Your Partners in Hawaii - Ubhonline.com

Common Issues Impacting Prompt
Claims Payment
• Member Eligibility:
– Coordination of Benefits (COB).
– Dual Eligible members (Medicare/Medicaid); Medicare is always primary.
– Member termed/Inactive at time of service (example: claim received for a member
who received services outside of the effective dates/timeline for coverage).
• Incomplete Claims Submission:
– Coding issues including incomplete or missing diagnosis (example: 295
Schizophrenic disorders is an incomplete diagnosis code as 5 digits are required).
– Invalid or missing HCPC/CPT examples:
• 99999 CPT code does not have description.
• 90899 in certain situations may be processed but will require manual intervention.
• Provider information missing/incorrect: An example, provider information has not been
completely entered on the claim form.
• Itemization needed and not provided on the claim form.
• Prior Authorization or Notification Required:
– No authorization or notification received for those services for which an authorization
is required (example: benefits require authorization for mental health inpatient
treatment).
– Units exceeded (example: authorization was given for 6 inpatient days, facility has
billed for 11 inpatient days).
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