Research and Resolve UB-04 Claim Denials. HP Provider Relations/October 2014

Transcription

1 Research and Resolve UB-04 Claim Denials HP Provider Relations/October 2014

2 Agenda Claim inquiry on Web interchange By member number and date of service Understand claim status information, disposition, and explanation of benefits (EOB) description Common claim denials Determine corrective action Helpful tools Question and answer 2

3 Objectives Participants will understand: How to research institutional claims on Web interchange How to read the denial Determine the resolution Take corrective action 3

4 Claim Inquiry

5 Claim Inquiry 5

6 Claim Inquiry National Provider Identifier (NPI) will automatically populate For multiple locations choose appropriate service location Member recipient identification number (RID) From and through date of service of specific claim Search by date of service (DOS) Why not search by internal control number (ICN)? ICN will only give information on one specific claim Review all claim submissions and denial reasons Use paid claim (if applicable) for corrections Adjust the paid claim or void and start over 6

7 Claim Inquiry 7

8 Claim Inquiry HIPAA-required fields Do not give specifics on why the line item denied 8

9 Claim Inquiry Claim submission information is displayed Choose the appropriate claim to work with (for example, most recent ICN or paid claim) Click on the ICN Choose Scroll to the bottom of the claim Adjustment reason codes (ARCs) Health Insurance Portability and Accountability Act (HIPAA)-required fields not the reason detail denied Remarks HIPAA-required fields not the reason detail denied Provide Patient liability/waiver liability information 9

10 Claim Inquiry Claim status information Provides detailed information Disposition of each EOB code Look for the D H/D The header or detail level Which detail line Why did the claim/detail line deny? Description explains reason 10

11 Common Claim Denials

12 2017 Recipient ineligible on date of service (due to enrollment in a managed care plan) Resolution: Verify eligibility Understand the eligibility information Submit claim to the appropriate entity 12

13 2017 Recipient ineligible on date of service 13

14 2017 Recipient ineligible on date of service 14

15 2007 QMB recipient bill Medicare first Claim is submitted where the recipient has "QMB only" aid category Resolution: Verify eligibility Qualified Medicare Beneficiary (QMB) only The IHCP pays only for services covered by Medicare Note: QMB-Also members are eligible for all covered IHCP services, in addition to services covered by Medicare 15

16 2007 QMB recipient bill Medicare first 16

17 0558 Coinsurance and deductible amount missing Claim submitted has no coinsurance and deductible amount indicating that this is not a crossover claim Resolution: Verify claim is a crossover claim - Submit claim with appropriate crossover information - Primary EOB is not required if payment has been made If claim is not crossover - Submit as Medicaid primary - Include supporting EOB documentation if applicable 17

18 Medicare and Replacement Plans 18

19 Crossover claim information Payer ID = Replacement plan or Medicare payer ID Payer Name = Wisconsin Physician Services (Traditional Medicare) or replacement plan name in the Payer Name field Medicare Paid Amount = The total amount paid by Medicare for the claim Subscriber Name = Name of policy holder for primary insurance Primary ID = ID number of the primary insurance (Medicare or replacement plan) Relationship Code = 18 (self) Claim Filing Code = 16 (replacement plan) or MA or MB (Traditional Medicare) Click Save Benefits at the bottom of the screen Click Save and Close at the top of the screen Note: Obtain coordination of benefits (COB) information from the HELP tab, Reference Materials on Web interchange 19

20 Include qualifiers field 39 Value Code A1 Medicare deductible amount Value Code A2 Medicare coinsurance/copayment amount Value Code 06 Medicare blood deductible amount Value Code 80 IHCP Covered days 20

21 0520 Invalid Revenue code/procedure code combination Procedure code entered in any of the detail lines is not compatible or linked to the revenue code billed on the same line Resolution: See UB editor for appropriate revenue code and procedure code combination If combination is listed, and no other valid options are available, provider can submit a request for linkage through an to Policyconsideration@fssa.in.gov Form for Policy Consideration and additional information can be found on the IHCP Provider Home Page > Forms > Provider Correspondence Forms > Policy Consideration Form 21

22 4019 Procedure code requires an attachment Claim submitted without the appropriate documentation Resolution: See IHCP Provider Manual Chapter 8, Section 7 Informed Consent attachment and instructions Chapter 8, Section 8 Healthcare Common Procedure Coding System (HCPCS) codes requiring attachments Submit claim with appropriate documentation Documentation must be submitted each time the claim is submitted even if it was previously sent 22

23 0512 Claim past timely filing The days between the last date of service and the ICN date (date of receipt) are greater than the one-year filing limit Resolution: Claim inquiry on Web interchange Search by member number and date of service Print the screen with claim information Reference Julian date (IHCP Provider Manual, Chapter 10, Section 2) if needed for proof Submit proof of timely filing with the claim Review the IHCP Provider Manual, Chapter 10, Section 5 for additional information on acceptable proof of timely filing documentation 23

24 0512 Claim past timely filing The days between the last date of service and the ICN date are greater than the one-year filing limit Use Julian date for proof of filing Proof of timely filing 24

25 4182 Outpatient Column I / II and Mutually Exclusive edit Procedure code pair submitted on a UB-04 outpatient claim form should not be reported together (Column I/Column II) and/or cannot reasonably be performed at the same anatomic site or during the same patient encounter (ME) Resolution: See CMS website at cms.gov See IHCP Provider Manual, Chapter 8, Section 1, for additional code explanation and claim filing guidelines See IHCP Provider Manual, Chapter 10, Section 6, for appeal information - Send claim and all appropriate documentation 25

26 5001 Exact duplicate Claim being processed is an exact duplicate of a previously paid claim Resolution: Use claim inquiry on Web interchange Use member number and specific date of service If there are multiple paid claims, look at each claim and detail information Contact Customer Assistance 26

27 3001 Dates of service not on PA database The code billed requires prior authorization (PA) for that program, and the dates of service indicated on the claim do not fall within the start/stop dates prior authorized for that code Resolution: Confirm PA information through PA inquiry on Web interchange Verify service requires PA - Fee schedule - IHCP Provider Manual, Chapter 6 27

28 3001 Dates of service not on PA database Requesting providers can use member ID to check status. All other providers must have the PA number to see authorization status. 28

29 4021 Procedure code vs. program indicator Procedure code billed is restricted to specific programs for the claim's dates of service The recipient is not eligible for one of the programs indicated Example: The procedure code billed is not covered for Package C members and the claim is for a member that is on Package C Resolution: Verify eligibility Consult fee schedule for program coverage 29

30 4021 Procedure code vs. program indicator The Program Coverage Value descriptors are: 1. Traditional Medicaid and Hoosier Healthwise covered. 2. Traditional Medicaid and Hoosier Healthwise covered, with the exception of Package C. 3. Package C covered only. 4. Not covered. 30

31 Helpful Tools

32 Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual Customer Assistance Locate area consultant map on: indianamedicaid.com (provider home page > Contact Us > Provider Relations Field Consultants) or Web interchange > Help > Contact Us Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN

33 Q&A