3. The Health Plan accepts the standard current billing forms: the CMS 1500 (02/12) form and the UB- 04 hospital billing forms.

Transcription

1 BILLING PROCEDURES SECTION 11 Billing Procedures 1. All claims should be submitted to: The Health Plan 1110 Main St Wheeling WV Claim forms must be completed in their entirety. The efficiency with which the claim form is completed directly affects the efficiency with which the claim is processed for payment. Submission of a clean claim ensures timely and appropriate processing of payment. A clean claim is defined as one that can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim review for medical necessity. 2. The Health Plan requires that all claims are submitted with accurate and current CPT-4, HCPC, as well as ICD-10 codes as appropriate. For each procedure that is listed on the claim a diagnosis code (ICD-10) must support the services (listed in block 24D on the CMS 1500 form) to ensure expeditious and accurate processing of the claim. You must relate the diagnosis(es) listed in block 21 to the individual service lines. You need ONLY to relate diagnosis A, B, C, etc. NOT the ICD-10 code in block 24E. THP encourages the use of category II codes to report performance measures. Use of category II codes will decrease the need for medical record abstraction and chart review. 3. The Health Plan accepts the standard current billing forms: the CMS 1500 (02/12) form and the UB- 04 hospital billing forms. 4. When indicating the member ID number on the billing form, the entire number, including the ninedigit Plan ID number and two digit suffix should be indicated as shown on The Health Plan ID card. Patient ID number starts with the letter H, the remaining eight digits are numeric. The suffix identifies the family member. Example: John Doe H Subscriber Jane Doe H Spouse Mary Doe H Child (eldest) 5. The Health Plan provider website offers a link to the National NPI Registry for referring providers and facilities. 6. All services must be billed within 365 days from the date of service. 7. Coordination of benefits (COB) claims (where another carrier has primary responsibility for making payment), must be submitted within 12 months from the date of service or three months from the date of the primary carrier s explanation of benefits (EOB). If you do not receive payment or rejection from the primary carrier and the 12-month time limit is approaching, you must bill The

2 BILLING PROCEDURES SECTION 11 Health Plan before the 12-month deadline, whether or not you have received the EOB from the primary carrier. (Refer to Section 11 of this manual for additional COB information.) 8. All claims are paid within 30 days from the date of receipt by The Health Plan or as otherwise required by prompt pay requirements. If a clean claim is not paid within the applicable timeframes, appropriate interest will be applied to the claim when it is paid as required by state law, Medicare or Medicaid requirements. For WV Medicaid services, interest will be paid to in-network providers at 7 percent per annum calculated daily for the full period the claim remains unpaid beyond the 30-day clean claims payment deadline. 9. Payment and payment vouchers are available electronically or mailed by request bi-monthly, depending on the line of business. Please refer to section 10 for information regarding electronic remittances. 10. Questions concerning payment or denial must be submitted to The Health Plan within 180 days from the payment/denial date of the claim. Please refer to section 14 for additional information on claims resubmission procedures. 11. When submitting a refund check to The Health Plan for overpayment (e.g., coordination of benefits, workers' compensation, subrogation, etc.), include a copy of the payment voucher underlining or circling the claim, and document the reason for the refund. If unsure of the voucher date for the paid claim, you may contact the COB/funds recovery representative. It is best to include detailed information such as patient name, ID number, date of service, and the reason for the refund. 12. Provider should collect applicable deductible, copayments, or coinsurance at the time of service whenever possible. Copayments may not be waived (with the exception of COB) as this is in direct violation of the physician contract with The Health Plan. 13. The Health Plan members are NOT to be billed directly or balance billed for covered services. 14. Procedural manuals will be supplied by The Health Plan to all participating providers, upon request, to assist with The Health Plan guidelines and procedures. The manual can be found on The Health Plan provider secure website that can be accessed from the main website. Procedural manuals are also available on CD. 15. The Health Plan will NOT reimburse physicians, nor can the member be billed, for the following services: Services not rendered Phone calls (including phone consults) Canceled/missed appointments Making referrals Normal postoperative care

3 BILLING PROCEDURES SECTION 11 Completion of paperwork Unnecessary services not indicated by diagnosis Mileage Stat charges Educational services Prescriptions False information/fraudulent billing Never events/avoidable hospital conditions/provider preventable conditions 16. Changes in reimbursement/fee schedules issued by federal and/or state entities will become effective by The Health Plan on the date of notification. 17. The Health Plan will comply with Ohio, West Virginia, and Medicare prompt pay requirements. 18. Self-funded employers require submission of claims and formal appeals within 365 days in order to be honored.

4 BILLING PROCEDURES SECTION 11 Never Events and Avoidable Hospital Conditions Never Events Procedures performed on the wrong side, wrong body part, wrong procedure, or wrong person are commonly referred to as never events. These never events are not medically necessary as they are not required to diagnose or treat an illness, injury, disease, or its symptoms and are not consistent with generally accepted standards of medical practice. All never events involving a wrong procedure, or a procedure performed on the wrong side, wrong body part, or wrong person are considered not medically necessary, and reimbursement is not allowed. Hospitals generally refrain from billing members for these never events. In the instances where The Health Plan does receive bills for such services, these shall appropriately be denied for lack of medical necessity. Avoidable Hospital Conditions Avoidable hospital conditions (a.k.a. hospital acquired conditions) are conditions which could reasonably have been prevented through application of evidence-based guidelines. These conditions are not present when patients are admitted to a hospital, but present during the course of the stay. Effective October 1, 2008, Centers for Medicare and Medicaid Services (CMS) identified the following as preventable hospital acquired conditions: Foreign objects retained after surgery Air embolism Blood incompatibility Pressure ulcers stages III and IV Falls and trauma Catheter-associated urinary tract infection Vascular catheter-associated infection and surgical site infection Mediastinitis, following coronary artery bypass graft (CABG) Manifestations of poor glycemic control Surgical site infection following certain orthopedic procedures Surgical site infection following bariatric surgery for obesity; and Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures.

5 BILLING PROCEDURES SECTION 11 CMS provided that effective October 1, 2007, hospitals should begin submitting inpatient hospital charges with a present on admission (POA) indicator. POA is defined as a condition that is present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including the emergency department, observation, or outpatient surgery are considered as POA. The Health Plan reviews and tracks admissions with identifiable never events and avoidable hospital conditions. When it is determined there were additional hospital inpatient days at a participating provider facility, which directly and exclusively resulted from an avoidable hospital condition (not present on admission), reimbursement for additional inpatient days and/or services may be denied. Further, avoidable hospital conditions and never events shall not be considered in DRG determinations for facilities reimbursed through a DRG methodology. Denials for inpatient hospital days or services which are the result of such circumstances are not billable to the member. These reimbursement denials will not apply to hospital admissions in which the avoidable hospital condition was present on admission, or where another secondary diagnosis is a major complicated/comorbidity (MCC)/complication/comorbidity (CC) in addition to the POA diagnosis, and potentially impacted the avoidable hospital condition.

6 BILLING PROCEDURES SECTION 11 Electronic Billing Documentation Submission To assist with the submission of required documentation for claims adjudication, The Health Plan has a dedicated fax line to submit your documentation. The fax number is In order to assure the required documentation is routed correctly, you must accurately complete The Health Plan fax cover sheet in its entirety. Failure to complete the fax cover sheet may result in claim denials. A separate fax cover sheet is required for each document faxed. Your electronic claim should be marked in the claim note or claim line area with notification stating additional documentation has been faxed. Placing the work FAX in the claim note area will alert our claim reviewers. You must fax all required documentation within 24 hours of your electronic claims transmission.

7 BILLING PROCEDURES SECTION 11 Credit Balance Explanation When a claim is credited against your account, the credit amount can carry over more than one payment. Accordingly, it may be necessary to hold multiple vouchers and post them all at once. In order to assist your accounts receivable representative, here are the basic steps to follow in order to balance out to your deposit when credits have been applied over more than one voucher process. 1. You will need to make sure to evaluate every voucher that you receive, even those that are not accompanied by a check or electronic deposit. Vouchers with zero payments often include denials that need to be worked as well as credits applied to current and future paid claims. In the event a credit balance appears on the voucher, you will want to hold the voucher in order to reference the credit activity until the credit has cleared (i.e., until your next voucher with a positive payment amount. This excludes any voucher that only show Claims In Process, no payments or credits.) 2. In the meantime, please be sure to re-submit corrected claims for all claims denied because the information submitted on the original claim was incorrect. This will avoid a timely filing denial and ensure those claims are promptly reprocessed for payment upon correction. 3. Once the credit has been satisfied and you receive a voucher with a check or an electronic deposit, then you can post all the debits and credits that you have been holding, along with the voucher that you received a check or deposit. After all the debits and credits have been posted, you will balance out to the check or deposit. Example: (See sample vouchers starting on the next page.) - $ (Plus on to member s account this is where your credit begins) - $ (Payment - Credit off of member s account) - $ Outstanding Credit Balance (HOLD Voucher) - $ (Payment - Credit off of member s account) - $ Reduced Outstanding Credit Balance (HOLD Voucher) - $ (Payment - Credit off of member s account) - $ Reduced Outstanding Credit Balance (HOLD Voucher) - $ (Payment - Credit off of member s account) - $ (Payment - Credit off of member s account) - $ (Payment - Credit off of member s account) - $ (Payment - Credit off of member s account) $ (As you can see, if you post all the debits and credits together, you will balance out to your check or electronic deposit.) HOLD UNTIL YOU RECEIVE A VOUCHER THAT IS ACCOMPANIED WITH A CHECK OR ELECTRONIC DEPOSIT

8 PAGE: 1 Health Plan Upper Ohio Valley 10/29/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJ DATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT OTHER COB PAID W/H FEE DSCNT CD MEDICARE RISK-MEMBER RESPONSIBLE FOR ONLY CO-PAY, CO-INSURANCE & DEDUCTIBLE. PER PROVIDER LETTER CLAIM IS PAID IN DUPLICATE. 03/24/ CLAIM CODES: /24/ CLAIM CODES: /24/2014 J CLAIM CODES: /24/2014 J TOTAL CLAIM CODES: 45 Add payment & adjustments back on to Member s Account MEDICARE RISK-MEMBER RESPONSIBLE FOR ONLY CO-PAY, CO-INSURANCE & DEDUCTIBLE. 09/29/ L SQ CLAIM CODES: 253 TOTAL CLAIM CODES: 45 Credit payment & adjustments off of Member s Account

9 PAGE: 2 Health Plan Upper Ohio Valley PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 3 TOTAL BILLED $ BALANCE CARRIED FORWARD $186.37CR COPAYMENTS $4.43CR WITHHOLD $3.80CR And you will still have this outstanding credit ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $ CLAIMS IN PROCESS $ TOTAL ALL CLAIMS $ PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. HOLD UNTIL YOU RECEIVE A VOUCHER THAT IS ACCOMPANIED WITH A CHECK OR ELECTRONIC DEPOSIT

10 PAGE: 1 Health Plan Upper Ohio Valley 11/05/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJ DATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT OTHER COB PAID W/H FEE DSCNT CD MEDICARE RISK-MEMBER RESPONSIBLE FOR ONLY CO-PAY, CO-INSURANCE & DEDUCTIBLE. 10/07/ L SQ CLAIM CODES: TOTAL CLAIM CODES: 45 Health Plan Upper Ohio Valley Credit payment & adjustments off of Member s Account

11 PAGE: 2 Health Plan Upper Ohio Valley PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 1 TOTAL BILLED $ TOTAL TO BE PAID $34.90 CREDIT BALANCE $186.37CR BALANCE CARRIED FORWARD $151.47CR COPAYMENTS $35.00 WITHHOLD $.71 And you will still have this outstanding credit ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $ CLAIMS IN PROCESS $ TOTAL ALL CLAIMS $ PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *********************************** *** FOR CUSTOMER SERVICE CALL *** *********************************** COMMERCIAL: or (740) PEIA: or (740) SECURE CARE: or (740) MOUNTAIN HEALTH TRUST: or (740) Health Plan Upper Ohio Valley ALL THESE CLAIMS WERE DENIED FOR A CORRECTED NPI NUMBER. You do not have to hold this voucher. These claims should be corrected and re-submitted to The Health Plan as soon as possible so they don t deny for Timely Filing.

12 PAGE: 1 Health Plan Upper Ohio Valley 11/12/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS DENIED *** SECURE CARE *** CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJ DATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT OTHER COB PAID W/H FEE DSCNT CD RENDERING NPI MISSING 10/22/ /22/ TOTAL NPI CLAIM CODES: 206 RENDERING NPI MISSING 10/22/ AS /22/ AS TOTAL NPI CLAIM CODES: 206 RENDERING NPI MISSING 10/29/ TOTAL NPI CLAIM CODES: 206

13 Health Plan Upper Ohio Valley PAGE: 2 Health Plan Upper Ohio Valley PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 3 TOTAL BILLED $7, CREDIT BALANCE $151.47CR BALANCE CARRIED FORWARD $151.47CR ACCOUNT STATUS BILLED CHARGES # CLAIMS Outstanding credit carried over and not reduced because nothing paid this time. CLAIMS PAID / DENIED $7, CLAIMS IN PROCESS $ TOTAL ALL CLAIMS $7, PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *********************************** *** FOR CUSTOMER SERVICE CALL *** *********************************** COMMERCIAL: or (740) PEIA: or (740) SECURE CARE: or (740) MOUNTAIN HEALTH TRUST: or (740) HOLD UNTIL YOU RECEIVE A VOUCHER THAT IS ACCOMPANIED WITH A CHECK OR ELECTRONIC DEPOSIT

14 PAGE: 1 Health Plan Upper Ohio Valley 11/19/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJ DATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT OTHER COB PAID W/H FEE DSCNT CD MEDICARE RISK-MEMBER RESPONSIBLE FOR ONLY CO-PAY, CO-INSURANCE & DEDUCTIBLE. 10/15/ L SQ CLAIM CODES: TOTAL CLAIM CODES: 45 Credit payment & adjustments off of Member s Account

15 Health Plan Upper Ohio Valley PAGE: 2 Health Plan Upper Ohio Valley PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 2 TOTAL BILLED $1, TOTAL TO BE PAID $67.97 CREDIT BALANCE $151.47CR BALANCE CARRIED FORWARD $83.50CR COPAYMENTS $35.00 WITHHOLD $1.39 And you will still have this outstanding credit ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $1, CLAIMS IN PROCESS $ TOTAL ALL CLAIMS $1, PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *********************************** *** FOR CUSTOMER SERVICE CALL *** *********************************** COMMERCIAL: or (740) PEIA: or (740) SECURE CARE: or (740) MOUNTAIN HEALTH TRUST: or (740) Health Plan Upper Ohio Valley

16 PAGE: 1 Health Plan Upper Ohio Valley 12/17/2014 PROVIDER REIMBURSEMENT VOUCHER PROVIDER S NAME PROVIDER NO: _ TAX ID: _ NOW IF YOU POST ALL THE DEBITS AND CREDITS, YOU WILL BALANCE OUT TO THE CHECK OR ELECTRONIC DEPOSIT AMOUNT. CLAIMS PAID *** SECURE CARE *** CHECK NUMBER: CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJ DATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT OTHER COB PAID W/H FEE DSCNT CD MEDICARE RISK-MEMBER RESPONSIBLE FOR ONLY CO-PAY, CO-INSURANCE & DEDUCTIBLE. 11/13/ L SQ CLAIM CODES: 253 TOTAL CLAIM CODES: 45 Credit payment & adjustments off of Member s Account MEDICARE RISK-MEMBER RESPONSIBLE FOR ONLY CO-PAY, CO-INSURANCE & DEDUCTIBLE. 10/03/ L SQ CLAIM CODES: TOTAL CLAIM CODES: 45 Credit payment & adjustments off of Member s Account MEDICARE RISK-MEMBER RESPONSIBLE FOR ONLY CO-PAY, CO-INSURANCE & DEDUCTIBLE. 10/29/ L SQ CLAIM CODES: 253 TOTAL CLAIM CODES: 45 Credit payment & adjustments off of Member s Account MEDICARE RISK-MEMBER RESPONSIBLE FOR ONLY CO-PAY, CO-INSURANCE & DEDUCTIBLE. 11/13/ L SQ CLAIM CODES: TOTAL CLAIM CODES: 45 Credit payment & adjustments off of Member s Account CLAIMS DENIED *** SECURE CARE *** CLAIM NO ACCOUNT NO HID NO MEMBER NAME MEMBER RESPONSIBLE ADMIN ADJ DATE SRV CPT MODIFIERS UNT BILLED ALLOWED DISALLOW COPAY CO-INS DEDUCT OTHER COB PAID W/H FEE DSCNT CD 10/22/ /22/ TOTAL R1 CLAIM CODES: 16 10/22/ AS /22/ AS TOTAL R1 CLAIM CODES: 16

17 PAGE: 4 Health Plan Upper Ohio Valley PROVIDER S NAME PROVIDER NO: TAX ID: _ Provider s Name Provider s Street Address City, State & Zip NUMBER OF CLAIMS 6 TOTAL BILLED $8, TOTAL TO BE PAID $ LESS ADVANCE $83.50CR NET PAID $ COPAYMENTS $35.00 WITHHOLD $8.99 Outstanding credit has now cleared and you receive a check in this amount. ACCOUNT STATUS BILLED CHARGES # CLAIMS CLAIMS PAID / DENIED $8, CLAIMS IN PROCESS $16, TOTAL ALL CLAIMS $25, PROVIDER HAS THE RIGHT TO APPEAL DECISION. REFER TO THE APPEAL PROCESS IN THE PROVIDER BILLING MANUAL. *********************************** *** FOR CUSTOMER SERVICE CALL *** *********************************** COMMERCIAL: or (740) PEIA: or (740) SECURE CARE: or (740) MOUNTAIN HEALTH TRUST: or (740) Health Plan Upper Ohio Valley