! Claims and Billing Guidelines

Transcription

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

2 Electronic Claims Clearinghouses and Vendors General Information Using a clearinghouse eliminates the need to use multiple billing systems. Please note that clearinghouses are connected with numerous vendors who may not be identified on UNICARE s vendor list. Cross Reference Electronic Billing. Definition A claims clearinghouse provides a central source for the collection, classification, and distribution of claims to multiple payers. Policies Claims data must be formatted in the required UNICARE format before electronic transmission. Procedures The vendors listed below supply software that supports the acceptable UNICARE electronic formats via asynchronous, bisynchronous, or other telecommunication modes. The clearinghouses and vendors listed below have been approved for electronic transmission to UNICARE: Note: If you are currently using one of the following vendors, no change is required. WebMD/ENVOY Corp, Nashville, TN, National Data Corp. (NDC), Norcross, GA, PerSe Technologies, Elgin, IL, Proxymed, Inc, Santa Ana, CA, THIN, Richardson, TX, The mention of these organizations does not constitute an endorsement by UNICARE of these companies or their services CLAIMS AND BILLING GUIDELINES:

3 Electronic Billing General Information Electronic Data Interchange (EDI) is the computerto-computer transfer of business-to-business document transactions and information between trading partners. Many health care organizations, including providers, payers, vendors and fiscal intermediaries choose EDI as a fast, inexpensive, and safe method of automating the business processes. It also streamlines tasks and reduces costs. Cross Reference Electronic Claims Clearinghouses and Vendors. How to submit claims directly using SPC Mailbox. Direct Access Lease Lines. Get a current list of approved software vendors and clearinghouses. Assistance with technical support. Current HIPAA information. USING EDI Providers who use EDI need to include the UNICARE payor ID number when submitting claims. Definition Electronic Billing: The ability to submit a claim through electronic media. Policies Call UNICARE EDI Services for information and help with Electronic Billing. Procedures DIRECT ELECTRONIC SUBMISSION Claims can be submitted electronically to UNICARE directly through the SPC Mailbox, Direct Access Lease Line or can be submitted through an approved vendor or clearinghouse. EDI SERVICES Claims submission. Encounter data submission. Eligibility and benefits inquiries and responses. Claim status inquiries and responses. EDI SUPPORT EDI Services/UNICARE can assist you with a variety of EDI options: CLAIMS AND BILLING GUIDELINES:

4 Institutional Claims and Billing Guidelines General Information For questions regarding billing and form completion please contact UNICARE s Customer Care Center, 8 a.m.-10 p.m. ET, Monday-Friday. Member Eligibility Eligibility with UNICARE and PCP assignment must be verified before service is given. Refer to Member Eligibility Verification. Pre-Authorization Some specialty procedures require pre-authorization review for medical necessity by UNICARE Utilization Management. Refer to Pre-Authorization for requirements. Providers seeking reimbursement for non-emergency services, requiring pre-authorization but performed without an authorization number will be denied for lack of authorization. Pre-authorized claims must have the authorization number or any other authorization information in locator 63 of the UB-92 Claim Form. Inpatient Service Review All non-emergency inpatient hospital services (except routine delivery) require Pre-Authorization. Emergent/urgent admissions must be reported as soon as reasonably possible. Utilization Management reviews for medical necessity appropriate level of care, length of stay, and post-hospitalization services. Refer to Pre-Authorization for additional requirements. Claims Submission PAPER BILLING Submitted claims must be completed with all required information to ensure timely processing and payment. Claims submitted with incomplete or invalid information are mailed back to the provider for correction. The provider must respond within the contracted filing limit from the date of service for the services to be considered for payment. All paper claims must be submitted on the most current version of the UB-92 Claim Form for institutional services. Refer to the Appendices for a sample of this form.. Any other form will be mailed back with a request to resubmit using the appropriate form. CLAIM FILING LIMIT The provider must bill using the appropriate forms and in a manner acceptable to UNICARE. The standard UNICARE claims filing limit for institutional providers is 150 days from the discharge date (time limits may vary depending on contracted filing limit). Claims received by UNICARE past the filing limit will be denied. If the claim is mailed back to the provider for corrective action, institutional providers have 150 days from the date of service to submit the corrected claim information back to UNICARE (time limits may vary depending on contracted filing limit) CLAIMS AND BILLING GUIDELINES:

5 If the claim is not resubmitted within this timeframe, it will be denied for untimely filing. CLAIMS CODING The provider must bill in a manner acceptable to UNICARE. Providers must include their Medicaid ID number on each claim form submitted to UNICARE. Additionally, HIPAA mandates standards for Electronic Data Interchange (EDI) transactions and code sets. It establishes uniform health care identifiers for providers, health plans, and employers. Compliance with HIPAA requires the use of ANSI ASC X12N (Version 4010) transaction standards and implementation guides. It also addresses privacy and security. COORDINATION OF BENEFITS UNICARE coordinates benefits with any other carrier(s) that the member may have for health care coverage, including Medicare. Indicate other coverage information in locator of the UB-92 Claim Form. UNICARE is always payer of last resort; the provider is expected to submit the claim to all other carriers before submitting the claim to UNICARE. REMITTANCE ADVICE (RA) Claims submitted as COB (Coordination of Benefits) to UNICARE must include an RA (Remittance Advice) or a letter explaining the denial of reimbursement from the other carrier(s). If a claim where other coverage is identified (COB Claim) is received without an RA or letter, the claim is mailed back to the submitting provider requesting that the claim be first submitted to the other carrier. Claims submitted as COB must be received within 150 days of the date of the other carrier RA, or letter of denial of coverage, and/or reimbursement. CLAIM STATUS INQUIRIES/FOLLOW-UP The provider should receive a response from UNICARE within 30 days of receipt of a claim. If the claim contains all required information, the claim is entered into the UNICARE system for processing and the provider receives an RA. If there has been no response to a submitted claim within days from the date of service, it is recommended that the provider initiate follow-up action to determine claim status. UNICARE s Customer Care Center is available to answer any questions and provide further instructions regarding claims follow-up. A Customer Care Center Representative will: Research status of the claim. Advise provider of necessary follow-up actions, if any. If the disposition of a claim is being disputed, a Customer Care Center Representative will review and correct the discrepancy if no additional information or documentation is needed. INFORMATION REQUEST/MAILBACK A mailback is a request for additional information from the provider before UNICARE can process the claim. An Information Request/Mailback requires an immediate response from the provider. If the claim is mailed back to the provider for corrective action, the filing limit is not extended. The provider still must submit a complete and accurate claim to UNICARE within 150 days from the date of discharge CLAIMS AND BILLING GUIDELINES:

6 If the claim is not resubmitted within this timeframe, it will be denied for untimely filing. Up to two-day stay for vaginal delivery. Up to four-day stay for cesarean section delivery. CLAIM SUBMISSION ADDRESS UNICARE of West Virginia, Inc. P.O. Box 91 Charleston, WV UB-92 CLAIM FORM All institutional services billed to UNICARE must be billed on an UB-92 Claim Form with all the required information and within the filing limit before UNICARE can reimburse the claim. Refer to Appendices for a sample of UB-92 Claim Form and field descriptions. Self-Referable Services UNICARE members may access self-referable services at any time without pre-authorization review requirements. Refer to Referrals for a list of self-referable services. Sterilization Claims Sterilization is any procedure/treatment performed to permanently take away the ability of reproducing. BILLING Claims for sterilization services must be submitted on the most current version UB-92 Claim Form and follow the appropriate coding guidelines. A copy of the completed Sterilization Consent Form (DHHR 3004) must be attached to the claim for either gender receiving the sterilization. Maternity Services DELIVERY Pre-authorization is not required for normal deliveries. BILLING Mother and baby charges should be billed on separate claims forms. UNICARE requires the itemization of maternity services when submitting claims for reimbursement. Please use the appropriate CPT/HCPCS and diagnosis codes when billing. This includes the applicable Evaluation and Management code along with coding for all other procedures performed. Delivery charges should be billed with appropriate CPT procedure codes = C-Section = Vaginal Delivery. EXTENDED CARE Requires UNICARE Utilization Management review for stays longer than the standard two (for vaginal delivery) or four days (for cesarean delivery). NEWBORN BILLING Any newborn whose mother is a UNICARE enrollee at the time of birth is automatically eligible under the mother s Medicaid identification number for 30 days after the date of birth. Before the 30 days have expired, the mother must call UNICARE to notify us and must also enroll the newborn, who will automatically be eligible for 12 months after enrollment. Newborns who are not assigned a Medicaid number before the 30 days have expired will no longer be covered by UNICARE. The initial newborn care should be billed under the mother s Medicaid Identification Number as long as the mother remains in the hospital. This includes the physical examination of the baby, and CLAIMS AND BILLING GUIDELINES:

7 the initiation of diagnostic and/or treatment programs. Physician s care provided to the infant after the mother leaves the hospital should be billed under the newborn s own identification number. Circumcision of a newborn male is covered when billed under the newborn s own identification number. This cannot be paid if billed under the mother s identification number. Emergency Room Services Services will be reimbursed at the UNICARE fee schedule according to the provider contract. BILLING Indicate the injury date in locator of the UB-92 Claim Form. HOSPITAL REQUIREMENTS Give a copy of the emergency room record to the PCP after services are rendered. Calculating Reimbursements Authorized inpatient hospital services are reimbursed according to the methodology and rate factors provided by DHHR (Department of Health and Human Resources) to UNICARE. UNICARE is using the Medicare DRG (Diagnosis Related Group) structure. The DRG weighting is derived from the diagnosis codes listed on the UB-92 Claim Form. The diagnosis codes should be placed in locator No. 67 of the UB-92 Claim Form. To ensure the correct payment, and to ensure the claim is paid under the outlier methodology if applicable, please do not send interim bills. Please include all dates of service relative to the entire stay on one claim form. If covered billed charges exceed the state-specific outlier amount established by the Bureau of Medical Services for each hospital, additional calculations are required to determine the applicable reimbursement. Late charges must be submitted within 30 days of discharge to affect the outlier provision. Providers must write corrected billing on any claim that is submitted with late or corrected charges. Claim Reconsideration and Appeal RECONSIDERATION Reconsideration is initiated when the provider requests a review subsequent to claim processing by UNICARE; the provider has received a Remittance Advice (RA). Providers may resubmit previously processed claims for reconsideration verbally to a Customer Care Center representative or in writing on the Claim Resubmission Form. Requests must be submitted within six months of the date of the UNICARE RA. This includes any paid claim that was originally submitted with incorrect information. UNICARE will render a decision and notify the provider within 30 days of the receipt of the request for reconsideration If it is determined that the claim was handled correctly based on the information and documentation received by UNICARE, the provider is advised of the proper procedure for further claim appeal. If the claim was handled incorrectly, if necessary UNICARE will adjust the claim payment APPEAL If the provider disagrees with the outcome of the reconsideration, an appeal may be submitted in writing within six months of the decision on the reconsideration. The provider may also include additional information that may affect the outcome of the appeal. An Appeal resubmission must include, but is not limited to: A completed Claim Resubmission Form with all points of contention itemized and explained. A copy of the original/corrected claim form CLAIMS AND BILLING GUIDELINES:

8 Any and all supporting documentation (i.e., records, reports) which the provider deems pertinent or which has been requested by UNICARE. Claims being submitted for reconsideration (written submissions) and/or appeal must be mailed to the appropriate claims unit. Refer to the Phone Numbers and Addresses section for reconsideration and appeal submissions. FINALIZATION When the review process is completed, the provider is notified of the outcome by either a Notice of Action, if no additional reimbursement will be made, or an RA that reflects an adjusted reimbursement. CLAIM RESUBMISSION FORM A completed Claim Resubmission Form should accompany any written correspondence the provider sends to UNICARE requesting the review of a previously processed claim. All issues regarding the claim the provider wishes. UNICARE to review should be clearly outlined on the form CLAIMS AND BILLING GUIDELINES:

9 Professional Claims and Billing Guidelines General Information For questions regarding billing and form completion please contact UNICARE s Customer Care Center, 8 a.m.-10 p.m. ET, Monday-Friday. Member Eligibility Eligibility with UNICARE and PCP assignment must be verified before service is rendered. Refer to Member Eligibility Verification verification resources. Pre-Authorization Some specialty procedures will require preauthorization review for medical necessity by UNICARE Utilization Management. Refer to Pre- Authorization for requirements. Providers seeking reimbursement for non-emergency services requiring pre-authorization, performed without an authorization number will be denied for lack of authorization. Pre-authorized claims must have the authorization number or any other authorization information in locator 23 of the CMS-1500 Claim Form. Claims Submission CMS-1500 CLAIM FORM All professional services billed to UNICARE must be billed on the most current version CMS 1500 Claim Form with all the required information and within the filing limit before UNICARE can reimburse the claim. PAPER BILLING Submitted claims must be completed with all required information to ensure timely processing and payment. Claims submitted with incomplete or invalid information will be mailed back to the provider for correction. The provider must respond within the contracted filing limit from the date of service for the services to be considered for payment. All paper claims must be submitted on the most current version CMS 1500 Claim Form for professional services. Any other form will be mailed back with a request to resubmit using the appropriate form. CLAIM FILING LIMIT The standard UNICARE claims filing limit is 90 days from the date of service (check your contracted filing limit for your specific limit). Claims received by UNICARE past the filing limit will be denied. If the claim is mailed back to the provider for corrective action, the provider has 90 daysfrom the date of service to submit the corrected claim information back to UNICARE. If the claim is not resubmitted within this timeframe, it will be denied for untimely filing. COORDINATION OF BENEFITS UNICARE coordinates benefits with any other carrier(s) that the enrollee may have for health care coverage, including Medicare CLAIMS AND BILLING GUIDELINES:

10 Indicate other coverage information in locators 9a-d of the CMS-1500 Claim Form. UNICARE is always payer of last resort; the provider is expected to submit the claim to all other carriers before submitting the claim to UNICARE. Claims submitted as Coordination of Benefits (COB) to UNICARE must include an Explanation of Benefits (EOB) or a letter explaining the denial of reimbursement from the other carrier(s). If a COB claim is received without an EOB or letter, the claim will be mailed back to the submitting provider requesting that the claim be first submitted to the other carrier. Claims submitted as COB must be received within 90 days of the date of other carrier EOB or letter of denial of coverage and/or reimbursement. CLAIM STATUS INQUIRIES/FOLLOW-UP The provider should receive a response from UNICARE within 30 days of receipt of a claim. If the claim contains all required information, the claim is entered into the UNICARE system for processing and the provider receives an Explanation of Benefits (EOB). If there has been no response to a submitted claim within days from the date of service, it is recommended that the provider initiate follow-up action to determine claim status. UNICARE s Customer Care Center is available to answer any questions and provide further instructions regarding claims follow-up. A Customer Care Center Representative will: Research status of the claim. Advise provider of necessary follow-up actions, if any. If the disposition of a claim is being disputed, a Customer Care Center Representative will review and correct the discrepancy if no additional information or documentation is needed. INFORMATION REQUEST/MAILBACK A mailback is a request for additional information from the provider before UNICARE can process the claim. An Information Request/Mailback requires an immediate response from the provider. If the claim is mailed back to the provider for corrective action, the filing limit is not extended. The provider still must submit a complete and accurate claim to UNICARE within 90 days from the date of service. If the claim is not resubmitted within this timeframe, it will be denied for untimely filing. CLAIM SUBMISSION ADDRESS Claims UNICARE Health Plan of West Virginia, Inc. P.O. Box 91 Charleston, WV Preventive Services When billing for preventive services, use: ICD-9 Diagnosis Code V70 for adults (19 years and older). ICD-9 Diagnosis Code V20.2 for children (newborn to 18 years old). Self-Referable Services UNICARE enrollees may access self-referable services at any time without pre-authorization requirements. Refer to Referrals for a list of self-referable services CLAIMS AND BILLING GUIDELINES:

11 Sterilization Claims Sterilization is any procedure/treatment performed to permanently take away the ability of reproducing. BILLING Claims for sterilization services must be submitted on a CMS-1500 Claim Form and follow the appropriate coding guidelines. A copy of the completed Sterilization Consent Form must be attached to the claim for either gender receiving sterilization. Maternity Services DELIVERY Pre-authorization review is not required for normal deliveries. Up to two-day stay for vaginal delivery. Up to four-day stay for cesarean section delivery. BILLING Mother and baby charges should be billed on separate claims forms. Indicate Last Menstrual Period data in locator 15 of the CMS-1500 Claim Form. Use the appropriate Diagnosis Code in locator 21 of the CMS-1500 Claim Form. UNICARE requires the itemization of prenatal and maternity services when submitting claims for reimbursement. Please use the appropriate CPT/HCPCS and diagnosis codes when billing. This includes the applicable Evaluation and Management code along with coding for all other procedures performed. Delivery charges should be billed with appropriate CPT procedure codes = C-Section = Vaginal delivery EXTENDED CARE Requires UNICARE Utilization Management review. NEWBORN BILLING Any newborn whose mother is a UNICARE enrollee at the time of birth is automatically eligible under the mother s Medicaid identification number for 30 days after the date of birth. Before the 30 days have expired, the mother must call UNICARE to enroll the newborn, who will automatically be eligible for 12 months after enrollment. The initial newborn care should be billed under the mother s Medicaid Identification Number as long as the mother remains in the hospital. This includes the physical examination of the baby, and the initiation of diagnostic and/or treatment programs. Physician s care provided to the infant after the mother leaves the hospital should be billed under the newborn s own identification number. Circumcision of a newborn male is covered when billed under the newborn s own identification number. This procedure is sex-specific and cannot be paid if billed under the mother s identification number. Emergency Room Services Services are reimbursed at the UNICARE fee schedule according to the provider contract. BILLING Indicate the injury date in locator 14 of the CMS 1500 Claim Form. HOSPITAL REQUIREMENTS Provide a copy of the emergency room record to the PCP after services are rendered. Durable Medical Equipment (DME) DME is covered when prescribed for the purpose to preserve bodily functions or preventing disability CLAIMS AND BILLING GUIDELINES:

12 PRE-AUTHORIZATION All custom made DME requires preauthorization review. Services requiring pre-authorization review will be denied if approval is not obtained. Billing MANUFACTURER S INVOICE Attach manufacturer s invoice to the claim for all miscellaneous equipment codes Catalog pages are not acceptable. RENTAL Most DME is dispensed on a rental basis, except for non-renewable DME, which is purchased. Items rented remain the property of the DME provider, until purchase price is reached. - DME providers cannot bill enrollees. Rental extensions may be obtained only on items approved. - Medical documentation from the prescribing doctor is required. PURCHASE Most DME to be purchased (except for nonrenewable DME) is dispensed on a rent-topurchase basis over a period of ten months, unless specified otherwise at time of review. Claim Reconsideration and Appeal RECONSIDERATION Reconsideration is initiated when the provider requests a review subsequent to claim processing by UNICARE; the provider has received an Explanation of Benefits (EOB). Providers may resubmit previously processed claims for reconsideration verbally to a Customer Care Center representative or in writing on the Claim Resubmission Form. Send the form to: UNICARE Attn: Correspondence P.O. Box 91 Charleston, WV Requests must be submitted within six months of the date of the UNICARE EOB. This includes any paid claim that was originally submitted with incorrect information. UNICARE will render a decision and notify the provider within 30 days of the receipt of the request for reconsideration. If it is determined that the claim was handled correctly based on the information and documentation received by UNICARE, the provider is advised of the proper procedure for further claim appeal. If the claim was handled incorrectly, if necessary UNICARE will adjust the claim payment. APPEAL If the provider disagrees with the outcome of the reconsideration, an appeal may be submitted in writing within six months of the decision on the reconsideration. The provider may also include additional information that may affect the outcome of the appeal. An Appeal resubmission must include, but is not limited to: A completed Claim Resubmission Form with all points of contention itemized and explained. A copy of the original/corrected claim form Any and all supporting documentation (i.e., records, reports) which the provider deems pertinent or which has been requested by UNICARE. Claims being submitted for reconsideration (written submissions) and/or appeal must be mailed to the appropriate claims unit. Refer to the Phone Numbers and Addresses for reconsideration and appeal submissions CLAIMS AND BILLING GUIDELINES:

13 FINALIZATION When the review process is completed, the provider is notified of the outcome by either a Notice of Action, if no additional reimbursement will be made, or an EOB that reflects an adjusted reimbursement. CLAIM RESUBMISSION FORM A completed Claim Resubmission form should accompany any written correspondence the provider sends to UNICARE requesting the review of a previously processed claim. All issues regarding the claim the provider wishes UNICARE to review should be clearly outlined on the form. Refer to the Appendices for a sample of the Claim Resubmission Form CLAIMS AND BILLING GUIDELINES:

14 UniCare Health Plan of West Virginia, Inc. (UniCare) Billing Dispute External Review Process As of May 4, 2006, the Billing Dispute External Review Process is available to physicians who are class members of the Shane-Thomas Managed Care Settlement Agreement ( the Settlement Agreement ) and physician groups comprised of such physicians. The process is intended to resolve: 1) Disputes over the application of UniCare s coding, payment rules and methodologies for fee-forservice claims to patient specific factual situations. 2) Disputes relating to whether UniCare has complied with the provisions of the Settlement Agreement, requiring a physician to submit records in connection with a claim for payment (either prior to or after payment). Please note that physicians and physicians' groups must exhaust UniCare s internal appeal/review process for billing disputes before submitting a dispute to the Billing Dispute External Review Board (BDERB). This requirement will be deemed to have been satisfied if UniCare has responded to your appeal, and their response indicates internal review has been exhausted or if there is no notice of UniCare s decision within 30 calendar days after you have supplied all documentation reasonably needed to complete the internal appeal/review. Physicians and physicians' groups must submit their Billing Dispute request directly to the BDERB. It must be post-marked no later than 90 calendar days after exhausting UniCare s internal appeals/review process. In order to initiate the external Billing Dispute External Review Process, certain criteria must be met, and a fee is required. The requirements are: Disputes may be submitted only by a physician who is a member of the Shane-Thomas settlement class or a physician group comprised of such physicians. UniCare s internal appeals/review process must be exhausted. The amount in dispute (for either a single claim for covered services or multiple claims involving similar issues) must be greater than $500*. The dispute must be filed in writing within 90 calendar days after the exhaustion of UniCare s Internal Appeals/review Process The physician or physician group must submit the proper filing fee as shown below. *A physician or physician group may submit a dispute with a disputed amount less than $500 to the BDERB if the physician or group intends to submit additional disputes involving similar issues within one year such that the aggregate amount in dispute will exceed $500. The BDERB will defer consideration of the dispute until and unless such additional disputes are submitted. Filing fees are as follows: If the amount in dispute is less than or equal to $1,000, the fee is $50. If the amount in dispute is more than $1,000, the fee is $50 plus 5% of the amount by which the amount exceeds $1,000, but in no event more than 50% of the cost of the review. If the Physician prevails, the filing fee will be refunded. Instructions: Please be sure that your submission meets the requirements set forth below. You must be able to answer Yes to these questions. (Note, if this is a dispute regarding a Records Requirement, please download and complete a copy of the Request for Dispute of Records Requirement at A. Are you a class member of the Shane-Thomas Managed Care Settlement Agreement? B. Date of Service - Is the date of service after July 11, 2005?

15 C. Exhaustion of the Plan s Internal Appeals/review. 1. Have you filed an internal appeal with UniCare and been notified of the outcome? OR 2. Have you filed an internal appeal about which UniCare has failed to communicate a notice of its decision within 30 calendar days after receiving all documentation reasonably needed to complete the appeal/review? D. Amount in Dispute - The amount in dispute (the additional amount you believe UniCare should have paid) for the single or multiple claims must be more than $ Is the disputed amount of the single or multiple claim(s) submitted at this time more than $500? Or Have you previously filed and deferred consideration of billing disputes involving similar issues within one (1) year, and if so, does the filing of this claim result in an aggregate disputed amount greater than $500? Or If this request is less than $500, but you would like this request to be deferred so that you may submit additional billing disputes later? (Note: The filing fee is payable with your first submission.) You must submit UniCare s final appeal letter with your dispute. You must also attach to the Billing Dispute External Review Form and all supporting documentation that you would like to be considered by the Billing Dispute External Review Board. Examples of supporting documentation include Remittance Advice(s) and clinical information. The Billing Dispute External Review Board may request additional documentation from you. Any such additional documentation must be submitted within 30 calendar days of the request.

16 UniCare Health Plan of West Virginia, Inc. (UniCare) Billing Dispute External Review Form Please send this completed form, and the filing fee to the Billing Dispute External Review Board, IMEDECS (formerly known as HAYES Plus, Inc.). Attach the final appeal denial letter and supporting documentation: Explanation of Benefits (EOB) and additional clinical information, etc. IMEDECS 157 S. Broad Street, Lansdale, PA Phone: (215) Fax: (215) Physician Information: Treating Physician Name (as submitted on claim): Tax ID (as submitted on claim): Billing Address (Street, City, State, ZIP): Telephone Number: Fax Number: Office ( ) ext. Office ( ) Contact Name: Contact Phone Number: Contact If Codes/Modifiers are Disputed: A specific code set must be identified; a minimum of two codes must be entered below. Note: To see examples of the types of disputes eligible for review, please refer to the attached Example Billing Dispute Category List. CPT Code (Primary) CPT Code (secondary) (and/or) Modifier Claim Information: If your billing dispute contains multiple claims for the same code set, please attach a separate sheet noting the physician s name, member s name, member s ID, date of service, and claim number. Member Name: Member ID Number: Member Group Number (Optional) Member Address (Street, City, State, ZIP): Request for Physician Billing Dispute External Review: Date of Service: Claim Number(Indicated on Explanation of Payment): Amount in dispute (the additional amount you believe you are entitled to receive in this dispute): $ Filing fee: (Please check one.) $50.00 Disputed amount greater than $500 and less than or equal to $ $ % of amount of dispute which exceeds $ The fee may not exceed 50% of the cost of the review. No amount is enclosed because this claim is an aggregate of a deferred claim for which a filing fee has previously been paid. Amount enclosed: Please Make check payable to IMEDECS. The decision of IMEDECS is final and binding on UniCare and the physician or physician group only with respect to the specific case under review by IMEDECS. Physicians may access the UniCare website ( or the IMEDECS website ( for further information. Comments: I hereby acknowledge the terms of the Billing Dispute External Review Process, further certify that I am a member of the class, and further certify the accuracy of the material and information submitted with the request. Signature of Physician: Date:

17 DISPUTE CATEGORY EXAMPLE LIST The following list contains examples of the types of billing disputes that are eligible for submission to the Billing Dispute External Review Process. It is not an exhaustive list of every eligible dispute, but is provided to assist you in submitting eligible disputes for External Review. Disputes that are not eligible for this process may still be referred to UniCare s resolution through the internal appeal process. For example, disputes about the reimbursement rates set by UniCare through its fee schedules or about allowable fee determinations for out of network physicians may be referred to UniCare. IMEDECS will determine whether your dispute is eligible for review. To assist IMEDECS with the determination, please indicate the type of issue that you are raising. Examples of Billing Disputes eligible for review if all requirements indicated above are satisfied include: Assistant Surgeons (includes modifier 82) Eligible/Non Eligible Consultation on X-ray Examination, Written Report (CPT code 76140) Modifier 22 Unusual Procedural Services Modifier 23 Unusual Anesthesia Modifier 24 Unrelated Evaluation & Management Service by the Same Physician during a Postoperative Period Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service Modifier 51 Multiple Procedures Modifier 59 Distinct Procedural Service Modifier 62 Two Surgeons Modifier 66 Surgical Team Therapies Modalities per Date of Service Reduction of the intensity of an E&M code(s). Reduction of the intensity of a service (other than an E&M code) Other bundling edits

18 Frequently Asked Questions: Q. When I file a dispute, how quickly will I have a resolution? A. Once the Billing Dispute External Review Board (BDERB) receives your billing dispute, it will evaluate your submission to determine if you have met the requirements. The BDERB will then request verification and documentation from UniCare. UniCare has 30 days to submit documentation to the BDERB. After the BDERB receives all necessary documentation, the BDERB has 30 days to review the billing dispute. Q: If my billing dispute is decided in my favor, what is the resolution time for UniCare to process the claim for reimbursement? A: If the billing dispute is decided in the physician s favor, the plan will reprocess the claim and send payment to you within 15 days after receipt of notification of the BDERB S decision. Q: What is a retained claim? A: Retained claims are claims that were in process as of July 11, Specifically, a retained claim can be: A claim that had been filed with UniCare, but had not been finally adjudicated as of July 11, 2005; or A claim that has not yet been filed with UniCare, but for which the contractual period allowed for filing has not expired. A claim is considered finally adjudicated when UniCare s internal appeals/review process has been completed. Q: Can I submit a dispute about a retained claim to the BDERB? A: Billing disputes about retained claims can be submitted to the BDERB provided they are submitted before the later of: (1) May 4, 2006; or (2) 90 days after you exhaust UniCare s internal appeals process. Q: What do I do if I want to challenge a request for records? A: If the dispute relates to UniCare s requirement that records be submitted (either prior to or after payment), the physician or physician group may elect not to utilize UniCare s internal appeals process and request that the BDERB grant an expedited review, but must demonstrate that UniCare s requirement has a significant adverse economic effect on the physician. If the BDERB determines that this has not been demonstrated, it will dismiss the claim pending exhaustion of UniCare s internal appeals process. A copy of the Request for Dispute of Records Requirement can be downloaded at Q: Are there further appeal rights after the BDERB decision? Is the decision binding? A: The decision made by the BDERB is final and is binding on both UniCare and the physician or physician group. Q: What if I have multiple claims for the same situation? A: A physician or physician group with multiple claims for similar situations may submit those disputes to the BDERB together, so long as the total of disputes add up to more than $500. Note: The filing fee is payable with your first submission. Q: What if I have disputed amounts of $500 or less? A: If physician s billing dispute amounts are $500 or less, additional, similar billing disputes may be submitted within one year of the original billing dispute submission date to accumulate an amount in excess of $500. Note: The filing fee is payable with your first submission. Q: Do I have to pay the filing fee? A: Yes, the filing fee is required. Q: Where do I send my payment for the filing fee? A: The filing fee must be submitted to the BDERB at the same time the billing dispute is submitted. Q: How will I know that I have exhausted the Internal Appeals/Review Process? A: Please refer to the internal appeals/review policies and procedures on the UniCare website to be sure that the proper procedures have been followed. If you have followed the proper procedures and received UniCare s decision, the related notification will state that the internal appeal/review process is exhausted. Also, if you have followed the proper procedures but UniCare has failed to notify you of its decision within 30 calendar days after receiving all documentation reasonably needed to complete the internal appeal/review, the internal appeal/review process is deemed to be exhausted. Q: Who may submit disputes to the BDERB

19 A: Physicians who have participated as class members of the Shane-Thomas Managed Care Settlement Agreement and physician groups comprised of such physicians. If you are uncertain whether you are part of the Settlement Class, please contact UniCare s provider services at Q: Who should I contact to check the status of my billing dispute submitted to the BDERB? A: Please contact the BDERB, IMEDECS at Q: Can I fax my request to the BDERB? If so, what is the fax number? A: Yes, physicians may fax the billing dispute to IMEDECS at