2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Claims and Paymentsubmission. Claims listed on the acceptance reportare transmitted to Presbyterian. You then receiveeither an acceptance or rejection report fromPresbyterian through the clearinghouse.If You Encounter ProblemsIssue: An electronic claim is rejected by theclearinghouse as “unclean.”Solution: Call the clearinghouse within 48 hours ofreceipt of the rejection report.Issue: An electronic claim is accepted byPresbyterian but does not show as paid in yoursystem.Solution: Check the claim status online or contactthe Provider Claims Activity Review and Evaluation(CARE) Unit through their online web form within30 days from the date of service.Issue: A claim is rejected by Presbyterian with anerror message that you do not understand.Solution: Contact your clearinghouse or yourprovider network management relationshipexecutive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf)within 48 hours of receipt of the rejection report forthe needed information so that you can submit yourclaim.Issue: You consistently submit claims that are notshowing in Presbyterian’s claims system and thatare not recorded on your error reports that youreceived from your clearinghouse and Presbyterian.Solution: Contact your provider networkmanagement relationship executive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdfhttps://docs.phs.org/idc/groups/public/@phs/@php/documents/phscontent/pel_00140718.pdf) and discussthe issue. If the issue is determined to be atechnical problem, your provider networkmanagement relationship executive(http://docs.phs.org/idc/groups/public/%40phs/%40php/documents/phscontent/pel_00140718.pdf)coordinates contact with Presbyterian’s InformationServices Department. It is important to check on aregular basis to ensure that the claims are notdenied for lack of timely filing. Also, please be sureto keep detailed records regarding this activity.Paper Claims Submission ProcessPaper claims are printed on a form and mailed toPresbyterian. Presbyterian requires all providers touse one of two forms when billing hard copy paperclaims, the CMS 1500 (02-12) or the UB-04.A complete itemization and medical records arerequired for all claims with billed amounts of$100,000 or greater. Payment will be deniedwithout these documents.CMS 1500The CMS 1500 (02-12) billing form is used whensubmitting claims for all professional services,including ancillary services and professionalservices billed by a hospital. The CMS 1500 (02-12) is available to providers as of January 6, 2014,and is the only acceptable version of this form. Box21 of these forms requires the use of ICD-10 codesand they should be billed in sequential alphabeticalorder. Diagnosis pointer in box 24E should be billedalpha as well.18-32014 Practitioner and Provider Manual - Ver. 3