Provider Healthcare Portal Demonstration: Claim Denials Professional Claims (CMS-1500) HPE October 2016
Agenda Getting started Searching claims Copying and correcting claims Most common denials; how to avoid Helpful Tools Q&A 2
Getting started
Researching and correcting claims The Provider Healthcare Portal allows providers to: Search for claims in the system Locate paid and denied claims Determine the reason for full claim or line item denials Correct denials and resubmit claims 4
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Menu bar shows provider or delegate s authorized functions 6
Searching claims
hover on Claims and click Search Claims or click Claims and click Search Claims
Search for claims by Claim ID, Member Information, or Service Information If not searching by Claim ID, enter paid date, or service from/to dates When searching by DOS, you can search up to 60- day range 9
A list of claims meeting search criteria is displayed Click + to see service line detail Click Claim ID to retrieve actual claim
Click + to display service line detail. Click - to collapse information
Displaying claim information Claim data can be copied, edited, voided, previewed, and printed Data display can be expanded and collapsed Diagnosis codes Service details Claim EOB information Insurance details Attachment information Notes Adjustment reason codes (ARCs) Adjudication errors 12
Full claim display shows provider, patient, and claim information Expand All to display more information Denied claims have Copy feature Paid claims have Edit, Copy, and Void features
Paid claims can be edited, which is similar to REPLACE on Web interchange Paid claims can be voided. Entire payment is recouped from future claim payments 14
Provider and patient information displayed 15
Claim information displayed 16
All PAY and DENY codes will post for each service line EOB codes are displayed for each service line. 9058 pay dispostion code example 2043 deny dispostion code example 17
Copying and correcting claims
Correcting claims If a denied claim has a correctable error it can be copied and resubmitted Correctable error examples: Transposing numbers on a procedure code Incorrect billed charge amount Misspelling member s name Error code 2043-THE MEMBER IS ENROLLED IN HIP, is not a correctable error. Claim needs to be billed to the correct MCE 19
Choose the information you want to copy 20
Correcting claim errors If a claim denies for error code 2505-RECIPIENT COVERED BY PRIVATE INSURANCE or 2502-RECIPENT COVERED BY MEDICARE, the insurance information can be added Diagnosis codes can be added or removed Service line information can be corrected Attachments can be added and uploaded to submit electronically Claim notes can be added 21
Other insurance information can be added when Medicaid is the secondary payer 22
Coordination of Benefit (COB) information for other insurance 23
Drop-down arrows display Relationship to Patient and Claim Filing Code 24
Invalid or missing data will generate pop-up responses in red 25
Click on claim line # to display service Cline data. Make corrections, as necessary 26
Click + to add service lines 27
Diagnosis codes can be edited, added, or removed 28
Search diagnosis codes by key words or numbers 29
Attachments can be submitted by file transfer (jpeg, tif, pdf); or by mail Total size of attachments is limited to five megabytes 30
Attachments sent by mail require a control # and attachment type code 31
Drop-down arrow displays attachment types 32
Claim notes can be added 33
Drop-down arrow displays Note Reference Code 34
After submitting claim, Claim ID displays 35
Most common denials How to avoid
Most common denials EOB code Description #(000 s) 0593 Medicare denied detail 488 4021 Procedure code vs. program indicator 395 0558 Coinsurance and deductible missing 255 0268 Billed amount missing 226 5001 Exact duplicate 133 2043 HIP or HCC member not eligible for service 110 2502 Recipient covered by Medicare 74 1120 Rendering NPI not reported 71 1003 Billing provider not enrolled at service location for DOS 70 2505 Recipient covered by private insurance 69 37 Claim data is for physician provider type-january to July 2016
Best way to prevent claim denials is to stay informed! Subscribe to automatic email notification of Banner pages and bulletins Use Provider Reference Modules 38
Claims and Billing Procedures modules 39
Helpful Tools
Helpful Tools IHCP website at indianamedicaid.com IHCP Provider Reference Modules Medical Policy Manual Customer Service 1-800-577-1278 Provider Relations Field Consultants indianamedicaid.com > Provider Home page > Contact Us Written Correspondence HPE Provider Written Correspondence P.O. Box 7263 Indianapolis, In 46207-7263 41
Q&A