How To Get A Claim For A Claim From Masshealth

Transcription

1 COMPLETE ALL IFORMATIO REQUIRED O THE REQUEST FOR CLAIM REVIEW FORM. ICOMPLETE SUBMISSIOS WILL BE RETURED UPROCESSED. Please direct any questions regarding this form to the plan to which you submit your request for claim review. Today s Date (MM/DD/): Health Plan ame: *Denotes required field(s) Provider Information *Provider ame: *Contact ame: *ational Provider Identifier (PI): *Contact Phone umber: Contact Fax umber: Contact Address: *Contact Address: Member / Claim Information *Member ID: *Date(s)of Service (MM/DD/): *Member ame: *Claim umber: *Denial Code: * Review Type Enter X in one box, and/or provide comment below, to reflect purpose of review submission. Contract term(s): The provider believes the previously processed claim was not paid in accordance with negotiated terms. Coordination of Benefits: The requested review is for a claim that could not fully be processed until information from another insurer has been received. Corrected Claim: The previously processed claim (paid or denied) requires an attribute correction (e.g., units, procedure, diagnosis, modifiers, etc.). Please specify the correction to be made: Duplicate Claim: The original reason for denial was due to a duplicate claim submission. Filing Limit: The claim whose original reason for denial was untimely filing. Payer Policy, Clinical: The provider believes the previously processed claim was incorrectly reimbursed because of the payer s clinical policy. Payer Policy, Payment: The provider believes the previously processed claim was incorrectly reimbursed because of the payer s payment policy. Pre-Certification/otification or Prior-Authorization or Reduced Payment: The request for a claim whose original reason for denial or reimbursement level was related to a failure to notify or pre-authorize services or exceeding authorized limits. Referral Denial: The claim whose original reason for denial was invalid or missing primary care physician (PCP) referral. Request for additional information: The requested review is in response to a claim that was originally denied due to missing or incomplete information (OC Codes, Home Infusion Therapy). Retraction of Payment: The provider is requesting a retraction of entire payment or service line (e.g., not your patient, service not performed, etc.). MassHealth: The MassHealth provider has received a Final Deadline Exceeded error message. MassHealth providers must only use this review type to submit claims for review to MassHealth. Use of this form for submission of claims to MassHealth is restricted to claims with service dates exceeding one year and that comply with regulation 130CMR Other: Comments (Please print clearly below): Attach all to the completed. Massachusetts Administrative Simplification Collaborative Review V1.1

2 Participating Health Plans: Reference Guide Review

3 Reference Guide Review This guide will help you to correctly submit the. The information provided is not meant to contradict or replace a payer s procedures or payment policies. For-up-to-date details, please consult the respective payer s Provider Manual. Please direct any questions regarding this guide to the plan to which you submit your request for claim review. Please note that failure to abide by the following may affect your compliance with a payer s individual policies. Terminology/Definitions... 3 Request for Review...4 Filing Limit...4 Request for...4 Address to Submit Review Requests...4 Fax # to Submit Review Requests...4 Multiple Requests...5 Initial Review Timeframes...5 Subsequent Requests to Review Same Claim...5 Vehicles to Submit...5 Request for Denied Claim Review s...6 Contract Terms...6 Coordination of Benefits...7 Corrected Claim... 7/8 Duplicate Claim...8 Filing Limit...9 Payer Policy Clinical...10 Payer Policy Payment...10 Precert/otification/Authorization Denial or Reduced Payment...11 Referral Denial Request for Additional Information...12 Retraction of Payment...13 Other... 13/14 Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 2

4 *please see page #14 for specific MassHealth Final Deadline Appeal information. Terminology/definitions used in this document: Contract terms Coordination of Benefits Corrected claim Duplicate claim Filing limit Payer Policy Clinical Payer Policy Payment Pre-certification/notification or prior-authorization denials Referral denial Request for additional information Retraction of payment MassHealth Final Deadline Appeal* Other Belief that processed claim was not paid in accordance with contract terms/rates resulting in either an under or overpayment Resubmission of a claim previously denied for other primary insurance with from other payer. A reply to a request for other insurance information. Original claim denied as the claim requires an attribute correction, e.g., incorrect member, incorrect member ID number, incorrect date of service, incorrect/missing procedure/diagnosis code/location code, incorrect count, and modifier added/removed. A first time claim submission that denied for, or is expected to deny for duplicate filing. Original claim or service lines within a claim that denied as a duplicate. A first time claim submission that denied for, or is expected to deny for untimely filing. When the member did not identify himself or herself as a payer s member (misidentified member). A re-review of a claim denied for insufficient filing limit. Provider believes that the final claim payment was incorrect because of an associated clinical policy. Provider believes that the final claim payment was incorrect because of global reimbursement or (un)bundling of billed services (e.g., claim editing software). A claim denied because no notification or authorization is on file. A claim denied for exceeding authorized limits. A claim submission denied for a missing/invalid PCP referral that is greater than 90 days from the date of service and within 180 days from the original denial (ote: claims denied for a missing/invalid PCP referral that are within ninety 90 days from the date of service may be corrected and resubmitted as a first time claim submission via paper or EDI). A claim for a POS member paid at the out of network rate due to invalid/missing PCP referral information on the claim form. A re-review of a claim denied for a missing/invalid PCP referral that is within 180 days from the original denial date. A first time claim submission that denied for additional information. An unlisted procedure code not submitted with. A procedure code that was denied or not submitted with: operative notes, anesthesia notes, pathology report, and/or office notes. Provider requests a retraction of entire payment or service line (e.g., Member on claim was not your patient or service on claim was not performed). ote: Multiple retractions can be submitted with one review form write multiple in the Member ID field. A MassHealth final deadline appeal must satisfy all the requirements of MassHealth regulations at 130 CMR , including meeting the criteria at 130 CMR (A) and including the required specified in 130 CMR (B) to substantiate the contention that the claim was denied or underpaid due to MassHealth error. A review request not covered by any aforementioned category; please provide specific background and in support of a request. Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 3

5 Request for Review Category Filing Limit Request for Address to Submit Review Requests Fax # to Submit Review Requests Initial Filing Limit (days). Defined as the number of days elapsed between the date of service (or EOB date, if another insurer is involved) and the receipt by a plan. HMO-90 Medicare Advantage-90 PPO-90 Indemnity-365 Commercial-90 MassHealth 150 Commonwealth Care 150 Health ew HP Form required? BCBSMA/Provider Appeals P.O. Box Boston, MA BMC Healthet Plan Claims Resolution Unit Attn: Provider Appeals P.O. Box Boston, MA Fallon Community Health Plan Attn: Request for Claim Review / Provider Appeals P.O. Box Worcester, MA For all products unless noted below: Harvard Pilgrim Health Care P.O. Box Quincy, MA Passport Connect Mail to the address on the back of the member s ID card Health Plans Inc. Refer to the Health Plans, Inc. product page in the HPHC Provider Manual. Harvard Pilgrim Student Resources Refer to the Student Resources product page in the HPHC Provider Manual. Health ew One Monarch Place Suite 1500 Springfield, MA * *Form not required at this time. eighborhood Health Plan 253 Summer Street Boston MA, etwork Health Tufts Health Plan etwork Health Attn: Provider Appeals 101 Station Landing, Fourth Floor Medford, MA Commercial-90 Tufts Medicare Prefered-60 es for paper claim o for online claim Tufts Health Plan Provider Payment Disputes PO Box 9190 Watertown, MA US Family Health Plan Provider Payment Disputes P.O. Box 9195 Watertown, MA Tufts Medicare Preferred Provider Payment Disputes P.O. Box 9162 Watertown, MA /A /A (508) /A /A (617) /A /A Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 4

6 Request for Review, (continued) Category Health ew HP etwork Health Tufts Health Plan Can multiple similar requests be submitted with one form? * *Multiple requests accepted for Retraction of Payment Requests only. /A Initial Review Timeframes Initial Denied Claim Review Timeframes. Defined as the # of days from original appeal determination on the appeal resolution letter. 365 Commercial-90 MassHealth 150 Commonwealth Care Filing Limit Appeals 180 All other appeal types for filling limit appeals, 365 for corrected claims and duplicate claim denial appeals Second Level Review? if new information is provided. es- with not previously submitted Filing Limit: es - within 90 days from original denial date Duplicate Claim, Referral Denial, Corrected Claim: es - within 180 days from date of original denial Pre-Certification/ otification or Prior- Authorization, Contract Rate, Payment or Clinical Policy: es within 30 days of date on original review resolution letter es with not previously submitted. /A Consult specific policy for further details. Time allowed to file? /A 30 /A /A As the # of days from How Defined? the original appeal As the # of days from 30 days from date of 60 days from receipt of From date of disputed /A determination on an /A adjusted remittance date. appeal denial letter Level l appeal denial letter. remittance. appeal resolution /A letter. if new information is Third Level Review? provided. /A Time allowed to file? 365 /A /A /A /A /A 60 /A How defined? As the # of days from adjusted remittance date. /A /A /A /A /A From date of disputed remittance. /A Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 5

7 Request for Review, (continued) Category Vehicles for Submission Health ew HP etwork Health Tufts Health Plan Ways to submit a Review: Mail Phone * * etool * Other Fax Fax Fax * *ot all review requests can be submitted over the phone or via etool. *Limited instances related to notification. *Fax in some instances. Request for Denied Claim Review s Contract Term(s) EHE output, etc.) Health ew HP etwork Health Tufts Health Plan es for paper claim o for online claim. es for paper claim o for online claim Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 6

8 Request for Denied Claim Review s, (continued) Coordination of Benefits EHE output, etc.) Health ew HP etwork Health Tufts Health Plan es for paper claim o for online claim * * * * Corrected Claim EHE output, etc.) Copy of Primary Insurer s remittance advice required. *EOP of the appealed BMCHP claim not required-but will require OI EOP Copy of Primary Insurer s remittance advice required. Copy of Primary Insurer s remittance advice required. *Refer to the COB Policy within the HPHC Provider Manual. *EOP of the appealed HE claim not required-but will require OI EOP Copy of Primary Insurer s remittance advice required. *OI EOP required Copy of Primary Insurer s remittance advice required. es for paper claim o for online claim * es for paper claim o for online claim Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 7

9 Request for Denied Claim Review s, (continued) Health ew HP etwork Health Tufts Health Plan Corrected Claim *If no payment made on original c laim and still within in itial filing limits, new c laim should be f iled versus submitting an appeal. Duplicate Claim EHE output, etc.) * If multiple services rendered on the same DOS- should show differentiation between the services (e.g. different times/different locations etc). If multiple services are rendered on the same DOS should show differentiation between the services (e.g. different times/different locations etc.) For multiple services rendered on the same DOS- should show differentiation between the services (e.g. different times/different locations etc). If multiple services rendered on the same DOS should show differentiation between the services (e.g. different times/different locations etc).. Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 8

10 Request for Denied Claim Review s, (continued) Filing Limit EHE output, etc.) Health ew * HP etwork Health Tufts Health Plan es for paper claim o for online claim * * * *Provider should refer to their BlueBook for complete listing of acceptable. The following are considered acceptable proof of timely submission: EOB from primary insurance. Proof that the member or another insurance carrier was billed. EDI transmission report if claims were submitted electronically *Provider should refer to the FCHP Provider Manual for requirements. *Provider should refer to the Filing Limit Appeal Policy within the Harvard Pilgrim Provider Manual for requirements. The following are considered acceptable proof of timely submission: Computer printout of patient account ledger. EOB from primary insurance. Proof that the member or another insurance carrier was billed.. Provider should refer to the Filing Limit Adjustments section in the Claims s Chapter of the Tufts Health Plan Provider Manual for requirements. Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 9

11 Request for Denied Claim Review s, (continued) Payer Policy Clinical Payer Policy Payment EHE output, etc.) Comments EHE output, etc.) Health ew HP etwork Health Tufts Health Plan es for paper claim o for online claim Payer Policy Clinical = Individual Consideration (e.g. Medical Technology denials).. es for paper claim o for online claim Example: Inclusive service denials. es for paper claim o for online claim. Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 10

12 Request for Denied Claim Review s, (continued) Pre-Cert/ otification/ Authorization Denial or Reduced Payment EHE output, etc.) Health ew HP etwork Health Tufts Health Plan es for paper claim o for online claim * This appeal process is to request an adjustment for claims which have denied for Precert/ Authorization and a valid Pre-Cert/ Authorization is now on file. Appeals to overturn a denied Pre- Cert/ Authorization or request Pre-Cert/ Authorization follows the Clinical Appeals process as outlined in the BlueBook and would not fall under this review process for claims. Use this appeal process to request adjustment of claims denied for no Pre- Cert/Authorization where a valid Pre- Cert/Authorization is now on file. This process is also to be used for denied clinical appeals related to Pre-Cert/ Authorization and Level of Care appeals. Add comment re: Provider pursuing other payer incorrectly.. Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 11

13 Request for Denied Claim Review s, (continued) Referral Denial Request for Additional Information EHE output, etc) EHE output, etc.) /A- Referrals not required /A Submit corrected claim. Health ew /A (We don't require referrals.) HP etwork Health Tufts Health Plan es for paper claim o for online claim /A /A /A /A /A /A Corrected claim should be submitted with Referring Physician's name and PI #.. es for paper claim o for online claim Include Case # when indicated on appeal letter.. Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 12

14 Request for Denied Claim Review s, (continued) Health ew HP etwork Health Tufts Health Plan es for paper claim adjustments Retraction of Payment Other EHE output, etc.) EHE output, etc.) * * * * * * *Request must indicate reason for retraction. If for Other Insurance (OI), OI EOP must be included. Request must indicate reason for retraction. *Please specify reason for retraction. Please specify reason for retraction. Please specify reason for retraction. *Request must indicate reason for retraction. If for Other Insurance (OI), OI EOP must be included. Request must indicate reason for retraction. Please specify reason for retraction. /A /A * /A * Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 13

15 Request for Denied Claim Review s, (continued) Other MassHealth Final Deadline Appeal Plan Remittance Advise (EOP) Can multiple similar requests be submitted with one form? Vehicles for submission Dependant upon the reason for the es es es An appeal must meet the conditions outlined at MassHealth All Provider Regulations 130 CMR (A) and must include all as specified in 130 CMR (B) to substantiate the contention that the claim was denied or underpaid because of MassHealth s error Required for TPL submissions only o DDE via the Provider online Service Center (POSC) Dependant upon the reason for the Dependant upon the reason for the Dependant upon the reason for the Health ew Dependant upon the reason for the HP etwork Health Tufts Health Plan Dependent upon the reason for the *EOP is preferred. Additional dependant upon the reason for the Dependant upon the reason for the MASSHEALTH MassHealth Final Deadline Exceeded Appeals of Erroneously Denied or Underpaid Claims are governed by MassHealth Regulations at 130 CMR All such, Appeals must be submitted to the Final Deadline Appeal Unit within 30 days after the date on the remittance advice that first denied the claim for exceeding the final billing deadline. Electronic submitters can submit appeals to MassHealth via the Provider On Line Service Center at: MassHealth strongly encourages all providers with electronic capability to submit Final Deadline appeals electronically. However, Paper Final Deadline appeals may be sent to: Final Deadline Appeal Unit 100 Hancock Street 6 th floor Quincy, MA Please refer to the following links for additional information regarding MassHealth s electronic appeal submission process and Final Deadline Appeal Q&A: Final Deadline Appeal FAQ will be available soon Providers must continue to meet the criteria outlined in the MassHealth All Provider Regulations and Appeal Procedures. For more information, please read the 130 CMR : Appeals of Erroneously Denied or Underpaid Claims. Massachusetts Administrative Simplification Collaborative Review Reference Guide V1.1 14