Provider News Brief Gateway Health Plan Medicare ... - CBHNP

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CLAIMS MAILING ADDRESS Gateway’s claims office moved from Albany, New York to Harrisburg, PA. The new mailing address for Medical and Behavioral Health Claim forms is: Gateway Health Plan ® P.O. Box 69359 Harrisburg, PA 17106-9359 Please be advised that submitting claims to the incorrect mailing address may result in a delay in claims processing or possibly Gateway not receiving the claim at all. Gateway issued new Member ID cards to all existing members which includes the new address information. Just a reminder, please remember to check eligibility at each service. ELECTRONIC CLAIMS SUBMISSION Requirements for Submitting Claims to Gateway Health Plan ® through Emdeon and RelayHealth To submit claims to Gateway Health Plan Medicare Assured ® please note the Payer ID Number is 60550. Gateway Health Plan ® has a health plan specific edit through Emdeon and RelayHealth for electronic claims that differs from the standard electronic submission format criteria. The edits requires: • A Gateway Health Plan Medicare Assured ® assigned 8-digit Member identification number; the Member number field allows 8 or 12 digits to be entered. For providers who do not know the Member's Gateway Health Plan Medicare Assured ® identification number it is acceptable to submit the Member's HIC Number on electronic claims. In addition to edits that may be received from Emdeon and RelayHealth, Gateway Health Plan Medicare Assured ® has a second level of edits that apply to procedure codes and diagnosis codes. Claims can be successfully transmitted to Emdeon or RelayHealth, but if the codes are not currently valid they will be rejected by Gateway Health Plan Medicare Assured ® . Providers must be diligent in reviewing all acceptance/rejection reports to identify claims that may not have successfully been accepted by Emdeon, RelayHealth and Gateway Health Plan ® . Edits applied when claims are received by Gateway Health Plan Medicare Assured ® will appear on an EDI Report within the initial acceptance report or claims acknowledgement report. A claim can be rejected if it does not include current procedure and diagnosis codes. To ensure that claims have been accepted via EDI, practitioners should receive and review the following reports on a daily basis: • Emdeon -- Provider Daily Statistics (RO22) • Emdeon -- Daily Acceptance Report by Provider (RO26) • Emdeon -- Unprocessed Claim Report (RO59) Medicare Assured ® Provider News Brief February 2012 Page 2 of 21
• RelayHealth – Claims Acknowledgement Report (CPI 651.01) • RelayHealth – Exclusion Claims Report (CPI 652.01) • RelayHealth – Claims Status Report (CPA 425.02) HIPAA 5010 Electronic Claim Submission Effective 1/1/2012 Changes in the 5010 requirements that may impact claims. Effective 1/1/2012, the billing provider address submitted on claims MUST be a physical address. Effective 1/1/2012, providers can no longer use a P.O. Box number address as a billing address. Claims submitted via Emdeon or RelayHealth may be REJECTED if a P.O. Box number is submitted as the billing address. In order to prevent claims from being rejected, please be sure to submit a physical address as the billing address. If you are not submitting claims electronically, please contact either your Gateway Health Plan Medicare Assured ® Provider Relations Representative or an EDI vendor for information on how you can submit claims electronically. You may also call Emdeon directly at 1-877 469-3263 or RelayHealth at 1-800 545-2488 (phone numbers are current as of October 2008). Gateway Health Plan ® will accept electronic claims for services that would be submitted on a standard CMS-1500 or a UB-04 Form. However, the following cannot be submitted as attachments along with electronic claims at this time: • Claims with EOBs CONFIDENTIALITY Gateway Health Plan Medicare Assured ® Providers will seek to assure that beneficiary personal and clinical information is kept secure and confidential, and that access will be permitted for treatment, payment or healthcare operations or as permitted or required by law. Additional access will be limited to those authorized persons as identified by valid releases signed by the beneficiary. Providers are required to abide by all state and federal laws and regulations in regards to Member confidentiality, including HIPAA. To guarantee Beneficiary confidentiality, Gateway Health Plan ® and CBHNP comply with federal and state regulations governing the release of client information (disclosure of confidential information) and record retention. Gateway Health Plan ® and CBHNP maintain strict policies concerning internal security, review processes, disposal of confidential documents and distribution of statistical information. Gateway Health Plan ® and CBHNP also require all Providers to adhere to strict confidentiality measures including: • Password protection of on-line Beneficiary information. • Written consent from Beneficiary/guardian is required before disclosure of any information, except as allowed by law, (e.g., emergency treatment, under court-order, etc.). Drug and Alcohol services require Beneficiary consent regardless of age. • Beneficiaries, 14 years and older, receiving mental health services shall control the release of their medical record. Any release of information forms needed shall be signed by the beneficiary, when the beneficiary is 14 years or older. Drug and Alcohol services require beneficiary consent regardless of age. Medicare Assured ® Provider News Brief February 2012 Page 3 of 21
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Provider News Brief Gateway Health Plan Medicare ... - CBHNP

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