Billing and Claims Overview. January February 2018

Transcription

1 Billing and Claims Overview January February 2018 BH

2 Claims Submission option 1 Online Entry through Submitting claims closely mirrors the process of manually completing a CMS-1500 form This option is not available for claims submitted on a UB-04 You must have a registered user ID and password to gain access to the online claim submission function. To obtain a user ID, register online or call (866)

3 Claims Submission option 2 EDI/Electronically Electronic Data Interchange (EDI) Electronic Claims Payer ID: You may use any clearinghouse vendor to submit claims Additional information regarding EDI is available on and 3

4 Claims Submission option 3 Hardcopy Paper claims submitted via U.S. Postal Service should be mailed to: United Healthcare PO Box 5220 Kingston, NY

5 Reminders Providers must bill on the appropriate Form - HCFA-1500: Used for CPT/HCPCS Codes - UB-04: Used for Revenue Codes and/or Revenue + HCPCS Code combinations Providers must refer to their Fee Schedule/Payment Appendix for the appropriate codes/modifiers Providers are responsible to obtain Prior Authorizations for applicable services. A list of those services can be found at All services performed by non-participating Providers require a Prior Authorization 5

6 UHCCommunityPlan.com 6

7 UnitedHealthcareOnline.com 7

8 Check Member Eligibility on UnitedHealthcareOnline.com To see the various programs a member belongs to, search for member by Alpha Search and enter the member s name and date of birth. 8

9 Check Member Eligibility on UnitedHealthcareOnline.com (Cont.) Select Details for the program information and to view the member s ID Card which will show the member s correct Member ID Card number. 9

10 Check Member Eligibility on UnitedHealthcareOnline.com (Cont.) 10

11 Claims and Payments UnitedHealthcareOnline.com 11

12 Billing Reference Providers with NPI & Medicaid Numbers* Enter the name, licensure/certification and NPI number of the Provider who is directly rendering services: Box 24J: NPI number of Provider Box 31: Name and licensure/certification of Provider Box 33: Agency name, address, and phone number Box 33a: Agency NPI number *Provider Types include: DO, MD, PA, Health Service Provider in Psychology, Licensed Psychologist, LISW, LMFT, LMHC, ARNP, RN, LMSW, TLMFT, TLMHC, CADC, TCADC, IADC, IAADC Providers without NPI & Medicaid Numbers* The rendering provider s information does not need to be included anywhere on the claim: Box 24J: NPI number of Supervising Provider or Agency NPI when there is no Supervising Provider Box 31: Agency name Box 33: Agency name, address, and phone number Box 33a: Agency NPI number The name and license/certification should be exactly the same as it appears on the agency roster or individual application. 12

13 Placement of NPI Number on CMS

14 Placement of Billing vs. Rendering Clinician Name on CMS 1500 Claim Form 14

15 Placement of Billing Group/Agency on CMS 1500 Claim Form 15

16 Prior Authorization Number Needed on CMS 1500 Claim Form 16

17 Billing Units on CMS 1500 Claim Form Bill the appropriate number of units for the applicable CPT/HCPCS code. For example, this provider performed 30 minutes of support services on Oct 1. Support services are billed with HCPCS T1016 where 1 unit = 15 minutes. Therefore, bill 2 units. 17

18 Duplicate Denials Please ensure that multiple claim lines, or clams, are not billed with overlapping date spans. Please note that claim turnaround time is 30 days. It is critical to allow initial claim submissions to fully process before attempting to resubmit. 18

19 Billing Reminder 59 Modifier Modifier 59 must be attached to a component code to indicate that the procedure was distinct or separate from other services performed on the same day and was not part of the comprehensive service. Claims submitted utilizing modifier 59 may be subject to Medical Review. 19

20 Billing and Limitations and Common Codes Some services may not be billed on the same day as other covered services and most codes have a daily or annual limit to the amount of services that may be provided. Example: - Max Frequency Per Day Policy :the maximum allowed amount of units for individual services - CCI Editing Policy: services that will not be reimbursed if billed on the same day by the same health care provider Codes may also have maximum unit, age or gender limits that flag a claim for additional review. Example: PMIC Services can only be billed for Member's age 21 and under. 20

21 Billing Tips You can only bill with a Group NPI if you are contracted in a way that allows it. We do not use modifiers to identify license level. License levels are identified by using the rendering provider NPI. There are certain codes and license levels that primary insurance (including Medicare) will not cover. In that case, our systems will pass the claim through. However, if the service and license level is allowed by primary insurance (including Medicare), you must bill primary first. 21

22 Habilitation Billing Prior authorization is not required for 1915 (i) Habilitation services. Z76.89 will deny as an invalid diagnosis code for 1915 (i) habilitation service claims. Please resubmit the claim using an applicable behavioral health diagnosis code. All claims must be billed on a CMS-1500 form or through an electronic equivalent. 22

23 Reminders Clean claims, including adjustments, will be adjudicated within 30 days of receipt. The member cannot be balance billed for behavioral services covered under the contractual agreement. Provider is responsible to verify member eligibility through the DHS website United Healthcare follows the CMS National Correct Coding Initiative (NCCI edits/methodologies) when processing claims. 23

24 Submitting Corrected Claims (HCFA-1500) Providers have one year from the date of service to correct and resubmit claims, if the initial submission was received within the contracted time limit. Corrected HCFA-1500 claims can be submitted electronically by entering Frequency code 7 in Loop 2300 Segment CLM05-3. Corrected HCFA-1500 claims can be submitted on paper, with Corrected on the top of the claim form and the previous claim number located in box 22 of the HCFA United Healthcare PO Box 5220 Kingston, NY **REMINDER: Initial claims must be submitted within 180 days of the date of service 24

25 Submitting Corrected Claims (UB-04) Providers have one year from the date of service to correct and resubmit claims, if the initial submission was received within the contracted time limit. Corrected UB-04 claims can be submitted electronically by submitting with the last character of the Type of Bill as 7, to indicate Frequency code 7. Corrected UB-04 claims can be submitted on paper, with the previous claim number located in field 64. Submit with the last character of the Type of Bill as 7, to indicate Frequency code 7. United Healthcare PO Box 5220 Kingston, NY **REMINDER: Initial claims must be submitted within 180 days of the date of service 25

26 Claim Disputes - IA Medicaid (C&S) First Level Dispute Reconsideration Second Level Dispute - Formal Appeal Last Level - American Arbitration Association 26

27 Iowa Network Manager by Counties Lori Moncherry Steve Inzerello

28 Thank You.