CHAPTER 7 SUBMITTING CLAIMS AND ENCOUNTERS

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1 CHAPTER 7 SUBMITTING CLAIMS AND ENCOUNTERS 7.0 SUBMITTING CLAIMS AND ENCOUNTERS TO HEALTH CHOICE INTEGRATED CARE Health Choice Integrated Care subcontracted providers are required to submit claims or encounters in conformance with the AHCCCS Office of Program Support Operations and Procedures Manual, the AHCCCS Covered Behavioral Health Services Guide, the AHCCCS Financial Reporting Guide the Client Information System (CIS) File Layouts and Specifications Manual requirements, AHCCCS Rules and Regulations, the AHCCCS Companion Guides, and in accordance with HIPAA for each covered service delivered to a member. The Health Choice Integrated Care Claims Department is responsible for claim/encounter adjudication; resubmissions, claim/encounter inquiry/research and provider claim/encounter submissions to AHCCCS. All providers who participate with Health Choice Integrated Care must first register with AHCCCS to obtain an AHCCCS Provider Identification Number. AHCCCS requires all providers providing and billing for AHCCCS covered services to have an NPI number. Please contact AHCCCS directly for this number (AHCCCS Provider registration link). Once you have obtained your 6 digit AHCCCS provider ID, notify Health Choice Integrated Care s Provider Network Department at (928) or (877) BILLING REQUIREMENTS Health Choice Integrated Care members may NOT be billed, or reported to a collection agency, for covered services or for services not reimbursed due to the failure of the provider to comply with Health Choice Integrated Care's prior authorization or billing requirements. Please refer to Arizona Revised Statute A.R.S (L) and Administrative Codes R , R for additional information. In particular, Arizona Administrative Code R states in part, an AHCCCS registered provider shall not do either of the following, unless services are not covered or without first receiving verification from the Administration [AHCCCS] that the person was not an eligible person on the date of service: Charge, submit a claim to, or demand or collect payment from a person claiming to be AHCCCS eligible; or Refer or report a person claiming to be an eligible person to a collection agency or credit reporting agency Providers may NOT collect copayments, coinsurance or deductibles from members with other insurance, whether it is Medicare, a Medicare HMO or a commercial carrier (except for AHCCCS mandated co-pay members). Providers must bill Health Choice Integrated Care for these amounts and Health Choice Integrated Care will coordinate benefits. Unless otherwise stated in contract, Health Choice Integrated Care adjudicates payment using the lesser of methodology and members may not be billed for any remaining balances due to the lesser of methodology calculation. Page 1 of 15

2 When to Bill a Member A member may be billed when the member knowingly receives non-covered services. Providers MUST notify the member in advance of the charges. Providers should have the member sign a statement agreeing to pay for the services and place the document in the member s medical record. A member may be billed applicable co-payments assigned by Health Choice Integrated Care in accordance with state law and Arizona Administrative Code requirements. Please reference Chapter 8 Copayment and Other Member Fees for additional information. Prior Period Coverage On occasion AHCCCS eligible members are enrolled retrospectively into Health Choice Integrated Care. The retrospective enrollment is referred to as Prior Period of Coverage (PPC). Members may have received services during PPC and Health Choice Integrated Care is responsible for payment of covered services that were received. For services rendered to the member during PPC, the provider must submit PPC claims/encounters to Health Choice Integrated Care for payment of covered benefits. The provider must promptly refund, in full, any payments made by the member for covered services during the PPC period. While prior authorization is not required for PPC services, Health Choice Integrated Care may, at its discretion, retroactively review medical records to determine medical necessity. If such services are deemed not medically necessary, Health Choice Integrated Care reserves the right to recoup payment, in full, from the provider. The provider may not bill the member. CLAIM/ENCOUNTER SUBMISSION REQUIREMENTS Claim/Encounter Overview A claim/encounter is a record of medically necessary services provided to an enrolled member. When to File a Claim/Encounter AHCCCS requires the submission of claims and encounters for all services provided to enrolled members, even those that are sub-capitated. Health Choice Integrated Care uses the claim/encounter information to determine if care requirements have been met and to establish rate adjustments. AHCCCS /Encounter Data Validation AHCCCS performs periodic data validation studies. All AHCCCS contractors and subcontractors are contractually required to participate in this process. In addition, the data validation studies enable AHCCCS to monitor and improve the quality of claim/encounter data. Information regarding AHCCCS Claim/Encounter Data Validation Study procedures can be found in the Office of Program Support Operations and Procedures Manual. Timely Filing of Claim/Encounter Submission Page 2 of 15

3 In accordance with contractual obligations, claims/encounters for services provided to a Health Choice Integrated Care member must be received in a timely manner. Health Choice Integrated Care s timely filing limitations are as follows: New Claim/Encounter Submissions Claims/Encounters must be filed on a valid claim form within 180 days (6 months) from the date services were performed or from the date of eligibility posting, whichever is later, unless there is a contractual exception. For hospital inpatient claims/encounters, date of service means the date of discharge of the patient, or the statement end date for interim first/continued claims/encounters. Claims initially received beyond the six-month timeframe, except retro-eligibility claims (see description of 'retro-eligibility claims' below), will be denied. If a claim is originally received within the six-month timeframe, the provider has up to 12 months from the date of service to resubmit the claim in order to achieve clean claims status or to correct a previously processed claim, unless the claim is a retro-eligibility claim. If the claim does not achieve clean clam status or is not corrected within 12 months, Health Choice Integrated Care is not liable for the payment. A retro-eligibility claim is a claim where no eligibility was entered in the AHCCCS system on the date(s) of service but, at a later date, eligibility was posted retroactively to cover the date(s) of service. Retro-eligibility fee-for-service claims are considered timely submission if the initial claim is received no later than six-months from the AHCCCS date of eligibility posting. Retroeligibility claims must attain clean claim status no later than 12 months from the AHCCCS date of eligibility posting. Corrections to paid retro-eligibility claims must be received no later than 12 months from the AHCCCS date of eligibility posting. Claim/Encounter Resubmission Claim/Encounter resubmissions must be filed within 365 days (1 year) from the date of service or eligibility posting deadline, whichever is later. The only exception to this is if a claim/encounter is recouped, the provider is given an additional 60 days from the recoupment date to resubmit a claim/encounter. Please submit any additional documentation that may effectuate a different outcome or decision. See the paragraph above for further clarification of time-frames for claim submission regarding retro-eligibility. Failure to submit claims and/or encounter data within the prescribed time period may result in payment delay and/or denial. Fines and penalties are levied against Health Choice Integrated Care for failure to correctly report claims/encounters in a timely manner. Health Choice Integrated Care may pass along these financial sanctions to a provider that fails to comply with claim/encounter submissions. Health Choice Integrated Care is the payer of last resort It is critical that you identify any other available insurance coverage for the member and bill the other insurance as primary. For example, if a member has Medicare, Medicare is primary and Health Choice Integrated Care is secondary. File an initial claim/encounter with Health Choice Integrated Care if you have not received payment or denial from the other insurer before the expiration of your required filing limit. Make sure you are submitting timely in order to preserve your claim dispute rights. Upon the receipt of payment or denial by the other insurer, you should then submit your claim/encounter to Health Choice Integrated Care, showing the other insurer payment amount or denial reason, if applicable, and enclosing a complete legible copy of the remittance advice or Explanation Of Benefits (EOB) from the other insurer. If billing electronically, the other insurer s Page 3 of 15

4 payment information must be included on the 837 transaction. Health Choice Integrated Care will pay co-payments, deductibles and/or coinsurance for AHCCCS Covered Services up to the lower of either Health Choice Integrated Care's fee schedule or the Medicare/other insurance allowed amount, unless otherwise specified in a provider contract. Claims/Encounters should be submitted within 180 days from the date of service for a first submission to retain appeal rights, whether the other insurance explanation of benefits has been received or not. Claim/Encounter Resubmissions should be submitted within one year from the last date of service or six months from the date of the other insurance explanation of benefits, whichever is later, once the other insurance explanation of benefits is received. Claims/Encounters can be submitted electronically when Health Choice Integrated Care is not the primary payer. The appropriate electronic loops for primary and any other payer needs to be completed or the claim/encounter will deny. When a member has other health insurance, such as Medicare, a Medicare HMO or a commercial carrier, Health Choice Integrated Care will deduct, from the allowed amount, payments from other payers. Dual Eligibility Health Choice Integrated Care/ Health Choice Generations Cost Sharing and Coordination of Benefits For members enrolled in both Health Choice Integrated Care and Health Choice Generations, any cost sharing responsibilities will be coordinated between the two payers. Providers need to submit their claim/encounter to Health Choice Generations. Providers will then need to submit claim with HCG EOB to Health Choice Integrated Care. Claims do not automatically crossover at this time. Injuries due to an Accident In the event the member is being treated for injuries suffered in an accident, the date of the accident should be included on the claim/encounter in order for Health Choice Integrated Care to investigate the possibility of recovery from any third-party liability source. This is particularly important in cases involving work-related injuries or injuries sustained as the result of a motor vehicle accident. HOW TO FILE A CLAIM/ENCOUNTER 1) Select the appropriate claim form (refer to table below). Claim Form Type Medical and professional services, including behavioral health. Family planning services (medical, hospital inpatient, outpatient or emergency. Obstetrical care * Should be billed using Complete Obstetrical Care Package. Hospital inpatient, including all behavioral health inpatient services, outpatient, skilled nursing facility and emergency room services Page 4 of 15 Claim Form / Electronic Format Original CMS 1500 Form (02-12)/837P Current required format CMS UB-04 Form/837I Current required format General dental services ADA 2006 Claim Form (02/12) Dental, services that are considered medical services (oral surgery, anesthesiology) CMS 1500 Form/837P Current required format

5 1) Submit original copies of claims/encounters electronically or through the mail (do NOT fax). To include required or requested supporting documentation, such as members medical records, clearly label and send to the Claims department at the correct address. Please Note: Not every claim/encounter needs supporting documentation; items that always require supporting records include but are not limited to: Inpatient claims, emergency transportation/ambulance, and unlisted procedure codes; and potential other items on a case by case basis. 2) Paper claim/encounter Submissions. a) Claims/Encounters must be legible, on the required form type(s), and suitable for imaging and/or hand data entry. Complete ALL required fields and include additional documentation when necessary. b) The claim form may be returned unprocessed and/or denied if illegible or poor quality copies are submitted or required documentation is missing. This could result in the claim/encounter being denied for untimely filing. 3) Electronic Submissions Providers who are contracted with Health Choice Integrated Care can submit claims/encounters electronically. Electronic billing ensures faster processing and payment of claims, eliminates the cost of sending paper claims, allows tracking of each claim sent, and minimizes clerical data entry errors. Methods: a. Clearinghouse: The EDI Clearinghouse Vendor that Health Choice Integrated Care uses is Change Healthcare. b. Direct Submission: Upon approval, qualified Providers have the option of submitting electronic files directly to Health Choice Integrated Care. All electronic submissions shall be submitted in compliance with applicable law including HIPAA regulations, AHCCCS policies and procedures, and Health Choice Integrated Care policies and procedures. Please reference the Health Choice Integrated Care Electronic submission policy for additional information. Contact your software vendor and Health Choice Integrated Care s Claims Department for more information about electronic billing. Claim/Encounter Submission Locations: Mail To Electronic Submission* All Form Types Health Choice Integrated Care Integrated Care Claims Department: 1300 S. Yale Street Flagstaff, AZ Through Electronic Clearinghouse or Direct Submission * Please contact your software vendor and Health Choice Integrated Care s Claims Department for Electronic Submission. General Billing Information Dates of Service within a claim/encounter must not span a contract year. If a service spans a contract year, the claim/encounter must be split into two separate claims/encounters indicating the different Page 5 of 15

6 date segments (not to span the contract year), with the appropriate number of units for each segment. Submitted encounters for services delivered to eligible persons will result in one of the following dispositions: Rejected; Pended; or Adjudicated (Approved/Paid or Denied) Rejected claims/encounters: Claims/Encounters are typically rejected because of a discrepancy between submitted form field(s) and HIPAA structural guidelines or the RBHA s, AHCCCS edit tables. A rejected claim/encounter may be resubmitted as long as the encounter is submitted within the RBHA s established timeframe of 6 months from the date of service (one year from the date of service if the claim/encounter was adjudicated by the RBHA but rejected by AHCCCS). Pended claims/encounters: Claims/Encounters pended by Health Choice Integrated Care are worked by Claims staff within 30 days of the date of receipt, resulting in the claim/encounter being adjudicated (approved/paid or denied). Adjudicated claims/encounters: Adjudicated claims/encounters are claims/encounters that have passed all formatting edits and have been accepted into the Health Choice Integrated Care Claiming System and processed to approved/paid or denied status. Providers are expected to correct and resubmit denied claims/encounters when applicable. Approved/Paid or denied claims/encounters are reported back to the provider on their Explanation of Benefits (EOB) and/or 835 Electronic Remittance Advice for EDI Providers. Non-Title XIX XXI claims/encounters submitted to Health Choice Integrated Care must be submitted in the same manner and timeframes as above. Claims/encounters will fall into the same dispositions as listed above: Rejected, Pended, Paid or Denied. All approved/paid, and some denied claims/encounters are submitted to AHCCCS for processing. Non- Title XIX-XXI services are adjudicated by AHCCCS based on a minimum set of criteria. Claims/Encounters sent to AHCCCS will originally result in a status of Rejected (824/999 errors) or Accepted for Adjudication. Once AHCCCS adjudicates the accepted claims/encounters, the status will change to Approved, Denied, or Pended. If the claim/encounter is rejected, denied, or pended and the issue cannot be corrected internally by Health Choice Integrated Care, the claim/encounter may be reversed back to the provider and/or the provider will be notified and required to correct the claim/encounter. Quick Pay Discount/Interest Payments The following procedures apply to claim payments to contracted providers with fee-for-service and single case agreements. Page 6 of 15

7 Hospital: A quick pay discount of 1% will be applied to hospital clean claims paid within 30 days of the date of the receipt of the clean claim. For all hospital clean claims, a slow payment penalty is paid in accordance with A.R.S Slow payments are those that are paid more than 60 days after the receipt of a clean claim. Interest shall be at the rate of 1% per month unless a different rate is stated in a written contract. Interest shall accrue starting on the 61 st day after receipt of a clean claim until the date of payment. Non-Hospital: For non-hospital claims, late payments are those that are paid after 45 days of receipt of a clean claim. Interest shall be at the rate of 10% per annum unless a different rate is stated in a written contract. Interest shall accrue starting on the 46 th day after receipt of a clean claim until the date of payment. In the event a claim is reprocessed as a result of an overturned claim dispute or State Fair Hearing, the claims shall be reprocessed within 15 days from the date of the decision, and interest shall be paid back to the date the clean claim was received. Correct Coding Initiative Health Choice Integrated Care, and AHCCCS follow the same standards as Medicare s Correct Coding Initiative (CCI) policy and perform CCI edits and audits on claims/encounters for the same provider, same recipient, and same date of service. For more information on this initiative, please review the CMS website at: Health Choice Integrated Care utilizes comprehensive code auditing solutions that ensures proper reimbursement. Correct Coding Initiative guidelines will be followed in accordance with both AHCCCS and CMS, in addition to pertinent coding information received from other medical organizations/societies. Correct Coding Correct coding means billing for a group of procedures with the appropriate comprehensive code. All services that are integral to a procedure are considered bundled into that procedure as components of the comprehensive code when those services: Represent the standard of care for the overall procedure; or Are necessary to accomplish the comprehensive procedure; or Do not represent a separately identifiable procedure unrelated to the comprehensive procedure. Page 7 of 15

8 Incorrect Coding Examples of incorrect coding include: Unbundling - Fragmenting one service into components and coding each as if it were a separate service. Billing separate codes for related services when one code includes all related services. Breaking out bilateral procedures when one code is appropriate. Down-coding a service in order to use an additional code when one higher level, more comprehensive code is appropriate. Modifiers Appropriate modifiers must be billed in order to reflect services provided and for claims/encounters to pay appropriately. Health Choice Integrated Care can request copies of operative reports or office notes to verify services provided. Common modifier issue clarification is below: Modifier 59 Distinct Procedural Services -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. Medical records must reflect appropriate use of the modifier. Modifier 59 cannot be billed with evaluation and management codes ( ) or radiation therapy codes ( ). Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service -must be attached to a component code to indicate the procedure was distinct or separate from other services performed on the same day and was not part of the comprehensive service. Medical records must reflect appropriate use of the modifier. Modifier 25 is used with evaluation and management codes and cannot be billed with surgical codes. Modifier 50 Bilateral Procedure -if no code exists that identifies a bilateral service as bilateral, you may bill the component code with modifier 50. Health Choice Integrated Care follows the same billing process as CMS and AHCCCS when billing for bilateral procedures. Services should be billed on one line reporting one unit with a 50 modifier. Modifier 57 Decision for Surgery must be attached to an Evaluation and Management code when a decision for surgery has been made. Health Choice Integrated Care follows CMS guidelines regarding whether the Evaluation and Management will be payable based on the global surgical period. CMS guidelines found in the Medicare Claims Processing Manual, Chapter Physicians/Non-physician Practitioners indicate: Carriers pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier "-57" to indicate that the service resulted in the decision to perform the procedure. Carriers may not pay for an evaluation and management service billed with the CPT modifier "-57" if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period. *Please refer to your Current Procedural Terminology (CPT) manual for details on modifier usage. Page 8 of 15

9 Medical Claims Review To ensure medical appropriateness and billing accuracy, any inpatient and outpatient outlier claims are sent for Medical Claims Review. Checking Status of Claims/Encounters Providers may check the status of a claim/encounter by accessing Health Choice Integrated Care s Secure Website at Health Choice Integrated Care encourages providers to take advantage of using online status, as it is quick, convenient and can be used to determine status for multiple claims/encounters. Providers may call the Health Choice Integrated Care Claims Customer Service at or e- mail HCIC_claimsunit@iasishealthcare.com. Claims Customer Service is available to: Answer questions about claims/encounters. Assist in resolving problems or issues with a claim/encounter. Provide an explanation of the claim adjudication process. Help track the disposition of a particular claim/encounter. Assist in correcting errors in claim/encounter processing: o Excludes corrections to prior authorization numbers (providers must call the Prior Authorization department directly). o Excludes rebilling a claim/encounter (the entire claim/encounter must be resubmitted with corrections, as per the Claim/Encounter Resubmission or Reconsideration section below). Please be prepared to provide Claims Customer Service the following information: Provider name and AHCCCS provider number, tax id, or NPI number. Member name and AHCCCS or billing identification number. Date of service. Claim number from the remittance advice on which you have received payment or denial of the claim if applicable. Claim/Encounter Resubmission or Reconsideration Providers have 12 months from the date of service to request a resubmission or reconsideration of a clean claim/encounter originally adjudicated (approved/paid or denied) within 6 months. A request for review or reconsideration of a claim/encounter does not constitute a claim dispute. Providers may resubmit a claim/encounter that: Was originally denied because of missing documentation, incorrect coding, etc. Was incorrectly paid or denied because of processing errors. When filing paper resubmissions or reconsiderations, please include the following information: An updated copy of the claim/encounter. All lines must be re-billed or a copy of the original claim/encounter (reprint or copy is acceptable). A copy of the remittance advice on which the claim/encounter was denied or incorrectly paid. Any additional documentation required. Page 9 of 15

10 A brief note describing requested correction. Clearly label as Resubmission or Reconsideration at the top of the claim/encounter in black ink and mail to appropriate claims address as indicated in the Claim Submission Table, listed above. Original claim number Resubmissions and reconsiderations can be submitted electronically, however, we are unable to accept electronic attachments at this time. To include required or requested supporting documentation, such as members medical records, clearly label, include the corrected paper claim, and send to the Claims department at the correct address. Please Note: Not every claim/encounter needs supporting documentation. Items that always require supporting records include but are not limited to: Inpatient claims, emergency transportation, emergency ambulance, and unlisted procedure codes; and potential other items on a case by case basis. When submitting paper resubmissions, failure to accurately label the resubmission or reconsideration may cause the claim/encounter to deny as a duplicate. For additional information regarding resubmission/reconsideration/void/reversal claims please see the HCIC website at or the Claims Help Desk at HCIC_claimsunit@iasishealthcare.com OVER PAYMENTS Any person (including a provider of Medicaid-funded services) who has received an overpayment is required to report and return the overpayment, and provide a reason for the overpayment within 60 days after the date on which the overpayment was identified. (See the Affordable Care Act of , 42 U.S.C. 1320a-7j(d)). The federal False Claim Act defines retention of overpayments as an obligation under the FCA, 31 U.S.C What is an Overpayment? An overpayment means any funds that a person receives or retains under title XVIII (Medicare) or XIX (Medicaid) to which the person, after applicable reconciliation, is not entitled under such title. (Affordable Care Act, 6402, 42 U.S.C. 1320a-7j(d)). Overpayments can occur for many reasons. Examples can include (but are not limited to) a duplicate payment for the same service, incorrect code, non-covered service, medically unnecessary service, third party pay or, billing error, member eligibility or enrollment changes, provider license or certification changes, adjustments identified through audits, claim/encounter or data validation audits, clinical record reviews, appeals, inadequate documentation or lack of documentation, payments to an excluded party, and a host of other reasons. To be considered an overpayment, the claim/encounter must have been previously submitted to Health Choice Integrated Care for processing and have been paid. Page 10 of 15

11 Overpayments must be reported and returned within 60 days after they are identified according to federal law. Health Choice Integrated Care may impose sanctions and corrective actions for incurring overpayment(s). If a provider does not correct and return an overpayment to Health Choice Integrated Care as required within 60 days after the overpayment is identified, Health Choice Integrated Care will impose sanction(s) for each incorrect claim/encounter or delay, and take other action, up to and including provider subcontract termination. Federal law states that any overpayment retained by a person after the deadline for reporting and returning the overpayment [60 days after identification] is regarded as a false claim and subject to penalties and enforcement under the False Claim Act (31 U.S.C et seq). Health Choice Integrated Care will notify appropriate state/federal authorities about the provider s False Claim Act obligation. Providers may need to take appropriate action, in addition to the steps listed above, to report or notify AHCCCS, and other agencies depending on the circumstances of the overpayment. [See HCIC Provider Manual, Chapter 17.0 Corporate Compliance] INSTRUCTION FOR SPECIFIC CLAIM/ENCOUNTER SCENARIOS Health Choice Integrated Care claims/encounters are always paid in accordance with the terms outlined in the healthcare provider s contract. Prior authorized services from Non-contracted healthcare providers will be paid in accordance with AHCCCS processing rules. Dental Claims Claims for dental services should be submitted on the standard American Dental Association form - ADA 2006 Claim Form. Services provided by an anesthesiologist or medically related oral surgery procedure should be submitted on CMS 1500 Form. Family Planning Claims Claims for medical services will only be accepted on the CMS 1500 Form for paper claims or 837 Professional for electronic claims. Inpatient hospitalizations, outpatient surgery and emergency department facility claims should be filed on the CMS UB-04 Form for paper claims or 837 Institutional for electronic claims. See Chapter 4.2 Covered Services, Family Planning for covered family planning services and appropriate billing codes on the Health Choice Integrated Care website for additional billing information. Family Planning services may be billed with other services on the same claim. Providers must submit the following information on Family Planning Claims: AHCCCS Provider ID number. Family planning service diagnosis (all claims must have). Explanation of Benefits from other insurance (including Medicare). Correctly signed and dated sterilization consent forms. Operative reports for surgical procedures. Use HCPCS J codes, and provide the drug administered, NDC code and the dosage for injected substances. Payment for IUDs requires a copy of the invoice to establish cost to the provider. Page 11 of 15

12 Anesthesia claims require an ASA code for surgery with the appropriate time reflected in minutes. A separate claim must be submitted for each date of service. Members may request services, such as infertility evaluations and abortions, from providers, whether or not they are registered with AHCCCS, but must sign a release form stating that they understand the service is not covered and that the member is responsible for payment of these services. If you have authorization or claims questions related to family planning, please call: Health Choice Integrated Care at (877) or (928) Obstetrical Claims Complete Obstetrical Care Package Reimbursement for obstetrical care is dependent upon the provider s contract with Health Choice Integrated Care. Please refer to your contract for further detail. Providers are expected to bill for obstetrical care according to the terms of their contract and should file claims using a CMS Global Case Rate Providers contracted at a global case rate are reimbursed as follows: Services Included in the Package: Initial and subsequent prenatal visits, including early, periodic, screening, diagnosis and treatment services (EPSDT -see below) for patients less than 21 years of age Treatment of pregnancy related conditions, including hypertension and gestational diabetes Treatment of urinary tract infections and pelvic infections Routine labs and blood draws In-hospital management of threatened premature labor In-hospital management of hyperemesis gravidarum External cephalic version performed in hospital Induction of labor by prostaglandins and/or oxytocin and/or combined Amnioinfusion Trial of vaginal birth after a cesarean (VBAC) Delivery by any method, including cesarean section Episiotomy and repair, including 4th degree lacerations All routine post-partum care, including follow-up visit Any management that would ordinarily be considered part of OB care. Services will not be separately reimbursed if billed separately. If a provider does not complete all the services in the Global Obstetrical Care Package, this may result in a lesser payment or potential recoupment of the payments made. Page 12 of 15

13 Services Not Included in the Package: Amniocentesis Obstetrical Ultrasonography Non-stress and contraction stress tests Coloscopy and/or biopsy for accepted indication Return to operating or delivery room for postpartum hemorrhage/curettage Non-obstetrical related medical care Cerclage Separate reimbursement will be provided, if medically necessary. Trimester of Entry into Prenatal Care Claims for obstetrical services are submitted on CMS Health providers must bill Evaluation and Management codes with the date span, and zero charges on one line and the total OB service charges on another. The health professional must then list out each pre-and post-natal visit using an E&M code with a $0.00 amount billed and 1 unit of service. While the goals of early entry into prenatal care and regular care during pregnancy have not changed, HEDIS guidelines will be followed to determine trimester of entry into prenatal care. Entry into prenatal care and the number of prenatal visits are measured and monitored by Health Choice Integrated Care and AHCCCS as part of the Quality Management Program. Pseudo Identification Numbers Pseudo identification numbers are only applicable to behavioral health providers under contract with Health Choice Integrated Care. On very rare occasions, usually following a crisis episode, basic information about a behavioral health recipient may not be available. When the identity of a behavioral health recipient is unknown, a behavioral health provider may use a pseudo identification number to register an unidentified person. This allows a claim/encounter to be submitted to AHCCCS, allowing Health Choice Integrated Care and the provider to be reimbursed for delivering certain covered services. Covered services that can be encountered/billed using pseudo identification numbers are limited to: Crisis Intervention Services (Mobile); Case Management; and Transportation Pseudo identification numbers must only be used as a last option when other means to obtain the needed information have been exhausted. Inappropriate use of a pseudo identification number may be considered a fraudulent act. PAYMENT OF CLAIMS Health Choice Integrated Care processes and records the payment of claims through a Remittance Advice. Providers may choose to receive checks through the mail or electronically. Health Choice Integrated Care encourages providers to take advantage of receiving Electronic Remittance Advices (ERA), as you will receive the ERA much sooner than receiving a remittance through the mail, enabling you to post payments sooner. Page 13 of 15

14 Provider Remittance Advice Health Choice Integrated Care (HCIC) generates checks weekly. Claims processed during a payment cycle will appear on a remittance advice ( remit ) as approved/paid, denied or reversed. Adjustments to incorrectly paid claims may reduce the check amount or cause a check not to be issued. Please review each remit carefully and compare to prior remits to ensure proper tracking and posting of adjustments. We recommend that you keep all remittance advices and use the information to post payments and reversals and make corrections for any claims requiring resubmission. Call your Provider Relations representative or HCIC_claimsunit@iasishealthcare.com if you are interested in receiving electronic remittance advices. Additional information can be attained on HCIC website The Provider Remittance Advice (remit) is the notification to the provider of the claims/encounters processed during the payment cycle. A separate remit is provided for each line of business in which the provider participates. An electronic version of the Remittance Advice can be attained. In order to qualify for an Electronic Remittance Advice (ERA), you must currently submit claims through EDI and receive payment for claim by EFT. You must also have the ability to receive ERA through an 835 file. We encourage our providers to take advantage of EDI, EFT, and ERA, as it shortens the turnaround time for you to receive payment and reconcile your outstanding accounts. Please contact your Provider Relations Representative or HCIC Help Desk (HCIC_claimsunit@iasishealthcare.com) to assist you with this process. Electronic Funds Transfer Through Electronic Funds Transfer (EFT), providers have the ability to direct funds to a designated bank account. Health Choice Integrated Care encourages you to take advantage of EFT. Since EFT allows funds to be deposited directly into your bank account, you will receive payment much sooner than waiting for the mailed check. Please contact your Provider Relations Representative at 1-(877) or Claims Help desk at HCIC_claimsunit@iasishealthcare.com if you are interested in enrolling in EFT. Remittance Advice Each Remittance Advice contains the following information: Paid claims Adjusted claims Denied claims The last page provides a listing of denial reasons, pricing explanation codes, billing and dispute information. Information reported on the Remittance Advice (RA) page includes: Billing Provider ID number Check date Invoice Number which links payments to the services that generated the payment Page 14 of 15

15 Service Code Quantity billed (units #) Amount billed Excluded and non-allowed amounts Allowed amounts Amount of other payer s payment Member Co-pay amount Contractual write off amount/quick Pay Discount Withhold Amount (if applicable) Amount paid Adjustment/Denial code Working the Remittance Advice Here are some suggestions for working the Health Choice Integrated Care Remittance Advice to reconcile claims billed to HCIC and the status of those claims: Review the RA to determine which claims have been paid and if the claims are paid correctly. Any errors, such as claims that have not paid the correct number of units, should be marked for resubmission, noting associated CRNs. Review the RA to determine if any claims submitted by the provider as adjustments are adjusted correctly. If problems still exist with a claim, it may be submitted again. The RA will also report any claims that were adjusted by HCIC as a result of an audit or review. Review the RA for any claims submitted by the provider as void transactions. There are many reasons a claim may be voided. These may be claims that have been paid by other insurance and now need to be voided so that HCIC can recoup its payment. The RA will also report any claims that were voided by HCIC as a result of an audit or medical review recoupment. Providers who believe that a claim was voided in error should contact the HCIC Claims Help Desk. Review the RA for denied services. Review each denial reason and determine the action necessary to correct the claim. Providers who have questions about the remittance Advice or about resubmitting, adjusting or voiding a claims should contact the HCIC Provider s Help Desk at (928) or HCIC_claimsunit@iasishealthcare.com. Page 15 of 15