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CHAPTER 5: CLAIMS PROCEDURES We aim to pay you quickly and accurately. Refer to this chapter for information about: • Submitting claims • Checking claim status • Receiving payment reports • Requesting claim review • Avoiding denials • Requesting and applying adjustments • Refunding payment or requesting voids Submitting claims Jump to top You must submit: • A single claim for each patient • Separate claims for each provider who saw a patient • Separate claims for each site where a patient received services Prior to submission, make sure claims: • Meet all prior authorization requirements and include the authorization number, if applicable • Include both your National Provider Identifier (NPI) and tax ID numbers. Per the Health Insurance Portability and Accountability Act (HIPAA) requirements, all claims must contain your NPI number for us to pay you. • Are on a Centers for Medicare and Medicaid Services (CMS)-1500 (professional) or UB04 (facility) claim form for paper claim submissions. For procedures performed in a hospital, submit separate claims for hospital services and a provider’s professional service charge. Please submit complete and accurate claims since missing or invalid data may cause us to delay payment of, deny, or return your claim. You should always: • Check patient eligibility on the date of service. Please see Chapter 2 for details on the ways to verify eligibility, and remember to keep proof of eligibility for your records. • File initial claims electronically. You can check the status of electronic claims online the business day following submission. • Submit claims to Network Health for services we cover. DO NOT send claims to the Commonwealth Health Insurance Connector Authority (Connector), MassHealth, the Department of Unemployment Assistance, or other state agencies for your Network Health patients. Provider Manual 2012 1 CHAPTER 5: CLAIMS PROCEDURES TIMELY FILING Jump to top Submit all claims within 90 days of the date of service. We deny claims we do not receive within 90 days of the date of service. Acceptable forms of proof of timely filing for proof of eligibility include an eligibility verification system (EVS) printout or screenshot. The acceptable form of proof of timely filing for electronic submissions is a 999 transaction report to the direct submitter or clearinghouse that indicates the claim was submitted and accepted by Network Health within timely filing limits. For more information, see our Timely Filing of Claim Submissions and Adjustment Requests Payment Policy. METHODS FOR CLAIM SUBMISSION Jump to top Electronic claims Submit claims electronically to save time and money. We offer your practice five ways to submit electronic claims: • Network Health Connect — Access Network Health Connect, our online self-service tool, to electronically submit individual CMS-1500 and UB04 claims. Through Network Health Connect, you can also check claims status, view claims details, and much more. For more details, please see Chapter 8. • Direct electronic data interchange (EDI) submission — This method is ideal if you submit a large volume of claims to us. You can submit electronic claims files through secure file transfers, as well as through virtual private network (VPN) transmission. Direct claims submission is free and offers you customized reporting and increased control over testing and processing. For more information, please send us an e-mail or call us at 888-257-1985 and ask to speak with an EDI specialist. • New England Healthcare Exchange Network (NEHEN) — NEHEN is a consortium of regional payers and providers that offers a secure and innovative e-commerce solution for claims submission and other health care transactions. Visit NEHEN for information on how to join or call them at 781-290-1300. • NEHENnet — The NEHEN consortium collaborated on a single Web site called NEHENnet which allows smaller practices and providers with less IT support to manage the most popular and essential transactions for a fixed monthly fee. Visit NEHENnet for more information, send an e-mail to ask for an invitation to a weekly Webinar, or call NEHENnet at 781-290-1290. • Clearinghouse submission — We accept professional and institutional EDI claims via the Emdeon and MD On-Line clearinghouses. Make sure you update the clearinghouse with Network Health’s payer ID number: 04332. ❍ ❍ ❍ Provider Manual 2012 Emdeon — For questions about setup and connectivity, please contact Emdeon Business Services Support at 800-845-6592. MD On-Line — For questions about setup and connectivity, please visit MD On-Line, call 888-499-5465, or read about the special offer for Network Health providers. Other clearinghouses — For questions about setup and connectivity to another clearinghouse, or how to appropriately configure your clearinghouse’s software, please e-mail us or call us at 888-257-1985 and ask to speak with an EDI specialist. 2 CHAPTER 5: CLAIMS PROCEDURES To get started or ask questions about submitting electronic claims, e-mail us or call us at 888-257-1985 and ask to speak with an EDI specialist. For quality assurance purposes, you must complete our testing procedures. Your provider relations representative will help coordinate the testing and implementation process with our EDI team. To submit claims electronically, include your: • NPI number — if you need your NPI number, please call us at 888-257-1985 • Tax ID number • Payment address For more details about our electronic capabilities, please see information about Network Health Connect in Chapter 8. Please note: When submitting any claim that requires an attachment, such as an invoice or other documentation (e.g., for coordination of benefit claims) you must submit by paper. Paper claims While there are many benefits to filing electronically, sometimes you must submit paper claims (e.g., claims that require attachments). You can expect to see claims you submit by paper on your Explanation of Payment (EOP) Report within 30 days. Submit all initial paper claims to: Network Health P.O. Box 390310 Cambridge, MA 02139 Mail all claim corrections, timely filing override requests, and electronically denied claims corrections to: Network Health Attn: Provider Appeals Team 101 Station Landing, Fourth Floor Medford, MA 02155 TYPES OF CLAIM SUBMISSION Jump to top Professional services claims You must file all claims for professional services, including laboratory services performed by an independent laboratory, on the CMS-1500 Claim Form. If you file electronically, use the 837 Professional HIPAA file. Include all required data on your claims forms so we do not have to delay payment of, deny, or return a claim. Through Network Health Connect, you can look up procedure and diagnosis codes. Follow these instructions to accurately complete each claim: • Get an NPI number before submitting a claim if you are a non-ancillary provider • Validate all procedure and diagnosis codes submitted for the date of service and bill to the fourthand fifth-digit specification when appropriate Provider Manual 2012 3 CHAPTER 5: CLAIMS PROCEDURES • Bill all procedure codes with a modifier when applicable • Submit all anesthesia claims with the total number of anesthesia minutes of face-to-face attendance time for all services and bill with the appropriate anesthesia code; do not submit surgery procedure codes for anesthesia services • Give us medical records to review for payment accuracy upon request Required fields for submitting professional claims CMS-1500 (paper) Block # Required or Not Required 1 1a* 2** 3 4** 5** 6 7** 8 9 9a 9b 9c 9d 10a-c 11 11a 11b 11c 11d 12 13 14 15 16 17 17a N R R R R R R R R R R N R R R N N R R R R R R N N R R CMS-1500 (paper) Block # 18 19 20 21 22 23 24a 24b 24c 24d 24e 24f 24g 24h 24i 24j 24k 25 26 27 28 29 30 31 32 33 Required or Not Required N N N R R R R R R R R R R R N R N R N R R R R R R R * In Block 1a, enter the member’s unique Network Health identification number that begins with “N”. ** For Network Health Extend™ members, the patient’s name and address may not be the same as the insured’s name and address. For information on required fields for electronic filing, use the “code lookup” feature in Network Health Connect or call us at 888-257-1985. Provider Manual 2012 4 CHAPTER 5: CLAIMS PROCEDURES Hospital and facility claims File all hospital and facility claims, including laboratory services a hospital performs, using the UB04 Claim Form. If you file electronically, use the 837 Institutional HIPAA file. For procedures performed in a hospital, bill the provider’s professional service charges separately on a CMS-1500 Claim Form. Through Network Health Connect, you can also look up procedure and diagnosis codes. Follow these instructions to accurately complete each hospital and facility claim: • Validate all procedure and diagnosis codes submitted for the date of service and bill to the fourthand fifth-digit specification when appropriate • Include the prior authorization number on all inpatient submissions • Submit the attending physician’s name and Massachusetts license number on the claim form • Give us medical records to review upon request for payment accuracy Required fields for submitting hospital and facility claims Provider Manual 2012 UB04 (paper) Block # Required or Not Required UB04 (paper) Block # Required or Not Required 1 2 3a 3b 4 5 6 7 8a 8b 9a 9b 9c 9d 9e 10 11 12 13 14 15 16 17 18 19 R R R R R R R R R N R N N N N R R R R R R R R R R 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 R R R R R R R R R R R R R R R R R N N R R R R R R 5 CHAPTER 5: CLAIMS PROCEDURES UB04 (paper) Block # 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60* 61 62 63 64 65 66 67 Required or Not Required R R R R N R R R R R N R N R R R N N R N R N R UB04 (paper) Block # 68 69 70 71 72 73 74 74a 74b 74c 74d 74e 75 76 77 78 79 80 81a 81b 81c 81d Required or Not Required R R R R R N R N N N N N N R R N N R R R R R * In Block 60, enter the member’s unique Network Health identification number that begins with “N”. For information on required fields for electronic filing, use the “code lookup” feature in Network Health Connect or call us at 888-257-1985. CODING Jump to top HIPAA transactions and codes We are fully compliant with federal government regulations regarding the privacy of protected health information as outlined in HIPAA. We keep any protected health information sent to us strictly confidential and securely store this information once it is on our premises. For more information, you can read about HIPAA and how we protect the privacy of your Network Health patients’ protected health information. Diagnosis coding We accept diagnosis codes published in the International Classification of Diseases, 9th Revision Clinical Modification (ICD-9). Bill all ICD-9 codes to the fourth- and fifth-digit specification when appropriate. Through Network Health Connect, you can quickly look up procedure and diagnosis codes. Provider Manual 2012 6 CHAPTER 5: CLAIMS PROCEDURES Federal and state legislation imposes stringent penalties for failing to keep confidential certain highly sensitive information, such as substance use treatment and AIDS-related information. These laws, however, are not intended to prevent providers from accurately and appropriately submitting claims to health plans. Submit all diagnosis codes for sensitive diagnoses on the claim form accurately. Procedure coding We use the Healthcare Common Procedure Coding System (HCPCS) to identify services you provide to your Network Health patients. HCPCS codes include Current Procedure Terminology (CPT) codes, as well as codes CMS develops. Due to HIPAA requirements, we do not accept any nonstandard codes. We accept standard HCPCS Level I and Level II codes. Submit modifiers with procedure codes when appropriate (see our payment policies for more information on using modifiers). We may request operative or clinical notes for all unlisted procedures and for specific codes or code combinations. Please use unlisted procedure codes only when no other code exists for the services provided. BILLING Jump to top Third-party liability Third-party liability (TPL) describes a situation in which your Network Health patients have additional coverage that pays for their care. According to federal and state regulations, you must bill all available carriers before any managed care organization covering a MassHealth, Commonwealth Care, or Medical Security Program member will reimburse you. In cases where a member has another commercial plan available, after you receive claim processing notification from the primary payer, bill us as the secondary insurer. We are the payer of last resort. When filing a claim for a member with third-party resources: • Attach documentation to the CMS-1500 or UB04 form showing claims processing results from the primary payer • Attach a copy of the TPL carrier’s EOP, denial notice, and benefits-exhausted statement to include both personal injury protection (PIP) and MedPay (auto insurance covering medical and funeral expenses resulting from an accident for the policyholder and any passengers riding with the policyholder) for claim payment. The primary insurance carrier’s EOP must contain the date the claim was processed or the check date. Also, you need to submit a description of any remark codes indicated on the EOP. We will not pay a claim if the reason for a TPL carrier’s denial is because of a claim preparation error or because they did not receive sufficient information to process the claim. • Include a copy of the primary carrier’s EOP and check when: ❍ ❍ Reimbursing us by check, or Submitting a claim retraction request due to payment by a motor vehicle, worker’s compensation, health, or other third-party insurer If we receive your claim later than 60 calendar days from the date of denial or processing date from the third-party carrier, we will deny it. Notify our TPL recoveries team when attorneys or insurance companies request copies of a member’s medical records or bills. Fax a copy of the letter to the TPL team at 781-393-2654. Provider Manual 2012 7 CHAPTER 5: CLAIMS PROCEDURES Balance billing As part of our contracting guidelines, Network Health in-network providers must accept as payment in full monies paid in accordance with applicable fees, rates, and amounts established under your provider agreement and applicable reimbursement regulations. Therefore, providers are prohibited from balance billing members. You should only bill members for services not covered by Network Health. If you are going to provide a service not covered by one of our plans, please inform your patient before the procedure, and let them know you will directly bill them and what you will charge for that particular service. Failure to explain to a patient in advance that the service will cost them money may result in your not getting paid. You also may not bill Network Health patients for missed appointments. Checking claim status Jump to top To check the status of a claim 24 hours a day, seven days a week, use Network Health Connect. You can review the status of an electronic claim the business day following submission. Please have the following information available to expedite checking a claim’s status: • The patient’s name • The patient’s Network Health ID number • The claim number, if applicable • The date of service • The amount billed • The authorization number, if applicable • Your patient account number • Your NPI number and your tax ID number You can also check the status of submitted claims through NEHEN within one business day, if your organization is a member. You can also call us at 888-257-1985, Monday through Friday, from 8 a.m. to 5 p.m., to check claim status. We will only check claim status for up to five members per call. For all paper claim submissions, please allow 30 days for processing. Receiving payment reports Jump to top We send two types of reports related to claims payment depending on your method of claim submission. EXPLANATION OF PAYMENT (EOP) REPORT If you submit paper claims, you will receive an EOP Report with checks for payment and claim denials. This report reflects claims submitted on paper that we paid or denied during the previous period. All denied claims will have denial codes and our reasons for denying the claim. If the explanation is unclear, please contact us at 888-257-1985. Provider Manual 2012 8 CHAPTER 5: CLAIMS PROCEDURES ELECTRONIC DATA INTERCHANGE (EDI) REJECT REPORT If you submit claims via direct EDI submission, we will send you an EDI Reject Report electronically if we do not accept your claim. Claims that appear on our EDI Reject Report will not appear on your EOP Report and are not active for processing in our claims system. You must correct and resubmit these claims on paper for processing within the timely filing limits, or within 60 days from the date of the EDI Reject Report. If you resubmit a claim within 60 days from the date of the EDI Reject Report, but 90 days or more past the date of service, please resubmit on paper with a copy of the Network Health EDI Reject Report. We may deny your claim if you do not follow timely filing limits and these instructions. Requesting claim review Jump to top We offer our providers the opportunity to submit a request for claim review, which includes corrected claim submissions. As indicated on the Request for Claim Review Form, you can resubmit a claim for review for reasons such as: • Coordination of benefits — We denied your claim because we needed information from another insurer before processing and you believe the denial is inappropriate. • Corrected claim — You are submitting a corrected claim because the original claim had missing, inaccurate, or invalid data. Please indicate “corrected claim” at the top of the corrected claim. Please highlight new or updated data elements on the claim. • Duplicate claim — We denied your claim as a duplicate claim submission and you believe the denial is inappropriate. • Filing limit — We denied your claim for untimely filing. For more information, see our Timely Filing of Claim Submissions and Adjustment Requests Payment Policy. • Prior authorization — We denied your claim for failure to obtain prior authorization or referral, or for including services that were different from what we authorized. • Reduced payment or retraction of payment — We underpaid your claim and you would like to request additional payment; or we overpaid your claim and you would like to report the overpayment to us. You believe the underpayment or overpayment may be the result of a Network Health error or other billing error. • Request for additional information — We denied your claim for lack of supporting documentation and you would like to submit the required documentation. For more detail, please see the “Review Type” section of the Request for Claim Review Form. Provider Manual 2012 9 CHAPTER 5: CLAIMS PROCEDURES You can submit a request for claim review in writing or by calling us. We must receive your request for claim review within 60 days of the EOP Report date. If you believe we incorrectly denied a claim or would like a claim review for any reason, please submit a completed Request for Claim Review Form along with your claim and supporting documentation. Send this request to: Network Health Attn: Provider Appeals Team 101 Station Landing, Fourth Floor Medford, MA 02155 Your request for claim review must include the following information: • Date of service • Reason for request • Claim number • Clinical information (if applicable) • Contact name and address for the request for communication purposes A claim you submit for correction must be a complete claim, including all other encounter data for that date of service. The corrected claim must also include: • Clear identification of corrected and/or added information • The words “corrected claim” on the claim You can use the Request for Claim Review Form to ensure we have all the information necessary to begin reviewing your request. Submit a request for claim review, including corrected claim submissions, by mail to the same address: Network Health Attn: Provider Appeals Team 101 Station Landing, Fourth Floor Medford, MA 02155 You can also submit an initial request for claim review by calling us at 888-257-1985. Please refer to Chapter 7 for information on member appeals. Provider Manual 2012 10 CHAPTER 5: CLAIMS PROCEDURES Avoiding denials Jump to top To avoid claim denials, make sure to follow all claim procedures described in this chapter. We may deny payment of a claim if you:    • Do not include your NPI and tax ID number • Request a service that is not a covered benefit • Did not get prior authorization (for services requiring it) • Do not provide enough clinical information to support the requested service • Submit an incomplete claim form • Submit the claim more than 90 days after the date of service Always be sure to verify your Network Health patient’s eligibility on the date of service. We will deny a claim if the member was not eligible on the date of service. As a reminder, we do not determine eligibility. If we deny your claim, you can request a claim review by following the process outlined in the section on “Requesting a claim review” above. Requesting and applying adjustments Jump to top We will review requests made within the appropriate time frames to adjust any overpaid or underpaid claims. We evaluate overpayments and underpayments on a case-by-case basis to determine appropriate action. We will either apply adjustments to future paid claims or request a refund check from you in the case of overpayment. We may initiate adjustment for up to 24 months after the original Network Health EOP date. If we apply adjustments to future payments, the EOP Report will identify the adjustment, member name, member ID number, claim number, provider name, and correct payment amount. If an overpayment causes the adjustment, and the retraction results in a negative balance, we will not send additional payment until we receive additional claims to offset the negative balance. For more information, please see our Payment Adjustments Payment Policy. If you have any questions regarding the receipt of an overpayment or underpayment, please call us at 888-257-1985. Refunding payment or requesting voids Jump to top If you receive a payment you feel is inappropriate, please call us at 888-257-1985 before sending a refund check. Direct all provider refund checks or issues about Network Health checks, including requests for stop payments or voids, to: Network Health Attn: Provider Appeals Team 101 Station Landing, Fourth Floor Medford, MA 02155 Provider Manual 2012 11 CHAPTER 5: CLAIMS PROCEDURES