Billing and Payment Billing and Claims On the Web www.unitedhealthcareonline.com Register for UnitedHealthcare Online SM, our free Web site for network physicians and health care professionals. At UnitedHealthcare Online, you can: Check enrollee eligibility You may also check enrollee eligibility by phone by calling Customer Service. Check claims status Submit claims (HCFA 1500) electronically, for faster claims payment. To register, call 1-866-UHC-FAST (1-866-842-3278) or your local Evercare provider representative. Electronic Claim Submission* In addition to UnitedHealthcare Online, you can also submit electronic claims through Electronic Data Interchange (EDI) using a claims clearinghouse. To facilitate claim submission for Skilled Nursing Facilities, Evercare has partnered with a national clearinghouse to provide a fast, convenient way of submitting claims electronically. This secure, HIPAA compliant process alleviates delays and costs caused by preparing, mailing and manually keeping paper claims, and provides near real time notification of missing or incorrect fields. If your facility currently has Internet access bill Medicare and/or Medicaid electronically, you likely are eligible to participate. If your facility does not have Internet access, it may be possible to individualize the process for your facility. For more information about EDI, contact your claims clearinghouse vendor or United HealthCare at 1-800-842-1109 or ProxyMed at 1-605-362-3090 to obtain or receive assistance in completing the implementation application. For electronic claim submissions please use, or have the clearinghouse use Payer ID 87726 7-1
*There may be costs associated with EDI submission. Please check with the clearinghouse for details. On Paper Use a UB92 for facility or hospital claims Use a HCFA 1500 for physician and ancillary claims Whether you use an electronic or paper form, complete a HCFA 1500 or UB92 form. Please see How to Bill HCFA 1500 and How to Bill a UB92 sections for more details. Mail paper claims to the claims address on the enrollee s ID card at: Claim Payment Evercare P.O. Box 659754 San Antonio, TX 78265-9754 Please do not bill Medicare directly Evercare contracted physicians, other providers, and facilities are paid primarily on a fee-for-service basis. The fees are based on a contractual rate that will vary depending on the type of physician or health care provider and the type of contract signed. Each physician or health care provider/facility is assigned a unique Evercare (billing) provider number. This number must be included on all claims to identify the provider/facility that rendered the service. Only the provider number of the physician or health care provider/facility rendering the service should be used. Claims should not be submitted using another provider/facility s unique provider number. The enrollee s complete 16 digit Evercare ID number must always be legible. Participating physicians and health care providers and facilities must submit claims on the enrollee s behalf and work directly with Evercare for reimbursement. Enrollees should not be asked to submit claims for services rendered. 7-2
Prompt Payment It is Evercare s policy to encourage physician and health care providers to submit claims for covered benefits as soon as possible and no later than the time frames set forth in your participation agreement. Physician and health care providers should submit claims for health services to Evercare using the appropriate claim form: HCFA 1500 Claim Form for outpatient services; UB92 Claim Form for facility services Unless otherwise specified in your contract, Evercare must receive all information necessary to process the claims no more than 90 days from the date of discharge from a facility; or 90 days from the date, the services are rendered to the Evercare enrollee. Any claims received after this time period may be rejected for payment, at Evercare s discretion. Evercare will pay claims for health services provided to an enrollee in accordance to the contractual agreement. Payment to contracted physician and health care providers will be generated within 45* days of receipt of all information necessary to process the claim. Physician and health care providers cannot bill the enrollee for health services provided if the physician or health care provider fails to submit a claim. The enrollee cannot be balance billed for services covered under the contractual agreement at a pre-determined contracted rate. If a claim is filed within the time period allowed under Medicare and the service is Evercare s liability, the claim must be paid by Evercare even if the contract between CMS and Evercare is no longer in effect; or if the enrollee has disenrolled from Evercare, provided that the enrollee was enrolled and effective at the time that the service(s) were rendered and that the service was a covered benefit through Evercare. *Actual prompt payment requirements may vary by state. Common Claim Administration Issues If two identical claims are received for the same service on the same date (for the same enrollee), one will be denied as an exact duplicate. The correct Evercare enrollee ID number should be on the claim. 7-3
For HCFA 1500 claims, only valid procedure codes should be used. Consult the current CPT book and HCPCS Manual when submitting claims for payment. For UB92 claims, only valid revenue codes must be used. Consult with your local provider relations representative for the appropriate codes. The physician or health care provider/facility should provide detailed information if their contract has therapy or IV thresholds. For example: The contract may have a per diem rate that includes therapy. If so, the actual amount of the therapy included in the per diem rate should be indicated on the claim and, if necessary, the amount of therapy provided over what is included in the contracted per diem rate. (Please see sample claims on How to Bill section.) Coding Reference Manuals CPT code books are available at most book stores or they can be ordered by contacting the American Medical Association at (312) 464-5000 or toll free at 1-800-621-8335. ICD-9-CM diagnosis codebook can be found at most bookstores or by contacting the American Hospital Association at (312) 422-3000 or toll free at 1-800-242-2626. HCFA 1500 claim forms may be obtained by contacting the American Medical Association at (312) 464-5000 or toll free at 1-800-621-8335 UB92 claim forms may be obtained by contacting the American Medical Association at (312) 464-5000 or 1-800-621-8335. Claims Submission Information Patient information required for each claim Patient s 16-digit Evercare identification number (unique for each enrollee) Patient s name enter the patient s last name, first name and middle initial, if any as shown on patient s Evercare ID card Patient s address Patient s birth date and sex Patient s authorization (signature on file) Other health insurance coverage, if applicable 7-4
Physician and health care provider/facility information required on each claim Name of physician/provider providing service Name of the clinic or facility Seven-digit Evercare number (unique for each physician and health care provider) Name of the referring physician Federal Tax ID Number Medicare Assignment for HCFA 1500 claims Physician Signature/Date for HCFA 1500 claims Service information required on each claim Itemization of Services Date(s) of service CPT/Revenue codes or HCPCS procedure code ICD-9-CM diagnosis code and description specified to the 4 th and 5 th digit Procedure code modifiers when applicable Charges/Total Charges Days or units Service location for HCFA 1500 claims Standard CMS site codes are required to indicate where services were rendered. Guidelines for submitting claims to Evercare Claims should be submitted for only one enrollee and one physician or health care provider/facility per claim form. For HCFA 1500 claims, multiple visits rendered by a physician or health care provider over several days (such as hospital visits) should be itemized, by date of service. (See section on How to Bill HCFA 1500. ) For UB92 see section on How to Bill UB92 Procedure codes from the Physicians Current Procedural Terminology (CPT) book or the HCPCS Manual, CMS Common Procedural Coding System should be used. Unlisted procedure codes should be submitted only when a specific code to describe the service is not available or when indicated in the contract. Submit these codes with complete description indicated on the HCFA 1500. Modifiers are located at the beginning of each major section of CPT. The modifiers provide a means by which the definition of a particular service can be modified to better describe the circumstances of the service. When appropriate, the two-digit modifier should be used immediately following the five-digit procedure code. (Do not insert a space or a dash.) 7-5
When submitting modifiers, which require further explanation, supporting documentation should be included, such as operative report, progress notes, etc. (i.e., 22 unusual service). Examples of reasons Evercare would return claims Original claim submittals will be returned for any of the following reasons: Enrollee s Evercare ID number is invalid for date of service and/or missing Enrollee s Evercare ID number does not match patient name Bill Type is missing ICD-9 diagnosis code is invalid and/or missing the 4 th and 5 th digit Revenue or CPT code is invalid and/or missing Claim was not submitted on appropriate form (i.e., HCFA 1500 or UB92) Claims Paid and/or Denied in Error Returned claims will include a request that the physician or health care provider resubmit the claim as an original claim. All claims which were processed and paid/denied incorrectly must be submitted with an Adjustment Request Form. Failure to use the Adjustment Request Form may cause a delay in adjusting the claim. See sample and instructions on pages following. Overpayment If you receive an overpayment from Evercare, you can return the original UHG/Evercare check by mailing it to the local Evercare office c/o Operations Manager with the reason for the return. (See How to Reach Us section) To properly credit any returned check or refund check please include a copy of the PRA with your correspondence. If you wish to mail a refund check to Evercare on your own check stock paper, please mail it to: COSMOS Refunds 1111 Arion Parkway #150 San Antonio, TX 78216 Durable Medical Equipment (DME) Billing Prior authorization is required for DME providers that provide wheelchair pressure reducing cushions and/or mattress overlays. If you are a supplier of DME products, please verify the appropriate billing source for your products. As with Medicare, it is your responsibility to identify the skill level of the 7-6
resident before the provision of services. In most cases, the nursing home will reimburse you for services rendered. This knowledge of the level of care provided will assure the appropriate party is billed for the services. In most cases, Evercare does not reimburse vendors separately for DME services and associated supplies, provided to our enrollees in either a Part A or Part B stay. Payment for covered DME and associated supplies are included in the nursing home per-diem rate. Please work with the nursing facilities to identify the appropriate payment source. 7-7