Articles on this Page
- 09/06/16--00:05: _Critical Care Servi...
- 09/06/16--00:07: _When Beneficiary St...
- 09/10/16--23:56: _what provider can d...
- 09/14/16--00:07: _Teaching Physician ...
- 09/17/16--22:37: _Form CMS-1500 Items...
- 09/20/16--00:26: _UB 04 Clean claim s...
- 09/24/16--22:43: _Remark code MA114 -...
- 09/27/16--22:45: _Billing tips for di...
- 09/30/16--22:47: _Billing tips for La...
- 10/03/16--23:33: _Paper Claim Submiss...
- 10/06/16--00:59: _ Claims Processing...
- 10/10/16--23:37: _Different way of su...
- 10/14/16--23:35: _Condition for Clean...
- 10/18/16--21:51: _Concept of Retroact...
- 10/22/16--22:59: _CLIA approved CPT l...
- 10/26/16--23:21: _How to bill inpatie...
- 10/30/16--22:52: _What is Healthcare ...
- 11/04/16--03:10: _ Carrier Receipted ...
- 11/10/16--02:52: _Present On Admissio...
- 11/10/16--23:17: _Meaning of Accept A...
- 09/10/16--23:56: what provider can do after termination from Medicare ?
- 09/14/16--00:07: Teaching Physician Criteria billing critical care
- 09/17/16--22:37: Form CMS-1500 Items Affected the reporting
- 09/20/16--00:26: UB 04 Clean claim submission
- 09/27/16--22:45: Billing tips for dialysis patient capitation payment - code N290
- 09/30/16--22:47: Billing tips for Laboratory claims in CMS 1500
- 10/03/16--23:33: Paper Claim Submission Requirements
- 10/06/16--00:59: Claims Processing and Payment (PCIP) program
- 10/10/16--23:37: Different way of submitting corrected claim
- 10/14/16--23:35: Condition for Clean claim
- 10/18/16--21:51: Concept of Retroactive Eligibility and Spouse and Dependent Coverage
- 10/22/16--22:59: CLIA approved CPT lab code list
- 10/30/16--22:52: What is Healthcare Fraud and abuse ?
- 11/04/16--03:10: Carrier Receipted Bill - Definition
- 11/10/16--02:52: Present On Admission (POA) Indicators
- 11/10/16--23:17: Meaning of Accept Assignment ?
Preoperative critical care and/or postoperative care may be paid in addition to a global fee if the patient is critically ill and requires the full attention of the physician, and the critical care is unrelated to the specific anatomic injury or general surgical procedure performed. Such patients may meet the definition of being critically ill and criteria for conditions where there is a high probability of imminent or life threatening deterioration in the patient’s condition.
• For preoperative care modifier -25 (significant, separately identifiable evaluation and management services by the same physician on the day of the procedure) must be used with the HCPCS code
• For postoperative care modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) must be used with the HCPCS code.
In addition, for each preoperative and postoperative care the diagnosis must clearly indicate that the critical care was unrelated to the surgery.
Medicare recognizes the ventilator codes (CPT codes 94002 - 94004, 94660 and 94662) as physician services payable under the physician fee schedule. Medicare Part B under the physician fee schedule does not pay for ventilator management services in addition to an evaluation and management service (e.g., critical care services, CPT codes 99291 - 99292) on the same day for the patient even when the evaluation and management service is billed with CPT modifier -25.
A. Enrollee Signature Requirements
A request for payment signed by the enrollee must be filed on or with each claim for charge basis reimbursement except as provided below. All rules apply to both assigned and unassigned claims unless otherwise indicated.
1. When no enrollee signature required:
a. Claim submitted for diagnostic tests or test interpretations performed in a medical facility which has no contact with enrollee.
b. Unassigned claim submitted by a public welfare agency on a bill which is paid.
c. Enrollee deceased, bill unpaid and the physician or supplier agrees to accept Medicare approved amount as the full charge.
2. When signature by mark is permitted: The enrollee is unable to sign his name because of illiteracy or physical handicap.
3. When another person may sign on behalf of the enrollee:
a. Enrollee who is resident of a nonprofit retirement home gives power of attorney to the administrator of the home.
b. Enrollee physically or mentally unable to transact business: The request may be signed by a representative payee, legal representative, relative, friend, representative of an institution providing the enrollee care or support, or of a governmental agency providing him/her assistance.
c. Enrollee physically or mentally unable to transact business and full documentation is supplied that the enrollee has no one else to sign on his behalf: The physician, supplier, or clinic may sign.
d. Enrollee deceased and bill paid or liability assumed: Person claiming payment should sign. If Form CMS-1500 was signed before the enrollee dies, claimant should sign separate request for underpayment.
4. When request retained in file may cover extended future period:
a. Assignment in files of welfare agency covers all services furnished during the period when the enrollee is on medical assistance.
b. Authorization in files of organization approved under §22.214.171.124 covers all services paid for by that organization under that procedure.
c. Assignment in the files of group practice prepayment plan covers services furnished by the plan during the period of the enrollee’s membership.
d. Assignment in the files of a participating provider (hospital, SNF, home health agency, outpatient physical therapy or speech-language pathology provider or comprehensive rehabilitation facility) or ESRD facility covers physician services for which the provider or facility is authorized to bill, and may cover the physician services furnished in the provider or facility as follows:
• Inpatient services - effective for period of confinement.
• Outpatient services - effective indefinitely.
e. Assignment in files of individual physician, supplier (except in the case of unassigned claims for rental of durable medical equipment) or qualified reassignee under §30.2 is effective indefinitely.
B. Physician (Supplier) Signature Requirement
The rules below apply to both assigned and unassigned claims unless otherwise indicated.
1. In a claim for services furnished by an individual physician (or supplier), the physician may:
a. In an unassigned claim, provide an itemized bill on his own letterhead - no physician signature required. A Form CMS-1500 on which the name or identification code of the physician has been stamped or preprinted in item 31 is the equivalent of the physician’s own letterhead.
b. Sign item 31 of Form CMS-1500.
c. Sign one time certification letter for machine-prepared claims submitted on other than paper vehicles.
d. Authorize an employee (e.g., nurse, secretary) to enter the physician’s signature in item 31 of the Form CMS-1500.
ii. By stamp-facsimile or block letters
iii. By computer
e. Authorize a nonemployee agent, e.g., billing service or association, to enter as in d. above, the physician’s signature in item 31 of the Form CMS-1500, followed by the agent’s name, title, and organization (e.g., a billing agent might enter by stamp “Dr. Tom Jones by Robert Smith, Secretary, Ajax Billing Service”). Alternatively, the agent may simply enter the physician’s signature.
2. In a claim by a clinic, hospital, or other entity authorized to bill and receive payment in its name for the services of the physician, the entity may:
a. In an unassigned claim, provide an itemized bill on its letterhead-no signature necessary. A Form CMS-1500 on which the name or identification code of the billing entity has been stamped or preprinted in item 8 is the equivalent of the reassignee’s own letterhead.
b. Have authorized official sign in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556).
c. Have authorized official sign one-time certification letter for machine-prepared claims submitted on other than paper vehicles.
d. Have authorized employee, e.g., a secretary, enter authorized official’s signature in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556) as in 1d.
e. Have nonemployee agent enter authorized official’s signature in item 25 of the Form CMS-1500 (item 13 of Form CMS-1554, item 6 of Form CMS-1556) as in 1.e.
Readmission to Medicare Program After Involuntary Termination
After the involuntary termination of its agreements, a health facility cannot participate again as a provider unless:
• The reasons for termination of the prior agreement have been removed, and
• There is reasonable assurance that they will not recur.
The RO makes the final decision as to whether the facility is eligible for readmission. In doing so, it reviews the case in its entirety and makes the final decision regarding the following:
• Correction of deficiencies upon which the termination was based;
• Reasonable assurance of continued compliance, and
• Reasonable assurance of availability of information pertinent to reasonable cost reimbursement.
The RO will then process the case in the same way as an initial certification.
Effective Date of Provider Agreement
Since one of the key issues is whether the facility has furnished “reasonable assurance” that the reasons for termination will not recur, the provider agreement cannot be effective before the date on which “reasonable assurance” is deemed to have been provided.
Generally, a facility will be required to operate for a period of 60 days without recurrence of the deficiencies that were the basis for the termination. The provider agreement will be effective with the end of the 60-day period. If corrections were made before filing the new request for participation, the period of compliance before filing the new request will be counted as part of the 60-day period; however, in no case can the effective date of the provider agreement be earlier than the date of the new request for participation.
Exceptions to the 60-day period of compliance will be made where:
• Structural changes have eliminated the reasons for termination. “Reasonable assurance” will be considered established as of the date such structural changes were completed. The effective date will be that date or the date of filing the new request to participate, whichever is later.
• "Reasonable assurance” is not established even after 60 days of compliance, because of the facility’s history of misrepresentation or of making temporary corrections and then relapsing into the old deficiencies that were the basis for termination. The effective date in such cases would be the earliest date after 60 days at which “reasonable assurance” is deemed to have been established, or the filing date of the new request to participate, whichever is later.
In order for the teaching physician to bill for critical care services the teaching physician must meet the requirements for critical care described in the preceding sections. For CPT codes determined on the basis of time, such as critical care, the teaching physician must be present for the entire period of time for which the claim is submitted. For example, payment will be made for 35 minutes of critical care services only if the teaching physician is present for the full 35 minutes. (See IOM, Pub 100-04, Chapter12, § 100.1.4)
Time spent teaching may not be counted towards critical care time. Time spent by the resident, in the absence of the teaching physician, cannot be billed by the teaching
physician as critical care or other time-based services. Only time spent by the resident and teaching physician together with the patient or the teaching physician alone with the patient can be counted toward critical care time.
A combination of the teaching physician’s documentation and the resident’s documentation may support critical care services. Provided that all requirements for critical care services are met, the teaching physician documentation may tie into the resident's documentation. The teaching physician may refer to the resident’s documentation for specific patient history, physical findings and medical assessment. However, the teaching physician medical record documentation must provide substantive information including: (1) the time the teaching physician spent providing critical care, (2) that the patient was critically ill during the time the teaching physician saw the patient, (3) what made the patient critically ill, and (4) the nature of the treatment and management provided by the teaching physician. The medical review criteria are the same for the teaching physician as for all physicians.
Unacceptable Example of Documentation:
“I came and saw (the patient) and agree with (the resident)”.
Acceptable Example of Documentation:
"Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs, and oxygen. I reviewed the resident's documentation and I agree with the resident's assessment and plan of care."
Item 3 - Patient’s Birth Date
Item 9b - Other Insured’s Date of Birth
Item 11a - Insured’s Date of Birth
Note that 8-digit birth dates, when provided, must be reported with a space between month, day, and year (i.e., MM_DD_CCYY). On the Form CMS-1500, the space between month, day, and year is delineated by a dotted, vertical line.
If a birth date is provided in items 3, 9b, or 11a, and is not in 8-digit format, carriers must return the claim as unprocessable. Use remark code N329 on the remittance advice. For formats other than the remittance, use code(s)/messages that are consistent with the above remark codes.
If carriers do not currently edit for birth date items because they obtain the information from other sources, they are not required to return these claims if a birth date is reported in items 3, 9b, or 11a. and the birth date is not in 8-digit format. However, if carriers use date of birth information on the incoming claim for processing, they must edit and return claims that contain birth date(s) in any of these items that are not in 8-digit format.
For certain other Form CMS-1500 conditional or required date items (items 11b, 14, 16, 18, 19, or 24A.), when dates are provided, either a 6-digit date or 8-digit date may be provided.
If 8-digit dates are furnished for any of items 11a., 14, 16, 18, 19, or 24A. (excluding items 12 and 31), carriers must note the following:
• All completed date items, except item 24A., must be reported with a space between month, day, and year (i.e., MM_DD_CCYY). On the Form CMS-1500, the space between month, day, and year is delineated by a dotted, vertical line;
• Item 24A. must be reported as one continuous number (i.e., MMDDCCYY), without any spaces between month, day, and year. By entering a continuous number, the date(s) in item 24A. will penetrate the dotted, vertical lines used to separate month, day, and year. Carrier claims processing systems will be able to process the claim if the date penetrates these vertical lines. However, all 8-digit dates reported must stay within the confines of item 24A;
• Do not compress or change the font of the “year” item in item 24A. to keep the date within the confines of item 24A. If a continuous number is furnished in item 24A. with no spaces between month, day, and year, you will not need to compress the “year” item to remain within the confines of item 24A.;
• The “from” date in item 24A. must not run into the “to” date item, and the “to” date must not run into item 24B.;
• Dates reported in item 24A. must not be reported with a slash between month, day, and year; and
• If the provider of service or supplier decides to enter 8-digit dates for any of items 11b, 14, 16, 18, 19, or 24A. (excluding items 12 and 31), an 8-digit date must be furnished for all completed items. For instance, you cannot enter 8-digit dates for items 11b, 14, 16, 18, 19 (excluding items 12 or 31), and a 6-digit date for item 24A. The same applies to those who wish to submit 6-digit dates for any of these items.
Carriers must return claims as unprocessable if they do not adhere to these requirements.
UB-04 clean claim submission - Minimum required field
The UB-04 form (previously known as the UB-92 and CMS-1450 claim forms) captures essential data elements for providers of services in institutional/inpatient/facility settings. The form can be used to bill Medicare fiscal intermediaries, Medicaid state agencies and health plans/insurers. The required elements of a clean claim must be complete, legible and accurate.
In the following line item description, the parenthetical information following each term is a reference to the field number to which that term corresponds on the UB-04 claim form.
• Provider’s name, address and telephone number (field 1);
• Patient control number (field 3);
• Type of bill code (field 4);
• Provider’s federal tax ID number (field 5);
• Statement period (beginning and ending date of claim period) (field 6);
• Patient’s name (field 8);
• Patient’s address (field 9);
• Patient’s date of birth (field 10);
• Patient’s gender (field 11);
• Date of admission (field 12);
• Admission hour (field 13);
• Type of admission (e.g. emergency, urgent, elective, newborn) (field 14);
• Source of admission code (field 15);
• Patient-status-at-discharge code (field 17);
• Value code and amounts (fields 39-41);
• Revenue code (field 42);
• Revenue/service description (field 43);
• HCPCS/Rates (current CPT or HCPCS codes are required) (field 44);
• Service date (field 45), (required for each date of facility-based non-inpatient services or itemization in a separate attachment is required);
• Units of service (field 46);
• Total charge (field 47);
• HMO or preferred provider carrier name (field 50);
• Type 2 main NPI number (field 56);
• Subscriber’s name (field 58);
• Patient’s relationship to subscriber (field 59);
• Insured’s Unique ID (field 60);
• Principal diagnosis code (ICD-10 codes are required effective 10/1/15) (field 67);
• Rendering provider Type 1 NPI (field 76-79); and
• Attending physician ID (field 76-79).
Data elements: Unless otherwise agreed by contract, the data elements contained in this paragraph are necessary for claims filed by physicians or providers if circumstances exist which render the data elements applicable to the specific claim being filed. The applicability of any given data element contained in this paragraph is determined by the situation from which the claim arose.
(1) Discharge hour (UB-04, field 16), is applicable if the patient was an inpatient, or was admitted for outpatient observation;
(2) Condition codes (UB-04, fields 18-28 are applicable if the CMS UB-04 manual contains a condition code appropriate to the patient’s condition;
(3) Occurrence codes and dates (UB-04, fields 31-34), are applicable if the CMS UB- 04 manual contains an occurrence code appropriate to the patient’s condition;
(4) Occurrence span code, from and through dates (UB-04, field 36), is applicable if the CMS UB-04 manual contains an occurrence span code appropriate to the
(5) HCPCS/Rates (UB-04, field 44), is applicable if Revenue Code description used does not adequately describe service provided or if Medicare is a primary or
(6) Prior payments – payer and patient (UB-04, field 54), is applicable if payments have been made to the physician or provider by the patient or another payer or
subscriber, on behalf of the patient or subscriber, or by a primary plan;
(7) Diagnoses codes other than principle diagnosis code (UB-04, fields 67), is applicable if there are diagnoses other than the principle diagnosis and ICD-10
code is required effective 10/1/15;
(8) Ambulance trip report, submitted as an attachment to the claim; and
(9) Anesthesia report is applicable to report time spent on anesthesia services.
Effective for claims with dates of service on or after October 1, 2007, the name, address, and 9-digit ZIP Code of the service location for services paid under the Medicare Physician Fee Schedule and anesthesia services, other than those furnished in place of service home – 12, and any other places of service A/B MACs treat as home, must be entered according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1. (Remark code MA114 is used.)
Effective for claims with dates of service on or after October 1, 2007, for claims received that require a 9-digit ZIP Code with a 4 digit extension, a 4-digit extension that matches one of the ZIP9 file or a 4-digit extension that can be verified according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1 must be entered on the claim. (Remark code MA114 is used.)
Effective January 1, 2011, for claims processed on or after January 1, 2011, on the Form CMS-1500, the name, address, and 5 or 9-digit ZIP code, as appropriate, of the location where the service was performed for services paid under the Medicare Physician Fee Schedule and anesthesia services, shall be entered according to Pub. 100-04, Chapter 1, sections 10.1.1 and 10.1.1.1 for services provided in all places of service. (Remark code MA114 is used.)
Effective January 1, 2011, for claims processed on or after January 1, 2011, using the 5010 version of the ASC X12 837 professional electronic claim format for services payable under the MPFS and anesthesia services when rendered in POS home (or any POS they consider home) if submitted without the service facility location. (Remark code MA114 is used.)
1. If the physician is a member of a professional corporation, similar group, or clinic, and the NPI is not entered into item 24J of the Form CMS-1500. (Remark code N290 is used.)
2. If the name, address, and ZIP Code of the facility other than the patient’s home or physician’s office involved with the patient’s maintenance of care and training is not entered in item 32. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered.
B. For certified registered nurse anesthetist (CRNA) and anesthesia assistant (AA) claims, if the CRNA or AA is employed by a group (such as a hospital, physician, or ASC) and the group’s name, address, and ZIP Code is not entered in item 33 or if the NPI is not entered in item 33a of the Form CMS-1500, if their personal NPI is not entered in item 24J of the Form CMS-1500. (Remark code MA112 is used.)
C. For durable medical, orthotic, and prosthetic claims, if the name, address, and ZIP Code of the location where the order was accepted were not entered in item 32. (Remark code MA 114 is used.)
E. For routine foot care claims, if the date the patient was last seen and the attending physician’s NPI is not present in item 19. (Remark code N324 or N253 is used.)
F. For immunosuppressive drug claims, if a referring/ordering physician, physician’s assistant, nurse practitioner, clinical nurse specialist was used and their name is not present in items 17 or 17a., or if the NPI is not entered in item 17b. of the Form CMS-1500. (Remark code N264 or N286 is used.)
1. Involving EKG tracing and the procurement of specimen(s) from a patient at home or in an institution, if the claim does not contain a validation from the prescribing physician that any laboratory service(s) performed were conducted at home or in an institution by entering the appropriate annotation in item 19 (i.e., “Homebound”). (Remark code MA116 is used.)
2. If the name, address, and ZIP Code where the test was performed is not entered in item 32, if the services were performed in a location other than the patient’s home or physician’s office. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered.
3. When a diagnostic service is billed as an anti-markup service and the service is purchased from another billing jurisdiction, the billing physician or supplier must submit the name, address, and ZIP Code of the performing physician or supplier in Item 32, and the NPI of the performing physician or supplier in Item 32a. If Items 32 and 32a are not entered, remark code MA114 is used.
For all laboratory services, if the services of a referring/ordering physician, physician’s assistant, nurse practitioner, clinical nurse specialist are used and his or her name is not present in items 17 or in 17a. or if the NPI is not entered in item 17b. of the Form CMS-1500. (Remark code N264 or N286 is used.)
For laboratory services performed by a participating hospital-leased laboratory or independent laboratory in a hospital, clinic, laboratory, or facility other the patient’s home or physician’s office (including services to a patient in an institution), if the name, address, and ZIP Code of the location where services were performed is not entered in item 32. (Remark code MA114 is used.) Effective for claims received on or after April 1, 2004, the name, address, and ZIP Code of the service location for all services other than those furnished in place of service home – 12 must be entered.
For all laboratory work performed outside a physician’s office, if the claim does not contain a name, address, and ZIP Code for where the laboratory services were performed in item 32 or if the NPI is not entered into item 32a of the Form CMS-1500 if the services were performed at a location other than the place of service home – 12. (Use Remark code MA114)
For all physician office laboratory claims, if a 10-digit CLIA laboratory identification number is not present in item 23. This requirement applies to claims for services performed on or after January 1, 1998. (Remark code MA120 is used.)
All paper CMS 1500 and UB-04 claims must be submitted on standard red claim forms. Black and white versions of these forms, including photocopied versions, faxed versions and resized representations of the form that do not replicate the scale and color of the form required for accurate OCR scanning, will not be accepted and will be returned with a request to submit on the proper claim form.
To avoid a filing deadline denial, rejected paper claims must be submitted within 60 days from the date of service for professional or outpatient services or within 60 days from the date of discharge.
Submitted paper claim forms should include all mandatory fields as noted in the Claim Specifications section of this chapter. Paper claim forms deemed incomplete will be rejected and returned to the submitter. The rejected claim and a letter stating the reason for rejection will be returned to the submitter, and a new claim with the required information must be resubmitted for processing.
** Industry-standard codes should be submitted on all paper claims.
** Diagnosis codes must be entered in priority order (primary, secondary condition) for proper adjudication. Up to 12 diagnosis codes will be accepted on the CMS-1500 form.
** Paper claims will be rejected and returned to the submitter if required information is missing or invalid. Common omissions and errors include but are not limited to the following:
** Illegible claim forms
** Member ID number
** Date of service or admission date
** Physician’s signature (CMS-1500 Box 31)
Paper claims should be mailed to the following address:
Tufts Health Plan Medicare Preferred P.O. Box 9183 Watertown, MA 02471-9183
A. General Overview
Incentive payments will be made on a quarterly basis and shall be equal to 10 percent of the amount paid for such services under the Medicare Physician Fee Schedule (PFS) for those services furnished during the incentive payment year. PCIP payments for newly enrolled practitioners will be delayed due to the lag in their eligibility determination. Newly enrolled primary care practitioners will receive a single cumulative PCIP payment, retroactive for primary care services furnished from the beginning of the PCIP payment year, following the fourth quarter of the PCIP payment year after the primary care practitioner is deemed eligible. Quarterly payments will be made for subsequent incentive payments.
On an annual basis Medicare contractors shall receive a Primary Care Incentive Payment Program Eligibility File and PCIP Payment for New Providers Enrolled in Medicare File that they shall post to their websites. The files will list the NPIs of all practitioners who are eligible to receive PCIP payments for the PCIP payment year.
B. Method of Payment
• Calculate and pay qualifying primary care practitioners an additional 10 percent incentive payment.
• Calculate the payment based on the amount actually paid for the services, not the Medicare approved amount.
• Combine the PCIP incentive payments, when appropriate, with other incentive payments, including the HPSA physician bonus payment, and the HPSA Surgical Incentive
Payment Program (HSIP) payment;
• Provide a special remittance form that is forwarded with the incentive payment so that physicians and practitioners can identify which type of incentive payment (HPSA physician and/or PCIP) was paid for which services.
• Practitioners should contact their contractor with any questions regarding PCIP payments.
C. Changes for Contractor Systems
The Medicare Carrier System, (MCS), Common Working File (CWF) and the National Claims History (NCH) shall be modified to accept a new PCIP indicator on the claim line. Once the type of incentive payment has been identified by the shared systems, the shared system shall modify their systems to set the indicator on the claim line as follows:
1 = HPSA;
2 = PSA;
3 = HPSA and PSA;
4 = HSIP;
5 = HPSA and HSIP;
6 = PCIP;
7 = HPSA and PCIP; and
Space = Not Applicable.
The contractor shared system shall send the HIGLAS 810 invoice for incentive payment invoices, including the new PCIP payment. The contractor shall also combine the provider’s HPSA physician bonus, physician scarcity (PSA) bonus (if it should become available at a later date), HSIP payment and/or PCIP payment invoice per provider.
The contractor shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per provider.
Tufts Health Plan accepts both electronic and paper corrected claims, in accordance with guidelines of the National Uniform Claim Committee (NUCC), the Medicare Managed Care Manual, and HIPAA EDI standards for Tufts Medicare Preferred HMO claims.
To submit a corrected facility or professional claim electronically:
** Enter the frequency code (third digit of the bill type for institutional claims; separate code for professional claims) in Loop 2300, CLM05-3 as either “7” (corrected claim), “5” (late charges), or “8” (void or cancel a prior claim).
** Enter the last 8 digits of the original claim number in Loop 2300, REF segment with an F8 qualifier. For example, for claim #000123456789, enter REF*F8*23456789.
Note: Provider payment disputes that require additional documentation must be submitted on paper.
Disputes (not corrected claims) must include a completed Provider Request for Claim Review Form. Both corrected claims and disputes, however, should be mailed to the address on the form.
For a corrected facility claim:
** On the UB-04 (CMS-1450) form, enter either “7” (corrected claim), “5” (late charges), or “8” (void or cancel a prior claim) as the third digit in Box 4 (Type of Bill), and enter the original claim number in Box 64 (Document Control Number).
For a corrected professional claim:
** In Box 22 (Medicaid Resubmission Code) on the CMS-1500 form, enter the frequency code “7” under “Code” and the original claim number in the same box under “Original Ref No.”
Medicare defines a clean claim as a claim that does not require the Medicare contractor to investigate or develop prior to adjudication. Clean claims must be filed within the filing period.
For information about the forms to use for submitting claims, see Claim Specifications section in this chapter.
To qualify for payment, clean claims must also meet the following Conditions of Payment:
** The billed services must be:
** Covered in accordance with the applicable benefit document provided to Tufts Medicare Preferred HMO members who meet eligibility criteria and are Members on the date of service
** Furnished by a provider eligible for payment under Medicare
** Provided or authorized by the member’s PCP or the PCP’s covering provider in accordance with the applicable benefit document, or as identified elsewhere in your agreement with Tufts Health Plan (if applicable)
** Provided in the member’s Evidence of Coverage document
** Medically necessary as defined in the Medicare coverage guidelines
** Tufts Health Plan received the claim within 60 days from the date of service or the date of discharge if the member was inpatient, or date of the primary insurance carrier's explanation of benefits (EOB).
** The services were preregistered and/or prior authorized in accordance with Tufts Medicare Preferred HMO’s preregistration and precertification procedures.
** The services were billed using the appropriate CPT codes and/or HCPCS codes.
** In the case of professional services billed by the hospital, services were billed electronically according to the HIPAA standard or on CMS-1500 and/or UB-04 forms with a valid CPT code and/or HCPCS code.
All services rendered to Tufts Medicare Preferred HMO members must be reported to Tufts Health Plan as claims data. Claim forms are submitted by providers for both payment and tracking purposes.
All services rendered to Tufts Medicare Preferred HMO members must be reported to Tufts Health Plan Medicare Preferred as encounter or claims data. An encounter is a billing form submitted by capitated providers for tracking purposes. Claim forms are submitted by noncapitated providers for both payment and tracking purposes.
If the 1199SEIU Benefit Funds verify a member’s eligibility but subsequently learn that the member was not eligible at the time of service, the member will be retroactively ineligible for services provided and the 1199SEIU Benefit Funds will not be liable for any services rendered
to that ineligible member.
Coordination of Benefits
When a member, spouse or child is covered by more than one group health plan, the two plans share the cost of the member’s family health coverage by “coordinating” benefits.
The primary plan makes the first payment on a claim, and the secondary plan pays an additional amount according to its terms. Members are routinely sent Coordination of Benefits forms in order to establish whether or not the 1199SEIU Benefit Funds are their primary insurance.
If the Benefit Funds are unable to establish if they are the primary or secondary payer, the claim may be denied until additional information is received. Please remind members to complete all requested forms promptly to avoid claim and payment delays.
Spouse and Dependent Coverage
Unless court-ordered, if the member and his or her spouse both have dependent coverage, the primary payer for any children will be the plan of the parent whose birthday is earlier in the year. The other parent’s plan is the secondary payer.
For spousal care, the spouse’s plan is the primary payer. The 1199SEIU Benefit Funds are the member’s primary payer and the spouse’s secondary payer.
Listed below are the latest tests approved by the FDA as waived tests under CLIA. The CPT codes for the following new tests must have the modifier QW to be recognized as a waived test. However, the CPT codes 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651 do not require a QW modifier to be recognized as a waived test.
CPT Code Effective Date Description
G0434QW from August 21, 2015 to December 31, 2015 Healgen Scientific LLC, Healgen Multi-Drug Urine Test Dip Card
G0477QW on and after January 1, 2016 Healgen Scientific LLC, Healgen Multi-Drug Urine Test Dip Card
G0477QW March 8, 2016 Tanner Scientific Multi-Panel Drug Test Cup
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Easy Cup
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Split Key Cup
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Test Cassette
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Marijuana Test Dip Card
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Easy Cup
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Split Key Cup
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Test Cassette
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Metamphetamine Test Dip Card
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Easy Cup
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Split Key Cup
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Test Cassette
G0477QW March 18, 2016 Hangzhou Clongene Biotech Co., Ltd. Clungene Morphine Test Dip Card
87338QW March 22, 2016 Meridian Bioscience Immunocard STAT! HpSA (Stool)
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Dip Card
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Quick Cup
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Strip
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Amphetamine Turn-Key Split Cup
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine Dip Card
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine Quick Cup
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine Strip
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Cocaine TurnKey Split Cup
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Dip Card
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Quick Cup
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Strip
G0477QW March 31, 2016 Assure Tech Co., Ltd. AssureTech Morphine Turn-Key Split Cup
G0477QW April 21, 2016 Chemtron Biotech, Inc. Chemtrue Multi-Pane Drug Screen Cup Tests
G0477QW April 21, 2016 Chemtron Biotech, Inc. Chemtrue Multi-Panel Drug Screen Cup with OPI 2000 Tests
The new waived complexity code 87338QW [Qualitative or semiquantitative detection test for helicobacter pylori in stool, multiple-step method] was assigned for the detection of Helicobacter pylori antigens in stool performed using the Meridian Bioscience Immunocard STAT! HpSA (Stool) test
The Centers for Medicare & Medicaid Services (CMS) has provided guidance on reporting days of utilization for a beneficiary’s inpatient stay. Days of utilization are charged based upon actual days of coverage, including grace and waiver days. The number of covered days used is maintained by CMS to track the beneficiary's eligible days in a benefit period.
There are special billing guidelines to follow when the beneficiary becomes entitled to Part A benefits in the middle of an inpatient stay. Pre-entitlement days are not counted for utilization or for the hospital’s inpatient prospective payment system (PPS) pricer. Furthermore, pre-entitlement days are not used for the cost report or for utilization in non-PPS hospitals, exempt units or skilled nursing facilities (SNFs). In this situation, the days are calculated based on the beneficiary’s Medicare Part A entitlement date through discharge/transfer/death.
The hospital may not bill the beneficiary or other persons for days of care preceding entitlement, except for days in excess of the outlier threshold. The hospital may charge the beneficiary or other persons for applicable deductible and/or coinsurance amounts.
Listed below are the claim submission guidelines for inpatient hospital admit to discharge claims (no outlier):
• Type of bill (TOB) -- Enter 111
• Admit date -- Enter the actual date of admission
• Do not enter the Medicare Part A entitlement date as the admit date
• Statement coverage period “From” date -- Enter the Medicare Part A entitlement effective date
• Do not enter the admit date as the coverage period “From” date
• Statement coverage period “Through” date -- Enter the end date of the inpatient stay
• Utilization days -- Enter the total number of days for the statement coverage period
• Do not report any pre-entitlement days as covered or non-covered
• Covered and non-covered days are reported utilizing value codes 80, 81, 82, and/or 83
Value code 80 -- Covered days
Value code 81 -- Non-covered days
Value code 82 -- Co-insurance days
Value code 83 -- Lifetime reserve days
• Diagnosis codes -- enter all diagnosis codes from admission to discharge/transfer/death
• Accommodation days/units -- Enter the appropriate number of units and charges as covered and/or non-covered for the statement coverage period
• Do not report the pre-entitlement days as covered or non-covered room and board units or charges
• Revenue codes -- 010X – 016X are appropriate for billing room and board
• Revenue code -- 018X is appropriate for billing a leave of absence (non-covered days and charges)
• Remarks -- Medicare Part A effective xx/xx/xx
The patient is admitted on April 25, 2016 and discharged on May 13, 2016. The patient’s Medicare Part A entitlement effective date is May 1, 2016. The claim should be billed as follows:
• TOB -- 111
• Admit date -- April 25, 2016
• Statement coverage period “From” date – May 1, 2016
• Statement coverage period “Through” date -- May 13, 2016
• Utilization days -- 12 covered days
• Accommodation days/units -- 12 covered units and covered charges
• Remarks -- Medicare Part A effective May 1, 2016
What Is Healthcare Fraud?
The 1199SEIU Benefit Funds define healthcare fraud as an intentional deception or misrepresentation that an individual knows to be false, or that could knowingly result in some unauthorized benefit to that individual or another person.
The most common kind of fraud involves a false statement or misrepresentation made in order to take advantage of 1199SEIU Benefit Funds’ benefits. The violator may be a healthcare provider, an employee of a medical provider, a beneficiary or some other person or business entity.
Examples of fraud include:
• Billing for services and supplies that were not provided;
• Misrepresenting the diagnosis for a patient to justify the services or equipment furnished;
• Altering claim forms to obtain a higher payment amount;
• Unbundling (exploding) charges or upcoding; or
• Participating in schemes that involve collusion between a provider and a beneficiary or between a supplier and a provider, which result in higher costs or charges to the 1199SEIU Benefit Funds.
What Is Healthcare Abuse?
The 1199SEIU Benefit Funds define healthcare abuse as actions that are inconsistent with sound medical, business or fiscal practices. Abuse directly or indirectly results in higher costs to the 1199SEIU Benefit Funds through improper payments for treatments that are not medically necessary.
Common examples of abuse include:
• Performance of medically unnecessary services;
• Failure to document medical records adequately;
• Intentional, inappropriate billing practices such as misuse of modifiers; or
• Failure to comply with a participation agreement.
A receipted bill is a written acknowledgment by a person or organization furnishing specified covered services, which states that payment has been made for all services on the bill.
Where a receipted bill is submitted, benefits for the services shown on the bill should not be paid to the physician (or his/her supplier) since there can be no assignment.
The bill itself bearing the words “received payment,” “paid in full,” “paid,” or a phrase with the same meaning, is the best evidence of payment if it is signed or initialed by the physician (or his/her employee, etc.) or by the person or organization furnishing supplies or services. There will, however, be other evidence of payment that will be acceptable, such as machine-produced bills that clearly show the amount paid for each service. A rubber-stamp imprint on the bill which includes the name of the physician or other supplier is acceptable, absent a reason to question it. It is also reasonable to accept, as evidence of payment, a cancelled check that is related in time and amount to a doctor’s, or other Part B supplier’s bill.
A bill paid by promissory note is treated as a “receipted bill” unless the bill shows on its face that the note is not given and accepted unconditionally as payment of the bill. For example, a bill marked “paid by promissory note” or “$25 paid in cash, balance paid by promissory note” is treated as a receipted bill. On the other hand, a bill marked “paid subject to payment on promissory note,” or which otherwise clearly indicates that the promissory note was not unconditionally accepted in payment of it, is not a receipted bill.
Provider Types Affected
** Hospitals who submit claims to fiscal intermediaries (FI) or Medicare Part A/B Administrative Contractors (A/B MACs) for Medicare beneficiary inpatient services.
** Tufts Health Plan recommends that your billing staff is aware of this requirement, and that your physicians and other practitioners and coders are collaborating to ensure complete and accurate documentation, code assignment and reporting of diagnoses and procedures.
Reporting Options and Definitions
N (No) Not present at the time of inpatient admission
U (Unknown) Documentation is insufficient to determine if condition is present at time of inpatient admission
W Not Applicable
Y (Yes) Present at the time of inpatient admission
** The POA data element on your electronic claims has been moved from the K3 segment (version 4010A1) to the HI - PRINCIPAL DIAGNOSIS and HI - OTHER DIAGNOSIS INFORMATION segments.
NOTE: The value of “1” has been removed in 5010.
Example: Below is an example of acceptable coding on an electronic claim: HI*BF:4821:::::::N*HI*BF:25000:::::::Y
2. Effective Date - If the participant files the agreement with any MAC/carrier during the enrollment period, the agreement becomes effective _____________________.
3. Term and Termination of Agreement - This agreement shall continue in effect through December 31 following the date the agreement becomes effective and shall be renewed automatically for each 12-month period January 1 through December 31 thereafter unless one of the following occurs:
a. During the enrollment period provided near the end of any calendar year, the participant notifies in writing every MAC/carrier with whom the participant has filed the agreement or a copy of the agreement that the participant wishes to terminate the agreement at the end of the current term. In the event such notification is mailed or delivered during the enrollment period provided near the end of any calendar year, the agreement shall end on December 31 of that year.
b. The Centers for Medicare & Medicaid Services may find, after notice to and opportunity for a hearing for the participant, that the participant has substantially failed to comply with the agreement. In the event such a finding is made, the Centers for Medicare & Medicaid Services will notify the participant in writing that the agreement will be terminated at a time designated in the notice. Civil and criminal penalties may also be imposed for violation of the agreement.