Medicare Advantage Provider Manual

Medicare

Advantage

Provider Manual

Section 5:

HealthSpan Integrated Care

Provider Manual

Billing and Payment

Section 5:

HealthSpan Integrated Care

Medicare Advantage Provider Manual

Billing and Payment

Table of Contents

SECTION 5: BILLING AND PAYMENT ... 5

5.1

I

NTRODUCTION

... 5

5.2

K

EY

C

ONTACTS

... 5

5.3

E

LECTRONIC

D

ATA

I

NTERCHANGE

(EDI) ... 6

5.3.1 Billing Guidelines for Electronic Claims ... 6

5.3.1.1 National Provider Identifier (NPI) ... 6

5.3.1.2 Federal Tax Identification Number (TIN)... 6

5.3.1.3 Coordination of Benefits ... 8

5.3.2 Electronic Data Interchange (EDI) Requirements ... 8

BENEFITS OF EDI CLAIMS SUBMISSION ... 8

HIPPA Requirements ... 8

EDI ROLES... 9

UNDERSTANDING ELECTRONIC SUBMISSION PROCESS ... 9

TO INITIATE ELECTRONIC CLAIM SUBMISSIONS ... 10

TO INITIATE ELECTRONIC PAYMENT/ REMITTANCE ADVICE ... 10

TO INITIATE ELECTRONIC FUNDS TRANSFER ... 11

HEALTHSPAN REQUIREMENTS ... 11

SUPPORTING DOCUMENTATION ... 11

EDI CLAIM ERRORS ... 12

CORRECTION & RESUBMISSION FOR ACCEPTED EDI CLAIMS ... 12

5.4

P

APER

C

LAIMS

... 12

5.4.1 Billing Guidelines for Paper Claims ... 13

5.4.1.1 National Provider Identifier (NPI) ... 13

5.4.1.2 Paper Claims Address: ... 13

5.4.1.3 Paper Claim Tips... 13

5.4.1.4 Federal Tax Identification Number (TIN) ... 14

5.4.1.5 Coordination of Benefits ... 15

5.5

S

UPPORTING

D

OCUMENTATION

... 16

5.5.1 Supporting Documentation Cover Sheet ... 17

5.6

C

LAIM

C

ORRECTIONS

... 17

5.6.1 Professional Claims: ... 17

5.6.1.2 CMS-1500 Form Paper Claims ... 18

5.6.2 Institutional Claims: ... 18

5.6.2.1 387I Electronic Claims ... 18

5.7

C

LAIM

S

UBMISSION

T

IMEFRAMES

... 18

5.7.1 Initial Claim Submissions:... 18

5.7.1.1 Payment consideration for Claims filed/appealed after filing limit: ... 19

5.8

C

LAIM

P

ROCESSING

T

IMEFRAMES

... 19

5.9

I

NCORRECT

C

LAIM

P

AYMENTS

... 20

5.10

P

ROVIDER

P

AYMENT

D

ISPUTES

... 21

5.11

P

ROVIDER

A

PPEALS

... 21

5.12

M

EMBER

H

OLD

H

ARMLESS

... 21

5.13

C

ODING AND

B

ILLING

V

ALIDATION

... 21

5.13.1 CODING RULE DESCRIPTIONS ... 22

5.14

D

O

N

OT

B

ILL

E

VENTS

(DNBE) ... 32

5.14.1 Claims Submission Related to a Do Not Bill Event ... 34

5.14.1.1 Institutional Claims ... 34

5.14.1.2 Professional Claims ... 34

5.15

A

NESTHESIA

... 35

GLOBAL ANESTHESIA PACKAGE ... 35

OFFICE-BASED SURGICAL PROCEDURES ... 35

ANESTHESIA REPORTING REQUIREMENTS & REIMBURSEMENT ... 35

EXCEPTIONS TO BILLING ANESTHESIA CODES ... 37

ANESTHESIA MODIFIERS... 37

5.16

A

DDITIONAL

S

ERVICES

... 39

BEHAVIORAL HEALTH SERVICES ... 39

DURABLE MEDICAL EQUIPMENT (DME) ... 39

EVALUATION/ MANAGEMENT (E/M) SERVICES ... 40

EMERGENCY ROOM (ER) SERVICES ... 41

INJECTIONS/ IMMUNIZATIONS ... 41

INJECTIONS/ IMMUNIZATIONS cont. ... 42

NEWBORN SERVICES ... 42

OUTPATIENT REHABILITATION... 42

5.17

C

OORDINATION OF

B

ENEFITS

(COB) ... 42

DESCRIPTIONS OF COB PAYMENT METHODOLOGIES ... 43

EOB or MSN STATEMENT ... 43

MEMBERS ENROLLED IN TWO HEALTHSPAN PLANS ... 43

IMPORTANT COB POINTS TO REMEMBER ... 44

5.18

E

XPLANATION OF

P

AYMENT

(EOP)

F

ORM

... 44

5.18.1 Explanation of Payment (EOP) Form Field Descriptions ... 45

5.18.2 Sample Explanation of Payment (EOP) Form ... 46

5.19

I

NSTRUCTIONS FOR

B

ILLING

S

AME

/D

IFFERENT

D

ATES OF

S

ERVICE

&

P

LACES OF

S

ERVICE

T

ABLE

... 47

Section 5: Billing and Payment

5.1 Introduction

HealthSpan has developed Section 5 of the Provider Manual for use by all Plan

Practitioners/Providers

and their staff to:

•

Educate Practitioners/Providers

about HealthSpan’s Claims submission

requirements.

•

Reduce the number of Claim rejections and/or Claim re-submissions

because of initial Claim errors.

•

Facilitate timely payment of Claims.

•

Simplify and clarify increasingly complex coding/billing requirements.

NOTE: HealthSpan will only pay for Covered healthcare Services when

HealthSpan Referral and Authorization requirements are met. This policy

includes those instances when HealthSpan is the secondary Payor for

HealthSpan Medicare Advantage Members.

If you have any questions relating to Claims policies and procedures, Claim

status Provider Disputes or Appeals, call the HealthSpan Customer Relations

Department at 800-441-9742, option 1.

We encourage all Plan Practitioners/Providers and their staff to become

familiar with the requirements outlined in this Section of the Provider Manual

which either conform to or are permitted by applicable federal, state and local

regulations. We welcome Plan Provider input as to how we can make this

Section of the Manual more useful and informative. Please forward any

comments/suggestions for documentation improvements to:

HealthSpan

Network Development and Performance Department

1001 Lakeside Avenue, Suite 1200

Cleveland, OH 44114

5.2 Key Contacts

See

Section Two

of this HealthSpan Medicare Advantage Provider Manual for a

list of Key Contacts by Department.

5.3 Electronic Data Interchange (EDI)

EDI is an exchange of information in a standardized format that adheres to all

Health Insurance Portability and Accountability Act (HIPAA) requirements. EDI

Claims transactions replace the submission of paper Claims. The Claim Status

Inquiry and Notification transactions eliminate the need to telephone

HealthSpan to determine the status of an outstanding Claim. The Benefit

Coverage and Eligibility Inquiry and Response eliminates the need to

telephone HealthSpan to determine a Member’s Eligibility status.

5.3.1 Billing Guidelines for Electronic Claims

5.3.1.1 National Provider Identifier (NPI)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

mandates that all providers use a standard unique identifier on all standard

electronic transactions. Your National Provider Identifier (NPI) must be used

on all HIPAA-standard electronic transactions.

Electronic Transactions: HealthSpan exchanges the following electronic

transactions:

HealthSpan receives:

•

837P - Professional Healthcare Claim

•

837I - Institutional Healthcare Claim

•

270 - Healthcare Eligibility, Coverage or Benefit Inquiry

•

276 - Healthcare Claim Status Request

HealthSpan sends:

•

999 - Functional Acknowledgement

•

835 - Healthcare Claim payment/remittance advice

•

270 - Healthcare Eligibility, Coverage or Benefit Information

•

277 - Healthcare Claims status Notification

•

277U - Unsolicited Healthcare Claim Status Notification

5.3.1.2 Federal Tax Identification Number (TIN)

The TIN as reported on any and all Claim forms must match the information

filed with the Internal Revenue Service (IRS). Failure to report the correct TIN

-- as filed with the IRS at the time of incorporation or start of the “business” ----

could result in a 28% backup withholding tax (payable to the IRS) and/or the

suspension of any and all payments made to the Practitioner/Provider

by

HealthSpan, until this matter is resolved.

IRS Form W-9: Request for Taxpayer Identification Number and

Certification.

When completing IRS Form W-9, note the following:

1) Name

This should be the equivalent of your “entity name,” which you use to file

your tax forms with the IRS.

Sole Practitioner/Proprietor: List your name, as registered with the IRS.

Group Practice/Facility: List your “group” or “facility” name, as

registered with the IRS.

2) Business Name

Leave this field blank, unless you have registered with the IRS as a

“Doing Business As” (DBA) entity. If you are doing business under a

different name, enter that name here.

3) Address/City, State, Zip Code

Enter the address where HealthSpan should mail your IRS Form 1099.

4) Taxpayer Identification Number (TIN)

The number reported in this field (either the social security number or

the employer identification number) MUST be used on all Claims

submitted to HealthSpan.

•

Sole Practitioner/Proprietor: Enter your taxpayer

identification number, which will usually be your social

security number (SSN), unless you have been assigned a

unique employer identification number (because you are

“doing business as” an entity under a different name).

•

Group Practice/Facility: Enter your taxpayer identification

number, which will usually be your unique employer

identification number (EIN).

If you have any questions regarding the proper completion of IRS Form W-9,

or the correct reporting of your TIN on your Claim forms, call the IRS help line

in your area or refer to the following website:

irs.gov/Forms-&-Pubs

Completed IRS Form W-9 should be mailed to the following address:

HealthSpan

Network Development and Performance Department

1001 Lakeside Avenue, Suite 1200

NOTE: If your TIN should change, notify the HealthSpan Network

Development and Performance Department immediately, so that appropriate

corrections can be made to HealthSpan’s records. Failure to do so may delay

Claim payment.

5.3.1.3 Coordination of Benefits

Explanation of Benefit (EOB) or Medicare Summary Notice (MSN) Required. If

HealthSpan is the secondary Payor, send the completed electronic Claim with

the payment fields from the primary insurance carrier, as per the X12

requirements. For more information regarding see page 42 of this Section.

5.3.2 Electronic Data Interchange (EDI) Requirements

HealthSpan is contracted exclusively with RelayHealth. RelayHealth identifies

us using the electronic payor ID RH007 which needs to be populated in loop

2010BB, segment NM109 on all submitted Claims.

TOPIC INSTRUCTIONS BENEFITS OF EDI

CLAIMS SUBMISSION 1) Reduced Overhead Expenses

Administrative expenses are reduced; there is no longer a need to print or mail Claims or to call HealthSpan by phone for

information.

2) Improved Data Accuracy

Since there is no need to re-enter data, data accuracy of Claims is improved, improving Claims payment quality and speed. Both the billing software and the EDI Clearinghouse apply validations to the data that ensure the Claims data is accurate before the Claim is processed.

3) Decreased Claim Turnaround

Electronic Claims can be received more quickly than those submitted on paper. Once received, they can be loaded to the Claims processing system more quickly and accurately, enabling a faster turnaround time.

HIPPA Requirements _{Claims submitted electronically must adhere to all Health Insurance}

Portability and Accountability Act (HIPAA) requirements. The following websites (listed in alphabetical order) include additional information on HIPAA and electronic loops and segments. If a Practitioner/Provider does not have internet access, HIPAA Implementation Guides can be ordered by calling Washington Publishing Company (WPC) at 301-949--9740.

• www.dhhs.gov

• www.wedi.org

TOPIC INSTRUCTIONS

EDI ROLES 1) Submitter:

An EDI submitter is the party sending a transaction. For Claims submission, this is usually the Practitioner/Providerora billing service submitting Claims on its behalf.

2) Clearinghouse:

An intermediary that receives transactions from multiple submitters and sends transactions to the correct recipient. A Clearinghouse may also perform validations and edits on the transactions to ensure their compliance with HIPAA guidelines, or with standards unique to a specific recipient.

3) Recipient:

The party receiving a transaction. For Claims submission, this is HealthSpan.

UNDERSTANDING ELECTRONIC

SUBMISSION PROCESS

1) Practitioners’/Providers’EDI Responsibilities:

A Practitioner/Providersets up a contract with a Clearinghouse to submit Claims to payers. The Practitioner/Providerenters all of the required data Claims elements and sends all of this

information to the contracted Clearinghouse for further data sorting and distribution. The Practitioner/Provider is responsible for ensuring that the transaction complies with the HIPAA requirements and contains all information necessary to process the Claim.

NOTE: All EDI transactions must be routed through HealthSpan’s preferred Clearing House, Relay Health.

2) Clearinghouse’s EDI Responsibilities:

The Clearinghouse receives information from a variety of Practitioners/Providers. The Clearinghouse batches all of the information sorts the information by payer, and then sends the information to the correct payer for processing. The

Clearinghouse should ensure the transactions are in compliance with the HIPAA requirements, and may apply unique edits specified by the payer.

In addition, Clearinghouses:

• Often provide software enabling direct data entry in the Practitioner’s/Provider’s office.

• Edit the submitted data so that it is accepted by the payer.

• Transmit the data to the correct payer in a standard format

NOTE: If a Clearinghouse has a contract with a Practitioner/Provider to process Claims transactions, but does not have a contract with the payer to send that payer Claims transactions, the Clearinghouse will work with other Clearinghouse’s to route the claim to the payer. Therefore, the Clearinghouse to which a Practitioner/Provider submits Claims may not be the same Clearinghouse that delivers those Claims to HealthSpan.

3) HealthSpan’s EDI Responsibilities:

HealthSpan receives the EDI information from the Clearinghouse distribution, and loads it into HealthSpan Claims processing

TOPIC INSTRUCTIONS UNDERSTANDING ELECTRONIC SUBMISSION PROCESS cont. system.

When Claims are received, HealthSpan prepares an electronic acknowledgement (997 transaction) which is sent to the Clearinghouse.

NOTE: A Practitioner/Provider may work with their Clearinghouse to receive HealthSpan’s acknowledgement.

When Claims are rejected by HealthSpan for Fatal front-end Errors, HealthSpan returns a Claims status transaction (277U) detailing why the claim was rejected. Rejected Claims may be re-submitted once they are corrected.

When Claims are paid, HealthSpan will, if requested, return a payment/remittance advice (835) transaction to the Clearinghouse requested by the provider.

TO INITIATE

ELECTRONIC CLAIM SUBMISSIONS

1) No Registration with HealthSpan is Required for Claims Submission

A Practitioner/Providerdoesnot need to register with HealthSpan to submit Claims electronically. It is the

Practitioner/Provider’s responsibility to set up a contract with a Clearinghouse to process the Claim submissions.

2) Electronic Payer ID

HealthSpan is contracted exclusively with RelayHealth. RelayHealth identifies us using the electronic payor ID RH007 which needs to be populated in loop 2010BB, segment NM109 on all submitted claims.

TO INITIATE

ELECTRONIC PAYMENT/ REMITTANCE ADVICE

1) Registration Is Required to receive Electronic /Remittance Advice (835)

A Practitioner/Provider must register with both their

Clearinghouse and HealthSpan to receive a Payment/Remittance Advice (835) transaction when Claims are finalized.

2) Requesting an 835 Registration Form To register for 835, a Practitioner/Provider can:

• Go to HealthSpan’s Provider website

(healthspan.org/providers/north-coast) and download the registration form.

• Call the Customer Relations Department at

800-441-9742, option 1

and request the form.

• E-mail the HealthSpan EDI Coordinator

(EDI_Coordinator@healthspan.org) to request the form. Once the form is received by HealthSpan, set-up can take up to two weeks.

3) Paper Remittance Advice

Unless requested, HealthSpan will continue to send the Explanation of Payment even when the Electronic Payment/Remittance advice transaction is enabled.

TOPIC INSTRUCTIONS

TO INITIATE

ELECTRONIC FUNDS TRANSFER

While not technically an EDI transaction, Electronic Funds Transfer (EFT) or Direct Deposit is also available from HealthSpan. An EFT transaction replaces a paper check for the payment of Claims.

Requesting an EFT Authorization Agreement To request an EFT Authorization Agreement , a Practitioner/Provider can:

• Go to HealthSpan’s Provider website

(healthspan.org/providers/north-coast) and download the form.

• Call the Customer Relations Department 800-441-9742, option 1 and request the form.

• E-mail the HealthSpan EDI Coordinator

(EDI_Coordinator@healthspan.org) to request the form. Once the form is received by HealthSpan, set-up and pre-payment testing with the bank can take up to four weeks.

HEALTHSPAN

REQUIREMENTS Additional HealthSpan EDI data requirements are reflected within the HealthSpan EDI Companion Guide, which may be obtained by contacting the Customer Relations Department at 800-441-9742, option 1. Items of note within this document include:

• Unique Provider Per Claim

In cases where there are multiple providers for the same Claim, split the Claim by provider and list the individual provider only at the Claim level.

• HealthSpan Member Identification Number (Medical Record Number {MRN})

Subscriber vs Patient: Submit Claims using only the patient's information (e.g. name, date of birth, MRN/ID). Do not use the Subscriber's information. Since each HealthSpan Member has a unique MRN/ID, they are considered their own Subscriber for electronic transmissions, i.e. patient relationship = self (18). Professional Claims: Paper: blocks #1a, 2, 3, 4, 5, 6, 7

EDI: 2010BA

Institutional Claims: Paper: blocks #12, 13, 14, 15, 58, 59, 60 EDI: 2010BA

NOTE: Each HealthSpan Member has a unique Member identification number (MRN. Do not use a parent’s HealthSpan Medical Record Number on a Claim for a child; similarly, do not use a spouse’s MRNon a Claim for the other spouse. Beginning in 2015, MRNs are eight digits long.

SUPPORTING

TOPIC INSTRUCTIONS

EDI CLAIM ERRORS _{All electronic Claim submissions are monitored to ensure that an}

acceptable percentage of Claims are error-free. HealthSpan will contact the Practitioner/Provider if a high rate of Fatal Errors are detected in their EDI Claim submissions. The error(s) will be analyzed and resolved by working with the Practitioner/Provider office or their billing service.

CORRECTION & RESUBMISSION FOR ACCEPTED EDI CLAIMS

CMS-1500 Claim Forms: (837P)

HealthSpan prefers corrections to 837P Claims which were already accepted by HealthSpan to be submitted on paper Claim forms. Corrections submitted electronically may inadvertently be denied as a duplicate Claim. UB-04 Claim Forms: (837I)

NOTE: 837I corrections may be submitted electronically



Electronic

Include the appropriate Type of Bill code when electronically submitting a corrected 837I Claim to HealthSpan for processing. NOTE: Claims submitted without the appropriate 3rd digit (XXX) in the “Type of Bill” code will be denied.



Paper

Refer to page 17 for further information and instructions pertaining to paper submission of corrected Claims to HealthSpan for processing.

5.4 Paper Claims

Paper Claims MUST be submitted on one of the following standard Claim

forms:

CMS-1500 (02/12)

Required for all professional services and suppliers.

Any professional services (for example, services rendered by radiologists, ER

physicians, etc.) should be billed on CMS-1500 Claim forms, unless you are

contracted under a GLOBAL rate, in which case “professional services” should

not be billed separately.

UB-04

Required for all facilities (i.e., hospitals) services.

Any professional services (for example, services rendered by radiologists, ER

physicians, etc.) should be billed on CMS-1500 Claim forms, unless you are

contracted under a GLOBAL rate, in which case “professional services” should

not be billed separately.

NOTE: Use standard Claim forms formatted with RED ink to ensure maximum

compatibility with HealthSpan’s optical scanning equipment. Claim forms

formatted with black or blue lines will not scan as efficiently as those

formatted with red.

5.4.1 Billing Guidelines for Paper Claims

5.4.1.1 National Provider Identifier (NPI)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

mandates that all providers use a standard unique identifier on all standard

electronic transactions. Your NPI must be used on all HIPAA-standard

electronic transactions.

5.4.1.2 Paper Claims Address:

HealthSpan

P.O. Box 5316

Cleveland, OH 44101

5.4.1.3 Paper Claim Tips

Avoid Highlighter Usage/ Use Blue or Black Ink

•

Do not use a highlighter on any Claims or any attachments to a Claim (for

example, a Referral form, EOB statement, etc.). When a Claim form or a

Referral form is scanned, highlighter shading turns black and blocks key

data under the highlighter.

•

You may use blue or black ink.

Align Your Office Printer Correctly

•

Align your office printer with the fields on the Claim form. Letters and

numbers that fall on the lines of the form will not scan clearly.

•

Verify that the print is clear and dark. If a printer ribbon or cartridge is

light, the Claim will not scan clearly and Claims processing will be

delayed.

Use Paper Clips for Attachments

•

Do not use staples for attachments. Paper clips are acceptable.

Avoid Handwritten Information

•

Poor, light handwriting affects scanning quality and processing accuracy.

Please submit typed Claims.

Do Not Use “Super Bills” or “Encounter Forms” as Claim Forms

•

Office “super bill” or “encounter” forms are NOT acceptable as Claim

forms. These forms delay processing because important Claims

information is not in the standard format.

Send Originals Whenever Possible

•

Do not submit the second or third page of a multi-part Claim form. The

print is often light, smeared, or unreadable.

One Member per Claim Form/One Provider per Claim Form

•

Do not bill for different Members on the same Claim form.

•

Do not bill for different Practitioners/Providers on the same Claim form.

Complete a separate Claim form for each Member and for each

Practitioner/Provider.

Record Each Procedure on a Separate Line

•

Only one procedure should be reported on a Claim line number. Do not

enter two reimbursable procedures under one Claim line.

Do Not Record Any “Extraneous” or “Extra” Information on Claim Forms

•

Do not list the narrative “descriptions” of ICD-9-CM codes, CPT codes,

etc. on the CMS-1500 (HCFA-1500) Claim form.

Example: 99213 – Office or Other Outpatient Visit

Record only the code itself

(99213)

on the Claim form, without the

accompanying narrative description

(Office or Other Outpatient Visit).

•

Do not list any “explanations” or “notes” on Claim forms, unless you are

specifically instructed to do so.

Exceptions:

•

Unclassified drugs: Specify the name of the drug and the NDC#.

•

Durable Medical Equipment (DME) special supplies: Specify the

durable medical equipment/supply used.

5.4.1.4 Federal Tax Identification Number (TIN)

The TIN as reported on any and all Claim forms must match the information

filed with the Internal Revenue Service (IRS). Failure to report the correct TIN

-- as filed with the IRS at the time of incorporation or start of the “business” ----

could result in a 28% backup withholding tax (payable to the IRS) and/or the

suspension of any and all payments made to the Practitioner/Provider

by

HealthSpan, until this matter is resolved.

IRS Form W-9: Request for Taxpayer Identification Number and

Certification

When completing IRS Form W-9, note the following:

1) Name

This should be the equivalent of your “entity name,” which you use to file

your tax forms with the IRS.

•

Sole Practitioner/Proprietor: List your name, as registered with the

IRS.

•

Group Practice/Facility: List your “group” or “facility” name, as

registered with the IRS.

Leave this field blank, unless you have registered with the IRS as a “Doing

Business As” (DBA) entity. If you are doing business under a different

name, enter that name here.

3) Address/City, State, Zip Code

Enter the address where HealthSpan should mail your IRS Form 1099.

4) Taxpayer Identification Number (TIN)

The number reported in this field (either the social security number or the

employer identification number) MUST be used on all Claims submitted

to HealthSpan.

•

Sole Practitioner/Proprietor: Enter your taxpayer identification

number, which will usually be your social security number (SSN),

unless you have been assigned a unique employer identification

number (because you are “doing business as” an entity under a

different name).

•

Group Practice/Facility: Enter your taxpayer identification number,

which will usually be your unique employer identification number

(EIN).

If you have any questions regarding the proper completion of IRS Form W-9,

or the correct reporting of your TIN on your Claim forms, call the IRS help line

in your area or refer to the following website:

irs.gov/Forms-&-Pubs

Completed IRS Form W-9 should be mailed to the following address:

HealthSpan

Network Development and Performance Department

1001 Lakeside Avenue, Suite 1200

Cleveland, OH 44114

NOTE: If your TIN should change, notify the HealthSpan Network

Development and Performance Department immediately, so that appropriate

corrections can be made to HealthSpan’s records. Failure to do so may delay

Claim payment.

5.4.1.5 Coordination of Benefits

If HealthSpan is the secondary Payor, send the completed Claim form with a

copy of the corresponding Explanation of Benefit (EOB) or Medicare Summary

Notice (MSN) from the primary insurance carrier attached to the paper Claim

to ensure efficient processing/adjudication. HealthSpan cannot process a

Claim without an EOB or MSN from the primary insurance carrier. If you are

submitting a paper Claim for more than one Member on the same MSN, attach

a copy of the MSN to each Claim form being submitted.

CMS-1500 claim form



Complete

Field 29 (Amount Paid)

UB-04 claim form



Complete

Field 54 (Prior Payments)

See page 42 of this Section for additional information regarding Coordination

of Benefits, and for a list of the specific COB fields which must be completed

to ensure accurate COB payment determinations.

NOTE: Upon a Member’s appointment check in, verify if there have been any

changes to the insurance coverage. This could include more than one

coverage.

5.5 Supporting Documentation

To expedite Claims processing and adjudication, a Practitioner/Provider

should submit supporting written documentation (for example, copies of

pertinent medical records) with certain types of Claims.

Supporting Documentation Submitted WITH a Claim:

When supporting documentation is submitted WITH the corresponding paper

Claim form, attach/secure the documentation to the paper Claim with a paper

clip (do not staple) and mail to HealthSpan’s mailing address (see page 13 of

this Section).

Supporting Documentation Submitted SEPARATELY From a Claim:

When sending supporting documentation SEPARATELY from the Claim (for

example, when sending in requested medical information for a pended Claim)

1) Complete a Supporting Documentation Cover Sheet (see sample

and instructions on page 17 of this Section) for each Member for

whom you are submitting paper documentation.

2) Attach the cover sheet to each Member’s paper documentation with

a paper clip.

3) Mail the supporting documentation as per the instructions on the

form.

For electronic Claim submissions, complete a Supporting Documentation

Cover Sheet (see page 17 of this Section for additional information and

complete instructions) to submit supporting written documentation.

Exception: Coordination of Benefits.

ATTACHMENT CIRCUMSTANCE

ADMITTING NOTES _{Except in the case of Emergency Services rendered in accordance with}

Prudent Layperson guidelines, if the Claim is for inpatient services provided outside of the time or scope of the Authorization.

CONTRACTUAL REQUIREMENTS IN THE GLOBAL CONTRACT

Documents referenced in global contract between HealthSpan and a health care Practitioner, hospital, or person entitled to reimbursement.

EXPLANATION OF BENEFITS/

MEDICARE

SUMMARY NOTICE

To determine HealthSpan liability when another health plan and/or Medicare is primary for medical coverage.

ITEMIZED BILL _{Except in the case of Emergency Services rendered in accordance with}

Prudent Layperson guidelines, if the claim is for services rendered in a hospital and the hospital claim has no prior authorization for an admission or the admission is inconsistent with a HealthSpan concurrent review determination rendered prior to the delivery of services, regarding the medical necessity of the service.

OFFICE/PHYSICIAN

NOTES Except in the case of Emergency Services rendered in accordance with _{Prudent Layperson guidelines, if the claim for services provided is outside}

of the time or scope of the authorization, or when there is an authorization in dispute.

OFFICE VISIT

NOTES/ ANESTHESIA RECORDS

If the claim includes modifier 21 or 22.

If the claim for anesthesia services rendered includes modifier P4 or P5.

OPERATIVE NOTES _{If the claim is for multiple surgeries, or includes modifier 22, 58, 62, 66 or}

78.

5.5.1 Supporting Documentation Cover Sheet

See

Appendix F.13

of this HealthSpan Medicare Advantage Provider Manual.

5.6 Claim Corrections

5.6.1 Professional Claims:

Use the following guidelines when submitting a corrected Professional Claim

to HealthSpan for processing.

NOTE: HealthSpan prefers corrections to 837P Claims which were already

accepted by HealthSpan to be submitted on paper Claim forms. Corrections

submitted electronically may inadvertently be denied as a duplicate Claim.

5.6.1.1 837P Electronic Claims

Ensure you include the correct Claim Frequency code is populated in Loop

2300, segment CLM05-3 to indicate the void or replacement claim.

5.6.1.2 CMS-1500 Form Paper Claims

When submitting a corrected CMS-1500 paper Claim to HealthSpan for

processing:

1) Write “CORRECTED CLAIM” in the top (blank) portion of the

standard Claim form.

2) Attach a copy of the corresponding page of HealthSpan’s

Explanation of Payment (EOP) to each corrected Claim, to prevent

these Claims from being rejected by HealthSpan as duplicate

Claims. Attach with a paper clip.

3) Mail the corrected Claim(s) to HealthSpan using the standard

Claims mailing address (see page 13 in this Section).

5.6.2 Institutional Claims:

Use the following guidelines when submitting a corrected Institutional Claim

to HealthSpan for processing.

5.6.2.1 387I Electronic Claims

Ensure you include the appropriate Claim Frequency Code is populated in

Loop 2300, segment CLM05-03 to indicate a void or replacement claim.

5.7 Claim Submission Timeframes

Abide by the following guidelines for Claim submission timeframes, to prevent

denial for untimely filing.

5.7.1 Initial Claim Submissions:

All Claims must be submitted for processing within 12 months (365 days) of

the date of service. Any Claims submitted after 12 months (365 days) from the

date of service must be accompanied by documentation as to why the Claims

should be considered for payment. Complete a Supporting Documentation

Cover Sheet (see sample and instructions on page 17 of this Section) and

attach the documentation with a paper clip. Claims submitted without this

documentation will be denied.

5.7.1.1 Payment consideration for Claims filed/appealed after filing limit:

Examples of documentation deemed valid are:

1. Documented call into the HealthSpan Network Development or

Customer Relations Departments:

Provide the date that you contacted HealthSpan inquiring about a Claim status

or payment rejection. If you followed up with an appropriate HealthSpan area,

we will have documentation of that call and will be able to accept that in order

to determine if the filing limit rejection will be overturned. Follow up calls in

relation to a previous payment must occur within 180 days of the last

processed date. This would be considered as proof of filing.

2. Fax Confirmation:

Provide a copy of a fax confirmation sheet showing the fax was successful,

detailing that you faxed a Claim over for processing or reconsideration. This

would be considered as proof of filing.

3. HealthSpan EDI Claim Receipt Confirmation:

HealthSpan assigns all Claims received a HealthSpan Claim number whether

they are received via paper or electronically. Upon receipt, the claims system

generates a confirmation back to the submitter with the Claim number, in a

999. This would be considered as proof of filing.

4. Copy of delivery confirmation from U.S. Postal Service or Commercial

Carrier (i.e. UPS, FedEx….):

If you have a delivery confirmation from a package submitted to HealthSpan

as it relates to Claims involved in a timely filing dispute, we will consider that

receipt as proof of filing.

5.8 Claim Processing Timeframes

Allow 30 days for HealthSpan to process and adjudicate your Claim(s). Claims

requiring additional supporting documentation and/or Coordination of

Benefits may take longer to process.

NOTE: While HealthSpan may require the submission of specific supporting

documentation necessary for benefit determination (including medical and/or

Coordination of Benefits information), HealthSpan may have to make a

decision on the Claim before such information is received.

A "complete” or “Clean" Claim is defined as a Claim that has no defect or

impropriety, including lack of required substantiating documentation from

providers, suppliers, or Members or particular circumstances requiring special

treatment that prevents timely payments from being made on the Claim.

5.9 Incorrect Claim Payments

If you receive an incorrect payment (i.e., either an overpayment or an

underpayment), elect one of the following options.

Option 1: Do not cash or deposit the incorrect payment check.

•

Mail the incorrect payment check back to HealthSpan, along with a copy

of the Explanation of Payment (EOP

)

and a brief note explaining the

payment error to:

HealthSpan

Recovery Unit

P.O. Box 74843

Cleveland, OH 44194-4843

NOTE: If HealthSpan’s EOP is not available, record the Member’s Medical

Record Number on the payment check you are returning.

•

HealthSpan will re-issue and mail you a new, corrected payment check

within 30 days.

Option 2: Deposit the incorrect HealthSpan payment check in your account or

accept the Electronic Funds Transfer (EFT).

For an Underpayment Error:



Call the HealthSpan Customer Relations Department at 800-441-9742,

option 1, and explain the error. Upon verification of the error, appropriate

corrections will be made to HealthSpan’s accounting system and the

underpayment amount owed you will be added to/reflected in your next

HealthSpan reimbursement check.



For an Overpayment Error: You may do either one of the following:

Write a refund check to HealthSpan for the excess amount paid to you by

HealthSpan. Attach a copy of HealthSpan’s Explanation of Payment (EOP)

to your refund check, as well as a brief note explaining the error. Attach

with a paper clip.

NOTE: If HealthSpan’s EOP is not available, record the Member’s Medical

Record Number on the payment check you are returning.

Mail your refund check (and brief note) to:

HealthSpan

Recovery Unit

P.O. Box 74843

Cleveland, OH 44194-4843

Appropriate corrections will be made to HealthSpan’s accounting system and

the overpayment amount will be automatically deducted from your next

HealthSpan reimbursement.

5.10 Provider Payment Disputes

See

Section 4.14

of this HealthSpan Medicare Advantage Provider Manual.

5.11 Provider Appeals

See

Section 4.12.4

of this HealthSpan Medicare Advantage Provider Manual.

5.12 Member Hold Harmless

A Practitioner/Provider should not bill a Member for a Covered Service that is

not the responsibility of the Member under the Evidence of Coverage, such as

an amount denied by HealthSpan because of inaccurate coding or the

Practitioner’s/Provider’s failure to obtain an Authorization. The

Practitioner/Provider may bill for Copayments, Coinsurance amounts, subject

to the Deductible or amounts the Member has expressly agreed to pay prior to

the services being rendered.

HealthSpan Payments:



The payments from HealthSpan shall be limited to the amount specified

in the Practitioner’s/Provider’s Agreement with HealthSpan, less any

Copayments, Coinsurance, or Deductibles in accordance with the

Member’s specific Evidence of Coverage.

Items You May Bill For:



The Practitioner/Provider may bill the Member for any applicable

Copayments, Coinsurance, or Deductibles, and/or for any non-covered

services as indicated on the remittance advice received from HealthSpan.

5.13 Coding and Billing Validation

HealthSpan uses code editing software (CES) from third party vendors to

assist in determining the appropriate processing and reimbursement of

Claims. Currently, HealthSpan has selected Optum™ for CES. From time to

time, HealthSpan may change this coding editor or the specific rules that it

uses in analyzing Claims submissions. HealthSpan’s goal is to help ensure the

accuracy of Claims payments.

Optum’s CES is a code editor application designed to evaluate Claims data

including procedure codes and associated modifiers. CES assists HealthSpan

in identifying various categories of Claims coding and possible

inconsistencies. Claims with coding errors/inconsistencies are pended to the

Medical Claim Review staff for manual review. Each Claim is validated against

HealthSpan’s payment criteria, and then is subsequently released for

processing. This process has a goal of improving the accuracy of coding and

consistency in Claims payment procedures.

To help illustrate how this process works, examples have been provided. If

you have questions about the application of these rules, call the HealthSpan

Customer Relations Department at 800-441-9742, option 1.

5.13.1 CODING RULE DESCRIPTIONS

EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION

# 1

MULTIPLE PROCEDURS REDUCTION

Rule Description: Identifies procedures that require a reduction based on multiple procedure guidelines.

Rule Justification: American Medical Association (AMA) guidelines establish that certain procedures require the billing of the multiple procedure

modifiers. Any procedure included in Appendix D or E of the Current Procedural Terminology book are exempt and not included in this list of procedures.

Rule Application: Use all procedures in the surgical section (10021 – 69990) from the Current Procedural Terminology book to determine procedure codes that will accept the multiple modifier. Any codes the AMA has designated to be “Add-On” codes or “Modifier 51 Exempt” will not be considered.

• Multiple surgeries are indicated by use of modifier 51

• The primary procedure is identified by the highest total RVU as set by the Centers for Medicare & Medicaid Services (CMS).

Example:

Multiple surgeries are separate procedures performed by a Practitioner/Provider on the same patient at the same operative session or on the same day. HealthSpan will reimburse for multiple procedures performed during the same operative session according to the following schedule:

1st (major) procedure …100% of allowed fee, no modifier required

2nd procedure ……….50% of allowed fee, modifier 51 required

3rd procedure ………..50% of allowed fee, modifier 51 required

4th procedure ………...… 50% of allowed fee, modifier 51 required

Each procedure after the fourth procedure will require submission of documentation and HealthSpan review, to determine an appropriate reimbursement amount.

EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION

# 2

OUTPATIENT CONSULTATIONS.

Rule Description: Identifies office or other outpatient consultations that should have been billed at the appropriate level of office visit, established patient, or subsequent hospital care.

Rule Justification: According to the AMA, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source." Furthermore, "If subsequent to the completion of the consultation, the consultant assumes responsibility for the management of a portion or all of the patient's condition[s], the follow-up consultation codes should not be used."

Rule Application:

• Deny the consultation with the reason code indicating the denial reason.

• Match on the first three digits of an ICD9 code to determine same diagnosis.

Definition: A non-initial consultation is a consultation billed with a date of service within 6 months of another consultation.

Example:

Office or other outpatient consultation codes (99241-99245) are services provided by a Practitioner/Provider whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician. These consultation services should be performed at the written or verbal request of another Practitioner/Provider and documented in the patient's medical record. If the consulting Practitioner/Provider assumes responsibility for the management of a portion or all of the patient's condition, the follow-up visits should be coded using the established patient office evaluation and management codes.

99241 DOS 1/5/13 Dx Code of 250.30 99241 DOS 3/1/13 Dx Code of 250.30 Service for DOS 3/1/13 will be denied.

# 4

INITIAL INPATIENT CONSULTATIONS

Rule Description: Identifies initial inpatient consultations that should have been billed at the appropriate level of subsequent hospital care.

Rule Justification: According to the AMA, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source." Furthermore, "If subsequent to the completion of the consultation, the consultant assumes responsibility for the management of a portion or all of the patient's condition[s], the follow-up consultation codes should not be used."

Rule Application: AMA/CPT industry standard of payment is followed for paying initial inpatient consultations, only when they are truly the initial. Example:

A consultation is a type of service provided by a Practitioner/Provider whose opinion or advice regarding evaluation and management of a specific

EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION

# 4

INITIAL INPATIENT CONSULTATIONS cont.

problem is requested by another Practitioner/Provider. CPT states that only one initial consultation should be reported by a consultant per admission utilizing the initial inpatient consultation codes (99251-99255).

# 5

CONSULTATIONS BY PRIMARY CARE PHYSICIANS (PCP)

Rule Description: Identifies consultation codes that are billed by the Member's Primary Care Physician (PCP).

Rule Justification: According to the AMA, "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”

Rule Application: All consultations will be denied when billed by the Member’s PCP, except for Claims submitted with a pre-op diagnosis (V72.81-V72.85) when appropriate.

# 6

NEW PATIENT CODE FOR ESTABLISHED PATIENT

Rule Description: Identifies new patient procedure codes that are submitted for established patients.

Rule Justification: According to the AMA "A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years."

Rule Application:

• Denywith a reason code indicating the denial reason when a Practitioner/Provider bills more than one new patient code for the same Member.

• In addition, same group, same specialty within the 3 years will be denied.

• The time period is three (3) years to determine if the visit is for a new patient.

Example:

Member ID 1234 DOS 1/5/14 99201  This service will be denied. Member ID 1234 DOS 12/20/12 99201  This service will be approved.

# 7

GLOBAL SURGICAL PACKAGE (GSP)

Rule Description: Identifies Evaluation & Management (E/M) or certain supply codes billed within a procedure’s follow-up period.

Rule Justification: The Centers for Medicare & Medicaid Services (CMS) guidelines have established that the concept of the Global surgical package applies to certain procedures. Additional payment should not be made for services that fall within the follow-up days.

Rule Application:

• Deny E/M codes and supplies billed within the Global surgical package for surgeries with Global periods of 10 or 90 days.

• Use Modifiers 22, 24, 25, 27, 50,51,52,53,54,55,57,58,59,62,78,79,80,82 and AS, if applicable.

EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION

# 7

GLOBAL SURGICAL PACKAGE (GSP) cont.

Example:

A Global surgical package is an all-inclusive fee for the surgical procedure which includes the surgery and some pre-operative and post-operative care. Below outlines types of Global surgical packages and what each package includes.

Major Surgery:

The following services are included in the Global surgical package:

• Pre-operative visit/services, in or out of the hospital, one day prior to surgery all intra-operative procedures medical/surgical services for complications which DO NOT require a return trip to the Operating Room all related post-operative care and visits, for a period of 90 days following surgery

Minor Surgery:

The following services are included in the Global surgical package:

• The Practitioner’s/Provider’s visit/services performed on the day of surgery the procedure itself all related post-operative care and visits, for a period of ten days after surgery

Endoscopic Procedures:

For endoscopic procedures, the Global "package" includes:

• The Practitioner’s/Provider’s visit/services on the day of the procedure,

• The procedure itself,

There is NO post-operative period for

endoscopic procedures performed through an existing body orifice; procedures requiring an incision for insertion of a scope (for example, a laparoscopic cholecystectomy) will be subject to either the MAJOR or MINOR surgical policy, whichever is appropriate.

# 8

SAME DAY SURGERY INCLUSIVE

Rule Description: Identifies supplies that have been submitted on the same day as a surgical procedure.

Rule Justification: According to the Centers for Medicare & Medicaid Services (CMS) Program Manuals - Medicare Carriers (PUB. 14), guidelines have established that additional payment should not be made for some supplies when billed on the same day as certain surgical procedures. This list includes, but is not limited to, "Items such as dressing changes; local

incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.”

EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION

# 9 OPTUM™ BUNDLING

Rule Description: Identifies procedures that have been unbundled according to the Optum’s CES product.

Rule Justification: The Optum’s CES product has identified re-bundling coding relationships. Coding relationships are established and influenced by CPT Code definitions, CPT Instructions and Guidelines, Medicare Guidelines and Physician Specialty Organizations. Edit level justifications are available upon request.

Rule Application: Use Optum edits for all Claims.

Definition: Procedure unbundling occurs when two or more CPT-4 procedures are used to describe a procedure performed, when a single, more comprehensive, CPT-4 procedure code exists that accurately describes the entire procedure performed or when mutually exclusive procedures (procedures which would not be reasonably performed at the same session by the same provider on the same Member) are reported. Example:

Billing the following two codes together:

58150: Total abdominal hysterectomy (corpus and cervix) with or without removal of tubes; with or without removal of ovary(s). 58240: Pelvic exenterating for gynecologic malignancy with total abdominal hysterectomy or cervicectomy with or without removal of tube(s); with or without removal of ovary(s).

58150 would be rebundled into 58240.

# 10

CMS CORRECT CODING INITIATIVE BUNDLING

Rule Description: Identifies procedures that have been unbundled according to the Correct Coding Initiative (CCI) of the Centers for Medicare & Medicaid Services (CMS).

Rule Justification: The correct coding initiative coding policies are based on coding conventions defined in the American Medical Association's CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practice and review of current coding practice.

Rule Application:

• Use CMS CCI edits for all Claims.

• Deny the code with the lowest work RVU for mutually exclusive procedures

• Apply the Correct Coding Initiative modifier overrides 25, 58, 59, 78, 79, E1-E4, F1-F9, FA, LC, LD, LT, RC, RT, T1-T9, and TA if appropriate. Definition: Procedure unbundling occurs when two or more CPT-4

procedures are used to describe a procedure performed, when a single -- more comprehensive -- CPT-4 procedure code exists that accurately describes the entire procedure performed or when mutually exclusive procedures (procedures which would not be reasonably performed at the same session by the same provider on the same Member) are reported.

EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION # 10 CMS CORRECT CODING INITIATIVE BUNDLING cont. Example:

Billing the following two codes together:

58150: Total abdominal hysterectomy (corpus and cervix) with or without removal of tubes; with or without removal of ovary(s). 58240: Pelvic exenteration for gynecologic malignancy with total abdominal hysterectomy or cervicectomy with or without removal of tube(s); with or without removal of ovary(s).

58150 would be rebundled into 58240.

# 11

CMS ALWAYS BUNDLED PROCEDURES

Rule Description: Identifies procedures indicated by the Centers for

Medicare & Medicaid Services (CMS) as always bundled when billed with any other procedure.

Rule Justification: According to CMS National Physician Fee Schedule Relative Value File, this procedure has a status code indicator of "B", which is defined as: "Payment for covered services is always bundled into payment for other services not specified. There will be no RVUs or payment amount for these codes and no separate payment is made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident."

Rule Application: Deny services indicated by CMS as always bundled when billed with any other procedure not indicated as always bundled.

# 12

ANESTHESIA CROSSWALK

Rule Description: Identifies and crosswalks non-anesthesia services to a designated anesthesia code as appropriate based on the provider's specialty.

Rule Justification: The Optum Anesthesia Crosswalk Table converts E/M, surgery, radiology, laboratory/pathology, and medicine codes to anesthesia codes as appropriate when a Claim for anesthesia services, as identified by provider type, specialty, or identification number is submitted with other than a designated anesthesia code

(00100–01996). Rule Application:

• Use Optum’s crosswalk list to crosswalk any non-anesthesia codes billed by an anesthesiologist to the appropriate anesthesia code and deny with anesthesia reason code.

• For non-anesthesia codes that have a “one to many” crosswalk, flag the code for review and deny anesthesia with denial reason code.

• For non-anesthesia codes that do not have an established crosswalk, flag the code for review and deny anesthesia with denial reason code.

Example:

Code 10080 would be denied because the anesthesia code of 00300 is a valid crosswalk.

# 13 HOLIDAY

Rule Description: Identifies misuse of procedure codes designated for Federal holidays or Sundays.

EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION

# 13

HOLIDAY cont.

defined as "Services requested on Sundays and holidays in addition to basic service." The date of service on this line is not a Federal holiday or a Sunday. Rule Application: Deny code 99050 when it is NOT billed on a Sunday or Federal holiday.

Example:

A provider billed 99050 and the date of service is not 12/31/2015 or 12/25/2015.

# 14

GENDER/AGE SPECIFIC CODES

Rule Description: Identifies procedures and diagnoses that are inconsistent with the Member's gender or which are inconsistent with the Member’s age. Rule Justification: The Optum CES product has identified this procedure or diagnosis as gender specific. The Optum CES product also edits the Member age for inconsistent for stated diagnosis codes. The procedure code or diagnosis on this line is not consistent with the Member's gender or age. Rule Application: Use Optum’s list to deny any Claim lines with procedures or diagnoses that are inconsistent with the Member’s gender or age.

# 15

PROCEDURES NOT COVERED

Rule Description: Identifies procedure codes that are typically not covered by the plan.

Rule Justification: The Centers for Medicare & Medicaid Services (CMS) guidelines or industry accepted standards establish that certain procedures are not covered by the plan. In regards to CMS not covered services, procedures with a Status Indicator of E, G, I, N, P, or X in the National Physician Fee Schedule Relative Value File are included in this list of procedures.

Rule Application: Deny procedure codes that are not covered. Services not covered by CMS and which are covered by HealthSpan are excluded from this rule.

# 16 UNLISTED

PROCEDURE RULE

Rule Description: Identifies procedure codes that are "unlisted."

Rule Justification: The Optum CES product has identified procedure codes that contain phrases in their descriptions such as “not elsewhere specified” or “not otherwise specified”.

Rule Application: Pend for review CPT codes that are unlisted procedures. Definition: An unlisted procedure is a "catch all" code for a procedure that cannot be assigned a more specific procedure code. These procedures are identified in CPT-4 with the word "unlisted" in the procedure code’s description.

Example:

Unlisted musculoskeletal procedure, head (21499). Clinical Review staff will review all Claims with an unlisted procedure code listed on the Claim form.

EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION

# 16 UNLISTED

PROCEDURE RULE cont.

After a detailed review of the Claim -- and any required supporting

documentation -- Clinical Review staff may be able to assign a more specific CPT code to the procedure.

# 17

DUPLICATE LINE ITEMS

Rule Description: Identifies line items that have been submitted on a previous Claim.

Rule Justification: Duplicate claim lines match a previous Claim's Member, Practitioner/Provider, procedure code, modifier, date of service, quantity, and billed amount.

Rule Application:

• Deny the Claim line based on a match on Member ID, procedure code, Provider ID or vendor Federal Tax Identification Number, date of service, requested amount, quantity and modifier.

• An exact match is not required on Evaluation and Management CPT Codes.

# 18

PROFESSIONAL/ TECHNICAL CODES VS. MODIFIERS

Rule Description: Identifies situations where a modifier 26, denoting professional component, should have been reported for the procedure performed at the noted place of service.

Rule Justification: The Centers for Medicare & Medicaid Services (CMS) guidelines establish that certain procedures, when performed in certain settings, require the billing of the professional component modifier. Procedures with a "PCTC Ind" indicator of 1 or 6 in the National Physician Fee Schedule Relative Value File are included in this list of procedures. Rule Application:

• Add the professional component (modifier 26) when an applicable procedure is performed in a facility setting by a non-hospital Provider.

• Use CMS’s list of procedures that will accept technical/professional component split.

# 19

INVALID ASSISTANT SURGEON

Rule Description: Identifies surgical procedures billed with an assistant surgeon modifier that typically do not require an assistant surgeon. Rule Justification: The Centers for Medicare Services (CMS) guidelines establish that certain procedures do not warrant an assistant surgeon. Procedures with an "Asst. Surg" indicator of 1 or 9 in the National Physician Fee Schedule Relative Value File are included in this list of procedures. Rule Application: Use CMS’s list to identify codes that typically do not require an assistant surgeon in the procedure, but have an assistant surgeon modifier attached, and deny those procedures.

Definition: An assistant at surgery is defined as an individual who assists the primary surgeon during surgery. An assistant at surgery

EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION

# 19

INVALID ASSISTANT SURGEON cont.

can be another physician, a physician’s assistant (PA), or a qualified resident.

Example:

CMS has identified a list of procedures which require the skills of an assistant surgeon.

HealthSpan reviews all "assistant surgeon" Claims to determine the appropriateness of the assistant surgeon’s services. HealthSpan uses physician consultants, as well as current, publicly available assistant surgeon guidelines (CMS).

# 20

FILING DEADLINES

Rule Description: Identifies Claim lines that have been submitted after the filing deadline.

Rule Justification: According to the Centers for Medicare & Medicaid Services (CMS) Program Manuals - Medicare Carriers (PUB. 14), "the terms of the law require that the Claim be filed no later than the end of the calendar year following the year in which the service was furnished, except as follows: The time limit on filing Claims for service furnished in the last 3 months of a year is the same as if the services had been furnished in the subsequent year. Thus, the time limit on filing Claims for services furnished in the last 3

months of the year is December 31 of the second year following the year in which the services were rendered."

Rule Application:

• The decision is to compare the date of service to the received date to determine whether a Claim has been filed on time.

Contracted Providers

• Deny Claims submitted beyond the HealthSpan initial Claims submission of 12 months from date of service.

Non Contracted Providers

• Deny Claims submitted beyond the CMS filing deadline.

# 21

INVALID / DELETED CODES

Rule Description: Identifies procedures codes invalid or deleted by the AMA received after the Centers for Medicare & Medicaid Services (CMS)

submission guidelines.

Rule Justification: The Centers for Medicare & Medicaid Services (CMS) guidelines have established that AMA deleted CPT and HCPCS codes should not be reimbursed when they are submitted after the procedure code's deletion and beyond the permitted submission period. A valid procedure code is one that is present in the system and is effective.

Rule Application: If a Claim line has a date of service in the current year, CMS permits a three-month grace period (based on the date the Claim is received). When a Claim is received beyond the grace period, deny the code. Example:

33035 - Complete ventricular decortication, with cardiopulmonary bypass (Code deleted in 1990; to report, use 33031).

EDIT RULE # / NAME CODING RULE DESCRIPTIONS / RULE JUSTIFICATION

# 22

ADD-ON CODES

Rule Description: Identifies an add-on code billed without the presence of a primary service/procedure.

Rule Justification: According to the AMA, "add-on codes are always performed in addition to the primary service/procedure, and must never be reported as a stand-alone code." The indicated add-on procedure has been identified because this provider has not billed its related primary

service/procedure for this Member on the same date of service.

Rule Application: Deny add-on codes when billed without the appropriate base code.

Example:

11000 (Base Code) billed with 11001 (Add-on)

# 23 BILATERAL

Rule Description: Identifies the same surgical code being billed twice without the appropriate use of modifier 50.

Rule Justification: When performed bilaterally, the same surgical procedure should not be billed twice. HealthSpan’s reimbursement guidelines require the code to be billed on one line with a bilateral modifier indicated. Rule Application:

• Modify lines for bilateral procedures that are submitted incorrectly.

• The decision determines an incorrect submission by the presence of the same surgical code billed twice for the same date of service. Definition: Bilateral procedures are surgeries performed on both sides of the body during the same operative session or on the same day.

Example:

If two codes are billed, and both have a -50 modifier, the Plan will pay one line with the -50 modifier accordingly, and deny one line.

First (bilateral) procedure: Report the appropriate 5-digit CPT code, which describes the bilateral procedure, with a modifier -50 as required.

Second (bilateral) procedure: The same 5-digit CPT code for the second procedure will be denied.

Example:

A bilateral mastectomy should be reported as follows: 19303 (Mastectomy, simple, complete)  Add Modifier 50.

# 25

BASE CODE QUANTITY

Rule Description: Identifies situations where a Practitioner/Provider is billing a primary service/procedure with a quantity greater than one, rather than billing the appropriate add-on code(s).

Rule Justification: When a Practitioner/Provider is billing a primary