SECTION 4. A. Balance Billing Policies. B. Claim Form

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Participating Physicians, hospitals and ancillary providers shall be entitled to payment for covered services that are provided to a DMC Care member. Payment is made at the established and prevailing DMC Care fee schedule.

DMC Care payment is subject to adjustment due to applicable co-payments, deductibles, and by any amount payable by another payor according to the Coordination of Benefit provisions of the applicable group policy or non-insured plans.


Balance Billing Policies

Except for co-payments/coinsurance deductibles and non-covered services, Participating Physicians, hospitals and ancillary providers may not bill or seek payment from a DMC Care member for services which are either 1) not Medically Necessary or 2) not rendered at an appropriate level of care as determined in accordance with the Medical and Quality Management Program described in this Manual. Provider may only charge and collect payment from member when member agrees in writing to pay for such services prior to such service being rendered.


Claim Form

All Participating Physicians and ancillary providers must use a standard CMS-1500 (08-05) (universal) claim form to bill for services provided to DMC Care members. Hospitals must use the UB-04 claim form, supplying information as specified in Appendix A of the DMC Participating Hospital Agreement.

CMS-1500 Form: Effective May 23, 2007, all paper-submitted professional claims must use the CMS-1500 (08-05) form. The CMS-1500 form is revised to accommodate the National Provider Identifier (NPI) reporting. When using the revised form it is important to note:

• Field 24J is for Type 1 NPIs (Rendering Provider)

• Field 32a is for Type 2 NPIs (Service Facility)

• Field 33a is for Type 1 or 2 NPIs (Billing Provider)


When using the revised form it is important to note:

• Field 56 is for the NPI of the Billing Facility/Provider

• Field 75 is for Type 1 NPIs (Attending Provider)

• Field 77 is for Type 1 NPIs (Other Referring Provider)

For information regarding National Provider Identifier (NPI) refer to the National Provider Identifier website.

When billing for Authorized Services, the claim form must be accurately completed, including the authorization number. Claim forms should be mailed to the address indicated on the Subscriber’s ID card.

For questions regarding the status of a claim submitted, payment rendered or eligibility of a particular patient, refer to the instructions and phone numbers on the back of the Subscriber’s I.D. card.

C. Claims Processing

Providers can normally expect to receive payment or notification and reason for non-payment, within 45 days after receipt by the Third-Party Administrator. DMC Care claims for contracted DMC Care providers must be submitted directly to DMC Care. Paper claims must be submitted to:

DMC Care Claims Department P.O. Box 44290

Detroit, MI 48244 1-800-543-0161

PLEASE NOTE: Contracted DMC Care providers (Tier 1) should not submit claims, paper or electronically, to Cofinity. If claims are submitted to Cofinity, payment will be delayed.

For electronic claims submission please review subsection G – “Electronic Data Interchange Strategy” of this document (Section 4).

1. Pended Claims


2. Clinical Reports

Specific claim types require the submission of clinical reports (e.g., emergency service records should accompany a claim for services provided in an emergency room).

3. Coordination of Benefits

The Coordination of Benefits (COB) Provision of the group health plan offering DMC Care applies when the combined benefit for which the member is eligible under all group policies or plans covering the member exceeds the amount payable for covered services under the plan with DMC Care.

The primary payor will be responsible for payment of such benefit amount as is provided in its policy or plan.

The secondary payer may be responsible for payment, depending upon its COB policy:

o Up to the balance of the amount not paid by the primary payor; or o Up to an amount not to exceed what it would have covered if it was

primary, reduced by any amount paid: 1) by the primary payor, and 2) the member.

4. Individual Consideration

On rare occasions, a procedure performed by a provider might not be adequately defined according to CPT-4 coding methodology. Individual consideration will be appropriate in these situations.

Claims involving individual consideration are referred to the DMC Care Medical Director. When a claim is submitted which requires individual consideration, the Medical Director may request the provider to furnish certain medical records, such as operative notes, in order for the Medical Director to appropriately review the claim. Based upon the Medical Director’s review, DMC Care will calculate the appropriate claim payment and forward the claim to the Third–Party Administrator. Because of this review, normal claim processing time is delayed. 5. Incomplete Claim Forms


6. Late Claims

Claims should be submitted within 30 days of the date services were provided. If claims are not submitted in a timely manner, additional research may be necessary before the claim can be processed.

Claims not submitted within one year from the date of service will be denied and the member shall be held harmless.

7. “Members not on file”

DMC Care will no longer be returning hard copy claims for “members not on file.” Instead, these claims will be entered into the claim system as a “Member Not on File,” and therefore a denial code of member not on file will be included on the EOP.

This change will allow for easier claim inquiry and reprocessing. As always, for member eligibility and verification, please call 1-800-543-0161.

8. Anesthesia Claims

In order to standardize the payment of Anesthesia Claims, DMC Care will require Providers to bill anesthesia claims with the ASA procedure codes 00100-01999 along with the industry standard modifiers.

D. Code Auditing Software

DMC Care Health Plan has implemented code auditing software. This code auditing system is a user driven, feature rich software product that permits a health claims administration system to mine a claims database for duplicate payments, claims that were paid on behalf of members that were retroactively terminated as well as conformance to the National Correct Coding Initiative edits, better known as NCCI as well as CMS Guidelines. The system has the ability to identify overpayments in the areas of Global Surgical Days, Secondary Surgical Procedures, add-on codes in addition to a dozen other industry standard edits. Auditing software is an expert system that assists the claims processor in evaluating the accuracy of submitted CPT/HCPCS codes. The code auditing system uses a clinical knowledge base that results in one of three types of medically based recommendations to the claims processor:

To accept the code(s) as submitted


Manual, HCFA’s HCPCS Level II Codes Manual, CMS guidelines, as well as the opinions of prominent physicians within the specialty

To seek additional information from the physicians’ office because there is inconsistent information in the claim.

The types of services that will be evaluated by code auditing software are as follows:

Policies based on the CPT Manual

Policies based on health care coding standards Bundling/Unbundling of procedures

Global Periods

Multiple procedures performed the same day Appropriateness of assistance of surgery The proper use of modifiers

This code auditing software assists the claims processor in evaluating the accuracy of the coding of the procedure(s), not the medical necessity of the procedure(s). When a change is made to your submitted code(s) the coding software will provide a medical explanation of the reason for the change.

In a few instances where a change is made, it is usually because the CPT-4 Manual or the HCPCS Level II Manual indicates that one of the submitted codes should not be used separately when submitted with another code on the claim. This does not mean that the procedure/service was unnecessary; it means that according to generally accepted coding practice, the procedure/service is not coded separately under this circumstance.

Any appeals regarding coding audits should be forwarded within 180 days of receipt of denial to:


Code Audit Appeals P.O. Box 44290 Detroit, MI 48244

Note: Appeals require medical documentation attached to the code audit denials claim form.


Billing Codes, Modifiers and Policies

1. General Instructions


Occasionally, there may be multiple CPT-4 codes which could be used to bill for a service. In these cases, please read each definition carefully and bill the appropriate CPT-4 code.

2. Definitions

Unlisted Procedure or Service – New or unusual procedures may be reported by using the “Unlisted Procedure” code included in each applicable section of the CPT-4 Manual.

3. Modifiers

A CPT modifier is a two-digit code reported in addition to the CPT service or procedure code (Item 24d on the CMS-1500 form) which indicates that the service or procedure was modified in some way. Understanding how and when to use CPT modifiers is vital for proper reporting of medical services and procedures.

The lack of modifiers or the improper use of modifiers can result in claims delays or claims denials. The following is a list of modifiers that can be used. For a detailed explanation, please refer to your CPT manual.

21 Prolonged Evaluation and Management Services 22 Unusual Procedural Services

23 Unusual Anesthesia

24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period


Significant Separately Identifiable Evaluation and Management Service by the Same Physician or the Same Day of the Procedure or Other Service.


54 Surgical Care Only

55 Postoperative Management Only 56 Preoperative Management Only 57 Decision for Surgery

58 Staged or Related Procedure or Service by Same Physician During the Postoperative Period 59 Distinct Procedural Service

62 Two Surgeons 66 Surgical Team

76 Repeat Procedure by Same Physician 77 Repeat Procedure by Another Physician

78 Return to the Operating Room for a Related Procedure During the Postoperative Period


Unrelated Procedure or Service by the Same Physician During the Postoperative Period

80 Assistant Surgeon

81 Minimum Assistant Surgeon

82 Assistant Surgeon (when qualified resident surgeon not available) 90 Reference (Outside) Laboratory

91 Repeat Clinical Diagnostic Laboratory Test 92 Multiple Modifiers

The most common modifiers used (but not limited to) are:

22 Unusual Procedural Services

When the service(s) provided is greater than that usually required for the listed procedure.

NOTE: An Operative Report must be attached to the claim.

25 Significant Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service


preoperative and postoperative care associated with the procedure that was performed. Medical documentation is required for claim to be considered for payment.

26 Professional Component

Certain procedures are a combination of a physician component and a

technical component. When the physician component is reported separately, the service may be identified by adding the modifier ‘26’ to the usual procedure number.

57 Decision for Surgery

An evaluation and management service that resulted in the initial decision to perform the surgery may be identified adding the modifier ‘57.’

62 Two Surgeons

When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding the modifier ‘62’ to the single definitive procedure code. An Operative Report should be attached to the claim.

80 Assistant Surgeon

Surgical assistant services may be identified by adding the modifier ‘80.


Claims Appeal Process

The Provider Appeal Process offers prompt review of claims that are initially denied or claims where the Provider disputes the payment amount (For claims related to code auditing please see Section 4, Subsection D). A Provider has 180 days* from the date of the denial or receipt of payment from DMC Care to initiate the appeal process.

If the Provider decides to appeal, all pertinent information and the reason(s) you believe your claim should be reconsidered must be included in the request. Your appeal information should be mailed to the Outcomes Management Specialist Appeals Coordinator at:

DMC Care

Provider Claims Appeal P.O. Box 44290

Detroit, MI 48244


Providers who are denied at Level I have the option of appealing at Level II. All Level II appeals should be submitted with additional documentation and rational within sixty (60) days of notification of Level I denial. The Benefit Interpretation Committee will provide investigative review and/or forward to the Quality Advisory Committee for final decision.

A written notification of decision to the provider within thirty (30) days of Level II Appeal decision.

G. Electronic Data Interchange Strategy

1. Purpose of This Section

The purpose of this section is to provide the reader with a general overview and description of the electronic claims portion of DMC TPA EDI strategy. This companion guide is to be used in conjunction with the ANSI X12N implementation guides. The information describes specific requirements for processing data within the payer’s system.

2. Types of Claim Files

DMC TPA is currently accepting the following 837 files electronically: Inpatient services;

Outpatient services;

All professional services including, but not limited to: o Ambulatory Surgery;

o Emergency Room; o Lab services;

o Radiology professional services. 3. Definition of Terms Used

Health Care Providers

Health care providers are individuals and organizations that provide health care services. Health care providers can include physicians, hospitals, clinics, pharmacies, and long-term care facilities. The legal definition of health care provider is included in section 262, Administrative Simplification, of the Health Insurance Portability and Accountability Act of 1996.


The payer is the party that pays claims and/or administers the insurance coverage, benefit, or product. A payer can be an insurance company; Health Maintenance Organization (HMO); Preferred Provider Organization (PPO);


Third Party Administrator (TPA)

A sponsor may elect to contract with a Third Party Administrator (TPA) or other vendor to handle collecting insured member data if the sponsor chooses not to perform this function.

Frequently Ask Questions

1. What is the Benefit to Providers and DMC TPA to receive claims electronically?

EDI allows DMC TPA to meet state and federal regulations for adjudication; EDI improves business process and provides a faster response;

EDI reduces customer service calls while improving member and provider satisfaction;

EDI benefits will attract customers and providers to DMC TPA. 2. Does DMC TPA accept and process all claims electronically?

DMC TPA will not electronically accept at this time any claims for COB claims, re-bills, corrections or claims with attachments. These claims must be billed on paper claim forms.

3. Timing of Submissions?

Providers may submit claims as often as they like with the understanding that each submission will be treated as a separate batch.

5. Will Trading Partners and/or Providers receive electronic responses? A confirmation file of the claim being accepted.

Electronic Claims Status reporting and Electronic Remittance.

6. Are there any specific payer rules for DMC TPA’s 837 Professional?

The submitter of data should follow the version of the 837 Implementation Guide that includes the Addenda dated October 2002. See the 837P Companion Guide below for any specific payer rules.

7. Are there any specific payer rules for DMC TPA’s 837 Institutional?


837 Companion Guide (v. 5010) 1. Trading Partner Information:

ID - DMC’s trading partner ID is DMC TPA. Trading partners will also need to communicate their ID to DMC. Generally, this should be the Trading Partner’s Federal Tax Identification Number. Additionally, the ID code should be identified as a Federal Tax ID within the ISA and GS Segments.

A Trading Partner Agreement will be required for all trading partners. Transactions received with unidentified IDs will be rejected.

Please contact a provider services representative toll-free at 1 (866) 494-1247 for further information.

2. 837 Reply:

DMC will send the 999 back to the submitter for each file received once mapping has been completed.

DMC will send the current paper Explanation of Payment once the claim has been through the DMC claims processing system. An 835 Remittance





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