Claims Submission Process Overview. For Consumer-Directed Attendant Care and Waiver Care Providers

Transcription

1 Claims Submission Process Overview For Consumer-Directed Attendant Care and Waiver Care Providers

2 Agenda Member Liability Claims Submission CMS-1500 Form Claims Reconsideration

3 Member Liability for Payment Iowa Medicaid mails client participation information to you and the member when they determine the amount members must pay for services To verify eligibility and determine the member s client participation, go to UnitedHealthcareOnline.com > Patient Eligibility & Benefits If Client Participation is required: You may bill the member for their client participation amount We will deduct this amount from the first claim received for processing every month and the following claim if needed ( first in/first out basis ) If a member is unable to pay their share of cost, providers can choose not to provide services to the member Please notify UnitedHealthcare if you are considering discharging a member due to non-payment of the patient liability/client participation Please call Provider Services at if you have questions about a member s financial responsibility.

4 Guidelines for Claims Submission Submit claims using the current 1500 claim form with appropriate coding including, but not limited to, ICD-10, CPT and HCPCS coding Timely filing: 180 days from date of service Claims will be processed within 14 days of receipt Corrected claims: 365 days from payment/denial receipt date Balance billing: You may not balance bill members for services covered under their benefit plan Check for third-party liability before submitting claims Claim submissions must include: Member name, Medicaid ID and date of birth Your tax ID number (TIN) or employer identification number (EIN) National provider identifier (NPI) Nationally recognized Centers for Medicare and Medicaid Services (CMS) Correct Coding Initiative (CCI) standards as outlined at cms.gov

5 Online Claims Submission UnitedHealthcareOnline.com > Link > Claims Management Sign-in to Link with your Optum ID If you don t have an Optum ID, select New User to register Click on the claim submission tile to submit claims through Link Click on the UnitedHealthcare Online tile to submit claims through UnitedHealthcareOnline.com

6 Electronic and Paper Claims Submission Electronic Claims Submission You may use any clearinghouse vendor to submit claims. Payer ID: To receive remittance advices: Payer ID: Paper Claims Submission Mail to: UnitedHealthcare Attention: Claims PO Box 5220 Kingston, NY

7 Claims Submission Best Practices Include Complete, Accurate Information Include a NPI number on claims unless you have an Atypical NPI (one that starts with a X) number Do not include NPIs that start with the letter X (Leave field blank instead) Include a complete diagnosis on claims; if you are a waiver care provider, use Z76.89 Use valid and complete HCPC/CPT codes; e.g. be sure codes are for covered services and include all required data elements Provide complete, current care provider information Obtain Prior Authorization for Services HCBS waiver services must be requested and authorized through the member s community-based case manager (CBCM) Request authorization for services when required as listed at UHCCommunityPlan.com > For Health Care Professionals > Iowa > Prior Authorization Make sure the units billed matches the units authorized; e.g. authorization given for 10 days, only bill for 10 days.

8 CMS-1500 Form Example

9 Side by Side Comparison: Targeted Medical Care Form/CMS-1500 Form Targeted Medical Care CMS-1500 Member ID 1 1A Member Name 2 4 Provider NPI 3 24J / 33A* Provider Name 4 33 Provider Address 5 33 Provider Zip Code 6 33 Other Health Insurance 8 11d Other Health Insurance Payment Client Participation Procedure Code 12 24D CPT/HCPCS Modifier 13 24D Mod Place of Services 14 24B First Date of Service 15 24A Last Date of Service 16 24A Units 17 24G Total Line Charge 18 24F Total Claim Charge Diagnosis Code 21 Diagnosis Pointer Provider Signature 31 Member/Guardian Signature 12 24E *If atypical, leave blank.

10 Sample CMS-1500 Form Box 1: Member Medicaid ID number (ex Z) Box 2: Member name Box 3: Member date of birth and sex Box 5: Member address

11 Sample CMS-1500 Form (cont d.) If Member Has Other Insurance: Box 9: Other insured s name Box 9a: Other insured s policy or group number Box 11d: Is there another health benefit plan?

12 Sample CMS-1500 Form (cont d.) Box 21: Diagnosis Required element Enter 0 for the ICD Ind. (Indicator) Use ICD-10CM diagnosis Z76.89 Relate diagnosis pointer A to service line 24E

13 Sample CMS-1500 Form (cont d.) Box 24A: Dates of service Box 24B: Place of service Box 24E: Diagnosis pointer Use A to relate to Box 21 diagnosis

14 Sample CMS-1500 Form (cont d.) Box 24F: Charges Box 24G: Days or units Box 24J: For Consumer-Directed Attendant Care and Atypical Providers, e.g., taxi and respite service with home and vehicle modification providers: Do not bill with Atypical NPI (X ). Leave blank. System will pay based on TIN/EIN.

15 Sample CMS-1500 Form (cont d.) Box 25: Federal Tax ID number Check to indicate social security number (SSN) or Employer Identification Number (EIN) Box 28: Total charge Box 29: Amount paid Include other insurance paid and member liability paid

16 Sample CMS-1500 Form (cont d.) Box 31: Signature Box 33: Billing care provider information (address) and phone number Box 33a: Provider NPI: If you use an Atypical NPI (X ), leave blank. Claim will be paid based on your TIN or EIN. If you use a Typical NPI ( ), enter your NPI.

17 Claims Reconsideration Online: UnitedHealthcareOnline.com > Link > Claims Management Sign-in to Link with your Optum ID If you don t have an Optum ID, select New User to register Click on the claim submission tile to submit claims through Link Click on the UnitedHealthcare Online tile to submit claims through UnitedHealthcareOnline.com Mail: UnitedHealthcareOnline.com > Tools & Resources > Forms > Paper Claim Reconsideration Form to: UnitedHealthcare Community Plan Attention: Claims P.O. Box 5220 Kingston, NY

18 Claims Resolution Dispute Process If you are not satisfied with the outcome of a claim reconsideration request, you may submit a claim dispute using the process outlined in your Provider Manual at UHCCommunityPlan.com > For Health Care Professionals > Iowa > Provider Administrative Manual. Mail to: UnitedHealthcare Community Plan Attn: Provider Dispute P.O. Box Salt Lake City, UT Reviews take days depending on the complexity of the claim.

19 Contacting Provider Services For all general and specific inquiries, contact Provider Services at Helpful reminders Have your tax ID (TIN) or social security number (SSN) available to be entered. If you do not have a tax ID or if you have an Atypical NPI, you may use your social security number instead. Saying representative will also connect you to an agent for further assistance.

20 Quick Reference Guide Prior Authorization Requests Phone: Fax: Medical Benefits UnitedHealthcareOnline.com > Link > Eligibility & Benefits UnitedHealthcareOnline.com > Notification/Prior Authorizations Paper Claims Submission UnitedHealthcare Attn: Claims P.O. Box 5220 Kingston, NY Electronic Claims Submission UnitedHealthcareOnline.com > Link > Claims Management UnitedHealthcareOnline.com > Claims & Payment > Claims Submission Payer ID: Claims Status Provider Services: UnitedHealthcareOnline.com > Link > Claims Management UnitedHealthcareOnline.com > Claims & Payments > Claim Status Claims Appeals Provider Advocates UnitedHealthcare Attn: Appeals Department P.O. Box Salt Lake City, UT Find yours at UHCCommunityPlan.com > For Health Care Professionals > Iowa > Provider Information

21 Questions? Thank You. Doc #: PCA _