How secondary claims are processed by insurance

When the Recipient Has Other Insurance

Introduction 

If the recipient has other insurance coverage, Medicaid payment will be denied unless the provider indicates receipt of a third party payment or attaches a denial from the other insurance company or documentation that the other insurance company will not cover the service.

Note: See Chapter 1 of the Florida Medicaid Provider General Handbook for information about third party liability (TPL).

Insurance Information on the Remittance Voucher

If the recipient has other insurance, the third party carrier code appears on the remittance voucher underneath the denied claim.

Note: A list of third party carrier codes and carrier billing information can be obtained from the Medicaid fiscal agent’s website at http://floridamedicaid.acs-inc.com or from the fiscal agent’s field representatives.

The field representatives’ phone numbers are listed on the last page of this chapter.

How claim are processed by insurance - paid or denied

Level of Claims Processing

Paper Claim Handling

When the Medicaid fiscal agent receives a paper claim, it is screened for missing information and necessary attachments. If information or documentation is missing, the claim will not be entered into the Florida Medicaid Management Information System (FMMIS). It will be returned to the

provider with a Return to Provider (RTP) letter that will state the reason the claim is being returned. The provider needs to correct the error, attach any missing documentation, and return the claim to the fiscal agent for processing.

Claim Entry 

Data entry operators image and key into FMMIS each paper claim that passes initial screening. Electronic claims are loaded by batch into FMMIS by the fiscal agent’s data processing staff.

Claim Adjudication 

FMMIS analyzes the claim information and determines the status or disposition of the claim. This process is known as claim adjudication.

what is complete claims?

Complete claims

For proper payment and application of deductibles and coinsurance, it is important to accurately code all diagnoses and services (according to national coding guidelines). It is particularly important to accurately code because a member’s level of coverage under his or her benefit plan may vary for different services. You must submit a claim for your services, regardless of whether you have collected the copayment, deductible or coinsurance from the member at the time of service.

To assist you in understanding how your claims will be paid, UnitedHealthcare’s Claim Estimator includes a feature called Professional Claim Bundling Logic which helps you determine allowable bundling logic and other claims processing edits for a variety of CPT (CPT is a registered trademark of the American Medical Association) and HCPCS procedure codes. Note: Only bundling logic and other claims processing edits are available under this option.

Pricing and payment calculations are not included.

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.

Medical billing claims processing

How insurance process the claim

Claims Processing

HP verifies that the claim contains all of the information necessary for processing. 

The claim is processed using both clerical and automated procedures.

First, the system performs validation edits to ensure the claim is filled out correctly and contains sufficient information for processing. Edits ensure the recipient’s name matches the recipient identification number (RID); the procedure code is valid for the diagnosis; the recipient is eligible and the provider is active for the dates of service; and other similar criteria are met.

For electronically submitted claims, the edit process is performed several times per day; for paper claims, it is performed five times per week. If a claim fails any of these edits, it is returned to the provider.

Once claims pass through edits, the system reviews each claim to make sure it complies with Alabama Medicaid policy and performs cost avoidance. Cost avoidance is a method that ensures Medicaid is responsible for paying for all services listed on the claim. Because Medicaid is the payer of last resort, the system confirms that a third party resource is not responsible for services on the claim.