! Claims and Billing Guidelines

Size: px
Start display at page:

Download "! 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 (www.unicare.com) or the IMEDECS website (www.imedecs.com) 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

Provider Appeals and Billing Disputes

Provider Appeals and Billing Disputes Provider Appeals and Billing Disputes UniCare Billing Dispute Internal Review Process A claim appeal is a formal written request from a physician or provider for reconsideration of a claim already processed

More information

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

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

More information

Instructions for submitting Claim Reconsideration Requests

Instructions for submitting Claim Reconsideration Requests Instructions for submitting Claim Reconsideration Requests A Claim Reconsideration Request is typically the quickest way to address any concern you have with how we processed your claim. With a Claim Reconsideration

More information

PROSPECT MEDICAL GROUP DOWNSTREAM PROVIDER NOTICE CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION MECHANISM

PROSPECT MEDICAL GROUP DOWNSTREAM PROVIDER NOTICE CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION MECHANISM PROSPECT MEDICAL GROUP DOWNSTREAM PROVIDER NOTICE CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION MECHANISM As required by Assembly Bill 1455, the California Department of Managed Health Care has set

More information

Compensation and Claims Processing

Compensation and Claims Processing Compensation and Claims Processing Compensation The network rate for eligible outpatient visits is reimbursed to you at the lesser of (1) your customary charge, less any applicable co-payments, coinsurance

More information

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

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

More information

SECTION 4. A. Balance Billing Policies. B. Claim Form

SECTION 4. A. Balance Billing Policies. B. Claim Form SECTION 4 Participating Physicians, hospitals and ancillary providers shall be entitled to payment for covered services that are provided to a DMC Care member. Payment is made at the established and prevailing

More information

CHAPTER 7 (E) DENTAL PROGRAM CLAIMS FILING CHAPTER CONTENTS

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

More information

Section 9. Claims Claim Submission Molina Healthcare PO Box 22815 Long Beach, CA 90801

Section 9. Claims Claim Submission Molina Healthcare PO Box 22815 Long Beach, CA 90801 Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your

More information

Molina Healthcare of Ohio, Inc. PO Box 22712 Long Beach, CA 90801

Molina Healthcare of Ohio, Inc. PO Box 22712 Long Beach, CA 90801 Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your

More information

Molina Healthcare of Puerto Rico (MHPR) Non-Participating Provider Information

Molina Healthcare of Puerto Rico (MHPR) Non-Participating Provider Information Molina Healthcare of Puerto Rico (MHPR) Non-Participating Provider Information Please refer to Carta Normativa 15-0326 Re Transicion for details regarding the ASES-established Transition of Care and Reimbursement

More information

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

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

More information

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

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

More information

Claims Procedures. H.2 At a Glance. H.4 Submission Guidelines. H.9 Claims Documentation. H.17 Codes and Modifiers. H.

Claims Procedures. H.2 At a Glance. H.4 Submission Guidelines. H.9 Claims Documentation. H.17 Codes and Modifiers. H. H.2 At a Glance H.4 Submission Guidelines H.9 Claims Documentation H.17 Codes and Modifiers H.22 Reimbursement H.25 Denials and Appeals At a Glance pledges to provide accurate and efficient claims processing.

More information

The benefits of electronic claims submission improve practice efficiencies

The benefits of electronic claims submission improve practice efficiencies The benefits of electronic claims submission improve practice efficiencies Electronic claims submission vs. manual claims submission An electronic claim is a paperless patient claim form generated by computer

More information

Molina Healthcare of Washington, Inc. CLAIMS

Molina Healthcare of Washington, Inc. CLAIMS CLAIMS As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your reference:

More information

Ancillary Providers General Billing Requirements

Ancillary Providers General Billing Requirements Introduction... 2! Claims Settlement Practices and Provider Dispute Resolution Mechanism Regulations (Assembly Bill 1455)...2 Claim Submission Instructions... 2 Dispute Resolution Process for Contracted

More information

Certain exceptions apply to Hospital Inpatient Confinement for childbirth as described below.

Certain exceptions apply to Hospital Inpatient Confinement for childbirth as described below. Tennessee Applicable Policies PRECERTIFICATION Benefits payable for Hospital Inpatient Confinement Charges and confinement charges for services provided in an inpatient confinement facility will be reduced

More information

Third Quarter Updates Q3 2014

Third Quarter Updates Q3 2014 Third Quarter Updates Q3 2014 0714.PR.P.PP. 2014 Agenda Claim Process Reminders and Updates Top Rejections Top Denials IHCP Updates Resources Claim Process Electronic submission MHS accepts TPL information

More information

Coventry receives claims in two ways:

Coventry receives claims in two ways: Coventry receives claims in two ways: Paper Claims Providers send claims to the specific Coventry PO Box, which are keyed by our vendor and sent via an EDI file for upload into IDX. Electronic Claims -

More information

Chapter 15 Claim Disputes and Member Appeals

Chapter 15 Claim Disputes and Member Appeals 15 Claim Disputes and Member Appeals CLAIM DISPUTE AND STATE FAIR HEARING PROCESS (FOR PROVIDERS) Health Choice Arizona processes provider Claim Disputes and State Fair Hearings in accordance with established

More information

CLAIMS AND BILLING INSTRUCTIONAL MANUAL

CLAIMS AND BILLING INSTRUCTIONAL MANUAL CLAIMS AND BILLING INSTRUCTIONAL MANUAL 2007 TABLE OF ONTENTS Paper Claims and Block Grant Submission Requirements... 3 State Requirements for Claims Turnaround Time... 12 Claims Appeal Process... 13 Third

More information

Qtr 2. 2011 Provider Update Bulletin

Qtr 2. 2011 Provider Update Bulletin West Virginia Medicaid WEST VIRGINIA Department of Health & Human Resources Qtr 2. 2011 Provider Update Bulletin West Virginia Medicaid Provider Update Bulletin Qtr. 2, 2011 Volume 1 Inside This Issue:

More information

Handbook for Home Health Agencies

Handbook for Home Health Agencies Handbook for Home Health Agencies Chapter R-200 Policy and Procedures For Home Health Agencies Illinois Department of Public Aid CHAPTER R-200 Home Health Agency Services TABLE OF CONTENTS FOREWORD R-200

More information

Medical and Rx Claims Procedures

Medical and Rx Claims Procedures This section of the Stryker Benefits Summary describes the procedures for filing a claim for medical and prescription drug benefits and how to appeal denied claims. Medical and Rx Benefits In-Network Providers

More information

Mental Health Rehabilitative Services and Mental Health Targeted Case Management TXPEC-0870-14

Mental Health Rehabilitative Services and Mental Health Targeted Case Management TXPEC-0870-14 Mental Health Rehabilitative Services and Mental Health Targeted Case Management TXPEC-0870-14 1 Agenda Key contacts Eligibility Mental Health Rehabilitative services (MHR) and Mental Health Targeted (TCM)

More information

Top 50 Billing Error Reason Codes With Common Resolutions (09-12)

Top 50 Billing Error Reason Codes With Common Resolutions (09-12) Top 50 Billing Error Reason Codes With Common Resolutions (09-12) On the following table you will find the top 50 Error Reason Codes with Common Resolutions for denied claims at Virginia Medicaid. This

More information

Surgical/ASC Claims Revenue Cycle Management: An Introduction to Our Processes and Protocols

Surgical/ASC Claims Revenue Cycle Management: An Introduction to Our Processes and Protocols Surgical/ASC Claims Revenue Cycle Management: An Introduction to Our Processes and Protocols 200 Old Country Road, Suite 470 Mineola, NY 11501 Phone: 516-294-4118 Fax: 516-294-9268 www.businessdynamicslimited.com

More information

Billing Guidelines Manual for Contracted Professional HMO Claims Submission

Billing Guidelines Manual for Contracted Professional HMO Claims Submission Billing Guidelines Manual for Contracted Professional HMO Claims Submission The Centers for Medicare and Medicaid Services (CMS) 1500 claim form is the acceptable standard for paper billing of professional

More information

Title 40. Labor and Employment. Part 1. Workers' Compensation Administration

Title 40. Labor and Employment. Part 1. Workers' Compensation Administration Title 40 Labor and Employment Part 1. Workers' Compensation Administration Chapter 3. Electronic Billing 301. Purpose The purpose of this Rule is to provide a legal framework for electronic billing, processing,

More information

Harbor s Payment to Providers Policy and Procedures is available on the Harbor website and will be updated annually or as changes are necessary.

Harbor s Payment to Providers Policy and Procedures is available on the Harbor website and will be updated annually or as changes are necessary. Original Approval Date: 01/31/2006 Page 1 of 10 I. SCOPE The scope of this policy involves all Harbor Health Plan, Inc. (Harbor) contracted and non-contracted Practitioners/Providers; Harbor s Contract

More information

Early Intervention Central Billing Office. Provider Insurance Billing Procedures

Early Intervention Central Billing Office. Provider Insurance Billing Procedures Early Intervention Central Billing Office Provider Insurance Billing Procedures May 2013 Provider Insurance Billing Procedures Provider Registration Each provider choosing to opt out of billing for one,

More information

CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030

CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030 CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030 Missing service provider zip code (box 32) 031 Missing pickup

More information

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

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

More information

Compensation and Claims Processing

Compensation and Claims Processing Compensation and Claims Processing Compensation The network rate for eligible outpatient visits is reimbursed to you at the lesser of (1) your customary charge, less any applicable co-payments, coinsurance

More information

Handbook for Providers of Therapy Services

Handbook for Providers of Therapy Services Handbook for Providers of Therapy Services Chapter J-200 Policy and Procedures For Therapy Services Illinois Department of Healthcare and Family Services CHAPTER J-200 THERAPY SERVICES TABLE OF CONTENTS

More information

The Department of Services for Children, Youth and Their Families. Division of Prevention and Behavioral Health Services

The Department of Services for Children, Youth and Their Families. Division of Prevention and Behavioral Health Services The Department of Services for Children, Youth and Their Families Claim Addresses and Telephone Numbers Division of Prevention and Behavioral Health Services Billing Manual for Treatment Service Providers

More information

GEORGIA MEDICAL BILLING AND REIMBURSEMENT FOR WORKERS COMPENSATION

GEORGIA MEDICAL BILLING AND REIMBURSEMENT FOR WORKERS COMPENSATION Approved GEORGIA MEDICAL BILLING AND REIMBURSEMENT FOR WORKERS COMPENSATION Table of Contents Section 1: Section 2: Section 3: Section 4: Section 5: Section 6: Section 7: Section 8: Section 9: Section

More information

BadgerCare Plus & Medicaid SSI Provider Manual

BadgerCare Plus & Medicaid SSI Provider Manual BadgerCare Plus & Medicaid SSI Provider Manual Administered by: Group Health Cooperative of Eau Claire 2503 North Hillcrest Parkway Altoona, WI 54720 715.552.4300 or 888.203.7770 group-health.com 2015

More information

Patient Account Services. Patient Reference & Frequently Asked Questions. Admissions

Patient Account Services. Patient Reference & Frequently Asked Questions. Admissions Patient Account Services Patient Reference & Frequently Asked Questions Admissions Each time you present for a new medical service, a new account number will be assigned. You will be asked to pay any patient

More information

Please have the following available when calling to ensure timely assistance:

Please have the following available when calling to ensure timely assistance: Please submit claims for Molina Healthcare Medicaid, Healthy Michigan Plan and MIChild to the following billing address: Molina Healthcare P.O. Box 22668 Long Beach, CA 90801 Please do not submit initial

More information

Providers must attach a copy of the payer s EOB with the UnitedHealthcare Community Plan dental claim (2012 ADA form).

Providers must attach a copy of the payer s EOB with the UnitedHealthcare Community Plan dental claim (2012 ADA form). UnitedHealthcare Community Plan (formerly APIPA) Medicaid Dental Claims and Billing Process Effective Dates of Service October 01, 2015 or after AHCCCS Provider Identification Number and NPI Number All

More information

Glossary of Insurance and Medical Billing Terms

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

More information

SUBCHAPTER 10F ELECTRONIC BILLING RULES SECTION.0100 ADMINISTRATION

SUBCHAPTER 10F ELECTRONIC BILLING RULES SECTION.0100 ADMINISTRATION SUBCHAPTER 10F ELECTRONIC BILLING RULES SECTION.0100 ADMINISTRATION 04 NCAC 10F.0101 ELECTRONIC MEDICAL BILLING AND PAYMENT REQUIREMENT Carriers and licensed health care providers shall utilize electronic

More information

005. Independent Review Organization External Review Annual Report Form

005. Independent Review Organization External Review Annual Report Form Title 210 NEBRASKA DEPARTMENT OF INSURANCE Chapter 87 HEALTH CARRIER EXTERNAL REVIEW 001. Authority This regulation is adopted by the director pursuant to the authority in Neb. Rev. Stat. 44-1305 (1)(c),

More information

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

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

More information

New York Health Insurance Marketplace Provider Resource Guide

New York Health Insurance Marketplace Provider Resource Guide New York Health Insurance Marketplace Provider Resource Guide WellCare Health Plans, Inc., (WellCare) understands that having access to the right tools can help you and your staff streamline day-to-day

More information

Request for Claim Review Form

Request for Claim Review Form COMPLETE ALL INFORMATION REQUIRED ON THE REQUEST FOR CLAIM REVIEW FORM. INCOMPLETE SUBMISSIONS WILL BE RETURNED UNPROCESSED. Please direct any questions regarding this form to the plan to which you submit

More information

Network Facility Handbook

Network Facility Handbook Network Facility Handbook 115 Fifth Avenue New York, NY 10003 www.multiplan.com Table of Contents Introduction... 3 Section One Important Definitions...4 Section Two Network Participation...6 Section Three

More information

01172014_MHP_ProTrain_Billing

01172014_MHP_ProTrain_Billing 01172014_MHP_ProTrain_Billing Welcome to Magnolia Health s Billing Clinic 101! We thank you for being part of or considering Magnolia s network of participating providers, hospitals, and other healthcare

More information

Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account

Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account PAYER ID: SUBMITTER ID: Emdeon Claims Provider Information Form *This form is to ensure accuracy in updating the appropriate account 1 Provider Organization Practice/ Facility Name Provider Name Tax ID

More information

Chapter 5 Claims Submission Unit 1: Benefits of Electronic Communication

Chapter 5 Claims Submission Unit 1: Benefits of Electronic Communication Chapter 5 Claims Submission Unit 1: Benefits of Electronic Communication In This Unit Topic See Page Unit 1: Benefits of Electronic Communication Electronic Connections 2 Electronic Claim Submission Benefits

More information

Insurance Intake Form, Authorization and Assignment of Benefits

Insurance Intake Form, Authorization and Assignment of Benefits Recipient Information Insurance Intake Form, Authorization and Assignment of Benefits Return completed and signed form with copies of insurance card(s), front and back, to: Fax: (303) 200-5441 E-mail:

More information

Zimmer Payer Coverage Approval Process Guide

Zimmer Payer Coverage Approval Process Guide Zimmer Payer Coverage Approval Process Guide Market Access You ve Got Questions. We ve Got Answers. INSURANCE VERIFICATION PROCESS ELIGIBILITY AND BENEFITS VERIFICATION Understanding and verifying a patient

More information

CLAIM FORM REQUIREMENTS

CLAIM FORM REQUIREMENTS CLAIM FORM REQUIREMENTS When billing for services, please pay attention to the following points: Submit claims on a current CMS 1500 or UB04 form. Please include the following information: 1. Patient s

More information

Florida Medicaid Provider Resource Guide

Florida Medicaid Provider Resource Guide Florida Medicaid Provider Resource Guide Staywell Health Plan of Florida, Inc., (WellCare) understands that having access to the right tools can help you and your staff streamline day-to-day administrative

More information

SHARP HEALTH PLAN Provider Notice CLAIMS SETTLEMENT PRACTICES, DISPUTE RESOLUTION MECHANISM & FEE SCHEDULE NOTICE

SHARP HEALTH PLAN Provider Notice CLAIMS SETTLEMENT PRACTICES, DISPUTE RESOLUTION MECHANISM & FEE SCHEDULE NOTICE SHARP HEALTH PLAN Provider Notice CLAIMS SETTLEMENT PRACTICES, DISPUTE RESOLUTION MECHANISM & FEE SCHEDULE NOTICE As required by Assembly Bill 1455, the California Department of Managed Health Care has

More information

IHCP 3 rd Quarter Workshop Hoosier Healthwise/HIP. MDwise Claims HHW HIPP0264 (6/13) Exclusively serving Indiana families since 1994.

IHCP 3 rd Quarter Workshop Hoosier Healthwise/HIP. MDwise Claims HHW HIPP0264 (6/13) Exclusively serving Indiana families since 1994. IHCP 3 rd Quarter Workshop Hoosier Healthwise/HIP MDwise Claims HHW HIPP0264 (6/13) Exclusively serving Indiana families since 1994. Agenda 1. Provider Enrollment 2. Claim submission for MDwise Hoosier

More information

AETNA MEDICARE OPEN SM PLAN PROVIDER TERMS AND CONDITIONS OF PAYMENT

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

More information

Medicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) FQHC/RHC Claims and Billing Training

Medicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) FQHC/RHC Claims and Billing Training Medicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) FQHC/RHC Claims and Billing Training 2012 Provider Training Rev 030512 A Division of Health Care Service Corporation,

More information

Long Term Care (LTC) Nursing Facility Resource Guide

Long Term Care (LTC) Nursing Facility Resource Guide Long Term Care (LTC) Nursing Facility Resource Guide January 2015 Table of Contents Section 1: Introduction and Overview Introduction... 4 Purpose and Organization of Long Term Care Nursing Facility Resource

More information

Understanding Your Role in Maximizing Revenue in a FQHC

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

More information

MEDICAL CLAIMS AND ENCOUNTER PROCESSING

MEDICAL CLAIMS AND ENCOUNTER PROCESSING MEDICAL CLAIMS AND ENCOUNTER PROCESSING February, 2014 John Williford Senior Director Health Plan Operations 2 Medical Claims and Encounter Processing Medical claims and encounter processing is part of

More information

ANSI REASON CODES Code Description

ANSI REASON CODES Code Description ANSI REASON CODES Reason codes, and the text messages that define those codes, are used to explain why a claim may not have been paid in full. For instance, there are reason codes to indicate that a particular

More information

Premera Blue Cross Medicare Advantage Provider Reference Manual

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

More information

MyCare Ohio Skilled Nursing Facility Orientation

MyCare Ohio Skilled Nursing Facility Orientation MyCare Ohio Skilled Nursing Facility Orientation Demonstration/Pilot Area Demonstration/Pilot Area 2 Health Plan Options Northwest Southwest West Central Central East Central Northeast Central Northeast

More information

May 13, 2015 Third Party Liability Recovery

May 13, 2015 Third Party Liability Recovery May 13, 2015 Third Party Liability Recovery On May 13, 2015, the Department of Public Welfare's (Department) Division of Third Party Liability (TPL) issued a Medicare Part B TPL/Coordination of Benefits

More information

1. All patient services must be billed on a fully completed CMS 1500 or UB04 form, unless otherwise indicated by contract.

1. All patient services must be billed on a fully completed CMS 1500 or UB04 form, unless otherwise indicated by contract. Claims 8.0 As a Participating Provider billing for services with a fee-for-service contract with MAPMG, please follow the procedures listed below. Participating Providers billing for services rendered

More information

MEDICAID BASICS BOOK Third Party Liability

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

More information

Payer Agreement Instructions for Trailblazer Medicare Payers

Payer Agreement Instructions for Trailblazer Medicare Payers Capario EDI 1901 E. Alton Ave. #100 Santa Ana, CA. 92705 Phone: (800) 792-5256 Option 1 Fax: (404) 877-3324 provider.enrollment@capario.com Payer Agreement Instructions for Trailblazer Medicare Payers

More information

Basics of the Healthcare Professional s Revenue Cycle

Basics of the Healthcare Professional s Revenue Cycle Basics of the Healthcare Professional s Revenue Cycle Payer View of the Claim and Payment Workflow Brenda Fielder, Cigna May 1, 2012 Objective Explain the claim workflow from the initial interaction through

More information

Molina Healthcare Post ICD 10 FAQ

Molina Healthcare Post ICD 10 FAQ Molina Healthcare Post ICD 10 FAQ On March 31, 2014, the Senate voted to approve a bill to delay the implementation of ICD-10-CM/ PCS by at least one year. President Obama signed the bill into law on April

More information

KPMAS also has the ability to receive your claims electronically through the Emdeon Clearinghouse.

KPMAS also has the ability to receive your claims electronically through the Emdeon Clearinghouse. 8.0 Claims As a Participating Provider billing for services with a fee-for-service contract with MAPMG, please follow the procedures listed below. Participating Providers billing for services rendered

More information

Enrollment Guide for Electronic Services

Enrollment Guide for Electronic Services Enrollment Guide for Electronic Services 2014 Kareo, Inc. Rev. 3/11 1 Table of Contents 1. Introduction...1 1.1 An Overview of the Kareo Enrollment Process... 1 2. Services Offered... 2 2.1 Electronic

More information

Claims Filing Instructions

Claims Filing Instructions Claims Filing Instructions Table of Contents Procedures for Claim Submission... 3 Claims Filing Deadlines...4 Claim Requests for Reconsideration, Claim Disputes and Corrected Claims...5 Procedures for

More information

OSCAR Health Insurance Frequently Asked Questions/General Information

OSCAR Health Insurance Frequently Asked Questions/General Information Q: What is the relationship between Oscar and ValueOptions? A. ValueOptions administers the mental health and substance abuse benefits for Oscar Health Insurance. They have contracted with ValueOptions,

More information

Provider Adjustment, Time limit & Medicare Override Job Aid

Provider Adjustment, Time limit & Medicare Override Job Aid Provider Adjustment, Time limit & Medicare Override Job Aid Contents Overview... 1 Medicaid Resolution Inquiry Form... 1 Medicare Overrides... 3 Time Limit Overrides... 3 Adjusting a Claim through the

More information

California Division of Workers Compensation Medical Billing and Payment Guide 2007

California Division of Workers Compensation Medical Billing and Payment Guide 2007 California Division of Workers Compensation Medical Billing and Payment Guide 2007 Draft Version July 26, 2007 1 INTRODUCTION... 3 SECTION ONE BUSINESS RULES...4 1.0 STANDARDIZED BILLING / ELECTRONIC BILLING

More information

Handbook for Home Health Agencies. Chapter R-200 Policy and Procedures For Home Health Agencies

Handbook for Home Health Agencies. Chapter R-200 Policy and Procedures For Home Health Agencies Handbook for Home Health Agencies Chapter R-200 Policy and Procedures For Home Health Agencies Illinois Department of Healthcare and Family Services Issued February 2011 Chapter R-200 Home Health Agency

More information

Final. National Health Care Billing Audit Guidelines. as amended by. The American Association of Medical Audit Specialists (AAMAS)

Final. National Health Care Billing Audit Guidelines. as amended by. The American Association of Medical Audit Specialists (AAMAS) Final National Health Care Billing Audit Guidelines as amended by The American Association of Medical Audit Specialists (AAMAS) May 1, 2009 Preface Billing audits serve as a check and balance to help ensure

More information

CONNECTIONS TESTING FOR ICD-10

CONNECTIONS TESTING FOR ICD-10 TESTING FOR ICD-10 In conjunction with the Centers for Medicare and Medicaid Services (CMS), Providence Health Plan (PHP) and all major payers will convert from International Classification of Diseases,

More information

TABLE OF CONTENTS. Claims Processing & Provider Compensation

TABLE OF CONTENTS. Claims Processing & Provider Compensation TABLE OF CONTENTS Claims Address... 2 Claim Submission... 2 Claim Payment... 2 Claim Payment Adjustments.... 2 Claim Disputes... 2 Recovery of Overpayments... 3 Balance Billing... 3 Annual Health Assessment

More information

Jurisdiction D EDI Customer Profile Instructions

Jurisdiction D EDI Customer Profile Instructions Jurisdiction D EDI Jurisdiction D EDI Customer Profile Instructions IMPORTANT: Read the instructions before completing your applications. Incomplete or incorrect applications will be returned. The entity

More information

MEDICARE PART B CALIFORNIA SOUTH PRE ENROLLMENT INSTRUCTIONS MR002

MEDICARE PART B CALIFORNIA SOUTH PRE ENROLLMENT INSTRUCTIONS MR002 MEDICARE PART B CALIFORNIA SOUTH PRE ENROLLMENT INSTRUCTIONS MR002 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is approximately 4 6 weeks. WHAT FORM SHOULD I DO? EDI Enrollment Agreement

More information

VI. Appeals, Complaints & Grievances

VI. Appeals, Complaints & Grievances A. Definition of Terms In compliance with State requirements, ValueOptions defines the following terms related to Enrollee or Provider concerns with the NorthSTAR program: Administrative Denial: A denial

More information

ActivHealthCare EDI User Guide

ActivHealthCare EDI User Guide ActivHealthCare EDI User Guide Table of Contents Page Enrollment 2 Preparing Your Management Software 3 Claims Submission for AHC Network Affiliates 4 Online Entry Tool 7 Claims Follow-Up 8 Frequently

More information

Texas Workers Compensation

Texas Workers Compensation Texas Workers Compensation Tips for Successful Medical Billing and Reimbursement Practices Presented by: Regina Schwartz Health Care Specialist Texas Dept of Insurance - Division of Workers Compensation

More information

Arkansas Department Of Health and Human Services Division of Medical Services P.O. Box 1437, Slot S-295 Little Rock, AR 72203-1437

Arkansas Department Of Health and Human Services Division of Medical Services P.O. Box 1437, Slot S-295 Little Rock, AR 72203-1437 Arkansas Department Of Health and Human Services Division of Medical Services P.O. Box 1437, Slot S-295 Little Rock, AR 72203-1437 Fax: 501-682-2480 TDD: 501-682-6789 Internet Website: www.medicaid.state.ar.us

More information

New York. UnitedHealthcare Community Plan Claims System Migration Provider Quick Reference Guide. Complete Claims. Our Claims Process

New York. UnitedHealthcare Community Plan Claims System Migration Provider Quick Reference Guide. Complete Claims. Our Claims Process Our Claims Process Here are a few steps to ensure you receive prompt payment: 1 Review and copy both sides of the member s ID card. members receive an ID card containing information that helps you process

More information

(2) compliance with the treatment guidelines established by the Division;

(2) compliance with the treatment guidelines established by the Division; 133.301. Retrospective Review of Medical Bills. (a) The insurance carrier shall retrospectively review all complete medical bills and pay for or deny payment for medical benefits in accordance with the

More information

ifuse Implant System Patient Appeal Guide

ifuse Implant System Patient Appeal Guide ifuse Implant System Patient Appeal Guide Table of Contents PURPOSE OF THIS BOOKLET...................................................... 2 GUIDE TO THE APPEALS PROCESS..................................................

More information

EZClaim Advanced 9 ANSI 837P. Capario Clearinghouse Manual

EZClaim Advanced 9 ANSI 837P. Capario Clearinghouse Manual EZClaim Advanced 9 ANSI 837P Capario Clearinghouse Manual EZClaim Medical Billing Software December 2013 Capario Client ID# Capario SFTP Password Enrollment Process for EDI Services 1. Enroll with the

More information

SECTION E Molina Healthcare CLAIMS

SECTION E Molina Healthcare CLAIMS SECTION E Molina Healthcare CLAIMS CLAIMS CLAIM SUBMISSION (Refer to Section J, Claims, in the 2007 Provider Manual for detailed information) Professional Fees Claims must be submitted on a CMS (Centers

More information

MEDICARE ADVANTAGE PRIVATE FEE FOR SERVICE (PFFS) PLAN 2009 TERMS AND CONDITIONS OF PAYMENT. Table of Contents

MEDICARE ADVANTAGE PRIVATE FEE FOR SERVICE (PFFS) PLAN 2009 TERMS AND CONDITIONS OF PAYMENT. Table of Contents MEDICARE ADVANTAGE PRIVATE FEE FOR SERVICE (PFFS) PLAN 2009 TERMS AND CONDITIONS OF PAYMENT 1. Introduction Table of Contents 2. When a provider is deemed to accept Blue Cross of Idaho Flexi Blue PFFS

More information

Provider Manual. Billing and Payment

Provider Manual. Billing and Payment Provider Manual Billing and Payment Billing and Payment This section of the Manual was created to help guide you and your staff in working with Kaiser Permanente s billing and payment policies and procedures.

More information

Sending Electronic Secondary Claims

Sending Electronic Secondary Claims Sending Electronic Secondary Claims Claim Adjustment Codes When submitting secondary claims electronically, you need to add Claim Adjustment Codes (CAS). These are adjustment codes that associate any adjustment

More information

Table of Contents. Introduction Provider Manual 4 Disclaimer 4 Key Term 4

Table of Contents. Introduction Provider Manual 4 Disclaimer 4 Key Term 4 Provider Manual Table of Contents Introduction Provider Manual 4 Disclaimer 4 Key Term 4 How to Contact Us 5 Provider Resources Member ID Cards 6 Customer Service Telephone Numbers 10 Provider Web Site

More information

COLORADO MEDICAL ASSISTANCE PROGRAM

COLORADO MEDICAL ASSISTANCE PROGRAM COLORADO MEDICAL ASSISTANCE PROGRAM Electronic Data Interchange (EDI) Submitter Enrollment & Agreement The Colorado Medical Assistance Program PO Box 1100 Denver, Colorado 80201-1100 1-800-237-0757 ELECTRONIC

More information

MEDICARE TEXAS (TRAILBLAZERS) PRE ENROLLMENT INSTRUCTIONS MR085

MEDICARE TEXAS (TRAILBLAZERS) PRE ENROLLMENT INSTRUCTIONS MR085 MEDICARE TEXAS (TRAILBLAZERS) PRE ENROLLMENT INSTRUCTIONS MR085 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 5 business days after receipt. WHAT FORM(S) SHOULD I COMPLETE? IF you have

More information

Electronic Data Interchange Companion Document

Electronic Data Interchange Companion Document Electronic Data Interchange Companion Document HIPAA...3 Getting Started with EDI...4 When You Are Set Up for EDI...4 When You Are Ready to Go Live...5 Specifications for 837P Transactions...6 Transaction

More information