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Medicare
Advantage
Provider Manual
Section 5:
HealthSpan Integrated Care
Section 5:
Provider Manual
HealthSpan Integrated Care
Billing and Payment
Medicare Advantage Provider Manual
Billing and Payment
Table of Contents
SECTION 5: BILLING AND PAYMENT ........................................................................ 5
5.1 INTRODUCTION ....................................................................................................................................... 5
5.2 KEY CONTACTS .................................................................................................................................... 5
5.3 ELECTRONIC DATA INTERCHANGE (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...................................................................................................................................................................... 8
UNDERSTANDING ELECTRONIC SUBMISSION PROCESS ................................................................. 9
TO INITIATE ELECTRONIC CLAIM SUBMISSIONS ................................................................................. 10
TO INITIATE ELECTRONIC PAYMENT/ REMITTANCE ADVICE ..................................................... 10
TO INITIATE ELECTRONIC FUNDS TRANSFER ...................................................................................... 10
HEALTHSPAN REQUIREMENTS......................................................................................................................... 11
SUPPORTING DOCUMENTATION ..................................................................................................................... 11
EDI CLAIM ERRORS .................................................................................................................................................. 11
CORRECTION & RESUBMISSION FOR ACCEPTED EDI CLAIMS ..................................................... 11
5.4 PAPER CLAIMS ..................................................................................................................................... 12
5.4.1 Billing Guidelines for Paper Claims...................................................................................................... 12
5.4.1.1 National Provider Identifier (NPI)..................................................................................... 12
5.4.1.2 Paper Claims Address: .......................................................................................................... 12
5.4.1.3 Paper Claim Tips ...................................................................................................................... 12
5.4.1.4 Federal Tax Identification Number (TIN) ...................................................................14
5.4.1.5 Coordination of Benefits .....................................................................................................15
5.5 SUPPORTING DOCUMENTATION......................................................................................................15
5.5.1 Supporting Documentation Cover Sheet......................................................................................... 17
5.6 CLAIM CORRECTIONS ........................................................................................................................ 17
5.7 CLAIM SUBMISSION TIMEFRAMES .................................................................................................. 18
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5.8 CLAIM PROCESSING TIMEFRAMES ................................................................................................. 18
5.9 INCORRECT CLAIM PAYMENTS ....................................................................................................... 19
5.10 PROVIDER PAYMENT DISPUTES .................................................................................................. 20
5.11 PROVIDER APPEALS ......................................................................................................................... 20
5.12 MEMBER HOLD HARMLESS ........................................................................................................... 20
5.13 CODING AND BILLING VALIDATION .............................................................................................. 21
5.13.1 CODING RULE DESCRIPTIONS ........................................................................................................... 21
5.14 DO NOT BILL EVENTS (DNBE) ................................................................................................... 31
5.14.1 Claims Submission Related to a Do Not Bill Event ..................................................................32
5.15 ANESTHESIA ...................................................................................................................................... 33
GLOBAL ANESTHESIA PACKAGE ..................................................................................................................33
OFFICE-BASED SURGICAL PROCEDURES .............................................................................................. 34
ANESTHESIA REPORTING REQUIREMENTS & REIMBURSEMENT .............................................. 34
EXCEPTIONS TO BILLING ANESTHESIA CODES ...................................................................................35
ANESTHESIA MODIFIERS ................................................................................................................................... 36
5.16 ADDITIONAL SERVICES .................................................................................................................. 37
BEHAVIORAL HEALTH SERVICES .................................................................................................................37
DURABLE MEDICAL EQUIPMENT (DME) ...................................................................................................38
EVALUATION/ MANAGEMENT (E/M) SERVICES ..................................................................................38
EMERGENCY ROOM (ER) SERVICES........................................................................................................... 39
EMERGENCY ROOM (ER) SERVICES cont................................................................................................ 40
INJECTIONS/ IMMUNIZATIONS ...................................................................................................................... 40
NEWBORN SERVICES .......................................................................................................................................... 40
OUTPATIENT REHABILITATION ..................................................................................................................... 40
5.17 COORDINATION OF BENEFITS (COB) ........................................................................................ 41
DESCRIPTIONS OF COB PAYMENT METHODOLOGIES .....................................................................41
COB QUESTIONS ......................................................................................................................................................41
EOB or MSN STATEMENT ....................................................................................................................................41
MEMBERS ENROLLED IN TWO HEALTHSPAN PLANS ..................................................................... 42
IMPORTANT COB POINTS TO REMEMBER .............................................................................................. 42
5.17.1 COB Fields on the CMS-1500 Claim Form ................................................................................... 43
5.17.2 COB Fields on the UB-04 Claim Form .......................................................................................... 44
PRIOR PAYMENTS .................................................................................................................................................. 45
INSURED’S NAME.................................................................................................................................................... 45
5.18 EXPLANATION OF PAYMENT (EOP) FORM ............................................................................. 46
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5.18.1 Explanation of Payment (EOP) Form Field Descriptions .................................................... 46
5.18.2 Sample Explanation of Payment (EOP) Form .......................................................................... 46
5.19 INSTRUCTIONS FOR BILLING SAME/DIFFERENT DATES OF SERVICE & PLACES OF
SERVICE TABLE ........................................................................................................................................... 47
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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.
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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)
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 Federal Tax ID Number as reported on any and all Claim forms must
match the information filed with the Internal Revenue Service (IRS). Failure to
report the correct Federal Tax ID Number -- 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.
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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 Federal Taxpayer ID Number 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 44101
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NOTE: If your Federal Tax ID Number 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 41
5.3.2 Electronic Data Interchange (EDI) Requirements
TOPIC
BENEFITS OF EDI
CLAIMS SUBMISSION
INSTRUCTIONS
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
EDI ROLES
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
•
www.wpc-edi.com
1) Submitter:
An EDI submitter is the party sending a transaction. For Claims
submission, this is usually the Practitioner/Provider or a 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
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TOPIC
INSTRUCTIONS
EDI ROLES cont.
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/Provider sets up a contract with a Clearinghouse to
submit Claims to payers. The Practitioner/Provider enters 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.
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
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.
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TOPIC
TO INITIATE
ELECTRONIC CLAIM
SUBMISSIONS
INSTRUCTIONS
1) No Registration with HealthSpan is Required for Claims
Submission
A Practitioner/Provider does not 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 Network Development Department (Option 4)
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.
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 Network Development Department (Option 4)
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.
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TOPIC
INSTRUCTIONS
HEALTHSPAN
REQUIREMENTS
Additional HealthSpan EDI data requirements are reflected within the
HealthSpan EDI Companion Guide, which may be obtained by contacting
the Network Development Department (Option #4). 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)
Subscriber vs Patient: Submit Claims using only the patient's
information (e.g. name, date of birth, Medical Record Number/ID).
Do not use the Subscriber's information. Since each HealthSpan
Member has a unique Medical Record Number/ID, they are
considered their own Subscriber for electronic transmissions, i.e.
patient relationship = self (18).
Professional Claims:
Institutional Claims:
SUPPORTING
DOCUMENTATION
EDI CLAIM ERRORS
CORRECTION &
RESUBMISSION FOR
ACCEPTED EDI CLAIMS
Paper: blocks #1a, 2, 3, 4, 5, 6, 7
EDI: 2010BA
Paper: blocks #12, 13, 14, 15, 58, 59, 60
EDI: 2010BA
NOTE: Each HealthSpan Member has a unique Member identification
number (Medical Record Number). Do not use a parent’s HealthSpan
Medical Record Number on a Claim for a child; similarly, do not use a
spouse’s Medical Record Number on a Claim for the other spouse.
See page 15.
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.
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.
rd
NOTE: Claims submitted without the appropriate 3 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.
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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 National Provider Identifier (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.
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• 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.
• Avoid the use of photocopies and fax copies as well.
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.
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5.4.1.4 Federal Tax Identification Number (TIN)
The Federal Tax ID Number as reported on any and all Claim forms must
match the information filed with the Internal Revenue Service (IRS). Failure to
report the correct Federal Tax ID Number -- 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).
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If you have any questions regarding the proper completion of IRS Form W-9,
or the correct reporting of your Federal Taxpayer ID Number 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 44101
NOTE: If your Federal Tax ID Number 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 41 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.
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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 12 in
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) 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 for additional information and complete
instructions) to submit supporting written documentation. Exception:
Coordination of Benefits.
ATTACHMENT
ADMITTING NOTES
CONTRACTUAL
REQUIREMENTS IN
THE GLOBAL
CONTRACT
EXPLANATION OF
BENEFITS/
MEDICARE SUMMARY
NOTICE
ITEMIZED BILL
OFFICE/PHYSICIAN
NOTES
CIRCUMSTANCE
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.
Documents referenced in global contract between HealthSpan and a health
care Practitioner, hospital, or person entitled to reimbursement.
To determine HealthSpan liability when another health plan and/or
Medicare is primary for medical coverage.
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.
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.
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ATTACHMENT
OFFICE VISIT
NOTES/ ANESTHESIA
RECORDS
CIRCUMSTANCE
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.
5.6 Claim Corrections
Professional Claims:
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.
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.
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 12 in this section).
Institutional Claims:
When submitting a corrected Institutional Claim to HealthSpan for processing:
387I Claims
Ensure you include the appropriate Claim Frequency Code is populated in
Loop 2300, segment CLM05-03 to indicate a void or replacement claim.
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5.7 Claim Submission Timeframes
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) and attach the
documentation with a paper clip. Claims submitted without this
documentation will be denied.
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
Clean Claims:
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.
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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), do one of the following:
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.
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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.
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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
#1
MULTIPLE
PROCEDURS
REDUCTION
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
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:
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EDIT RULE # /
NAME
#1
MULTIPLE
PROCEDURS
REDUCTION
cont.
#2
OUTPATIENT
CONSULTATIONS
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
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.
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.
#4
INITIAL
INPATIENT
CONSULTATIONS
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.
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
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EDIT RULE # /
NAME
#4
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
paying initial inpatient consultations, only when they are truly the initial.
INITIAL
INPATIENT
CONSULTATIONS
cont.
Example:
A consultation is a type of service provided by a Practitioner/Provider whose
opinion or advice regarding evaluation and management of a specific 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
Rule Description: Identifies consultation codes that are billed by the Member's
Primary Care Physician (PCP).
CONSULTATIONS
BY PRIMARY
CARE
PHYSICIANS
(PCP)
#6
NEW PATIENT
CODE FOR
ESTABLISHED
PATIENT
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.
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:
•
Deny with 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
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EDIT RULE # /
NAME
#7
GLOBAL
SURGICAL
PACKAGE (GSP)
cont.
#8
SAME DAY
SURGERY
INCLUSIVE
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
and AS, if applicable.
Example:
A Global surgical package is an all-inclusive fee for the surgical
procedure which includes the surgery and some pre-operative and postoperative 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.
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.”
Rule Application: Deny supplies when billed on the same day as a surgery.
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EDIT RULE # /
NAME
#9
OPTUM™
BUNDLING
# 10
CMS CORRECT
CODING
INITIATIVE
BUNDLING
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
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.
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.
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.
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EDIT RULE # /
NAME
# 11
CMS ALWAYS
BUNDLED
PROCEDURES
# 12
ANESTHESIA
CROSSWALK
# 13
HOLIDAY
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
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.
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.
Rule Description: Identifies misuse of procedure codes designated for Federal
holidays or Sundays.
Rule Justification: According to the AMA, this procedure code has been 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
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EDIT RULE # /
NAME
# 14
GENDER/AGE
SPECIFIC CODES
cont.
# 15
PROCEDURES
NOT COVERED
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
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.
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
Rule Description: Identifies procedure codes that are "unlisted."
UNLISTED
PROCEDURE
RULE
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.
# 17
DUPLICATE LINE
ITEMS
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. 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.
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.
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EDIT RULE # /
NAME
# 18
PROFESSIONAL/
TECHNICAL
CODES VS.
MODIFIERS
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
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 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."
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EDIT RULE # /
NAME
# 20
FILING
DEADLINES cont.
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
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
•
# 21
INVALID /
DELETED CODES
Deny Claims submitted beyond the CMS filing deadline.
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.
# 22
ADD-ON CODES
# 23
BILATERAL
Example:
33035 - Complete ventricular decortication, with cardiopulmonary bypass (Code
deleted in 1990; to report, use 33031).
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)
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.
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EDIT RULE # /
NAME
# 23
BILATERAL cont.
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
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.
# 25
BASE CODE
QUANTITY
Example:
A bilateral mastectomy should be reported as follows:
19303 (Mastectomy, simple, complete)  Add Modifier 50.
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
service/procedure with a quantity greater than one, those additional services
beyond the primary service/procedure should be billed as add-on codes.
According to the AMA, add-on procedures are to be listed in addition to the
primary service/procedure.
Rule Application: Deny base codes when billed with a quantity greater than
one.
#26
PLACE OF
SERVICE NOT
TYPICAL FOR
PROCEDURE
Rule Description: Identifies claim lines that contain a specified procedure
performed in a place of service inconsistent with Centers for Medicare &
Medicaid Services (CMS) guidelines.
Rule Justification: According to CMS the service location and procedure code
information used by physicians/practitioners/suppliers to report the name,
address and Zip code of the service location where they furnished services (e.g.,
hospital, clinic, or office). Furthermore, the service location is used by
contractors to determine the applicable “locality” and Geographic Practice Cost
Index.
Rule Application: If a claim contains procedures which are performed at a place
of service that is inconsistent with CMS guidelines those claim lines will be
denied.
Example:
Procedure code 99231 Subsequent hospital care is not typically performed in
Place of Service 11 (Physician Office).
#27
MEDICARE NONPHYSICIAN
SERVICE
Rule Description: This edit identifies claim lines that contain a certain place of
service (hospital Inpatient, hospital Outpatient, or nursing facility residents) and
a PC/TC status indicator of 5. These procedures typically are not performed by
a physician.
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EDIT RULE # /
NAME
#27
MEDICARE NONPHYSICIAN
SERVICE
CODING RULE DESCRIPTIONS / RULE JUSTIFICATION
Rule Justification: According to Centers for Medicare & Medicaid Services
(CMS), CPT or HCPCS codes with PC/TC indicators of 0, 2, 3, 4, 5, 7, 8, and 9 are
not considered eligible for reimbursement when submitted with modifiers 26
and/or TC.
Rule Applications: Deny procedures when performed by a physician.
Example: Procedure Code 92977 does not require a physician to perform the
procedure and therefore is not considered eligible for reimbursement when
submitted with modifiers 26 and/or TC.
5.14 Do Not Bill Events (DNBE)
HealthSpan’s DNBE policy is based on payment rules that waive fees for all or
part of health care services directly related to the occurrence of certain
adverse events as defined by the Centers for Medicaid and Medicare Services
(CMS) National Coverage Determinations for surgical errors and the published
listing of CMS Hospital Acquired Conditions, as may be amended from time to
time. The DNBE policy will apply to all Claims for all Members enrolled in
HealthSpan. HealthSpan expects Plan Providers to report every DNBE as set
forth in Section 8.31 of this HealthSpan Medicare Advantage Provider Manual.
Waive or Reimburse Fees – Plan Providers may not be compensated for
Services directly related to any Do Not Bill Event (as defined below) and may
be required to waive Member Cost Share associated with, and hold Members
harmless from, any liability for Services directly related to DNBE. Plan
Providers shall waive fees otherwise owed by Payors and Members (or
reimburse such fees that may have already been paid by Payors or Members)
that are directly related to the DNBE, whether the DNBE is reported by the
Plan Provider or later discovered by HealthSpan. “Directly related” fees mean
fees associated with the Medically Necessary health care Services required to
treat the DNBE, taking into account all relevant factors.
Surgical Do Not Bill Events include the following surgical errors (SEs)
identified by CMS in its National Coverage Determinations (NCD) that
occur in any care setting:
•
•
•
Wrong surgery or other invasive procedure performed on patient.
Surgery or other invasive procedure performed on wrong patient.
Surgery or other invasive procedure performed on wrong body part.
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The Hospital Acquired Conditions (HAC) identified by CMS that occur in a
general hospital or acute care setting are as follows:
• Intravascular air embolism that occurs while being cared for in a health
care facility.
• Blood incompatibility (hemolytic reaction due to administration of
ABO/HLA incompatible blood or blood products).
• Pressure ulcer (stage three or four) acquired after admission to a health
care facility
• Falls and Trauma (fractures, dislocations, intracranial injuries, crushing
injuries, burns, electric shock).
• Catheter associated urinary tract infection.
• Vascular catheter associated infection.
• Manifestation of poor glycemic control (diabetic ketoacidosis,
nonketotic hyperosmolar coma, hypoglycemic coma, secondary
diabetes with ketoacidosis, and secondary diabetes with
hypersmolarity).
• Mediastinitis following coronary artery bypass graft.
• Surgical site infection following orthopedic procedures (spine, neck,
shoulder, elbow).
• Surgical site infection following bariatric surgery for obesity
(laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric
restrictive surgery).
• Deep vein thrombosis or pulmonary embolism following orthopedic
procedures (total knee or hip replacement).
• Any new HAC later added by CMS.
In any care setting, the following HAC if not present on admission for
inpatient services or if not present prior to provision of other Services:
•
Removal (if medically indicated) of foreign object retained after surgery
(RFO).
5.14.1 Claims Submission Related to a Do Not Bill Event
HealthSpan will follow the Centers for Medicare & Medicaid Services (CMS)
billing requirements for Services directly related to a DNBE.
Institutional – If you submit a UB-04 or 837I claim for inpatient facility Services
to a Member wherein a HAC (including a RFO) has occurred, you must include
the following information:
Present on Admission (POA) indicators, applicable diagnostic (ICD) codes and
all applicable standard modifiers (including CMS National Coverage
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Determination (NCD) modifiers for Surgical Errors) in the manner required by
CMS for Medicare fee-for-service Claims.
Submit Services directly related to a DNBE as a no-pay Claim (Type of Bill 110).
If there are also unrelated Services provided during the same stay as the
DNBE, you must split the Claim and submit both a no-pay Claim (Type of Bill
110) setting forth all Services directly related to the DNBE including the
applicable ICD codes, present on admission indicators and all standard
modifiers (including CMS National Coverage Determination modifiers for
Surgical Errors) in the manner required by CMS for Medicare fee-for-service
Claims and a Type of Bill ‘11X’ (with the exception of 110)’ setting forth all
Covered Services not directly related to the DNBE.
Professional– If you submit a CMS 1500 form or 837P claim for any inpatient or
outpatient professional Services provided to a Member wherein a SE or RFO
has occurred, you must include the applicable ICD codes and all applicable
standard modifiers (including CMS NCD HCPCS modifiers for Surgical Errors)
for the associated charges on all lines related to the surgical error in the
manner required by CMS for Medicare fee-for-service Claims as follows:
PA: Surgery on Wrong Body Part.
PB: Surgery on Wrong Patient.
PC: Wrong Surgery on Patient.
Additionally, any claim submission should reflect all Services provided
(including those related to a DNBE) and all associated fees (including those
related to the DNBE) with an adjustment in fees to reflect the waiver of fees
directly related to the DNBE.
5.15 Anesthesia
HealthSpan provides coverage for anesthesia services that are Medically Necessary
as part of authorized medical or surgical care in accordance with the Member’s
Evidence of Coverage.
TOPIC
EXPLANATION/INSTRUCTIONS
GLOBAL ANESTHESIA
PACKAGE
The “Global” anesthesia package includes:
•
The performance of a pre-anesthetic examination and evaluation
(even if the exam is done on a date different from the date of
surgery).
•
The administration of the anesthetic.
•
The administration of fluids and/or blood Incidental to the
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TOPIC
GLOBAL ANESTHESIA
PACKAGE cont.
EXPLANATION/INSTRUCTIONS
delivery of anesthesia (or the procedure being performed).
•
The usual monitoring services (ECG, blood pressure, etc.).
The provision of post-operative anesthesia care (post-operative visit).
OFFICE-BASED
SURGICAL
PROCEDURES
When an office-based surgical procedure is performed, reimbursement for
the procedure includes reimbursement for anesthesia services as part of
the Global surgical Fee, because it is expected that appropriate anesthesia
will be administered with the office-based procedure.
ANESTHESIA
REPORTING
REQUIREMENTS &
REIMBURSEMENT
HealthSpan reimburses participating providers for anesthesia services based
on nationally recognized criteria for reporting of anesthesia services,
including:
• The American Medical Association (AMA) CPT codes (00100 –
01999).
• American Society of Anesthesiologists’ (ASA) Relative Value Guide
(RVG).
• Medicare Guidelines.
BASE UNITS:
Providers are NOT to indicate the ASA base unit values in the Days/Units
field on the Centers for Medicare & Medicaid Services (CMS) 1500 (Field 24,
Box G). Base units are determined as defined by the American Society of
Anesthesiologists Relative Value Guide. The base units assigned to a
procedure are intended to demonstrate the relative complexity of a specific
procedure and include the value of all anesthesia services, except the value
of the actual time spent administering the anesthesia. HealthSpan stores the
base unit value within our Claims system and will calculate the anesthesia
payment of the base units according to the information provided on the
Claim.
REPORTING OF ANESTHESIA TIME:
Anesthesia time begins when the anesthesiologist starts to prepare the
patient for the induction of anesthesia in the operating room or in an
equivalent area. Anesthesia time ends when the anesthesiologist is no longer
in personal attendance, which is when the patient may be safely placed
under postoperative supervision. Time units are calculated by allowing 1 unit
for each 15 minute interval or remaining fraction thereof.
Providers are to show time as follows.
Paper:
Providers are to show time as total number of minutes in the Units field
(Item 24, Box G).
EDI:
837 Professional Claim Service Line - Unit or Basis for Measurement
Loop: 2400
Segment: SV103
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TOPIC
EXPLANATION/INSTRUCTIONS
ANESTHESIA
REPORTING
REQUIREMENTS &
REIMBURSEMENT
cont.
Description: For claims requiring minutes, such as Anesthesia claims, submit
using the qualifier of "MJ" to denote minutes in loop 2400 SV103.
Example: Submitted claim line with 100 minutes.
SV1*HC:01967*12.25*MJ*100****1:2:3**N~
REIMBURSEMENT:
Payment for most anesthesia services is based on:
•
The base unit value.
•
Plus anesthesia time units.
•
Multiplied by the fee schedule conversion factor, as appropriate.
Other services are reimbursed based upon the CPT code.
MULTIPLE SURGICAL PROCEDURES:
When multiple surgical procedures are performed during a single anesthetic
administration, the anesthesia code representing the most complex with the
multiple procedure modifier “-51“ is reported. The time reported is the
combined total of all procedures reported on the primary procedure.
EXCEPTIONS TO
BILLING ANESTHESIA
CODES
Anesthesiologists should bill using anesthesia codes only, unless one or
more of the following services was performed by the anesthesiologist (in
which case the appropriate “non-anesthesia” CPT code(s) may be reported
and billed in accordance with Centers for Medicare & Medicaid Services
(CMS) guidelines):
•
Evaluation and management services.
•
Hospital inpatient services.
•
Consultations.
•
Critical care services.
•
Pain management.
•
Nerve blocks. Destruction by neurolytic agents.
•
Services not included in the Global anesthesia Fee.
•
Other miscellaneous services.
QUALIFYING CIRCUMSTANCES:
CPT codes 99100, 99116, 99135 and 99140 represent various patient
conditions that may impact the anesthesia service provided. Such codes
may be billed in addition to the anesthesia being billed. Charges for these
codes are to be shown on the same line as the CPT Qualifying
Circumstances Code in Field 24, Box F on the CMS-1500.
PATIENT-CONTROLLED ANALGESIA (PCA):
Benefits may be available for the administration of patient-controlled
analgesia (PCA) following a surgical procedure. PCA billed by a surgeon is
covered as part of the Global surgical package and is not separately
reimbursable. PCA reimbursements are limited to anesthesiologists only.
An anesthesiologist’s services for PCA should be submitted as a single line
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TOPIC
EXPLANATION/INSTRUCTIONS
EXCEPTIONS TO
BILLING ANESTHESIA
CODES cont.
on the claim form as follows:
•
Span the dates to include the entire care for the PCA (reimbursement
will be made as a Global allowance, and will include the entire course
of PCA).
•
Any “hospital care” provided by the anesthesiologist subsequent to
the initial day of PCA will be considered covered under the Global
PCA Fee.
•
Use CPT code 01996 when billing for PCA services.
CONSCIOUS SEDATION:
Sedation with or without analgesia (conscious sedation), CPT codes 9914399145, are considered eligible for reimbursement when billed by an
anesthesiologist, pain management or certified registered nurse anesthetist
ANESTHESIA
MODIFIERS
Personally Performed or Medically-Directed/Supervised Anesthesia
Services:
Use an appropriate HCPCS anesthesia modifier to denote whether the
anesthesia services were personally performed, medically directed, or
medically supervised:
AA - Anesthesia service performed personally by the
Anesthesiologist.
AD - Medical supervision by a physician of more than four concurrent
procedures.
G8 - Monitored anesthesia care (MAC) for deep complex
complicated, or markedly invasive surgical procedures.
G9 - Monitored anesthesia care for patient who has a history of
severe cardio-pulmonary condition.
QK - Medical direction of two, three, or four concurrent anesthesia
procedures involving qualified individuals.
QX - CRNA service with medical direction by a physician.
QY - Medical direction of one CRNA by anesthesiologist
QZ - CRNA service without medical direction by a physician.
QS - Monitored anesthesia care service (can be billed by a CRNA or a
physician).
GC - These services have been performed by a resident under the
direction of a teaching physician.
Physical Status Modifiers:
As indicated in the CPT book, the following Physical Status modifiers
should be appended to the CPT anesthesia code to distinguish between the
various levels of complexity of the anesthesia service(s) provided:
P1 - A normal healthy patient.
P2 - A patient with mild systemic disease.
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TOPIC
EXPLANATION/INSTRUCTIONS
ANESTHESIA
MODIFIERS cont.
P3 - A patient with severe systemic disease.
P4 - A patient with severe systemic disease that is a constant threat
to life.
P5 - A moribund patient who is not expected to survive without the
operation.
P6 - A declared brain-dead patient whose organs are being removed
for donor purposes.
DO NOT enter additional minutes for the Physical Status modifier. If eligible
for reimbursement, the additional unit(s) will be calculated by our Claims
system. The patient cannot be billed for Physical Status modifiers not
allowed by HealthSpan.
Other CPT Modifiers/Qualifying Circumstances Codes:
Other modifiers and “qualifying circumstances” codes may be used as
appropriate. Follow the instructions in the CPT/HCPCS books when
reporting these additional modifiers and/or codes.
5.16 Additional Services
TOPIC
EXPLANATION/INSTRUCTIONS
BEHAVIORAL HEALTH
SERVICES
Description:
Behavioral health procedures are used to identify the psychological,
behavioral, emotional, cognitive, and social factors in relation to the
prevention, treatment, or management of behavioral health problems.
CMS-1500
Field 24d  CPT codes are required for all professional services. Record the
code for the predominant service only when performing psychiatric health
assessment/ intervention on the same date as psychiatric therapeutic
procedures.
UB-04
•
Field 14  Required for all inpatient behavioral health Claims
•
Field 44 For outpatient services, enter the appropriate
HCPCS/CPT code that corresponds to the Revenue Code in Field
42.
Supporting Documentation for Behavioral Health Claims:
•
Unlisted Procedure Codes: Any behavioral health claims which
contain any “unlisted,” “unclassified,” “unspecified” or
“miscellaneous” CPT or HCPCS procedure codes.
Repeated procedures performed on the SAME date of service require
supporting documentation.
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TOPIC
EXPLANATION/INSTRUCTIONS
DURABLE MEDICAL
EQUIPMENT (DME)
Description:
Durable Medical Equipment is medically necessary equipment that is:
• Appropriate for use at home.
• Primarily and customarily used to service a medical purpose.
• Not useful to a person in absence of an illness.
• Able to withstand repeated use.
CMS-1500
•
Field 24d  CPT codes are required for all professional services.
Use HCPCS Level II codes to define DME. Use modifiers, if
applicable.
UB-04
EVALUATION/
MANAGEMENT (E/M)
SERVICES
•
Field 42 Enter the appropriate revenue code.
•
Field 44 HCPCS/Rates required.
•
Field 46 Number of rental months.
•
Field 54 DME cost sharing amounts collected from the Member.
•
Field 80 For DME billing, rental rate costs and anticipated months
of usage.
CMS-1500
•
Field 19 When “covering” for another physician, enter the name of
the physician you are covering for.
NOTE: If a non-participating Practitioner/Provider will be covering
for you in your absence, notify that individual of this requirement.
Inpatient E/M Services:
If a patient is admitted for observation following the performance of a
major/minor “surgical package” procedure, do not report hospital
observation service codes, because all post-operative E/M services are
included as part of the Global surgical package.
Consultations:
•
HealthSpan will reimburse for initial consultations when billed with
any surgical procedure done on the same day of service.
•
For office/outpatient: If the consultant assumes patient
management responsibilities following the initial consultation, office
E/M (established patient) visit codes should be used for all
subsequent patient encounters, NOT office consultation codes.
•
For inpatient: If the consultant assumes patient management
responsibilities, use subsequent hospital care codes (NOT follow-up
inpatient consultation codes) to report all additional E/M
encounters with the patient.
Surgery and E/M Services:
•
Reimbursement will generally NOT be made for a pre- or postoperative E/M visit provided on the same day as major/minor
surgery, or an endoscopic procedure, unless HealthSpan agrees that
there was a significant, separately identifiable E/M service provided
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TOPIC
EVALUATION/
MANAGEMENT (E/M)
SERVICES cont.
EXPLANATION/INSTRUCTIONS
in addition to the procedure. In these instances, the provider must
bill for the E/M visit using the appropriate modifier.
•
If E/M services are performed during the post-operative period for a
reason unrelated to the original procedure (such as for other
disease or injuries), you may bill for these services using modifier 24
(Unrelated E/M service by the same physician during a postoperative period), and you must list a corresponding diagnosis code
which reflects that the E/M services were for a problem other than
the surgical diagnosis.
Urgent or Emergency Services Provided in the Office:
For urgent or Emergency Services provided in the office setting, use code
Office services provided on an Emergency basis in addition to the
appropriate E/M office visit code. Because CPT procedure codes series are
considered to be adjunct services to the basic services provided,
HealthSpan will reimburse providers for BOTH the E/M visit code and
“Emergency Services” code.
Non-Surgical Procedure that Include E/M Services:
There are certain instances where HealthSpan will deny medical visits when
billed with certain non-surgical procedures, because the codes for these
procedures include admission to the hospital and/or daily visits. The nonsurgical procedures which fall into this category include:
•
Clinical brachytherapy.
•
End stage renal disease services.
•
Allergy immunotherapy services.
Preventive Medicine Services:
Preventive medicine codes -- NOT office evaluation/management codes -should be used to report the routine evaluation and management of adults
and children, in the absence of patient complaints. For example, preventive
medicine codes should be used for:
EMERGENCY ROOM
(ER) SERVICES
•
Well-baby checkups.
•
Routine pediatric visits.
•
Camp or school physicals.
•
Routine, annual gynecological exams.
UB-04
•
Field 15 Enter the code indicating the source of the admission or
outpatient registration
•
Field 44 The emergency department E/M visit codes should
ONLY be used if the patient is seen in the emergency department.
For urgent or Emergency Services provided in the office setting, bill
code 99058 (Office services provided on an emergency basis) in
addition to the appropriate E/M office visit code.
Emergency department E/M visit codes should be used for E/M services
provided in the emergency department, even if these were “nonemergency” services. The only requirement for using “emergency
department” codes is that the patient must be registered in the emergency
department. Office visit E/M codes should be used if the patient is seen in
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TOPIC
EXPLANATION/INSTRUCTIONS
EMERGENCY ROOM
(ER) SERVICES cont.
the ER as a convenience to the physician and/or patient, but the patient is
not registered in the emergency department.
NOTE: If both an “emergency department” physician and an “attending”
physician are involved in admitting a patient from the ER, the ER physician
should bill for his services utilizing the emergency department E/M codes,
and the attending physician should bill for his services using the initial
hospital visit codes. The two physicians cannot each bill for both the ER
services rendered and the hospital admission.
INJECTIONS/
IMMUNIZATIONS
CPT codes are required for all professional services. Use HCPCS Level II
codes to define Injections/ Immunizations.
NOTE: If there was no identifiable E/M service rendered by the nurse or the
provider, and the patient received only an injection during the encounter, it
is permissible to report an injection administration code in lieu of the E/M
visit code and the appropriate HCPCS code (specifying the drug
administered).
Unlike injections, immunization procedures include the supply of materials.
Additionally, injection administration fees are not eligible for reimbursement
when billed with immunization codes.
NEWBORN SERVICES
CMS-1500
•
OUTPATIENT
REHABILITATION
Field 2 Enter the first and last name of the newborn.
•
Field 3  Enter the newborn’s date of birth.
The Claim must include one of the following modifiers to distinguish the
discipline of the plan of care under which the service was delivered for
therapy, even if the code is not recognized by Centers for Medicare &
Medicaid Services (CMS) as requiring a therapy modifier; such as 97014 or
97545:
•
•
•
GN- Services delivered under an outpatient speech-language
pathology plan of care.
GO- Services delivered under an outpatient occupational therapy
plan of care.
GP- Services delivered under an outpatient physical therapy plan of
care.
This is applicable to all claims from physicians, non-physician practitioners,
hospitals and skilled nursing facilities. Modifiers GN, GO, and GP refer only to
services provided under plans of care for physical therapy, occupational
therapy and speech-language pathology services.
The inclusion of these modifiers will assist HealthSpan in applying the
correct benefits as part of Claims adjudication for Claims for outpatient
rehabilitation services.
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5.17 Coordination of Benefits (COB)
Coordination of Benefits is a way of determining the order in which benefits are
paid and the amounts which are payable when a claimant is covered under more
than one plan. It prevents duplication of benefits when an individual is covered
by multiple plans providing benefits or services for medical, dental or other care
and treatment.
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.
HealthSpan follows the National Association of Insurance Commissioners (NAIC)
model regulations for coordinating benefits, except in those instances where the NAIC
model regulations differ from Ohio state Law. Ohio state Law supersedes the NAIC
model regulations.
TOPIC
EXPLANATION / INSTRUCTIONS
DESCRIPTIONS OF
COB PAYMENT
METHODOLOGIES
HealthSpan Coordination of Benefits allows benefits from multiple carriers
to be added on top of each other so that the Member receives the full
benefits from their primary carrier and the secondary carrier pays their
entire benefit up to 100% of allowed charges.
Benefit carve-out calculations are based on whether or not the provider
accepts Medicare assignment for the provider contract corresponding to
the Claim. Medicare assignment means the provider has agreed to accept
the Medicare Allowed Amount as payment.
COB QUESTIONS
If you have any questions relating to the Coordination of Benefits, call the
HealthSpan Customer Relations Department at 800-444--9742, option 1.
EOB or MSN
STATEMENT
Whenever HealthSpan is the SECONDARY Payor, Claims can be submitted
EITHER electronically or on one of the standard paper Claim forms:
• Electronic Claims
If HealthSpan is the secondary Payor, send the completed electronic
Claim formatted per the Implementation Guide’s direction on
Provider to Payer COB.
• Paper Claims
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 claims
processing/adjudication. HealthSpan will deny a Claim without an
EOB or MSN from the primary insurance carrier.
CMS-1500 claim form  Complete Field 29 (Amount Paid).
UB-04 claim form  Complete Field 54 (Prior Payments).
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TOPIC
EXPLANATION / INSTRUCTIONS
MEMBERS ENROLLED
IN TWO HEALTHSPAN
PLANS
Some Members may be enrolled under two separate plans offered through
HealthSpan (dual coverage). In these situations, standard COB rules still
apply.
Example: A married couple both work for a company that offers
HealthSpan to its employees. Both the husband and wife enroll in
HealthSpan as Subscribers and each lists the other as a
dependent spouse and each lists their children as dependent
children.
Practitioners/Providers should submit one claim under the primary plan to
HealthSpan for processing. After we pay under the primary plan, HealthSpan
will then process and pay the second claim under the secondary plan.
IMPORTANT COB
POINTS TO
REMEMBER
COB ANNUAL UPDATES
HealthSpan reviews and updates Coordination of Benefits information
annually (by contacting Members as required), in an attempt to maintain upto-date COB records.
BIRTHDAY RULE
HealthSpan follows the “birthday rule”, which states that the insurance
carried by the parent/Subscriber whose birthday falls earlier in the
calendar year will be the primary Payor for a dependent child who is
covered by two different insurances (for example, when a dependent child
is covered BOTH by an insurance carried by the dependent’s mother, as
well as under a different insurance carried by the dependent’s father).
Example:
Parent A: Date of Birth: 03/06/1948. This coverage is primary.
Parent B: Date of Birth: 07/20/1948. This coverage is secondary.
NOTE: In rare cases both parents may have the same birth date. In these
cases the plan that has been in effect the longest is the primary carrier.
DEPENDENT CHILD OF SEPARATED OR DIVORCED PARENTS
• Divorce Decree/Court Order
If specific terms of a court decree state that one of the parents is
responsible for the healthcare expenses of a child, and the entity
obligated to pay or provide benefits of the plan of that parent
has actual knowledge of those terms, the benefits of that plan are
determined first. The Member may be required to submit a copy of
their court order or divorce decree.
In the absence of a divorce decree/court order stipulating parental
healthcare responsibilities for a dependent child, insurance benefits
for that child are applied according to the following order:
Insurance carried by the
1) Natural parent with custody  pays first
2) Step-parent with custody  pays next
3) Natural parent without custody  pays next
4) Step-parent without custody  pays last.
If the parents have joint custody of the dependent child, then
benefits are applied according to the birthday rule referenced above.
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5.17.1 COB Fields on the CMS-1500 Claim Form
The following fields should be completed on the CMS-1500 Claim form, to ensure
timely and efficient Claims processing. Incomplete, missing, or erroneous COB
information in these fields may cause Claims to be denied or pended and
reimbursements delayed.
For electronic Claim submissions, refer to a HIPAA website for additional
information on electronic loops and segments (suggested websites on page 8 in this
section).
FIELD
NUMBER
9
FIELD NAME
INSTRUCTIONS/EXAMPLES
OTHER INSURED’S NAME
When additional insurance coverage exists (through a
spouse, parent, etc.) enter the LAST NAME, FIRST NAME,
and MIDDLE INITIAL of the insured.
NOTE: This field must be completed when there is an entry
in Field 11d (Is There Another Health Benefit Plan?).
9a
OTHER INSURED’S POLICY
OR GROUP NUMBER
Enter the policy and/or group number of the insured
individual named in Field 9. If you do not know the policy
number, enter the Social Security number of the insured
individual.
NOTE: 1: Field 9a must be completed when there is an
entry in Field 11d (Is There Another Health Benefit Plan?).
2. For each entry in this field, there must be a
corresponding entry in 9d (Insurance Plan Name or
Program Name).
9b
OTHER INSURED’S DATE
OF BIRTH/SEX
Enter date of birth and sex, of the insured named in Field
9. The date of birth must include the month, day, and
FOUR DIGITS for the year (MM/DD/YYYY). Example:
01/05/1971
NOTE: This field must be completed when there is an entry
in Field 11d (Is There Another Health Benefit Plan?).
9c
EMPLOYER’S NAME or
SCHOOL NAME
Enter the name of the employer or school name (if a
student), of the insured named in Field 9.
NOTE: This field must be completed when there is an entry
in Field 11d (Is There Another Health Benefit Plan?).
9d
INSURANCE PLAN NAME
or PROGRAM NAME
Enter the name of the insurance plan or program, of the
insured individual named in Field 9.
NOTE: This field must be completed when there is an entry
in Field 11d (Is There Another Health Benefit Plan?).
10
IS PATIENT’S CONDITION
RELATED TO:
a. Employment?
b. Auto Accident?
Check “yes” or “no” to indicate whether employment, auto
liability, or other accident involvement applies to one or
more of the services described in Field 24.
NOTE: If yes, there must be a corresponding entry in Field
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FIELD
NUMBER
10 cont.
FIELD NAME
c. Other Accident?
PLACE (State)
11d
IS THERE ANOTHER
HEALTH BENEFIT PLAN?
INSTRUCTIONS/EXAMPLES
14 (Date of Current Illness/ Injury) and in Field 21
(Diagnosis).
PLACE (State)  Enter the state the Auto Accident
occurred in.
Check “yes” or “no” to indicate if there is another health
benefit plan. (For example, the patient may be covered
under insurance held by a spouse, parent, or some other
person).
NOTE: If “yes,” then Field Items 9 and 9a-d must be
completed.
14
21
DATE OF CURRENT
• Illness (First symptom)
• Injury (Accident)
• Pregnancy (LMP)
Enter the date of the current illness or injury. The date
must include the month, day, and FOUR DIGITS for the
year (MM/DD/YYYY).
DIAGNOSIS OR NATURE
OF ILLNESS OR INJURY
Enter the diagnosis and if applicable, enter the
Supplementary Classification of External Cause of Injury
and Poisoning Code.
Example: 01/05/2004
NOTE: This field must be completed when there is an entry
in Field 10 (Is The Patient’s Condition Related To).
29
AMOUNT PAID
Enter the amount paid by the primary insurance carrier in
Field 29.
5.17.2 COB Fields on the UB-04 Claim Form
The following fields should be completed on the UB-04 Claim form to ensure
timely and efficient Claims processing. Incomplete, missing, or erroneous COB
information in these fields may cause Claims to be denied or pended and
reimbursements delayed. For additional information, refer to the current UB-04
National Uniform Billing Data Element Specifications Manual.
For electronic Claim submissions, refer to a HIPAA website for additional
information on electronic loops and segments (suggested websites on page 8 in this
section).
FIELD
NUMBER
31-36
(UB-04)
FIELD NAME
INSTRUCTIONS/EXAMPLES
OCCURRENCE
CODE/DATE
Enter the appropriate occurrence code and date defining
the specific event(s) relating to the Claim billing period.
NOTE: If the injuries are a result of an accident, complete
Field 77 (E-Code) on the UB-04. You can include the ecode in Field 81 (Code-Code).
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FIELD
NUMBER
50
54
FIELD NAME
INSTRUCTIONS/EXAMPLES
PAYOR
(Payer Identification)
Enter the name and number (if known) for each Payor
organization from whom the provider expects (or has
received) payment towards the bill.
List payers in the following order on the claim form:
A = primary Payor.
B = secondary Payor.
C = tertiary Payor.
PRIOR PAYMENTS
Enter the amount(s), if any, that the provider has received
toward payment of the bill PRIOR to the billing date, by
the indicated payer(s). List prior payments in the following
order on the Claim form:
A = primary payer.
B = secondary payer.
C = tertiary payer.
INSURED’S NAME
Enter the name (Last Name, First Name) of the individual
in whose name insurance is being carried. List entries in the
following order on the Claim form:
A = primary payer.
B = secondary payer
C = tertiary payer.
(Payers and Patient)
58
NOTE: For each entry in Field 58 , there MUST be
corresponding entries in Fields 59 through 62 and 65.
59
PATIENT’S RELATION TO
INSURED
Enter the code indicating the relationship of the patient to
the insured individual(s) listed in Field 58 (Insured’s
Name). List entries in the following order:
A = primary payer.
B = secondary payer.
C = tertiary payer.
60
INSURED’S UNIQUE ID
CERT. – SSN – HIC – ID NO.
(Certificate/Social Security
Number/Health Insurance
Claim/Identification
Number)
Enter the insured person’s (listed in Field 58) unique
individual Member identification number (medical/health
record number), as assigned by the payer organization.
List entries in the following order:
A = primary payer.
B = secondary payer.
C = tertiary payer
61
GROUP NAME
(Insured Group Name)
62
INSURANCE GROUP NO.
Enter the name of the group or plan through which the
insurance is being provided to the insured individual (listed
in Field 58). Record entries in the following order:
A = primary payer.
B = secondary payer.
C = tertiary payer.
Enter the identification number, control number, or code
assigned by the carrier or administrator to identify the
GROUP under which the individual (listed in Field 58) is
covered. List entries in the following order:
A = primary payer.
B = secondary payer.
C = tertiary payer.
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FIELD
NUMBER
64
FIELD NAME
INSTRUCTIONS/EXAMPLES
ESC
(Employment Status Code
of the Insured)
Enter the code used to define the employment status of
the insured individual (listed in Field 58). Record entries in
the following order:
A = primary payer.
B = secondary payer.
C = tertiary payer.
NOTE: This field has been
deleted from the UB-04
65
EMPLOYER NAME
(Employer Name of the
Insured)
Enter the name of the employer who provides health care
coverage for the insured individual (listed in Field 58).
Record entries in the following order:
A = primary payer.
B = secondary payer.
C = tertiary payer.
67 A-Q
(UB-04)
DIAGNOSIS CODE
The primary diagnosis code should be reported in Field 67.
Additional diagnosis code can be entered in Field 68-76.
72 (UB04)
EXTERNAL CAUSE OF
INJURY CODE (E-CODE)
If applicable, enter an ICD-9-CM “E-code” in this field.
5.18 Explanation of Payment (EOP) Form
An EOP is a written statement to a Plan Provider showing action taken on a
Claim for a Member.
5.18.1 Explanation of Payment (EOP) Form Field Descriptions
Reserve for future use.
5.18.2 Sample Explanation of Payment (EOP) Form
Reserved for future use.
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5.19 Instructions for Billing Same/Different Dates of Service & Places of Service Table
NOTE: Only one Practitioner/Provider and one Member may be listed on a claim form.
If
DATE(S)
of
SERVICE
are:
AND
PLACE(S) of
SERVICE
are:
AND
SERVICE(S)
Are:
Number of
Claims
to SUBMIT:
Explanation
And
Instructions
Different
Different
Related
Two
Separate
Claims
Different
Unrelated
Two
Separate
Claims
If a Practitioner/Provider renders
care/treatment to a Member on
DIFFERENT dates of service in
DIFFERENT places of service, the
Practitioner/Provider must submit a
SEPARATE Claim form for each different
place of service, reflecting the services/
treatment rendered in each location.
If a Practitioner/Provider renders
care/treatment to a Member on the
SAME date in two DIFFERENT places of
service, for UNRELATED diagnoses, the
practitioner/ provider may submit a
SEPARATE claim for each different place
of service reflecting the services/
treatment rendered in each location.
Same
Same
Different
Related
Two
Separate
Claims
Example(s)
If a Practitioner/Provider sees a Member
on the SAME day in DIFFERENT
locations for RELATED diagnoses/
services, these services should be billed
on SEPARATE Claim forms.
If a Practitioner/Provider sees a Member in
his OFFICE on 1/2/04, and then a few days
later sees the Member in the HOSPITAL on
1/5/04 – ONE claim should be submitted for
the OFFICE visit, and another (separate)
claim should be submitted for services
rendered in the HOSPITAL.
If a Practitioner/Provider sees a Member early
in the day in his OFFICE for a routine
physical, and then later that same day sees
the Member in the HOSPITAL because the
Member was stung by a bee and suffered a
severe allergic reaction -- ONE claim may be
submitted for the OFFICE visit and another
(SEPARATE) Claim may be submitted for the
unrelated services rendered in the
HOSPITAL.
Do NOT bill separately for E/M services
(office visit, hospital observation service,
nursing facility visit, etc.) provided on the
SAME DATE as a hospital admission. All E/M
services provided by the physician in
conjunction with a Member’s admission are
considered part of the initial hospital care
when provided on the SAME DATE as the
hospital admission.
Do not bill separately for emergency
department E/M codes when the Member is
admitted directly from the ER.
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If
DATE(S)
of
SERVICE
are:
AND
PLACE(S) of
SERVICE
are:
AND
SERVICE(S)
Are:
Different
Same
Related
Number of
Claims
to SUBMIT:
Explanation
And
Instructions
One Claim
If the Practitioner/Provider sees the
Member on DIFFERENT dates but at the
SAME place of service/location (i.e.,
hospital, physician’s office, etc.) – these
services may be billed on ONE Claim
form, with each different date of service
listed as a separate line on the form,
along with the corresponding diagnosis
code(s), procedure code(s), and charges.
Example(s)
1) If a Practitioner/Provider sees a Member in
his OFFICE on 2/2/04 and then a few days
later sees the Member in his OFFICE on
2/5/04 – list each date of service as a
separate line on ONE Claim form, along
with the diagnosis, procedure code(s), and
corresponding charge relating to each
date of service.
2) If a physical therapist renders services to a
Member on 3/2, 3/4, and 3/6 at the same
location for each date of service, list each
date of service as a SEPARATE line on the
Claim form, along with the corresponding
service/procedure code, diagnosis, and
charge relating to each date of service.
Same
(multiple
on same
day)
Same
Related or
Unrelated
One Claim
If a Practitioner/Provider sees the SAME
Member two or more times on the SAME
day, in the SAME location (i.e., hospital,
physician’s office, etc.) – these services
should be billed on ONE Claim form.
1) If a Practitioner/Provider sees the Member
in the HOSPITAL early in the day, and then
LATER that SAME day sees the Member in
the HOSPITAL again to monitor the
Member’s progress/ condition-- only ONE
Claim form should be submitted for both
hospital visits, with all services billed at the
cumulative level of intensity for both visits.
2) If the Member is seen TWICE in the
OFFICE on the SAME day for UNRELATED
problems/diagnoses, these services should
be billed as separate lines on ONE Claim
form.
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