2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Claims and PaymentEncounter ReportingPresbyterian is required by HSD to report allservices rendered to Presbyterian Centennial Caremembers. The reporting of these services, alsoknown as encounter data reporting, is an essentialelement to the success of Presbyterian CentennialCare.HSD uses encounter data reporting to evaluatehealth plan compliance on many vital issues.Regardless of whether the service you provide iscapitated or fee-for-service, claims should besubmitted to Presbyterian within 90 days of thedate of service to accommodate the State of NewMexico’s request for timely encounter data.Presbyterian is required to submit encounter datato the State of New Mexico within 120 days.Providers are required to submit to Presbyteriancomplete encounter data in a form acceptable toand meeting Presbyterian’s standards. Encountersmust be submitted within 90 calendar days of thedate of service for outpatient services or the date ofdischarge for inpatient services in an approvedformat. Presbyterian accepts encounters submittedon CMS 1500 (02-12) and UB claim forms or anequivalent or substitute approved by Presbyterian.Providers identify services rendered to members byusing appropriate diagnosis and procedure codesas defined by the CPT and/or ICD-9-CM orsubsequent editions. In accordance with Section2702 of the Patient Protection and Affordable CareAct (PPACA), Presbyterian has mechanisms inplace to preclude payment to providers for providerpreventableconditions. Providers report providerpreventableconditions through the claimssubmission process. Presbyterian tracks providerpreventableconditions data and reports data toHSD through encounter data.Correct Coding StandardsPresbyterian uses a Correct Coding Standards(CCS) claim editing system to ensure consistentprocessing of professional and facility claims and todecrease manual intervention. This interfaceapplies pattern recognition and intelligent reasoningto identify potential incorrect payments beforeclaims are paid.Presbyterian applies the National Correct CodingInitiative (NCCI) policy manual, McKesson edits,and other edits based on coding industry standardsfor consistency in the processing of certain codepairs. CMS standards require that providers mustcode correctly even if CCS edits do not exist. Thispromotes consistency of claims submission andreimbursement and prevents the use ofinappropriate code combinations.There are times when Presbyterian reviews certainedits and determines that they may not beappropriate to our current purpose:–to improve thehealth of the patients, members, and communitieswe serve. Most of these reviews are the result ofappeals that are received by the Appeals andGrievances Department at Presbyterian.Presbyterian reviews these edits to determine ifthey are clinically appropriate for situations thatmay arise when providing care to our members.If it is determined that a certain edit does notsupport our purpose, Presbyterian either removesthe edit or revises it. Presbyterian is supportive of18-162014 Practitioner and Provider Manual - Ver. 3