Sunday, October 3, 2010

CMS BOX 22 Re-submission claims on CMS 1500 AND UB 04

For Adjustments:

When requesting an adjustment to a paid claim, enter an “A” followed by the 13-character internal control number (ICN) assigned to the paid claim. This ICN appears on the remittance advice on which the original claim was paid. Please refer to Subchapter 5, Part 6, of your MassHealth provider manual for detailed billing instructions on claim status and correction.

For Resubmittals:

When resubmitting a denied claim, enter an “R” followed by the 13-character ICN assigned to the denied claim. This ICN appears on the remittance advice on which the original claim was denied.
Please refer to Subchapter 5, Part 6, of your MassHealth provider  manual for detailed billing instructions on claim status and correction.

Medicaid Resubmission Code Situational. If filing an adjustment or void, enter an “A” for an adjustment or a “V” for a void as appropriate AND one of the appropriate reason codes for the adjustment or void in the “Code” portion of this field. Enter the internal control number from the paid claim line as it appears on the remittance advice in the “Original Ref. No.” portion of this field. Appropriate reason codes follow:

Adjustments 

01 = Third Party Liability Recovery
02 = Provider Correction
03 = Fiscal Agent Error
90 = State Office Use Only – Recovery
99 = Other

Voids 

10 = Claim Paid for Wrong Recipient
11 = Claim Paid for Wrong Provider
00 = Other


To adjust or void a previously paid claim, use an adjustment or void reason code to complete the CODE area of Field 22 (MEDICAID RESUBMISSION). Resubmitting a denied claim is not considered an adjustment or void.

Adjustment/Void reason codes for Field 22

To adjust or void a previously paid claim, use an adjustment or void reason code to complete the CODE area of Field 22 (MEDICAID RESUBMISSION). Resubmitting a denied claim is not considered an adjustment or void.

Adjustment reason codes

Use one of the following codes in Field 22 when adjusting a previously paid claim.

Medicaid resubmission: Complete this field to adjust or void a previously paid claim. Otherwise, leave this field blank.

** In the Code area, enter an adjustment or void reason code (see section, Adjustment/Void reason codes for Field 22).

** In the Original Reference Number area, enter the last paid Internal Control Number (ICN) of the claim.

Adjustments and voids apply to previously paid claims only (including zero paid claims). resubmitting a denied claim is not considered an adjustment.


Resubmissions, replacements, and Voids

The AHCCCS Claims Processing system will deny claims with errors that are identified during the editing process. These errors will be reported to you on the AHCCCS Remittance Advice. You should correct claim errors and resubmit claims to AHCCCS for processing within the 12- month clean claim time frame (See Chapter 26, Correcting Claim Errors).

When resubmitting a denied claim, you must submit a new claim form containing all previously submitted lines. The original AHCCCS Claim Reference Number (CRN) must be included on the claim to enable the AHCCCS system to identify the claim being resubmitted. Otherwise, the claim will be entered as a new claim and may be denied for being received beyond the initial submission time frame.

You must resubmit any documentation that was sent with the denied claim.

You will resubmit a corrected claim when the original claim was denied or partially denied.

To resubmit a denied CMS 1500 claim:

Enter “A” in Field 22 (Medicaid Resubmission Code) and the CRN of the denied claim in the field labeled "Original Ref. No." Failure to resubmit a 1500 claim without Field 22 completed will cause the claim to be considered a “new” claim and will not link to the original denial. The “new” claim may be denied for timely filing exceeded.

Resubmit the claim in its entirety, including all original lines if the claim contained more than one line.

Note: Failure to include all lines of a multiple-line claim will result in recoupment of any paid lines that are not accounted for on the resubmitted claim.

Example:

You submit a three-line claim to AHCCCS. Lines 1 and 3 are paid, but Line 2 is denied. When resubmitting the claim, you should resubmit all three lines. If only Line 2 is resubmitted, the AHCCCS system will recoup payment for Lines 1 and 3.

To void a paid CMS 1500 claim enter “V” in Field 22 (Medicaid Resubmission Code) and the CRN of the claim to be voided in the "Original Ref. No." field.


How to File Corrected Claims - BCBS Guidelines

At Horizon NJ Health, we understand that claims sometimes may not be filed correctly.

Here is how to bill and submit a corrected claim. Both paper and electronic claims must be submitted within 365 calendar days from the initial date of service.

For paper claims:

CMS-1500 should be submitted with the appropriate resubmission code (value of 7) in Box 22 of the paper claim with the original claim number of the corrected claim. Include a copy of the original Explanation of Payment (EOP) with the original claim number for which the corrected claim is being submitted. Horizon NJ Health will reject any claims that are not submitted on red and white forms or that have any handwriting on them.


UB-04 claims:

UB-04 should be submitted with the appropriate resubmission code in the third digit of the bill type (for corrected claim this will be 7), the original claim number in Box 64 of the paper claim and a copy of the original EOP.

Send red and white paper corrected claims to:
Horizon NJ Health
Claims Processing Department
PO Box 24078
Newark, NJ 07101-0406


Correcting electronic HCFA 1500 claims:

EDI 837P data should be sent in the 2300 Loop, segment CLM05 (with value of 7) along with an additional loop in the 2300 loop, segment REF*F8* with the original claim number for which the corrected claim is being submitted.

Correcting electronic UB-04 claims:

EDI 837I data should be sent in the 2300 Loop, segment CLM05 (with value of 7) along with an additional loop in the 2300 loop, segment REF *F8* with the original claim number for which the corrected claim is being submitted.


Clarification to corrected claims process

Summary of change: Effective for claims with dates of service on or after January 1, 2016, providers have 365 days from the date of service to correct a claim.

If you receive a recoupment notice, and the claim could be corrected in order to avoid the recoupment, you have 70 days from the date of the first recoupment notification to send a correction (if the 365 days has already passed). Amerigroup Kansas, Inc. must receive a copy of the recoupment notice along with the corrected claim so that we know the correction is in response to the notice. If we do not receive a copy of the recoupment notice, the claim may be denied. If a corrected claim is not received within 70 days of the recoupment notice, the claim will be recouped and any subsequent corrections will be denied.

What this means to you: Paper corrective claim submissions should be stamped with  “corrected claim” at the top.

Claims – Paid or Denied

The heading Claims – Paid or Denied Claims is centered on the top of each page in this section. Claims  in this section finalized the week before the preparation of the R&S Report. The claims are sorted by claim status, claim type, and by order of client names. The reported status of each claim will not change unless further action is initiated by the provider, HHSC, or TMHP.

The following information is provided on a separate line for all inpatient hospital claims processed according to prospective payment methodology:

• Age. Client’s age according to TMHP records
• Sex. Client’s sex according to TMHP records: M = Male, F = Female, U = Unknown
• Pat-Stat. Indicates the client’s status at the time of discharge or the last DOS on the claim (refer to instructions for UB-04 CMS-1450 paper claim form, Block 17)
• Proc. ICD-10-PCS code indicates the primary surgical procedure used in determining the DRG Important: Only paper claims appear in this section of the R&S Report. Claims filed electronically without required information are rejected. Users are required to retrieve the response file to determine reasons for rejections.

TMHP cannot process incomplete claims. Incomplete claims may be submitted as original claims only if the resubmission is received by TMHP within the original filing deadline.



Facility claims/UB-04: 

Corrections should be billed using the type of bill XX7 for a correction, or XX8 for a replacement, for Amerigroup to identify the submission as a correction. Professional claims/CMS1500: Corrections should be billed using the claim number you are correcting and the proper resubmission codes, as outlined below:

* -5 for late charges
* -7 for replacement of a prior claim
* -8 for voided or canceled claim

If you wish to submit the correction and attachments on paper, please include a Claim Correspondence Form (found on our website) and mail the submission to:

Claim Correspondence
Amerigroup Kansas, Inc.
P.O. Box 61599
Virginia Beach, VA 23466
As a reminder, we do not accept handwritten claim alterations.




Procedures for Claim Submission

Passport Health Plan (Passport) is required by state and federal regulations to capture specific data regarding services rendered to its members. The provider must adhere to all billing requirements in order to ensure timely processing of claims. When required data elements are missing or invalid, claims will be rejected by Passport for correction and resubmission.

The provider who performed the service to the Passport member must submit the claim for a billable service.

Claims filed with Passport are subject to the following procedures:
• Verification that all required fields are completed on the CMS-1500 or UB-04 forms.
• Verification that all diagnosis and procedure codes are valid for the date of service.
• Verification of the referral for specialist or non-primary care physician (PCP) claims.
• Verification of member eligibility for services under Passport during the time period in which services were provided.
• Verification that the services were provided by a participating provider or that the “out- ofnetwork” provider has received authorization to provide services to the eligible member (excluding “self-referral” types of care).
• Verification of whether there is Medicare coverage or any other third party resources and, if so, verification that Passport is the “payer of last resort” on all claims submitted to Passport.
• Verification that an authorization has been given for servicesthat require prior authorization by  Passport

Claim Submission for New Providers

New providers with Passport awaiting receipt of their Medicaid Identification (MAID) number are subject to the timely filing guidelines and may begin to submit claims once their Passport ID number has been assigned. These claims will initially deny for no MAID number. After Passport receives a provider?s MAID number, all claims submitted and initially denied will be reprocessed without resubmission.

Corrected Claims

Corrected or resubmitted claims must be sent to Passport on paper, with either “corrected” or “resubmitted” noted on the claim as appropriate. Claims that originally denied for missing/invalid information or for inappropriate coding must be submitted as a corrected claim. In addition to writing “Corrected Claim,” the corrected information should be circled to easily identify the corrected information.

Claims that have been denied for additional information must be submitted as a resubmitted claim. “Resubmitted Claim” must be written on the form and the new information must be attached. It is important to remember that these claims are scanned as part of the resubmission process. Red ink and/or highlighted text is not legible.

NOTE: Please use BLUE or BLACK ink only

Timely Filing Requirements

Original invoices must be submitted to Passport within 180 calendar days from the date services were rendered or compensable items were provided. Resubmission of previously processed claims with corrections and/or requests for adjustments must be submitted within two years of the last process date. Claims originally rejected for missing or invalid data elements must be corrected and resubmitted within 180 calendar days from the date of service. Rejected claims are not registered as received in the claims processing system.


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