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Provider toolbox

Sylvia Strickland, MBA, Provider Reimbursement Bridgette Ampey, CPC, Code Review Jorri Smith, Network Innovation & Education

Agenda

Today, we’re going to review the tools we offer that can

help us work together as efficiently as possible.

Feel free to ask questions throughout. We’ll also

make time at the end to address questions.

Provider reimbursement

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Provider Helpline: 800.942.4765

• General Email:

[email protected]

• Website:

priorityhealth.com/provider

Viewing prior authorizations

• You must have a web account and auth inquiry as a

tool in your profile.

• If you’re the requesting provider as well as the

servicing (ie. orthopedic surgeon for a knee

arthroscopy), an authorization will be entered into our

system under both the facility where this will take place

and the surgeon performing.

• If you’re a referring provider “only” and the service will

be performed by someone else, you will not be able to

view the authorization on our provider portal. You must

call our provider helpline for a status.

Mid-level provider billing

Surgical assist or facility rounding

• Mid-levels employed by a physician group may contract and bill Priority Health directly for surgical assist or facility rounding. All office-based services need to be billed under the supervising participating physician. Reimbursement and coding

• Most services reimbursed at 85% of the professional fee schedule

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Past filing limit

Correction timelines

Follow-up is required within one year of the date of service, including

resolving all claim discrepancies. Corrected or augmented information received after that date will automatically deny. Negligence by the provider's staff does not justify an exception to the policy.

Medicaid claims must be processed within 45 days of when we receive

them to comply with the Timelines of Claims Payment Public Act 187. We’ll notify you in writing of any problems or defects with your claim within 30 days;

you’ll have 30 days to correct and resubmit the claim.

When another payer makes or recovers payment near or after our filing

limit, you have 90 days from the date on the EOB to submit the claim to us.

Corrected claim submission

Corrected claim submission changes for Oct. 1, 2014 • To comply with contract language regarding claim submission,

effective Oct. 01, 2014, we will no longer accept requests for reprocessing claims by email, reports or Excel files. • If a claim was denied or paid incorrectly as the result of the

way the claim was originally billed (i.e. billing error, improper billing), the provider must submit a corrected or voided claim. Find complete information on how to submit a corrected claim in the Provider Manual at priorityhealth.com.

Denial reasons

• Billing error – Claim resubmitted with a frequency 5 or 7, original claim adjusted

and new claim paid

• Disenrollment retroactive – Coverage terminated, member did not elect COBRA

coverage

• Priority Health is secondary – Claim submitted without primary carrier

explanation of benefits

• Claim reprocessed: Work related injury – Information provided confirming

workers comp coverage

• Claim reprocessed: Auto insurance primary – Information provided confirming

auto coverage

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Coding and clinical edits

Bridgette Ampey, Medical Coding Coordinator

Clinical edits

• Priority Health clinical edits decisions are based on multiple criterion that may include:

• Medicare edits such as Medically Unlikely Edits (MUE) or National Correct Coding Initiative (NCCI edits)

• CMS guidelines • CPT or ICD-9 guidelines

• Standard clinical practices and recommendations from medical societies • Clinical edits are applied to all claims submitted by facilities or

professionals, in and out of network, for all Priority Health medical plans, including Medicaid and Medicare, self-funded and fully funded.

• Providers often assume that if there’s no NCCI edit for the code combination they submitted, then Priority Health should pay both codes. However, the claim may generate a clinical edit from any of the other sources of our clinical edit database.

Changes for Modifier 59

• Modifier 59: Used to describe a circumstance when

services commonly bundled should be considered

separate and distinct

• Different encounters • Different anatomical sites • Different practitioner • Distinct services

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Modifier 59 continued

• New modifiers effective Jan. 1, 2015:

• XE – Separate encounter

• XS – Separate anatomical structure (separate organ/structure) • XP – Separate practitioner

• XU – Unusual non-overlapping service

• CPT guidelines require use of most descriptive modifier

• MLN Matters Number MM8863 outlines changes for these

modifiers

• Additional resource:

http://www.wpsmedicare.com/j8macpartb/resources/modifi

ers/modifier-59.shtml

Modifier 25

• Modifier 25 is used to identify a significant, separately identifiable service

• Documentation must meet all requirements for reporting an E/M service

• In many cases, E/M services are inherent to procedures or services performed on the same date

• Problem oriented E/M services and preventive medicine • When should these be coded together?

• Do these need to be documented separately?

• Do chronic conditions or health problems support separate E/M? • Additional resource:

http://www.wpsmedicare.com/j8macpartb/resources/modifiers/ modifier-25.shtml

Medicare LCD & NCD edits

• Provide benefit, limit and frequency criteria for both

medically necessary and non-covered services

– Commonly driven by CPT/HCPCS, modifiers and/or diagnosis codes

– GA modifier – GY modifier

– Medical documentation must support services rendered and coded

– Priority Health supplemental services – CMS website contains listing of all policies

http://www.cms.gov/medicare-coverage-database/indexes/lcd-state-index.aspx?bc=AgAAAAAAAAAA&

• For more information on NCDs and LCDs, visit

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Edit Checker

• Enter data pre-claim submission for edit scrubbing

or verify edit criteria between code pair(s)

• Edit Checker can mirror how a claims submitted will

process for criteria outlined below:

• Age • Gender

• Unbundling and bundling • Frequency

• Medicare LCD & NCD Criteria • Inappropriate modifier use

• Remember to input all criteria to obtain accurate

data – missing or incorrect data can impact claim

processing

• Gender

• Claim type (Medicare, HMO, Medicaid, etc.)

This information does not guarantee coverage or payment by the patient's plan.

Edit Checker

Coding and clinical edit appeals

• To dispute a coding or clinical edit denial, please

include the following:

– Priority Health Provider Appeal form – Supporting medical documentation – Any supporting coding documentation

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Coding and clinical edit appeals

• Common reasons appeals are upheld:

– No supporting documentation submitted – Insufficient documentation

– Unsigned medical records or medical records not authenticated – Submitting wrong documentation

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