Perforación y Voladura.

9.1a Claim Submission Requirements 9.1b Billing Reduced Services Modifiers 9.1c Prompt Payment

9.1d Claims Filing Limit

9.1e Provider Claim Payment Inquiries 9.1f Claims Submission Address 9.1g General Claim Guidelines

9.1h Filing Adjustments/Amended Claims

9.1BILLING/CLAIM SUBMISSION REQUIREMENTS 9.1a Claim Submission Requirements

Gundersen Health Plan prefers electronic claim submission. All paper claims must be submitted on the appropriate claim forms, either CMS1500 or UB04 (CMS1450), and include completion of all required elements. Services must be submitted with appropriate HCPCS Level I (Current Procedural Terminology-CPT), HCPCS Level II (National HCPCS) and Revenue codes. Level I and Level II HCPCS modifiers are also required for claim adjudication and accurate

reimbursement. ICD9CM codes must be submitted at the highest level of specificity.

Claim edits and submission requirements are consistent with CMS requirements. Claims must be legible, black ink on original CMS1500 or CMS 1450 claim form (red print) and free of alteration.

Incomplete or unacceptable claims will be returned with a letter of explanation. All returned claims must be resubmitted with the necessary information for adjudication.

Claims received with incorrect coding will be denied. Providers should bill, based on the

services provided, following standard billing guidelines unless otherwise communicated (i.e. Hot Topics). Your Explanation of Payment will contain an Explanation Code/Claim Adjustment Reason Code and the description for the reason for denial.

Contracted providers are required to submit claims on behalf of Gundersen Health Plan members and refrain from billing members until claims have been adjudicated by Gundersen Health Plan. Providers must not bill members for services that are denied due to contractual limitations as indicated in the Explanation of Payment.

9.1b Billing Reduced Services Modifiers

Providers submitting claims with reduction modifiers, including but not limited to modifiers 51, 80, and 82, must submit full charges. Payment will be reduced appropriately upon receipt of the claim. Providers that are unable to submit full fees must notify the Provider Network

Management Department prior to claim submission at (608) 775-8034 or (800) 370-9718, ext. 58026/58034.

9.1c Prompt Payment

Gundersen Health Plan will reimburse providers within thirty (30) days of receipt of a clean claim. A “clean claim” has no defect or impropriety (including any lack of any required substantiating documentation) or particular circumstance requiring special treatment that prevents timely payment. Claims that require additional information or investigation will be adjudicated promptly upon receipt of the required information.

9.1d Claim Filing Limit

A claim for benefits should be submitted within 60 days of the date services are provided, or as soon as possible. Timely filing limits vary by plan. Questions concerning filing limits should be directed to the Customer Service Department at (608) 775- 8007, or (800) 897-1923 ext. 58007. 9.1e Provider Claim Payment Inquiries

Questions concerning claim status, claim payment or adjustments should be directed to the Customer Service Department at (608) 775- 8007, or (800) 897-1923 ext. 58007.

Gundersen Health Plan prefers overpayment recovery through an electronic recoupment process. Questions regarding recoveries or recoupments resulting in a negative balance should be directed to Claims Administration at (608) 775-8074 or (800) 370-9718, ext. 58074.

9.1f Claim Submission Address: Gundersen Health Plan

Attn.: Claims Administration NCA2-01 1900 South Avenue

La Crosse, WI 54601

Please refer to your Senior Preferred Provider Manual regarding submission of Senior Preferred claims.

9.1g Filing Adjustments/Amended Claims

An adjustment or amendment is a correction to a claim that has already been adjudicated.

Claim adjustments can result in a negative balance for providers. Negative balances should resolve themselves with subsequent claim submission and payment. Questions regarding negative balances should be directed to Claims Administration at (608)775-8074 or (800) 370- 9718, ext. 58074.

CMS 1500 Form

Adjusted or amended paper claims must be clearly marked as such, i.e. “Corrected Claim,” “Amended Claim,” or “Adjusted Claim”. The claim re-submission should include any necessary supporting documentation. Clearly marked claim re-submissions will bypass Data Entry queues and be routed directly for adjudication.

CMS 1450 (UB04) Form

Adjustments are identified on the CMS 1450 paper claim form by the type of bill (TOB), Form Locator 4. An adjustment claim should be submitted using

TOB code 0XX7.

9.1h Electronic Claim Submission

Gundersen Health Plan has contracted with a clearinghouse to accept institutional and/or

professional electronic claim transactions. Claims are received on a daily basis. Claims must be submitted with correct member demographics in order to be adjudicated. Providers should verify insurance information and demographics at the time service is provided. Claims submitted with missing data elements or inaccurate data will be rejected or denied as billing errors in the claim adjudication process.

Questions concerning electronic claim submission should be directed to the Configuration Department at (608) 775-8053 or (800) 370-9718, ext. 58053.

9.1i Therapy Claim Submission Requirements

Gundersen Health Plan requires therapy modifies to apply appropriate member benefits and counters for all outpatient therapy claims.

This is applicable to all claims from physicians, non-physician practitioners (NPPs), physical therapists in private practice (PTPPs), occupational therapists in private practice (OTPPs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), outpatient physical therapy providers (OPTs), hospitals, Skilled Nursing Facilities (SNFs), and any others billing for physical therapy, speech-language pathology or occupational therapy services.

Claims submitted without an appropriate modifier will be denied as provider responsibility and will need to re-submitted with the modifier.

Required discipline or plan of care modifiers:

GN Services delivered under an outpatient speech-language pathology plan of care; GO Services delivered under an outpatient occupational therapy plan of care; or GP Services delivered under an outpatient physical therapy plan of care.