El proceso verbal de las ofertas reales

8.1 CLAIM SUBMISSION

Correct claim submission increases cash flow to the provider organization and prevents costly follow-up time on the part of the provider’s office/billing staff. HealthAmerica’s guidelines comply with HIPAA, Medicare, CHAMPUS Claim Form rules and applicable state law “clean claim”

definition.

Please submit claims electronically to HealthAmerica whenever possible. Electronic submission is the most cost effective solution for claim submission. Electronic Claim Submission/EDI is covered in detail in section 8.1.2.

Click here for the Timely Filing Grid or refer to section 8.15.2.

8.1.1 Paper Claim

For professional claim services submit the claim by using the updated Health Insurance Claim Form, known as the CMS 1500 form. This form is recognized as the universal Claim Form throughout the industry, and has been approved by the American Medical Association (AMA) Council on Medical Services.

Refer to the CMS 1500 requirements in the Clean Claim section for the required fields. Click here to go to that section of the manual or refer to section 8.8.

For facility and/or ancillary claim services submit the claim by using the updated Health Insurance Claim Form, known as the CMS 1450 form (i.e. UB 04). This form is recognized as the universal Claim Form throughout the industry, and has been approved by the American Medical Association (AMA) Council on Medical Services.

Refer to the CMS 1450 (UB 04) requirements in the Clean Claim section for the required fields.

Click here to go to that section of the manual or refer to section 8.8.

Providers have a designated number of days to submit a new claim (timely filing). Claims need to be submitted based on the terms of the provider agreement. Any claims received after the designated time frame outlined in the provider agreement will automatically be denied for untimely filing. Providers may still collect for Member responsibilities such as supplemental charges, non-covered Services, and co-pays.

Please Note: It is the provider’s responsibility to check with the Plan periodically on all claim submissions. It is suggested your organization contact the Plan within 30 days from the date of original submission to determine if the Plan has received the claim.

Providers can also use Directprovider.com within 7 days from the date of submission to determine if the plan received the claim. If the Plan has no record of the claim, the provider should re-submit the claim within the timely filing limits as defined in the provider agreement. If the timely filing time period has passed, and the Plan has no record of the claim in its system, the provider will need to submit proof of timely filing of the claim in order for the Plan to review the claim for processing.

Refer to 8.15.1 Claims Addresses, the appropriate region’s Quick Reference Guide in section 1.9 Contact Information – Quick Reference Guides, or the Member’s ID card for claims mailing addresses.

8.1.2 Electronic Claims Submission - Electronic Data Interchange (EDI)

The Health Insurance Portability and Accountability Act (HIPAA) requires Coventry Health Care and all other covered entities to comply with Electronic Date Interchange (EDI) standards for health care as established by the Secretary of Health and Human Services. In support of HIPAA and its goal of Administrative Simplification, HealthAmerica encourages providers to submit claims electronically. Electronic claims submission can have a significant, positive impact on the productivity and cash flow for your organization:

 EDI reduces the paperwork and costs associated with printing and mailing paper claims.

 EDI reduces the time it normally takes for the Health Plan to receive a claim by eliminating mailing time.

 EDI reduces the delays due to in correct claim information by returning these errors directly to you through the same electronic channel. These claims can be corrected and re-submitted electronically.

 Electronic claim submission improves claim accuracy by decreasing the chance for transcription errors and missing/incorrect data.

 EDI claims can be tracked and monitored through claim status reports received electronically.

Electronic claim submission to the Health Plan is easy to establish. Contact your practice management system vendor or clearinghouse to initiate the process. Electronic claim

submissions will be routed through Emdeon who will review and validate the claims for HIPAA compliance and forward them directly to Coventry.

Providers can also submit directly to Emdeon. Emdeon will provide the electronic requirements and set-up instructions. Providers should call 1-800-215-4730 or go to www.emdeon.com for information on direct submission to Emdeon.

EDI claim submitters should review HealthAmerica’s EDI Exclusion List and Electronic Claim Submission Requirements. All Coventry health plans use the ANSI X12N 837 v4010 and v4010A1 implementation guides that have been established as the standard claim transactions for HIPAA. The official implementation guides for claim transactions are available electronically from the Washington Publishing Company website: http://www.wpc-edi.com.

Coventry Health Care encourages and recommends regular review of all EDI Acknowledgement and Reject Reports returned to you. Coventry Health Care, Inc. has staff available to assist you

with EDI claim filing. For more detail on each of these topics please click here or refer to section 8.4.

EDI Submission Requirements

For Professional Claim EDI Submission Requirements, click here or go to section 8.2.

For Institutional Claim EDI Submission Requirements, click here or go to section 8.3.

EDI Specifications

For EDI Specifications refer to the following section 8.1.3.

Plan: HealthAmerica

Emdeon business services Payer ID: 25133

8.1.3 EDI Specifications

The 837 claim transaction is utilized for electronic professional and institutional claims and encounters. Coventry Health Care, Inc. uses the ASC X12N 837 Professional Health Care Claim (004010X098A1) and the ASC X12N 837 Institutional Health Care Claim

(004010X096A1) implementation guides. The official implementation guides for claim

transactions are available electronically from the Washington Publishing Company website at www.wpc-edi.com.

This Coventry document contains clarifications and payer specific requirements related to data usage and content with submitting an EDI claims to Coventry. Please note that this document is intended to list only those elements where payer specific requirements or clarifications apply.

The loop, segment and data element references below in italics relate to the 004010X098A1or 004010X096A1 format. If you submit your electronic claims using a different format, you should check with your software vendor or clearinghouse to ensure that your data is mapped to the proper data elements.

8.1.4 Coventry Specific Payer Edits at Emdeon

All EDI claims submitted through Emdeon will be subject to these Coventry specific payer edits (unless indicated for one transaction only) that are in place at Emdeon. Submitters will receive these types of rejections on their level 1 payer rejection reports.

 The insured id must be at least two characters in length or the claim will reject.

 To allow zero dollar line charges and zero dollar claim charges.

 The billing provider id may not contain a value of 999999999 or the claim will reject.

 If the procedure code begins with 0, then Anesthesia Minutes are required or the claim will reject (Prof Only). Excluding procedure code is 01995 or 01996 then service units are required and the Anesthesia Minutes should contain 00 or the claim will reject. If the procedure code begins with a 0 and ends with a T, then service units are required and the Anesthesia Minutes should contain 00 or the claim will reject (Prof Only).

 If the procedure code does not begin with a 0, then service units are required and the Anesthesia Minutes should contain 00 or the claim will reject (Prof Only).

 The discharge hour must contain a numeric value of 00-23 or 99 if the batch type

contains an inpatient value of x10, x11, x14 or x17 and the statement period from date is equal to the statement period thru date (Institutional Only).