2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
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Claims <strong>and</strong> PaymentQuicker confirmation of claims receipt <strong>and</strong> integrityof the data, higher percentage of claims accuracy,resulting in faster paymentRequired HIPAA formatting of claims dataANSI-X12 837 claims formatTypically free service for claims submitted to<strong>Presbyterian</strong>RequirementsYou need:A compatible computer system; check with theclearinghouse technical representative forPC/Macintosh compatibility informationA billing system that can produce the data requiredby the HIPAA compliant claim format (ANSI X12837 version 5010); check with your clearinghousetechnical representative to determine thisA modem or internet connectionTwo important aspects of <strong>Presbyterian</strong>’srelationship with the clearinghouses are compliance<strong>and</strong> data protection. New Mexico legislationenacted during 2001 requires stringent approachesto protecting both personal health information <strong>and</strong>personal financial information. HIPAA legislationrequires even more exacting procedures <strong>and</strong>processes to ensure data is protected. <strong>Presbyterian</strong><strong>and</strong> its contracted clearinghouses work to ensurethat all data is appropriately protected as it movesthrough the electronic environment needed to fosterrapid <strong>and</strong> accurate payment.How to Begin Filing ElectronicallyYou may begin filing electronically by calling one orseveral of the clearinghouses listed at the end ofthe e-Business chapter. <strong>Presbyterian</strong> hascontracted with these companies to provide youwith the software that enables you to transmitclaims electronically. All of these companies areendorsed by <strong>Presbyterian</strong> <strong>and</strong> they help you getstarted <strong>and</strong> provide timely <strong>and</strong> accurate processingof your claims.The clearinghouse asks you some questions, morethan likely sends you an informational packet, <strong>and</strong>may ask you to fill out <strong>and</strong> send in a questionnaireto help determine your needs. You may comparethe services available through each clearinghouse.The service is free for claims submitted to<strong>Presbyterian</strong>. There may be additional services theclearinghouse can provide at an additional cost toyour office, including the submittal of claims toother payers. The clearinghouse evaluates yoursystem, sets up a test, <strong>and</strong> instructs you in the useof their system. You are up <strong>and</strong> running quickly,barring any major problems.You do not need to notify <strong>Presbyterian</strong> to startbilling electronically. However, you do need your<strong>Presbyterian</strong> assigned provider number <strong>and</strong> youmust have a National <strong>Provider</strong> Identifier (NPI). Youmust also provide your tax identification number tosubmit an electronic claim. For special concerns orbilling issues, first contact your provider networkmanagement relationship executive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf) foradvice. <strong>Presbyterian</strong> does not pay claims if an NPIis NOT submitted. More information regarding NPIis discussed later in this chapter.You receive either an acceptance or rejectionreport from the clearinghouse within one day of18-22014 <strong>Practitioner</strong> <strong>and</strong> <strong>Provider</strong> <strong>Manual</strong> - Ver. 3
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