BILLING & COLLECTIONS PROCEDURES INSURANCE BILLING & COLLECTIONS PROCEDURES I. PURPOSE: To establish logical, consistent methods of billing and collections follow-up for Insurance balances to ensure that all staff members possess a good

More information

THE BASICS OF RHC BILLING. Thursday, April 28, 2011 Presented by: Health Services Associates, Inc.

THE BASICS OF RHC BILLING. Thursday, April 28, 2011 Presented by: Health Services Associates, Inc. THE BASICS OF RHC BILLING Thursday, April 28, 2011 Presented by: Health Services Associates, Inc. TABLE OF CONTENTS Commercial and Self Pay billing Define RHC Medicaid Specified Medicare RHC billing guidelines

More information

Billing Code DOS Issue Law Payments Award

Billing Code DOS Issue Law Payments Award Billing Code DOS Issue Law Payments Award DRG 460 64635 64636 93307 93320 1 1-18-to 01-23- February 11, February 11, February 12, February 12, Implants not separately reimbursed for DRG 460 Denial of the

More information

Related CR Transmittal #: 412 Implementation Date: January 24, 2005

Related CR Transmittal #: 412 Implementation Date: January 24, 2005 MLN Matters Number: MM3592 Revised Related Change Request (CR) #: 3592 Related CR Release Date: December 23, 2004 Effective Date: May 21, 2004 Related CR Transmittal #: 412 Implementation Date: January

More information

Qtr 2. 2011 Provider Update Bulletin

Qtr 2. 2011 Provider Update Bulletin West Virginia Medicaid WEST VIRGINIA Department of Health & Human Resources Qtr 2. 2011 Provider Update Bulletin West Virginia Medicaid Provider Update Bulletin Qtr. 2, 2011 Volume 1 Inside This Issue:

More information

Workers Compensation Provider Billing Guidelines

Workers Compensation Provider Billing Guidelines Billing transactions are covered under Chapter 127 (127.201 through 127.211) of the Workers Compensation Act (the Act) for the State of Pennsylvania: Workers Compensation Medical Cost Containment rules

More information

Compensation and Claims Processing

Compensation and Claims Processing Compensation and Claims Processing Compensation The network rate for eligible outpatient visits is reimbursed to you at the lesser of (1) your customary charge, less any applicable co-payments, coinsurance

More information

Top 50 Billing Error Reason Codes With Common Resolutions (09-12)

Top 50 Billing Error Reason Codes With Common Resolutions (09-12) Top 50 Billing Error Reason Codes With Common Resolutions (09-12) On the following table you will find the top 50 Error Reason Codes with Common Resolutions for denied claims at Virginia Medicaid. This

More information

ICD-10 Compliance Date

ICD-10 Compliance Date ICD-10 Implementation Frequently Asked Questions Updated September 2015 ICD-10 Compliance Date The U.S. Department of Health and Human Services (HHS) issued a rule on July 31, 2014 finalizing October 1,

More information

Surgical/ASC Claims Revenue Cycle Management: An Introduction to Our Processes and Protocols

Surgical/ASC Claims Revenue Cycle Management: An Introduction to Our Processes and Protocols Surgical/ASC Claims Revenue Cycle Management: An Introduction to Our Processes and Protocols 200 Old Country Road, Suite 470 Mineola, NY 11501 Phone: 516-294-4118 Fax: 516-294-9268 www.businessdynamicslimited.com

More information

Protect and Improve Profitability in Your Practice. Positioning Your Organization for a RAC Audit

Protect and Improve Profitability in Your Practice. Positioning Your Organization for a RAC Audit Protect and Improve Profitability in Your Practice Positioning Your Organization for a RAC Audit 2011 Annual Educational Seminar March 9, 2011 Presented By: Cindy Tipton-Cain, Exec. Director Physician

More information

Status Active. Assistant Surgeons. This policy addresses reimbursement for assistant surgical procedures during the same operative session.

Status Active. Assistant Surgeons. This policy addresses reimbursement for assistant surgical procedures during the same operative session. Status Active Reimbursement Policy Section: Surgery/Interventional Procedure Policy Number: RP - Surgery/Interventional Procedure - 001 Assistant Surgeons Effective Date: June 1, 2015 Assistant Surgeons

More information

CONNECTIONS TESTING FOR ICD-10

CONNECTIONS TESTING FOR ICD-10 TESTING FOR ICD-10 In conjunction with the Centers for Medicare and Medicaid Services (CMS), Providence Health Plan (PHP) and all major payers will convert from International Classification of Diseases,

More information

1. All patient services must be billed on a fully completed CMS 1500 or UB04 form, unless otherwise indicated by contract.

1. All patient services must be billed on a fully completed CMS 1500 or UB04 form, unless otherwise indicated by contract. Claims 8.0 As a Participating Provider billing for services with a fee-for-service contract with MAPMG, please follow the procedures listed below. Participating Providers billing for services rendered

More information

Physical Therapy (PT) Modalities and Evaluation

Physical Therapy (PT) Modalities and Evaluation Status Active Reimbursement Policy Section: Rehabilitative Services Policy Number: RP - Rehabilitative Services - 001 PT Modalities and Evaluation Effective Date: June 1, 2015 Physical Therapy (PT) Modalities

More information

Claim Features Training

Claim Features Training Claim Features Training Molina Healthcare s Web Portal The Web Portal is secure and available 24 hours a day, seven days a week. Register for access to our Web Portal for selfservices, including: Submit

More information

CPT Coding in Oral Medicine

CPT Coding in Oral Medicine CPT Coding in Oral Medicine CPT - Current Procedural Terminology Medical Code Set (00000-99999) Established as an indexing/coding system to standardize terminology among physicians and other providers

More information

Preventing claim denials KSPEC

Preventing claim denials KSPEC Preventing claim denials KSPEC-0976-15 1 We will cover Contacts for Amerigroup Kansas, Inc. Routine claim inquires Amerigroup provider website Top denials Specific ways to avoid denials Levels of appeals

More information

5/2/2014. Beginning Biller / Coder 101 Thursday, May 8 1:00 p.m. to 2:30 p.m. Disclaimer. Stay in touch through Facebook Please note

5/2/2014. Beginning Biller / Coder 101 Thursday, May 8 1:00 p.m. to 2:30 p.m. Disclaimer. Stay in touch through Facebook Please note Disclaimer Beginning Biller / Coder 101 Thursday, May 8 1:00 p.m. to 2:30 p.m. Presented by: Judy B Breuker, CPC, CPMA, CCS P, CDIP, CHC, CHCA, CEMC, AHIMA Approved ICD 10 CM/PCS Trainer The class is intended

More information

Harbor s Payment to Providers Policy and Procedures is available on the Harbor website and will be updated annually or as changes are necessary.

Harbor s Payment to Providers Policy and Procedures is available on the Harbor website and will be updated annually or as changes are necessary. Original Approval Date: 01/31/2006 Page 1 of 10 I. SCOPE The scope of this policy involves all Harbor Health Plan, Inc. (Harbor) contracted and non-contracted Practitioners/Providers; Harbor s Contract

More information

About Cardea. Revenue Cycle Management Best Practices for Public Health Programs. Revenue Cycle. Public Health Programs & Revenue.

About Cardea. Revenue Cycle Management Best Practices for Public Health Programs. Revenue Cycle. Public Health Programs & Revenue. About Cardea Best Practices for Public Health Programs February 2014 Erin Edelbrock Program Manager, Cardea Our Mission: Improve organizations' abilities to deliver accessible, high quality, culturally

More information

REVENUE CYCLE MANAGEMENT (RCM) Bob Strickland Consultant R Strickland & Associates LLC

REVENUE CYCLE MANAGEMENT (RCM) Bob Strickland Consultant R Strickland & Associates LLC REVENUE CYCLE MANAGEMENT (RCM) Bob Strickland Consultant R Strickland & Associates LLC REVENUE CYCLE MANAGEMENT WHAT S THE BIG DEAL? Productivity = Efficiency + Effectiveness How much input (cost) is needed

More information

Inpatient Common Denials

Inpatient Common Denials Advanced Billing: Inpatient & Outpatient Services 1 Inpatient Common Denials Introduction Purpose This module will familiarize participants with an overview of the most common denial messages providers

More information

1. Section Modifications

1. Section Modifications Table of Contents 1. Section Modifications... 1 2. General Billing Information... 6 2.1. Introduction... 6 2.1.1. Online Portal Access... 6 2.1.2. Procedure Codes... 7 2.1.3. Billing Procedure for Date

More information

CONNECTIONS APPROPRIATE USE OF MODIFIER 59 HOLIDAY SCHEDULE

CONNECTIONS APPROPRIATE USE OF MODIFIER 59 HOLIDAY SCHEDULE APPROPRIATE USE OF MODIFIER 59 Modifier 59 is used to report Distinct Procedural Service. The CPT book says, Under certain circumstances, it may be necessary to indicate that a procedure or service was

More information

Medicaid National Correct Coding Initiative. Edit Design Manual. Page 1 of 54

Medicaid National Correct Coding Initiative. Edit Design Manual. Page 1 of 54 Medicaid National Correct Coding Initiative Edit Design Manual 2015 1/27/2015 Page 1 of 54 ` TABLE OF CONTENTS File Types... 4 MII Files File Formats... 4 Publication Files File Formats... 4 File Names...

More information

Patient Assistance Resource Center Health Insurance Appeal Guide 03/14

Patient Assistance Resource Center Health Insurance Appeal Guide 03/14 Health Insurance Appeal Guide 03/14 Filing a Health Insurance Appeal Use this reference guide to understand the health insurance appeal process, and the steps to take to have a health plan reconsider its

More information

Improved revenue cycle management for Epic. Cathrina Caldwell, CPC, CPC-H Director, Sales Product Consulting

Improved revenue cycle management for Epic. Cathrina Caldwell, CPC, CPC-H Director, Sales Product Consulting Improved revenue cycle management for Epic Cathrina Caldwell, CPC, CPC-H Director, Sales Product Consulting Agenda OptumInsight Overview Traditional physician claim workflow A better way Claims Manager

More information

Chapter 7. Billing and Claims Processing

Chapter 7. Billing and Claims Processing Chapter 7. Billing and Claims Processing 7.1 Electronic Claims Submission 3 7.1.1 How it Works... 3 7.1.2 Advantages... 3 7.1.3 How to Initiate... 4 7.1.4 Transactions Available... 5 7.1.5 NAIC Codes...

More information

OSCAR Health Insurance Frequently Asked Questions/General Information

OSCAR Health Insurance Frequently Asked Questions/General Information Q: What is the relationship between Oscar and ValueOptions? A. ValueOptions administers the mental health and substance abuse benefits for Oscar Health Insurance. They have contracted with ValueOptions,

More information

Part B Education Exclusive: Modifier 59 Edit Update Questions

Part B Education Exclusive: Modifier 59 Edit Update Questions Cahaba GBA would like to provide some clarification of the use of Modifier 59. The modifier is not limited to National Correct Coding Initiative (NCCI) pairs. We apologize for any confusion our July article

More information

Other Party Liability

Other Party Liability In this section Page Coordination of Benefits (COB) 14.1 Workers Compensation insurance 14.1 Subrogation 14.1 The Motor Vehicle Financial Responsibility Law 14.1 Frequently asked questions about COB 14.1!

More information

Anthem Blue Cross and Blue Shield (Anthem) CLAIMS XTEN TM RULES Version 4.4 Effective December 8, 2012

Anthem Blue Cross and Blue Shield (Anthem) CLAIMS XTEN TM RULES Version 4.4 Effective December 8, 2012 Rules Edit logic Example Suppted After Hours 99050 not Reimbursable with Preventive Diagnosis This will deny 99050 (services provided when the office is usually closed) when billed with a preventive diagnosis

More information

Klamath Tribal Health & Family Services 3949 South 6 th Street Klamath Falls, OR 97603

Klamath Tribal Health & Family Services 3949 South 6 th Street Klamath Falls, OR 97603 Klamath Tribal Health & Family Services 3949 South 6 th Street Klamath Falls, OR 97603 Phone: (541) 882-1487 or 1-800-552-6290 H.R. Fax: (541) 273-4564 OPEN: 05/08/2013 CLOSED: 05/24/2013 POSITION: RESPONSIBLE

More information

MODIFIERS. Original Effective Date: July 7, 2009 Revision Date: February 1 st, 2014

MODIFIERS. Original Effective Date: July 7, 2009 Revision Date: February 1 st, 2014 Original Effective Date: July 7, 2009 Revision Date: February 1 st, 2014 MODIFIERS Policy s are used to increase accuracy in recording patient encounters and compensation. A modifier provides the means

More information

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare is denying an increasing number of claims, because providers are not identifying the correct primary payer prior

More information

EHR s-new Opportunities for the Confident Coder

EHR s-new Opportunities for the Confident Coder EHR s-new Opportunities for the Confident Coder Angela Jordan, CPC Chair AAPCCA Board of Directors Manager Coding and Compliance EvolveMD amjordan.cpc@gmail.com Objective EHR basics Basic knowledge of

More information

PROVIDER MANUAL Page 1 of 12 Last Revised December 2008

PROVIDER MANUAL Page 1 of 12 Last Revised December 2008 Page 1 of 12 Last Revised December 2008 Table of Contents Introduction 3 General Information 4 Who Do I Call?.5 ID Card Logo.6 Credentialing.7 Provider Changes..8 Referral and Authorization.9 Claims Payment

More information

CMIS. Insurance Specialist (CMIS) Certified Medical CMIS. Class size is limited to 25 to maximize learning experience.

CMIS. Insurance Specialist (CMIS) Certified Medical CMIS. Class size is limited to 25 to maximize learning experience. CMIS Certified Medical Insurance Specialist (CMIS) Class size is limited to 25 to maximize learning experience. CMIS Understand payer models and rules for accurate claim filing and reimbursement. Improving

More information