2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Claims and PaymentAcceptable documentation includes computerledgers, written logs, and records of calls toPresbyterian (include date and contact name). Theexception report from Presbyterian or the ECTclearinghouse is required for ECT claims.Documentation that is not acceptable includes aregenerated claim.Submitted documentation must be legible andclearly identify the member, the charges inquestion, date of service, and original billed date.Proof of timely filing may be rejected if thesubmitted documentation cannot be clearly linkedto the claim in question. Any proof of timely filingmust be submitted within 12 months of the date ofservice. We encourage you to follow up on thestatus of your requests every 30 to 45 days. If youcontinue to receive no payment or documentationon your claim, contact the Provider CARE Unit.If a member fails to notify the provider that he orshe is covered through Presbyterian at the time ofservice, documentation that attempts were made todetermine the member’s coverage is required.Acceptable documentation includes:A copy of the patient information sheet thatindicates that insurance information was notprovidedWritten communication from the member verifyingthat he or she failed to notify the provider ofcoverage at the time of serviceA change in the provider’s office billing personnel isnot a valid reason to resubmit claims. You areencouraged to contact members regarding pastduepayments if the members do not respond tobilling statements. This helps determine if themember is covered by Presbyterian.“Clean” ClaimsPresbyterian has adopted CMS claims processingguidelines to ensure timely and accurate claimspayment by Presbyterian on behalf of members.The timeliness for processing a claim can be drivenby whether or not the claim is “clean.” Accuracyand completeness of the information provideddetermine if the claim is considered “clean” or“unclean.”A claim is defined as “clean” if it contains all of therequired data elements necessary for accurateadjudication without the need for additionalinformation from a source outside of Presbyterian,and if it has no defect or impropriety, including butnot limited toThe failure of an electronically transmitted claim tomeet HIPAA transaction standards with regard toformat or contentThe lack of required substantiation or particularcircumstances requiring special treatment thatprevents timely payment being made on the claimA claim may be “clean” even though Presbyterianrefers it to a medical specialist within Presbyterianfor examination.“Unclean” ClaimsA claim is defined as “unclean” if additionalsubstantiating documentation (such as medicalrecords, encounter data, emergency room reports,primary insurance explanation of payments, and fullitemization where necessary) is required from asource external to Presbyterian Centennial Care.18-152014 Practitioner and Provider Manual - Ver. 3