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Preface. Summary of Changes. Table of Contents. Service Contacts. June 2015 Replaces: May 2015 S /15

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Preface

Summary of Changes

Table of Contents

Service Contacts

June 2015

Replaces: May 2015

S-5780 06/15

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Preface

The Wellmark Provider Guide and specialty guides are billing resources for providers doing business with Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., and Wellmark Blue Cross and Blue Shield of South Dakota. The guides are referenced in your provider agreement, and include information that applies to all benefit plans in Iowa and South Dakota unless specified within the text.

Explanation of Terminology

Wellmark Throughout the guides, the term Wellmark indicates Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Health Plan of Iowa, Inc., and Wellmark Blue Cross and Blue Shield of South Dakota.

Member Individuals with health coverage through Wellmark are referred to as members.

Provider Guide Updates

Wellmark’s Provider guides are continually updated to bring you the most current information. The following items identify when the guide or section was last changed.

• The date of the most current update can be found next to the linked guide name on Wellmark.com > Provider > Communications and Resources > Provider Guides.

• The most current date is printed on the front cover and inside pages. The date of the version replaced is also printed on the front cover.

A Summary of Changes page lists all the substantial changes made in the most current updates. The page(s) affected and a brief explanation of the change is linked from the Summary of Changes page to the change within the document.

• Changed text and most links appear in blue type.

Printed Copies of Wellmark’s Provider Guides

We invite you to print Wellmark’s Provider Guides from the website. Guide updates are periodically listed in the BlueInk newsletter. You will always find the current version at Wellmark.com (Provider >

Communications and Resources > Provider Guides).

Current Procedural Terminology (CPT) is copyright 2015 by the American Medical Association. All Rights Reserved.

No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.

Blue Cross®, Blue Shield®, the Cross® and Shield® symbols, Blue Access®, Blue Advantage®, BlueCard®, Blue Choice®,

Blue Connections®, Classic Blue®, Blue Select®, and Senior Blue® are registered marks of the Blue Cross and Blue Shield

Association, an Association of Independent Blue Cross and Blue Shield Plans.

Wellmark Blue PPOSM, Wellmark Blue HMOSM, Wellmark Blue POSSM, Blue TraditionsSM, SimplyBlueSM, EnhancedBlueSM,

CompleteBlueSM, PremierBlueSM, and myBlue HSASM are service marks of the Blue Cross and Blue Shield Association.

Wellmark® is a registered mark and Alliance SelectSM is a service mark of Wellmark, Inc.

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_______________

Claims Filing Section

Summary of Changes- April, May, and

June 2015

Summaries below link to the actual changes in the text. The most recent changes appear in blue. Page 5: (June)

Updated the Iowa paper claims mailing address. Page 5: (June)

Added the Federal Employee Program (FEP) paper claims mailing address.

Page 5: (June)

Added instructions for paper claim submissions to avoid delays.

Pages 20-21: (April)

Added information on Medicare-related claims when Wellmark is secondary.

Page 26: (May)

Added urgent care centers as a provider type required to submit services on the 837P/CMS-1500. Currently, urgent care services are billed to Wellmark using one of two claim forms (CMS-1500 and UB-04). Moving forward, Wellmark contracted urgent care centers will use the CMS-1500 form only using the place of service code “20.” Page 59: (June)

Updated the Iowa paper claims mailing address. Page 59: (June)

Added the FEP paper claims mailing address. Pages 69 and 70: (June)

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_______________

Claims Filing

Table of Contents

I. Introduction ... 1

National Provider Identifier (NPI) ... 1

Medically Necessary Services ... 1

Investigational or Experimental Services ... 2

Medical Necessity; Investigational or Experimental Determinations ... 2

Criteria for Obtaining Patient Waivers ... 2

Elements of a Valid Patient Waiver Form ... 3

II. Methods of Claims Filing ... 3

Electronic Format and HIPAA-AS Information ... 3

Submitting Claims Electronically ... 4

Electronic Provider Reports ... 4

Paper ... 5

III. Coding Claims ... 5

ICD-9-CM ... 6

CPT* ... 6

HCPCS ... 6

UB-04 Billing Guide ... 6

Online Coding Courses ... 6

Specialty Specific Provider Guides ... 7

IV. Modifiers in CPT and HCPCS ... 7

Modifier Review ... 7

V. Wellmark’s Payment Policies ... 7

Payment Policy Comment Period and Notification of Change ... 8

“Incident To” Billing ... 9

Telemedicine Services ... 9

Audiovisual Services ... 11

Imaging/Monitoring Services ... 13

VI. BlueCard Program ... 14

BlueCard PPO ... 15

BlueCard HMO ... 16

BlueCard Managed Care/Point of Service (POS) ... 16

ACA Premium Grace Period and BlueCard Members ... 16

Ancillary Claims Filing ... 17

Independent Clinical Lab ... 17

Durable Medical Equipment Supplier/Orthotic & Prosthetic Supplier ... 17

BlueCard Worldwide Program ... 18

BlueCard Questions? ... 18

VII. Timely Filing ... 19

Timely Filing Exceptions ... 19

Claims Denied Because of the Timely Filing Deadline ... 20

VIII. Claims Filing Instructions ... 20

Blue Cross and Blue Shield Claims ... 20

Medicare-Related Claims ... 20

When to File Clinical Documentation with Claims ... 23

Placing the Authorization Number on a Claim ... 23

837 Electronic Claim Form ... 23

CMS-1500 Paper Claim Form ... 24

UB-04 Paper Claim Form ... 24

IX. Providers Required to Submit Services on the 837P/CMS-1500 ... 25

X. Required Information on the 837P/CMS-1500 ... 26

Bill Services Delivered on a Single Date on One Claim ... 27

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_______________

How to Submit Late Charges on a CMS-1500 ... 28

How to Submit Late Credits on a CMS-1500 ... 28

CMS-1500 Claim Form Example ... 29

CMS-1500 Required Field Information ... 30

XI. Providers Required to Submit Services on the 837I/UB-04 ... 36

XII. Required Information on the 837I/UB-04 ... 36

Facility Specific Billing Information ... 37

UB-04 Claim Form Example ... 38

UB-04 Required Field Information ... 39

Interim Billing ... 45

How to Submit Outpatient Services ... 46

Other Outpatient Billing Information... 47

Implants and Revenue Code 278 ... 47

Submitting Corrections for Facility Claims ... 48

Filing Corrected Claims ... 48

Late Charges Only ... 48

Replacement of a Prior Claim ... 49

Void/Cancel of a Prior Claim ... 49

XIII. How to File Accident/Injury-Related Claims ... 50

CMS-1500, UB-04, and Electronic Submission Field Requirements for Accident/Injury Claims ... 50

Filing Vehicle Accident-Related Claims ... 51

Filing Workers' Compensation Claims ... 52

Member Questionnaires ... 52

Provider Response Option ... 52

How to Correct Payment on Services that were also paid by Workers’ Compensation or Auto Insurance ... 52

XIV. Subrogation ... 53

How to Refund a Payment ... 53

XV. Coordination of Benefits ... 53

COB and BlueCard ... 56

COB and Medicare ... 57

Nonduplication of Benefits Provision ... 57

XVI. Double Coverage ... 58

XVII. Claims Denied for Missing Information ... 58

F-Code Reject Messages ... 59

X-Code Reject Messages, Paper Claims Only ... 61

XVIII. Verify Claim Status ... 62

XIX. Claims Inquiries and Appeals ... 63

Step 1: The Claims Inquiry Process ... 63

Claim Corrections Which Must Be Submitted in Writing ... 64

Provider Inquiry Form ... 64

Provider Inquiry Form Replies ... 65

Provider Inquiry Form Examples ... 65

To Access Provider Inquiry Forms... 65

Modifier Adjustments ... 68

How Adjustments Appear on Wellmark's Provider Reports ... 68

Step 2: Provider Appeal Process ... 68

XX. Claims Service Contacts ... 69

Mailing Addresses and Telephone Numbers ... 69

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_______________

Information in this guide applies to networks and products offered or

administered by Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Blue Cross and Blue Shield of South Dakota, and Wellmark Health Plan of Iowa, Inc. As individual benefit plans vary, always verify eligibility and benefits using our secure Web tools on Wellmark.com.

Definition of medical necessity

This section of the Wellmark Provider Guide explains how to file CMS-1500 and UB-04 claims with Wellmark Blue Cross and Blue Shield of Iowa, Wellmark Blue Cross and Blue Shield of South Dakota, and Wellmark Health Plan of Iowa, Inc. It also offers guidelines about filing specific claims (e.g., BlueCard®,

coordination of benefits, Workers' Compensation), and identifies tools available to inquire about claim status or claim adjustments.

National Provider Identifier (NPI)

Wellmark only accepts a provider's 10-digit, unique National Provider Identifier (NPI) number on electronic and paper submitted claims. Claims containing an NPI and any other legacy number are rejected. Providers who have never contracted with Wellmark or been registered to file claims with us must

complete the application process before they can submit claims using their NPI. To apply, visit Wellmark.com (Provider > Credentialing & Contracting), and select Practitioners or Facilities/Entities for your state.

Medically Necessary Services

Participating providers agree to file claims with Wellmark for services provided to members, regardless of other sources of recovery. Wellmark's payment is based on the member's eligibility, benefits, and the medical necessity of the service provided.

Medically necessary services are covered services that a physician or other health care provider, exercising prudent clinical judgment, would provide to a member for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

a) in accordance with generally accepted standards of medical practice; b) clinically appropriate, in terms of type, frequency, extent, site and

duration, and considered effective for the member's illness, injury or disease; and

c) not primarily for the convenience of the member, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that member's illness, injury or disease.

For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of physicians practicing in relevant clinical areas and any other relevant factors.

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_______________ GA modifier indicates

that the patient has signed a waiver

Investigational or Experimental Services

A treatment is considered investigational or experimental when it has

progressed to limited human application, but has not achieved recognition as being proven effective in clinical medicine.

The following criterion are used to determine investigational or experimental status:

• it has final approval from the appropriate governmental regulatory bodies; • the scientific evidence must permit conclusions concerning its effect on

health outcomes;

• it improves the net health outcome;

• it is as beneficial as any established alternatives; and

• the health improvement is attainable outside the investigational settings. Copies of the evaluation criteria for a specific service, supply, device, or drug are available upon request.

Medical Necessity; Investigational or Experimental Determinations

A Wellmark medical director, or designated health care professional, will determine whether health care services are medically necessary, or investigational or experimental. Services determined as not medically necessary, or investigational or experimental, are the liability of the provider.

Criteria for Obtaining Patient Waivers

Providers may seek payment from the member for experimental or

investigational services, and services that do not meet Wellmark's definition of medical necessity if:

the provider explains verbally and in writing to the member, prior to the signing of the waiver, that the specific services in question are

experimental or investigational, or do not or may not meet Wellmark's medical necessity criteria;

• the provider gives a cost estimate to the member for the specific services in question;

the member signs a valid waiver form before the services are performed;

and

• the provider bills such services with the GA modifier.

Modifier Description

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_______________ Components of a

valid waiver form

Elements of a Valid Patient Waiver Form

The patient waiver form must contain the following: • the date

• the place of service

• the description of the service • a cost estimate of the service

• a summary of Wellmark’s medical policy or an attached copy of the policy • a statement that you have met with and explained to the member that the

service provided for that condition may be considered experimental, investigational, or not medically necessary by the member’s health insurance policy or coverage manual and therefore, may not be covered by his or her health insurance contract benefits, and

• verification that the member agrees to be financially responsible for the services

The GA modifier does not affect a claim’s processing in any way. If the service is denied as not medically necessary, the charge will appear on your remittance and on the member’s statement as provider liability. If you’ve met the waiver requirements, you may bill the member for the services.

The provider will not attempt to collect from members any payment reduction resulting from the provider's failure to follow Wellmark's Utilization Management procedures, such as obtaining a required prior approval or precertification. Blanket or generic waivers, intended or attempting to include any and all services which the provider may render to the member, will not be considered valid waivers with respect to nonmedically necessary, experimental, or investigational services.

Please keep waivers with the member's medical record. Do not file the waiver with the claim.

New format for electronic submitters

You can file claims with Wellmark electronically or on paper. Electronic filing is the most effective way to get claims into Wellmark's processing system, track them, and receive payment. We use a third-party clearinghouse, EC Solutions, and its electronic interchange network, INet, to receive electronic claims. While there are a number of ways to transmit electronic claims, EC Solutions is the single entry point.

Electronic Format and HIPAA–AS Information

The current transaction standard for electronic submission is the ANSI 837x5010 format. Providers, vendors, billing services, clearinghouses, Wellmark, and other health insurance payers must use this format for

electronic transactions. For more information, go to Wellmark.com (Provider > Claims and Payment > HIPAA 5010).

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_______________ HIPAA-AS HIPAA-AS Implementation Guide Wellmark Companion Guides .txn Z16 Report

The Health Insurance Portability and Accountability Act—Administrative Simplification (HIPAA–AS) was passed by Congress in 1996 to set standards for the electronic transmissions of health care data and to protect the privacy of individually identifiable health care information. For more information on HIPAA–AS, visit http://www.cms.hhs.gov/HIPAAGenInfo/.

The HIPAA–AS Implementation Guide provides comprehensive information needed to create an ANSI 837 transaction. This guide is available for purchase online at http://www.wpc-edi.com/. A direct link to the 5010 guides follows: http://store.x12.org/store/healthcare-5010-consolidated-guides.

The Wellmark Companion Guides are available for use in conjunction with the HIPAA–AS Implementation Guide. This guide provides specific Wellmark requirements for electronic submission. To view these guides online, visit Wellmark.com (Provider > Claims and Payment > Electronic

Transaction/HIPAA Guides).

Submitting Claims Electronically

CMS-1500 submitters can send electronic claims to INet through the Internet using the Create & Submit a Claim tool on the Provider secure page on Wellmark.com.

To gain first-time access to our online tools, apply by selecting the Register now link on Wellmark.com > Provider. Each organization must designate a main Designated Security Coordinator whom registers for secure access and assigns others within the organization access to our various applications once registration is complete. Non-participating providers must also submit the Access Agreement.

Electronic Provider Reports

The following INet reports are sent to electronic submitters:

Transaction Summary Report - Lists all claims accepted and rejected during

HIPAA validation, including claims rejected for member eligibility reasons.

Claim Error Report - Lists all claims accepted and rejected by Wellmark's

system.

For more information on INet reports, download the Electronic Claims Reports Manual from INet's Account Library titled REPTMAN.PDF. To learn more about how to convert your office from paper to electronic or for any electronic filing questions, contact EC Solutions at 800-407-0267 or by email at

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_______________ Added categories

for electronic submission

Addresses for filing paper claims

Address for FEP paper claims

Filing paper claims

Most claims that once required a paper submission can now be submitted electronically. Eliminate payment delays by adding the following categories to claims filed electronically:

• Non-Medicare COB claims • Medicare COB claims • Modifiers 24, 25, 59 • Vaccines • Subrogation • Medicare Exhaust • Dental Paper

In Iowa, submit paper claims for Wellmark members to: Wellmark Blue Cross and Blue Shield of Iowa Station 1E238

PO Box 9291

Des Moines IA 50306-9291

In South Dakota, submit paper claims for Wellmark members to: Wellmark Blue Cross and Blue Shield of South Dakota 1601 West Madison Street

PO Box 5023

Sioux Falls SD 57117-5023

For Iowa and South Dakota FEP members, submit paper claims to: Wellmark Blue Cross and Blue Shield

Station 3E463 PO Box 9291

Des Moines IA 50306-9291

Please follow these instructions when filing paper claims to avoid delays: • Submit claims on original UB-04 or CMS-1500 claim form. Do not submit

copies.

• Submit all required claim information as indicated in this guide. • Data must be typed and not handwritten.

• Font size should be large enough to read.

• Information submitted should be within the specified box. Note: The printing alignment may have to be adjusted. • Paper claims must be mailed to the address specified above.

All aspects of patient care, including information regarding the need for, results of, and use of information, should be legibly documented in the patient's medical record. The medical record chronologically documents the patient's medical history in sufficient detail and substantiates services as medically necessary. An important element in claims filing is the submission of current and accurate codes to reflect the services provided.

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_______________ To request new or revise existing procedure codes UB-04 Data Specifications Manual

HIPAA-AS mandates the following code sets: 1) The International Classification of Diseases - Ninth Revision - Clinical Modification (ICD-9-CM); 2) the

Physicians' Current Procedural Terminology, Fifth Edition (CPT®)*; 3) the

Healthcare Common Procedure Coding System (HCPCS). The following information identifies the purpose of each code set. Coding books that explain how to submit code sets are updated annually.

ICD-9-CM

To code diagnoses (Volumes 1 & 2) and hospital procedure codes on inpatient claims (Volume 3), use the International Classification of Diseases- 9th

Revision-Clinical Modification (ICD-9-CM) developed by the Commission on Professional and Hospital Activities. ICD-9-CM Volumes 1 & 2 codes appear as three-, four- or five-digit codes, depending on the specific disease or injury being described. Volume 3 hospital inpatient procedure codes appear as two-digit codes and require a third and/or fourth two-digit for coding specificity.

CPT*

The Physicians' Current Procedural Terminology, Fifth Edition (CPT) code set is a systematic listing and coding of procedures and services performed by practitioners. CPT codes are developed by the American Medical Association (AMA). Each procedure code or service is identified with a five-digit code. If you would like to request a new code or suggest deleting or revising an existing code, obtain and complete a form from the AMA's website at http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing -your-practice/coding-billing-insurance/cpt/applying-cpt-codes/request-form -instructions.pageor submit your request and supporting documentation to: CPT Editorial Research and Development

American Medical Association 515 North State Street

Chicago IL 60610

HCPCS

The Healthcare Common Procedure Coding System (HCPCS) Level 2

identifies services and supplies. HCPCS Level 2 begins with letters A–V and is used to bill services such as home medical equipment, ambulance, orthotics and prostheses, drug codes, and injections.

UB-04 Billing Guide

The National Uniform Billing Committee (NUBC) offers a billing guide published by the American Hospital Association called the UB-04 Data Specifications Manual. To order a copy of this guide and updates, visit www.nubc.org/ and select Become a Subscriber.

Online Coding Courses

Wellmark offers free claims coding training courses online. To access these learning tools, visit Wellmark.com (Provider > Communication and Resources > Education).

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_______________

Specialty Specific Provider Guides

Wellmark also provides free specialty specific provider guides. To view these guides online, visit Wellmark.com (Provider > Communication and Resources > Provider Guides).

Modifiers submitted with an appropriate procedure code further define and/or explain a service provided. Valid modifiers and their descriptions can be found in the most current CPT or HCPCS coding book.

When submitting claims, use modifiers to:

• identify distinct or independent services performed on the same day • identify services not related to a global surgery period

• reflect services provided and documented in a patient's medical record Wellmark processes up to four modifiers per claim line on electronically submitted CMS-1500 claims and UB-04 outpatient facility claims. The order of the modifiers on facility outpatient claims may change based on an established priority. Modifiers that affect payment are listed first, with informational

modifiers secondary. Electronic remittance advices show up to four modifiers. Paper remittance advices do not include modifiers.

Inappropriate use of modifiers will cause a claim to deny.

Modifier Review

Wellmark biannually monitors the use of modifiers that "bypass" standard practices and policies: modifiers 24, 25, and 57 used to bypass global surgery and modifier 59 to bypass the Correct Coding Initiative. We focus educational efforts on providers who are at least two standard deviations above their specialty peer group in modifier usage.

Wellmark continually reviews our medical and payment policies to determine how our practices align with national coding and billing guidelines established by the American Medical Association's (AMA) Current Procedural Terminology (CPT),* the Centers for Medicare and Medicaid Services (CMS), and specialty societies. The process of implementing, modifying, or reinforcing our current policies to be more consistent with national standards is called iCAP—Improve the Claims Adjudication Process. Wellmark follows Medicare's National Correct Coding Initiative (NCCI) to process claims. In addition, because we serve a broader population than Medicare, we also have developed iCAP specialty payment policies. With security access, you can locate these policies on Wellmark's Provider Web page under Payment Policies. To gain first-time access to our secure online tools, apply by selecting the Register now link on Wellmark.com > Provider.

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_______________ Wellmark gives a

90-day comment period before changing payment policies Address for payment policy feedback iCAP applies to CMS-1500 and UB-04 outpatient facility claims

Web address for CCI information Web address for Medicare’s Physician Fee Schedule

Note: The institutional version of the NCCI edits was formerly implemented one

calendar quarter behind the physician version. The institutional edits are being implemented concurrently with the physician version. For more information, visit the CMS website at

http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp.

Payment Policy Comment Period and Notification of Change

Wellmark gives a 90-day comment period to providers prior to implementing a payment policy change. Notice of a proposed change is given by:

publishing information in Wellmark's Provider newsletter, BlueInk

• providing a description of the new policy on our secured Provider website • sending a letter to presidents of state and specialty societies affected by

the policy

Wellmark invites providers to share constructive feedback during the comment period. Send feedback by using the link available on our Payment Policies website or send a fax or letter to:

iCAP Policy

Wellmark Blue Cross and Blue Shield PO Box 9232

Des Moines IA 50306-9232

Fax: 515‑376-9041

All comments received during the 90-day period are reviewed. Final policies are posted on our website at Wellmark.com (Providers > Claims and Payments). The iCAP improvement process applies to CMS-1500 claims and UB-04 outpatient facility services claims and adjustments (electronic and paper). iCAP policies also apply to BlueCard Host professional and outpatient facility claims, Federal Employee Program (FEP) professional and outpatient facility claims, and home medical equipment (HME) and ambulance claims.

Claims where Wellmark is the secondary insurer are processed through the iCAP system. BlueCard professional and outpatient facility host claims (claims for members of Blue Plans other than Wellmark) are also subject to iCAP edits. iCAP currently does not apply to the following types of claims:

• Medicare supplement • BlueCard® Home

For information on Medicare's National Correct Coding Initiative, visit http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp. For information on the Medicare Physician Fee Schedule Database, visit www.cms.hhs.gov/PhysicianFeeSched/.

Specific information on how iCAP impacts outpatient services can be found in the “Outpatient Services” Provider Guide on Wellmark.com (Provider > Communications and Resources > Provider Guides).

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_______________ Definition Supervising physician availability Using supervising physician’s NPI Using midlevel practitioner’s NPI

When services do not meet “incident to” rules

Definition of telemedicine services

Telemedicine encounter

“Incident To” Billing

“Incident to” means services that are part of the patient’s normal course of treatment, during which a physician personally performs an initial service and remains actively involved in the course of treatment. The physician does not have to be physically present in the patient’s treatment room while all services are provided, but the physician must provide direct supervision: that is, he or she must be present in the office suite to render assistance, if necessary. Many midlevel practitioners are providing care under a physician’s supervision including those with a provisional license. Claims for those services, as long as the “incident to” rules are met, may be submitted using the physician’s NPI. However, if the midlevel practitioner has enrolled and completed credentialing with Wellmark, those services should not be billed as “incident to.” Midlevel practitioners who have enrolled with Wellmark should submit claims for all services performed using their own NPI.

Midlevel practitioners providing services that do not meet the “incident to” rules should enroll with Wellmark and bill for services under their own NPI.

Office personnel (i.e., RN, LPN) that do not meet the definition of a midlevel practitioner should always bill services under their supervising physician’s NPI number. Coverage for therapy services billed by a physician is dependent on whether the service meets the standards and conditions, other than licensing, applicable to a therapist. Services for physical therapy assistants and

occupational therapy assistants may be billed under the supervision of a licensed therapist or physician.

Telemedicine Services

Telemedicine usually involves physicians using interactive audio/video and/or electronic images to treat patients. Interactive audio/video allows medical specialists to directly communicate with their patients who are in another location, using television monitors and specially adapted equipment. Physicians may send electronic images such as pictures, x-rays, and other patient

information directly to the computer of a specialist. After reviewing that information, the specialist sends the diagnosis back to the local doctor, who treats the patients and provides follow-up care.

Telemedicine Exemption From Face-to-Face Meeting Requirement

The telemedicine encounter must meet the following criteria, which are either required by CMS (Centers for Medicare and Medicaid Services) or

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_______________ Standards of care Requirements for originating site personnel Medical record required

At the distant site:

• A practitioner performs an exam of a patient at a separate, remote originating site location.

• The information available to the distant site physician for the medical problem to be addressed is:

~ equivalent in scope and quality to what would be obtained with an original or follow-up face-to-face encounter

~ meets all applicable standards of care for that medical problem, including:

› documentation of a history › a physical exam

› ordering diagnostic tests › making a diagnosis

› initiating a treatment plan with discussion and informed consent

At the originating site:

• An individual with approved clinical training background (e.g., PA, ARNP, RN, etc.) and trained in the use of the equipment:

~ presents the patient ~ manages cameras

~ performs any physical activities to successfully complete the exam

A medical record, preferably a shared Electronic Medical Record:

• must be kept

• must be accessible at both distant and originating sites

• must be full and complete and meet the standards as a valid medical record

Follow-up care:

• must be equivalent to that available to face-to-face patients

Equipment and technical standards

Physicians providing telemedicine medical care must comply with all

relevant safety laws, regulations, and codes for technology and technical safety.

Organizations shall meet required published technical standards for

safety and efficacy for devices that interact with patients or are integral to the diagnostic capabilities of the practitioner when and where applicable.

Telemedicine technology must be sufficient to provide the same

information to the provider as if the exam had been performed face-to-face.

Telemedicine encounters must comply with HIPAA (Health Insurance

Portability and Accountability Act of 1996) security measures to ensure that all patient communications and records are secure and remain confidential

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_______________ CMS authorization CMS qualified originating sites Eligible Providers Authorized services Technology guidelines

• Audio and video equipment must permit interactive, real-time communications.

• Video screens must be of sufficient size, quality and resolution for the size and layout of the room at the originating site.

• Video cameras must provide high quality resolution and clarity. • Audio equipment must provide clear and audible sound.

• A network connection must have sufficient bandwidth so that no audio or video latency, jittering, or artifacting exists.

• Lighting must be sufficient for the size and layout of the room at the originating site.

• Technology must be HIPAA compliant.

Audiovisual Services

The Centers for Medicare and Medicaid Services (CMS) have authorized specific originating sites as “qualified” for furnishing a telehealth service. When reporting modifier GT, the physician or qualified health care professional is certifying that services are rendered to a patient located in a qualified originating site via an interactive audio visual telecommunications system. Originating sites authorized as qualified by CMS are listed below:

• The office of a physician or practitioner • A hospital (inpatient or outpatient) • A critical access hospital (CAH)

• A hospital-based or critical access hospital-based renal dialysis center (including satellites);

• A skilled nursing facility (SNF)

• A community mental health center (CMHC) Telemedicine services may be provided by:

• A physician

• A nurse practitioner • A physician’s assistant • A nurse midwife

• A clinical nurse specialist • A clinical psychologist • A clinical social worker

• A registered dietitian or nutrition professional • A licensed mental health counselor

Services provided by telemedicine may include the following: • Office or other outpatient visits

• Individual psychotherapy • Pharmacologic management

• Psychiatric diagnostic interview examination • End-stage renal disease related services • Neurobehavioral status exam

• Individual medical nutrition therapy performed by a dietetic professional under the supervision of a primary care provider

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_______________ Modifier GT Do not submit modifier GQ Nonreimbursable codes Payable with GT modifier

The use of modifier GT indicates a telehealth service was performed via interactive audiovisual telecommunications system and the patient was present at a qualified originating site.

Wellmark will reimburse for telehealth services recognized by CMS when reported with modifier GT (Interactive Telecommunications).

Any other service reported with modifier GT that is not recognized by CMS will not be reimbursed.

Wellmark will not reimburse telehealth services submitted with modifier GQ (Asynchronous Telecommunications), because these services do not include direct, in-person patient contact.

Wellmark follows CMS guidelines and does not reimburse for the following services, because they do not involve direct, in-person patient contact:

• telephone charges submitted with CPT codes 98966-98968*, 99441-99443 or 99446-99449.

• CPT codes 98969 and 99444 (Online Medical Evaluation) LIST OF SERVICES PAYABLE WITH A GT MODIFIER

90791-90792* 90832-90838 90951-90952 90954-90955 90957-90958 90960-90961 96116 96150-96151 96152-96154 97802-97804 99201-99215 99231-99233 99307-99310 99406-99407 G0108-G0109 G0270 G0396-G0397 G0420-G0421 G0436-G0437 G0442-G0447

If your facility is an originating site for a patient, i.e., the member's physical location at the time of service, submit a claim to Wellmark using HCPCS code Q3014 (Telehealth originating site facility fee). The provider at the distant site will submit a claim to the local Blue Plan for the service provided.

Example: Your hospital has the equipment to be an originating site. A

Wellmark member or a member of another Blue Plan comes to your hospital for an audiovisual face-to-face appointment with a practitioner in Ohio. Your hospital would bill Wellmark for the originating service, using Q3014. The Ohio practitioner would bill the Ohio Blue Plan for the professional services.

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_______________ Telemedicine services performed by out-of-state providers Telemedicine services performed by in-state providers

INTERACTIVE AUDIOVISUAL SERVICES Site of Origin (Member’s physical location at time of service) Distant Site (Provider location)

Plan Billed Services Billed

Site of Origin

Distant Site

Site of

Origin Distant Site

Wellmark Plan area

Wellmark

Plan area Wellmark Wellmark Q3014

Professional CPT* + GT modifier Wellmark Plan area Other Blue

Plan area Wellmark

Other Blue Plan Q3014 Professional CPT + GT modifier Imaging/Monitoring Services

If your practice or facility uses out-of-state providers for imaging and monitoring telemedicine services, bill Wellmark the global service (i.e., both the

professional and the technical component). Wellmark will reimburse you for the services at your Wellmark contracted rate. As the entity that contracts with the out-of-state provider, it is your responsibility to pay the out-of-state provider for the telemedicine services. Blue Cross and Blue Shield licensing rules state that Wellmark cannot contract with providers based outside our service area, except for durable medical equipment suppliers, clinical laboratories, and specialty pharmacies.

If you contract with other Iowa or South Dakota providers for imaging and monitoring telemedicine services:

1) You may each bill for the service you provided—professional or

technical—as long as each of you participates in Wellmark's networks, or 2) You may bill for both the technical and professional service, depending

on your contractual arrangement with the telemedicine provider, as long as you perform the technical service and the other provider has agreed not to bill Wellmark direct.

IMAGING/MONITORING SERVICES Technical Site (Member’s physical location at time of service) Professional Site (Provider location)

Plan billed Services Billed

Technical Site

Professional Site

Global or Split Bill

(with TC or 26* modifier, as appropriate) Wellmark Plan area Wellmark

Plan area Wellmark Wellmark Either global or split Wellmark Plan

area

Other Blue

Plan area Wellmark Wellmark

Global bill from par physicians; facilities bill an institutional claim for technical component and a professional claim for professional component

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_______________

Note: Wellmark Health Plan of Iowa is able to contract with providers in

contiguous counties. An out-of-state telemedicine provider who contracts with Wellmark Health Plan of Iowa may bill for telemedicine services provided for members covered by the following products:

TRADITIONAL HMO

PRODUCTS WELLMARKBLUEHMO

SM WELLMARKBLUE

POSSM

Blue Access SimplyBlueSM 4750 SimplyBlueSM 5000

Blue Advantage SimplyBlue MaxSM 6250 CompleteBlueSM 1500

Blue Choice CompleteBlueSM 2000A EnhancedBlueSM 1250

hawk-i Blue Access myBlue HSASM Silver 2000

EnhancedBlueSM 500 PremierBlueSM 500A BlueCard logo Claims filing instructions Ancillary services

The BlueCard Program links participating providers and the independent Blue Cross and Blue Shield Plans across the country and around the world through an electronic network for claims processing and payment. The alpha prefix in front of a member's identification (ID) number is what drives the BlueCard Program.

To help you identify members who participate in the BlueCard Program, you will see a suitcase logo on their ID card. This logo indicates that members have health coverage outside of their Blue Cross and Blue Shield Plan's service area.

The BlueCard Program allows you to file all Blue Cross and Blue Shield members' claims with Wellmark for processing.

Note to providers in border counties: Providers in counties along

Iowa’s borders may also be able to contract with the Blue Plan in the adjacent state. If you contract with the Plan under which your patient is covered, please file the claim direct with that Plan.

Providers in counties adjacent to Iowa may contract with Wellmark Health Plan of Iowa (WHPI) for our HMO and POS products only: Blue Access, Blue Advantage, and Blue Choice, as well as the new ACA products whose ID cards show the Wellmark Blue HMOSM or the Wellmark Blue

POS SM networks. If you are a WHPI contracting provider in a county

outside Iowa, please file claims for members covered by these products only with Wellmark. Claims for services to Wellmark members covered by our PPO, indemnity, and senior products must be processed through BlueCard; i.e., filed with the Blue Plan in the state where the services were provided.

BlueCard claims filing guidelines for ancillary service providers such as independent clinical labs, durable medical equipment suppliers, and orthotic & prosthetic suppliers are outlined later in this section.

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_______________ File BlueCard

claims with Wellmark

When ID card has no alpha prefix

BlueCard Program procedures

Out-of-state Blue Plan PPO Coverage

File BlueCard PPO claims before collecting coinsurance

If for some reason a claim cannot be processed through the BlueCard Program, we will electronically forward the claim to the member's Home Plan. If more information is needed to process the claim, the member's Home Plan will contact Wellmark. We will then research and forward the requested information to the Home Plan.

If the member's Home Plan returns a claim to you for more information, please provide the missing details and refile the claim with Wellmark. If the member's Home Plan requests medical records (or other information) to finish processing, but does not return the claim, please send the requested information to

Wellmark. We will forward the information to the Home Plan using the

appropriate address. Note: Please do not send information directly to the Home Plan.

The only time you would not send a claim directly to Wellmark is if the member carries an ID card without an alpha prefix. For ID cards without alpha prefixes, file the claim with the Blue Plan indicated on the back of the ID card.

Here's how the BlueCard Program works:

• File the BlueCard member's claim with Wellmark.

• Wellmark electronically routes the claim to the member's Home Plan. • The member's Home Plan processes the claim and approves payment. • Wellmark pays the participating provider while the member's Plan sends

an Explanation of Benefits form to the member.

• Determine a BlueCard member's managed care requirements (e.g., precertification, emergency admission) at Wellmark.com (Provider > Medical Policies and Authorizations > Medical Policy and Pre-Service Review for Out-of-Area Members). The member or the provider may also call the Home Blue Cross and Blue Shield Plan for this information.

BlueCard PPO

BlueCard PPO allows Blue Cross and Blue Shield members in Iowa or South Dakota who have preferred provider organization (PPO) coverage from another Blue Plan to receive the same benefits and savings they would in their home state. The only thing the member needs to do is receive services from a provider in the Wellmark Blue PPOSM network. The only thing you need to do is

file the claim with Wellmark for processing.

The PPO suitcase on the member's card helps you recognize BlueCard PPO members.

Note to PPO Practitioners: Coinsurance for members with BlueCard PPO

coverage is calculated off the lesser of charge or Wellmark's maximum allowable fee (MAF). File BlueCard PPO members' claims with Wellmark for processing before you collect any amount from the member. Settlement will be sent to your office.

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_______________ BlueCard HMO guest membership BlueCard POS UPS BlueCard HMO

BlueCard HMO allows Blue Cross and Blue Shield members to have guest memberships while temporarily residing outside their Home Plan HMO's service area. If patients enrolled in any of Wellmark Health Plan of Iowa's coverages (Blue Access® and Blue Advantage®, as well as the new ACA products with ID

cards showing the Wellmark Blue HMOSM network) need out-of-state services

for an extended period of time, advise them to call 800-355-2031 to enroll in guest membership.

BlueCard Managed Care/Point of Service (POS)

Patients with Blue Cross and Blue Shield POS coverage who live in Iowa, outside their Home Plan's service area, can participate in the BlueCard Managed Care/POS Program. Members with point-of-service coverage from other Blue Plans should access care from providers in the Wellmark Blue POSSM networkto receive the highest benefit levels. At the time of enrollment,

members must select a primary care physician from this network to coordinate their health care needs.

UPS is currently the only group enrolled in the BlueCard Managed Care/POS Program:

Alpha Prefix Company Name

UPP United Parcel Service

File claims for BlueCard Managed Care/POS members with Wellmark Blue Cross and Blue Shield of Iowa for processing.

ACA Premium Grace Period and BlueCard Members

The Affordable Care Act provides special protections to members who

purchase insurance policies on the exchange or health insurance marketplace. Individuals who don’t pay their monthly insurance premiums will have a 90-day grace period before their coverage is cancelled.

Since Wellmark is not participating on the exchange or health insurance marketplace in 2014 or 2015, Wellmark members will not be impacted in 2014 or 2015. However, you may see a few BlueCard members covered by other Blue Plans for whom this regulation will apply.

If an insured individual misses a premium payment, federal regulations require insurers to pay for services rendered the first 30 days after the payment lapse. Wellmark will identify the Blue Plan member and send a letter to the provider on behalf of the Home Plan, indicating claims for the insured are pending due to a lapse in payment. If, after 90 days, payment still has not been received, Wellmark will deny the pending claims for the last 60 days. Since there is no insurance coverage, the provider may collect the appropriate claim amount directly from the patient.

Providers can confirm claim receipt and status simply and quickly with the Check a Claim tool on the Provider secure page on Wellmark.com.

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_______________ Local Plan defined for

independent clinical labs

Local Plan defined for DME, O&P suppliers

In-network and out-of-network claims

Contact Blue Plans in states where you provide services

Ancillary Claims Filing

BlueCard claims filing guidelines have been clarified for Independent Clinical Labs and Durable Medical Equipment Suppliers (DME). Claims performed by these providers should be submitted to the local plan. The local plan is defined differently depending on the provider type. See explanation and examples below:

Independent Clinical Lab

The local Plan is defined as the Plan in whose service area the specimen was drawn. Independent Clinical Lab claims require that the NPI of the provider who performed the draw be included in Field 17b on the CMS-1500. On the 873 Professional Electronic Submission, enter the NPI in Loop 2310A (claim level).

Example: The patient sees his PCP in Iowa and has a specimen taken. The

specimen is sent to an independent clinical lab in North Carolina for analysis. The claim for the analysis of the specimen should be submitted to Wellmark. The NPI of the physician who performed the specimen draw should appear in Field 17b of the CMS-1500. The claim will be settled according to the

contracting relationship between the submitting provider and Wellmark.

Durable Medical Equipment Supplier/Orthotic & Prosthetic Supplier

The local Plan is defined as the Plan to whose service area the equipment was shipped, or in which it was purchased at a retail store. The address to which the equipment was shipped should appear in Field 5 on the CMS-1500, or in Loop 2010CA on the 837 Professional Electronic Submission.

Example: A patient residing in South Dakota receives medical supplies from a

mail order DME supplier based in Ohio. The DME supplier should submit this claim to Wellmark for processing. The claim will be settled according to the contracting relationship between the Ohio DME supplier and Wellmark. If the lab or DME participates in Wellmark’s networks, the claim will be settled as in-network, and if the lab or DME does not participate, the claim will be settled as out-of-network. In-network claims are settled directly with the provider, while out-of-network claims are settled with the member.

If you currently provide services in other states, we recommend contacting the Blue Plans in those states regarding enrollment and contracting options for processing claims for durable medical equipment, orthotics and prostheses, and independent clinical laboratory services. Your contract with Wellmark does not make you a participating provider with any other Blue Cross and Blue Shield Plan.

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_______________ How to file claims for

BCBS international members

BlueCard Worldwide Program

Through the BlueCard Worldwide Program, you can submit claims for

international Blue Cross Blue Shield (BCBS) Plan members direct to Wellmark for processing. Identification cards for international BCBS members carry the Blue Cross and Blue Shield names and logo, as well as the alpha prefix before the member's identification number.

Follow these steps to file claims for international BCBS members:

Step:

1

With the international BCBS Plan member’s ID card in hand, call the toll-free BlueCard Eligibility number at 800-676-BLUE (2583) to verify eligibility and coverage.

Step:

2

Provide the customer service associate (CSA) with the member’s alpha prefix, and the CSA will route your call to the member’s BCBS Plan to verify eligibility and coverage information.

Step:

3

Once the member receives care, collect the same out-of-pocket expenses (deductible, copayment, coinsurance, noncovered services) as you currently do for domestic BCBS members. Then submit the claim with the member’s alpha prefix and identification number to Wellmark.

BlueCard Questions?

Information Iowa South Dakota

BlueCard Program Web page Wellmark.com (Provider > BlueCard)

Out-of-State Blue Plans

Eligibility

Visit the secure Provider pages on Wellmark.com. Under Provider Tools, select Check Member Information.

or call 800-676-2583 Out-of-State Blue Plans

Claim Status or Payment Information

Visit the secure Provider pages on Wellmark.com. Under Provider Tools, select Check a Claim. or call

800-362-2218 800-774-3892

If you have questions regarding coordination of benefits for BlueCard members, turn to the “Coordination of Benefits” section in this guide.

To gain first-time access to our secure online tools, apply by selecting the Register now link on Wellmark.com > Provider.

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_______________ Wellmark’s timely filing

guideline Coordination of benefits claims BlueCard timely filing requirements Exceptions to the timely filing guideline

Medicaid exception for facilities

Effective January 1, 2015, to be considered for reimbursement, most Wellmark claims must be received within 180 days from the date of service or the discharge date. For dates of service prior to January 1, 2015, the claims must be received within 365 days from the date of service or the discharge date. The 180 day timely filing guideline will also apply to COB claims. When Wellmark is the secondary payer, claims must be filed within 180 days from the issue date of the primary payer's Explanation of Benefits (EOB). If the primary payer does not issue an EOB, we will use the date on the provider's remittance advice. BlueCard claims must meet both the member's Home Plan's and Wellmark's timely filing requirements to be eligible for benefit consideration. For example:

- If a member with out-of-state coverage has a timely filing guideline shorter than Wellmark's 180-day requirement, the claim will be denied as member liability. A Wellmark participating provider may bill the member in this instance.

- If a claim is within the member's timely filing timeline, but exceeds Wellmark's 180-day requirement, the claim will be denied as provider liability. A Wellmark participating provider cannot bill the member in this instance.

Timely Filing Exceptions

The following are exceptions to the 180-day guideline:

• Medicare supplement (e.g., MedicareBlue SupplementSM and Senior

Blue®) claims will process as long as the claim was filed within Medicare's

time frame.

Medicaid exception: Since Medicaid is always the payer of last resort,

Iowa Medicaid will return or disallow claims from facilities if it is

determined that Wellmark is primary. Wellmark will make exceptions to the timely filing deadlines when:

- the facility did not know the patient had Wellmark coverage - the facility filed the claim with Medicaid within 365 days of the

date of service

- the claim was disallowed within 36 months of the date of service

- the facility then files the claim with Wellmark

Claims filed outside Wellmark's timely filing guidelines will automatically be denied. For the claim to be considered, file a Provider Inquiry including the following:

- the reason the claim was not filed with Wellmark initially - the Medicaid disallowance letter

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_______________ Check for Wellmark

coverage first to avoid extra steps

Note: Avoiding these steps is within your control. We recommend that when a

member presents only a Medicaid card, providers check for Wellmark coverage on the secure Provider page of Wellmark.com and file with Wellmark first when appropriate. You may search for coverage using the member's name; the ID card is not required.

Claims Denied Because of the Timely Filing Deadline

If you, as a participating provider, fail to file claims within the 180-day

parameter, you cannot bill members for covered services associated with those claims. Whether or not you can collect payment from a BlueCard member depends on if the claim denies as member or provider liability (see examples above).

We will consider circumstances beyond a provider's control that resulted in delayed submission of claims on a case-by-case basis. Your request to review claims which were denied because of failure to meet the timely filing deadline should include documentation that supports your particular situation, and be submitted on the Provider Inquiry form.

Filing instructions for Blue Cross and Blue Shield claims

Filing instructions for Medicare-related claims

Allow 30 days from MRN date for claims to cross over from Medicare

N89 or MA18 remark codes

Blue Cross and Blue Shield Claims

Submit all Blue Cross and Blue Shield claims to Wellmark for processing. If claims cannot be processed through the BlueCard Program, Wellmark will either physically or electronically forward claims to each member's Home Plan and send you written notification that they have been forwarded. For more information, go to the “BlueCard Program” section in this guide.

Medicare-Related Claims

When you file claims with Medicare involvement, always file the claim with Medicare first. In most cases, Medicare will automatically forward the claim to us for processing. If a Medicare-related claim is not automatically forwarded to us, you may submit primary payment information to us electronically, or by submitting a paper form.

Effective October 13, 2013, providers must wait 30 calendar days from the date of the Medicare Remittance Notice (MRN) before submitting the claim to the local Plan. This includes Medicare primary claims and those with Medicare exhaust services. Medicare primary claims received before the 30 calendar days are up will be rejected. The 30-day time frame is designed to avoid duplicate processing and payment inconsistencies.

For Medicare-related claims :

 Wellmark will look for remittance advice remark codes N89 or MA18 on incoming provider submitted Medicare COB claims. The presence of one of these codes indicates the claim was crossed over to the secondary payer (Wellmark).

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_______________ Date is less than 30

days from receipt date

Date is greater than 30 days from receipt date

No N89 or MA18 remark codes

FEP exception

Filing Medicare COB claims electronically

 When N89 or MA18 is present, Wellmark will review the Medicare Adjudication date. When this date is not 30 days or more in the past, the claim will be rejected for MEDICARE REMIT DTE < 30 DAYS BEFORE RECEIPT DTE.

 When N89 or MA18 is present, and the date is more than 30 days in the past, the claim will continue to process through the Wellmark system and will not reject for MEDICARE REMIT DTE < 30 DAYS BEFORE RECEIPT DTE.

 When N89 or MA18 is not present, Wellmark will process the claim through the Wellmark system and will not reject for MEDICARE REMIT DTE < 30 DAYS BEFORE RECEIPT DTE.

Exempt from this requirement are claims for members with coverage through the Federal Employee Program (FEP). FEP claims may be submitted to the plan within 15 days of the date of service.

To submit Medicare COB claims electronically, follow the steps below:

1. When Medicare Part A (Institutional) is the primary payer and the claim is Inpatient, Medicare provides payment information at the claim level. Medicare payment information is to be created at the claim level when submitting these claims to Wellmark.

2. When Medicare Part A (Institutional) is the primary payer and the claim is Outpatient, Medicare provides payment information at the header and line level. Medicare payment information is to be created at the header and line level when submitting these claims to Wellmark.

3. When Medicare Part B (Professional) is the primary payer, Medicare provides payment information at the header and line level. Medicare payment information is to be created at the header and line level when submitting these claims to Wellmark.

Note: When submitting claims to Wellmark, place Medicare COB claims in a

separate file from other 837 formatted claims. A special Receiver ID (88848MC) is to be used in the ISA08 and GS03 elements. If Medicare COB claims are not submitted using this Receiver ID, the claim will be rejected and not allowed into Wellmark's system. When claims that are not Medicare COB are submitted using the new Receiver ID, the claims will be rejected out of the Wellmark system.

For additional information regarding the Medicare crossover process and examples for Wellmark specific requirements regarding various 837 loops and segments for Medicare COB claims, refer to the 837 COB HIPAA—AS

Wellmark Companion Guides at Wellmark.com (Provider > Claims and Payment > Electronic Transaction/HIPAA Guides).

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_______________ Faxing a

Medicare-related claim

Filing Medicare-related paper claims

MRN required details

Contact information

To fax a claim, please follow these steps:

1) Fax a photocopy of the front and back of the member's current Medicare ID card to Wellmark.

IA Fax: 515-376-9068; SD Fax: 515-376-9097

2) Include the member's Wellmark ID number along with the copy of the member's Medicare ID card.

Please follow these instructions when filing Medicare-related paper claims:

Practitioners (CMS-1500 Submitters)

Submit a completed CMS-1500 and a detailed Medicare Remittance Notice (MRN). All services listed on the CMS-1500 must be on the MRN.1 Facilities (UB-04 Submitters)

Submit a completed UB-04 and a detailed MRN that lists all services identified on the UB-04 claim form.1

• Total charges on the UB-04 must match the Total/Reported charges on the MRN.

• Noncovered charges billed to Wellmark must have Medicare codes (explanation of denials) in order for us to process the claim correctly. Enter noncovered individual charges in form locator 48.

Note: Inpatient claims do not require a detailed MRN.

To avoid denials, the following details MUST be submitted on an itemized MRN along with the original paper claim submission:

 Name of Patient  Date of service

 Total billed charges (not balance due)  Billed Procedure code(s) and modifier(s)

 Medicare approved amounts at header and line level  Medicare adjudication date

 Medicare deductible2 at header and line level

 Medicare coinsurance at header and line level

 Medicare non-covered and/or denied charges at header and line level  Medicare new claim adjustment reason code (CARC)/contractual

obligation amounts and reason codes at header and line level. If multiple CARC codes, each code requires an amount.

 Patient responsibility amounts and reason codes

Medicare Contacts

To obtain a copy of the MRN, providers can call Medicare Provider Service at 866-590-6702 or log in to C-SNAP found on the WPS Medicare Web page.

1We must receive both forms or the claim will be returned. We do not accept Medicare Summary

Reports.

2The Medicare Part B deductible for 2015 can never exceed $147. If an amount higher than the

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_______________ Types of clinical

documentation

When to File Clinical Documentation with Claims

The 22* modifier appended to the surgery code indicates that the work required to provide a service was substantially greater than typically required. When you submit this modifier, always attach to the claim additional documentation (e.g., an operative report) that supports the need for the additional work. After Wellmark reviews the documentation submitted with the claim, increased payment beyond the usual amount for that procedure may be made if our medical staff agrees that it is warranted.

Wellmark may require submission of clinical records before or after payment of claims beyond the situation noted above to investigate potential fraud, abuse, or other inappropriate billing practices, for as long as there is a reasonable basis that such investigation is warranted.

Types of clinical documentation include, but are not limited to: • operative notes

• MD office notes • facility notes • facility/MD notes • lab results

• anesthesia notes and time • radiology interpretation and report

Placing the Authorization Number on a Claim

Providers should include the prior approval authorization number on all claims related to the specific procedure or service requiring prior approval. Providers are also encouraged to include the authorization number for other authorized services.

837 Electronic Claim Form

Please place the authorization number in Loop 2300 of the 837 Electronic Claim Form.

837 Name Loop Segment Min 837

Max Entry

Max Format Requirements Notes

Prior

Authorization or Referral Number

2300 REF02 2 50 ID Not required1

REF01-G1

1This is a "not required" field when submitting the 837, but Wellmark requires it to ensure proper payment.

Institutional claims can have one authorization number and one referral

number at the claim level. If the primary reason for the admission is for a procedure that requires prior approval, submit that authorization number on the claim; otherwise, submit the inpatient notification/precertification number.

Professional claims can have one authorization number at the claim level

(Loop 2300) as well as one authorization number at each line level (Loop 2400), if required. In the REF-Prior Authorization segment, the G1 qualifier is used at the claim and line level for the authorization number; the 9F qualifier is used at the claim and line level for the referral number.

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_______________

CMS-1500 Paper Claim Form

Please place the authorization number in Field 23, Prior Authorization Number, of the CMS-1500.

Note: Field 23 is also used by ambulance service providers to report the ZIP

code only of the pick-up location, as there is no field on the paper form to accommodate the full address. Please separate numbers with a semicolon.

UB-04 Paper Claim Form

Please place the authorization number in Form Locator 63, Treatment

Authorization Codes, of the UB-04. Place the procedure authorization number on line A and the facility authorization number on line B.

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_______________

Providers listed in the chart below and on the next page are expected to submit services electronically on the 837P, or on the CMS-1500 claim form if

submitting on paper.

837P/CMS-1500 Submitters

by Provider Type Notes

Advanced Registered Nurse Practitioner (ARNP)

Certified Registered Nurse Anesthetist (CRNA) Certified Nurse Practitioner (CNP) Certified Nurse Midwife (CNM) Certified Clinical Nurse Specialist (CNS)

Ambulance Hospital-based ambulance

services are billed by the hospital.

Audiologist Chiropractor

Community Mental Health Centers (CMHC)

Dentist May bill for dental services

related to accidental injuries involving the teeth up to one year after the occurrence.

Durable Medical Equipment (DME) Home Medical Equipment Services

& Supplies (HMESS) Freestanding Magnetic Resonance

Imaging Facility

Freestanding Radiology Center

FS CT Scan Center FS Mammography Center FS PET Scan Center FS Portable X-Ray

FS Radiation Oncology Center FS Ultrasound Center

Home Infusion Therapy Hospital-based services

are submitted by the hospital.

Independent Clinical Laboratory Hospital-based services

are submitted by the hospital.

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