SCAN Member Eligibility & Benefits

Transcription

1 SCAN Member Eligibility & Benefits Interactive Voice Response (IVR) Available 24 hours a day, 7 days a week Toll free number is SCAN (7226) Online Eligibility Verification For initial setup, contact the SCAN Administrator at or psdbase@scanhealthplan.com Once you have an account, go to click on CA Provider Tools and then Eligibility Lookup. Page 1 of 11

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3 UM Authorization Guidelines SCAN must be notified of services provided to SCAN Members. When SCAN Members are serviced by Provider AND the claim will be submitted to SCAN, Provider is required to: 1. Obtain an authorization from the participating Physician Group/IPA. AND 2. FAX the Physician Group/IPA authorization to SCAN UM Department at (800) (available 24 hours a day 7 days a week). (Provider will receive a SCAN tracking number by return FAX within 3 business days.) 3. Include the Physician Group/IPA authorization number and SCAN tracking number on claim. Claims received by SCAN without this information, will be reviewed retrospectively, which may delay reimbursement. 4. If Provider s request is urgent please contact our UM Department at (800) and select option 3. Note: SCAN will provide our contracted Physician Groups/IPAs with a listing of all our contracted Providers for their use in selecting and authorizing services for our members. SNF UM Notification Process Notification to SCAN of Member Admissions When SCAN Pays Facility This is our process for collecting admission or registration information from Skilled Nursing and Sub Acute Care Facilities. The following are important steps regarding admission authorization/notification for SCAN members. 1. Contact the Physician Group for: An admission authorization number; clinical reviews; changes in level of care; and discharge (admissions not authorized by the Physician Group/IPA will be reviewed retrospectively, which may delay reimbursement). Page 3 of 11

4 2. Contact SCAN UM upon admission: Fax the admission face sheet to SCAN UM at (800) (You will receive a SCAN tracking number by return fax within 24 hours). Admissions without a SCAN Tracking Number will be reviewed retrospectively, which may delay reimbursement. 3. Reminder: Do not notify SCAN of Therapies, Podiatry, Diagnosis, or other specialty physician referrals. You must contact the Physician Group/IPA for these authorizations and claims for these services, when authorized, are paid by the Physician Group/IPA. Thank you for the service you provide to SCAN members. If you have questions about this communication, please call (800) (Option 3). Page 4 of 11

5 Claims Payment Claims Guidelines Our goal is timely accurate payment of Provider s claims and to ensure that, DON T FORGET that: 1. All claims must be submitted on appropriate billing forms (CMS1500 or UB04). 2. All claims must be computer generated or typed. No handwriting except signature on claims will be accepted. 3. All claims must be signed. 4. All claims submitted to SCAN must be accompanied by the following: Physician Group/IPA Authorization & SCAN Tracking # SCAN Member s medical records, if appropriate. Claims received by SCAN without this information will be returned for correction. 5. Claims are paid within the timeframe specified in the respective Ancillary Services Agreement between SCAN and Provider. Claims Status 1. Claims Customer Service Status Line: (800) Claims submitted to SCAN take approximately 2 weeks to appear in our system. DO NOT re-submit claims to SCAN until after this timeframe and after Provider has called the Claims Customer Service Status Line or used the Provider Tools website at to confirm whether Provider s claims have been received; this will only delay Provider from receiving timely payment. 3. Online Claims Status: Claims status may also be checked online via our Provider Tools website. To set up a log-in account and password please call (888) or contact Provider s designated SCAN Ancillary Contract Specialist for assistance. 4. Payments Received: Payment to Provider is accompanied by a Remittance Advice, which details claims being paid by that check. Upon receipt of payment, Provider is responsible for auditing this Remittance Advice for accuracy. In the event that Provider questions any payments made, Provider is to contact the Claims Customer Service line at (800) Page 5 of 11

6 Process for Filing a Claims Appeal/Dispute Each claim appeal/dispute submitted must include the following: 1. Name of Provider and Provider contact information 2. The date(s) of service 3. A clear identification of the disputed item(s), including a clear and concise explanation of the basis upon which the Provider believes the payment amount/denial is incorrect, the expected outcome, and appropriate documentation included. 4. All appeals/disputes must be submitted in writing to: Claims Disputes/Appeals SCAN Health Plan P.O. Box Long Beach, CA Timeframes 1. SCAN will strive to acknowledge receipt of Provider s claim appeal/dispute within 15 calendar days. In addition, SCAN will strive to resolve the appeal/dispute and send an outcome/decision letter to Provider within 60 calendar days of receiving complete information. 2. If Provider has followed the above process and continues to experience claims issues, please contact Provider s designated SCAN Ancillary Contract Specialist for assistance. Provider s SCAN Ancillary Contract Specialist will initially provide Provider with a claims paid report covering a specific timeframe in question that will allow Provider to reconcile accounts against our records. 3. Once Provider has reconciled the accounts against the claims paid report, your Ancillary Contract Specialist will work as a liaison with the SCAN Claims Department, Provider and if necessary, the Physician Group/IPA to ensure that all claims issues are resolved. If Provider is interested in submitting claims electronically, please call our SCAN HIPAA EDI Hotline at x Page 6 of 11

7 Instructions for Completing CMS 1500 Forms When filing a claim on a CMS 1500, there are certain fields on the form that are required fields and must be completed in order for SCAN to process the claim for payment. Listed below are the required field numbers, along with explanations. The number of the field corresponds with the field number on CMS 1500 claim form. Field # Definition SCAN Required Entry 1 Program Enter X in appropriate box 1a Insured s ID Number Enter SCAN Member ID Number 2 Patient s Name Enter Member s Name (Last Name, First Name, Middle Initial) 3 Patient s Date of Birth/Sex Enter Member s Date of Birth and Sex 4 Insured s Name Enter Member s Name (Last Name, First Name, Middle Initial) 5 Patient s Address Enter Member s Address 6 Patient Relationship to Insured Enter X in box next to SELF 7 Insured s Address & Telephone # Enter Member s Address and Telephone # 8 Patient Status Enter X in appropriate box 9 a-c N/A N/A Leave Blank 10a-d Patient s Condition Response is NO to a-d, enter X in each Box next to that response 11 Insured s Policy Group or FECA # N/A Leave Blank 11a Insured s Date of Birth/Sex Enter Member s Date of Birth and Sex 11b Employer s Name or School Name N/A Leave Blank 11c Insurance Plan Name or Program Enter SCAN 11d Is there another Health Benefit Plan Response is NO, enter X in Box next to that response 12 & 13 Patient s or Authorized Person s Response to both is Signature on File and the claim date Signature N/A N/A - Leave Blank 20 Outside Lab? Response is NO, enter X in the Box next to that response 21 Diagnosis or Nature of Illness or Enter five digit diagnosis code Injury Code 22 Medicaid Resubmission Code N/A Leave Blank 23 Prior Authorization Number Enter SCAN Authorization # 24a Date(s) of Service From/To Must Enter one date per line 24b Place of Service Enter 12 24c EMG (Emergency) Enter 01 24d Procedures, Services or Supplies Enter SCAN Personal Service Code and Modifier (if Page 7 of 11

8 Field # Definition SCAN Required Entry CPT/HCPCS Modifier applicable) to describe the specific care provided 24e Diagnosis Code Enter five digit diagnosis code 24f Charges Enter Contracted Rate 24g Days or Units Enter # of days or units, according to Authorization 24h& k N/A N/A Leave Blank 24i ID Qualifier Enter G2 24j Rendering Provider ID# Enter your SCAN provider identification number (above NPI) 25 Federal Tax ID Number - SSN/EIN Enter your Tax ID # and mark X in appropriate SSN or EIN box 26 Patient s Account Number Enter member s reference # assigned by your facility/agency 27 Accept Assignment Yes/No Enter X in appropriate box 28 Total Charges Enter total charge 29 Amount Paid Enter Amount Paid, if applicable 30 Balance Due Enter Balance Due 31 Signature of Physician or Supplier including Degrees or Credentials & Date Signature and Date 32 Name and Address of Facility where services were rendered (if other than patient s home or office) 32a NPI of Facility where services were rendered 32b Rendering Provider SCAN ID with Qualifier Enter Name and Address of facility where services rendered ( if other than member s home) Enter NPI Enter G2 followed by your SCAN provider identification number (legacy number) 33 Billing Provider Info & Phone Enter Billing Name, Address, City, State, Zip Code and Phone # 33a NPI of Billing Facility Enter NPI 33b Billing Provider SCAN ID with Qualifier Enter G2 followed by your SCAN provider identification number (legacy number) Instructions for Completing UB 04 Forms When filing a claim on a UB04, there are certain fields on the form that are required fields and must be completed in order for SCAN to process the claim for payment. Listed below are the required field numbers, along with explanations. The number of the field corresponds with the field number on the UB04 claim form. Page 8 of 11

9 Field # Definition SCAN Required Entry 1 Provider s Name, Address and Telephone Number 2 Pay-To Name and Address Enter Billing Name, Address, City, State, Zip Code and Phone # Enter Billing Name, Address, City, State, Zip Code and Phone # 3 Patient Control Number Enter Patient Control Number 4 Type Of Bill Code Enter three-digit bill code 5 Provider s Federal Tax ID Number Enter your Tax ID # 6 Beginning and Ending Date of Claim Must Enter one date per line Period 7 N/A N/A Leave Blank 8 Patient s Name Enter Member s Name (Last Name, First Name, Middle Initial) 9 Patient s Address Enter Member s Address 10 Patient s Date of Birth Enter Member s Date of Birth 11 Patient's Gender Enter Member s Sex 12 Date of Admission Enter Date 13 Admission Hour N/A Leave Blank 14 Type of Admission N/A Leave Blank 15 Source of Admission Code N/A Leave Blank 16 Discharge Hour N/A Leave Blank 17 Patient-Status-At-Discharge Code Enter Discharge Code Condition Codes N/A Leave Blank 29 Accident State N/A Leave Blank 30 Not Used N/A Leave Blank Occurrence Codes and Dates Enter Occurrence Code and Date Occurrence Span Code N/A Leave Blank 37 Not Used N/A Leave Blank 38 Responsible Party N/A Leave Blank Value Code and Amounts N/A Leave Blank 42 Revenue Code Enter Revenue Code 43 Revenue/Service Description Enter Description of Service(s) assigned to Revenue Code input in field HCPCS/Rates Enter HCPC code 45 Service Date Enter Date of Service 46 Units of Service Enter Units of Service provided on that date 47 Total Charge Enter Total Charges 48 Non-Covered Charges N/A Leave Blank 49 Not Used N/A Leave Blank 50 Payer Name Enter SCAN Health Plan 51 Health Plan ID N/A Leave Blank 52 Release of Info Certification Enter Y or N 53 Assignment of Benefit Certification N/A Leave Blank Page 9 of 11

10 Field # Definition SCAN Required Entry 54 Prior Payments N/A Leave Blank 55 Estimated Amount Due N/A Leave Blank 56 NPI Number Enter NPI 57 Other Provider ID Enter G2 followed by your SCAN provider identification number (legacy number) 58 Insured's Name Enter Member s Name (Last Name, First Name, Middle Initial) 59 Patient Relationship Enter 01 in box to note Self 60 Insured's Unique ID Enter SCAN Member ID Number 61 Group Name N/A Leave Blank 62 Group Insurance Number N/A Leave Blank 63 Treatment Authorization Codes N/A Leave Blank 64 Document Control Number N/A Leave Blank 65 Employer Name N/A Leave Blank 66 Diagnosis and Procedure Code N/A Leave Blank Qualifier 67 Diagnosis Codes N/A Leave Blank 68 Not Used N/A Leave Blank 69 Admitting Diagnosis N/A Leave Blank 70 Patient Reason Diagnosis N/A Leave Blank 71 PPS Code (DRG) N/A Leave Blank 72 ECI Code N/A Leave Blank 73 Not Used N/A Leave Blank 74 Procedure Codes N/A Leave Blank 75 Not Used N/A Leave Blank 76 Attending Physician ID N/A Leave Blank 77 Operating Physician ID N/A Leave Blank Other Provider ID N/A Leave Blank 80 Remarks N/A Leave Blank Specific SCAN SNF Instructions for Completing UB04 Forms 1. For Respite care only, you must enter Revenue code 669 in Box 42 and leave Box 43 blank. 2. For Respite care (ILP Benefit only), please enter or if known, the ICD9 Code for the actual diagnosis in Box For Custodial care (ILP and IHRB Benefits only), you must enter Revenue code 190 in Box 42 and leave Box 43 blank. Page 10 of 11

11 4. For Custodial care (LTC), you must enter Revenue code 190 in Box 42 and leave Box 43 blank. 5. For all other levels of care, please enter the appropriate Revenue Code in Box 42 and the applicable RUG III Code in Box 44. Revenue/Levels of Care Coding Definition Rev Code RUG III Code Respite 669 Custodial (Short term stay) 190 Custodial (Long Term Care) 190 SNF Level CC100 SNF Level RLB00 SNF Level SSC00 SNF Level SE100 Long Term Care services: SCAN is now responsible for LTC services for SCAN members who are MediCAL recipients and have signed their benefits over to SCAN. Billing with Revenue Code 120 and adding the Level of Care in Box 84 on the UB- 04 Form will no longer be accepted. You must use the Revenue coding referenced above, in the appropriate boxes to ensure prompt payment. All claims submitted to SCAN must be accompanied by the following: 1. Physician Group/IPA Authorization and SCAN Tracking # 2. SCAN member s medical record showing orders for all exclusions provided and being billed for. 3. It is critical that the Authorization provided to the SNF by the Physician Group/IPA matches the specific level(s) of care and level(s) of service rendered. SCAN cannot pay for a higher level of care or level of service than what was authorized by the Physician Group/IPA. If necessary, have Authorization revised before billing SCAN. Page 11 of 11