GATEWAY Health Plan Medicare AssuredÂ® Provider ... - CBHNP

More documents

Recommendations

Info

Gateway Health Plan Medicare Assured ® Provider Manual 2011 When you receive a denial requesting Coordination of Benefits (COB) information, you should resubmit the claim with the primary carriers EOB’s. When submitting claims to Gateway Health Plan Medicare Assured ® as a secondary payer, the EOB (Explanation of Benefits) from the primary insurer must be attached to the claim. Claims with attached EOB must be submitted within 180 days of your notification of payment or denial by the other insurance company. Expectations for Gateway Health Plan Medicare Assured ® Response to Claims Submission Gateway Health Plan Medicare Assured ® will pay all “clean” claims (claims that are accurate and complete) within forty-five (45) days. Our goal is to provide payment as quickly as possible and to pay most claims within thirty (30) days of receipt of a clean claim. If you have not heard from Gateway Health Plan ® within 30 days after you sent the claim in, please contact Provider Services at 1-800-685-5205 to inquire as to the status of the claim. If Gateway Health Plan ® indicates the claim was not received, Providers will be asked to resubmit the claim immediately. It is imperative that Providers closely monitor their claims submissions to identify potential issues quickly. Checking on the Status of a Claim You may check the status of a claim during normal business hours by calling Provider Services at 1-800-685- 5205. To make an inquiry, you will need to provide the provider/facility name, Member’s name and identification number, the procedure code(s) and the date(s) of service for which you are billing. Again, if you have not heard from Gateway Health Plan Medicare Assured ® on a claim within 30 days of the date you believe it was submitted, contact Gateway Health Plan ® immediately as this may indicate that the claim was not received. If Gateway Health Plan ® indicates the claim was not received, Providers will be asked to resubmit the claim immediately. Claims Appeals Claims appeals are subject to the Member Reconsideration/Appeal process outlined in Chapter VIII. Members may request reconsideration of prior authorization denials or of claim payment denials. Providers may address claim payment denials via the Provider Appeal Process. Revised 12/12/10 48
Gateway Health Plan Medicare Assured ® Provider Manual 2011 CMS-1500 (08-05) Data Elements for Submission of Paper Claims Forms EDI requirements must be followed for Electronic claims submissions Field # Description Requirements 1 Insurance Type Required 1a Insured Identification Number Gateway Health Plan ® Member Identification Number 2 Patient’s Name Required 3 Patient’s Birth Date Required 4 Insured’s Name Required 5 Patient’s Address Required 6 Patient Relationship to Insured Required 7 Insured’s Address Required 8 Patient Status Required 9 Other Insured’s Name Required, If Applicable 9a Other Insured’s Policy or Group Number Required, If Applicable 9b Other Insured’s Date of Birth, Sex Required, If Applicable 9c Employer’s Name or School Name Required, If Applicable 9d Insurance Plan Name or Program Name Required, If Applicable 10 Is Patient Condition Related to: Required, If Applicable a. Employment b. Auto accident c. Other accident 10d Reserved for Local Use Not Required 11 Insured’s Policy Group or FECA Number Required 11a Insured’s Date of Birth, Sex Required, If Applicable 11b Employer’s Name or School Name Required, If Applicable 11c Insurance Plan Name or Program Name Required, If Applicable 11d Is There Another Health Benefit Plan? Required, If Applicable 12 Patient or Authorized Person’s Signature Required 13 Insured’s or Authorized Person’s Signature Required 14 Date of Current: Illness OR Injury OR Required, If Applicable Pregnancy 15 If Patient has had Same or Similar Illness, Not Required Give First Date 16 Dates Patient Unable to Work in Current Required, If Applicable Occupation 17 Name of Referring Practitioner or Other Required, If Applicable Source 17a, b Identification Number of Referring Not Required Practitioner 18 Hospitalization Dates Related to Current Required, If Applicable Services 19 Reserved for Local Use May be Required in Specific Circumstances (Consult CMS Criteria) 20 Outside Lab Not Required 21 Diagnosis or Nature of Illness or Injury Required 22 Medical Resubmission Code Not Required 23 Prior Authorization Number Not Required 24a Date(s) of Service Required 24b Place of Service Required 24c EMG Not Required 24d Procedures, Services, or Supplies Required CPT/HCPCS/Modifier 24e Diagnosis Code Pointer Required 24f Charges Required 24g Days or Units Required 24h EPSDT Family Plan Not Required Revised 12/12/10 49
Page 1 and 2: GATEWAY Health Plan Medicare Assure
Page 3 and 4: Gateway Health Plan Medicare Assure
Page 17 and 18: Provider Profiling Gateway Health P
Page 47: Gateway Health Plan Medicare Assure
Page 83: Gateway Health Plan Medicare Assure

GATEWAY Health Plan Medicare AssuredÂ® Provider ... - CBHNP

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?