Cal Check Range
5.2 PROCEDIMIENTOS ANALIZADOR EN LINEA CN WAD
Flexibility (Web and EDI)
■
■ – You have more search
options for retrieving claim status information; the search capability allows physicians and other health care professionals to narrow searches by selecting from a range of optional inquiry data including claim ID numbers, extended date range, bill type, billed amount,
Social Security number return all claims for all member ID numbers associated with the requested Social Security number.
Increased efficiency in practice administration
■ ■
(Web and EDI) – Office administrators have the ability to inquire about submitted claims listed under the same federal tax ID number, allowing the user to conduct searches for all physicians or other health care
professionals in a practice without having to log in using multiple passwords.
A global view
■
■ – Claim status responses include all
claims that have been received by and forwarded to our third-party vendors.
More detailed claim status and code sets
■
■ [Web,
EDI and interactive voice response (IVR)] – Claims show all relevant detailed statuses of a claim, both at the claim detail level and at the claim header level; this allows a full view of how claims are processed from beginning to end; HIPAA claim status codes consist of a combination of the following three code types:
Status Category Code
■
— – Defines the category of
the status; claims are “Acknowledged,” “Pended” or “Finalized”
Status Code
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— – Identifies the reasoning behind the
category location of a claim; for example, if a claim was paid at a contracted rate, the claim is in the “Finalized” category
Entity Code
■
— – Rarely used in the claim status
response, this is used when business conditions apply or under error conditions, such as when a member or procedure code is not found; these codes further clarify the status category and status codes; status category and status codes will be used in most cases
Performance highlights include: Timely information
■
■ – Claim inquiries are retrieved and
returned within HIPAA-mandated time frames, 60 seconds for individual and multi-claim searches and 24 hours for batch inquiries.
Consistent response
■
■ – All of our electronic mediums
(including Web, Oxford Express, our automated IVR system, and EDI) communicate a consistent and HIPAA- compliant claim status response; additionally, we support Batch EDI claim status inquiry transactions.
claim status response offers you the ability to request and receive a faxed copy of the claims requested. Claims recovery policy (for individual physicians and other health care professionals)
In situations resulting from isolated mistakes or where the physician or other health care professional is in no way at fault, we will not pursue collection of overpayments with individual participating physicians and other health care professionals that were made more than one year prior to the date of notice of the overpayment (the one-year period runs from the date of payment to the date we provide notice to the physician or other health care professional). Discussions and actions to collect overpayments for which a physician or other health care professional is given notice within the one-year period are appropriate under this policy. We will not use extrapolation, unless the situation fits into items 1, 2 or 3 below. This would include, but would not be limited to, situations involving duplicate claims, overpayments related to fee schedule issues, isolated situations of incorrect billing/unbundling, and situations where we were not the primary insurer. This policy does not apply to facilities or ancillaries. 1. Reasonable suspicion of fraud exists or there is a
sustained or high level of billing error. 2. A physician or other health care professional
affirmatively requests additional payment on claims or issues older than one year, whether through suit, arbitration, or otherwise.
3. The Centers for Medicare & Medicaid Services (CMS) makes a retroactive change to enrollment or to primary versus secondary coverage of a Medicare member. We will pursue collection of past
overpayments beyond one year and utilize statistical methods and extrapolation.
Cases involving a reasonable suspicion of fraud or a sustained or high level of billing error would include extensive or systemic upcoding, unbundling, misrepresentation of services or diagnosis, services not rendered, frequent waiver of member financial responsibility, misrepresentation of physician or other health care professional rendering the services or licensure of such physician or other health care professional, and similar issues.
ICD-9-CM, CPT, HCPCS, and place codes We use the International Classification of Diseases, 9th Revision, Clinical Modification Diagnosis and Procedure * For information on additional HIPAA Code Sets, please refer to Appendix C of the 837 Health Care Claim: Professional ASC X12N (004010X98) Implementation Guide or the 837 Health Care Claim: Institutional ASC X12N (004010X96) Implementation Guide.
105 Codes (ICD-9-CM), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System
(HCPCS) to determine payment. Physicians and other health care professionals must correctly use these codes on their claims in order to receive payment. Some codes are included in this manual; however, you can obtain complete lists of these codes by contacting St. Anthony’s Publishing:
St. Anthony’s Publishing 11410 Isaac Newton Square Reston, VA 20190
1-800-632-0123, ext. 5814
In addition to the codes mentioned above, we use the bill type, occurrence codes and revenue codes, when applicable, to determine payment. You can obtain complete lists of these codes* by contacting the Centers for Medicare & Medicaid Services (CMS).
If any of the information is not submitted correctly, the clearinghouse will return the claim to you so that you can correct the error(s) and resend the claim electronically.