IHCS CLAIMS REFERENCE GUIDE

Transcription

1 CLAIMS REFERENCE GUIDE WHERE DO I SUBMIT CLAIMS? Yu will submit the claims fr members directly t at the claims address belw. Electrnic Claims: Direct t Payer ID: 1 Paper Claims: Claims: Address1: City, ST ZIP: Attn. Claims Department 3700 Cmmerce Parkway Miramar, FL HOW DOES OUR PRACTICE SET UP AS A PAYER? See the steps belw: Cntact the clearing huse and request the Payer ID that will be used t rute the claims t the Payer ID. The Payer ID assigned t by Plexis may r may nt wrk with ther clearing huses. The nly way t knw what Payer ID the practice shuld use is t cntact yur specific clearing huse. The practice will need t prvide the clearing huse with the fllwing infrmatin: The clearing huse name: Plexis Healthcare Systems The Payer ID: 1 The prper name f : Integrated Hme Care Services The practice will receive the Payer ID infrmatin needed t rute claims t and the Payer ID: 1. The practice will then need t setup their practice management r billing systems with the new Payer ID they received frm the clearing huse. The practice will need t fllw these steps: Lcate the ruting number field within yur Practice Management Enter 1 as a new payer ID Fr questins n Plexis Healthcare Systems Clearinghuse, please cntact Claims Department directly at ptin #2 WHO CAN I CONTACT WITH CLAIMS QUESTIONS? Fr all questins and inquiries r disputes and appeals regarding claims fr, please call the Claims Custmer Service line at ptin # 2 and a representative will assist yu. HOW CAN I VIEW THE CLAIMS STATUS? T review the status f a claim r the issue date f payment, use s nline claims lkup tl. G t and click n the Claims Lkup tab. Yu can sign up fr access by fllwing the prmpts. Yu can als btain a user name and passwrd by calling the Claims Custmer Service Department at , ext (Refer t the Claims Lk-Up Training Guide in yur packet)

2 WHAT IS THE EXPECTED TURNAROUND TIME ONCE A CLAIM IS SUBMITTED? adheres t the cntract and the timeline/prcess will be as fllws: Payment Turnarund Time All Paper claims 30 days turnarund time frm receipt f the claim fr duly authrized cvered services All Electrnic claims 20-day turnarund time frm receipt f the claim fr duly authrized cvered services Claims will be denied if all apprpriate claims prcessing infrmatin is nt received within the 60-day timeframe Timely Filing Claims infrmatin must be received by n mre than 60 days frm the date f service If requests additinal infrmatin t prcess the claim it must be prvided within 60 days f. If the payer is nt the primary payer, and the prvider is pursuing payment frm the primary payer, the 60 days filing limit begins n the date the prvider receives the claim respnse frm the primary payer. WHEN CAN I EXPECT PAYMENT? will run checks every Mnday, Tuesday and Wednesday. Reimbursement checks, prvider vuchers and member EOBs will be printed and mailed every Wednesday, Thursday and Friday. Yu will be mailed a paper check frm made ut t the practice TIN. (Refer t packet fr samples f: Checks-payment sent t the practice TIN fr submitted claims; Claims vucher/explanatin f payment-summary f claim payment sent t the practice; and Explanatin f benefits (EOB) summary sent t the patient explaining their benefits and what is being cvered). DOES THE REFERRAL AND AUTHORIZATION PROCESS CHANGE? The Prir Authrizatin department will cntinue t pre-certify all referrals t specialists and medical prcedures as utlined in the current prir authrizatin list. HOW DO I SUBMIT A REQUEST OR AUTHORIZATION? The quickest and easiest way t submit requests is at If yu dn t currently utilize Prtal, call the prvider relatins line at ptin # 3 fr access and training n the system. T help expedite all requests, make sure all relevant clinical infrmatin is submitted with the authrizatin request. The Prir Authrizatin department is available by phne Mnday-Friday frm 8:30 am 4:30 pm at , ptin # 9. If yu reach us after hurs, please leave a message and we will return calls within 24 hurs.

3 WHERE DO I SUBMIT APPEALS? Attn: Claims Research and Reslutin 3700 Cmmerce Parkway Miramar, FL WHAT IS THE RECONSIDERATION PROCESS FOR PROVIDERS? Prvider requests fr recnsideratin must be submitted within 30 days f the date f the denial decisin. Recnsideratins will g t the claims department. The request fr recnsideratin will be assigned t the senir claims examiner t prcess. The examiner will research the issue and either adjust the claim r cmmunicate back t the plan with recmmendatins fr cmpleting the request. A prvider request will either be reslved r a ntificatin f extended time will be prvided t the plan within 45 business days. The Claims Rewrk/Adjustment Request frm shuld be submitted with yur appeal. Yu will receive a recnsideratin letter frm with the decisin if denied. If apprved, a ntificatin will be by vucher. (In this packet is a sample Claims Rewrk/ Adjustment Request frm that will be used fr this prcess.) WHAT IS THE MEMBER APPEALS PROCESS? If yu have a member wh has questins abut their cverage decisin prcess, they shuld be directed t call Custmer Service at ptin #2 r TTY/TDD ### fr thse wh have difficulties with hearing r speaking. If a prvider wants t appeal n behalf f a member, the member needs t dcument that the prvider is appealing n their behalf. The member may als write their appeal and mail t: Appeals and Grievances Department Website:

4 SAMPLE APPEALS LETTER Date Prvider Name Address Address RE: ID #: Date f Service: Pt Acct #: Claim #: T Whm It May Cncern: We have received yur request fr recnsideratin regarding the patient referenced abve. Upn review, the fllwing determinatin has been made: Yur request(s) has been apprved and will be reprcessed fr additinal payment Yur request(s) has been denied Yur request(s) has been denied. The Integrated Hme Care Services () Prvider Manual requires that yu submit a request fr recnsideratin fr denied claim(s) within 30 days frm the date f the riginal denial (as recrded n the remittance vucher). Other: If yur request(s) has been apprved fr additinal payment, please allw tw (2) weeks fr prcessing. Feel free t cntact us if yu have any questins regarding the decisin nted abve. Sincerely, Claims Research and Reslutin , ptin 2

5 CLAIMS REWORK/ADJUSTMENT REQUEST Please submit all claim rewrk requests by cmpleting ne frm per claim. All requests must be submitted with all the applicable dcumentatin listed belw. Please submit the claim rewrk request frm and supprting dcumentatin t: Integrated Hme Care Services Attn: Claims Research and Reslutin, r Fax t: Date: Physician/Facility Name: Tax ID Number: Office Cntact Name: Phne Number: Fax Number: Member Name: Member ID Number: Date f Service: Amunt f Claim: Claims Number: REASON FOR CLAIM REWORK REQUEST Select Claim Issue Type Supprting Dcumentatin Required fr Each Issue Retr authrizatin Authrizatin number: Timely filing Dcumentatin shwing claim filed in a timely manner Claim check denial (NCCI Edit) Dcumentatin shwing (CMS) pays claim Claim nt paid per cntract Cpy f rate page and signature page frm cntract Clinical issue Cpy f medical recrds Length f stay all days nt paid Cpy f medical recrds Miscellaneus cde/additinal descriptin Itemized statement r invice Paid t wrng physician/prvider Crrect prvider name: Incrrect member Crrect member name: Other insurance Crrect plicy name and ID number: C-pay incrrect Crrect c-pay: Claim denied - n pre-authrizatin Circle ne: N auth. needed / Cpy f auth. attached Check lst/vided, need t reissue Check number: Crrected claim r additinal charges/mdifier Attach crrected claim frm Paid as nn-cntracted incrrectly Prvider cntracted number and tax ID: Benefits paid/denied incrrectly Denied duplicate in errr Capitated in errr services shuld be paid fee-fr-service Incmplete payment, check riginal claim frm fr ther prcedures listed Paid number f units incrrectly Other Explanatin: Please prvide a descriptin f the prblem/issue: