Billing & Claims Processing American Specialty Health (ASH)

Transcription

1 Billing & Claims Processing American Specialty Health (ASH) Affected Plans The Non-Discrimination in Health Care Provision applies to all plans that include the changes mandated by the Affordable Care Act for 2014 also referred to as non-grandfathered plans. It doesn t apply to Akamai Advantage, HMSA Quest, grandfathered, or transitional plans. Grandfathered Plans A grandfathered plan is a health plan that was in effect on March 23, 2010, when President Barack Obama signed the Patient Protection and Affordable Care Act. Under federal law, these plans aren t required to adopt the changes mandated in the Affordable Care Act, as long as substantial changes aren t made to the plan. The Non-Discrimination in Health Care provision doesn t apply to patients with grandfathered plans. Determining Your Patient s Plan To determine if your patient s medical plan is non-grandfathered, check the coverage code listed under MEDICAL on your patient s HMSA membership card. If the coverage code is also listed on the Coverage Codes for Affordable Care Act page in our Provider Resource Center, then your patient has a nongrandfathered plan that pays for covered services from complementary and alternative medicine (CAM) providers. American Specialty Health (ASH) Rider HMSA commercial and small groups may have ASH riders and all of our Individual Platinum PPO/HMO plans have ASH benefits. Check your patient s HMSA membership card. HMSA group plans with ASH riders have a coverage code listed under complementary care (CMPCARE). Individual PPO/HMO plans have one of the following coverage codes listed under MEDICAL: 960, 961, 962, A-A, IB, or I-C. 1 of 7 Rev 12/2016

2 Notes on Claims Filing: For your patients with PPO plans and the ASH rider, submit the chiropractic claim to HMSA (primary payer) first; o If HMSA pays, no further action is needed. o If HMSA denies, send the Report to Provider (RTP)/Explanation of Benefits (EOB) to ASH for processing. If ASH does not receive a RTP/EOB with each claim, ASH will deny the claim for resubmission. o Note: HMSA doesn t coordinate benefits covered under the patient s medical plan and ASH rider internally. Payment direction: Provider participation status determines where we ll send payments. We ll send payments directly to participating HMSA providers. Payments for claims submitted by nonparticipating providers will go to the member. For your patients with HMO plans and the ASH rider, submit claims directly to ASH For more information, see hmsa.com/prc of 7 Rev 12/2016

3 Out-of-Network ASH Providers American Specialty Health (ASH) In-Network ASH Providers Chiropractors The billing and claims process depends on your provider status (if you re a participating HMSA provider and if you re in the ASH network) and your patient s plan. See page 1 to learn how to determine your patient s plan. YOUR PATIENT HAS AN INDIVIDUAL PLATINUM PPO PLAN. HMSA Individual Platinum PPO Plan Submit a claim for the visit to HMSA Submit a claim for the visit to HMSA (primary payer) on your patient s HMSA will send you an RTP (report to behalf. provider)/eob. If your claims are paid, We recommend letting your patients you will also receive your payment. know that if their claims are paid, Your total payment won t exceed HMSA will send them a HMSA s eligible charge. reimbursement check based on their submit benefit for visits to nonparticipating the claim and RTP/EOB to ASH providers. (secondary you can submit the claim to ASH (secondary Be sure to include a copy of the RTM (report to member). Ask your patient for the RTM; the RTM is either mailed to the patient or posted to the patient s MyAccount on hmsa.com. Submit a claim for the visit to HMSA. Submit a claim to HMSA on your HMSA will reimburse you based on the patient s behalf. eligible charge. do not submit to ASH. Patient does NOT have out-of-network ASH benefits and gets NO reimbursement from ASH. HMSA will send your patient a percentage of the eligible charge for covered services. do not submit to ASH. Patient does NOT have out-of-network ASH benefits and gets NO reimbursement from ASH. Note: Individual Platinum PPO/HMO plans don t have any benefits covered through ASH when the member sees an out-ofnetwork ASH provider. ASH covered services are embedded in all Individual Platinum PPO/HMO plans. 3 of 7 Rev 12/2016

4 American Specialty Health (ASH) Out-of-Network ASH Providers In-Network ASH Providers YOUR PATIENT HAS AN INDIVIDUAL PLATINUM HMO PLAN. HMSA Individual Platinum HMO* Plan Submit the claim to ASH (primary Submit the claim to ASH (primary ASH reimburses ASH reimburses payment determination criteria and payment determination criteria and Submit a claim for the visit to HMSA. Submit a claim to HMSA on your HMSA will reimburse you based on the patient s behalf. eligible charge. HMSA will send your patient a do not submit to ASH. Patient does NOT have out-of-network ASH benefits and gets percentage of the eligible charge for covered services. NO reimbursement from ASH. do not submit to ASH. Patient does NOT have out-of-network ASH benefits and gets NO reimbursement from ASH. Note: Individual Platinum PPO/HMO plans don t have any benefits covered through ASH when the member sees an out-ofnetwork ASH provider. ASH covered services are embedded in all Individual Platinum PPO/HMO plans. * Members with HMO plans must have an approved administrative review when seeing a nonparticipating provider and a physician s referral when seeing a participating HMSA provider outside of their health center. Claims submitted to HMSA without an administrative review or referral will be denied. 4 of 7 Rev 12/2016

5 Out-of-Network ASH Providers American Specialty Health (ASH) In-Network ASH Providers YOUR PATIENT HAS AN ASH RIDER AND A NON-GRANDFATHERED PPO PLAN OR AN EXCLUDED MEDICAL PLAN. HMSA Non-Grandfathered PPO Plan Submit a claim for the visit to Submit a claim for the visit to HMSA (primary payer) on your HMSA patient s behalf. HMSA will send you an RTP We recommend letting your (report to provider)/eob. If patients know that if their claims your claims are paid, you will are paid, HMSA will send them a also receive your payment. reimbursement check based on Your total payment won t their benefit for visits to exceed HMSA s eligible charge. nonparticipating providers. submit the claim and RTP/EOB to ASH (secondary Collect medical copayment/coinsurance from your patient at the time of the Submit a claim for the visit to HMSA. HMSA will reimburse you based on the eligible charge. submit the claim and RTP/EOB to ASH (secondary you can submit the claim to ASH (secondary Be sure to include a copy of the RTM (report to member). Ask your patient for the RTM; the RTM is either mailed to the patient or posted to the patient s MyAccount on hmsa.com. You can collect the total cost of services rendered from the patient at the time of the We strongly encourage you to submit a claim to HMSA on your patient s behalf. HMSA will send your patient a percentage of the eligible charge for covered services. you can submit the claim to ASH (secondary Be sure to include a copy of the RTM (report to member). Ask your patient for the RTM; the RTM is either mailed to the patient or posted to the patient s MyAccount on Grandfathered Medical Plans 1 claims under the ASH rider. Collect the ASH copayment/coins urance (per your ASH contract) at the time of the Submit the claim to ASH (primary ASH reimburses claims under the ASH rider. Collect the ASH copayment/coins urance (per your ASH contract) at the time of the Submit the claim to ASH (primary ASH reimburses hmsa.com. 1 Grandfathered medical plans (including transitional, Akamai Advantage, and HMSA Quest) don t cover services from complementary and alternative medicine providers. If your patient has a grandfathered, transitional, Akamai Advantage, or HMSA Quest medical plan with an ASH rider, bill for the visit under the ASH rider only (not HMSA). Check the coverage codes on your patient s membership card; see page 1 for more information. 5 of 7 Rev 12/2016

6 Out-of-Network ASH Providers American Specialty Health (ASH) In-Network ASH Providers YOUR PATIENT HAS AN ASH RIDER AND A NON-GRANDFATHERED HMO PLAN OR AN EXCLUDED MEDICAL PLAN. HMSA Non-Grandfathered HMO Plan Submit the claim to ASH Submit the claim to ASH (primary ASH reimburses ASH reimburses Collect medical copayment/coinsurance from your patient at the time of the Submit a claim for the visit to HMSA. HMSA will reimburse you based on the eligible charge. You can collect the total cost of services rendered from the patient at the time of the We strongly encourage you to submit a claim to HMSA on your patient s behalf. HMSA will send your patient a percentage of the eligible charge for covered services. Grandfathered Medical Plans 1 claims under the ASH rider. Collect the ASH copayment/coin surance (per your ASH contract) at the time of the Submit the claim to ASH ASH reimburses claims under the ASH rider. Collect the ASH copayment/coin surance (per your ASH contract) at the time of the Submit the claim to ASH ASH reimburses 1 Grandfathered medical plans (including transitional, Akamai Advantage, and HMSA Quest) don t cover services from complementary and alternative medicine providers. If your patient has a grandfathered, transitional, Akamai Advantage, or HMSA Quest medical plan with an ASH rider, bill for the visit under the ASH rider only (not HMSA). Check the coverage codes on your patient s membership card; see page 1 for more information. 6 of 7 Rev 12/2016

7 American Specialty Health (ASH) Out-of-Network ASH Providers In-Network ASH Providers Acupuncturists & Massage Therapists For patients with the ASH rider that includes Acupuncture and Massage Therapy services, claims are sent to ASH (primary payer), regardless of your provider status. HMSA Non-Grandfathered PPO/HMO Plans Participating Providers Nonparticipating Providers Grandfathered Medical Plans 1 claims under the ASH rider. Collect the ASH copayment/coinsurance (per your ASH contract) at the time of the Submit the claim to ASH ASH reimburses 1 Grandfathered medical plans (including transitional, Akamai Advantage, and HMSA Quest) don t cover services from complementary and alternative medicine providers. If your patient has a grandfathered, transitional, Akamai Advantage, or HMSA Quest medical plan with an ASH rider, bill for the visit under the ASH rider only (not HMSA). Check the coverage codes on your patient s membership card; see page 1 for more information. 7 of 7 Rev 12/2016