**The provider handbooks and the Practitioner Fee Schedule referenced in the answers below may be viewed at:

Size: px
Start display at page:

Download "**The provider handbooks and the Practitioner Fee Schedule referenced in the answers below may be viewed at: www.hfs.illinois.gov/medical."

Transcription

1 **HFS would like to clarify the timely filing deadline information given to providers during the webinars, as new information has since become available (slides posted to the website are revised): Medicare crossovers WILL BE SUBJECT to the 180-day timely filing deadline. Any time a client has Medicare primary, Medicaid secondary, the claim must first be submitted to Medicare. Then, regardless of whether Medicare deems the claim payable (crossover) or denied, the claim must be submitted to Medicaid within 180 days of the Medicare adjudication date. **The provider handbooks and the Practitioner Fee Schedule referenced in the answers below may be viewed at: 1) If the patient presents for a "routine follow up visit" with no acute illness or problem and does not have the co-pay, is it OK to reschedule? This would not be refusing treatment just rescheduling for a future date. Rescheduling treatment on that date appears to be refusing treatment due to inability to pay the co-pay. Please refer to the co-pay Q&A document on the HFS web site at 5A directly addresses this topic. Additionally, if there is no acute illness or problem, is this visit medically necessary? Please refer to the list of non-covered services in Topic 104 of the Chapter 100 General Policy and Procedures, specifically Items or services for which medical necessity is not clearly established. 2) You stated there is a 180 timely deadline for secondary claims that begins 180 days from the final adjudication from the primary payer. We have several liability claims that remain open for a few years and do not pay until the case is settled. Will this apply to them as well? The 180 days from final adjudication of the primary payer will apply if that TPL is listed on the patient s file (i.e. commercial insurance). In the case of pending lawsuits or settlements, it is the provider s decision to EITHER: 1.) Bill HFS within the 180 timely filing deadline, thereby accepting as final payment the reimbursement from HFS, OR 2.) Wait for reimbursement from the settlement, in which case the provider risks being past timely filing limits this is NOT an exception which meets the criteria for a time override, and no time override will be given. 3) Do we rebill claims that were suspended for review? First review the Status column on your paper remittance advice. Example is shown in Chapter 100 Appendix 8. Status SS means the claim truly was suspended at the time the remittance advice was generated. If your remit shows a suspended service and no further response is received within 30 days, resubmit on paper with supporting documentation per the explanation in Appendix 5 Error Code Explanations of the Chapter 100 Handbook of General Policies and Procedures.

2 4) How do we bill for vaccines provided by VFC? Use the CPT code applicable to the vaccine. Do we enter a charge amount? Yes. This charge represents your practice expense of obtaining the vaccine through VFC. Also, is the administration for the vaccine covered? Reimbursement for the practice expense of administering the injection is included in the office visit. We use and for administration but we get an error message saying procedure not covered, prior approval required. These codes are covered for QMBs only. Use the CPT code applicable to the vaccine, such as **Please refer to the Chapter A-200 Handbook for Practitioners, Topic A-226 Vaccinations/Immunizations and Appendix A-8 for policy and billing procedures. 5) I received a D01 denial, on recipient ID XXXXXXXXX, date of service 03/15/12 for procedure modifier 80 (surgical assist) for $ The assist was performed by P.S. (a physician assistant); however we billed under his collaborative supervisor Dr. H who was actually the surgeon. I understand why the D01 was sent. HFS saw the same procedure same day performed by the same provider. But if we are unable to bill under the assistant P.S., we should be allowed to bill under the collaborative supervisor. Can you please advise how I should be billing the assist when the surgeon is the same as the collaborative provider?? Is this information located in the handbook? Please see policy and billing procedures in Topic A Surgical Assistance in the Chapter 200 Handbook for Practitioners Rendering Medical Service. Services provided by a physician assistant should be billed on a paper HFS 2360 claim, using the modifier AS and the physician assistant s name in the narrative portion of field 24C. 6) When a patient has spenddown, how does a provider find out the amount? HFS is unable to tell a provider the spenddown amount, but providers can check MEDI to see if spenddown is met or unmet. If spenddown is unmet, the patient does not have Medicaid and the provider may bill the patient. Please refer to Topic 113 Spenddown in the Chapter 100 Handbook of General Policies and Procedures. 7) Regarding the 99211, can we bill this code, along with the admin of injection, when only our nurse sees a patient? Yes. Please refer to Topic A-226 Vaccinations/Immunizations in the Chapter 200 Handbook for Practitioners Rendering Medical Services. 8) We bill for a Neurosurgeon and bill for multi-level fusions. We can get the primary procedures codes paid but the secondary codes are always denied. Is there a modifier we can put on the secondary codes to ensure that they will get paid? If you have already reviewed the remittance advice error code explanation in the Chapter 100 Appendix 5 and still are uncertain about the rejections, you may contact a physician billing consultant at , option 3, option 1 with the specific provider number, recipient number, date of service, and codes that were rejected. As a general rule, add-on codes are hand-priced. Please bill these on a paper claim with supporting documentation. There is no modifier.

3 9) When HFS asks for additional information and the claim was originally submitted electronically, how do we submit the additional information? Do we need to send the claim again on paper with the information that was requested? Yes, submit a new, original paper claim with supporting documentation. HFS does not accept reproduced or faxed claims. Please refer to Appendix A-1 of the Chapter 200 Handbook for Practitioners Rendering Medical Services for detailed instructions regarding billing on paper claims. 10) Thanks for the Webinar it answered a lot of my questions but I do have a question. When a patient has Medicare, Medicaid shows that they have Medicare and Medicaid as a second payor but what happens when a Medicare recipient chooses a Medicare replacement policy such as Wellcare, Healthspring, Humana Gold or Aarp Medicare Complete. With any of these plans they have a copay with that ins it could be $5 or $10. Can we bill the patient for the $3.65 with these plans? There is no deductible or coinsurance they pay different then regular Medicare but for office visit they pay 100% and the patient for example pay $5. Can you clarify if the patient can be billed $3.65? Please refer to the Informational Notice dated June 29, 2010 re: Payment of Cost Sharing for Medicare Advantage Plan Members. A patient enrolled in a PFFS plan cannot be billed the HFS co-payment. 11) I have several claims that have denied for the X06 (surgical package previously paid). Our PCP admits and discharges the patient (99222, and 99239). We are not the surgeon billing for the surgery. Please advise on how these claims should be billed to be considered, or is this something that will not be considered for payment due to surgery being paid first. Error code X06 means the department believes the service you are billing has already been paid as a part of another service, either to you or to another provider. Your first step is to follow the instructions in the Chapter 100 Provider Handbook, Appendix 5, and resubmit your claim on paper with supporting documentation. If you continue to receive the rejection, you should contact a billing consultant at , option 3 then option 1, for resolution to specific examples. 12) If a person has medicare primary & hfs secondary & medicare rejects the procedure code as non covered & we submit it to hfs on a 2360 form with medicare eob and the medicare noncovered letter, do we have 2 years to submit these claims also? No, these are subject to the 180 day timely filing limit. Is Medicare noncovered claims considered the same as Medicare crossover? No, Medicare will not crossover a denied claim. Medicare crossover claims go on a 3797 form. When Medicare says it s noncovered it goes on 2360 form would we still have 2 years or is it 180 days from when medicare responded to file the claim.? These are subject to the 180 day timely filing limit. Any time a client has Medicare primary, Medicaid secondary, the claim must first be submitted to Medicare. Then, regardless of whether Medicare deems the claim payable (crossover) or denied, the claim must be submitted to Medicaid within 180 days of the Medicare adjudication date.

4 13) Are immunizations for Adults covered by HFS? If so, what is the reimbursement amount on those, is it $6.40 like a child's vaccination? For a list of covered codes and reimbursement amounts please refer to the practitioner fee schedule at: 14) If an adult comes in for an injection by the nurse, can we charge an admin injection fee or do we charge the injection with a nurse visit - a 99211? Please refer to Topic A- 226 Vaccinations/Immunizations in the Chapter 200 Handbook for Practitioners Rendering Medical Services. 15) I had the question about what documentation needs to be sent with a claim for an incomplete Essure (sterilization) procedure and what the appropriate modifier is for the CPT code. Please refer to Topic A Sterilization in the Chapter 200 Handbook for Practitioners Rendering Medical Services for the policy and billing procedures. This claim must be submitted on paper with the appropriately completed sterilization form, as well as the documentation of the failure of the first procedure. There was some background discussion on the topic and it was difficult to discern what was said. If you could reiterate what was discussed on this topic I would be most grateful. 16) I was in the webinar on Sept 19. I m looking at the handout, 4 th screen. The address there for mailing timely filing overrides, is that for 2360 claims or all timely filing (UB04 and 2360 s). This address is for non-institutional claims only. I had thought that UB04 s go to my rep Aimee Isham. That is correct for institutional/hospital (UB04) claims. I was also told that on 2360 claims that a timely filing request was not allowed. An override may be requested for the exceptions to the 180 day timely filing deadline listed on slides 3-4. One additional exception to the slides is a claim submitted following an adjustment. A claim may be voided up to 12 months following the paid voucher date. The provider then has 90 days from the adjustment DCN date to resubmit a claim for payment reconsideration. Thanks for clarifying these things. Multiple questions about clarification on this. Supposedly, it was stated that yes Medicare- Medicaid clients could be charged the applicable HFS copay; and another time it was stated that no, these clients are exempt from copays. Please advise: 17) We were a little confused by the explanation in regards to Medicare/HFS patients. If Medicare is primary do we collect the $3.65 co-pay? No; services for which Medicare is the primary payer are exempt from copays. 18) Per the Webinar on 9/19/12 we can charge the 3.65 co-pay when the patient has a commercial insurance and IPA. Yes

5 19) Per the Webinar we can t charge the patient the 3.65 co-pay when the patient has Medicare and IPA. Correct My question is about the Medicare replacements. Per IPA memo we can t bill IPA for Medicare replacement plans unless they are PPFS. If we can t bill IPA for the reimbursement then why can t we bill for the 3.65 IPA co-pay for Medicare Replacement plan? Medicare recipients are exempt from being charged a co-payment when enrolled in a PFFS plan. 20) After attending the 09/19/2012 HFS webinar I was still not sure if the Medicaid co-payment should be collected when Medicare is primary. My understanding is that if Medicaid is secondary to an insurance plan the Medicaid co-payment should be collected, even if the insurance payment exceeds the Medicaid allowable and Medicaid pays nothing on the claim. Correct However, I thought I heard someone say that Medicare as primary is an exception. Could you please clarify? Medicare recipients are exempt from being charged a co-payment.

CHAPTER 9 THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS

CHAPTER 9 THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS CHAPTER 9 THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS 9.0 -THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS DETERMINING OTHER HEALTH INSURANCE COVERAGE Behavioral health/integrated care providers

More information

Question and Answers on Participant Liability and Co-payments

Question and Answers on Participant Liability and Co-payments Question and Answers on Participant Liability and Co-payments 1. If a participant has private insurance as primary, and has Medicaid as secondary: a. Is the participant responsible for the private insurance

More information

Submitting Special Batch Claims and Claim Appeals

Submitting Special Batch Claims and Claim Appeals Submitting Special Batch Claims and Claim Appeals Nevada Medicaid and Nevada Check Up August 2013 2012 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without

More information

ebilling Support ebilling Support webinar: ebilling terms Lifecycle of a claim

ebilling Support ebilling Support webinar: ebilling terms Lifecycle of a claim ebilling Support ebilling Support webinar: ebilling terms ebilling enrollment Lifecycle of a claim 2 Terms EDI Electronic Data Interchange Flow of electronic information, specifically claims information

More information

1. Long Term Care Facility

1. Long Term Care Facility Table of Contents 1.... 1 1.1. Introduction... 1 1.1.1. General Policy... 1 1.1.2. Advance Directives... 1 1.1.3. Customary Fees... 1 1.1.4. Covered Services... 1 1.1.5. Swing Bed General Policy... 2 1.2.

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

AETNA MEDICARE OPEN SM PLAN PROVIDER TERMS AND CONDITIONS OF PAYMENT

AETNA MEDICARE OPEN SM PLAN PROVIDER TERMS AND CONDITIONS OF PAYMENT AETNA MEDICARE OPEN SM PLAN PROVIDER TERMS AND CONDITIONS OF PAYMENT Table of Contents 1. Introduction 2. When a provider is deemed to accept Aetna Medicare Open Plan s terms and conditions 3. Provider

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

Please follow these suggestions in order to facilitate timely reimbursement of claims and to avoid timely filing issues:

Please follow these suggestions in order to facilitate timely reimbursement of claims and to avoid timely filing issues: Claims/Payment Section K-1 New Claims Submissions All claims must be submitted and received by Molina Healthcare of New Mexico, Inc. (Molina Healthcare) within ninety (90) days from the date of service

More information

ForwardHealth Provider Portal Professional Claims

ForwardHealth Provider Portal Professional Claims P- ForwardHealth Provider Portal Professional Claims User Guide i Table of Contents 1 Introduction... 1 2 Access the Claims Page... 2 3 Submit a Professional Claim... 5 3.1 Professional Claim Panel...

More information

Institutional Billing Guide

Institutional Billing Guide Program KANSAS MEDICAL ASSISTANCE PROGRAM Institutional Billing Guide Updated 10.2013 Institutional Billing The Kansas Medical Assistance Program (KMAP) offers different billing options to all providers.

More information

Provider Billing Manual. Description

Provider Billing Manual. Description UB-92 Billing Instructions Revision Table Revision Date Sections Revised 7/1/02 Section 2.3 Form Locator 42 and 46 Description Language is being added to clarify UB-92 billing instructions for form locator

More information

CHAPTER 17 CREDIT AND COLLECTION

CHAPTER 17 CREDIT AND COLLECTION CHAPTER 17 CREDIT AND COLLECTION 17101. Credit and Collection Section 17102. Purpose 17103. Policy 17104. Procedures NOTE: Rule making authority cited for the formulation of regulations for the Credit

More information

Occupational Therapy Protocol Checklist

Occupational Therapy Protocol Checklist Occupational Therapy Protocol Checklist Service Recipient s Name Date of Birth (Last, First) Reviewer s Name (Last, First) Date Request Submitted Technical Review YES NO Is the correct funding source,

More information

Medi-Pak Advantage: Frequently Asked Questions

Medi-Pak Advantage: Frequently Asked Questions Medi-Pak Advantage: Frequently Asked Questions General Information: What Medicare Advantage product is Arkansas Blue Cross Blue Shield offering? Arkansas Blue Cross and Blue Shield has been approved by

More information

REMITTANCE ADVICE MANUAL

REMITTANCE ADVICE MANUAL REMITTANCE ADVICE MANUAL MO HEALTHNET ELECTRONIC PROPRIETARY REMITTANCE ADVICE (RA) RECORD LAYOUT MANUAL OVERVIEW BASIC DESCRIPTION The "MO HealthNet Electronic Proprietary Remittance Advice Record Layout"

More information

New York State UB-04 Billing Guidelines

New York State UB-04 Billing Guidelines New York State UB-04 Billing Guidelines [Type text] [Type text] [Type text] Version 2014 01 03/27/2014 EMEDNY INFORMATION emedny is the name of the New York State Medicaid system. The emedny system allows

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

Billing Dashboard Review

Billing Dashboard Review Billing Dashboard Review 70 Royal Little Drive Providence, RI 02904 Copyright 2002-2013 Optum. All rights reserved. Updated: 3/13/13 Table of Contents 1 Open Batches...1 1.1 Posting a Batch...1 2 Unbilled

More information

Florida Medicaid Recipients With Other Medical Insurances. April 2013

Florida Medicaid Recipients With Other Medical Insurances. April 2013 Florida Medicaid Recipients With Other Medical Insurances April 2013 1 Section 1 The Basics 2 What is Third Party Liability? Third Party Liability (TPL) is the obligation of any entity other than Medicaid

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

Handbook for Ambulatory Surgical Treatment Centers

Handbook for Ambulatory Surgical Treatment Centers Handbook for Ambulatory Surgical Treatment Centers Chapter G-200 Policy and Procedures For Ambulatory Surgical Treatment Centers Illinois Department of Healthcare and Family Services Issued December 2014

More information

Patient Billing & Insurance Information Q&A

Patient Billing & Insurance Information Q&A Patient Billing Requirements Patient Billing & Insurance Information Q&A At your first visit our office you are required to bring your insurance card and driver s license. Our office will copy this information

More information

Administrative Code. Title 23: Medicaid Part 306 Third Party Recovery

Administrative Code. Title 23: Medicaid Part 306 Third Party Recovery Administrative Code Title 23: Medicaid Part 306 Third Party Recovery Table of Contents Title 23: Division of Medicaid... 1 Part 306: Third Party Recovery... 1 Part 306 Chapter 1: Third Party Recovery...

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

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

ARChoices. HPE Fiscal Agent for the Arkansas Division of Medical Services. September 2016

ARChoices. HPE Fiscal Agent for the Arkansas Division of Medical Services. September 2016 ARChoices HPE Fiscal Agent for the Arkansas Division of Medical Services September 2016 Topics for Today Provider Training Provider Manuals Submitting Claims Claim Adjustments and Voids Current CPT Codes

More information

Frequently asked Questions for Providers H1N1 Vaccine Administration

Frequently asked Questions for Providers H1N1 Vaccine Administration Frequently asked Questions for Providers H1N1 Vaccine Administration What is the coverage policy for Empire BlueCross members regarding the H1N1 vaccination? Empire BlueCross will reimburse for the administration

More information

Billing Medicaid as a Secondary Payer. Provider Relations / Second quarter 2015

Billing Medicaid as a Secondary Payer. Provider Relations / Second quarter 2015 Billing Medicaid as a Secondary Payer Provider Relations / Second quarter 2015 Agenda Other Coverage How to Identify Other Coverage and Request Coverage Updates Medicare Crossover Claims Third-Party Liability

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

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

Premera Blue Cross Medicare Advantage Provider Reference Manual

Premera Blue Cross Medicare Advantage Provider Reference Manual Premera Blue Cross Medicare Advantage Provider Reference Manual Introduction to Premera Blue Cross Medicare Advantage Plans Premera Blue Cross offers Medicare Advantage (MA) plans in King, Pierce, Snohomish,

More information

Question and Answer Submissions

Question and Answer Submissions AACE Endocrine Coding Webinar Welcome to the Brave New World: Billing for Endocrine E & M Services in 2010 Question and Answer Submissions Q: If a patient returns after a year or so and takes excessive

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

Learn to understand aged AR Learn to work AR. Learn to manage AR. Get the old stuff paid. Where do we go from here?

Learn to understand aged AR Learn to work AR. Learn to manage AR. Get the old stuff paid. Where do we go from here? Learn to understand aged AR Learn to work AR Get the old stuff paid Learn to manage AR Where do we go from here? Accounts Receivable are unpaid payments/charges that are owed to you by the patients and/or

More information

General Third-Party Liability Payment

General Third-Party Liability Payment KANSAS MEDICAL ASSISTANCE PROVIDER MANUAL PROGRAM General Third-Party Liability Payment PART I GENERAL THIRD-PARTY LIABILITY PAYMENT KANSAS MEDICAL ASSISTANCE PROGRAM TABLE OF CONTENTS Section OTHER PAYMENT

More information

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE

WHEN YOU HAVE MEDICAID AND OTHER INSURANCE WHEN YOU HAVE MEDICAID AND OTHER INSURANCE Balance Billing, Choosing Providers and Other Advice on Third Party Liability (TPL) A guide to understanding health coverage in New Jersey if you have Medicaid

More information

HOW TO CREATE A SECONDARY CLAIM

HOW TO CREATE A SECONDARY CLAIM HOW TO CREATE A SECONDARY CLAIM Secondary claims are accepted for those payers that are indicated on our Payer List by a Y in the column for secondary s (the column header is SEC ). In some instances,

More information

Claims and Billing Process. AHCCCS Provider Identification Number and NPI Number

Claims and Billing Process. AHCCCS Provider Identification Number and NPI Number Claims and Billing Process AHCCCS Provider Identification Number and NPI Number All United Healthcare Community Plan providers requesting reimbursement for services must be properly registered with AHCCCS

More information

Sample Patient Payment Policy

Sample Patient Payment Policy Sample Patient Payment Policy Thank you for choosing our practice! We are committed to the success of your medical treatment and care. Please understand that payment of your bill is part of this treatment

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

Granville Health System

Granville Health System Approved by: Granville Health System FINANCIAL POLICY Effective Date: Revised Date(s): FINANCIAL POLICY - DRAFT 09-16-2014 Granville Health System is a not-for profit hospital committed to providing quality

More information

RULES OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION BUREAU OF TENNCARE

RULES OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION BUREAU OF TENNCARE RULES OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION BUREAU OF TENNCARE CHAPTER 1200-13-17 TENNCARE CROSSOVER PAYMENTS FOR MEDICARE TABLE OF CONTENTS 1200-13-17-.01 Definitions 1200-13-17-.04 Medicare

More information

Medicaid. Important Contact Information. In This Issue

Medicaid. Important Contact Information. In This Issue In This Issue Medicare & Medicaid Limitations Page 2 Resubmitting Denied Claims Page 2 Certain DME Under $50 Require PA Page 3 Top Reasons Claims are Returned to Providers Page 4 Medicaid New Medicaid

More information

Chapter 4. Medicaid Provider Manual Claims Payments

Chapter 4. Medicaid Provider Manual Claims Payments Chapter 4 Medicaid Provider Manual Claims Payments CHAPTER 4 Date Revised: TABLE OF CONTENTS 4.1 Claim Forms... 1 4.1.1 Form Availability... 1 4.1.2 Procedure and Diagnosis Code Sources... 1 4.2 Third

More information

FOR YOUR BENEFIT. Flu Shot Is Free With Rx ID Card At Any Shoppers Or Kroger Pharmacy

FOR YOUR BENEFIT. Flu Shot Is Free With Rx ID Card At Any Shoppers Or Kroger Pharmacy 1099Rs for Retirees Will be Mailed in Late January. Look for Yours! FOR YOUR BENEFIT UFCW Unions & Participating Employers Health & Welfare Fund December 2012 Vol. 28, No. 4 Material Modification www.associated-admin.com

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

Glossary of Insurance and Medical Billing Terms

Glossary of Insurance and Medical Billing Terms A Accept Assignment Provider has agreed to accept the insurance company allowed amount as full payment for the covered services. Adjudication The final determination of the issues involving settlement

More information

Medical Claims. How to File a Medical Claim. Coordination of Benefits. Explanation of Benefits Instructions and Sample

Medical Claims. How to File a Medical Claim. Coordination of Benefits. Explanation of Benefits Instructions and Sample Medical Claims How to File a Medical Claim Coordination of Benefits Explanation of Benefits Instructions and Sample 07/01/2005 Visit our Website at http://mutualofomaha.com 1 How to File a Medical Claim

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

University Healthcare Administrative Policy

University Healthcare Administrative Policy Page 1 of 6 APPROVED BY: Signatures on File FINANCIAL POLICY (UH) is a not-for profit teaching hospital committed to providing quality health care services. In order to provide necessary medical services

More information

Mississippi Medicaid. Provider Reference Guide. For Part 203. Physician Services

Mississippi Medicaid. Provider Reference Guide. For Part 203. Physician Services Mississippi Medicaid Provider Reference Guide For Part 203 Physician Services This is a companion document to the Mississippi Administrative Code Title 23 and must be utilized as a reference only. January

More information

Welcome Information. Registration: All patients must complete a patient information form before seeing their provider.

Welcome Information. Registration: All patients must complete a patient information form before seeing their provider. Welcome Information Thank you for choosing our practice to take care of your health care needs! We know that you have a choice in selecting your medical care and we strive to provide you with the best

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

Chapter 5: Third Party Liability

Chapter 5: Third Party Liability I N D I A N A H E A L T H C O V E R A G E P R O G R A M S P R O V I D E R M A N U A L Chapter 5: Third Party Liability Library Reference Number: PRPR10004 5-1 Document Version Number Version 1.0 September,

More information

Inpatient and Outpatient Services Billing. Presented by EDS Provider Field Consultants

Inpatient and Outpatient Services Billing. Presented by EDS Provider Field Consultants Inpatient and Outpatient Services Billing Presented by EDS Provider Field Consultants October 2007 Agenda Objectives NPI New Paper Claim Form Who bills on a UB-04 Claim Form? Inpatient Claims Reimbursement

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

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

Medicare-Medicaid Crossover Claims FAQ

Medicare-Medicaid Crossover Claims FAQ Medicare-Medicaid Crossover Claims FAQ Table of Contents 1. Benefits of Crossover Claims... 1 2. General Information... 1 3. Medicare Part B Professional Claims and DMERC Claims... 2 4. Professional Miscellaneous...

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

Understanding Your Role in Maximizing Revenue in a FQHC

Understanding Your Role in Maximizing Revenue in a FQHC Understanding Your Role in Maximizing Revenue in a FQHC Cynthia M Patterson President N Charleston SC 29420-1093 Firstchoice.practicesolutions@gmail.com P: (843) 597-8437 F: (888) 697-8923 Have systems

More information

MEDICARE CROSSOVER PROCESS FREQUENTLY ASKED QUESTIONS

MEDICARE CROSSOVER PROCESS FREQUENTLY ASKED QUESTIONS MEDICARE CROSSOVER PROCESS FREQUENTLY ASKED QUESTIONS QUESTION 1. What is meant by the crossover payment? ANSWER When Medicaid providers submit claims to Medicare for Medicare/Medicaid beneficiaries, Medicare

More information

Anthem Blue Cross: I have not seen 1 alpha prefix and request that you send an email to network.education@anthem.com with an example of this.

Anthem Blue Cross: I have not seen 1 alpha prefix and request that you send an email to network.education@anthem.com with an example of this. QUESTION ANSWER 1 Caller: Will precert authorization be required for emergency ambulance or just hospital admissions? 2 Caller: Can we go over who will be considered the HOST Plan and who would be the

More information

Web interchange. UB-04 Institutional Claim Submission HP Provider Relations/May 2013

Web interchange. UB-04 Institutional Claim Submission HP Provider Relations/May 2013 Web interchange UB-04 Institutional Claim Submission HP Provider Relations/May 2013 Agenda Session Objectives Advantages to Electronic Claim Filing Providers Using the UB-04 Password Reminders Submitting

More information

The Health Insurance Marketplace: Know Your Rights

The Health Insurance Marketplace: Know Your Rights The Health Insurance Marketplace: Know Your Rights You have certain rights when you enroll in a Marketplace health plan. These rights include: Getting easy-to-understand information about what your plan

More information

MEDICAID BASICS BOOK Third Party Liability

MEDICAID BASICS BOOK Third Party Liability Healthy Connections Visual MEDICAID BASICS BOOK Third Party Liability An illustrated companion to the interactive courses at: MedicaideLearning.com. This topic includes content from the exclusive Third

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

Targeted Case Management. March 2016

Targeted Case Management. March 2016 Targeted Case Management March 2016 Topics for Today Provider Training Provider Manuals Submitting Claims Claim Adjustments and Voids Current CPT Codes and Place of Service Codes Timely Filing WebRA ICD-10

More information

Appendix A-1. Technical Guidelines for Paper Claim Preparation Form HFS 2360, Health Insurance Claim Form

Appendix A-1. Technical Guidelines for Paper Claim Preparation Form HFS 2360, Health Insurance Claim Form Appendix A-1 Technical Guidelines for Paper Claim Preparation Form HFS 2360, Health Insurance Claim Form Please follow these guidelines in the preparation of paper claims for imaging processing to assure

More information

Remittance Advice Remark Code. MMIS EOB Code. Claim Adjustment Reason Code. MMIS EOB Description

Remittance Advice Remark Code. MMIS EOB Code. Claim Adjustment Reason Code. MMIS EOB Description Reason 4 7 The procedure code modifier listed on your claim is either invalid or the RBRVS payment rules do not allow this procedure to be billed 4 45 Modifier is invalid for the procedure code billed.

More information

TRICARE Claims Tips. March 2014

TRICARE Claims Tips. March 2014 TRICARE Claims Tips March 2014 Welcome Health Net Federal Services, LLC (Health Net) is honored to serve nearly approximately 2.8 million beneficiaries in the TRICARE North Region. We thank you for caring

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

9.0 Government Safety Net Programs

9.0 Government Safety Net Programs 9.0 Government Safety Net Programs 9.1 Medicaid Managed Care, Child Health Plus and Family Health Plus Note: This section does not apply to Healthy New York, another government safety net program with

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

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

CLAIMS Section 5. Overview. Clean Claim. Prompt Payment. Timely Claims Submission. Claim Submission Format

CLAIMS Section 5. Overview. Clean Claim. Prompt Payment. Timely Claims Submission. Claim Submission Format Overview The Claims department partners with the Provider Relations, Health Services and Customer Service departments to assist providers with any claims-related questions. The focus of the Claims department

More information

306 276-277 HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

306 276-277 HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE Handbook for Electronic Processing Chapter 300 Requirements for Electronic Processing 306 276-277 HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE 306.1 GENERAL INFORMATION Introduction This chapter contains

More information

SECTION 7: APPEALS TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1

SECTION 7: APPEALS TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 SECTION 7: APPEALS 7.1 Appeal Methods................................................................. 7-2 7.1.1 Electronic Appeal Submission.......................................................

More information

Physical Therapy Protocol Checklist

Physical Therapy Protocol Checklist Physical Therapy Protocol Checklist Service Recipient s Name Date of Birth (Last, First) Reviewer s Name (Last, First) Date Request Submitted Technical Review YES NO Is the correct funding source, site

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

Medicare Prescription Drug Coverage

Medicare Prescription Drug Coverage Medicare Prescription Drug Coverage Information for Seniors and People with Disabilities Medicaid and Medicaid Spenddown A Question and Answer Guide Produced by the CHOICES Program * * * * * * * * * *

More information

CHAPTER 7 (E) DENTAL PROGRAM CLAIMS FILING CHAPTER CONTENTS

CHAPTER 7 (E) DENTAL PROGRAM CLAIMS FILING CHAPTER CONTENTS CHAPTER 7 (E) DENTAL PROGRAM CHAPTER CONTENTS 7.0 CLAIMS SUBMISSION AND PROCESSING...1 7.1 ELECTRONIC MEDIA CLAIMS (EMC) FILING...1 7.2 CLAIMS DOCUMENTATION...2 7.3 THIRD PARTY LIABILITY (TPL)...2 7.4

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

Office of Benefits Hospital Billing Guidelines

Office of Benefits Hospital Billing Guidelines Office of Benefits Hospital Billing Guidelines Published 4/30/2015 TABLE OF CONTENTS 1. HOSPITAL BILLING OVERVIEW... 5 1.1 Instructions for Hospital Providers... 6 2. SPECIAL CASES BILLING INSTRUCTIONS...

More information

Claims Reports: Overview

Claims Reports: Overview Claims Reports: Overview Introduction BCBSTX provides explanations of claims handling to you and the patient. There are two reports that may be sent to your office, and they are each described in this

More information

Frequently Asked Questions Verifying Medicaid Recipient Eligibility Training

Frequently Asked Questions Verifying Medicaid Recipient Eligibility Training Frequently Asked Questions Verifying Medicaid Recipient Eligibility Training Bureau of Medicaid Services & Area Medicaid Program Offices Last Updated-November 13, 2011 All Medicaid handbooks, fee schedules,

More information

EISENHOWER MEDICAL CENTER Financial Assistance Program Full Charity Care and Discount Partial Charity Care Policies

EISENHOWER MEDICAL CENTER Financial Assistance Program Full Charity Care and Discount Partial Charity Care Policies EISENHOWER MEDICAL CENTER Financial Assistance Program Full Charity Care and Discount Partial Charity Care Policies PURPOSE Eisenhower Medical Center (EMC) serves all persons within Rancho Mirage and the

More information

CMS Eliminates Medicare Payment for Consultation Codes. Prepared by the UFJHI Office of Physician Billing Compliance

CMS Eliminates Medicare Payment for Consultation Codes. Prepared by the UFJHI Office of Physician Billing Compliance CMS Eliminates Medicare Payment for Consultation Codes Outline Reasons for Change Effective Date New Modifier Impact on Other Payers Impact on Medicare Secondary Claims Code Selection Office/Outpatient

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

Questions From All Blue 2009 Workshops

Questions From All Blue 2009 Workshops Questions From All Blue 2009 Workshops All Lines of Business 1. Coding question: For Medical Decision Making-is additional work up considered work up only performed outside the office or emergency department?

More information

Transportation for health care appointments just got easier with

Transportation for health care appointments just got easier with Transportation for health care appointments just got easier with Molina Medicare! With Molina Medicare Options Plus HMO SNP Plan, we offer the added benefit of non-emergency transportation to get you to

More information

Third Party Liability. HP Provider Relations/October 2014

Third Party Liability. HP Provider Relations/October 2014 Third Party Liability HP Provider Relations/October 2014 Agenda Objectives Define Third Party Liability (TPL) TPL Program Responsibilities TPL Resources Cost Avoidance Medicare Buy-in Program Claims Processing

More information

Blue Cross Blue Shield of Georgia (BCBSGa) Billing Dispute External Review Process

Blue Cross Blue Shield of Georgia (BCBSGa) Billing Dispute External Review Process Blue Cross Blue Shield of Georgia (BCBSGa) Billing Dispute External Review Process Since May 4, 2006, the Billing Dispute External Review Process has been available to physicians who are class members

More information

IVR (Interactive Voice Response)

IVR (Interactive Voice Response) MO HealthNet Interactive Voice Response System User Manual This manual provides instructions for making eligibility, claim status, and the last two check amount inquiries. It explains the different options

More information

Use of Vaccine Purchased with 317 Funds Question and Answer Bank

Use of Vaccine Purchased with 317 Funds Question and Answer Bank Use of Vaccine Purchased with 317 Funds Question and Answer Bank General Policy Guidance 1. What is the role of the Section 317 Immunization Program? What will its role be after Affordable Care Act implementation?

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

Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company

Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company Insureds 2009 Contents How to contact us... 2 Our claims process...

More information

DAY TREATMENT SERVICES. [Type text] [Type text] [Type text] Version 2011-01

DAY TREATMENT SERVICES. [Type text] [Type text] [Type text] Version 2011-01 New York State UB04 Billing Guidelines [Type text] [Type text] [Type text] Version 2011-01 6/1/2011 EMEDNY INFORMATION emedny is the name of the electronic New York State Medicaid system. The emedny system

More information

Evidence. of Coverage. ATRIO Gold Rx (Rogue) (PPO) Member Handbook. Serving Medicare Beneficiaries in Josephine and Jackson Counties

Evidence. of Coverage. ATRIO Gold Rx (Rogue) (PPO) Member Handbook. Serving Medicare Beneficiaries in Josephine and Jackson Counties 2016 Evidence of Coverage ATRIO Gold Rx (Rogue) (PPO) Member Handbook Serving Medicare Beneficiaries in Josephine and Jackson Counties H6743_017_EOC_16 CMS Accepted January 1 December 31, 2016 Evidence

More information