Cedars-Sinai Medical Group Downstream Provider Notice CLAIMS SETTLEMENT PRACTICES & DISPUTE RESOLUTION MECHANISM

Transcription

1 Cedars-Sinai Medical Group Downstream Provider Notice CLAIMS SETTLEMENT PRACTICES & DISPUTE RESOLUTION MECHANISM As required by Assembly Bill 1455, the California Department of Managed Health Care has set forth regulations establishing certain claim settlement practices and the process for resolving claims disputes for managed care products regulated by the Department of Managed Health Care. This information notice is intended to inform you of your rights, responsibilities, and related procedures as they relate to claim settlement practices and claim disputes for commercial HMO, POS, and, where applicable, PPO products where Cedars- Sinai Medical Group is delegated to perform claims payment and provider dispute resolution processes. Unless otherwise provided herein, capitalized terms have the same meaning as set forth in Sections and of Title 28 of the California Code of Regulations. I. Claims Submission instructions and Claims Settlement Practices A. Sending Claims to Cedars-Sinai Medical Group. Claims for services provided to members assigned to Cedars-Sinai Medical Group must be submitted electronically or mailed to the following address: P.O. Box 6250 Newport Beach, CA B. Calling Cedars-Sinai Medical Group Regarding Claims. For claim filing requirements or status inquiries, you may contact Cedars-Sinai Medical Group by calling Claims Customer Service at C. Claim Submission Requirements. The following outlines the claim timeliness requirements and definition of a complete claim: i. Claim Timeliness requirements: 1. Contracting providers have 90 calendar days from the date of service to submit their claims and non-contracting providers have 180 days from the date of service to submit their claims. If Cedars-Sinai Medical Group is the secondary payer under Coordination of Benefits (COB), the period begins on the date the primary payer has paid or denied the claim.claims not received within the timely filing period can be denied. ii. Definition of a Complete Claim: 1. Complete claim means a claim or portion thereof, if separable, including attachments and supplemental information or documentation, which provides reasonably relevant information and information necessary to determine payer liability. Reasonably relevant information means the minimum amount of itemized, accurate and material information generated by or in the possession of the provider related to the billed services that enables a claims adjudicator with appropriate training, experience, and AB1455 Downstream Provider Notice 1 of 8

2 competence in timely and accurate claims processing to determine the nature, cost, if applicable, and extent of the plan s or the plan s capitated provider s liability, if any, and to comply with any government information requirements. Information necessary to determine payer liability means the minimum amount of material information in the possession of third parties related to a provider s billed services that is required by a claims adjudicator or other individuals with appropriate training, experience, and competence in timely and accurate claims processing to determine the nature, cost, if applicable, and extent of the plan s or the plan s capitated provider s liability, if any, and to comply with any governmental information requirements. D. Claim Receipt Verification. For verification of claim receipt by Cedars-Sinai Medical Group, please do one or combination of the following: i. Phone Call our Claims Customer Service at ii. Other mutually agreeable accessible method of notification by which provider readily confirms receipt of claim and recorded Date of Receipt. E. Claims Acknowledgment. Cedars-Sinai Medical Group will provide acknowledgement of receipt of claims as follows: i. Electronic claims will be acknowledged by Cedars-Sinai Medical Group within two (2) Working Days of the Date of Receipt by Cedars-Sinai Medical Group. ii. Paper claims will be acknowledged by Cedars-Sinai Medical Group within fifteen (15) Working Days of the Date of Receipt by Cedars-Sinai Medical Group. F. Forwarding Claims For Payment. If a claim is received by Cedars-Sinai Medical Group in error, Cedars-Sinai Medical Group will forward the claim to the appropriate payer within 10 working days from receipt of the claim. G. Time for Reimbursement. Cedars-Sinai Medical Group will reimburse each complete claim, or portion thereof, whether in state or out of state, as soon as practical, but no later than 45 working days after the date of receipt of the complete claim, unless the complete claim or portion thereof is contested or denied (see Contesting or denying claims). H. Contesting or Denying Claims. Cedars-Sinai Medical Group may contest or deny a claim, or portion thereof, by notifying the provider in writing that the claim is contested or denied within 45 working days after the date of receipt of the claim by the payer. Cedars-Sinai Medical Group will not improperly deny, adjust, or contest a claim. For each claim that is either denied, adjusted or contested, Cedars-Sinai Medical Group will provide an accurate and clear written explanation of the specific reasons for the action taken, within the specified time frames. I. Automatic Payment of Interest. Cedars-Sinai Medical Group will automatically pay interest, when applicable. If interest payment was not included in the original claim payment, Cedars- AB1455 Downstream Provider Notice 2 of 8

3 Sinai Medical Group will pay interest within 5 working days of the payment of the claim without the need for any reminder or request by the provider. In the event that the interest due on an individual late claim payment is less than $2.00 at the time that the claim is paid, the interest for that claim may be paid, along with interest on other such claims, within 10 calendar days of the close of the calendar month in which the claim was paid. J. Fee Schedules. The reasonable and customary fee schedule for non-contracted provider claims is based on the Medicare fee schedule. K. Claims Payment Policies and Rules. Cedars-Sinai Medical Group uses the following policies and rules when adjudicating claims. They are consistent with Current Procedural Terminology (CPT) and standards accepted by nationally recognized medical societies and organizations, federal regulatory bodies and major credentialing organizations. i. Global Major Surgery: Includes preoperative, intraoperative, and postoperative care of 90 days. Payment for these procedures includes the following services related to the surgery when furnished by the physician who performs the surgery. The services included in the global surgical package may be furnished in any setting, e.g., hospitals, Ambulatory Surgical Centers (ASCs), physicians' offices. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon. However, critical care services may be payable separately in some situations. Preoperative Visits--Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures. Intraoperative Services--Intraoperative services that are normally a usual and necessary part of a surgical procedure. Complications Following Surgery--All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room. Postoperative Visits--Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery. Post-surgical Pain Management--By the surgeon. ii. Services Not Included in the Global Surgical Package: Services listed below may be paid for separately. In some instances, providers will have to bill with the appropriate modifiers: The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care or as specified in CMS guidelines. This agreement AB1455 Downstream Provider Notice 3 of 8

4 may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record. Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery. Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery. Diagnostic tests and procedures, including diagnostic radiological procedures. Clearly distinct surgical procedures during the postoperative period which are not reoperations or treatment for complications. (A new postoperative period begins with the subsequent procedure.) This includes procedures done in 2 or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat epilepsy, which may be performed in succession within 90 days of each other. Treatment for postoperative complications which requires a return trip to the operating room (OR). An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient's condition was so critical there would be insufficient time for transportation to an OR). If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately. Critical care services (unrelated to the surgery) where a seriously injured or burned patient is critically ill and requires constant attendance of the physician. iii. Global Minor Surgery: Includes visits (unless a significant, separately identifiable service is also performed), surgery and postoperative care of 10 days. iv. Multiple Surgeries: Separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session. Mutually exclusive are 2 or more codes that are not usually performed on the same patient on the same date of service or, two or more codes that produce the same clinical results but are performed by different methods. Incidental procedures are those that are either clinically integral to a more complex procedure or that require little additional physician resources and therefore should not be billed separately. These intraoperative services, incidental surgeries, or components of more major surgeries are not separately billable. Highest valued procedure is allowed at 100%, second highest valued procedure allowed at 50%, third highest valued procedure allowed at 25%, fourth highest valued procedure allowed at 15% and the remaining procedures are allowed at 10%. Operative report is required and payment decision is at Cedars-Sinai Medical Group s discretion. v. Multiple Endoscopies: Major endoscopic procedures are allowed at 100%. Family Base code allowable amount is deducted from the fee schedule amount for each additional covered endoscopic procedure from that family. AB1455 Downstream Provider Notice 4 of 8

5 vi. Bilateral Procedures: Defined as performed on the same anatomic site on opposite sides of the body through separate incision. Allowed at 150%, if billed alone with the appropriate modifier. vii. Rebundling: Clinical edit that identifies a single comprehensive CPT code to describe services performed when two or more codes have been billed. viii. Alternate Code Replacement: Clinical edit that detects a discrepancy between the procedure being billed and the patient s age or sex relative to that procedure. Codes in question are flagged and the correct or alternate code is placed on the claim. ix. Cosmetic Procedures: Procedures that need review to determine if they were performed for cosmetic reasons only. x. Assistant Surgeons: Using clinical expertise and published guidelines by nationally recognized organizations, Cedars-Sinai Medical Group conducts a detailed review and assigns a designation for each assistant surgeon code. The designations are classified into two categories: 1) Always allowed and; 2) Never allowed. If assistant surgeons are generally required for the surgical procedure, services are reimbursed per Medicare guidelines. If not, services are denied as not medically necessary. xi. Administration of Immunizations and Injectable Medications: Separate payment is allowed for administration of immunization and some injectable medications. Please refer to your Contract for specific information. xii. Modifiers: Cedars-Sinai Medical Group understands that modifiers are vital for proper reporting of medical services and procedures; and recognizes all CPT modifiers. The lack of modifiers or the improper use of modifiers can result in claim delays or claim denials. II. Dispute Resolution Process for Contracted Providers A. Definition of Contracted Provider Dispute. A contracted provider dispute is a provider s written notice to Cedars-Sinai Medical Group and/or the member s applicable health plan challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar multiple claims that are individually numbered) that has been denied, adjusted or contested or seeking resolution of a billing determination or other contract dispute (or bundled group of substantially similar multiple billing or other contractual disputes that are individually numbered) or disputing a request for reimbursement of an overpayment of a claim. Each contracted provider dispute must contain, at a minimum, the following information: provider s name, provider s identification number, provider s contact information, and: i. If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from Cedars-Sinai Medical Group to a contracted provider, the following must be provided: Original Claim Number(s), a clear identification of the disputed item, the Date of Service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for AB1455 Downstream Provider Notice 5 of 8

6 reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect; ii. If the contracted provider dispute is not about a claim, a clear explanation of the issue and the provider s position on such issue; and iii. If the contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the Date of Service and provider s position on the dispute, and an enrollee s written authorization for provider to represent said enrollees. B. Sending a Contracted Provider Dispute to Cedars-Sinai Medical Group. Contracted provider disputes submitted to Cedars-Sinai Medical Group must be sent with a completed Provider Dispute Resolution Request form (Attachment A) and include the information listed in Section II.A., above, for each contracted provider dispute. All contracted provider disputes must be mailed to Cedars-Sinai Medical Group, attention Nautilus Healthcare Management Group, at the following address: P.O. Box 6250 Newport Beach, CA C. Time Period for Submission of Provider Disputes. i. Contracted provider disputes must be received by Cedars-Sinai Medical Group within 365 days from provider s action that led to the dispute (or the most recent action if there are multiple actions) that led to the dispute, or ii. In the case of inaction, contracted provider disputes must be received by Cedars-Sinai Medical Group within 365 days after the provider s time for contesting or denying a claim (or most recent claim if there are multiple claims) has expired. iii. Contracted provider disputes that do not include all required information as set forth above in Section II.A. may be returned to the submitter for completion. An amended contracted provider dispute which includes the missing information may be submitted to Cedars-Sinai Medical Group within thirty (30) working days of your receipt of a returned contracted provider dispute. D. Acknowledgment of Contracted Provider Disputes. Cedars-Sinai Medical Group will acknowledge receipt of all contracted provider disputes as follows: i. Electronic contracted provider disputes will be acknowledged by Cedars-Sinai Medical Group within two (2) Working Days of the Date of Receipt by Cedars-Sinai Medical Group. ii. Paper contracted provider disputes will be acknowledged by Cedars-Sinai Medical Group within fifteen (15) Working Days of the Date of Receipt by Cedars-Sinai Medical Group. E. Contacting Cedars-Sinai Medical Group Regarding Contracted Provider Disputes. All inquiries regarding the status of a contracted provider dispute or about filing a contracted provider dispute must be directed to Claims Customer Service at AB1455 Downstream Provider Notice 6 of 8

7 F. Instructions for Filing Substantially Similar Contracted Provider Disputes. Substantially similar multiple claims, billing or contractual disputes, may be filed in batches as a single dispute, provided that such disputes are submitted in the following format and include the information listed in Section II.A., above : i. Sort provider disputes by similar issue ii. Provide cover sheet for each batch iii. Number each cover sheet iv. Provide a cover letter for the entire submission describing each provider dispute with references to the numbered coversheets v. Complete Provider Dispute Resolution Request form (Attachment A) G. Time Period for Resolution and Written Determination of Contracted Provider Dispute. Cedars-Sinai Medical Group will issue a written determination stating the pertinent facts and explaining the reasons for its determination within forty-five (45) Working Days after the Date of Receipt of the contracted provider dispute or the amended contracted provider dispute. H. Past Due Payments. If the contracted provider dispute or amended contracted provider dispute involves a claim and is determined in whole or in part in favor of the provider, Cedars-Sinai Medical Group will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five (5) Working Days of the issuance of the written determination. III. Dispute Resolution Process for Non-Contracted Providers A. Definition of Non-Contracted Provider Dispute. A non-contracted provider dispute is a noncontracted provider s written notice to Cedars-Sinai Medical Group challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar claims that are individually numbered) that has been denied, adjusted or contested or disputing a request for reimbursement of an overpayment of a claim. Each non-contracted provider dispute must contain, at a minimum, the following information: the provider s name, the provider s identification number, contact information, and: i. If the non-contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from Cedars-Sinai Medical Group to provider the following must be provided: Original Claim Number(s), a clear identification of the disputed item, the Date of Service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, contest, denial, request for reimbursement for the overpayment of a claim, or other action is incorrect; ii. If the non-contracted provider dispute involves an enrollee or group of enrollees, the following must be provided: the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the Date of Service, provider s position on the dispute, and an enrollee s written authorization for provider to represent said enrollees. B. Dispute Resolution Process. The dispute resolution process for non-contracted Providers is the same as the process for contracted providers as set forth in sections II.B., II.C., II.D., II.E., II.F., II.G., and II.H. above. AB1455 Downstream Provider Notice 7 of 8

8 IV. Claim Overpayments A. Notice of Overpayment of a Claim. If Cedars-Sinai Medical Group determines that it has overpaid a claim, Cedars-Sinai Medical Group will notify the provider in writing within 365 days of the date of payment through a separate notice clearly identifying the claim, the name of the patient, the Date of Service(s) and a clear explanation of the basis upon which Cedars-Sinai Medical Group believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim. The 365-day time limit shall not apply if the overpayment was caused in whole or in part by fraud or misrepresentation on the part of the provider. B. Contested Notice. If the provider contests Cedars-Sinai Medical Group s notice of overpayment of a claim, the provider, within 30 Working Days of the receipt of the notice of overpayment of a claim, must send written notice to Cedars-Sinai Medical Group stating the basis upon which the provider believes that the claim was not overpaid. Cedars-Sinai Medical Group will process the contested notice in accordance with Cedars-Sinai Medical Group s contracted provider dispute resolution process described in Section II above. C. No Contest. If the provider does not contest Cedars-Sinai Medical Group s notice of overpayment of a claim, the provider must reimburse Cedars-Sinai Medical Group within thirty (30) Working Days of the provider s receipt of the notice of overpayment of a claim. D. Offsets to Payments. Cedars-Sinai Medical Group may only offset an uncontested notice of overpayment of a claim against provider s current claim submission when: (i) the provider fails to reimburse Cedars-Sinai Medical Group within the timeframe set forth in Section IV.C., above, and (ii) Cedars-Sinai Medical Group s contract with the provider specifically authorizes Cedars-Sinai Medical Group to offset an uncontested notice of overpayment of a claim from the provider s current claims submissions. In the event that an overpayment of a claim or claims is offset against the provider s current claim or claims pursuant to this section, Cedars-Sinai Medical Group will provide the provider with a detailed written explanation identifying the specific overpayment or payments that have been offset against the specific current claim or claims. AB1455 Downstream Provider Notice 8 of 8