General
Timely Filing Limit for Corrected Claims
365 days from the original process date
This is where we check Hospice Enrollment of members
GPS
If the claim was denied for no authorization on file, what should we advise the providers.
Submit recon or appeal with medical records supporting medical necessity.
Bill type for Corrected Claims
Bill Type 7
Timely Filing Limit for INN Reconsideration
365 days from the original denial date.
What tool do we access for ICES denials?
CPA
If the claim was denied for OCE error code 5522 - Invalid Modifier, what should we advise the provider?
Coordinate with coders and billers for the correct Modifier and submit a corrected claim with the correct Modifier.
What claim form do providers use to submit facility claims?
UB04 Form
Timely Filing for OON Appeal
60 days from the original denial date
Where do we check recoupment reasons for claims?
ODAR
If the claim was denied due to Hospice enrollment, and you verified that the member was indeed in Hospice during the DOS, what should you advise the provider?
Bill the services to Traditional Medicare.
What are the 3 ways we send payments to providers?
Via Paper check, EFT, or VCP
What do OON providers attach to their appeal request to waive any liability from members if ever the services are not paid?
Waiver of Liability or WOL
What tool do we use to pull up the EOB or Claim Form?
DOC360
Claim was denied for NCD/LCD Criteria, after checking CPA, you found out that it does not meet the associated diagnosis code relationship criteria for CMS ID. What should you advise the provider?
Advise provider to coordinate with their coders and billers and check CMS.gov for proper billing guidelines. Submit a corrected claim.
What is the status of a claim that has both a payment amount and a process date?
Paid Claim
What do OON providers submit along with their appeal if it is already past the timely filing deadline?
Letter of Good Cause
Claim is denied due to coding standards, what tool should we access to get an elaborated denial reason?
MARS
Advise to submit a corrected claim, and make sure to indicate that the servicing address matches the one registered in their CLIA Address.
What are the two important dates that we need to check to see if the claim was received within timely limit?
Date of Service and Receive Date