Read Paper Claims Process Change text version

Group Health Cooperative Claims Administration PO Box 34585 Seattle, WA 98124 www.ghc.org

November 1, 2010

Paper Claims Process Change

Dear Provider; Effective March 1, 2011, Group Health will be changing how we handle paper CMS-1500 claims. As of that date, we will start enforcing our policy of not accepting paper claim forms that are completely handwritten, have any handwritten notations, stamps or stickers on them (some exceptions apply--see attached grid). In addition, we will only accept claims on an original CMS-1500 form printed in red. Any claims outside this policy will be rejected and returned to the provider with a letter of explanation. Paper Claims Policy Group Health's Paper Claims policy, in the Billing and Claims section of our Contracted Provider Manual on MyGroupHealth for Contracted Providers (provider.ghc.org), is being updated and will be available on the Web site on or before March 1, 2011. We are enclosing a grid with details of our updated paper claims policy for your reference and to help you revise your claims submission processes prior to March 1, 2011. Please note there are additional changes to our currently stated policy. Why Group Health can no longer accept claims with handwritten notations Handwritten notes on the CMS forms cause our electronic claims processing system to automatically suspend the claim. Suspended claims require staff time to research and hand-enter all claim information from the form into our electronic systems. This is a time-consuming and costly process. How to get your claim processed quickly Group Health encourages all providers to bill electronically. If you do not currently bill electronically through a clearinghouse, OneHealthPort (OHP) provides access to a free electronic billing application-- Office Ally. Questions? If you have any questions regarding this policy change, or if you have question about an outstanding claim, please contact the Provider Assistance Unit (PAU) toll-free at 1-888-767-4670. Sincerely, (signature) Marlo Neal

Manager, Claims Administration, Health Plan Operations Group Health Cooperative

enc.: Group Health Paper Claims Submission Standards and Specifications

Group Health Paper Claim Submission Standards and Specifications

Paper Claim Standards Form Requirements Med/surg claims For all providers required: HCFA/CMS 1500 No Copies No faxes Official forms only Reject if claim is from provider (contracted or non-contracted) and does not come on original, red dropout, official HCFA/CMS 1500 form August 2005 version or later. Data Quality Standards HCFA/CMS-1500 Consumer number HCFA-1500 Box/Field # 1A Red drop-out for official HCFA/CMS 1500 form. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Paper Claims Submissions Standards for HCFA/CMS Forms Specifications (where required) Implementation Recommendations: Transition Period: 12/1/2010-3/1/2011 Enforcement Period: Begins 3/1/2011

Required data element Reject if missing

Preferred: Group Health consumer number; 8character numeric No symbols or special characters.

Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Will not be rejected if using SSN. If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process.

Consumer name

4

Required data element Reject if missing

Last Name, First Name, Preferred: Middle Initial (if known),

Provider Name (rendering provider)

31

Required data element Reject if missing

Last Name, First Name, Preferred: Middle Initial (if known), Preferred: Credentials if known

1

Paper Claim Standards Data Quality Standards HCFA/CMS-1500 (cont.) Patient Relationship to insured HCFA-1500 Box/Field # 6

Paper Claims Submissions Standards for HCFA/CMS Forms

Specifications (where required)

Implementation Recommendations: Transition Period: 12/1/2010-3/1/2011 Enforcement Period: Begins 3/1/2011

Not Required

Preferred: If no information available leave blank; if information known, check box

Tax ID#

25

Required data element Reject if missing

Required: 9-character numeric; no symbols or special characters. Tax ID that is valid at Time of Service (in case of subsequent change).

Enforcement period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period If missing reject claim and return claim following standard work for claim rejects. If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects.

NPI # 24J: Rendering 33A: Billing

24J 33A

Required data element Both required Reject if either one is missing

10-character alpha-numeric No symbols or special characters.

Procedure Code(s)

24D

Required data element Reject if missing

CPT-4/HCPC codes or most current versions

Provider Billing address

33

Required data element Reject if left blank Reject if Billing Name, Address, or Zip is missing

Billing Name, Address, Zip and Phone Number Preferred: USPS Address Standard Preferred: Phone number.

Diagnosis Code(s)

21

Required data element Reject if missing

Diagnosis at the highest level of specificity IDC-9 or most current version of coding standards

2

Paper Claim Standards Data Quality Standards HCFA/CMS-1500 (cont.) Date of Service HCFA-1500 Box/Field # 24A

Paper Claims Submissions Standards for HCFA/CMS Forms

Specifications (where required)

Implementation Recommendations: Transition Period: 12/1/2010-3/1/2011 Enforcement Period: Begins 3/1/2011

Required data element Reject if missing

Preferred: MM/DD/YY Required: Field 3: MM/DD/YY (required) Other fields will accept : MM/DD/YY or MM/DD/YYYY

Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period If missing - reject claim and return claim following standard work for claim rejects. If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period If missing - reject claim and return claim following standard work for claim rejects. Enforcement period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period If missing - reject claim and return claim following standard work for claim rejects. Enforcement period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period If missing - reject claim and return claim following standard work for claim rejects. If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period If missing - reject claim and return claim following standard work for claim rejects.

Place of Service

24B

Required data element Reject if missing

2 character numeric only

COB/ other payer information

9(A-D)

Not Required

Preferred: If no COB, then leave all fields blank If COB, then enter all fields section 9, 9a. ­ 9d. Check yes or no

Patient condition related to Referring or ordering physician name

10

Required data element Reject if missing Not Required

17

Preferred: Last Name, First Name, Middle Initial (if known), Credentials

Referring or ordering physician ID number

17B

Not Required

Preferred: 10-character alpha-numeric; no symbols or special characters.

Charges field(s)

24F

Required data element Reject if missing Reject if blank Reject if text in Field 24F (i.e. NC, NA, No Charges)

Numeric, 2-decimal place monetary format No symbols or special characters. Dollars and cents to align with field 24F, cents to follow the dashed dividing line. No charge or zero charge represented by zeros.

Total Charge

28

Required data element Reject if missing

Numeric, 2-decimal place monetary format No symbols or special characters. Dollars and cents to align with field 24F, cents to follow the dashed dividing line. No charge or zero charge represented by zeros.

3

Paper Claim Standards Units 24G

Paper Claims Submissions Standards for HCFA/CMS Forms Required data element Reject if missing Required: If more than one diagnosis, diagnosis pointer required. Reject if missing when more then one diagnosis present

Specifications (where required) Single numeric character Whole numbers only Single, numeric character that is: 1 or 2 or 3 or 4. Diagnosis pointer references the most relevant diagnosis code for the charge.

Implementation Recommendations: Transition Period: 12/1/2010-3/1/2011 Enforcement Period: Begins 3/1/2011 Enforcement period Reject claim and return claim following standard work for claim rejects. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Enforcement period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects.

Diagnosis pointers if more than one

24E

Amount Paid

29

Not Required

Total amount paid by primary insurance

Balance Due

30

Not Required

Amount due before contractual adjustment by primary insurance. Group Health will pay up to our contracted rate with provider.

Paper Quality Condition of paper form Required Reject if illegible Information/data must be legible We reserve the right to determine legibility Forms - unwrinkled, un-torn, Original, red drop-out, official HCFA/CMS 1500 form August 2005 version or later.

Type of forms

Required Reject if does not meet specification

Original, red drop-out, official HCFA/CMS 1500 form August 2005 version or later.

Size

Required Reject if does not meet specification

Original, red drop-out, official HCFA/CMS 1500 form August 2005 version or later.

4

Paper Claim Standards Paper Quality (cont.) Paper stock

Paper Claims Submissions Standards for HCFA/CMS Forms

Specifications (where required)

Implementation Recommendations: Transition Period: 12/1/2010-3/1/2011 Enforcement Period: Begins 3/1/2011 Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Enforcement period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Enforcement period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Enforcement period If does not conform to Group Health preferred standards, initiate "coaching" process

Required Reject if does not meet specification

Original, red drop-out, official HCFA/CMS 1500 form August 2005 version or later.

Staples

Recommend

Preferred: No staples Additional pages or documentation necessary for the proper administration of claim to be combined with paperclips. Black ink required for all data elements entered onto standard HCFA/CMS 1500 form

Print Quality Ink colors Required Reject if does not meet specification

Ink quality for data elements (Lightness ­ low ink status)

Recommend

Preferred: printed text must appear black Maybe using required black ink, but ink ribbon or ink reservoir may be low and printing gray Provider responsible for replacing/maintaining printer ink quality requirements Data must align to, and fit within, appropriate fields and not overlay vertical or horizontal lines that border the field.

Data Alignment

Required Reject if does not meet specification

Font (size, type, spacing, wt.)

Recommend

Preferred: 10-point mono space font (Courier New or PICA) Recommended o Minimum: 10-point font-size o Maximum: 12-point font-size Data must align to, and fit within, appropriate fields and not overlay vertical or horizontal lines that border the field. Do not combine two lines into one by using small font-size. Do not add additional information by using compressed or thin-stroke font or character spacing.

5

Paper Claim Standards Print Quality (cont.) Type of printer and/or DPI standards Margins

Paper Claims Submissions Standards for HCFA/CMS Forms

Specifications (where required)

Implementation Recommendations: Transition Period: 12/1/2010-3/1/2011 Enforcement Period: Begins 3/1/2011 Enforcement period If does not conform to Group Health preferred standards, initiate "coaching" process Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects. Transition period If does not conform to Group Health Paper Claim Submission Standards & Specifications, initiate "coaching" process. Enforcement period Reject claim and return claim following standard work for claim rejects.

Recommend

Preferred: 600 DPI laser printer

Required Reject if does not meet specification

If not using original, red drop-out, official HCFA/CMS 1500 form August 2005 version or later probably will not meet this standard and will be rejected due to size of form

Hand written

Required Reject if does not meet specification

No handwriting except in signature fields 12, 13, and 31 or above line 1.

Highlighting

Required Reject if does not meet specification

No highlighting accepted

Stickers

Required Reject if stickers on forms

No Stickers

Stamps

Required Reject if does not meet specification

Preferred: no stamps Required: no stamps in body of form; stamps allowed in white-space above line-1 or in signature fields 12, 13 and 31.

6

Information

Paper Claims Process Change

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