Chapter 10: Claims Processing Procedures

Transcription

1 I N D I A N A H E A L T H C O V E R A G E P R O G R A M S P R O V I D E R M A N U A L Chapter 10: Claims Processing Procedures Library Reference Number: PRPR

2 Chapter 10: Revision History Version Date Reason for Revisions Completed By 1.0 September 1999 Policies and procedures are current as of March 1, June 2001 Policies and procedures are current as of June 1, April 2002 Policies and procedures are current as of August 1, April 2003 Policies and procedures are current as of April 1, July 2004 Policies and procedures are current as of January 1, March 2005 Policies and procedures current as of January 1, December 2006 Policies and procedures current as of April 1, February 2008 Policies and procedures as of October 1, June 2008 Policies and procedures as of April 1, January 2009 Policies and procedures as of October 1, May 2009 Policies and procedures as of April 1, 2009 New Manual Chapters 1, 2, 3, 6, 7, 8, 9, 10, 13, 14, and Appendix A All Chapters All Chapters All Chapters Quarterly Update Quarterly Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update EDS Document Management Unit EDS Document Management Unit EDS Publications Unit EDS Client Services Unit EDS Client Services Unit EDS Publications Unit EDS Publications Unit EDS Provider Relations and Publications Units EDS Provider Relations and Publications Units EDS Provider Relations and Publications Units EDS Provider Relations and Publications Units 10-2 Library Reference Number: PRPR10004

3 Revision History Version Date Reason for Revisions Completed By 9.1 November 2009 Policies and procedures as of October 1, September 14, 2010 Policies and procedures as of April 1, February 3, 2011 Policies and procedures as of October 1, August 16, 2011 Policies and procedures as of April 1, Policies and procedures as of October 1, 2011 Published: December 29, Policies and procedures as of May 1, 2012 Published: August 21, Policies and procedures as of November 1, 2012 Published: January 15, Policies and procedures as of May 24, 2013 Published: July 11, Policies and procedures as of November 1, 2013 Published: February 13, Policies and procedures as of April 1, 2014 Published: June 12, Policies and procedures as of October 1, 2014 Published: December 18, Policies and procedures as of January 1, 2015 Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Updated Batch Range Descriptions table Removed Submitting Medicare Replacement Plan before August 9, 2012 section Updated Provider Responsibilities section Updated NCCI Claims Administrative Review section HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units Library Reference Number: PRPR

4 Chapter 10: Table of Contents Chapter 10: Revision History Chapter 10: Table of Contents Section 1: Introduction to Claims Processing Procedures General Information Managed Care Considerations Care Select Risk-Based Managed Care Section 2: Claims Processing Overview General Information Internal Control Number Internal Control Number Region Codes Julian Dates Batch Ranges Internal Control Number Examples Paper Claims Electronic Claims Attachments for Electronic Claims Claim Notes Accepted as Documentation Pharmacy POS Claim Submission Section 3: Suspended Claim Resolution General Information Suspended Claim Location Suspended Claims Processing Suspended Claim Guidelines for Processing Section 4: Crossover Claims Processing Procedures General Information Automatic Crossovers Claims That Do Not Cross Over Automatically Submitting a Medicare Remittance Notice Submitting Medicare HMO Replacement Professional-Web interchange10-23 Submitting Medicare HMO Replacement Institutional or Outpatient-Web interchange Submitting Medicare HMO Replacement Plans Medicare Denied Details for Crossover Claims Processing Medicare Exhaust Claims Section 5: Claim Filing Limitations General Information Provider Responsibilities Extenuating Circumstances to Waive the Filing Limit Timely Filing Limit Documentation How to Submit Claims for Filing Limit Waiver Section 6: Claim Reimbursement Administrative Review and Appeal Procedures Claims Administrative Review Policy Steps Taken Prior to the Administrative Review Process Filing Administrative Review Library Reference Number: PRPR

5 Table of Contents Administrative Review Responses Appeals Other Administrative Reviews and Appeals NCCI Claims Administrative Review NCCI Claim Appeals Surveillance and Utilization Review and Prior Authorization Appeals Managed Care Considerations Care Select Risk-Based Managed Care Section 7: Submission Summary Report Overview Submission Summary Report Description of Information Purpose of Report Index Library Reference Number: PRPR Policies and Procedures as of October 1, 2014 Version: 14.1

6 Section 1: Introduction to Claims Processing Procedures General Information This chapter provides information about claims processing. The following items are covered in this chapter: Claims Processing Overview Provides step-by-step procedures of how a claim is processed through IndianaAIM. Suspended Claim Resolution Provides an overview of the HP Enterprise Services Resolutions Unit, why and how a claim suspends, resolution procedures, and processing timeliness guidelines. Crossover Claims Processing Procedures Outlines what happens when a claim automatically crosses over from a Medicare carrier and what to do when the claim does not automatically cross over. Claim Filing Limitations Summarizes provider responsibilities concerning filing limitations, eligible claims, and filing limit waiver documentation. Claim Reimbursement Administrative Review and Appeals Procedures Describes avenues of resolution when a provider disagrees with a claim denial or payment amount. Submission Summary Report Provides information about the Submission Summary Report specific to the 837I, 837P, or 837D transactions. Managed Care Considerations Care Select Claims for members enrolled in Care Select are subject to all applicable procedures described in this chapter. Risk-Based Managed Care Claims for members enrolled with a managed care entity (MCE) in the risk-based managed care (RBMC) delivery system, other than the carved-out services, are submitted to and processed by the MCE in which the member is enrolled. Carved-out services include the following: Dental services rendered by providers enrolled in an IHCP dental specialty: Endodontist General dentistry practitioner Oral surgeon Orthodontist Pediatric dentist Periodontist Mobile dentist Prosthodontist Dental clinic Library Reference Number: PRPR

7 Section 1: Introduction to Claims Processing Procedures Services provided by a school corporation as part of a student s Individualized Education Plan (IEP) Psychiatric Residential Treatment Facility (PRTF) and Medicaid Rehabilitation Option (MRO) services Pharmacy point-of-sale (POS) services along with certain procedure-coded drugs and supplies when billed by a pharmacy (specialty 240) or durable medical equipment (DME) provider (specialty 250), billed on a CMS-1500, as listed in the Drug-Related Medical Supplies and Medical Devices table in Chapter 8: Billing Instructions. For pharmacy POS billing procedures, see Chapter 9: IHCP Pharmacy Services Benefit. When a provider submits a claim to the MCE, the MCE processes the claim and submits the encounter data to the state of Indiana. This claim data is used to track and trend the overall cost and utilization of the services provided to the Indiana Medicaid population and gives the State the data it needs to accurately report overall state Medicaid costs to the federal government. The compiled data has an impact on capitation payments to the MCEs and helps the State better understand the total medical costs involved in each case. Each MCE may establish and communicate its own criteria for claim submission and processing. Questions about claims processing for members in the RBMC delivery system should be directed to the MCE in which the member is enrolled. MCE contact information is included in Chapter 1: General Information, Section 2. Library Reference Number: PRPR Policies and Procedures as of October 1, 2014 Version: 14.1

8 Section 2: Claims Processing Overview General Information This section describes internal claims processing procedures after HP receives a claim. Claims may be submitted for payment consideration on standardized paper claim forms or by electronic submission. Information about each type of claim submission is outlined in this section. For information about electronic claims formatting, see the Indiana Health Coverage Programs (IHCP) Companion Guides on the EDI Solutions page at indianamedicaid.com. The claims processing procedures in this chapter are for all IHCP claim types except pharmacy. Information about pharmacy claims is included in Chapter 9: IHCP Pharmacy Services Benefit. Internal Control Number IHCP claims are identified, tracked, and controlled using a unique 13-digit internal control number (ICN) assigned to each claim. The ICN numbering sequence identifies when HP received the claim, the claim submission media used, and the claim type. This information assists providers with tracking claims, as well as tracking Remittance Advices (RAs) or 835 transaction reconciliations. Internal Control Number Table 10.1 describes the ICN format codes R R, Y Y, J J J, B B B, and S S S. Table 10.1 ICN Format Code R R Y Y J J J B B B S S S Description These two digits refer to the region code or the submission source assigned to a particular type of claim. Region codes are explained later in this chapter. These two digits refer to the calendar year the claim was received. For example, all claims received in calendar year 2014 would have 14 in this field. These three digits refer to the Julian date the claim was received. Julian dates are shown on many calendars as days elapsed since January 1. There are 365 days in a year, 366 in a leap year. Tables 10.3 and 10.4 display the Julian dates for a regular year and a leap year. These three digits refer to the batch range of the particular claim. Different claim types are assigned specific batch ranges to assist in identifying, tracking, and controlling claim inputs. Batch ranges are explained later in this chapter. These three digits refer to the specific number of a particular claim within a specific batch range. Paper claim batches have a maximum of 100 individual claims within a batch; electronic claims have a maximum of 1,000 individual claims within a batch. Note: The first claim in a batch is given a specific number of 00, or 000 for electronic claims. Thus, the last claim in a batch is numbered 99 or 999 for electronic claims. Library Reference Number: PRPR

9 Section 2: Claims Processing Overview Region Codes Table 10.2 describes region codes for specific claim types. Code 10 Paper without attachments 11 Paper with attachments 13 Paper attachment cover sheets Table 10.2 Region Codes Description 20 Electronic claims without attachments 21 Electronic claims with attachments 22 Encounter claim 23 Electronic crossover claims submitted by the provider 25 Pharmacy point of sale (POS)* 40 Conversion claim [Medicaid Management Information System (MMIS) to IndianaAIM] 49 Recipient linking Claims 50 Adjustments, non-check-related 51 Adjustments, check-related 52 Encounter claim replacements 53 Encounter claim void 54 Mass adjustments, void transactions 55 Mass adjustments, institutional retroactive rate 56 Mass adjustments, system generated 57 Adjustments reprocessed by HP systems engineers 59 Pharmacy POS reversal replacement* 60 Non-claim-specific financial transactions 61 Provider replacement Electronic with an attachment or claim note 62 Provider replacement Electronic without an attachment or claim note 63 Provider-initiated electronic void 64 Spend-down end of month (EOM) auto-initiated mass replacement 67 Mass adjustments, encounter claims 70 MCE capped 80 Claim reprocessed by HP systems engineers 82 Encounter claims reprocessed by HP 90 Special projects Note: *These codes are referring to pharmacy claims previous to May 24, Library Reference Number: PRPR

10 Chapter 10 Section 2: Claims Processing Overview Indiana Health Coverage Programs Provider Manual Julian Dates Julian dates and corresponding calendar dates for a regular year and a leap year are listed in Tables 10.3 and Table 10.3 Julian Dates Regular Year DAY JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC DAY Library Reference Number: PRPR10004

11 Section 2: Claims Processing Overview Table 10.4 Julian Dates Leap Year DAY JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC DAY Batch Ranges Adjustments and encounters use the same claim-type batch range. Library Reference Number: PRPR

12 Chapter 10 Section 2: Claims Processing Overview Indiana Health Coverage Programs Provider Manual Table 10.5 Batch Range Descriptions Claim Type Batch Range UB-04 Inpatient Crossover UB-04 Outpatient Crossover CMS-1500 Crossover American Dental Association (ADA) 2006 Dental Claim Form Inpatient Outpatient Long-Term Care Home Health CMS Financial Internal Control Number Examples The following examples illustrate the ICN sequence on the RA: A paper dental claim with no attachments received in 2014, is assigned the ICN 1014JJJ099CCC. This is a claim within batch 099, received in 2014, as a paper claim submission with no attachments. An 837 Professional (837P) claim transaction with no attachments received in 2014, is assigned the ICN 2014JJJ699CCC. This is a claim within batch 699, received in 2014, as an electronic claim submission. A paper UB-04 outpatient claim with attachments received in 2014, is assigned the ICN 1114JJJ147CCC. This is a claim within batch 147, received in 2014, as a paper claim submission that also included attached information. Paper Claims To assist providers using paper claims, the IHCP has identified specific billing errors that may cause processing delays or increased paper claims processing errors. To avoid these errors, providers should adhere to the following paper claim billing processes: Submit paper claims on standard Centers for Medicare & Medicaid Services (CMS)-approved claim forms. Use Helvetica, Times New Roman, or Courier font type with 12-point or 14-point font size. Avoid using handwritten information on the claim forms unless directed to do so. Ensure information is documented in the appropriate boxes on the form and is aligned correctly in those boxes. Add data within the boxes on the form. Data outside the boxes can cause errors and delay processing. Do not enter commas or dashes. Diagnosis pointers on the detail lines should read up to four of the following: A-L Library Reference Number: PRPR10004

13 Section 2: Claims Processing Overview Do not write or type any information, other than the appropriate address, on the claim form above the redline box. Do not put stray marks or X s on the claim form. Paper claims that require attachments must include the attachments with the claim form. Do not add stamps or stickers. Submit attachments on standard 8 ½-by-11-inch paper. Do not use paper clips or staples on claim forms or attachments. Write in only blue or black ink. Note: Claims submitted electronically or on the standard red-ink form expedite claims processing and improve the accuracy of claim scanning and data entry. This section outlines paper claim processing procedures. A step-by-step review of paper claims processing, also known as manual or hard-copy claims processing, follows: 1. The provider completes claims according to the instructions in Chapter 8: Billing Instructions of this manual and mails them to the appropriate claim-processing address. Mailing addresses are found in Chapter 1: General Information and on the Quick Reference Guide, which can be found on the Contact Us page at indianamedicaid.com. 2. The United States Postal Service delivers claims to HP by routine mail, special delivery, overnight mail, and courier. Claims are assigned a Julian date that corresponds to the date of receipt at HP. 3. The mailroom sorts claims by claim type with attachments or without attachments. Sending claims to the correct P.O. Box significantly speeds sorting time. 4. When a claim form is received for processing, specific form field locators are reviewed and validated for completion. If it is determined that the form field locators are completed incorrectly or blank, the claim form and any attachments are returned to the provider, which prevents processing of the claim. The provider should review the reasons the claim was returned, make the appropriate corrections, and then resubmit the claim for processing consideration. Claims that are reviewed in the mailroom may be returned for the reasons listed in Table Library Reference Number: PRPR

14 Chapter 10 Section 2: Claims Processing Overview Indiana Health Coverage Programs Provider Manual Table 10.6 Claims Returned to Provider Return To Provider (RTP) Letter Language For healthcare providers: Please resubmit claims with a valid National Provider Identifier (NPI). For atypical providers: Please resubmit claims with a valid IHCP provider number. All provider numbers require nine numerical digits and one alpha character to denote the service location code ( X). Explanation The NPI is required for healthcare providers and the taxonomy code is optional. Verify that the billing provider NPI and qualifiers are located in the correct field and are entered in the proper format. The correct field for each claim form is as follows: UB-04 Form field 56 CMS-1500 Form field 33a Dental Form field 49 Atypical providers continue to bill with the Legacy Provider Identifier (LPI). UB-04 CMS-1500 Form Field 57A Form Field 33b Note: Qualifiers are 1D = IHCP provider number (LPI) Or ZZ = Taxonomy Medicare information not submitted in field 22. Services were not submitted on an approved claim form. Please submit request for payment on the appropriate IHCP claim form. Provider must submit Medicare information on the UB-04 claim form in field 54A. Continuous paper claims are not accepted. The attachment control number (ACN) is not at the top of the attachment(s). Dental Form Field 50 For crossover claims and Medicare Replacement Plans, the combined total of the Medicare coinsurance or copayment, deductible, and psychiatric reduction must be reported on the left side of field 22 under the heading Code on the CMS-1500 claim form. The Medicare paid amount (actual dollars received from Medicare) must be submitted on the right side of field 22 under the heading Original Ref No. The IHCP accepts the UB-04 claim form, the CMS-1500 claim form, the ADA 2006 Dental Claim form, the National Council for Prescription Drug Programs, Inc. IHCP Drug Claim Form, and the IHCP Compounded Prescription Claim Form. Use form field 54A to indicate the Medicare paid amount. Do not include the Medicare-allowed amount or contract adjustment amount in field 54. Only six detail lines are billable on a CMS-1500 claim form. Only 10 detail lines are billable on an ADA 2006 form. Continuous paper claims are not accepted for dental and CMS claims. Each individual claim must have a total. The ACN allows the IHCP to match the attachment to the submitted claim and must be written at the top of each page of the attachment Library Reference Number: PRPR10004

15 Section 2: Claims Processing Overview Return To Provider (RTP) Letter Language The maximum number of detail lines has been exceeded for this claim form. Submit additional details on a separate claim form. The total billed amount on each claim form must equal the sum of the detail lines for each individual claim. An invalid or missing type of bill was submitted. Please correct and resubmit claim. Duplicate ACN was submitted for attachment. Must resubmit a new claim. The Attachment Cover Sheet has an invalid NPI or is missing a member identification number, or dates of service. A Medicare Remittance Notice (MRN) must be submitted for each claim filed for denied charges. It is optional for paid services. Crossover and Medicare Replacement Plan payment information can be indicated in field 22 on the CMS form and fields on the UB-04 form. Diagnosis submitted on claim without a valid ICD indicator Explanation This is sent whenever the allowable number of detail lines is exceeded. The CMS-1500 claim form has a maximum of six details that can be billed on one claim form. The UB-04 claim form has a maximum of 66 details (three-page continuation claim). The type of bill in form field 4 of the UB-04 claim form is required and must be three digits. It must also be an appropriate type of bill for the claim being submitted. Valid type of bill (TOB) codes may be found in Chapter8: Billing Instructions of this manual or on indianamedicaid.com. Each claim submitted with attachments must have a unique ACN. The Attachment Cover Sheet must be filled in completely. There are two instances when a provider submits a crossover claim on paper: When the claim does not cross over, the entire claim and MRN are submitted. The MRN is needed only if the claim is denied or paid at zero (applied to the deductible) by Medicare. Paid line items and denied line items must be submitted on separate claim forms. When submitting a paper claim for denied detail lines, the MRN must be attached. The ICD version indicator is missing from the claim or the ICD version indicator is invalid. A valid ICD indicator is 9 for ICD-9 or 0 for ICD-10. Claims may not be submitted without an ICD version indicator on or after April 1, Please submit with appropriate ICD version indicator. Note: Claims received without an NPI or LPI (for atypical providers only), a provider name, and return address cannot be processed by HP and cannot be returned. These claims are destroyed. 5. Claims are grouped together; for example, all CMS-1500 claims without attachments are sorted into batches of 100 and transferred to the scanning area. 6. All claims and attachments are scanned. During the scanning process, claims are assigned a specific ICN based on the claim type, region code, and receipt date. Claim attachments receive the same ICN as the claim. 7. Hard-copy batches are transferred to the data entry area, where the information is typed into the claims processing system. 8. Medical and dental batches are maintained in storage for 30 calendar days, and UB-04 batches are maintained in storage for 60 calendar days for potential review by claim examiners. After the Library Reference Number: PRPR

16 Chapter 10 Section 2: Claims Processing Overview Indiana Health Coverage Programs Provider Manual storage limit has been reached, the hard-copy batches are destroyed, because claims are stored electronically. 9. Claim data is stored in IndianaAIM. IndianaAIM claims processing has three possible results: All claims data complies with the correct format and IHCP policy rules and results in a paid claim. Claims data does not comply with the correct format or IHCP policy rules and results in a denied claim. A claim examiner must review a particular aspect of the claim because the claim is suspended. For example, a sterilization procedure suspends a claim for review of the required sterilization consent form. A claim examiner approves the claim for payment, if appropriate, and if the correct information was sent with the claim. Otherwise, the claim is denied. Suspended claim resolution is discussed in more detail in the Suspended Claim Resolution section in this chapter. Weekly, IndianaAIM generates an RA that contains the status of each processed claim: The electronic RA in the 835 format contains paid and denied claims. The Web interchange RA lists paid, denied, in process, and adjusted claims. The last Web interchange RA of the month includes information about all claims and adjustments not processed to a paid or denied status. Adjusted claims show one time on the RA when they are paid or denied. Remittance Advice information is presented in Chapter 12: Financial Services of this manual. Electronic Claims This section outlines electronic claims processing procedures. Electronic claims must be submitted in the 837 American National Standards Institute (ANSI) formats or through the direct data entry (DDE)- compliant web portal called Web interchange. See Chapter 3: Electronic Solutions of this manual for more information about electronic claim submission using the 837 format or Web interchange. A stepby-step review of electronic claims processing follows: 1. Claims data is compiled according to the instructions in this manual, the IHCP companion guides, and the National Electronic Data Interchange Transaction Set Implementation Guides located at wpc-edi.com. The data is transmitted electronically to HP, using secure file transfer protocols and in accordance with the specifications of hardware and software systems. An intermediary can also be involved in transmitting electronic claims. 2. HP receives electronic claims from multiple transmission sources, 24 hours a day, seven days a week: HP receives and immediately sorts claims by claim type, such as 837I (institutional), 837D (dental), or 837P (professional) formatted electronic claims. o Claims formatted incorrectly are rejected during pre-cycle editing. o A 999 Acknowledgement and Submission Summary Report (SSR) is available approximately two hours after claims submission between 6 a.m. and 4 p.m. The SSR contains error codes and claim specific descriptions for rejected claims. A list of SSR error code definitions is located in the IHCP companion guide titled 999 Acknowledgement and Submission Summary Report. o Accepted information is transferred to IndianaAIM, an ICN is assigned, and pre-edit functions are performed. IndianaAIM processes these claims Library Reference Number: PRPR10004

17 Section 2: Claims Processing Overview Electronic claims cannot be reprocessed in the event of denial. The provider must resubmit the claim for processing. Attachments for Electronic Claims The following list describes how to append attachments to electronic claims and how those attachments are processed: The provider indicates on the 837 claim transaction that additional documentation will be submitted. The provider must complete an IHCP Attachment Cover Sheet for each set of attachments associated with a specific claim. A unique attachment control number of up to 30 characters must be sent in loop 2300, segment PWK on the 837 and must match the paper Attachment Cover Sheet sent by mail. The Attachment Cover Sheet can be found on the Forms page at indianamedicaid.com. Each paper attachment submitted for an 837 transaction must include the ACN. The provider must include a unique ACN on each attachment. If an attachment has more than one page, the ACN must be written on each page of the document. The provider may submit a maximum of 20 ACNs with each cover sheet. When reporting the number of pages for the attachment, providers should not include the cover sheet in the count. The United States Postal Service delivers attachments to the HP mailroom by routine mail, special delivery, overnight mail, and courier, or attachments can be hand delivered. Attachments are assigned a Julian date that corresponds to the date of arrival in the HP mailroom. HP staff members briefly review the attachments for completeness and accuracy of the number of ACNs to the number of attachments. If errors are found, the cover sheets and attachments are returned to the provider for correction and resubmission. Batches are transferred to the data entry area, and data entry analysts enter the ACNs into the claims processing system. Providers must submit attachments within 45 calendar days of the Julian date the electronic claim is received or the claim denies. Note: Write in only blue or black ink on the attachments. Claim Notes Accepted as Documentation Third-Party Payer Fails To Respond (90 Day Provision) When a third-party insurance carrier fails to respond within 90 calendar days of the billing date, the provider can submit the claim to the IHCP for payment consideration. However, to substantiate attempts to bill the third party, the following must be documented in the claim note segment of the 837 transaction: Dates of the filing attempts The phrase no response after 90 days Member s RID Provider s IHCP provider number Name of primary insurance carrier billed Library Reference Number: PRPR

18 Chapter 10 Section 2: Claims Processing Overview Indiana Health Coverage Programs Provider Manual If submitting unpaid bills or statements, providers should include the third-party insurance carrier s name. Likewise, if providing a written notification with billing dates, providers need to include the name of the third-party insurance company. Consultations Billed 15 Days Before or After Another Consultation In the claim note, the provider can indicate the medical reason for a second opinion during the 15 days before or after the billed consultation. Joint Injections Four per Month In the claim note, the provider can document that the injections are performed on different joints and indicate the sites of the injections. Surgery Payable at Reduced Amount when Related Postoperative Care Paid, Postoperative Care within Days of Surgery, Preoperative Care on Day of Surgery, or Surgery Payable at Reduced Amount when Preoperative Care Paid Same Date of Service In the claim note, the IHCP accepts the following: Information that documents the medical reason and unusual circumstances for the separate evaluation and management (E/M) visit Information that supports that the medical visit occurred due to a complication, such as cardiovascular complications, comatose conditions, elevated temperature for two or more consecutive days, medical complications other than nausea and vomiting due to anesthesia, postoperative wound infection requiring specialized treatment, or renal failure Pacemaker Analysis Two within Six Months The provider should use the claim note to document the medical reason for the second analysis in the six-month time frame, such as a dysfunctional pacemaker. Assistant Surgeon Not Payable when Cosurgeon Paid In the claim note, the IHCP accepts information that documents the medical reason for the assistant surgeon, such as the situational problem requiring assistance. Excessive Nursing Home Visits or More than One per 27 Days In the claim note, the IHCP accepts documentation supporting the treatment of emergent, urgent, or acute conditions or symptoms with the new diagnosis code. Retroactive Eligibility Use claim notes when billing a claim that is past the filing limit and the member was awarded retroactive eligibility. In the case of retroactive member eligibility, claims must be submitted within one year of the eligibility determination date. Follow these steps to submit a claim on Web interchange: 1. Complete the claim as you would normally, using Web interchange. 2. Click Notes in header of claim and under Note Reference Code, type ADD. 3. In Note text, type Member has retroactive eligibility. Please waive timely filing Library Reference Number: PRPR10004

19 Section 2: Claims Processing Overview Mental Health HE or HO modifier and Edit 2503 Provider not approved to bill Medicare Mental health providers that submit claims with procedure codes and append modifier HE or HO when the member is dually eligible for Medicare and Medicaid may use claim notes for billing purposes to indicate the provider that performed the service is not approved to bill services to Medicare. Previously, providers were required to submit this documentation as a paper attachment. Therefore, with this change, providers can submit these types of claims electronically in an effort to expedite claim payment. Claims submitted with the appropriate claim notes must include the following text in the claim notes: Provider not approved to bill services to Medicare. The use of claim notes allows the claim to suspend for review of the claim note and be adjudicated appropriately. Pharmacy POS Claim Submission The pharmacy submits the drug claim at point of sale (POS). The claims are adjudicated immediately, as long as all information is included and correct. Additional information about pharmacy claims processing is contained in Chapter 9: IHCP Pharmacy Services Benefit of this manual. Library Reference Number: PRPR

20 Section 3: Suspended Claim Resolution General Information Edits and audits are designed to monitor and enforce federal and state laws, regulations, and program requirements. During the claims adjudication process, claims that fail an edit or audit do one of the following: Systematically deny Systematically cut back or reduce the number of units billed on the claim Suspend the claim When a claim suspends, processing is suspended until the error causing the failure is reviewed, corrected, or otherwise resolved. The process of reviewing, correcting, and resolving claim errors is performed in multiple areas including the following: HP Claims Resolution Unit, HP Adjustments Unit, the Medical Policy Departments at the managed care entities (MCEs), and the Indiana Health Coverage Programs (IHCP) Program Integrity Department. The examiners in these organizations follow written guidelines in adjudicating claims that fail defined edits or audits. Suspended Claim Location Claims data that fails edits and audits (suspend disposition) is routed to a suspense location within the claims processing system. Depending on the edit or audit that caused the failure, claims are routed to a specific claim location that identifies the type of edit or audit failed. These location codes are assigned to specific departments within HP, ADVANTAGE Health Solutions fee-for-service (FFS), MDwise- Care Select (CS), or ADVANTAGE Health Solutions-CS. ADVANTAGE and MDwise participate as the care management organization (CMO) vendors for the IHCP and are responsible for resolving certain claim errors or edit and audit failures. Adjustments that fail any edit or audit are routed to the Adjustments Unit at HP or the appropriate Medical Policy Department. Medical policy edit and audit failures are routed to the Medical Policy Department at ADVANTAGE Health Solutions-FFS, ADVANTAGE Health Solutions-CS, or MDwise-CS. Claims that fail for members on the Right Choices Program are routed to ADVANTAGE Health Solutions-FFS, ADVANTAGE Health Solutions-CS, or MDwise-CS. Prepayment provider review edits are routed to the Prepayment Review (PPR) Unit located within the IHCP Program Integrity Department. The remaining edit and audit failures are routed to the Claims Resolution Unit at HP. Library Reference Number: PRPR

21 Section 3: Suspended Claim Resolution Suspended Claims Processing IndianaAIM distributes claims in suspense to the appropriate resolution examiner, distributing the oldest suspended claim to the examiner first. This process ensures that older claims are processed first. Suspended claims, along with the error codes and descriptions, are displayed to the examiners in a format similar to the claim form. The screen provides examiners with a field to apply claims processing transactions, claim location for routing, or explanation of benefits (EOB) messages for claim denials. The screen allows examiners to access various reference files necessary to effectively process suspended claims. Examiners have the option of applying the following transactions when processing suspended claims, depending on the edit or audit failure: ADD/CHANGE The examiners can correct typing errors. Examiners cannot change reimbursement data except in the case of manual pricing. FORCE/OVERRIDE The edits and audits are overridden to force the claim to go through the claims processing cycle regardless of the presence of the overridden error. DENY The claim can be denied if called for by the edit or audit. ROUTE The claim may be routed to a different claim location. RESUBMIT The claim can be resubmitted. This action is applied if the claim failed an edit or audit that was set in error and has since been corrected. When resubmitted, the claim goes through the same processing procedures. Suspended claims display all the error codes that caused the claims to suspend, up to a maximum of 20 error codes. The process follows: 1. The examiner clears all the error codes applicable to the claim location. 2. The claim is routed to the next applicable location if there are other errors that require correction. 3. The claim is resubmitted for processing and is again subjected to all the edits and audits. Overrides applied to any errors are captured to prevent the claim from suspending again for the same error. These overrides stay with the claim record history. Suspended Claim Guidelines for Processing HP must adjudicate clean paper claims within 30 calendar days of receipt. Clean electronic claims must be adjudicated within 21 calendar days of receipt. These guidelines apply to all claims, even those that suspend for review. All suspended claims are processed according to IC (7)(A). The exceptions to the guidelines are as follows: Claims suspended for medical review Claims submitted by a provider subject to prepayment review Paper claims that are not adjudicated within 30 days and electronic claims that are not adjudicated within 21 days are subject to interest accrual, as outlined in this chapter. Electronic claims followed by attachments must contain the provider-assigned attachment control numbers (ACNs) corresponding to the ACNs on the attachment cover sheet and the pages of each attachment to match with the claim for review. Library Reference Number: PRPR

22 Section 4: Crossover Claims Processing Procedures General Information Claims for members eligible for Medicare and Traditional Medicaid, or for dually eligible members for whom Medicare has previously made payment, are called crossover claims. This section describes crossover claims processing procedures. Crossover and Medicare Replacement Plan claims can be submitted electronically in the 837 format or through Web interchange or on the appropriate institutional or medical paper claim forms. Claim billing procedures are outlined in Chapter 8: Billing Instructions of this manual. Information about reimbursement of crossover and Medicare Replacement Plan claims is located in Chapter 7: Reimbursement Methodologies of this manual. Automatic Crossovers Claims that meet certain criteria cross over automatically from Medicare and are reflected on the Indiana Health Coverage Programs (IHCP) Remittance Advice (RA) statement or 835 transaction. Wisconsin Physician Services (WPS) is the contractor for Coordination of Benefits Agreement (COBA). The basic criteria follow: Medicare makes a payment for the billed services. WPS validates against the member file submitted by Indiana Medicaid and submits claims based on the member information. Providers can also submit claims directly to Indiana Medicaid by indicating secondary payer information in the coordination of benefits (COB) loop for Indiana Medicaid. WPS is set up as a trading partner and approved to transmit claims data to HP. IndianaAIM has all Medicare codes on file. If the Medicaid allowed amount for the services billed exceeds the Medicare paid amount for the services, Traditional Medicaid pays the lesser of the coinsurance or copayment plus deductible amounts, or the difference between the Medicaidallowed amount and Medicare-paid amount. There is no Traditional Medicaid filing time limit for paid crossover claims from Medicare. Electronic crossover claims are received electronically in batch 837 files from WPS. Individual providers or billing agents can bill crossover claims electronically to Traditional Medicaid using the appropriate electronic 837 format or Web interchange. Claims That Do Not Cross Over Automatically Medicare crossover and Medicare Replacement Plan claims that do not automatically cross over to Traditional Medicaid must be submitted to the IHCP for adjudication. They can be submitted electronically using Web interchange or the 837 format, using approved software, or via paper claim form containing the payment information from Medicare and any other payer. For all crossover and Medicare Replacement Plan claims, the provider s National Provider Identifier (NPI) must be on file Library Reference Number: PRPR

23 Section 4: Crossover Claims Processing Procedures with the IHCP. If a Medicaid member has Medicare coverage and the Medicare payment amount on the claim being submitted is greater than zero, the Medicare Remittance Notice (MRN) is not required. However, if zero dollars is indicated in the Medicare-paid amount field on the claim, the MRN must be attached. Submitting a Medicare Remittance Notice If the Medicare paid amount in field 22 of the CMS-1500 claim form or field 54A of the UB-04 claim form is zero, providers must attach the MRN to claims when submitting them to the IHCP. The attachment verifies that the reason for Medicare nonpayment is due to the amount being applied to the deductible. These claims are treated like any other third-party liability (TPL) claim. If the attachment does not show that the amount entered in field 22 on the CMS-1500 claim form or in fields 39 through 41 on the UB-04 claim form was applied to the deductible, the claim is denied. Submitting Medicare HMO Replacement Professional-Web interchange Claim Submission Type Professional Web interchange Professional crossover claims submitted via Web interchange, including Medicare Replacement Plan claims, must contain information regarding the payment amount, coinsurance or copayment and/or deductibles. Failure to include this information in the correct fields will result in claims being denied or processed incorrectly. To submit Medicare Replacement Plan claims for professional services via Web interchange: Select Medical Crossover on the Claim Processing Menu. In the Coordination of Benefits section at the claim header, click Benefit Information to display the Coordination of Benefits window. In the Other Payer Information section of the window, enter the appropriate Payer ID of the Medicare Replacement Plan in the Payer ID field. In the Payer Name field, enter the name of the Medicare Replacement Plan. In the TPL/Medicare Paid Amount field, enter the paid amount for the entire claim. In the Other Payer Payment Adjustments section, complete the Group Code, Reason Code, and Amount information. In the Other Payer Subscriber Information section of the window, complete the required fields; Member Name, Primary ID, Relationship Code and Claim Filing Code. Enter 16 - Health Maintenance Organization (HMO) Medicare Risk for a Medicare Replacement Plan. Library Reference Number: PRPR

24 Chapter 10 Section 4: Crossover Claims Processing Procedures Indiana Health Coverage Programs Provider Manual Figure 10.1 Coordination of Benefits Window For the full instructions regarding Web interchange claim completion for professional claims, see the Quick Reference for Billing Medical Claims located in the Reference Materials section of the Web interchange Help. Submitting Medicare HMO Replacement Institutional or Outpatient-Web interchange Claim Submission Type Institutional/Outpatient Web interchange Institutional/Outpatient crossover claims submitted electronically via Web interchange, including Medicare Replacement Plan claims, must contain information regarding the Medicare Replacement Plan payment amount, coinsurance or copayment, and/or deductibles. Failure to include this information will result in claims being denied or processed incorrectly. To submit institutional/outpatient crossover claims: Select Institutional Crossover or Outpatient Crossover on the Claim Processing Menu, as applicable Library Reference Number: PRPR10004

25 Section 4: Crossover Claims Processing Procedures Under the Coordination of Benefits section, click Benefit Information to display the Coordination of Benefits window. In the Other Payer Information section of the window, enter the appropriate Payer ID of the Medicare Replacement Plan in the Payer ID field. In the Payer Name field, enter the name of the Medicare Replacement Plan. In the TPL/Medicare Paid Amount field, enter the amount that the Medicare Replacement Plan paid for the entire claim. In the Other Payer Payment Adjustments section complete the Group Code, Reason Code, and Amount information. In the Other Payer Subscriber Information section of the window, complete the required fields; Member Name, Primary ID, Relationship Code and the Claim Filing Code. Enter 16 Health Maintenance Organization (HMO) Medicare Risk for Medicare Replacement Plan claims. Figure 10.2 Coordination of Benefits Window For the full instructions regarding Web interchange claim completion for Institutional/Outpatient claims, see the Quick Reference for Billing Institutional Claims in the Reference Materials section of Web interchange Help. Library Reference Number: PRPR

26 Chapter 10 Section 4: Crossover Claims Processing Procedures Indiana Health Coverage Programs Provider Manual Submitting Medicare HMO Replacement Plans Medicare Replacement Plan claims are processed as Medicare crossover claims. The IHCP reimburses covered services for Medicare crossover claims only when the Medicaid-allowed amount exceeds the amount paid by Medicare. If the Medicaid-allowed amount exceeds the Medicare Replacement Plan paid amount, the IHCP reimburses using the lesser of the coinsurance or copayment plus deductible or the Medicaid-allowed amount minus the Medicare Replacement Plan paid amount. This change also affects claims paid at zero when the amount allowed has been allocated to the member s deductible. To process as a crossover claim, providers must include additional information on claims submitted on the CMS-1500 claim form. The combined total of the Medicare, coinsurance or copayment, deductible, and psychiatric reduction must be reported on the left side of field 22 under the heading Medicare Resubmission Code. The Medicare Replacement Plan paid amount, meaning the actual dollars received from Medicare, must be indicated in field 22 on the right side under the heading Original Ref No. All institutional and outpatient UB-04 claims must identify information from the Medicare Replacement Plan explanation of benefits (EOB) in Fields 39a-41d. The following value codes must be used, along with the appropriate dollar or unit amounts for each. These fields are required, if applicable: Value Code A1 Medicare deductible amount Value Code A2 Medicare coinsurance or copayment amount Value Code 06 Medicare blood deductible amount Field 50A must indicate Medicare as the payer Field 54A must contain the Medicare Replacement Plan paid amount, meaning the actual dollars received from Medicare. (Do not include the Medicare-allowed amount or contractual adjustment amount in field 54A.) Medicare Replacement Plan denials Please note that Medicare-denied services are not crossover services, and the submission procedures for Medicare-denied services have not changed. If a claim has been denied by the Medicare Replacement Plan, the EOB or Remittance Advice (RA) must be attached to the claim with Medicare Replacement Plan written on the top of the attachment. Medicare-denied services must be filed on a separate claim form from paid services, and the appropriate EOB or RA must be attached for reimbursement consideration. Medicare-denied services may be submitted via Web interchange. Follow the Attachments instructions to send the Medicare Replacement Plan EOB. Medicare Denied Details for Crossover Claims Processing Denied details for crossover claims processing deny with Edit 593 Medicare denied details. Web interchange allows providers to enter denied service lines for crossover claims. Crossover and Medicare Replacement Plan A (Inpatient and LTC) Claims Submitted through Web interchange For crossover and Medicare Replacement Plan A claims, providers may report coordination of benefits (COB) adjustment information at the header and detail levels, but this information must appear at the header level for claims adjudication. If only detail COB adjustment information is present, it is not recognized by Web interchange Library Reference Number: PRPR10004

27 Section 4: Crossover Claims Processing Procedures Crossover and Medicare Replacement Plan B (Medical) Claims Submitted through Web interchange For crossover and Medicare Replacement Plan B claims, providers must report COB adjustment information at the header and detail level. If COB adjustment information appears at the header and detail levels, the sum of the detail must equal the header amount. If they are not equal, the user receives an error stating, The header and detail crossover amounts are not equal. Crossover and Medicare Replacement Plan C (Outpatient) Claims Submitted through Web interchange Providers must report COB adjustment information for crossover and Medicare Replacement Plan C claims at the header or detail level. If COB adjustment information appears at the header and detail levels, the sum of the detail must equal the header amount. If they are not equal, the user receives an error stating, The header and detail crossover amounts are not equal. 837I Crossover and Medicare Replacement Plan A Claims Submitted through Electronic Data Interchange COB adjustment information can be reported at the header and detail level but must be present at the header for claims adjudication. If header COB adjustment information is not present, Submission Summary Report (SSR) error 280 is returned to the provider stating, Crossover A claims must contain crossover amounts (Medicare paid, deductible, coinsurance or copayment, and blood deductible amounts) at the header level. If header and COB adjustment information do not balance, the claim is still processed. Note: Provider specialties 260, 261, and 264 continue to report COB adjustment information at the header level, because the IHCP has excluded this specialty from the modification. 837I Crossover and Medicare Replacement Plan C Claims Submitted through Electronic Data Interchange COB adjustment information can be reported at the header and detail levels but must be present at the detail level for claims adjudication. If header and detail COB adjustment information is present, the header and the detail must balance. If they do not balance, SSR error 277 is returned to the provider stating, Crossover adjustment amounts (deductible, coinsurance or copayment, and blood deductible amounts) at the detail do not balance with the header crossover adjustment amounts. 837P Crossover and Medicare Replacement Plan B Claims Submitted through Electronic Data Interchange COB adjustment information can be reported at the header and detail levels. If COB adjustment information is present at the header and detail levels, the sum of the detail must equal the header. If the detail and the header do not balance, SSR error 277 is returned to the provider stating, Crossover adjustment amounts (deductible, coinsurance or copayment, and blood deductible amounts) at the detail do not balance with the header crossover adjustment amounts. Complete information about electronic data interchange (EDI) reports is published in the Companion Guide: 999 Acknowledgement and Submission Summary Report located on the EDI Solutions page at indianamedicaid.com. More information about COB can be found by clicking the FAQ menu option on Web interchange. Library Reference Number: PRPR

28 Chapter 10 Section 4: Crossover Claims Processing Procedures Indiana Health Coverage Programs Provider Manual Medicare Exhaust Claims Benefits Exhausted Prior to Inpatient Admission The IHCP reimburses acute care hospitals for dually eligible (Medicare and Medicaid) IHCP members who exhaust their inpatient hospital Medicare Part A benefits prior to admission to acute care hospitals. When a Medicare Part A stay is exhausted by Medicare prior to admission, providers must bill the date of admission through the date of discharge on the UB-04 claim form. Do not bill the IHCP for partial inpatient stays. The MRN must be submitted with the claim to show benefits were exhausted prior to the date of admission. Providers must bill services payable to Medicare Part B before billing the exhaust claim to Medicaid. Because these claims are considered Medicaid primary claims, all IHCP filing limit rules apply. See Section 5: Claim Filing Limitations for information about waiving filing limit procedures and supplying appropriate documentation for claim adjudication. Benefits Exhausted During an Inpatient Stay When a dually eligible member exhausts Medicare Part A benefits during an inpatient stay, the claim automatically crosses over from Medicare and adjudicates according to the IHCP inpatient crossover reimbursement methodology. Once the coinsurance or copayment and deductible amounts are considered, no additional payment is made on the claim. This is also true for claims that do not automatically cross over but are submitted via the web or paper. The IHCP will continue to reimburse Medicare Part B charges, as long as the revenue codes billed on the Medicare Part A and B claims are not the same. If the same revenue codes appear on both claims, the claim will deny for duplicate billing Library Reference Number: PRPR10004

29 Section 5: Claim Filing Limitations General Information Providers must submit all claims for services rendered within one year of the date of service. When submitting claims beyond the one-year filing limit, the provider can submit the claim with documentation for justification electronically or on paper. See the Indiana Administrative Code (IAC) 405 IAC for the complete rule narrative about filing limitations. Each claim stands on its own merit, so multiple claims must each have an individual documentation trail attached. Multiple claims with only one set of documentation are not acceptable for filing limit processing. Note: Explanation of benefits (EOB) Codes 0512 and 0545 and the associated adjustment reason codes (ARCs) state that a claim submitted after the oneyear filing limit without acceptable documentation does not apply to a crossover claim when Medicare made a payment. EOB codes 0512 and 0545 are both associated with ARC 29 and remark code N66. Specifically, EOBs 0512 and 0545 are bypassed for cases in which Traditional Medicaid is paying an amount up to the sum of the coinsurance or copayment and deductible amounts. If Medicare denies a claim, EOB codes 0512 and 0545 apply to the Traditional Medicaid claim. Provider Responsibilities To waive the filing limit, the provider is responsible for maintaining and attaching supportive information. Supportive information for claims exceeding the filing limit can include the following: Remittance Advice (RA) statement illustrating a denial 277 Claim Inquiry response transaction from the 276 Claim Inquiry transaction Claim Inquiry screen print from Web interchange Answered inquiries from the Written Correspondence Unit at HP Dated EOBs from third-party liability payers Indiana Health Coverage Programs (IHCP)-generated documentation of prior claim submission Note: Claims without documentation automatically deny. Provider-generated notes or claims filing time lines are not acceptable documentation. If providers have unresolved issues with a particular claim, the claim continues to fail until the issue is resolved. Providers are advised to research and resolve all claim issues with the Customer Assistance Unit or to send a properly completed and documented written correspondence inquiry to the Written Correspondence Unit prior to submitting the claim for filing limit waiver processing. The Written Correspondence address is listed in Chapter 1: General Information of this manual or on indianamedicaid.com. Library Reference Number: PRPR

30 Chapter 10 Section 5: Claim Filing Limitations Indiana Health Coverage Programs Provider Manual The following list includes criteria that must be present to waive the filing limit: The services reflected on the claim have not been paid during previous processing. If a partial payment was made, the claim must be sent to the HP Adjustments Unit at the address listed in Chapter 1: General Information of this manual. Adjustment claim submissions must also comply with the one-year filing rule; additional adjustment details are found in Chapter 11: Paid Claim Adjustment Procedures of this manual. If a line item on a claim is denied, that line item should be resubmitted separately. The date of service on the claim is past the one-year anniversary. The claim has documentation that notes one or more of the following extenuating circumstances: The claim was initially submitted within one year of the date of service. The documentation series must have subsequent activity within one year of the last activity toward resolving a claim issue. The documentation has no lapses in the one-year rule for activity, such as one year or less between reasonable and continuous attempts made toward getting the claim paid. Extenuating Circumstances to Waive the Filing Limit Claims not filed in a timely manner because the provider has misplaced them, office personnel has changed, or the provider has forgotten to file are not considered extenuating circumstances and result in rejection of the claim. HP has the authority to waive the filing limit if the following extenuating circumstances are documented: HP, state, or county error or action has delayed payment. The provider has made reasonable and continuous attempts to resolve a claim problem. Commonly accepted documentation used to waive the filing limit is outlined in the following section. The provider has made reasonable and continuous attempts to bill and collect from a third-party liability (TPL) source before billing the IHCP. Medicare and Traditional Medicaid claims have failed to cross over. A member has been enrolled retroactively in the IHCP. In the case of retroactive member eligibility, claims must be submitted within one year of the eligibility determination date. A cover letter explaining the circumstances must be attached to the claim, or at the minimum, an attachment stating retroactive eligibility as an issue. HP will review the eligibility award date in IndianaAIM for appropriate processing. Retroactive provider enrollment has been established. For example, a member who is not eligible for the IHCP sees a provider that is not an IHCP provider. The member becomes retroactively enrolled in Traditional Medicaid. The provider also needs to be retroactively enrolled. Or, if the provider sees an IHCP member in an emergency situation, the provider can be retroactively enrolled in Traditional Medicaid. The provider was unaware the recipient was eligible for assistance at the time services were rendered, and the following conditions are met: The provider's records document that the recipient refused or was physically unable to provide his or her Medicaid number. The provider can substantiate that reimbursement was continually pursued from the patient until Medicaid eligibility was discovered Library Reference Number: PRPR10004

31 Section 5: Claim Filing Limitations The provider billed the Medicaid program, or otherwise contacted Medicaid in writing, regarding the situation within 60 days of the date Medicaid eligibility was discovered [see 405 IAC 1-1-3(c)]. A recipient receives a service outside Indiana by a provider that has not yet been enrolled or has not received a provider manual at the time services were rendered, subject to approval by the Family and Social Services Administration (FSSA). Such situations will be reviewed on an individual basis by the FSSA to ascertain if the provider made a good faith effort to enroll and submit claims in a timely manner. Timely Filing Limit Documentation To waive the timely filing limit, the provider must show documentation of reasonable and continuous attempts made to resolve claim payment problems; this is acceptable for claims submitted by paper, 837 format, or Web interchange. The following is a list of commonly accepted documentation used to waive the filing limit: Action taken to collect from other insurers, the IHCP, or the person who received the services Examples of documentation are dated RAs with an internal control number (ICN) that notes filing timeliness; dated statements, bills, and claim forms; letters to and from insurers or the insured; and collection notices. Action taken if a third-party payer fails to respond The provider must indicate 90-Days NO RESPONSE on an attachment. The TPL form locator must be completed appropriately for carrier information. A copy of the letter, bill, or statement to the insurance company is appropriate documentation to waive the one-year filing limit. Detailed information is located in Chapter 5: Third Party Liability of this manual. Action taken to resolve the claim problem Examples of action taken include Written Inquiry responses, IHCP Prior Authorization Request Forms, letters to and from the county office, and letters to the regional HP field consultant or the member. The response from claim status inquiry showing all submissions of the claim for proof of timely filing For waiver providers, proof that a Plan of Care was issued late, or copies of the review findings letter from an audit How to Submit Claims for Filing Limit Waiver Paper claims sent for filing limit waiver processing are to be structured as follows: Legible and signed paper claim Photocopies are acceptable. Required supporting documentation, as applicable, such as letters from the local county office, sterilization consent forms, Medicare or TPL denials, and invoices Photocopies are acceptable. Documentation attached in chronological order that illustrates the provider s attempts to resolve extenuating circumstances Examples are IHCP RA statements, returned IHCP written inquiries, letters from the local county office, letters from other insurance carriers, and returned prior authorization (PA) forms. A chronological narrative is also helpful. Library Reference Number: PRPR

32 Chapter 10 Section 5: Claim Filing Limitations Indiana Health Coverage Programs Provider Manual Individual documentation trail attached to each claim Each claim stands on its own merit, so multiple claims must each have an individual documentation trail attached. Multiple claims with only one set of documentation are not acceptable for filing limit processing. Correct address for the claim type Send filing limit claims to the routine claim-processing address for the respective claim type, such as CMS-1500, dental, and inpatient hospital. There is no special mailing address for claim requests to waive the filing limit. Note: For providers using copies of claims for attachments: The CMS-1500 and UB-04 claim forms contain a bar code at the top of the claim form. The bar code indicates a new claim, and thus a new sequence number, to the scanner in the HP mailroom. When sending copies of claims as attachments, the provider must place a large X through the claim copy to indicate to the processor that the claim copy is being used for filing limit documentation Library Reference Number: PRPR10004

33 Section 6: Claim Reimbursement Administrative Review and Appeal Procedures Claims Administrative Review Policy If a provider disagrees with the Indiana Health Coverage Programs (IHCP) determination of payment, the provider's right of recourse is to file an administrative review and appeal, as provided for in 405 IAC Steps Taken Prior to the Administrative Review Process The provider must exhaust routine measures to obtain payment before filing an administrative review request. All provider claims for payment of services rendered to members must be originally filed with HP within 12 months of the date of service. The following information is the administrative review process in practical terms: Upon receipt of the claim denial, the provider must review the denial, make applicable corrections, and resubmit the claim via routine claim-processing channels. If the claim paid, and the provider disagrees with the reimbursement, the provider must submit an adjustment request with documentation stating why he or she disagrees with the reimbursement. If the provider received the same results following the two previous steps, the next action is to file for an administrative review. Filing Administrative Review The process for reconsideration of adjudicated claims follows. Providers must: Complete an IHCP Inquiry Form (available on the Forms page at indianamedicaid.com) or write a letter on letterhead stating the reason for disagreement with the denial or amount of reimbursement. Clearly note Administrative Review on the form or letter and submit with all pertinent documentation. If the formal administrative review request is specific to the National Correct Coding Initiative (NCCI), clearly note Healthcare Administrative Review Specialist on the form and submit with all pertinent documentation. File the formal administrative review request within 60 calendar days of notification of claim payment or denial from HP. Send the package of information to the following address: Administrative Review HP Written Correspondence P.O. Box 7263 Indianapolis, IN Note: For providers on prepayment review, see Chapter 13: Utilization Review of this manual for administrative review and appeal procedures. Library Reference Number: PRPR

34 Chapter 10 Indiana Health Coverage Programs Provider Manual Section 6: Claim Reimbursement Administrative Review and Appeal Procedures Administrative Review Responses An administrative review analyst or healthcare administrative review specialist responds to all administrative review requests within 90 business days of receipt of the request, regardless of the decision to pay or deny the claim. Each denial decision is specific, detailed, and fully documented. If the administrative review response is unfavorable to the provider, the appeal rights in 405 IAC and the time period during which appeal rights can be exercised are specified in the response. Appeals The provider must exhaust the formal administrative review process previously described prior to filing a request for appeal. The provider must comply with all requests to submit information or additional documentation, and must receive a final written review decision from the administrative review analyst. If the provider is still not satisfied with the determination after all the procedures required for administrative review have been exhausted, the provider can send a request for appeal. The appeal time line follows. An appeal request must be delivered to the following address within 15 business days after receipt of an adverse administrative review decision notice on which the appeal is premised: Secretary c/o Office of Medicaid Policy and Planning MS07 Indiana Family and Social Services Administration 402 W. Washington Street, Room W382 Indianapolis, IN An administrative law judge s adverse decision can be appealed by filing objections with the ultimate authority for the agency within 15 business days of receipt of the decision. An appellant can file a petition for judicial review in accordance with IC , if the appellant is not satisfied with the agency review decision. Other Administrative Reviews and Appeals NCCI Claims Administrative Review If there are unusual circumstances in which a provider believes a claim was coded correctly and would like reconsideration of the NCCI editing, the provider must submit a formal administrative review request by completing an IHCP Inquiry Form (available on the Forms page at indianamedicaid.com) or writing a letter stating the reason for disagreement with the denial or amount of reimbursement. Providers are encouraged to access the Medicaid.gov website at medicaid.gov for review of the NCCI Columns I and II, Mutually Exclusive (ME), and Medically Unlikely Edit (MUE) files. These files contain specific code pairs for Columns I and II and the ME edits. If the provider still believes a claim was coded correctly and would like reconsideration, the provider may submit a request for a formal administrative review. Before filing a claim administrative review request, the provider must exhaust routine measures to receive claim payment. Providers must continue to follow the normal avenues of resolution found in this manual when inquiring about claims activity Library Reference Number: PRPR10004

35 Section 6: Claim Reimbursement Administrative Review and Appeal Procedures The following information outlines the administrative review process: Administrative review must be requested within 60 days of notification of claims payment or denial. Complete an IHCP Inquiry Form or use provider letterhead to submit the following: Document the unusual circumstances in which the provider believes the claim was coded correctly and would like a reconsideration of the NCCI editing. Document the reason for disagreement. Document the denial reason and/or the reason the payment is being disputed. Attach all pertinent supporting documentation. Clearly note Healthcare Administrative Review Specialist on the IHCP Inquiry Form or letterhead and send to: Attn: Healthcare Administrative Review Specialist HP Written Correspondence P. O. Box 7263 Indianapolis, IN If a provider has questions regarding NCCI table edits, they can submit their questions to this address: Attn: Niles R. Rosen, M.D., Medical Director, and Linda S. Dietz, RHIA, CCS, CCS-P, Coding Specialist National Correct Coding Initiative Correct Coding Solutions LLC P.O. Box 907 Carmel, IN Note: Providers should not send claim or appeal questions to this address. NCCI Claim Appeals The provider must exhaust the formal administrative review process described in NCCI Claims Administrative Review prior to filing a request for appeal. The provider must comply with all HP requests for resubmission of information or additional documentation, and must receive a final written review decision from HP. All these steps must be followed to preserve appeal rights. If the provider is still not satisfied with the determination after all the procedures required for administrative review have been exhausted, the provider can send a request for appeal, within 15 business days of receipt of the final administrative review decision, to the following address: Secretary c/o Office of Medicaid Policy and Planning MS07 Indiana Family and Social Services Administration 402 W. Washington Street, Room W382 Indianapolis, IN See 405 IAC for appeal procedures. Library Reference Number: PRPR

36 Chapter 10 Indiana Health Coverage Programs Provider Manual Section 6: Claim Reimbursement Administrative Review and Appeal Procedures Surveillance and Utilization Review and Prior Authorization Appeals For more information about Surveillance and Utilization Review audit appeals, see Chapter 13: Utilization Review of this manual. For more information about appeals of prior authorization decisions, see Chapter 6: Prior Authorization of this manual. Managed Care Considerations Care Select Administrative review and appeal procedures related to claims for members in Care Select follow the guidelines described in this chapter. Claims for members enrolled in Care Select are subject to all applicable procedures described in this chapter. Risk-Based Managed Care Administrative reviews and appeals related to claims for members enrolled in the risk-based managed care (RBMC) component of Hoosier Healthwise are the responsibility of the managed care entity (MCE) in which the member was enrolled at the time of service. Claims related to carved-out services follow the guidelines specified in this chapter for fee-for-service. Each MCE that participates in Hoosier Healthwise is required to have a formal grievance procedure for providers and members who wish to appeal claim determinations made by the MCE. For specific information related to the MCE appeal process, see indianamedicaid.com Library Reference Number: PRPR10004

37 Section 7: Submission Summary Report Overview This section contains information about the Submission Summary Report (SSR) specific to the 837D, 837I, or 837P transactions. This information is also in the 999 Acknowledgement and Submission Summary Report Companion Guide located on the Electronic Data Interchange (EDI) Solutions page at indianamedicaid.com. The following claim transactions generate submission summary reports: 837D (Dental) 837I (Institutional) 837P (Professional) Submission Summary Report Table 10.7 Submission Summary Report Functional Area Report Number Job Name Report Title Electronic Claim Capture N/A N/A X12 Submission Summary Report Description of Information The Submission Summary Report details the results of pre-adjudication edits, which verify IHCP compliance of 837D, 837I, and 837P claims. Compliant claims are accepted for processing. Rejected claims contain errors that prevent them from continuing through the claims processing cycle. For claims with multiple details, the entire claim is rejected, even though only one service line is in error. The fact that a claim is accepted does not guarantee payment of the claim. It means only that it contained the basic information needed for processing. Submission Summary Reports are produced for every electronic claim file submitted and contain submission date and time, National Provider Identifier, number of claims accepted, number of claims rejected, dollar amount billed, and detailed information about all rejected claims. A list of Submission Summary Report error code definitions is located in the 999 Acknowledgement and Submission Summary Report Companion Guide located on the EDI Solutions page at indianamedicaid.com. Purpose of Report The Submission Summary Report summarizes claim files that are successfully submitted. These reports also summarize claims rejected because of missing or invalid information. Trading partners have the opportunity to download and view the Submission Summary Report, correct claim errors, and resubmit the claim or claims. Trading partners that transmit claim files directly to HP can download the report within two hours of the transmission. Library Reference Number: PRPR

38 Index A administrative review administrative review responses appeals , other administrative reviews and appeals10-34 attachments automatic crossovers B batch ranges C Care Select , claims administrative review claims filing limit , claims processing claims returned to provider claims that do not cross over automatically cross over automatically crossover A claims I crossover B claims P crossover C claims I crossover claims processing procedures crossovers automatic D documentation E edits and audits electronic claims F filing administrative review filing limit , filing limit waiver G general information I ICN internal control number examples introduction J Julian dates M managed care managed care considerations managed care entity MCE Medicare denied details for crossover claims Medicare Remittance Notice MRN N NCCI claim appeals NCCI claims administrative review O other administrative reviews and appeals P paper claim paper claim billing processes pharmacy POS claim submission POS prior authorization appeals process suspended claims provider responsibilities R RBMC , region codes reviews other administrative reviews and appeals10-34 risk-based managed care , S steps taken prior to the administrative review process Submission Summary Report description Surveillance and Utilization Review appeals suspended suspended claim add/change deny force/override Library Reference Number: PRPR

39 Index guidelines for processing resubmit route suspended claim resolution suspended claims processing T timely filing limit W waive filing limit Library Reference Number: PRPR