2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Claims and PaymentPresbyterian is responsible for paying thepractitioner or provider any difference betweenwhat the member’s cost sharing is as a MedicareAdvantage member and the cost sharing underFee-for-Service (FFS) Medicare for non-hospicerelated services. The member’s cost sharing isbased on their Medicare Advantage plan/coverage.Claims for services covered by Presbyterian’sMedicare Advantage Plans, above and beyondthose of Original Medicare, should be filed toMedicare Advantage for processing. Examples ofthese services include routine (not medicallynecessary) eye and vision exams, routine podiatry,and outpatient prescription drug coverage notalready covered under Original Medicare.Medicare Part D Description Drug CoverageMedicare Part D Prescription Drug Coverage isavailable to individual Medicare-eligiblebeneficiaries in two of the three Presbyterian SeniorCare (HMO) plans and two of the three plansoffered by Presbyterian MediCare PPO. Some ofthe Employer Group plans also have Medicare PartD coverage already built in.Please verify the member’s identification card at thetime of service. If the member’s coverage and planincludes prescription drug coverage, it will be notedon the member’s ID card, identified by specific planand benefit coverage as noted above.Filing Claims with Coordination of Benefits(COB)Presbyterian coordinates benefits in accordancewith CMS regulations and National Association ofInsurance Commissioners guidelines.When the member’s primary carrier is notPresbyterian, the primary carrier’s Explanation ofBenefits (EOB) or Explanation of Payment (EOP)must be provided when submitting the claim toPresbyterian for consideration.Presbyterian requires all COB claims be submittedwithin 90 days from the paid date on the primarycarrier’s EOB or EOP.Once you have billed the other carrier and receivedan EOB/EOP, submit the claim and matchingEOB/EOP to Presbyterian. When submitting theclaim electronically, the EOB/EOP may also bebilled electronically in an 837 compliant transaction.When submitting a paper claim, submit thematching EOB/EOP with the claim.The EOB/EOP must be complete in order tounderstand the paid amount or the denial reasonand must match the billed services for the member.Claims submitted without an EOB/EOP will bedenied.Presbyterian providers may bill the member forapplicable co-pays, co-insurance, and deductibles.Adjustment Requests Involving COBReview all explanation codes on your EOP todetermine if the denial was because of insufficientinformation or if the claim was submittedincorrectly. Corrected claims submitted mustinclude all charges to be considered with thecorrections clearly indicated, and must meet timelysubmission guidelines. A copy of the EOP shouldbe included along with your corrected claim.18-112014 Practitioner and Provider Manual - Ver. 3