RESEARCH AND RESOLVEProfessional Claim Denials

HP Provider Relations/June 2014

Research and Resolve Institutional Claim Denials June 20142

Agenda

• Claim Inquiry on Web interChange‒ Search by member number and date of service

‒ Understand Claim Status Information, Disposition and EOB (explanation of benefits) description

• Common claim denials

• Determine corrective action

• Helpful Tools

• Question and Answer

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Objectives

Participants will understand:

•How to research professional claims via Web interChange

•How to read the denials

•How to determine the resolution

•How to take corrective action

Claim Inquiry

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Claim Inquiry

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Claim Inquiry• National Provider Identifier (NPI) or LPI will automatically populate

‒ For multiple locations – choose appropriate service location• Member recipient identification number (RID) • From and through date of service of specific claim• Search by date of service (DOS)

Why not search by internal control number (ICN)?• ICN will only give information on one specific claim• Review all claim submissions and denial reasons• Use paid claim (if applicable) for corrections

‒ Adjust the paid claim or void and start over

Note: Documentation submitted with original claim must also be submitted with current claim. This applies to paper and electronic claims.

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Claim Inquiry

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Claim Inquiry

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Claim InquiryClaim submission information is displayed•Choose the appropriate claim to work with

i.e. most recent ICN or paid claim

•Click on the ICN•Choose •Scroll to the bottom of the claim

Adjustment reason codes (ARCS)•Health Insurance Portability and Accountability Act of 1996 (HIPAA) required fields – not the reason detail denied

REMARKS•HIPAA required fields – not the reason detail denied•Provide spend down information

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Claim Inquiry

CLAIM STATUS INFORMATION•Provides detailed information

‒ disposition of each EOB (explanation of benefits) code – LOOK FOR THE “D”

‒ H/D – the header or detail level

which detail line

•WHY DID THE CLAIM/DETAIL LINE DENY‒ description

Common claim denials

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Common Denials

2017 - Recipient ineligible on date of service – due to enrollment in a Managed Care Entity

Resolution:•VERIFY MEMBER ELIGIBILITY

‒ Understand the eligibility information•Submit claim to the appropriate entity

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Common Denials2017 - Recipient ineligible on date of service

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Common Denials

1130 – Ordering/Referring provider is not enrolled in the Indiana Health Coverage Programs (IHCP)

Resolution:•The NPI of the OPR provider must be in Field 17b on the CMS 1500 claim form or entered in the Referring field on Web interChange •Verify the OPR NPI is correct. If not, the provider needs to register with the IHCP.

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Common Denials

0558 - Coinsurance and deductible amount missing

Claim submitted has no coinsurance and deductible amount indicating that this is not a crossover claim

Resolution:•Verify claim is a crossover claim

‒ Submit claim with appropriate crossover information‒ Primary explanation of benefits (EOB) is not required if payment

has been made•If claim is not crossover

‒ Submit as Medicaid primary‒ Include supporting EOB documentation if applicable

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Medicare and Replacement Plans

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Medicare and Replacement Plans

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Common DenialsCrossover Claim Information

• Payer ID = REPLACEMENT PLAN OR MEDICARE PAYER ID

• Payer Name = Wisconsin Physician Services (Traditional Medicare) or

• Replacement Plan name in the Payer Name Field

• Medicare Paid Amount = The total amount paid by Medicare for the claim

• Subscriber Name = Name of policy holder for primary insurance

• Primary ID = ID number of the primary insurance (Medicare or Replacement Plan)

• Relationship Code = 18 (self)

• Claim Filing Code = 16 (Replacement Plan) or MB (Traditional Medicare)

• Click Save Benefits at the bottom of the screen

• Click Save and Close at the top of the screen

Note: Obtain coordination of benefits (COB) information from the HELP tab, Reference Materials on Web interChange

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Common DenialsInformation required in Field 22

Coinsurance/Deductible Information

Medicare Payment

Information

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Common Denials4189 - Multiple units of same lab not payable without modifiers on same Date of Service

Resolution: •All NCCI edits must be reviewed by an Administrative Review Specialist

•Resubmit claim(s) along with Lab Notes and an Administrative Review request to the IHCP Written Correspondence Unit.

HP Administrative Review Written Correspondence P.O. Box 7263

Indianapolis, IN 46207-7263

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Common Denials

2057 – Invalid Family Planning Diagnosis/Procedure Code

Resolution:•Verify your medical or medical crossover claim includes a diagnosis code that is a valid family planning diagnosis•Verify a family planning procedure code is included on each detail line of the claim•Please refer to BT201303 for the updated list of billable diagnosis codes

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Common Denials3001 - Dates of service not on PA database

The code billed requires PA (prior authorization) for that program, and the date(s) of service indicated on the claim do not fall within the start/stop dates prior authorized for that code

Resolution:•Confirm PA information through PA Inquiry on Web interChange•Verify service requires PA

‒ Fee schedule‒ IHCP Provider Manual, Chapter 6

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Requesting and service providers can use member ID to check status. All other providers must have the PA number to see authorization

status

3001 - Dates of service not on PA database

Common Denials

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Common Denials4021 - Procedure Code vs Program Indicator

Procedure code billed is restricted to specific programs for the claim's dates of service

The recipient is not eligible for one of the programs indicated

Example: Hoosier Healthwise, Package C

Resolution:•VERIFY ELIGIBILITY•Consult fee schedule for program coverage

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Common DenialsThe Program Coverage Value descriptors are:

  1. Traditional Medicaid and Hoosier Healthwise covered.  2. Traditional Medicaid and Hoosier Healthwise covered,      with the exception of Package C.  3. Package C covered only.  4. Not covered.

4021 - Procedure Code vs Program Indicator

Helpful Tools

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Helpful Tools

•IHCP website at indianamedicaid.com•IHCP Provider Manual •Customer Assistance

− 1-800-577-1278

•Locate area consultant map on:− indianamedicaid.com (provider home page> Contact

Us> Provider Relations Field Consultants)

or − Web interChange > Help > Contact Us

•Written Correspondence− HP Provider Written Correspondence

P. O. Box 7263Indianapolis, IN 46207-7263

Avenues of resolution

Q&A