PROVIDER MANUAL - Sendero Health Plans

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Sendero Provider Manual Page 56 of 184 7.5 Timeliness of Billing Claims and/or encounters must be submitted as follows: Type of Claim Professional Claims submitted on a CMS- 1500 or using the professional ANSI-837 electronic claim format Ancillary Services Claims submitted on a CMS-1500 or using the professional ANSI-837 electronic claim format Ancillary Services Claims for services that are billed on a monthly basis submitted on a CMS- 1500 or using the professional ANSI-837 electronic claim format (e.g. home health or rehabilitation therapy) Outpatient Hospital Services billed on the CMS-1450 (UB04 institutional claim form) or using the institutional ANSI-837 electronic claim format Inpatient Hospital Services claims billed on the CMS-1450 (UB04 institutional claim form) or using the institutional ANSI-837 electronic claim format Timely Billing Parameter 95 days from DATE OF SERVICE 95 days from DATE OF SERVICE 95 days from the LAST DAY OF THE MONTH for which services are being billed 95 days from the DATE OF SERVICE 95 days from the DATE OF DISCHARGE Claims not submitted in accordance with the above noted deadlines may be denied. Please do not submit a duplicate claim from original submission date prior to thirty (30) days for electronic claims, and forty-five (45) days for paper claims. 7.6 Timeliness of Payment Sendero will pay all clean claims submitted in the acceptable formats as previously detailed within thirty (30) days from the date of receipt or the date that the claim is deemed “clean”. Should Sendero fail to pay the provider within the thirty days, the provider will be reimbursed the interest on the unpaid claim at a rate of 1.5% per month (18% annum) for every month the claim remains unpaid. Sendero will pay all clean electronic pharmacy claims submitted in the acceptable format within eighteen (18) days from the date of receipt or the date that the claim is deemed “clean”. Should Sendero fail to pay the provider within the eighteen (18) days, the provider will be reimbursed the interest on the unpaid claim at a rate of 1.5% per month (18% annum) for every month the claim remains unpaid. Sendero Customer Services 1-855-526-7388 Network Management 1-855-895-0475 Health Services Dept.: 1-855-297-9191 (FAX 1-512-275-2862)
Sendero Provider Manual Page 57 of 184 7.7 Coding Requirements: ICD9 and CPT/HCPCS Codes Professional Medical Claims: Sendero requires the use of ICD9 diagnosis codes and CPT or HCPCS procedure codes. Emergency Professional Services Claims: Sendero requires the use of ICD9 diagnosis codes and CPT or HCPCS procedure codes. Inpatient Institutional Claims: Sendero requires the use of ICD9 diagnosis codes and either ICD9 or CPT surgical procedure codes. Line item charges must be coded with UB04 Revenue Codes. Outpatient Institutional Claims: Sendero requires the use of ICD9 diagnosis codes, HCPCS codes for applicable line item charges and the corresponding UB04 Revenue Code, and either ICD9 or CPT surgical procedure codes. Emergency Institutional Claims: Sendero requires the use of ICD9 diagnosis codes, HCPCS codes for applicable line item charges and the corresponding UB04 Revenue Code, and either ICD9 or CPT surgical procedure codes. Dental Claims: Dental services are provided through a Dental Management Organization (DMO) for the majority of Sendero members. Sendero will pay claims for Medicaid clients who are adults age 21 and older and pregnant women under the plan’s Value Added Services. Please call Customer Services number listed below or contact the State’s DMO by calling 1-866-561-5891 for questions concerning benefits and billing. Prescription Drug Claims: All pharmacy / drug claims should be submitted thru Navitus Health Solutions or call Navitus Customer Care 1-877-908-6023. Claims forms are available at www.navitus.com Claims can be submitted to: Navitus Health Solutions Operations division – claims P.O. Box 999 Appleton, WI 54912-0999 7.8 E&M Office Visits Billing Requirements Sendero follows standard E&M coding guidelines as promulgated by the Centers for Medicare and Medicaid Services (CMS). Sendero Customer Services 1-855-526-7388 Network Management 1-855-895-0475 Health Services Dept.: 1-855-297-9191 (FAX 1-512-275-2862)
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