2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

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Claims and PaymentUB-04The UB-04 billing form is used when submittingclaims for hospital inpatient and outpatient services,dialysis services, nursing home room and board,and hospice services.National Provider IdentifierCMS requires that all health care providers acquirean NPI. In order to properly adjudicate and correctlydirect reimbursement, all fields containing providerinformation require an NPI. All providers, with theexception of sole practitioners, must acquire andsubmit the appropriate Type 2 organization NPI inthe appropriate field. Examples are physician grouppractices, hospitals, or durable medical equipmentsuppliers. Additional information on Type 1 andType 2 NPI is available athttps://nppes.cms.hhs.gov/.A provider who does not have an NPI will not beable toSubmit claims for paymentReceive payments from a health planAccess information from a health planYou can apply for an NPI online athttps://nppes.cms.hhs.gov.Interim Billing Process for Institutional ServicesInterim billing is to be used when a patient isconfined in a facility for an extended period of time.Interim billings should be submitted on a monthlybasis.Interim UB (facility) claims are identified by the BillType Frequency and the Patient Status code (30).The appropriate Bill Type Frequencies are asfollows:XX2: Indicates the beginning of the stay.XX3: Indicates the middle of the stay.XX4: Indicates the final bill.Presbyterian encourages the submission of thesemonthly billings within 45 days of the beginning ofthe period for which you are billing.Submitting Late Charges and Replacement Claimsfor Institutional ServicesIn accordance with the CMS, facilities must bill latecharges, corrections, or a replacement claim withthe appropriate bill type and frequency.The appropriate Bill Type Frequencies are asfollows:XX5: Outpatient hospital late charges.XX7: Outpatient hospital replacement charges.XX7: Inpatient hospital late or replacementcharges.Ambulatory Surgical Centers must submit latecharges or replacement charges on a CMS 1500(02-12) form.For outpatient hospital late charges (XX5), submitthe late charges only. Do not include the originalcharges. If the original charges are billed with thelate charges:Clearly indicate that the claim contains late chargesDo not combine late charges with the originalchargesSeparate the late charges so that the charges areeasily identified to avoid a duplicate payment18-42014 Practitioner and Provider Manual - Ver. 3
Claims and PaymentSpecify the original date of serviceSubmit late charges within 12 months of the date ofserviceSubmitting Corrections on a CMS 1500 (02-12)formSubmit all corrections for a CMS 1500 (02-12) formon paper. Clearly indicate that the resubmission isa corrected claim.Submitting Unlisted/Unclassified CodesAn unlisted/unclassified Current ProceduralTerminology (CPT) or Healthcare CommonProcedural Coding System (HCPCS) code may bebilled if no other appropriate code exists or a codehas not been assigned. If a code exists for aservice or procedure you are performing, you mustuse the correct code and not theunlisted/unclassified procedure code. This includesboth CPT and HCPCS Level II (alpha numeric)codes.Unlisted/unclassified CPT/HCPCS codes can beaccepted in the electronic 837 claim format. Whensubmitting an unlisted/unclassified codeelectronically, information may be entered as aservice note or claim level note.When submitting an unlisted/unclassified code on apaper claim, include the description on the claim oras an attachment.If the description is incomplete, Presbyterian mayrequire written documentation with the report andthe invoice for review and pricing.If the description of the unlisted/unclassified code isnot submitted, the service will be denied.Guidelines for Submitting Hemoglobin A1cClaims and Test ResultsPresbyterian requires the reporting of the actualresult of hemoglobin A1c tests (CPT code 83036)so that there is an accurate assessment of thedegree of control of the Presbyterian diabeticmember’s blood glucose. This helps Presbyteriandevelop or maintain diabetes-related qualityimprovement programs.When submitting charges for the A1c test, pleasefollow these guidelines:Report the test result as a three-digit number withno decimal point and a leading zero. For example,a test result of 5.8 is entered as 058.Presbyterian edits for valid values between 3.0 and20.0 (030 and 200). If the result is not within thisrange, the test is invalid.For UB-04 claims, the test date is the service date(field location 45, Service Date). If a service date isnot entered, the test date is the from date (fieldlocation 6, Statement Covers Period).Requirement for 837 ProfessionalThe following information outlines where the A1ctest results need to be reported in the 837professional and institutional electronic claimtransactions. Provide this information to yoursoftware vendors in order to properly configure yourelectronic claims submission software.This information pertains to claims submitted byproviders to the clearinghouse in the 837professional formats.Place the A1C data in the NTE02 segment of the2400 loop with the code qualifier of ADD18-52014 Practitioner and Provider Manual - Ver. 3
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Nurse Advice Line .................
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Pharmacy Benefits .................
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Clearinghouses ....................
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Site Visits .......................
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Monitoring ........................
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Federally Funded Terminations .....
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Appendix A. Acronyms ..............
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1. Presbyterian Healthcare Services
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Presbyterian Healthcare Services(HS
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Presbyterian Healthcare ServicesReg
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Presbyterian Healthcare Services2.
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Provider Network Managementthis man
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Centennial Care Overview3. Primary
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Primary Care ProvidersClaims Activi
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Primary Care Providers4. Specialist
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SpecialistsOther Information for PC
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Specialists5. Preventive Health Car
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Preventive Health Care GuidelinesPr
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Preventive Health Care GuidelinesSe
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Care Coordination6. Care Coordinati
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Care CoordinationPresbyterian’s c
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Care Coordinationthe program. If th
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Care Coordinationdesignated family
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Care CoordinationFacilitate access
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Care CoordinationClinical Practice
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Care Coordinationformula, which is
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Care CoordinationAmerican Psychiatr
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Care Coordinationwithout obtaining
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Care CoordinationSpecialists as PCP
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Care Coordinationor when the member
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Care Coordination11. Prevention Scr
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Care CoordinationFollow-up plans or
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Care CoordinationPharmacy BenefitsP
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Care CoordinationThis page intentio
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Laboratory ServicesTriCore Contact
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Pharmacya multi-tier formulary stru
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Pharmacymedications. This multi-tie
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PharmacyCatastrophic coverage: Cove
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Pharmacywhich drugs are mandated th
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PharmacyThe drug must be accepted f
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PharmacyTypes of Pharmacy Prior Aut
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PharmacyThis page intentionally lef
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Behavioral Healthagreements, addend
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Behavioral HealthForm W-9Staff rost
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Behavioral Healthhttps://www.phs.or
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Behavioral HealthAn initial PCP con
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Behavioral HealthAccess StandardsMe
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Behavioral HealthThere is no charge
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Behavioral HealthThis page intentio
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Long-Term Carean individual provide
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Long-Term Careavailable services, a
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Long-Term Carethe agent to members
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Long-Term Carecare at the right tim
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Long-Term Careplanning process, and
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Long-Term Carebudget plan are suffi
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Long-Term CareOrganizationsFor the
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Home HealthPresbyterian’s credent
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Home HealthPresbyterian Medicaid me
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Home Healththese services. Services
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Home Healthfor review will be submi
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Home HealthPatient Care Conferences
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Home HealthThis page intentionally
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Quality Improvement ProgramNational
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Quality Improvement Programcomplian
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Quality Improvement Programresults
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Quality Improvement Programrespect
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Quality Improvement ProgramPresbyte
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Quality Improvement ProgramNCQA ori
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Page 147 and 148: Health Insurance Portability and Ac
Page 149 and 150: Health Insurance Portability and Ac
Page 151 and 152: Legalabove, nor from any recourse a
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Page 155 and 156: Legaltransactions (federal, state,
Page 157 and 158: Legalcontractual relationship with
Page 159 and 160: Legalcomply with all state and fede
Page 161 and 162: Legalany such program during the te
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Page 165 and 166: Legal15. Fraud, Waste, and Abuse15.
Page 167 and 168: Fraud, Waste, and Abuseas the time
Page 169 and 170: Fraud, Waste, and AbuseAll document
Page 171 and 172: Fraud, Waste, and AbuseVerifying th
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Page 175 and 176: Fraud, Waste, and Abuseis violated
Page 177 and 178: Fraud, Waste, and AbuseIs informed
Page 179 and 180: Fraud, Waste, and Abuse16. Credenti
Page 181 and 182: Credentialing and RecredentialingPr
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Page 187 and 188: e-BusinessFill out the form on the
Page 189 and 190: e-BusinessSign Up for this Free Ser
Page 191 and 192: e-BusinessClearinghouse Contact Inf
Page 193 and 194: e-Business18. Claims and Payment18.
Page 195: Claims and Paymentsubmission. Claim
Page 199 and 200: Claims and Paymentrequiring a leadi
Page 201 and 202: Claims and PaymentPlease note that
Page 203 and 204: Claims and PaymentPresbyterian is r
Page 205 and 206: Claims and Paymentnot made a recove
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Page 209 and 210: Claims and Paymentallowing provider
Page 211 and 212: Claims and PaymentNational Correct
Page 213 and 214: Claims and Payment19. Presbyterian
Page 215 and 216: Presbyterian Customer Service Cente
Page 227 and 228: Appeals and Grievances20. Appeals a
Page 229 and 230: Appeals and GrievancesMember Appeal
Page 231 and 232: Appendix A. AcronymsAppendix A. Acr
Page 233 and 234: Appendix A. AcronymsHMOHRAHSDHealth
Page 235 and 236: Appendix A. AcronymsWWEDIWorkgroup
Page 237 and 238: Appendix B: DefinitionsAppendix B.
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Appendix C. WebsitesAppendix C. Web
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Appendix C. WebsitesWebsitesNameCul
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Appendix C. WebsitesWebsitesNameMem
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Appendix C. WebsitesWebsitesNameWED
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Appendix C. WebsitesAppendix D. Pho
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Appendix D. Phone NumbersPhone Numb
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Appendix B: Business Associate Agre
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Appendix E. Business Associate Agre
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Appendix E. Business Associate Agre
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Appendix F. Prior Authorization Gui
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Appendix G. Alternative BenefitsG.
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Appendix G. Alternative Benefits Pa
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