CLAIMS Section 6. Overview. Timely Claims Submission. Clean Claim. Prompt Payment. Claim Submission Format

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1 Overview The Claims department partners with the Prvider Relatins, Health Services and Custmer Service departments t assist prviders with any claim-related questins. The fcus f the Claims department is t prcess claims timely, investigate the basis fr any issues and crrect their rt causes. The Plan has established tll-free telephne numbers fr prviders t access a representative in ur Custmer Service department. Please refer t the state-specific Quick Reference Guide fr cntact infrmatin. Timely Claims Submissin Timely filing is six mnths frm the date f service t the primary payers and 90 days t the secndary payers. Refer t the state-specific Quick Reference Guide fr the apprpriate mailing address. Clean Claim Prviders are required t submit clean claims. A clean claim is ne that can be prcessed withut btaining additinal infrmatin frm the prvider wh prvided the service r frm a third party. Prmpt Payment Clean claims must be paid within the number f days specified in the cntractual payment agreement between the prvider and health carrier. Interest is t be paid t the prvider based n the number f days that have elapsed between the date payments are due based n the cntractual payment arrangement entered int and the date payment is made. Claim Submissin Frmat Claims may be submitted t the Plan in ne f the fllwing frmats: Electrnic Claims Submissin (EDI) CMS-1500 Frm UB-04 Frm Claims shuld be submitted t the Plan accrding t the fllwing standards. Failure t cmply with these Medicare Advantage Prvider Manual Octber 2008 Page 1 f 13

2 standards may result in delay f payment r the rejectin (returned t prvider as unprcessed) f the claim. Claims must cntain the Natinal Prvider Identifier (NPI) fr all primary and secndary prvider fields n all electrnic and paper claims (UB-04 and CMS-1500) submissins. The NPI is a unique identificatin number fr all health care prviders mandated by the Health Insurance Prtability and Accuntability Act (HIPAA). This number is a 10-psitin, intelligence-free numeric identifier (10-digit number). Infrmatin fr btaining a NPI is available by: Telephne: (800) r TTY: (800) custmerservice@npienumeratr.cm Mail: NPI Enumeratr P.O. Bx 6059 Farg, ND Answers t frequently asked questins regarding NPI are available n Claims must cntain the Federal Tax ID (Emplyer Identificatin Number r Scial Security number) fr the prvider f service r supplier. All data fields are t be cmpleted. Claims shuld nt be handwritten r altered. Only current standard prcedural terminlgy is acceptable fr reimbursement per the fllwing cding manuals: Medicare Advantage Prvider Manual Octber 2008 Page 2 f 13

3 Current Prcedural Terminlgy (CPT) fr physician prcedural terminlgy. Internatinal Classificatin f Diseases (ICD9-CM) fr diagnstic cding. Health Care Prcedure Cding System (HCPC). CMS-1500 paper claim submissins must be submitted n frm OMB (08-05) as nted n the dcument s fter. The Plan accepts the revised CMS-1500 and UB-04 frms printed in Flint OCR Red, J6983, (r exact match) ink. Althugh a cpy f the CMS-1500 frm can be dwnladed frm the CMS Web site, cpies f the frm cannt be used fr submissin f claims as the cpy may nt accurately replicate the scale r clr f the frm when scanned using Optical Character Recgnitin (OCR). This scanning technlgy allws fr the data cntained n the frm t be read while the actual frm fields, headings and lines remain invisible t the scanner. OCR technlgy allws the Plan t recrd and prcess paper claims faster. Fr EDI submissins, prviders shuld fllw the HIPAA transactin and cde set requirements as fund in the Natinal Electrnic Data Interchange Transactin Set Implementatin Guides and the Cmpanin Guide when prvided by the Plan. HIPAA requires cmpliance with the Electrnic Data Interchange (EDI) standards. The Natinal Electrnic Data Interchange Transactin Set Implementatin Guides fr HIPAA transactin sets are available at All files submitted t the Plan must be in the ANSI ASC X12N frmat, versin 4010A. Medicare Advantage Prvider Manual Octber 2008 Page 3 f 13

4 Fr further instructins fr bth paper and EDI claim submissin including access t Plan EDI Cmpanin Guides, visit Refer t the state-specific Quick Reference Guide fr claim mailing addresses. The largest driver f payment turnarund time is the accuracy f the data n the claim regardless f whether it is an electrnic r paper claim submissin. T assist prviders in submitting the crrect data in the crrect fields n a claim, the Plan has prepared claim submissin guidelines. These guidelines identify key fields the Plan requires t be filled fr claims prcessing as well as the data surce t cmplete the field. These guidelines can be fund n the Plan s Web site at Tax ID and NPI Requirements The Plan requires the use f the payer-issued tax ID and NPI n all claim submissins, bth electrnic and paper. Natinal Prvider Identifiers Standard transactins such as claims submitted electrnically t the Plan must include the referring, rendering r attending, billing and facility prvider s Natinal Prvider Identifier (NPI), per requirements put frth in HIPAA s NPI Final Rule Administrative Simplificatin. The NPI and tax ID must be included with electrnic claim submissins fr prper adjudicatin. Mre infrmatin abut NPI is available n the CMS Web site. HIPAA Electrnic Transactins and Cde Sets HIPAA Electrnic Transactins and Cde Sets is a federal mandate that requires health care payers such as WellCare, as well as prviders engaging in ne r mre f the identified transactins, t have the capability t send and receive all standard electrnic transactins using the HIPAA designated cntent and frmat. Specific WellCare requirements fr claims and encunter transactins, cde sets, and SNIP validatin are Medicare Advantage Prvider Manual Octber 2008 Page 4 f 13

5 described as fllws. T prmte cnsistency and efficiency fr all claims and encunter submissins t the Plan, it is WellCare s plicy that these requirements als apply t all paper and direct data entry (DDE) transactins. Standard Guides Available nline r by calling Custmer Service, prviders may btain the Plan s recmmended transactin guidelines. These are: Electrnic Data Interchange Transactin Set Implementatin Guides Institutinal Claims/Encunter Cmpanin Guide Prfessinal Claims/Encunter Cmpanin Guide Standard Transactins Transactins, as defined by HIPAA, are activities invlving the transfer f health care infrmatin fr specific purpses, including claims and encunter infrmatin, payment and remittance advice, and claim status and inquiry. All prviders wh submit encunters and electrnic claims t the Plan must d s in the frmats established by HIPAA. The fllwing standard HIPAA electrnic claim/encunter transactins must be submitted in the *ANSI ASC X12N frmat, versin 4010A1: 270/271 Health Insurance Eligibility/Benefit Inquiry & Respnse 276/277 Health Care Claim Status Request & Respnse 278 Health Care Services Review Request fr Review and Respnse 835 Health Care Claim Payment/Advice 837 Health Care Claims Medicare Advantage Prvider Manual Octber 2008 Page 5 f 13

6 Standard Cde Sets Standard Cde Sets as required by HIPAA are the cdes used t identify specific diagnsis and clinical prcedures n claims and encunter frms. All prviders are required t submit claims and encunters using current HIPAA cmpliant cdes, which include the standard CMS cdes fr ICD9, CPT, HCPCS, NDC and CDT, as apprpriate. Strategic Natinal Implementatin Prcess (SNIP) All claims and encunter transactins submitted via paper, direct data entry (DDE) r electrnically will be validated fr transactin integrity/syntax based n the Strategic Natinal Implementatin Prcess (SNIP) guidelines. The SNIP validatins used by the Plan t verify transactin integrity/syntax are available in the Frms sectin f this manual and n ur Web site. The SNIP Validatin Descriptins dcument may be a helpful resurce t share with yur billing agent r clearinghuse. If yur claim is rejected fr lack f cmpliance t the Plan s claim and encunter submissin requirements, please crrect yur claim and resubmit it t the Plan. Fr additinal infrmatin, please cntact yur Prvider Relatins representative r the Custmer Service department. Electrnic Claim Submissins The plan accepts electrnic claim submissins thrugh Electrnic Data Interchange (EDI). Advantages f EDI Submitting claims electrnically is less cstly than billing with paper. In mst instances, the Plan can prcess yur electrnic claim in half the time f a paper claim. Clearinghuses charge varying fees. The Plan has Medicare Advantage Prvider Manual Octber 2008 Page 6 f 13

7 ptins, including cnnectivity and sftware, that are free. Cntact the EDI department t see if yu qualify fr this service. Yu may als cntact yur clearinghuse r billing sftware vendr t see if they ffer free ptins. There are six primary clearinghuses thrugh which we receive EDI transactins. Thse cmpanies are: ACS EDI Gateway Inc. Availity Emden (frmer WebMD Crpratin) RelayHealth (McKessn) SSI Grup Inc. Zirmed Because mst clearinghuses can exchange data with ne anther, prviders shuld wrk with their existing clearinghuse, if ther than thse listed, t establish EDI with the Plan. All files submitted t the Plan must be in the ANSI ASC X12N frmat, versin 4010A. Implementatin guides fr HIPAA transactin sets are available at If yu d nt have a clearinghuse r have been unsuccessful in submitting claims thrugh yur clearinghuse, please cntact ur EDI team. The EDI team cntact infrmatin can be fund n the statespecific Quick Reference Guide. Payer ID There are unique Payer IDs that must be used t identify ur Plan n electrnic claim submissins. The apprpriate Payer IDs fr each f the fur clearinghuses thrugh which claims may be submitted are listed as fllw: Medicare Advantage Prvider Manual Octber 2008 Page 7 f 13

8 ACS* EDI Gateway Availity, Emden,RelayHealth (McKessn), SSI * and ZirMed Electrnic Funds Transfer (EFT) and Electrnic Remittance Advice (ERA) Services We have partnered with Payfrmance Crpratin t ffer yu free Electrnic Funds Transfer (EFT) and nline Electrnic Remittance Advice services (ERA, als knwn as electrnic payment vucher) by registering with PaySpan Health. The benefits f enrlling fr EFT/ERA thrugh PaySpan Health include: A secure, self-service Web site; Abslutely n cst fr participating; Imprved cash flw thrugh autmated depsits; Cnvenient access t view remittance recrds nline, at any time; Reprting mechanisms t access adjudicated claims infrmatin; and Ability t imprt payment data directly int yur Practice Management r Patient Accunt System. Online registratin is simple and fast. PaySpan Health will mail a registratin letter t netwrk prviders cntaining a unique registratin cde and Persnal Identificatin Number (PIN). Using the infrmatin cntained in the registratin letter, prviders will prceed thrugh an easy registratin prcess that includes the fllwing steps: * Subject t change Medicare Advantage Prvider Manual Octber 2008 Page 8 f 13

9 Lg n t PaySpan Health using the registratin and PIN number prvided in the letter; Enter banking infrmatin and set up accunt administratrs; Select payment and remittance advice preferences; and Cnfirm receipt f fund transfer int prvider bank accunt. Shuld a prvider elect nt t receive payments r vuchers electrnically, they will cntinue t receive paper checks generated at the Payfrmance payment prcessing center. Fr questins related t this service, please visit the PaySpan Health Web site at r call the Plan s Prvider Htline. Refer t the state-specific Quick Reference Guide fr cntact infrmatin. Paper Claim Submissin Guidelines Paper claims must be cmpleted in full and include: The Plan member s name and his r her relatinship t the subscriber; The subscriber s name, address and Scial Security number; The subscriber s emplyer grup name and number (when applicable); Infrmatin n ther insurance r cverage fr the Plan member; The name, signature, place f service address, billing address and telephne number f the physician r prvider perfrming the service; The tax ID number; and Medicare Advantage Prvider Manual Octber 2008 Page 9 f 13

10 Qualifiers Each frm f identificatin shuld be accmpanied by a qualifier which will crrectly allcate the infrmatin when transferred int ur databases. Prper qualifiers fr identificatin numbers submitted t the Plan are: ID Qualifier Tax ID 24 NPI XX Taxnmy ZZ Ntice that sme frm fields will include a bx t submit the identificatin number s qualifier. In thers, hwever, the bx will nt be available and the qualifier shuld be included by preceding the identificatin number with a hyphen (Ex. XX-XXXXXXXXX). Apprpriate ICD-9 cdes; Standard CMS prcedure r service cdes (e.g., CPT-4 prcedure cdes and HCPC-I,II cdes with apprpriate mdifiers, revenue cdes); Number f service units rendered; Billed charges; Referring physician s name and NPI number; Date(s) f service; Place(s) f service and facility NPI (where applicable); Authrizatin Number (if applicable); NDC fr drug therapy (if applicable); and Medicare Advantage Prvider Manual Octber 2008 Page 10 f 13

11 Jb related, aut r ther accident infrmatin. Encunter Data Submissins If a prvider s payment methd is n a capitatin basis, claims still must be submitted t the Plan. This requirement is mandated t meet the reprting requirements f the Plan as well as thse established by regulatry agencies and the Balanced Budget Act. Claims submitted under a capitatin cntract are usually referred t as encunter data. Encunter data can be submitted n CMS 1500 r UB-04 frms r thrugh EDI fllwing the same rules as standard claim submissins. The Plan currently utilizes the six clearinghuses listed belw t prcess the 837 Health Care Claims transactins. The encunter payer ID fr all clearinghuses is ACS EDI Gateway Inc. Availity Emden RelayHealth (McKessn) SSI Grup Inc. Zirmed The Plan will recrd all encunter data received. The Plan recgnizes these services as under a capitated cntract and will nt make payment t the prvider. Any capitated prvider wh des nt submit encunter data is subject t crrective actin measures and penalties under applicable state and federal law and culd be terminated frm the Plan. Crdinatin f Benefits Crdinatin f Benefits (COB) is the prcedure used t prcess health care payments when a member has cverage with mre than ne insurer. Medicare Advantage Prvider Manual Octber 2008 Page 11 f 13

12 Prir t submitting a claim t the Plan, prviders must identify if anther payer has primary respnsibility fr payment f a claim. If determinatin is made that anther payer is primary: The primary payer shuld be billed prir t billing the Plan; Any balance due after receipt f payment frm the primary payer shuld be submitted t the Plan fr cnsideratin; and The claim must include infrmatin verifying the payment amunt received frm the primary plan as well as a cpy f their Explanatin f Payment (EOP) statement. Upn receipt f the claim, the Plan will review using the COB rule r ther, as applicable. Prhibitin n Billing Plan Members Yur agreement with the Plan requires prviders t accept payment directly frm the Plan. Payment frm the Plan cnstitutes payment in full, with the exceptin f applicable c-payments, deductibles, c-insurance and any ther amunts listed as member respnsibility n the Explanatin f Payment/Prvider Remittance Advice. Prviders may nt bill Plan members fr: The difference between actual charges and the cntracted reimbursement amunt; Services denied due t timely filing requirements; Cvered services fr which a claim has been returned and denied fr lack f infrmatin; Remaining r denied charges fr thse services where the prvider fails t ntify the Plan f a service that required prir authrizatin; Medicare Advantage Prvider Manual Octber 2008 Page 12 f 13

13 Payment fr that service will be denied; and Cvered services that were nt medically necessary, in the judgment f the Plan, unless prir t rendering the service, the prvider btains the member s infrmed written cnsent and the member receives infrmatin that they wuld be financially respnsible fr the specific services. Nn-Cvered Services Plan members may be billed fr nn-cvered services like csmetic prcedures and items f cnvenience (i.e., televisins). WellCare Health Plans, Inc. The WellCare Grup f Cmpanies Medicare Advantage Prvider Manual Octber 2008 Page 13 f 13