North Central Counties Introduction to Community Care's Claims ...

North Central Counties
Introduction to Community Care’s
Claims Process
Presented By:
Kimberly K. Casciato, Director, Claims
December 2006

IMPORTANT
• Providers who submit claims for North Central
Members, the process related to billing claims is an
ENTIRELY DIFFERENT PROCESS.
• Providers who submit claims for: Adams,
Allegheny, Berks, Chester, Lackawanna, Luzerne,
Susquehanna, Wyoming and York, Continue to
forward Original claims to DST Health Solutions
and continue to forward claim corrections to the
Pittsburgh office. This process is NOT changing.
• AGAIN, the CLAIMS process for the North
Central Contracted Providers will differ from any
other contract.
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General Claim Information
Claims Office at the Corporate site in Pittsburgh,
houses the following staff:
• Provider Claim Phone Lines
• Experienced staff to work on Claim Corrections
• Contract Specific Training Sessions
• One-on-One Sessions with Providers
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General Claim Information
General Claim Inquiries:
• 1-888-251-2224 - Follow the prompts
• Direct Claim Contacts for North Central Contract will
be provided at a later date.
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General Claim Information
Our Intent:
• To pay providers for services rendered to
HealthChoices members provided that the
Community Care clinical and claims
guidelines have been followed.
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Preparation for Claims Submission
Verification of Contract
• Services / Service codes are contracted by Community Care and
codes are accurately reflected on the Community Care Fee Schedule.
Verification of Member Eligibility for Date of Service billed
• Eligibility Verification System Phone #: 1-800-766-5387
• EVS Machine Purchase:
http://www.dpw.state.pa.us/omap/provinf/billing/270vendors.asp
Verification of Authorization/Registration for Date of Service billed
• Review of weekly authorization / registration reports
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North Central Timely Filing Standards
• 120 days from the date of service for initial claims
submission.
• 240 days from the date of service for claims
corrections or adjustments if the 120 day initial
submission requirement has been met.
• Secondary claims must be submitted within 30 days
of the date printed on the Primary EOB.
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Claims Submission
Community Care accepts claim submissions through the
following mechanisms:
• Electronic Claims Submission via an 837I / 837P.
(Direct or WebMD)
• Provider Online direct submit-NOT ePOWER
• Paper Claims Submission
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Electronic Claims Submission
Providers must be able to independently produce the
following EDI file formats:
• 837 I (Institutional)
– Inpatient, hospital based services
– Residential Treatment Facility – JCAHO accredited
• 837 P (Professional)
– All ambulatory levels of care
– Non Hospital, Residential levels of care
– Residential Treatment Facility – Non JCAHO
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Paper Claims Submission
Paper Claim Forms can be submitted on the following:
UB-92
• Inpatient, hospital based services
• Residential Treatment Facility – JCAHO accredited
CMS-1500 (previously known as HCFA-1500)
• All ambulatory levels of care
• Non Hospital, Residential levels of care
• Residential Treatment Facility – Non JCAHO
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Critical Claim Elements
Critical Details on a UB-92
• Box 1 Name & Address of Physician, Clinician or
Facility named on the Authorization Report for
the service.
• Box 3 Provider’s Invoice Number
• Box 4 Type of Bill
• Box 5 Federal Tax ID Number. It must be associated
with the Vendor information on your
Community Care contract.
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Critical Claim Elements (cont.)
Critical Details on a UB-92
• Box 6 Statement Covers Period - Must
include both the begin and end date.
• Box 7 Covered Days
• Box 8 Non-Covered Days
• Box 12 Member’s Name
• Box 13 Member’s Address
• Box 14 Member’s Birth Date (MMDDCCYY)
• Box 15 Member’s Sex
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Critical Claim Elements (cont.)
Critical Details on a UB-92
• Box 16 Member’s Marital Status
• Box 17 Admission Date (MMDDCCYY)
• Box 18 Admission Time (Military)
• Box 19 Admission Type
• Box 21 Discharge Hour
• Box 22 Member Discharge Status
• Box 38 Responsible Party Name & Address
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Critical Claim Elements (cont.)
Critical Details on a UB-92
•Box 42
•Box 43
•Box 44
•Box 45
•Box 46
•Box 48
3-Digit Revenue Code (Refer to the
Community Care Fee Schedule)
Revenue Code description
CPT or HCPCS Procedure Code
Service Date
Service Units
List Non-Covered charges
(If Block 8 is completed)
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Critical Claim Elements (cont.)
Critical Details on a UB-92
• Box 50 Enter Payer Identification Name
• Box 52 Release of Information Certification
(Patient Signature on File to authorize
payment to Facility / Provider)
• Box 54 Prior Payment - List amount paid by
other insurance
• Box 55 Enter Estimated Amount due
• Box 58A Enter Insured / Member’s Name
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Critical Claim Elements (cont.)
Critical Details on a UB-92
• Box 59A Member’s relationship to the Insured
(Always 18 - Self)
• Box 60A Member Number (10-Digit Recipient #)
• Box 61A Group Name
• Box 62A Insurance Group Number
• Box 64A Employment Status
• Box 65A Employer Name
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Critical Claim Elements (cont.)
Critical Details on a UB-92
• Box 66A Employer Location
• Box 67 Principal Diagnosis Code (290-319,
799.9 0r 995.5)
• Box 68-75 ‘Other’ Diagnosis Codes
• Box 76 Admission Diagnosis Code
• Line 82 Attending Physician’s State License
Number (Enter on the First Line)
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Critical Claim Elements (cont.)
Critical Details on a UB-92
• Box 82 Physician’s Name (Second Line)
• Box 83A Other Physician’s Identification
• Box 83B Physician’s UPIN Number
• Box 84 Provider’s Vendor Name, Address,
Zip Code. Information should mirror
contract.
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Critical Claim Elements (cont.)
Critical Details on a UB-92
• Box 85 Name of Physician, Clinician or Facility
named on the Authorization Report
• Box 86 Date Bill Submitted
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Critical Claim Elements (cont.)
Critical Details on a CMS-1500
• Box 1 ‘X’ in Medicaid Box
• Box 1a 10-digit Medicaid Recipient Number
• Box 2 Member’s Name (Last, First, Middle)
• Box 3 Member’s Birth Date (MMDDYY and Sex)
• Box 4 Insured’s Name (Last, First, Middle)
• Box 5 Member’s Address
• Box 6 Member’s Relationship to Insured (Self)
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Critical Claim Elements (cont’)
Critical Details on a CMS-1500
• Box 7 Member’s Address
• Box 8 Member’s Status
• Box 9 Other Insured’s Name (Last, First, Middle)
• Box 9A Other Insured’s Policy or Group
• Box 9B Other Insured’s Date of Birth
• Box 9C Employer’s Name or School Name
• Box 9D Insurance Plan Name or Program Name
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Critical Claim Elements (cont’)
Critical Details on a CMS-1500
• Box 10A-C Member’s Condition related to
employment, auto accident and/or other
accident
• Box 11 Insured Policy Group or FECA number
• Box 11A Insured’s Date of Birth / Sex
• Box 11B Employer’s Name or School
• Box 11C Insurance Plan Name or Program Name
• Box 11D Is there another Health Benefit plan?
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Critical Claim Elements (cont’)
Critical Details on a CMS-1500
• Box 12 Member’s or Authorized Person’s
signature (Signature on File)
• Box 13 Insured or Authorized Person’s Signature
• Box 21 Diagnosis or Nature of Illness, Injury
290-319, 799.9 or 995.5
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Critical Claim Elements (cont’)
Critical Details on a CMS-1500
• Box 24A Date of Service (Must include
From and To dates)
• Box 24B Place of Service
• Box 24D Refer to the Community Care Fee
Schedule
• Box 24E Diagnosis Code
• Box 24F Total Charges billed for the service line
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Critical Claim Elements (cont’)
Critical Details on a CMS-1500
• Box 24G Total Days or Units billed for the line
• Box 25 Federal Tax ID Number
• Box 26 Patient Account Number
• Box 28 Total Charges, enter sum of column 24F
• Box 29 Amount paid by the Other Insurance
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Critical Claim Elements (cont’)
Critical Details on a CMS-1500
• Box 30 Balance Due from Community Care
• Box 31 Name of Physician, Clinician or Facility
named on the Authorization Report.
• Box 32 Name and Address of the Facility where
services were rendered.
• Box 33 Provider’s Vendor Name, Address, Zip
Code and Telephone number.
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Critical for Correct Payment
• Member Number MUST be the 10-Digit Medicaid
Recipient Number
• Provider’s 13-Digit PROMISe Number
• Name of the Physician, Clinician or Facility, which
appears on the UB-92 or CMS-1500, MUST mirror
the service and date, which appears on the
‘Authorization Report’.
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Initial Claims Submission - Paper
• Paper Claims Submission
Mail Original North Central Member
Claims to:
CCBHO
P.O. Box 2972
Pittsburgh, PA 15230
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Initial Claims Submission - Paper
• If North Central Member Claims are mailed to
an address other than the address listed on the
previous slide, the claims will not be
processed or paid.
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Initial Claims Submission - EDI
• Providers have the ability to directly submit claims by
sending a 837I / 837P. To become a direct submitter
please contact Bill Simmons at (412) 454-8609.
• Providers also have the ability to submit claims using
Emdeon/WebMD.
– Providers who chose this method would contract
respectively with Emdeon/WebMD.
– The Emdeon/WebMD payer name is Community
Care BHO and the payer ID # is 23282.
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Initial Claims Submission
Provider Online
• Providers have the ability to submit claims via the internet
using ‘Provider Online’.
• Access Provider Online by using the following link:
https://online.ccbh.com/ccbhproduction
• Before you can submit direct claims, a tutorial must be
completed. The online tutorial is called the ‘OnLine Claims
Submission Tool’. Access the tutorial at
https://online.ccbh.com/elearning. This tutorial is provided
at no cost to providers.
• After the tutorial, an assessment is required. To obtain
security access to ‘Provider Online’, the user must pass the
assessment with a minimum score of 80%.
• Submit the results of the assessment and send an email to
simmonswj@ccbh.com with the subject line of Provider
Online.
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Secondary Claims Submission
• Secondary Claims Submission (Third Party Liability)
must be submitted via Paper Claims; UB-92 or CMS-
1500.
• Copy of the Primary Payer’s EOB / Remittance must
be submitted with the Claim Form (Do not staple to
the claim form)
• Community Care reimburses only those dollars
identified as ‘Patient Responsibility” on the Primary
Payer's EOB / Remittance. (Co-Pay, Deductible etc.)
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Corrected Claims
• Corrected UB-92 claims can be submitted via EDI
or Provider Online by utilizing the correct Bill
Type.
• Corrected CMS-1500 claims must be submitted in
paper.
• Corrected claims must be submitted anytime a
‘Critical’ component of a claim is to be changed.
• A copy of the original claim with “Corrected
Claim” written on the top of the form.
• Draw a line through the incorrect information and
write the correct information directly on the form.
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Claim / Authorization Status
• Using ‘Provider Online’ provider’s have the ability to
check the status of claims submitted.
• ‘Provider Online’ can also be accessed to view
authorizations.
• No assessment is required to obtain security access to
view Claim / Authorization status.
• Access ‘Provider Online’ by using the following link:
https://online.ccbh.com/ccbhproduction.
• Security is required. All new users must Sign up to be
provided a user id and password.
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Provider Facts
What Diagnosis / Service codes are acceptable?
• Community Care accepts ICD-9 Diagnosis codes.
• Psychiatric diagnosis range is 290-319, 799.9 or 995.5.
• Diagnosis codes must be billed to the 5 th digit.
• Do not bill V-Codes.
• Do not bill DSM Codes.
• Billable codes are listed on the Community Care Fee
Schedules.
• Make sure billable codes include any applicable
modifiers or services will be paid incorrectly or deny.
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Provider Payment
Payment Methodology:
• Community Care will generate reimbursement
to the Providers on a weekly basis.
• Providers have the ability to receive payment
via Electronic Funds Transfer. To receive
EFT’s, complete the EFT authorization form
and contact your provider representative.
• Providers who bill electronically can receive
an 835 file.
• Providers who do not bill electronically will
receive a paper remittance and a check.
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Reminders
• The North Central Presentation is exclusively for
providers contracted for the North Central
Counties. Providers who are contracted for other
counties must continue to bill DST HEALTH
SOLUTIONS.(Adams, Allegheny, Berks, Chester,
Lackawanna, Luzerne, Susquehanna, Wyoming
and York)
• Questions regarding Credentialing, Contracting, Fee
schedules, and EFT’s should be directed to your
Provider Representative.
• Contact the Claims Department with questions
regarding Claims and/or Provider Online Access at 1-
888-251-2224 and follow the North Central prompts.
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Thank You
Community Care would like
to thank you for your attendance.
We are looking forward to working
with you in the months to come.
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