Medicare Advantage Provider Manual

Transcription

1 Medicare Advantage Provider Manual

2 Provider Manual

3 Table of Contents SECTION 5: BILLING AND PAYMENT INTRODUCTION KEY CONTACTS ELECTRONIC DATA INTERCHANGE (EDI) Billing Guidelines for Electronic Claims National Provider Identifier (NPI) Federal Tax Identification Number (TIN) Coordination of Benefits Electronic Data Interchange (EDI) Requirements... 8 BENEFITS OF EDI CLAIMS SUBMISSION... 8 HIPPA Requirements... 8 EDI ROLES... 9 UNDERSTANDING ELECTRONIC SUBMISSION PROCESS... 9 TO INITIATE ELECTRONIC CLAIM SUBMISSIONS TO INITIATE ELECTRONIC PAYMENT/ REMITTANCE ADVICE TO INITIATE ELECTRONIC FUNDS TRANSFER HEALTHSPAN REQUIREMENTS SUPPORTING DOCUMENTATION EDI CLAIM ERRORS CORRECTION & RESUBMISSION FOR ACCEPTED EDI CLAIMS PAPER CLAIMS Billing Guidelines for Paper Claims National Provider Identifier (NPI) Paper Claims Address: Paper Claim Tips Federal Tax Identification Number (TIN) Coordination of Benefits SUPPORTING DOCUMENTATION Supporting Documentation Cover Sheet CLAIM CORRECTIONS Professional Claims: P Electronic Claims

4 CMS-1500 Form Paper Claims Institutional Claims: I Electronic Claims CLAIM SUBMISSION TIMEFRAMES Initial Claim Submissions: Payment consideration for Claims filed/appealed after filing limit: CLAIM PROCESSING TIMEFRAMES INCORRECT CLAIM PAYMENTS PROVIDER PAYMENT DISPUTES PROVIDER APPEALS MEMBER HOLD HARMLESS CODING AND BILLING VALIDATION CODING RULE DESCRIPTIONS DO NOT BILL EVENTS (DNBE) Claims Submission Related to a Do Not Bill Event Institutional Claims Professional Claims ANESTHESIA GLOBAL ANESTHESIA PACKAGE OFFICE-BASED SURGICAL PROCEDURES ANESTHESIA REPORTING REQUIREMENTS & REIMBURSEMENT EXCEPTIONS TO BILLING ANESTHESIA CODES ANESTHESIA MODIFIERS ADDITIONAL SERVICES BEHAVIORAL HEALTH SERVICES DURABLE MEDICAL EQUIPMENT (DME) EVALUATION/ MANAGEMENT (E/M) SERVICES EMERGENCY ROOM (ER) SERVICES INJECTIONS/ IMMUNIZATIONS INJECTIONS/ IMMUNIZATIONS cont NEWBORN SERVICES OUTPATIENT REHABILITATION COORDINATION OF BENEFITS (COB) DESCRIPTIONS OF COB PAYMENT METHODOLOGIES COB QUESTIONS

5 EOB or MSN STATEMENT MEMBERS ENROLLED IN TWO HEALTHSPAN PLANS IMPORTANT COB POINTS TO REMEMBER EXPLANATION OF PAYMENT (EOP) FORM Explanation of Payment (EOP) Form Field Descriptions Sample Explanation of Payment (EOP) Form INSTRUCTIONS FOR BILLING SAME/DIFFERENT DATES OF SERVICE & PLACES OF SERVICE TABLE

6 5.1 Introduction HealthSpan has developed Section 5 of the Provider Manual for use by all Plan Practitioners/Providers and their staff to: Educate Practitioners/Providers about HealthSpan s Claims submission requirements. Reduce the number of Claim rejections and/or Claim re-submissions because of initial Claim errors. Facilitate timely payment of Claims. Simplify and clarify increasingly complex coding/billing requirements. NOTE: HealthSpan will only pay for Covered healthcare Services when HealthSpan Referral and Authorization requirements are met. This policy includes those instances when HealthSpan is the secondary Payor for HealthSpan Medicare Advantage Members. If you have any questions relating to Claims policies and procedures, Claim status Provider Disputes or Appeals, call the HealthSpan Customer Relations Department at , option 1. We encourage all Plan Practitioners/Providers and their staff to become familiar with the requirements outlined in this Section of the Provider Manual which either conform to or are permitted by applicable federal, state and local regulations. We welcome Plan Provider input as to how we can make this Section of the Manual more useful and informative. Please forward any comments/suggestions for documentation improvements to: 5.2 Key Contacts HealthSpan Network Development and Performance Department 1001 Lakeside Avenue, Suite 1200 Cleveland, OH See Section Two of this HealthSpan for a list of Key Contacts by Department. 5

7 5.3 Electronic Data Interchange (EDI) EDI is an exchange of information in a standardized format that adheres to all Health Insurance Portability and Accountability Act (HIPAA) requirements. EDI Claims transactions replace the submission of paper Claims. The Claim Status Inquiry and Notification transactions eliminate the need to telephone HealthSpan to determine the status of an outstanding Claim. The Benefit Coverage and Eligibility Inquiry and Response eliminates the need to telephone HealthSpan to determine a Member s Eligibility status Billing Guidelines for Electronic Claims National Provider Identifier (NPI) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that all providers use a standard unique identifier on all standard electronic transactions. Your National Provider Identifier (NPI) must be used on all HIPAA-standard electronic transactions. Electronic Transactions: HealthSpan exchanges the following electronic transactions: HealthSpan receives: 837P - Professional Healthcare Claim 837I - Institutional Healthcare Claim Healthcare Eligibility, Coverage or Benefit Inquiry Healthcare Claim Status Request HealthSpan sends: Functional Acknowledgement Healthcare Claim payment/remittance advice Healthcare Eligibility, Coverage or Benefit Information Healthcare Claims status Notification 277U - Unsolicited Healthcare Claim Status Notification Federal Tax Identification Number (TIN) The TIN as reported on any and all Claim forms must match the information filed with the Internal Revenue Service (IRS). Failure to report the correct TIN - - as filed with the IRS at the time of incorporation or start of the business -- could result in a 28% backup withholding tax (payable to the IRS) and/or the suspension of any and all payments made to the Practitioner/Provider by HealthSpan, until this matter is resolved. 6

8 IRS Form W-9: Request for Taxpayer Identification Number and Certification. When completing IRS Form W-9, note the following: 1) Name This should be the equivalent of your entity name, which you use to file your tax forms with the IRS. Sole Practitioner/Proprietor: List your name, as registered with the IRS. Group Practice/Facility: List your group or facility name, as registered with the IRS. 2) Business Name Leave this field blank, unless you have registered with the IRS as a Doing Business As (DBA) entity. If you are doing business under a different name, enter that name here. 3) Address/City, State, Zip Code Enter the address where HealthSpan should mail your IRS Form ) Taxpayer Identification Number (TIN) The number reported in this field (either the social security number or the employer identification number) MUST be used on all Claims submitted to HealthSpan. Sole Practitioner/Proprietor: Enter your taxpayer identification number, which will usually be your social security number (SSN), unless you have been assigned a unique employer identification number (because you are doing business as an entity under a different name). Group Practice/Facility: Enter your taxpayer identification number, which will usually be your unique employer identification number (EIN). If you have any questions regarding the proper completion of IRS Form W-9, or the correct reporting of your TIN on your Claim forms, call the IRS help line in your area or refer to the following website: irs.gov/forms-&-pubs Completed IRS Form W-9 should be mailed to the following address: HealthSpan Network Development and Performance Department 1001 Lakeside Avenue, Suite 1200 Cleveland, OH

9 NOTE: If your TIN should change, notify the HealthSpan Network Development and Performance Department immediately, so that appropriate corrections can be made to HealthSpan s records. Failure to do so may delay Claim payment Coordination of Benefits Explanation of Benefit (EOB) or Medicare Summary Notice (MSN) Required. If HealthSpan is the secondary Payor, send the completed electronic Claim with the payment fields from the primary insurance carrier, as per the X12 requirements. For more information regarding see page 42 of this Section Electronic Data Interchange (EDI) Requirements HealthSpan is contracted exclusively with RelayHealth. RelayHealth identifies us using the electronic payor ID RH007 which needs to be populated in loop 2010BB, segment NM109 on all submitted Claims. TOPIC INSTRUCTIONS BENEFITS OF EDI CLAIMS SUBMISSION HIPPA Requirements 1) Reduced Overhead Expenses Administrative expenses are reduced; there is no longer a need to print or mail Claims or to call HealthSpan by phone for information. 2) Improved Data Accuracy Since there is no need to re-enter data, data accuracy of Claims is improved, improving Claims payment quality and speed. Both the billing software and the EDI Clearinghouse apply validations to the data that ensure the Claims data is accurate before the Claim is processed. 3) Decreased Claim Turnaround Electronic Claims can be received more quickly than those submitted on paper. Once received, they can be loaded to the Claims processing system more quickly and accurately, enabling a faster turnaround time. Claims submitted electronically must adhere to all Health Insurance Portability and Accountability Act (HIPAA) requirements. The following websites (listed in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Practitioner/Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at

10 TOPIC EDI ROLES UNDERSTANDING ELECTRONIC SUBMISSION PROCESS INSTRUCTIONS 1) Submitter: An EDI submitter is the party sending a transaction. For Claims submission, this is usually the Practitioner/Provider or a billing service submitting Claims on its behalf. 2) Clearinghouse: An intermediary that receives transactions from multiple submitters and sends transactions to the correct recipient. A Clearinghouse may also perform validations and edits on the transactions to ensure their compliance with HIPAA guidelines, or with standards unique to a specific recipient. 3) Recipient: The party receiving a transaction. For Claims submission, this is HealthSpan. 1) Practitioners /Providers EDI Responsibilities: A Practitioner/Provider sets up a contract with a Clearinghouse to submit Claims to payers. The Practitioner/Provider enters all of the required data Claims elements and sends all of this information to the contracted Clearinghouse for further data sorting and distribution. The Practitioner/Provider is responsible for ensuring that the transaction complies with the HIPAA requirements and contains all information necessary to process the Claim. NOTE: All EDI transactions must be routed through HealthSpan s preferred Clearing House, Relay Health. 2) Clearinghouse s EDI Responsibilities: The Clearinghouse receives information from a variety of Practitioners/Providers. The Clearinghouse batches all of the information sorts the information by payer, and then sends the information to the correct payer for processing. The Clearinghouse should ensure the transactions are in compliance with the HIPAA requirements, and may apply unique edits specified by the payer. In addition, Clearinghouses: Often provide software enabling direct data entry in the Practitioner s/provider s office. Edit the submitted data so that it is accepted by the payer. Transmit the data to the correct payer in a standard format NOTE: If a Clearinghouse has a contract with a Practitioner/Provider to process Claims transactions, but does not have a contract with the payer to send that payer Claims transactions, the Clearinghouse will work with other Clearinghouse s to route the claim to the payer. Therefore, the Clearinghouse to which a Practitioner/Provider submits Claims may not be the same Clearinghouse that delivers those Claims to HealthSpan. 3) HealthSpan s EDI Responsibilities: HealthSpan receives the EDI information from the Clearinghouse distribution, and loads it into HealthSpan Claims processing 9

11 TOPIC UNDERSTANDING ELECTRONIC SUBMISSION PROCESS cont. TO INITIATE ELECTRONIC CLAIM SUBMISSIONS TO INITIATE ELECTRONIC PAYMENT/ REMITTANCE ADVICE INSTRUCTIONS system. When Claims are received, HealthSpan prepares an electronic acknowledgement (997 transaction) which is sent to the Clearinghouse. NOTE: A Practitioner/Provider may work with their Clearinghouse to receive HealthSpan s acknowledgement. When Claims are rejected by HealthSpan for Fatal front-end Errors, HealthSpan returns a Claims status transaction (277U) detailing why the claim was rejected. Rejected Claims may be re-submitted once they are corrected. When Claims are paid, HealthSpan will, if requested, return a payment/remittance advice (835) transaction to the Clearinghouse requested by the provider. 1) No Registration with HealthSpan is Required for Claims Submission A Practitioner/Provider does not need to register with HealthSpan to submit Claims electronically. It is the Practitioner/Provider s responsibility to set up a contract with a Clearinghouse to process the Claim submissions. 2) Electronic Payer ID HealthSpan is contracted exclusively with RelayHealth. RelayHealth identifies us using the electronic payor ID RH007 which needs to be populated in loop 2010BB, segment NM109 on all submitted claims. 1) Registration Is Required to receive Electronic /Remittance Advice (835) A Practitioner/Provider must register with both their Clearinghouse and HealthSpan to receive a Payment/Remittance Advice (835) transaction when Claims are finalized. 2) Requesting an 835 Registration Form To register for 835, a Practitioner/Provider can: Go to HealthSpan s Provider website (healthspan.org/providers/north-coast) and download the registration form. Call the Customer Relations Department at , option 1 and request the form. the HealthSpan EDI Coordinator (EDI_Coordinator@healthspan.org) to request the form. Once the form is received by HealthSpan, set-up can take up to two weeks. 3) Paper Remittance Advice Unless requested, HealthSpan will continue to send the Explanation of Payment even when the Electronic Payment/Remittance advice transaction is enabled. 10

12 TOPIC INSTRUCTIONS TO INITIATE ELECTRONIC FUNDS TRANSFER HEALTHSPAN REQUIREMENTS While not technically an EDI transaction, Electronic Funds Transfer (EFT) or Direct Deposit is also available from HealthSpan. An EFT transaction replaces a paper check for the payment of Claims. Requesting an EFT Authorization Agreement To request an EFT Authorization Agreement, a Practitioner/Provider can: Go to HealthSpan s Provider website (healthspan.org/providers/north-coast) and download the form. Call the Customer Relations Department , option 1 and request the form. the HealthSpan EDI Coordinator (EDI_Coordinator@healthspan.org) to request the form. Once the form is received by HealthSpan, set-up and pre-payment testing with the bank can take up to four weeks. Additional HealthSpan EDI data requirements are reflected within the HealthSpan EDI Companion Guide, which may be obtained by contacting the Customer Relations Department at , option 1. Items of note within this document include: Unique Provider Per Claim In cases where there are multiple providers for the same Claim, split the Claim by provider and list the individual provider only at the Claim level. HealthSpan Member Identification Number (Medical Record Number {MRN}) Subscriber vs Patient: Submit Claims using only the patient's information (e.g. name, date of birth, MRN/ID). Do not use the Subscriber's information. Since each HealthSpan Member has a unique MRN/ID, they are considered their own Subscriber for electronic transmissions, i.e. patient relationship = self (18). Professional Claims: Paper: blocks #1a, 2, 3, 4, 5, 6, 7 EDI: 2010BA Institutional Claims: Paper: blocks #12, 13, 14, 15, 58, 59, 60 EDI: 2010BA NOTE: Each HealthSpan Member has a unique Member identification number (MRN. Do not use a parent s HealthSpan Medical Record Number on a Claim for a child; similarly, do not use a spouse s MRNon a Claim for the other spouse. Beginning in 2015, MRNs are eight digits long. SUPPORTING DOCUMENTATION See page 16 of this Section. 11

13 TOPIC INSTRUCTIONS EDI CLAIM ERRORS CORRECTION & RESUBMISSION FOR ACCEPTED EDI CLAIMS All electronic Claim submissions are monitored to ensure that an acceptable percentage of Claims are error-free. HealthSpan will contact the Practitioner/Provider if a high rate of Fatal Errors are detected in their EDI Claim submissions. The error(s) will be analyzed and resolved by working with the Practitioner/Provider office or their billing service. CMS-1500 Claim Forms: (837P) HealthSpan prefers corrections to 837P Claims which were already accepted by HealthSpan to be submitted on paper Claim forms. Corrections submitted electronically may inadvertently be denied as a duplicate Claim. UB-04 Claim Forms: (837I) NOTE: 837I corrections may be submitted electronically Electronic Include the appropriate Type of Bill code when electronically submitting a corrected 837I Claim to HealthSpan for processing. NOTE: Claims submitted without the appropriate 3 rd digit (XXX) in the Type of Bill code will be denied. Paper Refer to page 17 for further information and instructions pertaining to paper submission of corrected Claims to HealthSpan for processing. 5.4 Paper Claims Paper Claims MUST be submitted on one of the following standard Claim forms: CMS-1500 (02/12) Required for all professional services and suppliers. Any professional services (for example, services rendered by radiologists, ER physicians, etc.) should be billed on CMS-1500 Claim forms, unless you are contracted under a GLOBAL rate, in which case professional services should not be billed separately. UB-04 Required for all facilities (i.e., hospitals) services. Any professional services (for example, services rendered by radiologists, ER physicians, etc.) should be billed on CMS-1500 Claim forms, unless you are contracted under a GLOBAL rate, in which case professional services should not be billed separately. NOTE: Use standard Claim forms formatted with RED ink to ensure maximum compatibility with HealthSpan s optical scanning equipment. Claim forms 12

14 formatted with black or blue lines will not scan as efficiently as those formatted with red Billing Guidelines for Paper Claims National Provider Identifier (NPI) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that all providers use a standard unique identifier on all standard electronic transactions. Your NPI must be used on all HIPAA-standard electronic transactions Paper Claims Address: HealthSpan P.O. Box 5316 Cleveland, OH Paper Claim Tips Avoid Highlighter Usage/ Use Blue or Black Ink Do not use a highlighter on any Claims or any attachments to a Claim (for example, a Referral form, EOB statement, etc.). When a Claim form or a Referral form is scanned, highlighter shading turns black and blocks key data under the highlighter. You may use blue or black ink. Align Your Office Printer Correctly Align your office printer with the fields on the Claim form. Letters and numbers that fall on the lines of the form will not scan clearly. Verify that the print is clear and dark. If a printer ribbon or cartridge is light, the Claim will not scan clearly and Claims processing will be delayed. Use Paper Clips for Attachments Do not use staples for attachments. Paper clips are acceptable. Avoid Handwritten Information Poor, light handwriting affects scanning quality and processing accuracy. Please submit typed Claims. Do Not Use Super Bills or Encounter Forms as Claim Forms Office super bill or encounter forms are NOT acceptable as Claim forms. These forms delay processing because important Claims information is not in the standard format. Send Originals Whenever Possible Do not submit the second or third page of a multi-part Claim form. The print is often light, smeared, or unreadable. Avoid the use of photocopies and fax copies as well. 13

15 One Member per Claim Form/One Provider per Claim Form Do not bill for different Members on the same Claim form. Do not bill for different Practitioners/Providers on the same Claim form. Complete a separate Claim form for each Member and for each Practitioner/Provider. Record Each Procedure on a Separate Line Only one procedure should be reported on a Claim line number. Do not enter two reimbursable procedures under one Claim line. Do Not Record Any Extraneous or Extra Information on Claim Forms Do not list the narrative descriptions of ICD-9-CM codes, CPT codes, etc. on the CMS-1500 (HCFA-1500) Claim form. Example: Office or Other Outpatient Visit Record only the code itself (99213) on the Claim form, without the accompanying narrative description (Office or Other Outpatient Visit). Do not list any explanations or notes on Claim forms, unless you are specifically instructed to do so. Exceptions: Unclassified drugs: Specify the name of the drug and the NDC#. Durable Medical Equipment (DME) special supplies: Specify the durable medical equipment/supply used Federal Tax Identification Number (TIN) The TIN as reported on any and all Claim forms must match the information filed with the Internal Revenue Service (IRS). Failure to report the correct TIN - - as filed with the IRS at the time of incorporation or start of the business -- could result in a 28% backup withholding tax (payable to the IRS) and/or the suspension of any and all payments made to the Practitioner/Provider by HealthSpan, until this matter is resolved. IRS Form W-9: Request for Taxpayer Identification Number and Certification When completing IRS Form W-9, note the following: 1) Name This should be the equivalent of your entity name, which you use to file your tax forms with the IRS. Sole Practitioner/Proprietor: List your name, as registered with the IRS. Group Practice/Facility: List your group or facility name, as registered with the IRS. 2) Business Name 14

16 Leave this field blank, unless you have registered with the IRS as a Doing Business As (DBA) entity. If you are doing business under a different name, enter that name here. 3) Address/City, State, Zip Code Enter the address where HealthSpan should mail your IRS Form ) Taxpayer Identification Number (TIN) The number reported in this field (either the social security number or the employer identification number) MUST be used on all Claims submitted to HealthSpan. Sole Practitioner/Proprietor: Enter your taxpayer identification number, which will usually be your social security number (SSN), unless you have been assigned a unique employer identification number (because you are doing business as an entity under a different name). Group Practice/Facility: Enter your taxpayer identification number, which will usually be your unique employer identification number (EIN). If you have any questions regarding the proper completion of IRS Form W-9, or the correct reporting of your TIN on your Claim forms, call the IRS help line in your area or refer to the following website: irs.gov/forms-&-pubs Completed IRS Form W-9 should be mailed to the following address: HealthSpan Network Development and Performance Department 1001 Lakeside Avenue, Suite 1200 Cleveland, OH NOTE: If your TIN should change, notify the HealthSpan Network Development and Performance Department immediately, so that appropriate corrections can be made to HealthSpan s records. Failure to do so may delay Claim payment Coordination of Benefits If HealthSpan is the secondary Payor, send the completed Claim form with a copy of the corresponding Explanation of Benefit (EOB) or Medicare Summary Notice (MSN) from the primary insurance carrier attached to the paper Claim 15

17 to ensure efficient processing/adjudication. HealthSpan cannot process a Claim without an EOB or MSN from the primary insurance carrier. If you are submitting a paper Claim for more than one Member on the same MSN, attach a copy of the MSN to each Claim form being submitted. CMS-1500 claim form Complete Field 29 (Amount Paid) UB-04 claim form Complete Field 54 (Prior Payments) See page 42 of this Section for additional information regarding Coordination of Benefits, and for a list of the specific COB fields which must be completed to ensure accurate COB payment determinations. NOTE: Upon a Member s appointment check in, verify if there have been any changes to the insurance coverage. This could include more than one coverage. 5.5 Supporting Documentation To expedite Claims processing and adjudication, a Practitioner/Provider should submit supporting written documentation (for example, copies of pertinent medical records) with certain types of Claims. Supporting Documentation Submitted WITH a Claim: When supporting documentation is submitted WITH the corresponding paper Claim form, attach/secure the documentation to the paper Claim with a paper clip (do not staple) and mail to HealthSpan s mailing address (see page 13 of this Section). Supporting Documentation Submitted SEPARATELY From a Claim: When sending supporting documentation SEPARATELY from the Claim (for example, when sending in requested medical information for a pended Claim) 1) Complete a Supporting Documentation Cover Sheet (see sample and instructions on page 17 of this Section) for each Member for whom you are submitting paper documentation. 2) Attach the cover sheet to each Member s paper documentation with a paper clip. 3) Mail the supporting documentation as per the instructions on the form. For electronic Claim submissions, complete a Supporting Documentation Cover Sheet (see page 17 of this Section for additional information and complete instructions) to submit supporting written documentation. Exception: Coordination of Benefits. 16

18 ATTACHMENT CIRCUMSTANCE ADMITTING NOTES CONTRACTUAL REQUIREMENTS IN THE GLOBAL CONTRACT EXPLANATION OF BENEFITS/ MEDICARE SUMMARY NOTICE ITEMIZED BILL OFFICE/PHYSICIAN NOTES OFFICE VISIT NOTES/ ANESTHESIA RECORDS OPERATIVE NOTES Except in the case of Emergency Services rendered in accordance with Prudent Layperson guidelines, if the Claim is for inpatient services provided outside of the time or scope of the Authorization. Documents referenced in global contract between HealthSpan and a health care Practitioner, hospital, or person entitled to reimbursement. To determine HealthSpan liability when another health plan and/or Medicare is primary for medical coverage. Except in the case of Emergency Services rendered in accordance with Prudent Layperson guidelines, if the claim is for services rendered in a hospital and the hospital claim has no prior authorization for an admission or the admission is inconsistent with a HealthSpan concurrent review determination rendered prior to the delivery of services, regarding the medical necessity of the service. Except in the case of Emergency Services rendered in accordance with Prudent Layperson guidelines, if the claim for services provided is outside of the time or scope of the authorization, or when there is an authorization in dispute. If the claim includes modifier 21 or 22. If the claim for anesthesia services rendered includes modifier P4 or P5. If the claim is for multiple surgeries, or includes modifier 22, 58, 62, 66 or Supporting Documentation Cover Sheet See Appendix F.13 of this HealthSpan. 5.6 Claim Corrections Professional Claims: Use the following guidelines when submitting a corrected Professional Claim to HealthSpan for processing. 17

19 NOTE: HealthSpan prefers corrections to 837P Claims which were already accepted by HealthSpan to be submitted on paper Claim forms. Corrections submitted electronically may inadvertently be denied as a duplicate Claim P Electronic Claims Ensure you include the correct Claim Frequency code is populated in Loop 2300, segment CLM05-3 to indicate the void or replacement claim CMS-1500 Form Paper Claims When submitting a corrected CMS-1500 paper Claim to HealthSpan for processing: 1) Write CORRECTED CLAIM in the top (blank) portion of the standard Claim form. 2) Attach a copy of the corresponding page of HealthSpan s Explanation of Payment (EOP) to each corrected Claim, to prevent these Claims from being rejected by HealthSpan as duplicate Claims. Attach with a paper clip. 3) Mail the corrected Claim(s) to HealthSpan using the standard Claims mailing address (see page 13 in this Section) Institutional Claims: Use the following guidelines when submitting a corrected Institutional Claim to HealthSpan for processing I Electronic Claims Ensure you include the appropriate Claim Frequency Code is populated in Loop 2300, segment CLM05-03 to indicate a void or replacement claim. 5.7 Claim Submission Timeframes Abide by the following guidelines for Claim submission timeframes, to prevent denial for untimely filing Initial Claim Submissions: All Claims must be submitted for processing within 12 months (365 days) of the date of service. Any Claims submitted after 12 months (365 days) from the date of service must be accompanied by documentation as to why the Claims should be considered for payment. Complete a Supporting Documentation Cover Sheet (see sample and instructions on page 17 of this Section) and attach the documentation with a paper clip. Claims submitted without this documentation will be denied. 18

20 Payment consideration for Claims filed/appealed after filing limit: Examples of documentation deemed valid are: 1. Documented call into the HealthSpan Network Development or Customer Relations Departments: Provide the date that you contacted HealthSpan inquiring about a Claim status or payment rejection. If you followed up with an appropriate HealthSpan area, we will have documentation of that call and will be able to accept that in order to determine if the filing limit rejection will be overturned. Follow up calls in relation to a previous payment must occur within 180 days of the last processed date. This would be considered as proof of filing. 2. Fax Confirmation: Provide a copy of a fax confirmation sheet showing the fax was successful, detailing that you faxed a Claim over for processing or reconsideration. This would be considered as proof of filing. 3. HealthSpan EDI Claim Receipt Confirmation: HealthSpan assigns all Claims received a HealthSpan Claim number whether they are received via paper or electronically. Upon receipt, the claims system generates a confirmation back to the submitter with the Claim number, in a 999. This would be considered as proof of filing. 4. Copy of delivery confirmation from U.S. Postal Service or Commercial Carrier (i.e. UPS, FedEx.): If you have a delivery confirmation from a package submitted to HealthSpan as it relates to Claims involved in a timely filing dispute, we will consider that receipt as proof of filing. 5.8 Claim Processing Timeframes Allow 30 days for HealthSpan to process and adjudicate your Claim(s). Claims requiring additional supporting documentation and/or Coordination of Benefits may take longer to process. NOTE: While HealthSpan may require the submission of specific supporting documentation necessary for benefit determination (including medical and/or Coordination of Benefits information), HealthSpan may have to make a decision on the Claim before such information is received. A "complete or Clean" Claim is defined as a Claim that has no defect or impropriety, including lack of required substantiating documentation from providers, suppliers, or Members or particular circumstances requiring special treatment that prevents timely payments from being made on the Claim. 19

21 5.9 Incorrect Claim Payments If you receive an incorrect payment (i.e., either an overpayment or an underpayment), elect one of the following options. Option 1: Do not cash or deposit the incorrect payment check. Mail the incorrect payment check back to HealthSpan, along with a copy of the Explanation of Payment (EOP) and a brief note explaining the payment error to: HealthSpan Recovery Unit P.O. Box Cleveland, OH NOTE: If HealthSpan s EOP is not available, record the Member s Medical Record Number on the payment check you are returning. HealthSpan will re-issue and mail you a new, corrected payment check within 30 days. Option 2: Deposit the incorrect HealthSpan payment check in your account or accept the Electronic Funds Transfer (EFT). For an Underpayment Error: Call the HealthSpan Customer Relations Department at , option 1, and explain the error. Upon verification of the error, appropriate corrections will be made to HealthSpan s accounting system and the underpayment amount owed you will be added to/reflected in your next HealthSpan reimbursement check. For an Overpayment Error: You may do either one of the following: Write a refund check to HealthSpan for the excess amount paid to you by HealthSpan. Attach a copy of HealthSpan s Explanation of Payment (EOP) to your refund check, as well as a brief note explaining the error. Attach with a paper clip. NOTE: If HealthSpan s EOP is not available, record the Member s Medical Record Number on the payment check you are returning. Mail your refund check (and brief note) to: HealthSpan Recovery Unit P.O. Box Cleveland, OH

22 Appropriate corrections will be made to HealthSpan s accounting system and the overpayment amount will be automatically deducted from your next HealthSpan reimbursement Provider Payment Disputes See Section 4.14 of this HealthSpan Provider Appeals See Section of this HealthSpan Member Hold Harmless A Practitioner/Provider should not bill a Member for a Covered Service that is not the responsibility of the Member under the Evidence of Coverage, such as an amount denied by HealthSpan because of inaccurate coding or the Practitioner s/provider s failure to obtain an Authorization. The Practitioner/Provider may bill for Copayments, Coinsurance amounts, subject to the Deductible or amounts the Member has expressly agreed to pay prior to the services being rendered. HealthSpan Payments: The payments from HealthSpan shall be limited to the amount specified in the Practitioner s/provider s Agreement with HealthSpan, less any Copayments, Coinsurance, or Deductibles in accordance with the Member s specific Evidence of Coverage. Items You May Bill For: The Practitioner/Provider may bill the Member for any applicable Copayments, Coinsurance, or Deductibles, and/or for any non-covered services as indicated on the remittance advice received from HealthSpan Coding and Billing Validation HealthSpan uses code editing software (CES) from third party vendors to assist in determining the appropriate processing and reimbursement of Claims. Currently, HealthSpan has selected Optum for CES. From time to time, HealthSpan may change this coding editor or the specific rules that it uses in analyzing Claims submissions. HealthSpan s goal is to help ensure the accuracy of Claims payments. Optum s CES is a code editor application designed to evaluate Claims data including procedure codes and associated modifiers. CES assists HealthSpan in identifying various categories of Claims coding and possible 21

23 inconsistencies. Claims with coding errors/inconsistencies are pended to the Medical Claim Review staff for manual review. Each Claim is validated against HealthSpan s payment criteria, and then is subsequently released for processing. This process has a goal of improving the accuracy of coding and consistency in Claims payment procedures. To help illustrate how this process works, examples have been provided. If you have questions about the application of these rules, call the HealthSpan Customer Relations Department at , option CODING RULE DESCRIPTIONS EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION # 1 MULTIPLE PROCEDURS REDUCTION Rule Description: Identifies procedures that require a reduction based on multiple procedure guidelines. Rule Justification: American Medical Association (AMA) guidelines establish that certain procedures require the billing of the multiple procedure modifiers. Any procedure included in Appendix D or E of the Current Procedural Terminology book are exempt and not included in this list of procedures. Rule Application: Use all procedures in the surgical section ( ) from the Current Procedural Terminology book to determine procedure codes that will accept the multiple modifier. Any codes the AMA has designated to be Add-On codes or Modifier 51 Exempt will not be considered. Multiple surgeries are indicated by use of modifier 51 The primary procedure is identified by the highest total RVU as set by the Centers for Medicare & Medicaid Services (CMS). Example: Multiple surgeries are separate procedures performed by a Practitioner/Provider on the same patient at the same operative session or on the same day. HealthSpan will reimburse for multiple procedures performed during the same operative session according to the following schedule: 1st (major) procedure 100% of allowed fee, no modifier required 2nd procedure.50% of allowed fee, modifier 51 required 3rd procedure..50% of allowed fee, modifier 51 required 4th procedure... 50% of allowed fee, modifier 51 required Each procedure after the fourth procedure will require submission of documentation and HealthSpan review, to determine an appropriate reimbursement amount. 22

24 EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION # 2 OUTPATIENT CONSULTATIONS. Rule Description: Identifies office or other outpatient consultations that should have been billed at the appropriate level of office visit, established patient, or subsequent hospital care. Rule Justification: According to the AMA, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source." Furthermore, "If subsequent to the completion of the consultation, the consultant assumes responsibility for the management of a portion or all of the patient's condition[s], the follow-up consultation codes should not be used." Rule Application: Deny the consultation with the reason code indicating the denial reason. Match on the first three digits of an ICD9 code to determine same diagnosis. Definition: A non-initial consultation is a consultation billed with a date of service within 6 months of another consultation. Example: Office or other outpatient consultation codes ( ) are services provided by a Practitioner/Provider whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician. These consultation services should be performed at the written or verbal request of another Practitioner/Provider and documented in the patient's medical record. If the consulting Practitioner/Provider assumes responsibility for the management of a portion or all of the patient's condition, the follow-up visits should be coded using the established patient office evaluation and management codes DOS 1/5/13 Dx Code of DOS 3/1/13 Dx Code of Service for DOS 3/1/13 will be denied. # 4 INITIAL INPATIENT CONSULTATIONS Rule Description: Identifies initial inpatient consultations that should have been billed at the appropriate level of subsequent hospital care. Rule Justification: According to the AMA, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source." Furthermore, "If subsequent to the completion of the consultation, the consultant assumes responsibility for the management of a portion or all of the patient's condition[s], the follow-up consultation codes should not be used." Rule Application: AMA/CPT industry standard of payment is followed for paying initial inpatient consultations, only when they are truly the initial. Example: A consultation is a type of service provided by a Practitioner/Provider whose opinion or advice regarding evaluation and management of a specific 23

25 EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION # 4 INITIAL INPATIENT CONSULTATIONS cont. problem is requested by another Practitioner/Provider. CPT states that only one initial consultation should be reported by a consultant per admission utilizing the initial inpatient consultation codes ( ). # 5 CONSULTATIONS BY PRIMARY CARE PHYSICIANS (PCP) Rule Description: Identifies consultation codes that are billed by the Member's Primary Care Physician (PCP). Rule Justification: According to the AMA, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. Rule Application: All consultations will be denied when billed by the Member s PCP, except for Claims submitted with a pre-op diagnosis (V V72.85) when appropriate. # 6 NEW PATIENT CODE FOR ESTABLISHED PATIENT Rule Description: Identifies new patient procedure codes that are submitted for established patients. Rule Justification: According to the AMA "A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." Rule Application: Deny with a reason code indicating the denial reason when a Practitioner/Provider bills more than one new patient code for the same Member. In addition, same group, same specialty within the 3 years will be denied. The time period is three (3) years to determine if the visit is for a new patient. Example: Member ID 1234 DOS 1/5/ This service will be denied. Member ID 1234 DOS 12/20/ This service will be approved. # 7 GLOBAL SURGICAL PACKAGE (GSP) Rule Description: Identifies Evaluation & Management (E/M) or certain supply codes billed within a procedure s follow-up period. Rule Justification: The Centers for Medicare & Medicaid Services (CMS) guidelines have established that the concept of the Global surgical package applies to certain procedures. Additional payment should not be made for services that fall within the follow-up days. Rule Application: Deny E/M codes and supplies billed within the Global surgical package for surgeries with Global periods of 10 or 90 days. Use Modifiers 22, 24, 25, 27, 50,51,52,53,54,55,57,58,59,62,78,79,80,82 and AS, if applicable. 24

26 EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION # 7 GLOBAL SURGICAL PACKAGE (GSP) cont. # 8 SAME DAY SURGERY INCLUSIVE Example: A Global surgical package is an all-inclusive fee for the surgical procedure which includes the surgery and some pre-operative and post-operative care. Below outlines types of Global surgical packages and what each package includes. Major Surgery: The following services are included in the Global surgical package: Pre-operative visit/services, in or out of the hospital, one day prior to surgery all intraoperative procedures medical/surgical services for complications which DO NOT require a return trip to the Operating Room all related post-operative care and visits, for a period of 90 days following surgery Minor Surgery: The following services are included in the Global surgical package: The Practitioner s/provider s visit/services performed on the day of surgery the procedure itself all related post-operative care and visits, for a period of ten days after surgery Endoscopic Procedures: For endoscopic procedures, the Global "package" includes: The Practitioner s/provider s visit/services on the day of the procedure, The procedure itself, There is NO post-operative period for endoscopic procedures performed through an existing body orifice; procedures requiring an incision for insertion of a scope (for example, a laparoscopic cholecystectomy) will be subject to either the MAJOR or MINOR surgical policy, whichever is appropriate. Rule Description: Identifies supplies that have been submitted on the same day as a surgical procedure. Rule Justification: According to the Centers for Medicare & Medicaid Services (CMS) Program Manuals - Medicare Carriers (PUB. 14), guidelines have established that additional payment should not be made for some supplies when billed on the same day as certain surgical procedures. This list includes, but is not limited to, "Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes. Rule Application: Deny supplies when billed on the same day as a surgery. 25

27 EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION # 9 OPTUM BUNDLING Rule Description: Identifies procedures that have been unbundled according to the Optum s CES product. Rule Justification: The Optum s CES product has identified re-bundling coding relationships. Coding relationships are established and influenced by CPT Code definitions, CPT Instructions and Guidelines, Medicare Guidelines and Physician Specialty Organizations. Edit level justifications are available upon request. Rule Application: Use Optum edits for all Claims. Definition: Procedure unbundling occurs when two or more CPT-4 procedures are used to describe a procedure performed, when a single, more comprehensive, CPT-4 procedure code exists that accurately describes the entire procedure performed or when mutually exclusive procedures (procedures which would not be reasonably performed at the same session by the same provider on the same Member) are reported. Example: Billing the following two codes together: 58150: Total abdominal hysterectomy (corpus and cervix) with or without removal of tubes; with or without removal of ovary(s) : Pelvic exenterating for gynecologic malignancy with total abdominal hysterectomy or cervicectomy with or without removal of tube(s); with or without removal of ovary(s) would be rebundled into # 10 CMS CORRECT CODING INITIATIVE BUNDLING Rule Description: Identifies procedures that have been unbundled according to the Correct Coding Initiative (CCI) of the Centers for Medicare & Medicaid Services (CMS). Rule Justification: The correct coding initiative coding policies are based on coding conventions defined in the American Medical Association's CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practice and review of current coding practice. Rule Application: Use CMS CCI edits for all Claims. Deny the code with the lowest work RVU for mutually exclusive procedures Apply the Correct Coding Initiative modifier overrides 25, 58, 59, 78, 79, E1-E4, F1-F9, FA, LC, LD, LT, RC, RT, T1-T9, and TA if appropriate. Definition: Procedure unbundling occurs when two or more CPT-4 procedures are used to describe a procedure performed, when a single -- more comprehensive -- CPT-4 procedure code exists that accurately describes the entire procedure performed or when mutually exclusive procedures (procedures which would not be reasonably performed at the same session by the same provider on the same Member) are reported. 26

28 EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION # 10 CMS CORRECT CODING INITIATIVE BUNDLING cont. # 11 CMS ALWAYS BUNDLED PROCEDURES Example: Billing the following two codes together: 58150: Total abdominal hysterectomy (corpus and cervix) with or without removal of tubes; with or without removal of ovary(s) : Pelvic exenteration for gynecologic malignancy with total abdominal hysterectomy or cervicectomy with or without removal of tube(s); with or without removal of ovary(s) would be rebundled into Rule Description: Identifies procedures indicated by the Centers for Medicare & Medicaid Services (CMS) as always bundled when billed with any other procedure. Rule Justification: According to CMS National Physician Fee Schedule Relative Value File, this procedure has a status code indicator of "B", which is defined as: "Payment for covered services is always bundled into payment for other services not specified. There will be no RVUs or payment amount for these codes and no separate payment is made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident." Rule Application: Deny services indicated by CMS as always bundled when billed with any other procedure not indicated as always bundled. # 12 ANESTHESIA CROSSWALK Rule Description: Identifies and crosswalks non-anesthesia services to a designated anesthesia code as appropriate based on the provider's specialty. Rule Justification: The Optum Anesthesia Crosswalk Table converts E/M, surgery, radiology, laboratory/pathology, and medicine codes to anesthesia codes as appropriate when a Claim for anesthesia services, as identified by provider type, specialty, or identification number is submitted with other than a designated anesthesia code ( ). Rule Application: Use Optum s crosswalk list to crosswalk any non-anesthesia codes billed by an anesthesiologist to the appropriate anesthesia code and deny with anesthesia reason code. For non-anesthesia codes that have a one to many crosswalk, flag the code for review and deny anesthesia with denial reason code. For non-anesthesia codes that do not have an established crosswalk, flag the code for review and deny anesthesia with denial reason code. Example: Code would be denied because the anesthesia code of is a valid crosswalk. # 13 HOLIDAY Rule Description: Identifies misuse of procedure codes designated for Federal holidays or Sundays. Rule Justification: According to the AMA, this procedure code has been 27