2015 UnitedHealthcare hawk-i Iowa

Transcription

1 Community Plan A proud partner in Iowa s hawk-i program 2015 UnitedHealthcare hawk-i Iowa Physician, Health Care Professional, Facility and Ancillary Provider Manual Doc#: PCA16359_ UHCCommunityPlan.com

2 Table of Contents Welcome to UnitedHealthcare Community Plan... 1 Key Contact Information... 3 Identification Cards/Eligibility Verification... 4 Administrative Functions... 5 Claims Billing Procedures Reimbursement Member Cost Share Responsibility Provider e-services Emergent and Urgent Services Credentialing Covered Benefits Coverage of Abortions Member Rights and Responsibilities Care After Hours Health Services Prior Authorization Guidelines Referral Procedure Medical Record Charting Standards Member Access and Availability Utilization Care Management Programs Timing of Utilization Management Decisions Medical Hospital Utilization Management Care Management Disease Care Management Preventive Health and Clinical Practice Guidelines Practitioner Education Sanction Policy Summary Denied Payment Authorization Decisions Quality Improvement Member Complaint and Appeal Process Glossary of Terms Forms Appendix... 68

3 Welcome to UnitedHealthcare Community Plan UnitedHealthcare Community Plan, a division of UnitedHealth Group, provides services to the Healthy and Well Kids of Iowa hawk-i program. This Provider Manual contains information related to this specific program. If you are also a network provider for UnitedHealthcare commercial and Medicare products, you can access that Administrative Guide at UnitedHealthcareOnline.com > Policies, Protocols and Guides > Administrative Guides Healthy and Well Kids in Iowa hawk-i offers free or low-cost health insurance for children under 19 years old. UnitedHealthcare Community Plan partners with the Iowa Department of Human Services to participate in the hawk-i program across the state. This Manual is designed as a comprehensive reference source for the information you and your staff need to conduct interactions and transactions with us in the quickest and most efficient manner possible. Much of this material, as well as periodic updates and some additional electronic tools, is available on our website at UHCCommunityPlan.com > For Health Care Professionals > Select your state > Iowa Care Our goal is to help ensure that our members have convenient access to high-quality care provided according to the most current and efficacious treatment protocols available. We are committed to working with and supporting you and your staff to achieve the best possible health outcomes for our members. If you have any questions about the information or material in this Manual or about any of our policies or procedures, please call Provider Services at This toll-free number is conveniently located at the footer of each page in this Manual. We greatly appreciate your participation in our program and the care you provide to our members. Important Information Regarding the Use of This Guide In the event of a conflict or inconsistency between your state Regulatory requirements and this Manual, the provisions of the regulatory requirements will control, except with regard to benefit contracts outside the scope of that Regulatory requirement. Additionally, in the event of a conflict or inconsistency between your contract and this Manual, the provisions of your contract will control except for State of Iowa or Centers for Medicare and Medicaid Services (CMS) required language for provider contracts. Communications to Providers From time to time, there may be important information about policies and protocols that must be communicated to all participating providers. These communications may be done through Network Bulletins or through the Practice Matters Provider Newsletter. If the information communicated through these methods is a change to any protocol set forth in this Manual, you will see the updated information in this Manual upon the next Provider Manual revision notification. 1

4 Network Bulletin The Network Bulletin is a monthly publication available on UnitedHealthcareOnline.com > Tools & Resources > News & Network Bulletin > Network Bulletin. The Bulletin contains information and updates as well as administrative changes for all providers, not just Medicare, Medicaid and CHIP. Articles located in this Bulletin that are specific to hawk-i providers will also be communicated through the Provider Practice Matters. Practice Matters Practice Matters is the Provider Newsletter published quarterly specific to the hawk-i product within UnitedHealthcare Community Plan. This newsletter includes any policy changes and communicates any clinical topics or reminders. Articles regarding policy or administrative updates will be included in this publication but may also be found in the Network Bulletin as specified above. The Practice Matters newsletters are posted on the UHCCommunityPlan.com provider website. They can be found at UHCCommunityPlan.com > For Health Care Professionals > Select your state > Iowa > Newsletters. 2

5 Key Contact Information UnitedHealthcare hawk-i Provider Services (TDD 711) UnitedHealthcare hawk-i Member Services Inpatient Care Authorization Effective April 1, 2015, authorizations can be submitted on UnitedHealthcareOnline.com Pharmacy Program (Pharmacist) Fax: Prescription Prior Authorization (Physician) Effective April 1, 2015, authorizations can be submitted on UnitedHealthcareOnline.com. Epic Hearing Fax: OptumHealth Behavioral Services Routine vision services are managed by Superior Vision (previously known as Block Vision). Verification of eligibility and authorization for routine vision services are available online at or through Block Vision s Voice Response Unit at OptumHealth NurseLine State of Iowa hawk-i Customer Service (Member) Delta Dental Delta Dental contracts directly with the State of Iowa hawk-i program to cover routine dental services

6 UHCCommunityPlan.com Identification Cards - Eligibility Verification hawk-i due to the following: Steps to Verify Eligibility hawk-i Sample Plan ID Card hawk-i hawk-i Printed: Printed: 04/23/12 04/23/12 Health Health PlanPlan (80840) (80840) Member Member ID: ID: H H Member: Member: SUBSCRIBER SUBSCRIBER M BROWN M BROWN Group Group Number: Number: IAHAWKI IAHAWKI Unauthorized Unauthorized use use of non-plan of non-plan providers providers maymay result result in benefits in benefits denial. denial. TDDTDD TDDTDD TDDTDD Payer Payer ID ID ForFor Members: Members: NurseLine: NurseLine: Mental Mental Health: Health: ForFor Providers: Providers: P.O.P.O. BoxBox 5220, 5220, Kingston, Kingston, NY NY Medical Medical Claim Claim Address: Address: Rx Bin: Rx Bin: hawki Rx Grp: Rx Grp:hawki Rx PCN: Rx PCN: DHS14 DHS14 hawk-i hawk-i Administered Administered by UnitedHealthcare by UnitedHealthcare PlanPlan of the of River the River Valley, Valley, Inc. Inc. Pharmacy Pharmacy Claims: Claims: OptumRx, OptumRx, PO PO BoxBox 29044, 29044, HotHot Springs, Springs, AR AR ForFor Pharmacist: Pharmacist: hawk-i

7 Administrative Functions Regulatory Compliance Introduction As a business segment of UnitedHealth Group, UnitedHealthcare implements and is governed by the UnitedHealth Group Ethics and Integrity Program. UnitedHealthcare is dedicated to conducting business honestly and ethically with members, providers, suppliers and governmental officials and agencies. The need to make sound, ethical decisions as we interact with physicians, other health care providers, regulators and others has never been greater. It s not only the right thing to do, it is necessary for our continued success and that of our business associates. The Ethics and Integrity Program promotes compliance with applicable legal requirements, fosters ethical conduct within UnitedHealthcare and provides guidance to its employees and contractors. Additionally, the program focuses on increasing the likelihood of preventing, detecting, and correcting violations of law or UnitedHealthcare policy. The implementation of such a program, however, cannot guarantee the total elimination of improper employee or agent conduct. If misconduct occurs, UnitedHealthcare will investigate the matter, take disciplinary action, if necessary, and implement corrective measures to prevent future violations. Preventing, detecting and correcting misconduct safeguards UnitedHealthcare s reputation, assets and the reputation of its employees. Ethics and Integrity Program The Ethics and Integrity Program incorporates recommended compliance program guidance from the Department of Health and Human Services Office of the Inspector General (OIG), the Centers for Medicare and Medicaid Services (CMS), and the Federal Sentencing Guidelines for Organizations (revised and amended, 2010). The purpose of the program is to help ensure operational accountability and to provide standards of conduct for compliance with the obligations that govern our federal and state programs. Program activities support the following seven key elements that facilitate prevention, early detection and remediation of violations of law and UnitedHealthcare policies. 1. Written Standards, Policies and Procedures 2. High Level Oversight Governance 3. Effective Training and Education 4. Effective Lines of Communication/Reporting Mechanisms 5. Enforcement and Disciplinary Guidelines 6. Auditing and Monitoring 7. Response to Identified Issues Examples of applicable regulations and requirements include, but are not limited, to Medicaid: Title 42 CFR Part 438 Managed Care and executed state contracts. Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and state health information privacy laws; Federal and State False Claims Acts. UnitedHealthcare has compliance program staff, led by the Chief Medicaid Compliance Officer, which is responsible for oversight and management of the Ethics and Integrity Program. A compliance committee, consisting of senior managers from each of our key organizational functions, provides direction and oversight for the program. UnitedHealthcare also has compliance officers or compliance contacts located in each health plan or business unit who report to the senior management of their assigned entity. 5

8 Reporting and Auditing Any unethical, unlawful or otherwise inappropriate activity by a UnitedHealthcare employee that comes to the attention of a provider should be reported to a UnitedHealthcare senior manager in the health plan or directly to the Ethics and Compliance Help Center at An important aspect of the Ethics and Integrity Program is assessing high-risk areas of UnitedHealthcare operations and implementing periodic reviews and audits to help ensure compliance with law, regulations and contracts. When informed of potentially irregular, inappropriate or fraudulent practices within the plan or by our providers, UnitedHealthcare will conduct an appropriate investigation. Providers are expected to cooperate with the company and government authorities in any inquiry, both by providing access to pertinent records (as required by the Participating Provider Contract) and access to provider office staff. If activity in violation of law or regulation is established, appropriate governmental authorities will be advised. If a provider becomes the subject of a governmental inquiry or investigation, or a government agency requests or subpoenas documents relating to the provider s operations (other than a routine request for documentation from a regulatory agency), the provider must advise UnitedHealthcare of the details and of the factual situation that led to the inquiry. Fraud, Waste and Abuse UnitedHealthcare s Anti-fraud, Waste and Abuse Program focuses on proactive prevention, detection, and investigation of potentially fraudulent and abusive acts committed by providers and plan members. A toll-free Fraud, Waste and Abuse Hotline ( ) has been set up to facilitate the reporting process of any questionable incidents involving plan members or providers. Through the program, UnitedHealthcare s mission is to prevent paying fraudulent, wasteful and abusive health care claims, as well as identify, investigate and recover money it has paid for fraudulent, wasteful or abusive claims through evolving policies and initiatives to detect, prevent and combat fraud, waste and abuse. UnitedHealthcare will also appropriately refer suspected cases to law enforcement, regulatory, and administrative agencies pursuant to state and federal law. UnitedHealthcare seeks to protect the ethical and fiscal integrity of the company and its employees, members, providers, government programs, and the public, as well as safeguard the health and well-being of its members. UnitedHealthcare is committed to compliance with its Anti-fraud, Waste and Abuse Program and all applicable program. federal and state regulatory requirements governing the UnitedHealthcare recognizes that state and federal health plans are particularly vulnerable to fraud, waste and abuse, and it strives to tailor its efforts to the unique needs of its members and Medicaid, Medicare and other government partners. All suspected instances of fraud, waste and abuse in any way and in any form is thoroughly investigated. In appropriate cases, the matter is reported to law enforcement and/or regulatory authorities, in accordance with federal and state requirements. UnitedHealthcare cooperates with law enforcement and regulatory agencies in the investigation or prevention of fraud, waste and abuse. The Deficit Reduction Act of 2005 (DRA) contains many provisions reforming Medicare and Medicaid that are aimed at reducing fraud within the health care programs funded by the federal government. Under Section 6032 of the DRA, every entity that receives at least $5 million in Medicaid payments annually must establish written policies for all employees of the entity, and for all employees of any contractor or agent of the entity, providing detailed information about false claims, false statements and whistleblower protections under applicable federal and state fraud and abuse laws. 6

9 As a contracted provider with UnitedHealthcare, you and your staff are subject to this provision. The UnitedHealth Group policy, titled Integrity of Claims, Reports and Representations to Government Entities can be found at UHCCommunityPlan.com. This policy details our commitment to compliance with the federal and state false claims acts, provides a detailed description of these acts and of the mechanisms in our organization to detect and prevent fraud, waste and abuse, as well as the rights of employees to be protected as whistleblowers. HIPAA and Compliance/ Provider Responsibilities Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is aimed at improving the efficiency and effectiveness of the health care system in the United States. While the portability and continuity of insurance coverage for workers and greater ability to fight health care fraud and abuse were the core goals of the act, the Administrative Simplification provisions of HIPAA have had the greatest impact on the operations of the health care industry. UnitedHealthcare is a covered entity under the regulations as are all health care providers who conduct business electronically. 1. Transactions and Code Sets These provisions were originally added because of the need for national standardization of formats and codes for electronic health care claims to facilitate electronic data interchange (EDI). From the many hundreds of formats in use prior to the regulation, nine standard formats were adopted in the final Transactions and Codesets Rule. All providers who conduct business electronically are required to do so utilizing the standard formats adopted under HIPAA or to utilize a clearinghouse to translate proprietary formats into the standard formats for submission to UnitedHealthcare. 2. Unique Identifiers HIPAA also required the development of unique identifiers for health care providers for use in standard transactions. Providers The National Provider Identifier (NPI) is the standard unique identifier for health care providers. The NPI is a 10-digit number with no embedded intelligence that covered entities must accept and use in standard transactions. While the HIPAA regulation only requires that the NPI be used in electronic transactions, many state agencies require the identifier on fee-for-service claims and on encounter submissions. For this reason, UnitedHealthcare requires the NPI on paper transactions. The NPI number is issued by the National Plan and Provider Enumeration System (NPPES) and should be shared by the provider with all impacted trading partners, such as providers to whom you refer patients, billing companies and health plans. 3. Privacy of Individually Identifiable Health Information The privacy regulations help ensure a national floor of privacy protections for patients by limiting the ways that health plans, pharmacies, hospitals and other covered entities can use patients personal medical information. The regulations protect medical records and other individually identifiable health information, whether it is on paper, in computers or communicated orally. 7

10 The major purposes of the regulation are to protect and enhance the rights of consumers by providing them access to their health information and controlling the inappropriate use of that information. In addition, the regulation is designed to improve the efficiency and effectiveness of health care delivery by creating a national framework for health privacy protection that builds on efforts by states, health systems, and individual organizations and individuals. 4. Security The Security Regulations required that covered entities meet basic security objectives. 1. Ensure the confidentiality, integrity and availability of all electronic PHI the covered entity creates, receives, maintains and transmits; 2. Protect against any reasonably anticipated threats or hazards to the security or integrity of such information; 3. Protect against any reasonably anticipated uses or disclosures of such information that are not permitted or required under the Privacy Regulations; and 4. Ensure compliance with the Security Regulations by the covered entity s workforce. UnitedHealthcare expects all network providers to comply with the HIPAA regulations that apply to their practice or facility within the established deadlines. Additional information on the HIPAA regulations can be obtained from the website: Disclosure of Criminal Conviction, Ownership, and Control Interest Prior to payment for any services rendered to UnitedHealthcare members, the provider must have completed and filed with the health plan disclosure information in accordance with requirements in 42 CFR, Part 455, Subpart B. This disclosure of criminal convictions related to the Medicare and Medicaid programs is required by CMS. These requirements hold that individual physicians and other health care professionals must disclose criminal convictions, while facilities and businesses must additionally disclose ownership and control interest. Medical Review Hours The health plan staff is available for medical review Monday through Friday, 8 a.m. to 5 p.m. Medical review is available during standard business hours. Emergency medical services do not require prior authorization. ces are closed on the following holidays: New Year s Day, Martin Luther King, Jr. Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Day after Thanksgiving Day and Christmas Day. Refer to the website for additional holiday observances. Change Notification Any change in your provider information should be reported as soon as possible. Some examples of these changes are practice location, Tax Identification Number or practice status regarding acceptance of new patients. Please call the UHG VETSS line at or Provider Service at to communicate any changes. If terminating your participation, you must submit a termination notification to us in the time frames stated in your provider contract. All notices must be in writing and delivered personally or sent by certified mail with postage prepaid. If mailed, such notice shall be deemed to be delivered when deposited in the United States mail, at the UnitedHealthcare respective address as it appears on the signature sheet of your provider contract. 8

11 If services covered by the contract agreement are added or discontinued, the provider is responsible for notifying the health plan prior to such discontinuation or addition. The health plan will review the changes requested to help ensure adequacy of member access for service. If the need for additional service exists, the provider must comply with health plan credentialing requirements for that new service. A current provider contract will not automatically include a new location. Each request will be evaluated on an individual basis. Locum Tenens In instances when a network physician has a locum tenens covering for a short period of time (less than 60 days), it will be the network provider s responsibility to help ensure appropriate licensure, malpractice insurance and other pertinent information is validated prior to allowing the locum tenens to treat patients. Claims should be submitted under the network physician s name and NPI. Allied Health Professional Billing If your office employs an Allied Health Professional (e.g., Nurse Practitioner, Physician Assistant) who is providing services to members, the claim must be submitted to the health plan with the NP/PA s assigned provider identification number. These claims should not be filed under the supervising physician s number. Records and Patient Information for Claims and Medical Management Medical records and patient information must be supplied at the request of the health plan or appropriate regulatory agencies as required for claims payment and medical management. The provider is not allowed to charge the health plan or the member for copies of medical records provided for claims payment or medical management. The provider may charge the member for records provided at the member s request. Providers are not allowed to charge the health plan or the member for records provided when a member moves from one primary care provider to another. Pro-Children Act The Plan must comply with Public Law , Part C Environmental Tobacco Smoke, also known as the Pro-Children Act of This act requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted by an entity and used routinely or regularly for the provision of health, day care, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through State or local governments. Federal programs include grants, cooperative agreements, loans or loan guarantees, and contracts. The law also applies to children s services that are provided in indoor facilities that are constructed, operated or maintained with such federal funds. The law does not apply to children s services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities (other than clinics) where WIC coupons are redeemed. The Plan further agrees that the above language will be included in any subawards that contain provisions for children s services and that are subgrantees shall certify compliance accordingly. Failure to comply with the provisions of this law may result in the imposition of a civil monetary penalty of up to $1,000 per day. 9

12 Claims Billing Procedures Electronic Data Interchange (EDI EDI is our preferred choice for conducting business transactions with contracting/participating physicians and health care industry partners. EDI tools We offer an array of EDI tools designed to help you save time and money by automating several of your daily office administrative and reimbursement functions. Please refer to the UnitedHealthcare Community Plan published Companion Guides for the required data elements. Companion guides are available for viewing or download within the EDI section of your state home page at UHCCommunityplan.com. EDI claims/encounters EDI claim is the preferred method of submission for contracted physicians and health care providers. You may submit all professional claims and/or encounters electronically for UnitedHealthcare Community Plan. The HIPAA ANS1 X format is the only acceptable format for submitting claims/ encounter data. Claims requiring medical record attachments will require paper submission. However, do not submit medical record attachments unless instructed to do so by UnitedHealthcare Community Plan. Secondary Claims Please refer to the 837 Companion Guide located within the EDI Section of UHCCommunityPlan.com for technical requirements. Do not send paper claim backup for claims that have already been submitted electronically. To set up Carrier Tables within your Software Set your system payer tables for UnitedHealthcare Community Plan to generate electronic claims instead of paper claims. Make sure the Payer ID for the plan is spelled correctly and setup is consistent. Contact your software vendor or clearinghouse with any questions regarding placement of information on your system. Electronic Funds Transfer (EFT) EFT can reduce administrative costs, simplify bookeeping and offer greater security. EFT can significantly reduce reimbursement turnaround time and funds are available as soon as they are posted to your account. To enroll in EFT for UnitedHealthcare Community Plan, please visit the EDI section of your state home page on UHCCommunityplan.com. Electronic Remittance Advice (ERA) ERA allows a provider to obtain an electronic version of the Explanation of Payment (EOP). Depending on your system s capability, the data may be uploaded directly to the ledger of your practice computer system. ERA can potentially replace the tedious process of Guide EOP reconciliation, posting and data entry. This transaction is available only in the HIPAA ANSI X format. Electronic eligibility inquiry/response One of the primary reasons for claims rejection is incomplete or inaccurate eligibility information. This EDI transaction is a powerful productivity tool that allows providers to instantly obtain member eligibility and benefit information in real-time, using a computer instead of the phone, prior to scheduling and confirming the member s appointment. The HIPAA ANSI X /271 format is the only acceptable format for this EDI transaction. Electronic claims status inquiry/response This EDI transaction allows a provider to send and receive in real-time an electronic status of a previously submitted claim using a computer. Claims with missing or inaccurate information can be resubmitted, which greatly enhances the provider s receivables and cash flow cycle. The HIPAA ANSI X1 276/277 format is the only acceptable format for this 10

13 EDI transaction. Some software vendors and/or clearinghouses, may also offer Electronic Claims Status and Inquiry transaction services. Please refer to the UnitedHealthcare Community Plan Companion Guides for the data elements required for these transactions. Companion guides are available for viewing or download at UHCCommunityplan.com. Claims Format All claims for medical or hospital services must be submitted using the standard CMS 1500 (formerly known as HCFA 1500), UB-04, or respective HIPAA-compliant format. The health plan recommends the use of black ink when completing a CMS Black ink on a red CMS 1500 form will allow for optimal scanning into the claims processing system. No matter which format you use to submit the claim, ensure that all appropriate secondary diagnosis codes are captured and indicated for line items. This allows for proper reporting on encounter data. Claim Processing Time Please allow 30 days before inquiring about claims status. The standard turn-around time for clean claims is 10 business days, measured from date of receipt. Claims Submission Rules The following claims MUST be submitted on paper due to required attachments: Timely filing reconsideration requests. CCI edit reconsideration. Unlisted procedure codes if sufficient information is not sent in the notes field. Please do not send claims on paper or with attachments unless requested by the health plan. The following claims may be submitted electronically without specific rules: 59 Modifier. Paper claim specific rules include: Corrected claims may be submitted electronically; however the words corrected claims must be in the notes field. Your software vendor can instruct you on correct placement of all notes. Unlisted procedure codes may be submitted with a sufficient description in the notes field. Your software vendor can instruct you on correct placement of all notes. If sufficient information cannot be submitted in the notes field, paper must be submitted. X-ray, lab and drug claims with unlisted procedure codes should be submitted electronically with notes. Occupational Therapy, Speech Therapy, Physical Therapy, Mental Health/Substance Abuse and dialysis claims require the date of service by line item. The health plan does not accept span dates for these types of claims. Secondary COB claims may be submitted if the following required fields are included on the electronic submission: Institutional: Payer Prior Payment, Medicare Total Paid Amount, Total Non-Covered Amount, Total Denied Amount. Professional: Payer Paid Amount, Line Level Allowed Amount, Patient Responsibility, Line Level Discount Amount (Contractual Discount Amount of Other Payer), Patient Paid Amount (Amount that the payer paid to the member not the provider). Dental: Payer Paid Amount, Patient Responsibility Amount, Discount Amount (Contractual Discount Amount of Other Payer), Patient Paid Amount (Amount that the payer paid to the member not the provider). 11

14 Balance Billing The balance billing amount is the difference between the allowed charge and the provider s actual charge to the patient. UnitedHealthcare members cannot be balance billed for covered services in accordance with the federal law prohibition found at 42 U.S.C.A. 1395cc and 42 U.S.C.A 1396a(p). Services to members cannot be denied for failure to pay copayments. If a member requests a service that is not covered by UnitedHealthcare, providers should have the member sign a release form indicating understanding that the service is not covered by UnitedHealthcare and the member is financially responsible for all applicable charges. Federal and State law prohibit a provider who participates in the Medicaid program from billing members for covered services. Additionally, section 403 of the Children s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) applies Medicaid-managed care requirements to CHIP, which includes the Iowa hawk-i program. This section further explains that providers are prohibited from balance billing a member for service(s) in excess of the contracted amount, other than approved copayments and/or deductibles. Span Dates Exact dates of service are required when the claim spans a period of time. Please indicate the specific dates of service in Box 24 of the CMS 1500, Box 45 of the UB-04, or the Remarks field. This will eliminate the need for an itemized bill and allow electronic submission. ective Date / Termination Date Coverage will be effective on the date the member is effective with the health plan. Coverage will terminate on the date the member s benefit plan terminates with the health plan. If a portion of the services or confinement take place prior to the effective date, or after the termination date, an itemized split bill will be required. Please be aware that effective dates for members can be revised. You should verify eligibility at each visit, to assure coverage for services. Overpayments The best way to handle a potential overpayment is to call Provider Service. Be sure to have the Claim Number or Member ID and Date of Service available. The health plan s claim processing system will automatically deduct any overpayment made from the next remittance advice. If an overpayment is identified, contact Provider Service to submit an overpayment request. Checks should not be sent to the health plan for overpayment related issues unless specifically requested. Subrogation The health plan will not override timely filing denials based on decisions received from third-party carriers on subrogation claims. At the time of service, please submit all claims to the health plan for processing. Through recovery efforts, we will work to recoup dollars related to subrogation. In addition, if your office receives a third-party payment, notify the health plan s Customer Service and the overpayment will be recouped. 12

15 Timely Filing and Late Bill Criteria Timely filing improves cash flow for your office. It enables the health plan to settle fund accounts accurately and to intervene earlier in cases requiring case management to improve patient outcomes. Claims must be submitted and received by us in accordance with the time frames outlined in your provider contract. Claims that are filed untimely will be denied. The claims filing deadline is based on the date services were rendered, or the date when the provider identifies us as the primary health payer, or receives a claim response from the primary payer. Secondary claim submissions can be submitted electronically or with a copy of the primary health payer s remittance. If we receive a claim and return it to the provider for additional information, the provider must resubmit the claim within the time frame outlined in the provider s contract. Timely filing denials are often upheld due to incomplete or invalid documentation submitted with reconsideration requests. The following information has been compiled to help clarify the documentation required as valid proof of timely filing documentation. When submitting a request for reconsideration of a claim to substantiate timely filing, please follow the appropriate instructions below. For claims submitted electronically: Submit an electronic data interchange (EDI) acceptance report. This must show that UnitedHealthcare or one of its affiliates received, accepted and/or acknowledged the claim submission. Note: A submission report alone is not considered proof of timely filing for electronic claims. It must be accompanied by an acceptance report. The acceptance report must: Include the actual wording that indicates the claim was either accepted, received and/or acknowledged. (Abbreviations of those words are also acceptable.) Show the claim was accepted, received, and/or acknowledged within the timely filing period. For paper claims: Submit a screen shot from accounting software that shows the date the claim was submitted. The screen shot must show: Correct patient name Correct date of service Submission date of claim The submission date must be within the timely filing period. Note that timely filing limits can vary greatly, based on state requirements and contract types. If you are not aware of your timely filing limit, refer to your provider contract. Other valid proof of timely filing documentation Valid when incorrect insurance information was provided by the patient at the time the service was rendered: A denial/rejection letter from another insurance carrier Another insurance carrier s explanation of benefits Letter from another insurance carrier or employer group indicating coverage termination prior to the date of service of the claim Letter from another insurance carrier or employer group indicating no coverage for the patient on the date of service of the claim All of the above must include documentation that the claim is for the correct patient and the correct date of service. The date on the other carrier s payment correspondence starts the timely filing period for submission to UnitedHealthcare. In order to be considered timely, the claim must be received by UnitedHealthcare within the timely filing period from the date on the other carrier s correspondence. If the claim is received after the timely filing period, it will not meet timely filing criteria. 13

16 Provider Claim Reconsideration Requests Step 1: Claim Reconsideration. You must submit your Claim Reconsideration within 12 months (or as required by law or your provider contract) from the date of the original Explanation of Benefits (EOB) or Provider Remittance Advice (PRA) as required by law, together with a completed UnitedHealthcare Claims Reconsideration Request form. 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 request, we review whether a claim was paid correctly, including if your provider information and/or contract are set up incorrectly in our system, which could result in the original claim being denied or reduced. UnitedHealthcare acknowledges that providers remain eligible to file claims reconsiderations, resubmissions, disputes or appeals as permitted under the terms of their participation agreement or this manual. A request for claims reconsideration is intended solely for convenience and administrative ease. In the event this claims reconsideration process conflicts in any way with your participation agreement or this manual, the terms and conditions of the participation agreement or this manual shall govern. Providers are encouraged to review their participation agreement and this manual to understand all other available claims reconsideration, resubmission or appeals remedies. Below is the method for submitting Claim Reconsideration Requests. Paper Claim Reconsideration Request The paper Claim Reconsideration Request form can be downloaded from: UnitedHealthcareonline.com Claim Reconsideration Paper Claim Reconsideration instructions Where to send Claim Reconsideration Requests: UnitedHealthcare P.O. Box 5220 Kingston NY Claim Dispute If you do not agree with the outcome of the Claim Reconsideration decision in Step 1, you may submit a formal claim dispute. You must submit your appeal to us within 12 months (or as required by law or your participation agreement), from the date of the Explanation of Benefits (EOB) or Provider Remittance Advice (PRA). The provider dispute form can be found on UHCCommunityPlan.com. Forms should be mailed to: UnitedHealthcare Community Plan P.O. Box SALT LAKE CITY UT Or the form can be faxed to (801) A copy of the claim and supporting documentation will be required for review. 14

17 Reimbursement To align with federal mandates regarding enforcement of Correct Coding Initiatives (CCI) and Fraud, Waste and Abuse Prevention tools, the health plan performs coding edit procedures. These Program Integrity activities are referred to as reimbursement policies. Reimbursement policies are based on external sourcing including: CMS National Correct Coding Initiative. CMS National/Local Coverage Determinations (NCDs/LCDs). Current Procedural Terminology (CPT). Specialty Societies including, but not limited to: American Society of Anesthesiologists (AMA). American College of Cardiologists (ACC). American College of Obstetrics and Gynecology (ACOG). National Physician Fee Schedule (NPFS)/Relative Value File. Reimbursement policies are available online at UHCCommunityPlan.com. Reimbursement policies may be referred to in your agreement with UnitedHealthcare Community Plan as payment policies. UnitedHealthcare Community Plan may revise/update or add to these policies on occasion. As a participating provider, you agree to abide by these policies. UnitedHealthcare Community Plan is committed to notifying providers who are impacted by policy changes/additions. Payment of a claim is subject to our payment policies (reimbursement policies) and medical policies, which are available to you online or upon request to your Network Management contact. NOTE: Policies do not cover all issues related to reimbursement for services rendered to UnitedHealthcare Community Plan enrollees as legislative mandates, the physician or other provider contract documents, the enrollee s benefit coverage documents, and the Provider Manual all may supplement or in some cases supersede these policies. Provider Claim Editing Tools ices Clearinghouse from Ingenix: UnitedHealthcare Community Plan utilizes a customized version of the Ingenix Claim Edit System known as ices Clearinghouse (v2.5.1) ices-ch is a clinical edit system application that analyzes health care claims based on business rules designed to automate UnitedHealthcare Community Plan reimbursement policy and industry standard coding practices. Claims are analyzed prior to payment to validate billings in order to minimize inaccurate claim payments. Facility Claim Editing: UnitedHealthcare Community Plan utilizes an edited system application for claims for outpatient and inpatient services provided to Medicaid/CHIP beneficiaries. The Facility Editor is a rules-based software application that evaluates claims data for validity and reasonableness. UnitedHealthcare upgraded the claim system to improve the ability to audit submission of clean institutional (UB) claims. If a claim is denied for one of these edits, the facility can resubmit a corrected claim through the reconsideration process as outlined in this provider manual. Outpatient Code Edits These reasonableness tests incorporate the Outpatient Code Edits (OCE) developed by the CMS for hospital outpatient claims. The Facility Editor will be used to examine outpatient facility-based claims prior to payment to validate billings in order to minimize inaccurate claim payments. 15

18 The CMS OCE edits that will be applied by the Facility Editor include: 1. Basic field validity screens for patient demographic and clinical data elements on each claim. 2. Effective-dated ICD-9-CM, CPT-4 and HCPCS Level II code validation, based on service dates and patient clinical data. 3. Facility-specific National Correct Coding Initiative edits. The NCCI edits identify pairs of codes that are not separately payable, except under certain circumstances. NCCI edits were developed for use by all health care providers; the Facility Editor incorporates those NCCI edits that are applicable to facility claims. The NCCI edits in the Facility Editor are applied to services billed by the same hospital for the same beneficiary on the same date of service. There are two categories of NCCI edits: a. Comprehensive code edits, which identify individual codes, known as component codes, which are considered part of another code and which are designed to prevent unbundling; and b. Mutually exclusive code edits, which identify procedures or services that could not reasonably be performed at the same session by the same provider on the same beneficiary. 4. Other OCE edits for inappropriate coding, including incorrect coding of bilateral services, evaluation and management services, incorrect use of certain modifiers, and inadequate coding of services in specific revenue centers are also included in the Facility Editor. The inpatient edits are sourced to: Medicare Code Editor (MCE) which include (but are not limited to) the following edit rules: Data Validation Edits. Multiple Services on Same Visit: In certain situations, providers can bill for both evaluation and management (E&M) and preventive medicine (PM) on the same office visit. PM codes must be billed with one of the following E&M codes: 99211, 99212, or for an unrelated diagnosis. If the PM code is billed in any other combination of E&M codes, it will not be payable. The E&M code must be filed with a 25 modifier in these circumstances. Immunization Administration The health plan will pay for immunization administration in conjunction with an E&M or P&M visit. Providers should use code for the first injection and for subsequent injections. Note: the hawk-i program does not participate in the Vaccines for Children (VFC) program. Vaccinations are reimbursed according to your provider contract fee schedule. Inpatient Code Edits The inpatient editing rule sets are also developed by the CMS for hospital inpatient claims. As with the outpatient edits, the claims editing tool will review claims prior to payment to validate billings to minimize inaccurate claims payments. 16

19 Member Cost Share Responsibility Cost-Sharing for Members hawk-i members are only responsible for the costs allowed under the Rules and Regulations as valid cost sharing responsibilities. A contracted provider cannot refuse to provide Medically Necessary Services for a member s failure to pay. A network provider shall collect from the member any applicable costs. Reasonable efforts to collect should include, but are not limited to, referral to a collection agency and, where appropriate, court action. Documentation of the collection efforts must be maintained and made available to the health plan upon request. hawk-i Copayments hawk-i members have no copayments for most services, exceptions include but not limited to: Dental member must use dental carrier s schedule of benefits, contact Delta Dental for details. Non-emergent member will have a $25 copayment for any non-emergent visits to an emergency room. Hearing member can have one audiometric exam, one hearing aid evaluation, and one hearing aid per ear every 36 consecutive months. Costs for services above these benefits are the responsibility of the member. Prescription member will pay the full contracted price of any brand prescription filled when an equivalent generic is available on the Preferred Drug List (PDL). Vision member may receive 1 eye exam every 12 consecutive months and has a $100 material allowance per calendar year, they are responsible for any amount in excess of these limits. Non-plan services when not a result of an emergency or in absence of a prior authorization member is responsible for the costs of those service(s). Services without prior authorization where one is required member is responsible for the cost of those service(s). Services outside of their benefit plan. For questions, please contact Provider Services. For more information about hawk-i benefits, refer to the Covered Benefits section in this manual. Non-payment of Copayment When a member does not pay the applicable copayment at the time services are rendered, the physician has the following options: Render the service, and pursue member payment of cost sharing at a future time. Reschedule the appointment (unless the visit is for urgent/emergent care). Contact Provider Service for assistance if the member refuses to pay copayments. Coordination of Benefits Coordination of Benefits (COB) is designed to avoid duplicate payment for covered services. COB is applied whenever the Member covered by the health plan is also eligible for health insurance benefits through another policy. The health plan recommends the copayment not be collected until the second payer has paid the claim in order to prevent a possible overpayment. 17

20 As a network provider you agree to cooperate with the health plan toward the effective implementation of COB procedures, including identification of services and individuals for which there may be a financially responsible party other than the health plan, and assist in efforts to coordinate payments with those parties. How to file: When the health plan is primary, submit directly to us. When the health plan is secondary, submit to primary carrier first, then, submit the EOB with the claim to the health plan for consideration. EOBs can be submitted to the health plan electronically. Refer to Claims Submission Rules in this manual. Reminder: The Contract Agreement between UnitedHealthcare and the State of Iowa states: in the event a hawk-i child is enrolled with other health insurance coverage, the other insurance plan shall be the primary payer and hawk-i shall be the payer of last resort. Therefore, if the member is eligible for services or benefits under another policy, including Medicare, coverage under that plan will be primary. The only exception is in rare instances that the member also has Medicaid coverage. In these cases, Medicaid is the payer of last resort. 18

21 Provider e-services Provider e-services can be accessed from the health plan website at UHCCommunityPlan.com. Offering online features is just another way the health plan is working to strengthen our relationships with providers. Provider Registration How to Obtain a Username and Password To register for e-services provider portal, go to UHCCommunityPlan.com. Then click on Health Professionals and select the state of Iowa under Already Part of Our Network. Choose Claims and Member Information from the navigation buttons on the left side of the screen, under UnitedHealthcare hawk-i, click Access secure provider website. This will bring you to the log in page for the online provider portal. Reduce the number of claims rejected due to inaccurate eligibility information. Claim Status/Review Allows you to locate specific claims and obtain claim summary and line item detail information. Determine if your claims have been received by the health plan. Know if your claim is pended, denied or paid within seconds. Reduce your cost of duplicate claims submission and reduce administration cost. Submit online request for claim review and receive answer within 48 hours. From the Community Plan Online Provider Portal log in page, you will see a prompt to register for an account. Once you click on register, it will direct you to a page to set up your log in information. To access the non-secured portion of the provider website, go to UHCCommunityPlan.com and click on Health Professionals and select the state of Iowa under Already Part of Our Network. This brings you to the general home page. Here you can access our policies (including the Reimbursement Policies), Provider Manual, handouts, forms, and recent newsletters. e-services Verify Patient Eligibility Verify the eligibility of your patients before you see them. Know patients copayments that you can collect at time of service. View deductibles, out-of-pocket maximums and co-insurance of patients. 19