5 tips for prompt claim processing

Prompt claims processing

We know that you want your claims to be processed promptly for the covered services you provide to our members.

We work hard to process your claims timely and accurately. Here’s what you can do to help us:

1 Review the member’s eligibility at UnitedHealthcareOnline.com, using swipe card technology or keying in the member’s information.

You can also check member eligibility by phone by calling the United Voice Portal at (877) 842-3210 or the Customer Care number on the back of the member’s health care ID card.

Disclaimer: Eligibility & benefit information provided is not a guarantee of payment or coverage in any specific amount. Actual reimbursement depends on various factors, including compliance with applicable administrative protocols, date(s) of services rendered and benefit plan terms and conditions.

2 Notify us in accordance with the Standard Notification Requirements list.

3 Prepare complete and accurate claims (see “Complete Claims” below).

4 Submit claims online at UnitedHealthcareOnline.com or use another electronic option.

a) Connectivity Director is a free direct connection for those who can create a claim file in the HIPAA 837 format. This Web-based application enables real-time and batch submissions direct to UnitedHealthcare.

Connectivity Director provides immediate response back to all transaction submissions (claims, eligibility, and more). Additional information can be found at UnitedHealthcareCD. com, including a comprehensive User Guide and information on how to get started.

End Stage Renal Disease/ Dialysis Services CPT code and revenue code list

Services for the treatment of End Stage Renal Disease (ESRD), including outpatient dialysis services (as defined by, but not limited to, the revenue and CPT codes below), require notification.

No notification is required for end stage renal disease when a Medicare member travels outside of the service area.

Dialysis:

90935, 90937, 4052F, 4054F – hemodialysis

90945, 90947, 4055F – peritoneal

90963 – 90970 – ESRD

90989 – patient training, completed course

90993 – patient training, per session

90999 – unlisted dialysis procedure, inpatient or outpatient

Revenue Codes:

304 – Nonroutine Dialysis

800 – 804, 809 – Renal Dialysis

820 – 825, 829 – Hemo/op or home

830 – 835, 839 – Other outpatient/peritoneal dialysis

840 – 845, 849 – Capd/op or home

850 – 855, 859 – Ccpd/op or home

880 – 882, 889 – Dialysis / misc

For the most current listing of UnitedHealthcare contracted dialysis facilities, please refer to our online provider directory at UnitedHealthcareOnline.com or call us at (877) 842-3210. In an effort to maximize member benefit coverage and lifetime maximum limits, we ask that you refer to UnitedHealthcare contracted dialysis facilities whenever possible. 

Note that your agreement with us may include restrictions on referring members outside the UnitedHealthcare network.

Billing Physician Services - Renal services

Physician Services - Renal services

Physician services rendered to each outpatient maintenance dialysis patient provided during a full month shall be billed on a monthly capitation basis using the appropriate procedure code by age as outlined in the CPT. 

Monthly maintenance dialysis payment (i.e., uninterrupted maintenance dialysis) is comprehensive and covers most of a physician’s services whether a patient dialyzes at home or in an approved ESRD outpatient facility. 

Dialysis procedures are allowed in addition to the monthly maintenance dialysis payment. In general, the Agency follows Medicare guidelines related to monthly capitation payments for physicians. Physician services included in the monthly capitation payment for ESRD related services include, but are not limited to:

• Assessment and determination of the need for outpatient chronic dialysis therapy

• Assessment and determination of the type of dialysis access and dialyzing cycle,

• Management of the dialysis visits including outpatient visits for evaluation and management, management during the dialysis, and telephone calls.

• Assessment and determination if a recipient meets preliminary criteria as a renal transplant candidate including discussions with family members

• Assessment for a specified diet and nutritional supplementation for the control of chronic renal failure, including specifying quantity of total protein, sodium, potassium, amount of fluids, types of anemia and appropriate treatments, type of arthropathy or neuropathy and appropriate treatment or referral, estimated ideal dry weight, etc.

Assessment for diabetic patient’s diet and caloric intake is included also.

• Prescribing the parameters of intradialytic management including anticoagulant, dialysis blood flow rates and temperature, duration and frequency of treatments, etc.

The monthly capitation payment is limited to once per month, per recipient, per provide.

Renal dialysis facility provider type and speciality number

Renal Dialysis Facility

End Stage Renal Disease (ESRD) services are outpatient maintenance services provided by a freestanding ESRD facility or hospital-based renal dialysis center

National Provider Identifier, Type, and Specialty A provider who contracts with Alabama Medicaid as a renal dialysis provider is added to the Medicaid system with the National Provider Identifiers provided at the time application is made. 

Appropriate provider specialty codes are assigned to enable the provider to submit requests and receive reimbursements for dialysis-related claims.

NOTE: The 10-digit NPI is required when filing a claim.

Renal Dialysis Facility providers are assigned a provider type of 30 (Renal Dialysis Facility). The valid specialty for Renal Dialysis Facility providers is Hemodialysis (300).

Enrollment Policy for Renal Dialysis Facility Providers

To participate in Medicaid, End Stage Renal Disease (ESRD) facilities/centers must meet the following requirements:

• Certification for participation in the Title XVIII Medicare Program

• Approval by the appropriate licensing authority

Satellites and sub-units of facilities or centers must be separately approved and contracted with Medicaid .

LIST AND DEFINITION OF DUAL ELIGIBLES - Medicare and Medicaid

Dual Eligibles - The following describes the various categories of individuals who, collectively, are known as dual eligibles. Medicare has two basic coverages: Part A, which pays for hospitalization costs; and Part B, which pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services. Dual eligibles are individuals who are entitled to Medicare Part A and/or

Part B and are eligible for some form of Medicaid benefit.

1. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) - These individuals are entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance for Medicare services provided by Medicare providers. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).

2. QMBs with full Medicaid (QMB Plus) - These individuals are entitled to Medicare Part A, have income of 100% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and

coinsurance, and provides full Medicaid benefits. FFP equals FMAP.

3. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) - These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid.

Medicaid pays their Medicare Part B premiums only. FFP equals FMAP.

4. SLMBs with full Medicaid (SLMB Plus) - These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not in exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part B premiums and provides full Medicaid benefits. FFP equals FMAP.

5. Qualified Disabled and Working Individuals (QDWIs) - These individuals lost their Medicare Part A benefits due to their return to work. They are eligible to purchase Medicare Part A benefits, have income of 200% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only. FFP equals FMAP.

6. Qualifying Individuals (1) (QI-1s) - This group is effective 1/1/98 - 12/31/02. There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have income of at least 120% FPL, but less than 135% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid.

Medicaid pays their Medicare Part B premiums only. FFP equals FMAP at 100%.

Improve Medical Billing Collections - Billing Tips

Any medical billing company would like to have on-time collections, of course.  Although, it cannot be denied that there are issues that may hinder this from happening.  To make sure that every billing is paid successfully, you have to work hard and to be organized.  First, do not let a claim sit around for a long time.  Once you have received it, process it immediately and inform the insurance company.  If you take long in processing it, it would also take longer for the payment to arrive.  Follow it up with the insurance company and get a specific answer about when payment will be sent so you could easily inform the patient in case they call or drop by.  

Make good use of the available technology we have nowadays.  Invest on electronic modes of payment and claims.  This is not only convenient, it is also faster.  This method is also more reliable because an electronic machine would easily detect entry errors and missed fields.  It would immediately inform the patient or the insurance company about it so that it would be corrected right away.  

It is necessary to follow-up with insurance companies in a timely manner.  If a payment is expected today and it has not yet arrived, call them up.  If they give another date, follow it up again on that particular date.  If they do not reply at all, try calling them weekly.  Regular follow-ups give the insurance company an impression that you are serious about collecting.  Most insurance companies would do anything to avoid a payment.  Make sure you point out to them that you will keep calling until the collection is sent. 

Update on Evaluation Management CPT codes - HighMark insurance

Highmark Announces Adjustments to UCR and Premier Blue sm Shield Reimbursement

 As noted in the April 2011 issue of PRN, Highmark filed with, and has now received approval from, the Pennsylvania Insurance Department to implement a broad range of UCR Level II and Premier Blue Shield reimbursement adjustments.

The adjustments impact anesthesia, select surgical, diagnostic and evaluative services, including, but not limited to, musculoskeletal, eye, behavioral health, allergen immunotherapy and routine electroencephalography procedures.

• Increases in allowance will be implemented for dates of service beginning July 1, 2011.

• A minimum number of allowances will be decreased for dates of service on/after Sept. 26, 2011.

Highmark will also implement changes to its payment differential for evaluation and management procedure codes 99201 through 99215 when performed in the facility, compared to services performed in a non-facility setting. Effective Sept 26, 2011, Highmark will calculate payment for the facility service using Medicare's site-of-service differential, or at a predetermined cap, not to exceed a certain designated percentage. Currently, Highmark applies a 15 percent differential.

In addition, the allowances for CT studies of the abdomen and pelvis combined, procedure codes 74176, 74177 and 74178,will be increasing with this update. The allowances will be based upon additional data collection and analysis and have yet to be finalized.

Understanding CPT Code 28510 – Billing for Fracture Care Follow-Ups

With regards to Standard Fracture Care, a patient’s fracture follow-up can be billed by the doctor.  The doctor must make sure, however, that the appropriate procedure codes as well as the ICD-9 code is used.  This pertains to the site of the fracture.  

The follow-up care for closed fracture sites are covered by the CPT code 28510.  All, except those that involve the big toe.  Due to the details enclosed in this code, the need to perform site manipulations is no longer required if you plan to bill a patient’s follow-up care.  Because of the code 28510, it is immediately expected that a doctor will earn a hundred dollars for each patient.

A patient who comes in for a follow-up with regards to an injury such as a fracture is expected to spend time in a doctor’s clinic.  There is also a big possibility for them to inform you about certain medical issues they might have that would not be related to their fracture.  Doctors would not have to worry when this type of situation arises especially if they did not provide the fracture care initially. 

As long as you document the visit correctly, you would be able to bill for the fracture follow-up and the additional concerns separately.  This is justified by the fact that the other concerns are not in any way related to the fracture.  The doctor just has to be very detailed about the consultation with regards to the proper procedure codes and the injuries addressed.

If ever the situation involves a patient who has multiple fractures comes for a follow-up, you can bill for each type of fracture.  For example, a patient has a fracture in his ribs, legs, and arms.  You can bill each site separately.  It is, however, crucial to document each fracture addressed and how long it took you to address it.  

Most fractures are billed to insurance companies of patients.  There are cases, however, wherein their fracture is work-related.  With this situation, Worker’s Compensation and the Personal Injury Protection Policy are applied.  The guidelines with this type of insurance may vary from state to state so it is important for a doctor to know about them before applying codes for the follow-up and any procedures done on the patient.  

The important thing here is that the doctor gets paid for the care he has provided for the patient even if the initial check was done by another doctor.

Description of Healthcare Common Procedure Coding System - Beginner Guide

The HCPCS has been selected as the approved coding set for entities covered under the Health Insurance Portability and Accountability Act (HIPAA), for reporting outpatient procedures.

The HCPCS is based upon the American Medical Association’s (AMA) “Physicians’ Current Procedural Terminology, Fourth Edition” (CPT-4). It includes three levels of codes and modifiers. Level I contains only the AMA’s CPT-4 codes. This level consists of all numeric codes. Level II contains alpha-numeric codes primarily for items and nonphysician services not included in CPT-4, e.g., ambulance, DME, orthotics, and prosthetics. These are alpha-numeric codes maintained jointly by CMS, the Blue Cross and Blue Shield Association (BCBSA), and the Health Insurance Association of America (HIAA).

Normally Level I and Level II codes are updated annually, issued in October for January implementation. However, Level II codes also may be issued quarterly to provide for new or changed Medicare coverage policy for physicians’ services as well as services normally described in Level II. These codes may be temporary and be replaced by a Level I or Level II code in the related CPT or HCPCS code section, or may remain for a considerable time as “temporary” codes. Designation as temporary does not affect the coverage status of the service identified by the code. New temporary codes that have been approved will be issued in a Recurring Update Notification instruction quarterly.

New K or Q codes may be identified from time to time and, when they are, they will be announced in a Recurring Change Request issued on a quarterly basis.

The CMS monitors the system to ensure uniformity.

Use and Maintenance of CPT-4 in HCPCS

There are over 7,000 service codes, plus titles and modifiers, in the CPT-4 section of HCPCS, which is copyrighted by the AMA. The AMA and CMS have entered into an agreement that permits the use of HCPCS codes and describes the manner in which they may be used. See §20.7 below.

• The AMA permits CMS, its agents, and other entities participating in programs administered by CMS to use CPT-4 codes/modifiers and terminology as part of HCPCS;

• CMS shall adopt and use CPT-4 in connection with HCPCS for the purpose of reporting services under Medicare and Medicaid;

• CMS agrees to include a statement in HCPCS that participants are authorized to use the copies of CPT-4 material in HCPCS only for purposes directly related to participating in CMS programs, and that permission for any other use must be obtained from the AMA;

• HCPCS shall be prepared in format(s) approved in writing by the AMA, which include(s) appropriate notice(s) to indicate that CPT-4 is copyrighted material of the AMA;

• Both the AMA and CMS will encourage health insurance organizations to adopt CPT-4 for the reporting of physicians’ services in order to achieve the widest possible acceptance of the system and the uniformity of services reporting;

• The AMA recognizes that CMS and other users of CPT-4 may not provide payment under their programs for certain procedures identified in CPT-4. Accordingly, CMS and other health insurance organizations may independently establish policies and procedures governing the manner in which the codes are used within their operations; and

• The AMA’s CPT-4 Editorial Panel has the sole responsibility to revise, update, or modify CPT-4 codes.

The AMA updates and republishes CPT-4 annually and provides CMS with the updated data. The CMS updates the alpha-numeric (Level II) portion of HCPCS and incorporates the updated AMA material to create the HCPCS code file. The CMS provides the file to A/B MACs (A), (B), (HHH), and DME MACs and Medicaid State agencies annually.

It is the MAC’s responsibility to develop payment screens and limits within Federal guidelines and to implement CMS’ issuances. The coding system is merely one of the tools used to achieve national consistency in claims processing.

MACs may edit and abridge CPT-4 terminology within their claims processing area. However, MACs are not allowed to publish, edit, or abridge versions of CPT-4 for distribution outside of the claims processing structure. 

This would violate copyright laws. MACs may furnish providers/suppliers AMA and CMS Internet addresses, and may issue newsletters with codes and approved narrative descriptions that instruct physicians, suppliers and providers on the use of certain codes/modifiers when reporting services on claims forms, e.g., need for documentation of services, handling of unusual circumstances. 

The CMS acknowledges that CPT is a trademark of the AMA, and the newsletter must show the following statement in close proximity to listed codes and descriptors:

CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

If only a small portion of the terminology is used, MACs do not need to show the copyright legend. MACs may also print the code and approved narrative description in development requests relating to individual cases.

The CMS provides MACs an annual update file of HCPCS codes and instructions to retrieve the update via CMS mainframe telecommunication system. 

How to Buy Good Medical Billing Books

There are an overwhelming number of medical billing books available in the market today.  The electronic types, popularly known as eBooks are gaining more attention because it can easily be downloaded through the internet.  No matter how interesting the title is or how cheap the book is, do not rely on these factors in purchasing medical billing books.  There are things you must consider when choosing which one to purchase.

Do not just look at the title and the summary of a medical billing book.  Though the text is smaller, the author is also an important factor to consider.  If you really want to buy a good book about medical billing, research on the author.  Look at their credentials as well as their accomplishments.  Do not rely on their statements.  Their record should speak for itself.

Not all medical books are the same.  In fact, there are books that only tackle one specific part within the medical billing career.  If you really want to learn all you need to learn, you could buy several books.  This is, of course, not a practical thing to do.  It is expensive and unnecessary.  Research on each book with regards to the topics it tackles and the information it provides.  The important topics that should be part of a really good medical billing book are: Claim Processing, Insurance (Primary, Secondary, Tertiary), Forms that are commonly used, Medicare, Medicaid, HMO, PPO, Explanation of Benefits (EOB), Patient Billing, Aging Reports, Account Receivables, Commonly used Terms, HIPAA, Training, ICD diagnosis and CPT procedure codes and their uses.

Service covered under Newborn Care

Newborn Care

Provide the highest level of care for the newborn beginning immediately after birth. Such level of care shall include, but not be limited to, the following:

(1) Instilling of prophylactic eye medications into each eye of the newborn;

(2) When the mother is Rh negative, securing a cord blood sample for type Rh determination and direct Coombs test;

(3) Weighing and measuring of the newborn;

(4) Inspecting the newborn for abnormalities and/or complications;

(5) Administering one half (.5) milligram of vitamin K;

(6) APGAR scoring;

(7) Any other necessary and immediate need for referral in consultation from a specialty physician, such as the Healthy Start (postnatal) infant screen; and

(8) Any necessary newborn and infant hearing screenings (to be conducted by a licensed audiologist pursuant to Chapter 468, F.S., a licensed M.D. or D.O., or an individual who has completed documented training specifically for newborn hearing screenings and who is directly or indirectly supervised by a licensed physician or a licensed audiologist).

Pregnancy service - prior authorization information

Pregnancy

PCP’s or obstetricians are required to notify SHP of the first prenatal visit and/or positive pregnancy test within two (2) working days by completing the Pregnancy Notification Form (refer to the Forms Section), whether the pregnancy was identified through medical history, examination, testing or otherwise.

SHP will allow pregnant enrollees to choose in-network obstetricians as PCP’s if the obstetrician is willing to participate as a PCP.

If a pregnant member has not selected a PCP for her unborn child, SHP will assign a pediatrician for the care of their newborn babies no later than the beginning of the last trimester of gestation. If a provider treating a pregnant member for prenatal care decides to terminate the contract with the Plan, SHP will allow the  member to continue care with that provider until completion of the postpartum care.

Finding Good Medical Billing Software - Question need to Ask yourself

A medical billing business requires efficient software to be able to perform tasks related to medical insurance and benefits.  There are several billing software available in the internet today, finding the right one, however, can be challenging.  Below are some questions you can ask yourself to help you come up with a decision on which medical billing software to purchase.  

Is it cost-effective?  Our usual perception is that cheaper means less effective.  This is not always true.  Most expensive types come with a lot of extra features but you do not really need them.  Purchase software that has all the things you need, nothing more.

Is it user-friendly?  This question is asked not for computer illiterate employees.  Most medical billers are tech savvy but the software should be easy enough to use so they could spend the extra effort in dealing with complex software in dealing with other important tasks instead.

Has the software been around for a long time?  If it has, it is more likely to have encountered every bug and issues possible and a fix has already been applied.  New software says that it is bug-free.  It may be bug-free for now but it would surely encounter one in the future.

Is the medical billing software company experienced?  A company that has been around for a long time is more reliable especially if they have a lot of employees.  This ensures that there are experienced people to help you out in times of software trouble.

Is software training programs available?  An online training should be available because it is more convenient and less costly.  Vendors that require you to attend training seminars do not only save money, they do it at the expense of their customers.  

What is Second Medical Opinion service

Requests for a Second Medical Opinion

Second Opinion is a consultation by a physician other than the member’s Primary Care Physician, whose specialty is appropriate to the need, and whose services are obtained when the member disputes the appropriateness or necessity of a surgical procedure, is subject to a serious injury or illness, including failure to respond to the current treatment plan.

The member will be advised to contact the Primary Care Physician (PCP) and request a consultation with the necessary specialty provider. The member may select a contracted provider listed in the provider directory supplied by SHP or a non-contracted provider in the Plan’s geographic area. The UM Coordinator will contact the member’s PCP, or admitting physician if the member is in the hospital if necessary to assist in the second opinion process.

SHP shall pay the amount of all charges which are usual, reasonable and customary in the community for second opinion services performed by a physician not under contract with SHP, but the member may be responsible for part of the bill. SHP’s physician’s professional judgment concerning the treatment of a member derived after review of a second medical/surgical opinion shall be controlling as to the treatment obligations of SHP.

Does Emergency Services require Authorization ?

Emergency Services

Emergency services are not subject to prior authorization requirements and are available to our members 24 hours a day, seven days a week, 365 days a year.

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent lay person who possesses an average knowledge of health and medicine could reasonably

expect that the absence of immediate medical attention could reasonably be expect to result in any of the following:

*  Serious jeopardy to the health of the member, including a pregnant woman or fetus

*  Serious impairment to bodily functions

*  Serious dysfunction of any bodily organ or part

*  A pregnant woman having contractions

SHP shall not:

*  Require prior authorization for an enrollee to receive pre-hospital transport or treatment or for emergency services and care;

*  Deny payment for treatment obtained when a representative of the SHP instructs the enrollee to seek emergency services.

*  Specify or imply that emergency services and care are covered by the Plan only if secured within a certain period of time;

*  Use terms such as "life threatening" or "bona fide" to qualify the kind of emergency that is covered; or

*  Deny payment based on a failure by the enrollee or the hospital to notify SHP before, or within a certain period of time after, emergency services and care were given.

*  Deny claims for emergency services and care received at a hospital due to lack of parental consent.

Pre-hospital and hospital-based trauma services and emergency services and care will be authorized.

SHP shall cover all screenings, evaluations, and examinations that are reasonably calculated to assist the provider in arriving at the determination as to whether the member has an emergency medical condition. If the provider determines that an emergency medical condition does not exist, SHP is not required to cover services rendered subsequent to the provider's determination unless

authorized by the Plan.

If the provider determines that an emergency medical condition exists, and the enrollee notifies the hospital or the hospital emergency personnel otherwise have knowledge that the patient is an enrollee of SHP, the hospital must make a reasonable attempt to notify the enrollee's PCP, if known, or SHP, if the Plan has previously requested in writing that it be notified directly of the

existence of the emergency medical condition

If the hospital, or any of its affiliated providers, do not know the enrollee's PCP, or have been unable to contact the PCP, the hospital must notify SHP as soon as possible before discharging the enrollee from the emergency care area; or notify the Plan within twenty four (24) hours or on the next business day after the enrollee’s inpatient admission.

Incentive Plans in Medical Billing - tips for success

Incentive plans for medical billers are effective but it does not necessarily mean that it has to be expensive for it to work.  There are more affordable options, which are as effective in inspiring and motivating medical billers.  There are things you can do to ensure that the incentive plan will be successful.

First, you have to keep in mind that in a medical billing organization, there are different tasks being handled within and every task, when performed efficiently, will produce good results not only to one but also to everyone in the organization.  You would have to set specific targets so that billers would know what they are aiming for.  Divide the rewards by allotting half of it for team performance and the other half for individual performance.

Second, aim for cost-effective incentive plans.  Employees are most likely to be motivated with cheap plans than those that require them to pay more than they prefer.

Third, invest in incentive plans that target different performances like speed, accuracy, delivery, and more.  Study all these intensively to be able to determine which ones are much needed within the organization.

Fourth, if you have several accounts within a medical billing organization, make sure to take into consideration that not all accounts are the same.  When providing incentives, make sure it is given to each account accordingly.

Fifth, when giving incentive payouts, distribute it as a part of the medical biller’s salary and make sure you adhere to this schedule.  Provide them with a written statement of how much they earned and how much tax was deducted.  

Sixth, make sure your employees understand the incentive plan.  It would be difficult to achieve something when you do not know what you are aiming for.  Post a chart of the incentive plan and post their progress as well.  This way, every one of them is updated regularly.

Understand Prior Authorization - Full details

Prior Authorizations:

Prior authorization (pre-service requests) allows for the use of quality, cost-efficient covered health care services and helps to ensure that effective transition of care planning is done so that members receive the most appropriate level of care within the most appropriate setting. Prior authorization must be obtained for all services not included on the Quick Authorization Form (QAF) for PCP’s (see section above) that require an authorization.

SHP’s UM Department evaluates requests for services/procedures and makes determinations based on medical necessity, covered benefits and appropriateness based on SHP’s approved utilization criteria (Interqual) and evidence-based, nationally recognized clinical guidelines. Only a Medical Director may issue an adverse determination, with the exception of denials due to benefit issues. No provider or any other individual or SHP employee or associate is rewarded for issuing denials of coverage or care. Financial incentives will NOT encourage decisions that would result in underutilization nor are incentives to create barriers to care and services.

Prior Authorization Requests are to be made through the SHP’s UM Pre-Certification Department.

Prior Authorization or Notification Process:

*  Providers are to fax the Referral & Authorization Form (refer to Forms Section) to the SHP’s Utilization Management Pre-Certification Department at Fax number 1-800-283- 2114 or by calling the PreCertification Telephone Queue 1-800- 887-6888, ext 2271.

*  Routine (NOT STAT/URGENT) requests are processed within fourteen (14)

calendar days of the Plan receiving the authorization request and having received all supporting clinical information.

STAT/URGENT requests are processed within seventy-two (72) hours of the Plan receiving the request and having received the supporting clinical information.

NOTE: STAT/URGENT Authorizations should be CALLED IN to the SHP Pre-Certification Authorization Telephone Queue and NOT faxed, and the caller should identify the request as “STAT/URGENT”. These requests should always meet the defined medical criteria for such which are:

STAT/URGENT: Any condition where failure to issue an immediate response may result in an IRREVERSIBLE SIGNIFICANT, ADVERSE outcome of health and/or function.

*  Each Referral & Authorization Form received from the provider’s offices will be date and time- stamped, manually or electronically and is reviewed for completeness, eligibility, benefits, PCP and specialist network affiliation

List of procedure - Authorization required

All of the following procedures and services require Prior Plan Notification and must be provided in a SHP participating facility*:

o Inpatient and Observation Admissions, as noted above
o Admission to any rehabilitation and skilled nursing facility
o All surgical procedures, inpatient or outpatient

o The following have special reporting requirements (refer to Forms Section):
*  Abortions
*  Hysterectomies
*  Sterilization procedures

o Cosmetic or Reconstructive Surgery, including but not limited to:
*  Breast reconstruction or reduction
*  Blepharoplasty
*  Venous procedures
*  Sclerotherapy

o Services and items:
*  Allergy (immunotherapy), exept for those services identified on the QAF
*  Ambulance transportation (non emergent)
*  Amniocentesis
*  Cardiac and pulmonary rehabilitation programs
*  Circumcisions after 12 weeks of age
*  Court-ordered services
*  Chemotherapy
*  Dialysis
*  DME, including apnea monitors and bili-blankets
*  Upper endoscopies at colonoscopies at hospitals
*  Genetic testing
*  Gamma Knife, Cyberknife

Medical Billing: An Introduction

The need for well-experienced professionals in the health and medical industry increases every single day.  The reason behind this is that the Healthcare industry is so large and it covers an extensive area of technological equipment and procedures.  In fact, the medical technology we have nowadays may become outdated in just a few years time.  The fast pace of advancement with medical procedures makes the need for a coding system to be created.  This is to ensure that each medical procedure, diagnosis, as well as complaint is recognized by health insurance companies to be added with regards to medical professional compensation.  

Medical billing is a process that covers different process within.  It involves the filling up and completion of medical forms like insurance cards, patient profile and information, encounter forms, diagnosis sheet, treatment and surgeries performed, and more.  All these are then collected and assessed to make sure that every necessary field is filled up accurately.  After every form is verified, it is then processed for payment.  Processing includes transferring all the collected data into an accounting software program.

  

Medical billers, just like other types of billing professionals, deal with a lot of paperwork as well as time-management to make sure every processing of payment is updated real-time.  They should posses the skill to understand health insurance, payment processing, and benefits to be able to explain it to patients and doctors especially when there are claims for errors.

Quick Authorization Form (QAF) - whose responsibilty to get referral ?

Referrals or Prior Notifications

A referral or prior notification is a request by a PCP or a participating specialist for a member to be evaluated and/or treated by a participating specialty physician and/or facility. SHP uses two types of forms and processes:

1. Quick Authorization Form (QAF)

For those services included on the SHP Quick Authorization Form (QAF) (see the Forms Section of this handbook) a referral is NOT required. Primary Care Physicians (PCP’s) can refer a member to a articipating specialist and to many frequently requested services and procedures at free-standing facilities with the Simply Healthcare Plans Quick Authorization Form (QAF) without contacting the health plan for prior authorization.

IMPORTANT NOTE: Communication with the Plan prior to the provision of care is not necessary when using the QAF; however, all inpatient services, outpatient hospital services (including diagnostics), and ASC services do require an authorization (see section below).

Prenatal care referrals are NOT to be made using the QAF.

**The QAF form is not valid for any inpatient or outpatient hospital services or for any consultations or procedures not listed on the form, or for out-of-network providers.

The PCP or specialist ordering the consultation or test is required to fax or mail a copy of the completed QAF to the participating provider or facility that will be providing the service(s), or to give a copy to the member so that it is presented at the time of the service.

Services that Do NOT Require Prior Authorization or QAF:

* Family Planning*

* Participating Office/free standing laboratory tests at labs consistent with CLIA guidelines

* Emergent transportation services

* Urgent or emergent care at participating Urgent Care centers or any Emergency Room

* County Health Departments (CHD), Federally Qualified Health Centers , Rural Health Clinics and federally funded migrant health centers when providing:

* Vaccines

* STD diagnosis/treatment

* Rabies diagnosis/immunization

* Family planning services and related pharmaceuticals

* School health services and urgent services

*NOTE: If the member receives Family Planning Services from a non-network Medicaid provider, the Plan will reimburse the provider at the Medicaid reimbursement rate, unless another payment rate is negotiated.

List of procedure - Authorization required

All of the following procedures and services require Prior Plan Notification and must be provided in a SHP participating facility*:

o Inpatient and Observation Admissions, as noted above

o Admission to any rehabilitation and skilled nursing facility

o All surgical procedures, inpatient or outpatient

o The following have special reporting requirements (refer to Forms Section):

*  Abortions

*  Hysterectomies

*  Sterilization procedures

o Cosmetic or Reconstructive Surgery, including but not limited to:

*  Breast reconstruction or reduction

*  Blepharoplasty

*  Venous procedures

*  Sclerotherapy

o Services and items:

*  Allergy (immunotherapy), exept for those services identified on the QAF

*  Ambulance transportation (non emergent)

*  Amniocentesis

*  Cardiac and pulmonary rehabilitation programs

*  Circumcisions after 12 weeks of age

*  Court-ordered services

*  Chemotherapy

*  Dialysis

*  DME, including apnea monitors and bili-blankets

*  Upper endoscopies at colonoscopies at hospitals

*  Genetic testing

*  Gamma Knife, Cyberknife

*  Hearing aids

*  Home Health Services

*  Hospice care

*  Hyperbaric Oxygen Therapy (HBO)

*  Investigational and experimental procedures and treatments

*  IV Infusions

*  Laboratory services in POS 22 and 24

*  Lithotripsy

*  Mental Health (See Mental Health Section)

*  Nutritional counseling

*  MRI’s, MRA’s

*  Oral Surgery

*  Oxygen therapy and equipment

*  Out-of-Network Services

*  Pain Management and or Pain Injections

*  PET Scans

*  Prenatal care

*  Orthotics and Prosthetics, including Cranial Orthotics

*  Physical, Occupational and Speech Therapy

*  Radiation therapy

*  SPECT scans

*  Transplants and pre and post transplant evaluations

*  Wound Care and wound vacuums

*  Drugs that require pre-authorization

*  Any services or procedures not listed on the Quick Authorization  Form (QAF)

*Unless the service is only available in a non-participating facility. 

Understand Prior Authorization - Full details

Prior Authorizations:

Prior authorization (pre-service requests) allows for the use of quality, cost-efficient covered health care services and helps to ensure that effective transition of care planning is done so that members receive the most appropriate level of care within the most appropriate setting. Prior authorization must be obtained for all services not included on the Quick Authorization Form (QAF) for PCP’s (see section above) that require an authorization.

SHP’s UM Department evaluates requests for services/procedures and makes determinations based on medical necessity, covered benefits and appropriateness based on SHP’s approved utilization criteria (Interqual) and evidence-based, nationally recognized clinical guidelines. Only a Medical Director may issue an adverse determination, with the exception of denials due to benefit issues. 

No provider or any other individual or SHP employee or associate is rewarded for issuing denials of coverage or care. Financial incentives will NOT encourage decisions that would result in underutilization nor are incentives to create barriers to care and services.

Prior Authorization Requests are to be made through the SHP’s UM Pre-Certification Department.

Prior Authorization or Notification Process:

*  Providers are to fax the Referral & Authorization Form (refer to Forms Section) to the SHP’s Utilization Management Pre-Certification Department at Fax number 1-800-283- 2114 or by calling the PreCertification Telephone Queue 1-800- 887-6888, ext 2271.

*  Routine (NOT STAT/URGENT) requests are processed within fourteen (14) calendar days of the Plan receiving the authorization request and having received all supporting clinical information.

STAT/URGENT requests are processed within seventy-two (72) hours of the Plan receiving the request and having received the supporting clinical information.

NOTE: STAT/URGENT Authorizations should be CALLED IN to the SHP Pre-Certification Authorization Telephone Queue and NOT faxed, and the caller should identify the request as “STAT/URGENT”. These requests should always meet the defined medical criteria for such which are:

STAT/URGENT: Any condition where failure to issue an immediate response may result in an IRREVERSIBLE SIGNIFICANT, ADVERSE outcome of health and/or function.

*  Each Referral & Authorization Form received from the provider’s offices will be date and time- stamped, manually or electronically and is reviewed for completeness, eligibility, benefits, PCP and specialist network affiliation

*  The Referral & Authorization Form must be accompanied by supporting clinical information for medical necessity determination

*  An authorization number will be provided, via fax, to the PCP, specialist and other provider(s) that will provide services to the member, when the request is completed and approved

*  All authorization requests and documentation of supporting clinical information will be entered and maintained within the SHP computer system for future reference and claims payment

When faxing a Prior Authorization Request, the SHP Referral & Authorizations Form must be completed. The requesting provider is reminded to include:

*  Member demographic information (i.e. name, sex, DOB, SHP  Member Number)

*  Provider demographic information

* Requesting provider (i.e. name, SHP Provider Number, phone number, fax number, contact person)

* Referred-to specialist/facility (i.e. name, SHP Provider Number, address, phone number, fax number, date of service, and identification if PAR (Plan participating provider/facility) or Non-PAR (not a Plan participating provider/facility)

*  Diagnoses for authorization request, including ICD-9 Code(s)

*  Procedure(s) for authorization request, including CPT/HCPCS Code(s)

*  Number of visits requested, frequency and duration

*  Pertinent medical history and treatment, laboratory and/or radiological data, physical examinations/referrals that support the medical necessity for the requested service(s).

Requests that do not meet medical necessity, based upon approved criteria are reviewed by the Medical Director for a final determination. The Medical Director may conduct a peer-to-peer discussion with the requesting provider, if indicated.