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2 Claim Submissin: Crrect claim submissin increases cash flw t yur practice, and prevents cstly fllw-up time n the part f yur ffice/billing staff. HealthAmerica s guidelines cmply with HIPAA, Medicare, CHAMPUS Claim Frm rules and Act 68 clean claim definitin. Please submit claims electrnically t Health American whenever pssible. Electrnic submissin prvides the mst cst effective slutin in terms f time and mney. Fr details abut electrnic claim submissin, please refer t the next sectin. A. Paper Claim Fr prfessinal claim services, please bill by using the updated Health Insurance Claim Frm, knwn as the CMS 1500 frm, This frm is recgnized as the universal Claim Frm thrughut the industry, and has been apprved by the American Medical Assciatin (AMA) Cuncil n Medical Services. Please refer t the CMS 1500 requirements in the Clean Claim Sectin fr the required fields which must be cmpleted n all frms. Claims have a filing limit and need t be submitted based n the terms f yur cntract. Claims received after the filing limit will autmatically be denied. Please Nte: It is the prvider s respnsibility t check with the Plan peridically if yu have heard nthing regarding a submitted claim. It is suggested that yu check with the health plan 30 days frm the date f submissin t determine if the Plan has received the claim r lg int DirectPrvider.cm within 7 days frm the date f submissin t determine if the plan received the claim If the Plan has n recrd f the claim, yu may still submit the claim within the timely filing limits. If yu wait fr an extended perid f time t inquire abut a claim, and that claim is nt in ur system, the Plan will require yu t submit prf f timely filing fr review. Fr paper submissins, please send yur initial claims t the crrect mailing address. The crrect addresses fr HealthAmerica and Advantra prducts are: HealthAmerica Advantra Prviders: Central Pennsylvania Prviders: Advantra HealthAmerica PO Bx 7087 PO Bx 7089 Lndn KY Lndn KY Central Penn Teamsters Health & Welfare Fund PO Bx Reading PA HealthAmerica One: Attn: Claims P.O. Bx 7142 Lndn, KY Carelink Prviders: Carelink PO Bx 7373 Lndn KY *Refer t Advantra sectin f this manual fr additinal claims infrmatin. PDF created with pdffactry Pr trial versin 2

3 B. Billing Electrnically Electrnic Claims Submissin - Electrnic Data Interchange (EDI) The Health Insurance Prtability and Accuntability Act (HIPAA) requires that Cventry Health Care and all ther cvered entities cmply with Electrnic Date Interchange (EDI) standards fr health care as established by the Secretary f Health and Human Services. In supprt f HIPAA and its gal f Administrative Simplificatin, HealthAmerica will encurage physicians and medical prviders t submit claims electrnically. Electrnic claims submissin can have significant, psitive impact n the prductivity and cash flw fr yur practice: EDI reduces the paperwrk and csts assciated with printing and mailing paper claims. EDI reduces the time it nrmally takes fr Cventry Health Care t receive a claim by eliminating mailing time. EDI reduces the delays due t incrrect claim infrmatin by returning these errrs directly t yu thrugh the same electrnic channel. These claims can be crrected and re-submitted electrnically. Electrnic claim submissin imprves claim accuracy by decreasing the chance fr transcriptin errrs and missing/incrrect data. EDI claims can be tracked and mnitred thrugh claim status reprts received electrnically. Electrnic claim submissin t a Cventry Health Plan is easy t establish. Cntact yur practice management system vendr r clearinghuse t initiate the prcess. Electrnic claim submissins will be ruted thrugh Emden wh will review and validate the claims fr HIPAA cmpliance and frward them directly t Cventry. Prviders can als submit directly t Emden. Emden will prvide the electrnic requirements and set-up instructins. Prviders shuld call (800) r g t fr infrmatin n direct submissin t Emden EDI claim submitters shuld review HealthAmerica EDI Exclusin List and Electrnic Claim Submissin Requirements, which is belw. All Cventry health plans use the ANSI X12N 837 v4010 and v4010a1 implementatin guides that have been established as the standard claim transactins fr HIPAA. The fficial implementatin guides fr claim transactins are available electrnically frm the Washingtn Publishing Cmpany website: Cventry Health Care encurages and recmmends regular review f all EDI Acknwledgement and Reject Reprts returned t yu. Cventry Health Care, Inc. has staff available t assist yu with EDI claim filing. Fr mre details n each f these tpics please see belw: PDF created with pdffactry Pr trial versin 3

4 EDI Submissin Requirements EDI Specificatins Plan: HealthAmerica Emden business services Payer ID: EDI Specificatins - The 837 claim transactin is utilized fr electrnic prfessinal and institutinal claims and encunters. Cventry Health Care, Inc. uses the ASC X12N 837 Prfessinal Health Care Claim (004010X098A1) and the ASC X12N 837 Institutinal Health Care Claim (004010X096A1) implementatin guides. The fficial implementatin guides fr claim transactins are available electrnically frm the Washingtn Publishing Cmpany website at This Cventry dcument cntains clarificatins and payer specific requirements related t data usage and cntent with submitting an EDI claims t Cventry. Please nte that this dcument is intended t list nly thse elements where payer specific requirements r clarificatins apply. The lp, segment and data element references belw in italics relate t the X098A1r X096A1 frmat. If yu submit yur electrnic claims using a different frmat, yu shuld check with yur sftware vendr r clearinghuse t ensure that yur data is mapped t the prper data elements. 2. Cventry Specific Payer Edits at Emden: All EDI claims submitted thrugh Emden will be subject t these Cventry specific payer edits (unless indicated fr ne transactin nly) that are in place at Emden. Submitters will receive these type f rejectins n their level 1 payer rejectin reprts. NOTE: The insured id must be at least tw characters in length r the claim will reject. T allw zer dllar line charges and zer dllar claim charges. The billing prvider id may nt cntain a value f r the claim will reject. If the prcedure cde begins with 0, then Anesthesia Minutes are required r the claim will reject (Prf Only). Excluding prcedure cde is r then service units are required and the Anesthesia Minutes shuld cntain 00 r the claim will reject. If the prcedure cde begins with a 0 and ends with a T, then service units are required and the Anesthesia Minutes shuld cntain 00 r the claim will reject (Prf Only). If the prcedure cde des nt begin with a 0, then service units are required and the Anesthesia Minutes shuld cntain 00 r the claim will reject (Prf Only). The discharge hur must cntain a numeric value f r 99 if the batch type cntains an inpatient value f x10, x11, x14 r x17 and the statement perid frm date is equal t the statement perid thru date (Inst Only). Refer t 2010 Claim Submissin Lg Grid t lcate the respective Emden payer ID and paper mailing address fr all Cventry health plans. Cventry has cnslidated several f ur Emden Payer IDs int a single payer id t make claim submissin easier. Please refer t the cnslidated Emden Payer ID n the lg grid fr the Health plans included. PDF created with pdffactry Pr trial versin 4

5 3. Prfessinal EDI Claim Submissin Infrmatin Key Infrmatin required by HIPAA/Cventry r clarified as t Cventry's use f the data: Prvider Federal Tax ID (TIN) f Billing Prvider (9 digit number). Natinal Prvider ID (NPI) is required fr Billing, Rendering, Referring prviders, and all ther prvider lps. Billing Prvider's Last Name (NM103) and Prvider's First Name (NM104) are bth required if the prvider entity type qualifier indicates "persn". Prvider first name shuld be submitted cmpletely and nt just a first initial. Rendering Prvider Name and ID Number (Lp 2310B) is required when different than the billing prvider (2010AA). Prvider first name shuld be submitted cmpletely and nt just a first initial. If yu submit rendering prvider infrmatin at the claim header level (Lp 2310B), d nt als submit service line level (Lp 2420A) rendering prvider infrmatin. Cventry will read the prvider at the claim header level nly. If yu d nt have a rendering prvider at the claim header, Cventry will read the billing prvider data. Referring Prvider Name and ID Number (Lp 2310A) If the referring prvider is a persn, bth the first name(nm104) and last name (NM103) are required. D nt submit referring prvider infrmatin at the service line level (Lp 2420F). Cventry will read prvider data at the claim level nly (Lp 2310A). When there is nly ne referral n the claim, use cde DN in NM101. When tw referrals are reprted, use cde DN in NM101 f the first iteratin f the lp and cde P3 in NM101 in the secnd iteratin f the lp. Cventry will nly read the first referral submitted. Service Facility Lcatin (Lp 2310D) is required when the service lcatin is different than the lcatin in the billing prvider (2010AA). Service facility lcatin name (NM1) is required except when the place f service is the patient's hme. Include Service Facility NPI D nt submit service facility lcatin infrmatin at the service line level (Lp 2420C). Pay-T Prvider (Lp 2010). Cventry accepts and stres "Pay-T" prvider data. Hwever, will nly use this data in claim filing n an exceptin basis. Please cntact the EDI supprt number belw if yur submissins require prvider matching based n data in this lp. The Cventry standard is t use the rendering r billing prvider infrmatin fr claims. PDF created with pdffactry Pr trial versin 5

6 Other Claim Header Infrmatin: Admissin Date (Ref02 where REF0=435) is required per HIPAA guides fr inpatient medical visits and ambulance claims when the patient was admitted t the hspital. Cmpliant Medical Cde Sets such as HCPCS, ICD-9, and CPT-4 are required n bth electrnic and paper claims. ICD-9-CM cdes shuld be submitted with the highest level f specificity (the crrect number f digits) fr prper adjudicatin. Patient Member ID Number as shwn n the patient's ID card. Member Date f Birth & Gender Cde Subscriber's Date f Birth (DMG02 where DMG01=D8) and Gender Cde (DMG03)are preferred and are required if either: The subscriber is the same persn as the patient. Fr secndary COB claims when using Lps 2320 and Insurance Type Cde is required n secndary COB claims (Lp 2320 SBR05). Special Data Items Anesthesia EDI Claims. Cventry requires the submissin f time-based CPT cdes (frmally called ASA cdes) fr all anesthesia services. Anesthesia claims submitted with surgical CPT cdes will be denied during prcessing. Ttal Anesthesia Minutes are required n all time-based CPT cdes, with the exceptin f and Ttal Minutes shuld be entered in the SV104. The qualifier MJ shuld be entered in the SV103. All nn time-based services (01996 included) require units f service. Units shuld be entered in the SV104, with a Qualifier f UN in the SV103. Claims with Attachments. Cventry is able t receive and use in prcessing the EDI Claim Supplemental Infrmatin paperwrk segment as defined in the Health Care Claim 837 Implementatin Guide. This segment cntains paperwrk cdes t indicate dcuments available t the payer if needed Specificatins fr 2300 Lp - PWK Segment PWK01 - Reprt Type Cde (see applicable cdes belw) PWK02 - Reprt Transmissin Cde must be 'AA' fr available n request at prvider site. PWK06 - Attachment Cntrl number (if applicable). PWK07 - Descriptin (ptinal)(ub claims nly). Cventry's business practices supprt the fllwing paperwrk cdes (PWK01), which will be cnsidered during adjudicatin: PDF created with pdffactry Pr trial versin 6

7 (AS) Admissin Summary (DG) Diagnstic Reprt (DS) Discharge Summary (NN) Nurse Ntes (PN) Physical Therapy Ntes (B3) Physician Order (OB) Operative Ntes (EB) Explanatin f Benefits (RT) Reprt f Tests and Analysis Reprt (RR) Radilgy Reprts Please nte fr claims with attachments: The PWK segment and attachments shuld nly be used when supplemental infrmatin is necessary fr the claim t be accurately and cmpletely adjudicated accrding t established plicies. If the dcumentatin is needed fr adjudicatin, Cventry will cntact yu and request a faxed cpy. This cpy must be received within 72 hurs f the request r the claim will be denied. The specific paperwrk cdes in the PWK segment will trigger prcessrs t cnsider the cntents f the supplemental infrmatin btained via fax. Therefre, use f these cdes incrrectly may delay the prcessing f the claim as cmpared t a like claim withut a PWK. Cventry will cntinue t accept paper claims with attachments. Secndary COB Claims - secndary claims may be submitted electrnically. Send the secndary claim electrnically using the A1 using Lps 2320 and 2330 fr claim header data and Lps 2420G and 2430 fr claim service line data. All COB secndary claims must cntain infrmatin regarding the ther payer apprved and allwed amunts. Additinally, we need t receive the applicable claim adjustment reasn cdes at the header r line level fr ther payer amunts. Cventry des nt require secndary COB claims t be submitted electrnically. Prviders may cntinue t submit COB claims n paper and attach a cpy f the paper EOB. NOTE: Cventry receives Medicare Part A & B primary claims autmatically thrugh the crss ver prcess fr secndary payment. T eliminate duplicate claim submissins, refer t the EOB/RA frm Medicare (lk fr cde "MA-18" n yur Medicare Remittance Advice) befre submitting secndary claims directly t Cventry. PDF created with pdffactry Pr trial versin 7

8 Resubmitted Claims - Crrected r replacement claims may be submitted electrnically. Use the Claim Frequency Type Cde (CLM05-3) value equal t "7" t indicate a replacement claim. Pharmaceutical Claims - May be submitted electrnically. These drug claims shuld nt be fr retail pharmacy claims nr can they be in an NCPDP frmat. If yu are submitting a claim fr pharmaceutical services, the HCPCS J cdes are required t identify the drug. Hwever, if the apprpriate J-cde is J3490 r J9999, we als require the NDC cde using Lp Use a F2 qualifier n the service line level t indicate DOSAGE fr this NDC cde. If yu cannt submit the 2410 lp, then place the NDC and dsage infrmatin in the claim header nte segment (2300 NTE). We d nt read NTE infrmatin at the claim line level. DATA NOT USED Althugh Cventry accepts the fllwing data, it is nt used in claim adjudicatin. Prviders lps and segments at the claim line level. Supervising prvider infrmatin - Please cntact the EDI supprt number belw if yur submissins require prvider matching based n data in this lp. The Cventry standard is t use the rendering r billing prvider infrmatin fr claims. Purchasing prvider infrmatin. Currency. Infrmatin in the CUR segment will nt be cnsidered in prcessing. All electrnic transactins will be with trading partners in the United States. Select Patient Infrmatin Segment including date f death (PAT06), Weight (PAT08), and Pregnancy Indicatr (PAT09). Respnsible Party Infrmatin (Lp 2010 BC) infrmatin submitted n apprpriate legal dcumentatin and maintained in internal files will be used. Participatin Indicatr (Lp 2300 CLM16) we will use the participatin indicatr in ur internal prvider files. Service Authrizatin Exceptin Cde in Lp 2300 REF. Ambulatry Patient Grup in Lp 2300 REF. Demnstratin Prject Identifier in Lp 2300 REF. Durable Medical Equipment Service (Lp 2400 SV5 segment). DME shuld be billed in the Lp 2400 SV1 segment. Mandatry Medicare Crssver Indicatr (Lp 2300 REF). Mammgraphy Certificatin Number (Lps 2300 and 2400 REF). DMERC CMN Indicatr (Lp 2400 PWK). Hspice Emplyee Indicatr (Lp 2400 CRC). Credit/Debit Card Accunt Hlder Name (Lp 2010BD) and Credit/Debit Card Maximum Amunt (Lp 2300 AMT segment) PDF created with pdffactry Pr trial versin 8

9 4. Institutinal (UB) Claim Submissin Infrmatin Key Infrmatin required by HIPAA/Cventry r clarified as t Cventry's use f the data: Prvider Federal Tax ID (TIN) f Prvider (9 digit number). Natinal Prvider ID (NPI) fr Billing, Rendering, Attending prviders, and all ther prvider lps. Billing Prvider's Last Name (NM103) and Prvider's First Name (NM104) are bth required if the prvider entity type qualifier indicates "persn". Prvider first name shuld be submitted cmpletely and nt just a first initial. Attending Prvider Name and ID Number (Lp 2310A) is recmmended n all institutinal claims. If the attending prvider is a persn, bth the first name and the last name are required. Service Facility Name and Address (Lp 2310E) is required when the service facility is different than the billing prvider (2010AA). Admissin Date and Time is required fr all inpatient claims. DTP03 shuld be in this frmat: CCYYMMDDHHMM where DTP01=435 and DTP02=DT. Service Line Date is required n utpatient claims. DTP03 where DTP01=472 in Lp Unit r Basis fr Measurement Cde SV204 in Lp 2400 (days, units, internatinal unit r dsage) is required at the service line level. Quantity Segment (QTY in Lp 2300) shuld nly be used fr infrmatin related t DAYS, such as the number f cvered, c-insured, life-time reserve r nn-cvered days. D nt use this segment n utpatient claims. Cmpliant Medical Cde Sets such as HCPCS, ICD-9, and CPT-4 are required n bth electrnic and paper claims. ICD-9-CM cdes shuld be submitted with the highest level f specificity (the crrect number f digits) fr prper adjudicatin. These cdes shuld be submitted withut the decimal pint n electrnic claims. ICD-9-CM cdes are expected n all utpatient surgery claims. Patient Member ID Number (10-11 digit number) as shwn n the patient's ID card. Member's Date f Birth and Gender Cde Subscriber's Date f Birth (DMG02 where DMG01=D8) and Gender Cde (DMG03) are required if either: PDF created with pdffactry Pr trial versin 9

10 The subscriber is the same persn as the patient. Fr secndary COB claims when using Lps 2320 and Patient Status Cde CL103 in Lp 2300 (2-digit cde frm bx 22 f the UB-92) is required n all inpatient claims. RECOMMENDED INFORMATION Claims with Attachments. Cventry is able t receive and use in prcessing the EDI Claim Supplemental Infrmatin paperwrk segment as defined in the Health Care Claim 837 Implementatin Guide Specificatins fr 2300 Lp - PWK Segment PWK01 - Reprt Type Cde (see applicable cdes belw) PWK02 - Reprt Transmissin Cde must be 'AA' fr available n request at prvider site. PWK06 - Attachment Cntrl number (nt used nw, but will be implemented in the future). PWK07 - Descriptin (ptinal)(ub claims nly). Cventry's business practices supprt the fllwing paperwrk cdes (PWK01), which will be cnsidered during adjudicatin: (AS) Admissin Summary (DG) Diagnstic Reprt (DS) Discharge Summary (NN) Nurse Ntes (PN) Physical Therapy Ntes (B3) Physician Order (OB) Operative Ntes (EB) Explanatin f Benefits (RT) Reprt f Tests and Analysis Reprt (RR) Radilgy Reprts Please nte fr claims with attachments: The PWK segment and attachments shuld nly be used when supplemental infrmatin is necessary fr the claim t be accurately and cmpletely adjudicated accrding t established plicies. The specific paperwrk cdes in the PWK segment will trigger prcessrs t cnsider the cntents f the supplemental infrmatin btained via fax. Therefre, use f these cdes incrrectly may delay the prcessing f the claim as cmpared t a like claim withut a PWK. PDF created with pdffactry Pr trial versin 10

11 If the dcumentatin is needed fr adjudicatin, Cventry will cntact yu and request a faxed cpy. This cpy must be received within 72 hurs f the request r the claim will be denied. Cventry will cntinue t accept paper claims with attachments. Secndary COB Claims - secndary claims may be submitted electrnically: Send the secndary claim electrnically using the A1 using Lps 2320 and 2330 fr claim header data and Lp 2430 fr claim service line data. All COB secndary claims must cntain infrmatin regarding the ther payer apprved and allwed amunts. Additinally, we need t receive the applicable claim adjustment reasn cdes at the header r line level fr ther payer amunts. Cventry des nt require secndary COB claims t be submitted electrnically. Prviders may cntinue t submit COB claims n paper and attach a cpy f the paper EOB. NOTE: Cventry receives Medicare Part A & B primary claims autmatically thrugh the crss ver prcess fr secndary payment. T eliminate duplicate claim submissins, refer t the EOB/RA frm Medicare (lk fr cde "MA-18" n yur Medicare Remittance Advice) befre submitting secndary claims directly t Cventry. Pharmaceutical Claims - may be submitted electrnically using an 837. These drug claims shuld nt be fr retail pharmacy claims nr can they be in an NCPDP frmat. If yu are submitting a claim fr pharmaceutical services, the HCPCS J cdes are required t identify the drug. Hwever, if the apprpriate J-cde is J3490 r a J9999, we als require the NDC cde using Lp Use a F2 qualifier n the service line level t indicate DOSAGE fr this NDC cde. If yu cannt submit the 2410 lp, then place the NDC and dsage infrmatin in the claim header nte segment (2300 NTE). We d nt read NTE infrmatin at the claim line level. DATA NOT USED Althugh Cventry accepts the fllwing data, it is nt used in claim adjudicatin. Payer Secndary Infrmatin. (Lp 2010BB REF) Currency. Infrmatin in the CUR segment will nt be cnsidered in prcessing. All electrnic transactins will be with trading partners in the United States. Respnsible Party Infrmatin (Lp 2310BC) will nt be cnsidered in prcessing. The infrmatin submitted n apprpriate legal dcumentatin and maintained in internal files will be used. Demnstratin Prject Identifier in Lp 2300 REF. File Infrmatin in Lp 2300 K3 segment. This is nt needed as n usage fr this segment has been defined. Peer Review Organizatin Apprval Number (Lp 2300 REF segment). Infrmatin n internal files will be used. Medicare PPS Assessment Date (Lp 2400 DTP). PDF created with pdffactry Pr trial versin 11

12 Explanatin f Benefits Indicatr (CLM18). Infrmatin frm ur internal files will be used. Treatment Cde Infrmatin (in Lp 2300 HI segment). Hme Health Agency treatment plan infrmatin is nt needed fr prcessing at this time. Credit/Debit Card Accunt Hlder Name (Lp 2010BB) and Credit/Debit Card Maximum Amunt (Lp 2300 AMT segment) Prperty and Casualty Claim Number (REF segments in Lps 2010BA and 2010CA) EDI Acknwledgement and Reject Reprts Fr every claim filed electrnically, the prvider shuld mnitr whether r nt that claim has been rejected by reviewing EDI Acknwledgement and Reject reprts n a regular basis. The fllwing reprts shuld be mnitred regularly: Initial Reject Reprt (Emden reprt Rpt 05 r equivalent vendr reprt) - This is a reprt that shws claims rejected by Emden that were nt frwarded t Mail Handlers Benefit Plan. These claims shuld be crrected and re-submitted electrnically. Initial Accept Reprt (Emden Envy Reprt Rpt 04 r equivalent vendr reprt) - This is a reprt that shws Emden accepted the EDI claim and frwarded it t Cventry fr prcessing. Payer Reject Reprt (Emden Reprt Rpt 11 r equivalent vendr reprt) - This reprt states why the Cventry health plan rejected the claim. These claims shuld be crrected and re-submitted electrnically when pssible. Mnitring yur EDI Reprts Please nte that claims appearing n the Initial Reject Reprt have nt met the initial clearinghuse criteria apprved by Cventry and have nt been sent t Cventry fr adjudicatin. Any claims appearing n this reprt must be crrected and shuld be re-submitted electrnically as sn as pssible t avid timely filing issues. Claims displayed n the Initial Accept Reprt have passed the clearinghuse edits and have been frwarded t Cventry fr additinal payer editing. It is als imprtant t nte that a claim can pass the clearinghuse edits and be displayed n the Initial Accept Reprt, but still be rejected by Cventry. Claims rejected by Cventry will appear n the Payer Reject Reprt. Any claims appearing n this reprt shuld be crrected and re-submitted electrnically as sn as pssible t avid timely filing issues. Timely Filing Cventry must accept a claim within its timely filing limit r it will be denied fr untimely filing. If yu are nt receiving the described clearinghuse and payer reprts n a regular basis, please cntact yur clearinghuse r Emden business services. A prvider can avid timely filing issues thrugh understanding and regular mnitring f EDI Reprts. This prcess will help t ensure all rejected claims are re-filed timely and electrnically. PDF created with pdffactry Pr trial versin 12

13 Cmmn Rejectin Reasns Review the fllwing tips fr assistance with reslving the mst cmmn rejectins received by prviders. The mst cmmn claim reject reasn fr Cventry is member nt fund. Use the Cventry Health Care secure prvider prtal, directprvider.cm, Emden, r an integrated slutin thrugh yur vendr r clearinghuse t verify/validate member s eligibility prir t submitting claims. Patient Date Of Birth Submit a valid date f birth fr the patient. D nt send 00 fr the mnth r date. D nt send dummy dates such as " " D nt send a date f birth greater than the date f service. A claim will be rejected if a valid date f birth des nt match the date f birth n file in the Cventry system. If this is the case, please verify the patient date f birth with the patient r plicyhlder. Member Identificatin Number Submit the 11-digit number as displayed n the patient s ID card. Date Frmat Submit all dates in the fllwing frmat: CCYYMMDD unless therwise specified. Submit valid dates f service. D nt submit future dates f service. Mnetary Amunt Frmat Include the decimal pint in all mnetary amunts unless therwise specified. D nt submit negative dllar amunts. Cding Detail Cnsider the fllwing when verifying service cdes and/r mdifiers that have been rejected: Submit service cdes and mdifiers apprpriate t the age and gender f patient. Submit service cdes and mdifiers apprpriate t the date f service. EDI Assistance Yur Clearinghuse Typically, yur first pint f cntact fr reslving an EDI issue is yur practice s specific clearinghuse. Emden - The Emden custmer service center can track all EDI submissins received by them. Emden als maintains the status message returned n an EDI claim frm the health plan. This infrmatin is readily available fr 45 days after the submissin. Infrmatin n lder submissins is als available but will need frwarded t their research divisin fr fllw-up. Emden Custmer Supprt can be reached at (877) Additinally, Emden has a new webbased applicatin, Visin fr Claim Management, that cmpiles claim infrmatin received and generated during claim filing and prcessing. It in an easy t use applicatin fr tracking EDI claim submissins. Fr mre infrmatin and registratin fr Visin fr Claim Management, g t HealthAmerica Assistance - Health plan staff are available t assist yu with electrnic filing cncerns as they relate t ur submissin requirements r status messages. Please cntact Cventry Health EDI Supprt at Frnt End Operatins r via at EDIclaims@cvty.cm PDF created with pdffactry Pr trial versin 13

14 C. Electrnic Fund Transfer (EFT) Cventry Health Care, Inc. ffers its prviders the ability t receive payments electrnically thrugh an EFT transactin. All prviders wh submit claims t HealthAmerica are eligible t participate in the electrnic funds transfer. Prviders will receive claim payments mre quickly. The payments will be directly depsited int a prvider s bank accunt electrnically. The prvider shuld check with its banking institutin t verify that it will be able t receive Autmated Clearing Huse (ACH) transactins and if there are any assciated fees fr this service. When enrlling in EFT, the prvider als agrees they will n lnger receive a paper remittance advices by mail rather prvider will btain the remittance advises n Cventry s prvider prtal: A depsit transactin will appear n the mnthly bank statement fr each separate transactin. Hw T Enrll - The prvider must cmplete the Electrnic Fund Transfer Authrizatin Frm, indicating New Prvider and return it t: Cventry Health Care, Inc. Atten: PC & I -EST PO Bx Harrisburg, PA The Cventry EFT Authrizatin Frm is available t prviders by cntacting HealthAmerica Prvider Relatins, n the Cventry prvider prtal at r see page 14 f this sectin. The prvider must enclse an riginal vided check r depsit slip fr the depsiting accunt, a letter frm the prvider s bank is als accepted. When prperly executed, the EFT will becme effective apprximately 30 days after receipt by HealthAmerica. Banking Changes The prvider must give a written 30-day ntice t HealthAmerica describing any changes t their EFT Service. Prvider needs t cmplete a new EFT Authrizatin Frm with the revised banking infrmatin indicating Update t existing Prvider Infrmatin. Fr prviders wh were enrlled with EFT prir t September 1, 2009, yu will cntinue t receive paper Remittance Advises with any updates. The fllwing is a list f Cventry Health Care Plans that will be included in yur EFT Authrizatin: Health America Health Assurance, Inc. Suthern Health Services, Inc. Carelink Health Services, Inc. Cventry Health Care f Gergia, Inc. Cventry Health Care f Delaware, Inc. Wellpath Cventry Health Care f Luisiana, Inc. Advantra Freedm Cventry Health Care f Iwa, Inc. Cventry Health Care f Nebraska, Inc. Altius Health Plans, Inc. Cventry Health Care f Kansas, Inc. Grup Health Plan Persnal Care Vista Health Plans (Eff 4/1/2010) Cventry Natinal Health Plans Mail Handlers Benefit Plan PDF created with pdffactry Pr trial versin 14

15 Rural Carriers Health Plan Assciatin Benefit Plan American Freign Services Benefit Plan Carenet Omnicare HealthCareUSA CHC Cares Carelink Medicaid Diamnd Health Plan Cventry Cnsumer Chice If yu have any questins, please cntact yur Prvider Relatins Representative r yu may yur questin t CventryEFTrequest@cvty.cm. PDF created with pdffactry Pr trial versin 15

16 ELECTRONIC FUND TRANSFER AUTHORIZATION FORM Please return t the address belw: Cventry Health Care, Inc. Attn: PC&I-EST PO Bx Harrisburg, PA Request Type: New Prvider Update t Existing Prvider EFT Infrmatin The undersigned health care prvider ( Prvider ) hereby: (1) authrizes Cventry Health Care, Inc. and its affiliates ( Cventry ) t make payments fr Prvider s services by Electrnic Fund Transfer (EFT), (2) certifies that Prvider has selected the fllwing depsitry institutin, and (3) directs that all such EFT payments be made as prvided belw. (4) Prvider als acknwledges and agrees that by cmpleting this frm, Prvider will n lnger receive paper remittance advices by mail rather Prvider will btain the remittance advices n Cventry s prvider prtal Prvider Name: Prvider s Tax ID: Prvider s Grup NPI #: Prvider Cntact Name: Phne Number: Cntact Fax #: Depsitry Institutin: Address: Bank Ruting Number: Accunt Number: Accunt Name: Accunt Type: Checking Savings (must chse ne) This Authrizatin will remain in effect until Cventry receives ntificatin f terminatin frm Prvider. Prvider will give thirty (30) days advance ntice in writing t Cventry Health Care, Inc. f terminatin r any changes in its depsitry institutin r ther payment instructins. When prperly executed, this Authrizatin will becme effective thirty (30) days after its receipt by Cventry Health Care, Inc. Cventry reserves the right t recall an incrrect EFT transactin within 5 days. Befre submitting this Authrizatin frm, Prvider shuld check with its banking institutin t verify that it will be able t receive Autmated Clearing Huse (ACH) transactins and if there are any assciated fees fr this service. T ensure the crrect banking infrmatin is entered int ur system, please enclse a vided check, depsit slip, r letter frm yur banking institutin indicating the apprpriate accunt and financial institutin ruting numbers. The undersigned persn represents and warrants that he/she is authrized t execute this frm n behalf f the Prvider. Authrized Signature: Date: Print Name: Title: PDF created with pdffactry Pr trial versin 16

17 D. Clean Claims Pennsylvania Act 68 specifies that all clean claims submitted by a prvider fr fully insured business must be paid within 45 days f receipt r an interest penalty f 10% annually must be paid t the prvider f service regardless f participating status (par r nn-par). A clean claim has been defined as a claim that has n defect r imprpriety, including lack f required substantiating dcumentatin r particular circumstances requiring special treatment that prevents timely payment frm being made. This means that any claim requiring infrmatin that HealthAmerica must btain frm an external surce fr crrect prcessing makes the claim nn-clean. Recent legislatin was passed in reference t the prtectin f patient rights. Part f that legislatin als addressed the prmpt payment f Clean Claims t health care prviders by payrs. T that end, belw is an utline, which tgether, cnstitute HealthAmerica s definitin f a Clean Claim. 1. A clean claim includes accurate and cmplete infrmatin in all applicable fields n the CMS 1500 frm. (Please see the attached CMS 1500 frm and accmpanying legend that utlines each bx requirement in the sectin). 2. A clean claim has all dcumentatin attached, which substantiates and supprts any special treatment and/r cmplex prcedure(s), including perative reprts r use f an assistant surgen. 3. A clean claim includes current CPT cdes r Level II HCPC cdes (with apprpriate mdifiers) that accurately and best describe the services prvided. 4. A clean claim has all apprpriate ICD-9 diagnsis cde(s), carried t the highest level f specificity. 5. A clean claim has alphanumeric Level II HCPC J cdes if billing fr cvered injectables. PDF created with pdffactry Pr trial versin 17

18 Prviders are required t submit all claims in a timely manner in accrdance with their cntract. PA - It is HealthAmerica s intent t pay clean claims fr authrized cvered services within 45 days f receipt, as is required by Pennsylvania State law. Clean claims nt paid within this time perid are subject t interest charges, as is als in accrdance with Pennsylvania State law. Hwever, please be aware that there are certain valid cnditins, such as crdinatin f benefits r subrgatin, which legitimately may delay the payment f a claim which therwise meets the clean claim requirements. With yur help in submitting the abve mentined claim data elements, we are better able t ensure the prmpt and accurate payment f yur claims. Fr further infrmatin regarding claims submissin, please cntact ur Custmer Service ffice at r Advantra at The Natinal Unifrm Claim Cmmittee apprved the revised versin f the 1500 Health Insurance Claim Frm (versin 08/05) that accmmdates the reprting f the Natinal Prvider Identifier (NPI). The recmmended time line fr transitining t the revised frm is February 1, Cventry is able t accept this new claim frm and we strngly encurage all practices t switch t this frm as sn as pssible. Hwever,we will cntinue t accept the current versin and currently have n definitive cut ff date fr nt accepting the ld 1500 claim frm. Highlight f Changes: 1. Ability t include NPI and prprietary PIN fr all physician/prvider bxes referring physician (bx 17), rendering physician (bx 31), facility where services were rendered (bx 32) and billing (bx 33). 2. Six claim detail lines have been divided hrizntally t accmmdate submissin f NPI and prprietary identifiers. Additinally, the divided lines will als supprt the submissin f supplemental infrmatin t supprt billed services (such as NDC fr drug cdes r anesthesia time). 3. Bx 24C has been renamed frm type f service, which is n lnger used, t EMG (ld bx 24I) Submitting NPI and Cventry Prprietary Numbers (PIN/UPIN): Cventry is prepared t accept NPI prvider id numbers n inbund claims. We have made all internal changes necessary t accept, transmit and stre NPIs. Prviders may cntinue t use just their legacy identifiers (UPIN and Cventry s prprietary number) in additin t their NPI. Please refer t the fllwing guideline fr submitting NPI and legacy prvider ID numbers n the new CMS 1500 Claim Frm: Rendering Prvider (bx 31) prprietary ID number shuld be submitted in Bx 24J n the shaded part f the first claim line. The accmpanying qualifier in bx 24I is nt used, s any value may be included. (nte: Cventry will nly read ne rendering prvider ID per claim - nt different prvider ids n separate claim lines) Rendering prvider (bx 31) NPI number shuld be submitted in bx 24J n the lwer, nnshaded sectin f the first claim line. (nte: Cventry will nly read ne rendering prvider ID per claim -- nt different prvider ids n separate claim lines) The NPI # fr the Facility where services are rendered (bx 32) shuld be submitted in bx 32A n the new frm. The Billing prvider (bx 33) NPI shuld be submitted in bx 33A. The Billing Prvider (bx 33) prprietary number (if applicable) shuld be submitted in Bx 33b. PDF created with pdffactry Pr trial versin 18

19 PDF created with pdffactry Pr trial versin 19

20 E. Pended Claims HealthAmerica r Advantra may pend the payment f a claim fr several reasns. The majrity f pended claims result frm investigatin f a claim s authrizatin, r the ptential liability f anther insurance cmpany fr payment f the claims (Crdinatin f Benefits r COB). A claim that has been pended fr investigatin will be addressed as either a payment r a denial n a future remittance advice. Yu can help t reduce the number f pended claims by assuring that nly services, which have been specifically authrized fr payment by HealthAmerica are perfrmed. If yu discver at the time f service that additinal services are necessary, please cntact the Medical Management Department (Utilizatin), at F. Denied Claims HealthAmerica r Advantra may deny payment f a claim fr several reasns. It is imprtant t remember that if yu disagree with the reasn fr denial f a claim, yu shuld submit, within 60 days, a request fr recnsideratin t the Custmer Service Organizatin. Please see Claims Inquiry n the next page fr further instructin. Resubmissin f a denied claim will result in a duplicate denial. Fr sme denial cdes, yu are permitted t bill the member. Fr thers, yu are prhibited frm billing the member by virtue f yur cntractual participatin with HealthAmerica r Advantra. Editing Sftware: The Editing Sftware is a claim-prcessing tl which is used t expedite and ensure the accuracy f claims payment. This sftware is used t audit crrect cding cmbinatins based n the fllwing criteria: CPT-4, HCPCS and ICD-9-CM cding definitins AMA and CMS guidelines and industry standards Medical plicy and literature research Input frm academic affiliatins The Editing Sftware als affrds ur rganizatin the ability t custmize the prduct t ensure cnsistency with Cventry Health Care, Inc. s Medical Management plicies and prvider agreements. It is an integral part f ur claims payment plicy. Cmmn Terms seen with sftware auditing: Incidental - means the prcedure is perfrmed at the same time as a mre cmprehensive prcedure and is therefre nt reimbursable in the primary service e.g Nninvasive ear r pulse ximetry fr xygen saturatin; single determinatin - is incidental t a mre cmprehensive prcedure Mutually exclusive - means tw r mre prcedure which are usually nt perfrmed during the same encunter r n the same date f service e.g.- TAH and vaginal hysterectmy are nt generally perfrmed during the same encunter Duplicate edit - Based n prcedural definitin, there are 4 types f duplicate edits: 1. Bilateral - prcedure can be perfrmed nly nce n a single date f service 2. Unilateral/bilateral - prcedure can be perfrmed nly nce n a single date f service. 3. Unilateral billed twice when there is a bilateral cde with the same definitin 4. Maximum clinical pssibilities; chlecystectmy (nly 1 allwed) r applicatin f shrt arm splint (nly 2 allwed) PDF created with pdffactry Pr trial versin 20

21 Rebundle - means tw r mre cdes are being billed when there is a mre cmprehensive cde fr the services e.g (glucse) and (sdium) are rebundled int (basic metablic panel) when dne n the same date f service Multiple Surgery Reductins - The Editing Sftware will identify the primary prcedure as the ne with the highest RVU(relative value unit) and then add, if nt n the claim, the -51 mdifier t the rest f the surgical prcedures billed. Multiple Surgical Reductins are determined by the RVU that Medicare assigns each prcedure. Invalid cde cmbinatin - means an imprper mdifier was used with a CPT cde e.g.- using a 25 mdifier with a surgical cde e.g.- using a 51 mdifier n an exempt CPT cde Assistant Surgen Denial - this may appear if an assistant surgen is generally nt indicated fr the prcedure billed. If unusual prcedure r circumstance, please submit ntes with the claim. American Cllege f Surgens(ACS) is the primary surce fr determining assistant surgen designatins. McKessn uses ACS designatins based n the fact that ACS determines these designatins using clinical guidelines versus statistical measures. Included in the Surgical Glbal package - use apprpriate mdifiers if prcedure is utside the surgical glbal package. Submits ntes with appeal. Cnsider using CPT cde fr pst-p visit. Recnsideratin f an Editing Sftware Denial: If there is a disagreement with the Editing Sftware denial, yur practice can call the Custmer Service Organizatin at t initiate a recnsideratin, r mail the request t the claim re-submissin address. Please be prepared t submit ffice ntes, perative reprts r any additinal supprting dcumentatin. This prcess invlves a review f yur submitted infrmatin and the sftware auditing lgic. The Medical Claim Review nurse will review the ntes submitted and make a determinatin f whether r nt t verride the cding denial. Yu will be ntified via yur Remittance Advice as t the utcme f yur request. If the edit is upheld by the Medical Claims Review Nurse Department, the prvider can request a recnsideratin f the edit t the Medical Directr by sending the claim and a letter frm the dctr stating why they disagree with the edit. They shuld send the letter alng with ntes and dcumentatin t: HealthAmerica, P.O. Bx 7089, Lndn KY, , fr Cmmercial claims r HealthAmerica Advantra, P.O. Bx 7087, Lndn, Ky , fr Advantra claims. Attn: Medical Directr, Editing Sftware Recnsideratin. Recnsideratin s are mnitred n a HealthPlan level and ur Editing Sftware is custmized t pay based n HealthAmerica s requests and recnsideratin verrides. Helpful Resurces: ICD-9 Manual CPT(current year) manual HCPCS (current year) manual AMA Crrective Cding Initiative Mdifiers Made Easy CPT Assistant mnthly newsletter Federal Register- cpies are btainable thrugh the AMA St. Anthny s Medicare Crrect Cding Payment Manual PDF created with pdffactry Pr trial versin 21

22 Mdifiers Our Editing Sftware is set up t recgnize crrect cding which applies t the apprpriate use f mdifiers. It is imprtant the apprpriate mdifiers be used n the riginal submissin f the claim. Althugh sme payers d nt require the use f mdifiers, HealthAmerica des. Fr Example: If a prcedure is a staged prcedure, the apprpriate mdifier shuld be appended t the prcedure cde n the riginal submissin. If a prcedure is an unrelated prcedure r service by the same physician during the pstperative perid, the apprpriate mdifier shuld be appended t the prcedure cde n the riginal submissin. If the prcedure is a distinct prcedural service, the apprpriate mdifier shuld be appended t the prcedure cde n riginal submissin. If the prcedure is a significant, separately, identifiable evaluatin and management service by the same physician n the same day f the prcedure r ther service, the apprpriate mdifier shuld be appended t the prcedure cde n the riginal submissin. Medical recrds must supprt the use f the mdifier as the health plan reserves the right t ask fr supprting dcumentatin n the back end. If a claim is resubmitted and a mdifier is applied with the resubmissin, the Medical Review staff and Medical Directrs can and will ask fr medical dcumentatin t supprt the use f the mdifier. If the medical recrds/ntes d nt supprt r justify the use f the mdifier the denial will r can be upheld. Please Nte: Health America and Advantra require that all claims issues must be fully reslved within 18 mnths fr the State f Pennsylvania, frm the date f riginal payment r denial, and will nt cnsider claims lder than that time frame. Hld Harmless Because yur practice has agreed t prvide services in accrdance with HealthAmerica r Advantra plicies and prcedures, there may be times when a claim is denied payment. The hld harmless prvisin in yur cntract is mandated by the Cmmnwealth f Pennsylvania and prhibits yu frm billing the member in these circumstances. It is extremely imprtant that yu d nt bill ur members as a result f the denial f payment. Yu may request an appeal f the denial, but yu cannt bill the member. G. Claims Inquiry If yu have questins regarding a claim status, there are several avenues yu can use. Yu may check claim(s) status via Directprvider.cm (please see sectin X fr mre infrmatin); r call the autmated respnse system (My Vice Services) by calling Use Optin 2, then #2. Fr security purpses yu must be prepared t enter yur practice Tax Identificatin Number (TIN). At any time yu may access an assciate by using the apprpriate prmpt. PDF created with pdffactry Pr trial versin 22

23 My Vice Services My Vice Services uses state-f-the-art technlgy t give ur prviders and members direct access t infrmatin they need by phne. Yu n lnger need t press menu ptins and get stuck in vic limb. Yu are able t use yur wn vice t interact with ur telephne system and btain sme f the mst cmmnly requested infrmatin quickly and privately. With My Vice Services, infrmatin that used t require speaking with a Member Services representative is available 24 hurs a day, 7 days a week. Prviders are able t access the fllwing infrmatin thrugh My Vice Services: Claim Status summary and details regarding paid, denied, and pending claims. Authrizatin status infrmatin regarding authrizatins issued by HealthAmerica. (Infrmatin will be faxed, nt spken.) Eligibility infrmatin regarding member cverage status and PCP infrmatin. Benefit Infrmatin such as cpay and deductible infrmatin fr the mst cmmn benefits Members, t, are able t access claim, authrizatin, and benefit infrmatin as well as request ID cards via My Vice Services. My Vice Services is easy t use. Yu ll simply call the same tll-free number yu use t access ur Member Services Department and yu will be guided thrugh the available ptins. If yu call during nrmal business hurs, Mnday t Friday frm 7 a.m. 6 p.m. and Saturday frm 9 a.m. 1 p.m., yu can easily transfer t Member Services if yu need additinal assistance. Yu will als be tld hw t access help if yu have difficulty with any My Vice Services feature. Yu can als use yur phne tuch-tne keypad, rather than vice interactin, if yu prefer. Attached are sme helpful hints t using My Vice Services as yu becme familiar with My Vice Service, as well as an utline f the Menu Optins. PDF created with pdffactry Pr trial versin 23

24 My Vice Services Features and Functins f Menu Optins Menu Selectin Optins Result Required Entry Infrmatin Prvided Main Menu Member Must enter Member ID and DOB t prceed t Menu Selectins Prvider Must enter Tax ID t prceed t Menu Selectins Pharmacist Claim Status Remain in IVR, 10 claim maximum Benefit Infrmatin Authrizatin Infrmatin Remain in IVR Date f Service Select frm list f available ptins Summary Detail Prvider Name Mbr Respnsibility Dates f Service Mbr Cpay Billed Amunt Amt applied t Deductible Claim Status Rejected Amunt Paid Amunt Reasn fr Denial (if denied) Paid Date Check Number Claim Number Mst ppular benefit categries ffered fr selectin (i.e. physician ffice visit) C-pay Deductible Remain in IVR Date f Service Referral Number Referred By Referred T Frm and T Dates Type f Referral Ttal Days Remain in IVR Address cnfirmatin Individual r entire family ptin ID Card Request Nne f these G t Plan Specific Menu and Prmpts Claim Status Remain in IVR Member ID Date f Service Eligibility Infrmatin Same as Member Claim Status Remain in IVR Member ID Member effective date Member terminatin date PCP ffice visit cpay PCP name Member s grup name Member s grup number Effective date with PCP PCP telephne number PCP fax number Member Out f Netwrk deductible met Member Out f Netwrk deductible remaining Rider type Rider effective date Benefit Remain in IVR Member ID Same as Member Benefit Infrmatin Infrmatin Authrizatin Remain in IVR Member ID Same as Member Authrizatin Infrmatin Infrmatin Date f Service Nne f these G t Plan Specific Menu and Prmpts G t established pharmacy call wrkflw (Caremark, etc) PDF created with pdffactry Pr trial versin 24

25 Helpful Hints As Yu Becme Familiar With My Vice Services Shrt Cuts - Yu d nt have t wait fr the IVR t give yu the ptins. Once yu learn the menu prmpts yu can always shrt cut the system and immediately state the menu ptins yu want. Fr example, If yu knw yu are calling fr claim status infrmatin, using the guide n the previus page, yu can immediately state: Prvider, Claim Status and then fllw the prmpts frm there t enter member data. Ask fr Help if yu need it Say Repeat if yu missed the prmpt T skip smething, say next T return t the beginning, say Main Menu T end the call, say Exit Have any necessary accunt infrmatin handy When entering the 11 digit members ID number, please be sure t include the members suffix as part f the number, the 9 digits withut the suffix will nt be recgnized. When entering infrmatin such as ID numbers r dates f service, yu will be given 3 attempts t enter valid infrmatin in the crrect frmat. After three failed attempts, yu will be transferred t an agent queue. When callers are transferred by the system (n errrs, etc.) the caller will hear a message explaining why they are being transferred. Yu can easily btain persnal assistance by saying agent, r pressing 0 n yur keypad. Please Nte: Health America and Advantra require that all claims issues must be fully reslved within 18 mnths f the date f riginal payment fr the State f Pennsylvania and will nt cnsider claims lder than that time frame. If yu wish t appeal the payment r denial f a claim, please call the Custmer Service Organizatin wh will infrm yu f the appeal prcess, r yu can submit yur appeal in writing t : HealthAmerica 3721 TecPrt Drive PO Bx Harrisburg, PA Attn: Claims Appeals PDF created with pdffactry Pr trial versin 25