TABLE OF CONTENTS CLAIMS

TABLE OF CONTENTS CLAIMS CLAIMS OVERVIEW... 7-1 SUBMITTING A CLAIM... 7-1 PAPER CLAIMS SUBMISSION... 7-1 ELECTRONIC CLAIMS SUBMISSION... 7-2 TIMEFRAME FOR CLAIM SUBMISSION... 7-3 PROOF OF TIMELY FILING... 7-4 MISDIRECTED CLAIMS... 7-4 CLAIMS RECEIPT AND DETERMINATIONS... 7-5 ACKNOWLEDGEMENT OF CLAIM RECEIPT... 7-5 CLAIM PROCESSING TIME... 7-5 CLEAN CLAIM... 7-5 INTEREST ON CLAIMS... 7-5 BILLING MEMBERS... 7-5 OVERPAYMENT AND RECOUPMENTS... 7-6 AMBULANCE, EMERGENCY, URGENTLY NEEDED, AND POST-STABILIZATION CARE SERVICES... 7-6 SCREENING MAMMOGRAMS... 7-6 INFLUENZA AND PNEUMOCOCCAL VACCINES... 7-7 CPT Codes for Influenza... 7-7 Diagnosis Code Requirements... 7-7 LABORATORY: CLINICAL, CYTOPATHOLOGY, AND PATHOLOGY... 7-8 CLAIMS APPEALS AND DISPUTES... 7-8 CLAIMS APPEALS AND DISPUTES ON MEMBER BEHALF... 7-9 COORDINATION OF BENEFITS (COB)... 7-10 COORDINATING BENEFITS... 7-10 ALLIANCE COMPLETECARE MEMBERS WHO ARE NOT ALLIANCE MEDI-CAL MEMBERS... 7-11 CODE SETS... 7-11 BILLING CODES... 7-12 CODE AUDITING AND EDITING... 7-12

CLAIM FORMS... 7-13 CMS 1500 CLAIM FORM... 7-13 CMS 1500 Claim Form Instructions... 7-14 CMS 1450 CLAIM FORM... 7-19 ADDITIONAL DOCUMENTATION... 7-20

CLAIMS OVERVIEW Alliance CompleteCare has established requirements for filing a claim for payment consideration. These requirements include that the claim is valid and complete, furnished within a prescribed time, and delivered to the correct business address. Failure to comply with these requirements may jeopardize the claim for reimbursement. To be accepted as a valid claim, the submission must meet the following criteria: Must be submitted on a standard current version of a CMS 1500, CMS-1450 (UB04), or the ANSI X12-837-4010A1 (current version electronic format). Must contain appropriate information in all required fields. Must be a claim for an Alliance CompleteCare member eligible at the time of service. (Always verify eligibility via the Alliance CompleteCare web portal or calling Member Services. Some members may have Medi-Cal coverage through a carrier other than Alliance CompleteCare.) Must be an original bill. Must contain correct current national standard coding, including but not limited to CPT, HCPCS, Revenue, and ICD-9 codes. Must not be altered by handwritten additions to procedure codes and/or charges. Must be signed, if paper. Must be printed with dark ink that is heavy enough to be electronically imaged, if submitted as a paper claim. Must be received within the filing period as measured by the date stamp applied by an authorized Alliance CompleteCare representative at the correct business address for paper claims or by the receipt date of a compliant electronic claim file on the Alliance CompleteCare s or its contracted vendor s server. SUBMITTING A CLAIM Paper Claims Submission Paper claims for Alliance Complete Care Members should be submitted for payment as follows: 7-1

Professional Medical Service Claims If the Member/Patient is assigned to an Alliance CompleteCare Primary Care Physician, submit claims to: Alameda Alliance for Health P.O. Box 2460 Alameda, CA 94501-0460 If the Member/Patient is assigned to Community Health Center Network (CHCN) Primary Care Physician, submit claims to: Community Health Center Network 1320 Harbor Bay Parkway #250 Alameda, CA 94502 Institutional (Hospital, SNF, etc.) Claims Alameda Alliance for Health P.O. Box 2460 Alameda, CA 94501-0460 Mental Health Claims PacifiCare Behavioral Health P.O. Box 31053 Laguna Hills, CA 92654-1053 Dental Claims Delta Dental P.O. Box 537010 Sacramento, CA 95853 Vision Care Claims Vision Service Plan P.O. Box 997100 Sacramento, CA 95899-7100 Medi-Cal Claims not Covered by Medicare If the member has Medi-Cal coverage with the Alliance, submit claims to the Alliance address above. If the member has Medi-Cal coverage through another carrier, submit claims directly to the other carrier. Electronic Claims Submission Alliance CompleteCare offers providers the speed, convenience, and lower administrative costs of electronic claims filing, also known as Electronic Data Interchange (EDI). Providers interested in submitting claims electronically should contact Claims Customer Service Department for additional information. 7-2

Claims that require attachments may not be sent electronically. They must be submitted on the appropriate claim forms with the attachments. Timeframe for Claim Submission All claims must be submitted timely for consideration of payment. Claims submitted after the appropriate filing deadline will be denied, unless documentation substantiating the delay in billing is provided. Claims submitted prior to the actual date of service (or date of delivery for supplies and DME) will also be denied. Timely filing rules are as follows: Claims Filing Rules When Alliance CompleteCare is the primary payer on the claim When Alliance CompleteCare is not the primary payer under Coordination of Benefits (COB) When an Alliance CompleteCare member does not present accurate insurance information, and another payer or the member is billed for the service Participating (contracted) providers must submit claims postservice within the timely filing frame identified in your agreement with Alliance CompleteCare. Post-service is defined as after the date of service for professional or outpatient institutional providers, or after the date of discharge for inpatient institutional providers. Non-participating (non-contracted) providers must submit claims within 180 calendar days post-service. Providers must submit a claim to Alliance CompleteCare within 30 days from the date of payment or date of denial notice from the primary payer. Provider must also submit a copy of the Remittance Advice (RA)/ Explanation of Benefits (EOB) from the primary payer, indicating the date of resolution by the primary payer, whether paid, contested, or denied. The provider must submit a claim to Alliance CompleteCare within 30 days of receiving the correct insurance information from the member or incorrect payer. Provider must also submit proof that the member or another payer had been billed. 7-3

Claims Filing Rules Claims previously denied (corrected claims) by Alliance CompleteCare as an incomplete claim The claim must be submitted correctly for reconsideration of payment within 90 days of the date of the original denial by the Alliance. A corrected claim may be mistaken as a duplicate claim submission unless it is clearly identified as such. Paper: In order to properly identify a corrected claim, providers must place the letter C in section 10d of the CMS 1500 form. Changes to diagnosis, referring provider, procedure code, or quantity, require medical records to substantiate charge. EDI: Corrected Claims submissions must include a C in the NOTES segment. Proof of Timely Filing If a claim has been denied for timely filling, the following are acceptable forms of documentation for payment reconsideration: RA/EOB primary carrier Copy of enrollment card presented at time of service Misdirected Claims When a claim is incorrectly sent to Alliance CompleteCare that should have been sent to one of its delegated partners (i.e., Community Health Center Network (CHCN), PacifiCare Behavioral Health (PBH), etc.), Alliance CompleteCare will forward the claim to the appropriate delegated partner within ten working days of receipt of the claim that was incorrectly sent to Alliance CompleteCare. The provider will also receive a notice of denial with instructions to bill the delegated partner. 7-4

CLAIMS RECEIPT AND DETERMINATIONS Acknowledgement of Claim Receipt Alliance CompleteCare will identify and acknowledge the receipt of a claim within two working days of receipt, if the claim was received electronically or within 15 working days if a paper claim was received. Claim Processing Time Alliance CompleteCare will process and pay all clean claims within 30 days of receipt, and will deny all unclean claims within 60 days of receipt. Clean Claim A clean claim is defined as a claim which, when it is originally submitted, contains all necessary information, attachments, and supplemental information or documentation needed to determine payer liability, and make timely payment. Interest on Claims Alliance CompleteCare will calculate and automatically pay interest, in accordance with the Center for Medicare and Medicaid Services (CMS) requirements, to all providers of service who have not been reimbursed for payment, within 30 days after the receipt of their clean claim. Billing Members Do not bill Alliance CompleteCare members for covered services. Alliance CompleteCare members are never responsible to pay participating providers any amount for covered medical services, other than approved co-insurance or co-payment amounts as part of the member s benefit package. Providers may not seek reimbursement from the member for a balance due. Providers may not bill Alliance CompleteCare members for covered services, open bills, or balances in any circumstance, including when Alliance CompleteCare has denied payment. 7-5

Overpayments and Recoupments Overpayments can happen for many reasons, including, but not limited to: Alliance CompleteCare processing error. Another party paid for service (i.e., COB). Duplicate payment made by Alliance CompleteCare service is payable, in part or full, to another provider. Retroactive change to eligibility. An overpayment request will be made by written notification and is sent to the affected provider of service within 365 days of the date the original claim was paid. A provider must either contest or pay the requested monies within 30 working days of receipt of the notification of overpayment or adjustment by Alliance CompleteCare. If the provider does not contest or repay the requested monies within 30 working days, Alliance CompleteCare will offset the requested amount against future claim payments. Ambulance, Emergency, Urgently Needed, and Post-Stabilization Care Services Alliance CompleteCare is financially responsible for ambulance, emergency, urgently needed, and post-stabilization care services, whether services are obtained in or out of network. Alliance CompleteCare will make prompt determination and reasonable payment to, or on behalf of, the members, for these services when the financial responsibility is that of Alliance CompleteCare. Screening Mammograms Alliance CompleteCare members who are women aged 40 and over may directly access (through self-referral to any participating provider) screening mammography services annually. Alliance CompleteCare does not require a referral or authorization for this annual service. 7-6

The correct CPT code for a screening mammogram is 76092. Modifiers 26 and TC may be added to this code (26-professional component, TC-technical component). Diagnosis code V76.12 is to be used for screening mammograms. Influenza and Pneumococcal Vaccines Alliance CompleteCare members may directly access (through self-referral to any participating provider) influenza and pneumococcal vaccine services. Alliance CompleteCare members will not be charged for either the administration or serum for these vaccines. Alliance CompleteCare does not require a referral or authorization for these services. CPT Codes for Influenza 96056: Influenza virus vaccine, split virus, preservative free, for use in individuals three years and above, for intramuscular use. 90657: Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use. 90658: Influenza virus vaccine, split virus, for use in individuals three years of age and above, for intramuscular use. 90660: Influenza virus vaccine, live, for intramuscular use. G0008: Administration of pneumococcal vaccine. Diagnosis Code Requirements When a claim is filed, the appropriate diagnosis code must be reported. If the sole purpose for the visit was to receive the influenza vaccine, or if a vaccine is the only service billed on a claim, diagnosis code V04.81 must be reported. If the sole purpose of the visit was to receive the pneumococcal polysaccharide vaccine (PPV), or if a vaccine is the only service billed on a claim, diagnosis code V03.82 must be reported. If the purpose of the visit was to receive both the influenza vaccine and the pneumococcal polysaccharide vaccine (PPV), providers must report diagnosis code V06.6. 7-7

Laboratory: Clinical, Cytopathology, and Pathology Most outpatient lab services are capitated to Quest Diagnostics. Lab work done at facilities other than Quest Diagnostics requires medical review except as noted in the Utilization Management and Authorization section of this manual. CLAIMS APPEALS AND DISPUTES Alliance CompleteCare has created a dispute resolution process that complies with Title 28, Section 1300.71 of the California Code of Regulations, related to the resolution of a provider dispute. A dispute, under these circumstances, is the appeal of an action taken by the Alliance. If a provider wishes to dispute: 1) a claim payment or denial for reasons not related to a submission error or omission; 2) an authorization request outcome; or 3) the resolution to any other provider complaint/grievance, the provider may use the Alliance CompleteCare s dispute resolution process to appeal the decision. These disputes must be in writing and should be submitted to the appropriate department at one of the addresses listed below. Claims Disputes NOPD Unit - Claims Department Alameda Alliance for Health P.O. Box 2460 Alameda, CA 94501-0460 1-877-747-4506 (fax) Authorization Disputes Grievances and Appeals Unit Alameda Alliance for Health 1240 South Loop Road Alameda, CA 94502 1-877-748-4522 (fax) Other Provider Disputes NOPD Unit - Provider Services Department Alameda Alliance for Health 1240 South Loop Road Alameda, CA 94502 1-877-747-4508 (fax) The process for providers to submit a claims dispute, and the steps that Alliance CompleteCare will take in responding to it are as follows: 7-8

1. The provider must send a Notice of Provider Dispute (NOPD) via facsimile or in writing, along with any relevant and supporting documentation, within 365 days of the Alliance CompleteCare s action or in-action that is the subject of the dispute. 2. The NOPD shall include: a. The provider s name and provider identification number. b. The provider s contact information, including name, address, and telephone number, of the provider s contact person. 3. An explanation of the issue, including any pertinent attachments. a. Documentation, and supplemental information, and b. If the dispute involves a patient, the name of the patient and patient identification number. 4. Alliance CompleteCare will notify the provider of receipt of the NOPD within 15 working days of receipt by Alliance CompleteCare. The provider will be advised of Alliance CompleteCare s contact person and telephone number for follow-up and status inquiries. 5. If Alliance receives an incomplete NOPD from the provider, Alliance CompleteCare will return it and require that the NOPD be completed as indicated above. 6. The provider has 30 working days from the receipt of the returned NOPD to resubmit the completed notice. 7. When a provider resubmits the NOPD, the resubmission date shall be deemed to be the date of original submission. 8. Alliance CompleteCare must resolve the provider dispute after receipt of a complete NOPD within 45 working days. 9. The appropriate department, in consultation with other Alliance CompleteCare staff as necessary, will determine the resolution, and advise the provider of the decision. 10. Alliance CompleteCare s resolution of the dispute, including a statement of the pertinent facts and reasons upon which Alliance CompleteCare is relying, shall be sent to the provider in writing within 45 working days. CLAIMS APPEALS AND DISPUTES ON MEMBER BEHALF If an Alliance CompleteCare provider wishes to file an organization determination, grievance, or appeal on the member s behalf as his/her representative, the provider must follow the Alliance CompleteCare CMS regulated process (refer to Section 8E Organization Determinations, Grievance and Appeals). This section covers the various types of organization determinations (including expedited), grievances, and appeals when filed on the member s behalf. 7-9

COORDINATION OF BENEFITS (COB) Coordination of Benefits (COB) is designed to avoid duplicate payment for covered services by two or more health insurance plans, carriers, or programs. Alliance CompleteCare does not pay for services to the extent that there is a third party that is required to be the primary payer. A third party can refer to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured, self-funded, commercial carrier, automobile insurance, and worker's compensation) or program, that is, or may be, liable to pay all or part of the health care expenses of an eligible Alliance CompleteCare member. Providers must also ascertain from an Alliance CompleteCare member at the time of a visit whether an injury is work-related or caused by a third-party, such as an automobile accident. If an injury is work-related or caused by a third-party, the Provider agrees to relay this information to Alliance CompleteCare as soon as possible using the attached TPL Notification Form, or by indicating in the proper section of the CMS 1500 or CMS 1450 (UB04). Coordinating Benefits When Alliance CompleteCare is aware of another primary payer and an EOB/RA is not submitted with the claim, the claim will be denied advising the provider to submit the claim to the primary payer for appropriate consideration. When Alliance CompleteCare is the secondary payer under COB rules, Alliance CompleteCare will generally pay the lesser of the following amounts for covered services: The actual charge made by the provider, less the amount paid by the other coverage. The amount Alliance CompleteCare would have paid if the individual did not have other coverage. 7-10

Alliance CompleteCare Members who are not Alliance Medi-Cal Members Providers look only to Alliance CompleteCare, and its delegates for compensation for covered services rendered to an eligible Alliance CompleteCare member. However, when an Alliance CompleteCare member is dually enrolled in the State s fee-for-service Medi-Cal or another Medi-Cal managed care plan, providers must coordinate benefits with the Medi-Cal program when Alliance CompleteCare benefits are exhausted. In these situations, Alliance CompleteCare is considered the primary payer unless other insurance (other than Medi-Cal) is involved. When an Alliance CompleteCare member is dually enrolled in the Alliance s Medi-Cal program, a provider can submit all claims to Alliance CompleteCare for coordination and payment of Medi-Cal eligible benefits. CODE SETS Billing Codes Alliance CompleteCare is required to submit to the Center for Medicare and Medicaid Services (CMS), the federal agency responsible for administering Medicare, all necessary data that characterizes the context and purpose of each encounter between a Medicare enrollee and a physician/practitioner, supplier, or other provider. It is very important that providers report, on the claim form, all symptoms and identifiable conditions and co-morbidities that are documented during an encounter with an Alliance CompleteCare member. It is important that providers bill with codes applicable to the date of service on the claim. Billing with obsolete codes will result in a potential denial of the claim and a consequent delay in payment. Submit professional claims with current and valid modifiers, CPT-4, HCPCS Level I and II, ASA codes, and ICD-9 codes. Submit institutional claims with valid Revenue Codes, CPT-4 or 7-11

HCPCS Level I and II codes with modifiers (when applicable), and ICD-9 codes. Only Medicare CMS approved and HIPAA compliant revenue codes, HCPCS (CPT-4, Level II and modifiers), and ICD-9-CM codes are acceptable for reimbursement of services to Alliance CompleteCare members. ACC will not accept local Medi-Cal HCPCS Level III codes and modifiers for Medicare covered services. If you use unlisted or miscellaneous CPT-4 or HCPCS codes, notes and/or a description of services rendered must accompany the claim. Use of unlisted or miscellaneous codes will delay claims payment and should be avoided whenever possible. Claims received with unlisted or miscellaneous codes that have no supporting documentation, may result in claim denial, and the member may not be held liable for payment. Providers will also improve the efficiency of their reimbursement through proper coding and reporting of a member s diagnosis. We require the use and reporting on a claim of valid ICD-9 diagnosis codes, to the ultimate specificity, for all claims. This means that ICD-9 codes must be carried out to the fourth- or fifth-digit when indicated by the coding requirements in the ICD-9 manual (note: not all codes require a fourth- or fifth-digit). Any three-digit code that has subdivisions must be billed with the appropriate subdivision code(s) and be carried out to the fifth-digit if appropriate. Failure to code diagnoses to the appropriate level of specificity will result in denial of the claim and a consequent delay in payment. Code Auditing and Editing Alliance CompleteCare utilizes code-auditing software for automated claims coding verification, and to ensure that the Alliance CompleteCare is processing claims in compliance with general industry standards. The code-auditing software takes into consideration the conventions set forth in the healthcare insurance industry, such as, Center for Medicare and Medicaid Services (CMS) policies, current health insurance and specialty society guidelines, and the American Medical Association s CPT Assistant Newsletter. 7-12

Using a comprehensive set of rules, the code auditing software: Accurately applies coding criteria for the clinical areas of medicine, surgery, laboratory, pathology, radiology, and anesthesiology, as outlined by the American Medical Association s (AMA) CPT-4 manual. Evaluates the CPT-4 and HCPCS codes submitted by detecting, correcting, and documenting coding inaccuracies, including, but not limited to, unbundling, upcoding, fragmentation, duplicate coding, invalid codes, and mutually exclusive procedures. Incorporates historical claims auditing functionality which links multiple claims found in a member s claims history to current claims to ensure consistent review across all dates of service. CLAIM FORMS CMS 1500 Claim Form Alliance CompleteCare requires a CMS 1500 claim form (version 08/05) as the only acceptable document for paper claims submission for the following types of providers: All professional service providers, including physicians, specialists, and mid-level practitioners. Individual practitioners. Non-hospital outpatient clinics. Transportation providers. Ancillary providers. Durable medical equipment. Non-institutional expenses. Professional and/or technical components of hospital-based physicians and Certified Registered Nurse Anesthetists (CRNAs). Home health services. The CMS 1500 must be signed and provide all requested information to receive payment for services rendered. Failure to do so may result in delayed or denied reimbursement. An asterisk next to a field name indicates, required if applicable. Listed below are the field numbers and names, along with explanations of the fields. 7-13

CMS 1500 Paper Form Instructions The following information must be completed or the claim may be returned to you unprocessed or denied for insufficient information. CMS 1500 Field Number CMS 1500 Field Name/Description Completion Instructions 1 Coverage Enter an X in the appropriate box. 1a Insured s I.D. Number Enter the member s AAH identification number. 2 Patient s Name (Last Name, First Name, Middle Initial) Enter the patient's name (last name, first name, and middle initial). 3 Patient s Birth Date/Sex Enter the patient s date of birth in MMDDCCYY format, and place an X in the box indicating the sex of the patient. 4 Insured s Name (Last Name, First Name, Middle Initial) 5 Patient s Address (Street Number, Street), City, State, Zip Code, Telephone Number Enter the member s name (last name, first name, and middle initial). Enter the patient's address (street, apartment/p.o. Box number, city, state, zip code and telephone number with area code). 6 Patient's Relationship to Insured Place an X in the box indicating the patient s relationship to the member. 7 Insured s Address (Street Number, Street), City, State, Zip Code, Telephone Number Enter the member s address (street, Apartment/PO Box number, city, state, zip code and telephone number with area code). 8 Patient's Status Place an X in the box indicating the patient s marital status and an X in the box indicating if the patient is employed or a full/part time student. 9 Other Insured s Name (Last Name, First Name, Middle Initial) Required if Field 11d is marked Yes or if there is other insurance involved with the reimbursement of this claim. Enter the name (last name, first name, middle initial) of the person who is the member under the other payer. 7-14

9a CMS 1500 Field Number CMS 1500 Field Name/Description Other Insured s Policy or Group Number Completion Instructions Required if Field 11d is marked Yes or if there is other insurance involved with the reimbursement of this claim. Enter the other member s policy or group number, or the member s identification number. 9b Other Insured s Date of Birth Required if Field 11d is marked Yes or if there is other insurance involved with the reimbursement of this claim. Enter the date of birth in MMDDCCYY format, and place an X in the box indicating the other member s sex. 9c 9d Other Insured s Employer s Name or School Name Other Insured s Insurance Plan Name or Program Name Required if Field 11d is marked Yes or if there is other insurance involved with the reimbursement of this claim. Enter the other member s employer name. If another payer is involved, and the other member is eligible by virtue of employment or a policy provided through a school they are attending, enter the name of the employer or school. Required if Field 11d is marked Yes or if there is other insurance involved with the reimbursement of this claim. Enter the other member s insurance company or program name. 10a, b, c Is Patient s Condition Related to: a. Employment (Current or Previous)? b. Auto Accident? c. Other Accident? Place and X in the box indicating whether or not the condition for which the patient is being treated is related to current or previous employment, an auto accident, or any other accident. Enter an X in either the Yes or No box for each question. 10d Reserved for Local Use Place the letter C in this Field when submitting corrected claims. Failure to do so will result in incorrect adjudication. Corrected claim filing limits will not be extended by provider s failure to follow these instructions. 11 Insured s Policy Group or FECA Number 7-15

CMS 1500 Field Number CMS 1500 Field Name/Description Completion Instructions 11a Insured s Date of Birth Enter in MMDDCCYY format. 11b Employer Name or School Name Enter the member s employer name. If the member is eligible by virtue of employment or a policy provided through a school they are attending, enter the name of the employer or school. 11c 11d Insurance Plan Name or Program Name Is there Another Health Benefit Plan? Not applicable. Place an X in the box indicating whether or not there may be other insurance involved in the reimbursement of this claim. If yes, Fields 9a-d are required. 12 Patient s or Authorized Person s Signature (Medical/Other Information Release) 13 Insured s or Authorized Person s Signature (Payment Authorization) 14 Date of Current Illness, Injury, or Pregnancy 15 If Patient has had Same or Similar illness, give First Date. 16 Dates Patient Unable to Work in Current Occupation 17 Name of Referring Physician or Other Source The patient must sign and date the claim authorizing the release of medical information. If Signature on File is indicated, the provider must maintain a signed release form or CMS 1500. The patient must sign the claim authorizing the reimbursement of benefits. If Signature on File is indicated, the provider must maintain a signed release form or CMS 1500. Payment will always be issued to a contracted provider. Enter the member s LMP date here, when applicable. Claims that require this information will be denied if the LMP is not entered. Claim filing limits will not be extended by provider s failure to follow these instructions. Not applicable Required if the patient is eligible for disability or workers compensation benefits due to this illness; enter the from and to dates the patient was unable to work in MMDDCCYY format. Enter the name of the referring physician or other source, if applicable. 7-16

CMS 1500 Field Number CMS 1500 Field Name/Description Completion Instructions 17a I.D. Number of Referring Physician Enter the employee identification number of the referring physician indicated in Field 17. 18 Hospitalization Dates Related to Current Services Required if this bill contains charges for services rendered during an inpatient admission from and to dates in MMDDCCYY format. 19 Reserved for Local Use Please leave blank. 20 Outside Lab? / Charges Enter if lab tests were performed and being billed on this claim and were processed by a lab not located within the provider s premises. 21, Item 1 Diagnosis or Nature of Illness or Injury 21, Item 2 4 Diagnosis or Nature of Illness or Injury 22 Medicaid Resubmission Code/ Original Reference Number Enter a valid ICD-9 diagnosis code (including the fourth and fifth digits if applicable) that describes the principal diagnosis for the services rendered. Enter a valid ICD-9 diagnosis code (including the fourth- and fifth-digits if applicable) for any other conditions for the patient that exists for the services rendered. Not applicable. 23 Prior Authorization Number Not applicable. 24a Dates of Service Enter the from and to dates of service in MMDDCCYY format. Claim line items can include two dates of service for the same procedure code. Consecutive dates of service for the same procedure code can also be listed on one line as long as there is no interruption in the dates the services were rendered. 24b Place of Service Enter the appropriate CMS place of service code. Refer to CMS 1500 Reference Material for valid codes. 24c Type of Service Please leave blank. 7-17

CMS 1500 Field Number CMS 1500 Field Name/Description Completion Instructions 24d Procedures, Services, or Supplies Enter a valid VBH-PA procedure code, as identified in the service authorization letter, for the service rendered to the patient. 24d Procedures, Services, or Supplies HIPAA Compliant Codes Enter a valid HIPAA compliant procedure code. If the code is followed by modifiers, be sure that you include ALL modifiers in the order they appear on the provider grid. Your contract amendments should contain the procedure codes/modifiers that you are contracted to perform and bill. 24e Diagnosis Code Enter the number (1, 2, 3, or 4) of the diagnosis code entered in Field 21 for which this service was rendered. Do not enter the actual ICD9 diagnosis code. 24f $ Charges Enter the appropriate charge for services billed on the line item. 24g Days or Units Enter the appropriate number of units or days that correspond to the from and to date indicated in Field 24a. When entering multiple units, the dates in Field 24a must be in consecutive date order. 24h EPSDT Family Plan Leave blank. 24i EMG Please leave blank. 24j COB Enter a Y if another payer has already paid on this service; otherwise leave blank. 24k Reserved for Local Use Enter provider s license number. 25 Federal Tax I.D. Number and Type (SSN) Social Security Number, or (EIN) Employer Identification Number Enter the 9-digit employer identification number (EIN) or social security number (SSN) under which the VBH-PA provider agreement is contracted. This ID is used to ensure accurate reimbursement for services and is also used for reporting earnings to the IRS. Enter an X in the appropriate box that identifies the type of Federal I.D. number used for services rendered. 7-18

CMS 1500 Field Number CMS 1500 Field Name/Description Completion Instructions 26 Patient s Account Number Enter the unique number assigned by the provider for the patient. 27 Accept Assignment? Enter an X in the appropriate box. Will always be Yes. 28 Total Charge Enter the total charge for this claim. This is the total of all the charges for each service noted in Field 24f, lines 1-6. 29 Amount Paid Enter the total amount paid by the patient and/or another payer for services billed on this claim. 30 Balance Due Enter the total balance due for the services less any amount entered in Field 29. 31 Signature of Physician or Supplier Including Degrees or Credentials 32 Name and Address of Facility Where Services were Rendered 33 Physician s or Provider s Billing Name, Address, Zip Code and Phone Number. Enter License Number, Provider ID, and Vendor ID. Signature of physician or supplier including degree(s) or credentials and date of signature. If "signature on file" is indicated, the provider's office must maintain a signed release form from the rendering provider. Enter name and address of facility where services were rendered. (This is required even when billing address entered in box 33 is also a service address.) Enter the applicable name and address exactly as listed on the W-9. Inpatient or residential providersattending physician s (authorized billing psychiatrist), PA Dept of State License #. Include the provider/vendor number here. CMS 1450 Claim Form A CMS 1450 (UB-04) is the only acceptable claim form for submitting inpatient or outpatient hospital (technical services only) charges for reimbursement by Alliance CompleteCare. In addition, a CMS 1450 is required when billing for nursing home services, swing bed services with revenue and occurrence codes, inpatient hospice services, ambulatory surgery centers 7-19

(ASC) and dialysis services. Incomplete or inaccurate information will result in the claim/encounter being rejected or denied for corrections. Additional Documentation For valid supplies and drugs for which Medicare has no allowable amount, providers must submit the appropriate claim form and a copy of the supplier invoice in order to be reimbursed appropriately. When the supplier invoice is not submitted with the claim, the provider will be paid in accordance with the percentage identified in your agreement with Alliance CompleteCare. It is required that claims for sterilization services for Alliance CompleteCare members, including services for tubal sterilization, vasectomy, and hysterectomy, must be accompanied by a signed statement by the member, a minimum of 30 days prior to the date of surgery. Consequently, Alliance CompleteCare will not reimburse professional or facility fees associated with sterilization services, unless an appropriately completed consent form is submitted by the primary surgeon. Claims submitted without this form will be denied for payment. 7-20

PROVIDER DISPUTE RESOLUTION REQUEST INSTRUCTIONS Please complete the below form. Fields with an asterisk ( * ) are required. Be specific when completing the DESCRIPTION OF DISPUTE and EXPECTED OUTCOME. Provide additional information to support the description of the dispute. Do not include a copy of a claim that was previously processed. Multiple LIKE claims are when the claim is for the same provider, same dispute, and different member. For routine follow-up, please use the Claims Follow-Up Form instead of the Provider Dispute Resolution Form. Mail the completed form to: Alameda Alliance for Health, P. O. Box 2460, Alameda, CA 94501-2460 * PROVIDER NPI: * PROVIDER TAX ID: * PROVIDER NAME PROVIDER ADDRESS: PROVIDER TYPE MD Mental Health Professional Mental Health Institutional Hospital ASC SNF DME Rehab Home Health Ambulance Other (please specify type of other ) CLAIM INFORMATION Single Multiple LIKE Claims (complete attached spreadsheet) Number of claims: * Patient Name: Date of Birth: * Health Plan ID Number: Patient Account Number: Original Claim ID Number: (If multiple claims, use attached spreadsheet) Service From/To Date: ( *Required for Claim, Billing, and Reimbursement Of Overpayment Disputes) Original Claim Amount Billed: Original Claim Amount Paid: DISPUTE TYPE Claim Appeal of Medical Necessity / Utilization Management Decision Disputing Request For Reimbursement Of Overpayment Seeking Resolution Of A Billing Determination Contract Dispute Other: * DESCRIPTION OF DISPUTE: EXPECTED OUTCOME: ( ) Contact Name (please print) Title Phone Number ( ) Signature Date Fax Number [ ] CHECK HERE IF ADDITIONAL INFORMATION IS ATTACHED (Please do not staple) For Health Plan/RBO Use Only TRACKING NUMBER PROV ID# CONTRACTED NON-CONTRACTED

PROVIDER DISPUTE RESOLUTION REQUEST Tracking Form (For Optional Use by Health Plan/Delegated Provider) 1 Last * Patient Name First Date of Birth * Health Plan ID Number Original Claim ID Number * Service From/To Date Original Claim Amount Billed Original Claim Amount Paid 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Page of

PROVIDER CLAIM APPEALS & DISPUTES The Alliance has created a dispute resolution process that complies with Title 28, Section 1300.71 of the California Code of Regulations related to the resolution of a provider dispute. A dispute, under these circumstances, is the appeal of an action taken by the Alliance. If a provider wishes to dispute (1) a claim payment or denial for reasons not related to a submission error or omission, (2) an authorization request outcome, or (3) the resolution to any other provider complaint/grievance, the provider may use the Alliance s dispute resolution process to appeal the decision. These disputes must be in writing and should be submitted to the appropriate department at one of the addresses listed below. Claims Disputes NOPD Unit - Claims Department Alameda Alliance for Health P.O. Box 2460 Alameda, CA 94501-0460 (fax) 1-877-747-4506 Other Provider Disputes NOPD Unit - Provider Services Department Alameda Alliance for Health 1240 South Loop Road Alameda, CA 94502 (fax) 1-877-747-4508 Authorization Disputes NOPD Unit Authorization Department Alameda Alliance for Health 1240 South Loop Road Alameda, CA 94502 (fax) 1-877-747-4507 The process for providers to submit a claims dispute, and the steps that the Alliance will take in responding to it are as follows: 1. The provider must send a Notice of Provider Dispute (NOPD) via facsimile or in writing along with any relevant and supporting documentation within 365 days of the Alliance s action or inaction that is the subject of the dispute. 2. The NOPD shall include: a. The provider s name and provider identification number; b. The provider s contact information, including name, address, and telephone number of the provider s contact person; c. An explanation of the issue, including any pertinent attachments, d. documentation, and supplemental information; and, e. If the dispute involves a patient, the name of the patient and patient identification number. 3. Alliance will notify the provider of receipt of the NOPD within fifteen (15) working days of receipt by the Alliance. The provider will be advised of the Alliance s contact person and telephone number for follow-up and status inquiries. 4. If Alliance receives an incomplete NOPD from the provider, Alliance will return it and require that the NOPD be completed as indicated above. 5. The provider has thirty (30) working days from the receipt of the returned NOPD to resubmit the completed notice.

6. When a provider resubmits the NOPD the resubmission date shall be deemed to be the date of original submission. 7. Alliance must resolve the provider dispute after receipt of a complete NOPD within forty-five (45) working days. 8. The appropriate department, in consultation with other Alliance staff as necessary, will determine the resolution and advise the provider of the decision. 9. Alliance s resolution of the dispute, including a statement of the pertinent facts and reasons upon which Alliance is relying, shall be sent to the provider in writing within forty-five (45) working days.