Saturday, 20 August 2016

Timely filing limit for BBHHF providers

Timely Filing for BBHHF Providers;

Timely Filing Policy under Charity Care To meet timely filing requirements for the BBHHF Charity Care program, claims must be received within 180 days from the date of service. Claims that are 180 days old must have been billed and received within the 180 day filing limit.

The original electronic claim must have had the following valid information:
• Valid Provider Number
• Valid Member Number
• Valid Date of Service
• Valid Bill Type

Claims that are over 180 days must be submitted on paper with a copy of the original remittance advice showing where the claim was initially received PRIOR TO the 180 day limit. Claims with dates of service over 360 days are NOT eligible for reimbursement. This policy is applicable to reversal/replacement claims. If a reversal/replacement claim is submitted with a date of service that is over 180 days, the replacement claim must be submitted on paper with a copy of the original remittance advice to:

BBHHF Charity Care Program
Timely Filing
PO Box 2002
Charleston, WV 25327-2002.

You are NOT allowed to add additional services to the replacement claim. If additional services are billed on the replacement claim that were not billed on the original claim, and the dates of service are over 180 days, the claim will be denied for timely filing.

Wednesday, 17 August 2016

Helpful Tips in Medical coding in hospital billing - what is special days

• Diagnosis Codes: When reporting diagnosis codes a decimal point must not be submitted as the decimal point is implied.

• Single Date: Under 5010, a date range must be supplied and a single date is no longer permitted

• Admission Date: The admission date and hour only are allowed on inpatient claims and cannot be sent on outpatient claims.

• Special Days: 5010 has deleted the ‘Claim Quantity’ segment which contained the total covered days, non-covered days, coinsurance days and the lifetime reserve days. These days will now be sent in the Value information segment. The four valid values are:

o 80 - Covered days

o 81 - Non Covered days

o 82 - Coinsurance Days

o 83 - Lifetime Reserve Days

• Service Facility Location Name: Required when the location of health care service is different than the billing provider. The Service Facility must be a non-person and must contain a valid 9-digit postal code or zip code.

• Outpatient Services “Priority Type of Admission or Visit” and “Point of Origin for Admission or Visit”: Required for outpatient services submitted via paper or electronically for all bill types except 14X (Hospital laboratory Services provided to non-patients [OP/6]).

• National Drug Code (NDC): Drug quantity information is now required when an NDC is submitted.

o As an NDC unit of measurement, milligrams (ME) has been added. However Florida Blue does not recognize the ME unit of measure. Refer to the Billing Drug Services on a Professional claim section below

Saturday, 13 August 2016

Coding a Facility Claim Procedure, Modifier and Diagnosis Codes - Basic steps

 -    A critical element in claims filing is the submission of current and accurate codes to reflect the services provided. Correct coding is essential for correct reimbursement. We have applied procedure code edits to outpatient claims for our Medicare Advantage members since 2008. Effective September 15, 2012, wewill apply these edits to our Commercial outpatient claims.

Complete and accurate procedure code, modifier and diagnosis code usage at the time of billing ensures accurate processing of correct coding initiative edits. Wecan only use the primary modifier submitted with the alternate procedure code for outpatient billing. We encourage you to purchase current copies of CPT, HCPCS and ICD code books.

The correct coding initiative edits and medically unlikely edits will apply to outpatient claims from the following hospitals and facilities:

• Acute care hospitals

• Long term acute care hospitals

• Ambulatory surgical centers

• Psychiatric facilities

• Substance abuse facilities

• Inpatient rehabilitation facilities

• Skilled nursing facilities

Note: Ambulatory surgical centers will follow institutional correct coding initiative edits forour commercial business, while our Medicare Advantage business will process against the professional edits.

Unlisted Procedure Codes

Unlisted procedure codes are not recommended for outpatient claims since they impact reimbursement of the claim. Refer to the outpatient payment programs section of this manual and the participation agreement for coding and reimbursement instructions.

Code Updates

The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) update procedure codes to reflect changes in health care and medical practices. Coding updates occur quarterly with the largest volume effective January 1, of each year. Current Procedural Terminology (CPT) and Healthcare Common Procedure Code System (HCPCS) codes may be added, deleted or revised with each update. International Classification of Diseases-9th Revision-Clinical Modification (ICD-10-CM) updates may occur bi-annually, with the largest volume effective October 1 of each year.


A modifier allows a provider to indicate that a service or procedure is altered by some specific circumstance, but the definition or code is not changed. Modifiers may be used in some instances when additional information is needed for proper payment of claims. Valid modifiers and their descriptions are found in the most current CPT and HCPCS coding books.

Weprocess claims using only the first modifier for outpatient institutional claims. While up to three modifiers are accepted, claims are processed using only the first modifier. Therefore, submit the most important modifier affecting reimbursement in the first position on paper and electronic claims.

Note: If your claim is denied due to a lack of documentation to support the use of a specific modifier, you may submit an appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation. 4

Modifiers may be used to indicate that:

• A service or procedure has been increased or reduced

• Only part of a service was performed

• A bilateral procedure was performed

• A service or procedure was provided more than once

• Unusual Events Occurred

Wednesday, 10 August 2016

Provider having multiple location - how to enroll

Service Locations:

I have multiple service locations. How do I ensure all mail and checks go to one address?
Checks will be sent to the W9 address listed in the revalidation application. If multiple locations are currently enrolled with separate Medicaid ID numbers, the address to which your checks will be mailed is based on the Pay-To W9 information provided in the revalidation application. If all locations use the same W9 address, then all of your checks will be delivered to that address.

Our current services are provided outside of the office. How do I show this in our revalidation application?
When you revalidate in WV Medicaid, you will record the location of the office administering the provision of services only. Later, when you submit claims to Molina Medicaid Solutions, you will indicate where the services were provided using the National Place of Service code set.

Why do I have to answer the same question when I am adding a rendering provider and I have already provided the information under my service location? There are circumstances where a service location might provide a service that will not include participation by all rendering providers. For instance, a service location may offer Physician Assured Access System (PAAS) services, however not all rendering providers at that location may be eligible to provide PAAS services.

What is the PAAS Program?
The PAAS Program is only applicable to primary care type physicians and provider types. Examples of the provider type, and physician specialties are: Internal Medicine, Family or General Practice, Pediatricians, OB/GYN, FQHC’s, and RHC’s, etc.

I’m not a specialty, or provider type for primary care. How do I answer the questions “Are you a PAAS Provider”, and “Do you want to be a PAAS Provider?
Answer these questions as NO.

Why does the Service Location screen on the PEAP system ask for a minimum and maximum age?
Some provider specialties only accept patients of a certain age. An example would be a pediatrician would only have patients from under 1 year of age to 18 years of age.

Will each service location have to be added? Example we have 41 Service Locations.
Yes every location and Provider at that entity

Saturday, 6 August 2016

Coding tips for Diagnostic Imaging and Laboratory codes

Diagnostic Imaging

If the treating chiropractic provider refers the reading or interpretation of a radiology service to a radiologist, reimbursement for the professional component of that service will only be made to the radiologist, and the treating chiropractic provider should not bill for that component.

Component Modifier Description of Services

• Professional 26 Services rendered by a licensed practitioner to perform the diagnostic interpretation of each study. It is required to document the diagnostic conclusions of the study by a written and signed radiology report.

• Technical TC Radiology services that include providing the facilities, equipment, resources, personnel, supplies and support needed to perform and produce the diagnostic study.

• Global N/A Combines both the technical and professional components in the service provided.


BlueCare, BlueMedicare HMO, BlueMedicare PPO and BlueOptions members covered in-office laboratory services are restricted to:
81000, 81001, 81002, 82947, 82948, 85014, 85025 All other laboratory services should be referred to Quest Diagnostics, Inc.
For BlueChoice and Traditional members, members may be referred to any Florida Blue contracted laboratories, including Quest Diagnostics.

Laboratory services for select health and musculoskeletal conditions may comprise one or more of the procedure codes on the list of in-office laboratory codes. Reimbursement for routine venipuncture for collection of specimen (36415) is only payable when paired with modifier 90 and when the laboratory sample is drawn in the chiropractor’s office, but the sample is sent to an offsite laboratory for processing

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