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General Payment Guidelines

Claims should be submitted in one of three formats: x Electronic claims submission,

x CMS 1500 Form, or x UB04 Form.

Physicians/Providers are required to use the standard CMS codes for ICD9, CPT, and HCPCS services, regardless of the type of submission.

Claims processing is subject to change based upon newly promulgated guidelines and rules from CMS and AHCA.

Medicare General Payment Guidelines

For payment of Medicare claims, Freedom Health has adopted all guidelines and rules established by CMS. Freedom Health Medicare Members may only be billed for their applicable co-payments, co-insurance, deductibles, and non-covered services.

Mail Medicare claims to: Freedom Health, Inc. C / O Claims Processing P.O. Box 151348 Tampa, FL 33684

Medicaid General Payment Guidelines

In the case of Medicaid claims payment, the Plan reimburses providers for the delivery of authorized services as described in s. 41.3155, F.S., including, but not limited to:

a. The provider must mail or electronically transfer (submit) the claim to the health plan within six (6) months after:

i. The date of service or discharge from an inpatient setting.

ii. The date that the provider was furnished with the correct name and address of the health plan.

b. When the health plan is the secondary payer, the provider must submit the claim to the health plan within ninety (90) calendar days after the final determination of the primary payer.

Medicaid Members should not be billed for any services, at any time. Medicaid Members can only be billed for non-covered services when a signed waiver is obtained from the Member acknowledging payment responsibility prior to services being rendered.

Mail Medicaid claims to: Medicaid Claims

P.O. Box 152729 Tampa, FL 33684

Professional and Technical Component Payments

Freedom Health covers the professional and technical components of global CPT procedures. Therefore, the appropriate professional component modifiers and technical component modifiers should be included on the claim form.

Member Responsibility

The Physician/Provider should collect the following payments from the Member based upon the terms of your contract and the benefit plan design:

x Co-payments x Deductibles x Co-insurance

Charges that can be billed and collected from the Member will be indicated on the Explanation of Benefits (EOB) notice from the Plan. The provider gets an explanation of payment (EOP).

Prohibition of Billing Members

As a participating Physician/Provider you have entered into a contractual agreement to accept payment directly from Freedom Health. Payment from the Plan constitutes payment in full, with the exception of applicable co-payments, deductibles, and/or co-insurance as listed on the EOB/EOP. You may not “balance bill” Members for the difference between actual billed charges and your contracted reimbursement rate. A Member cannot be “balance billed” for covered services denied for “lack of information”. Failure to notify the Plan of a service that requires prior authorization will result in payment denial. In this scenario, Plan Members may not be “balance billed” and are responsible only for their applicable co-payments, deductibles, and/or co-insurance.

A Member cannot be billed for a covered service that is not medically necessary. Unless the Member’s informed written consent is obtained prior to rendering a non-covered service. This consent must include information regarding their financial responsibility for the specific services received.

Timely Submission of Claims

The Plan abides by Florida Prompt Payment Guidelines as stated in Florida Statutes 641.3155, regarding timely submission of claims, or as stated in your contract for Medicaid products. The Plan also follows CMS guidelines for Medicare timely submission of claims.

Timely submission is subject to statutory changes. Therefore, claims should be submitted within the timely filing period established by regulatory statute, unless your contract stipulates something different.

Plan Members cannot be billed for services denied due to a lack of timely filing. Claims appealed for “timely filing” should be submitted with “proof” along with a copy of the EOB and the claim. Acceptable proof of timely filing will be in the form of a registered postal receipt signed by a representative of the Plan, or a similar receipt from other commercial delivery services.

Maximum Out-of-Pocket Expenses (MOOP)

The term Maximum Out-of-Pocket (MOOP) refers to the limit on how much a Medicare Advantage Plan enrollee has to pay out-of-pocket each year for medical services that are covered under Medicare Part A and Part B. Co-payments, co-insurance and deductibles comprise member expenses for purposes of MOOP. MOOP is not applicable to the member’s Medicare Part B Premium.

All of our health plans have a MOOP. If a member reaches a point where they have paid the MOOP during a calendar year (coverage period), the member will not have to pay any out-of- pocket costs for the remainder of the year for covered Medicare Part A and Part B services. If a member reaches this level, the Plan will no longer deduct any applicable member expenses from the provider’s reimbursement.

The MOOP can vary by Plan and may change from year to year. Please refer to the Summary of Benefits available online at our website: www.freedomhealth.com. You may confirm that a member has reached their MOOP by contacting the Member Services Department.

Physician and Provider Reimbursement

Reimbursement for covered services is based on the negotiated rate as established in the

Physician or Provider Agreement. Services that require a referral and/or prior authorization will be denied if services were rendered prior to approval. Please refer to your Physician or Provider Agreement to determine the method that applies to your contract. Capitation payments, based upon the number of assigned Members, will be made by the 20th day of the month.

Completion of “Paper” Claims

Paper claims should be completed in their entirety including but not limited to the following elements:

x The Plan Member’s name and their relationship to the subscriber;

x The subscriber’s name, address, and insurance ID as indicated on the Member’s identification card;

x The subscriber’s employer group name and number (if applicable); x Information on other insurance or coverage;

x The name, signature, place of service, address, billing address, and telephone number of the Physician/Provider performing the service;

x The tax identification number, NPI number, for the Physician or Provider performing the service;

x The appropriate ICD-9 codes at the highest level;

x The standard CMS procedure or service codes with the appropriate modifiers; x The number of service units rendered;

x The billed charges;

x The name of the referring Physician; x The dates-of-service;

x The place-of-service;

x The referral and/or authorization number; x The NDC for drug therapy; and

x Any job-related, auto-related, or other accident-related information, as applicable.

Electronic Claims Submission

Electronic data filing requires billing software through which you can electronically send claims data to a clearinghouse. Since most clearinghouses can exchange data with one another, you can continue to use your existing clearinghouse even when it is not the clearinghouse selected by Freedom Health.

Prior to submitting claims through a clearinghouse exchange, you must check with your existing clearinghouse to make sure they can complete the transaction with the Freedom Health vendor. If you do not have a clearinghouse, or have been unsuccessful in submitting claims to your clearinghouse, please contact your Provider Relations Representative for assistance.

Our trading partner, EMDEON, can help establish electronic claims submissions connectivity with our Plan. You will need our payer number (distinct for each plan), which is 41212 for Freedom Health (Medicare).

Tips on successfully submitting electronic claims:

x Ensure your clearinghouse can remit information to our trading partner, EMDEON. You may

reach EMDEON at 1-800-845-6592.

x Use the billing name and address on the electronic billing format that matches our records.

x Please notify our office of any name and address changes in writing.

x Field NM1 relates to box 33 of a CMS1500 or the UB04 for all electronic claims

x Contact EMDEON with any transmission questions at 1-800-845-6592.

*Currently not available for dual specialty providers, PCP’s with IPA affiliations, Freedom 1st,

anesthesiology or ambulance providers.

Electronic Transactions and Code Sets

To improve the efficiency and effectiveness of the health care system, Congress enacted the Health Insurance Portability and Accountability Act (HIPAA). HIPAA includes a series of administrative simplification provisions including the adoption of national standards for electronic health care transactions.

On October 16, 2003, the Electronic Transaction and Code Set provision of HIPAA went into effect. Law requires payers to have the capability to send and receive all applicable HIPAA-compliant transactions and code sets.

One requirement is that the payer must be able to accept a HIPAA-compliant 837 electronic claim transaction, in standard format, using standard code sets and standard transactions. Specifically, claims submitted electronically must comply with the following Provider-focused transactions: x 270/271 – Health Insurance Eligibility/Benefit Inquiry & Response;

x 276/277 – Health Care Claim Status Request & Response;

x 278 – Health Care Services Review – Request for Review and Response; and x 835 – Health Care Claim Payment/Advice

The X12N-837 claims submission transactions replaces the manual CMS 1500/UB92 forms. All files submitted must be in the ANSI ASC X12N format, version 4010A, as applicable.

Encounter Data

Encounter Data is a record of covered services provided to our Members. An Encounter is an interaction between a patient and Provider (health plan, rendering physician, pharmacy, lab, etc.) who delivers services or is professionally responsible for services delivered to a patient. Freedom Health requires the submission of claims for all encounters in order for the Plan to achieve state and federal reporting requirements.

Providers reimbursed on a capitation basis must file claims for all services. Claims submitted under a capitation contract are referred to as “encounter data”. Encounter data can be submitted on a “paper claim” format or through Electronic Data Interface (EDI) following the same rules as submitting claims. Freedom Health recognizes these services as paid under the capitation

contract and not paid to the Physician or Provider directly. These services become an integral part of the Freedom Health claims history database and are used for analysis and reporting.

Capitated Physicians and Providers who do not submit encounter data could be terminated from the Plan.

Coordination of Benefits (COB) is the procedure used to process health care payments for a patient with one or more insurers providing health care benefit coverage. Prior to claims submission, it is important to identify if any other payer has primary responsibility for payment. If another payer is primary, that payer should be billed prior to billing Freedom Health.

When a balance is due after receipt of payment from the primary payer, a claim should be

submitted to the Freedom Health for payment consideration. The claim should include information verifying the payment amount received from the primary payer as well as a copy of their

explanation of payment statement. Upon receipt of the claim, Freedom Health will review its liability using the COB rules and/or the Medicare/Medicaid “crossover” rules—whichever is applicable.

Correct Coding

Freedom Health has adopted a policy of reviewing claims to ensure “correct coding”. The Plan utilizes a corrective coding re-bundling/unbundling software, which is integrated with our claims payment system IKA Solutions. Services that should be bundled and paid under a single procedure code will be subject to review.

Claims Appeals

Claims appealed for the denial “no authorization” or other medical reasons” should be submitted to the attention of the Appeals and Grievance Department. Please include documentation explaining why an authorization was not obtained, any pertinent medical records, a copy of the claim(s), and a copy of the denial statement received.

Claim appeals for denial of timely filing, incorrect payment, or denied in error, should be submitted to the attention of the Claims Department at the Plan’s claims address. The time frame for

appealing a claim denial is 90 days from the date of the denial on the explanation of

benefits/payment. Cases appealed after the 90-day time limit will be denied for “untimely filing”. There is no “second level” consideration for appeals outside the timely filing requirement. Acceptable proof of timely filing will be in the form of a registered postal receipt signed by a representative of the Plan, or a similar receipt from other commercial delivery services.

The Plan has up to 60 days to review it for medical necessity and conformity to Plan guidelines. The Plan is not responsible for payment of medical records generated as a result of a claims appeal. Cases received for lack of necessary documentation will be denied. The Physician or Provider is responsible for providing the requested documentation within 60 days of the denial in order to re-open the case. Records and documents received after that time frame will not be reviewed and the case will be closed.

In the case of a review in which the Physician or Provider has complied with Plan guidelines and services are determined to be medically necessary, the denial will be overturned. The Physician or Provider will be notified in writing to re-file the claim for payment. If the claim was previously submitted and denied, the Plan will adjust it for payment after the decision is made to overturn the denial.

Reimbursement for Covering Physicians

Covering Physicians for Primary Care Physicians must agree to abide by Utilization Management and Quality Management guidelines. The payment rate is according to the Physician Agreement between the contracted PCP and the Plan – unless other arrangements are in place. In the case of a capitated PCP, the covering Physician will seek payment for services from the contracted Physician. The covering Physician shall not seek payment from the Plan or the Plan Member with the exception of those services for which the assigned PCP would have been permitted to collect, i.e., co-payments, deductibles, and/or co-insurance from the Member.

Fee Schedule Updates

Freedom Health updates fee schedules at the time they are publicly available by Medicare or Medicaid. Most negotiated reimbursement rates are based upon “prevailing” rates of Medicare or Medicaid.

Online Claims Information

Freedom Health encourages Physicians and Providers to check the status of their claims on the Provider Portal of Freedom Health’s website at www.freedomhealth.com. In addition to checking claims status, you can also verify eligibility and benefit information. You will need your log in ID number and password to access this information.

To learn more about using our website, please contact your local Provider Relations representative.

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