BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...

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BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire June 2012 TABLE OF CONTENTS PAGE(S) Administrative Contacts 6 Section 1 – Claims Information 7 Claims Submission 7 Electronic Claim Submission - Clearinghouses 7 Electronic Claim Submission - Quickclaim 8 Balance Billing / Copayment Information 8 Payer of Last Resort 8 Subrogation and Recoupment 8 Coordination of Benefits 10 Corrected Claims 11 CMS 1500 Information 12 Sample CMS 1500 Form 13 Billing & Reimbursement of Professional Surgical Services 14 Obstetrics (OB)Coding 16 OB Billing Flowchart 18 UB-04 Information 19 Sample UB-04 Form 20 Sterilization Consent Form Requirements 21 Hysterectomy Consent Form Requirements 22 Abortion Certification Statement Requirements 23 Claim Appeal Process 24 Example of Provider Remittance Advice 25 Claims Coding Section 26 Section 2 – Credentialing 30 Section 3 – Quality Improvement 32 Section 4 – Member Rights & Responsibilities 33 Section 5 – Enrollment & Eligibility 34 Eligibility 34 Identification of Group Health Members 36 Disenrollment 37 Section 6 – Covered Services – Compcare & Group Health 38 Section 7 – Health Management Reviews for Medical Necessity 46 Overview of Health Management Program 46 Definitions 46 Inpatient Management Facilities 47 Services Requiring Prior Authorizations 48 Emergency Department Authorization 48
BadgerCare Plus & Medicaid SSI Provider Manual - GHC of Eau Claire June 2012 Section 8 – Behavioral Health & Alcohol and Other Drug Abuse 50 (AODA) Services Service Areas 50 Services Requiring Prior Authorization 50 Services Not Requiring Prior Authorization 51 Section 9 – Authorization Guidelines 52 All Facility Admissions 52 Alternative Medicine Services 52 Ambulance Transportation 53 Behavioral Health & Alcohol and Other Drug Abuse (AODA) 53 Non-Emergent Surgeries and Procedures 53 Out-of-Network Referral Requests 54 Out-of-Practice-Group Referral Requests (as applicable) 54 Outpatient Care 54 Outpatient Laboratory 54 Outpatient Psychology Testing 54 Outpatient Radiology 54 Outpatient Therapies 54 Prosthetics and Durable Medical Equipment (DME) 55 Specialized Pharmacy Services 55 Section 15 – Fraud, Waste & Abuse 62 Appendix A – Health Management Forms 63 DME Authorization Request 64 Home Health Authorization Request 65 Notification for Admission Event Authorization Request 66 Out-of-Network Referral Event Authorization Request 67 Out-of-Practice Group Referral Event Authorization Request 68 PT/OT/Cardiac Rehab/Pulmonary Rehab Request 69 Service Event Authorization Request 70 Speech Therapy Request 71 Appendix B – Behavioral Health Forms 72 Autism Treatment Services Request 73 Discharge Information Request 75 Inpatient Treatment Services Request 76 Intensive In-Home Therapy Request 77 Neuro/Psychological Testing Request 79 Outpatient Treatment Services Request 80 Partial Hospitalization Treatment Services Request 81 Appendix C – County Handbook 82
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Home Health Authorization Request F
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Out-of-Network Referral Event Autho
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Therapy Request Form Please indicat
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Speech Therapy Request Form Patient
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Autism Treatment Services Request F
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Discharge Information Request Form
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Intensive In-Home Therapy Request F
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Neuro/Psychological Testing Request
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Partial Hospitalization Treatment S
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