DOCSLIB.ORG

Provider Manual

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Provider Manual Provider Manual . Billing and Payment Billing and Payment Kaiser Permanente’s billing and payment policies and procedures aim to ensure that you receive timely payment for the care you provide. This section of the Manual provides a quick and easy resource with contact phone numbers, detailed processes and site lists for services. If you have a question or concern about the information in this section, please call 1 -888-681-7878 or 303-338-3600. Table of Contents SECTION 5: BILLING AND PAYMENT .......................................................................... 8 CONTACTS FOR QUESTIONS ............................................................................................................... 8 5.1. METHODS OF CLAIMS FILING ........................................................................................... 9 5.2.1 Paper Claim Forms ................................................................................................................. 9 5.2.1.1 Record Authorization Number ............................................................................................ 9 5.2.1.2 One Member/ Provider per Claim Form ............................................................................. 9 5.2.1.3 No Fault/ Workers’ Compensation/Other Accident ............................................................. 9 5.2.1.4 Record the Name of the Provider You Are Covering For ................................................... 9 5.2.1.5 Submission of Multiple Page Claim .................................................................................... 9 5.2.1.6 Entering Dates ................................................................................................................. 10 5.2.1.7 Multiple Dates of Services and Place of Services ............................................................ 10 5.2.1.8 Surgical and/or Obstetrical Procedures ............................................................................ 10 5.2.1.9 Billing Inpatient Claims That Span Different Years ........................................................... 10 5.2.1.10 Interim Inpatient Bills ...................................................................................................... 11 5.2.1.11 Supporting Documentation for Paper Claims ................................................................. 11 5.2.1.12 Where to Mail Paper Claims ........................................................................................... 11 5.2.2 Electronic Data Interchange (EDI) ...................................................................................... 11 5.2.2.1 Electronic Claims Forms / Submissions ........................................................................... 12 5.2. CLAIM FILING REQUIREMENTS ....................................................................................... 13 5.3.1 Clean Claims .......................................................................................................................... 13 5.3.2 Claims Submission Timeframes .......................................................................................... 14 5.3.3 Claims Processing Turn-Around Time .............................................................................. 14 5.3.4 Proof of Timely Claims Submission ................................................................................... 14 5.3. CLAIM ADJUSTMENTS/ CORRECTIONS ........................................................................... 16 5.4.1 Incorrect Claims Payments .................................................................................................. 16 Kaiser Permanente Provider Manual Section 5: Billing & Payment 2016 3 5.4.2 Rejected Claims Due to EDI Claims Error ......................................................................... 17 5.4. REQUIRED IDENTIFICATION INFORMATION ................................................................... 17 5.4.1 Federal Tax ID Number ....................................................................................................... 17 5.4.2 Changes in Federal Tax ID Number ................................................................................... 18 5.4.3 National Provider Identification (NPI) .............................................................................. 18 5.5. MEMBER COST SHARE ..................................................................................................... 19 5.6. MEMBER CLAIMS INQUIRIES ........................................................................................... 19 5.7. VISITING MEMBERS .......................................................................................................... 19 5.8. CODING FOR CLAIMS ....................................................................................................... 19 5.8.1 Coding Standards ................................................................................................................. 19 5.8.2 Modifiers in CPT and HCPCS ............................................................................................. 21 5.8.3 Modifier Review .................................................................................................................... 22 5.8.4 Coding & Billing Validation ................................................................................................ 22 5.8.4.1 Claims Editing Software Programs ................................................................................... 23 5.8.4.2 Types of edits ................................................................................................................... 23 5.8.4.3 Modifiers ........................................................................................................................... 26 5.8.5 Coding Edit Rules ................................................................................................................. 27 5.9. MEDICAL CLAIMS REVIEW .............................................................................................. 30 5.9.1 Major Categories of Claim Coding Errors/Inconsistencies ............................................. 30 5.9.1.1 Procedure Unbundling ...................................................................................................... 30 5.9.1.2 Incidental Procedures ....................................................................................................... 31 5.9.1.3 Separate Procedures ....................................................................................................... 31 5.9.1.4 Mutually Exclusive Procedures ........................................................................................ 31 5.9.1.5 Age and Gender (Sex) Conflicts ....................................................................................... 31 5.9.1.6 Obsolete/Deleted Codes .................................................................................................. 32 5.9.1.7 Multiple/ Duplicate Component Billing .............................................................................. 32 Kaiser Permanente Provider Manual Section 5: Billing & Payment 2016 4 5.10. THIRD PARTY LIABILITY (TPL) ....................................................................................... 32 5.11. WORKERS’ COMPENSATION ............................................................................................ 32 5.12. THIRD PARTY ADMINISTRATOR (TPA) .......................................................................... 32 5.13. PROVIDER CLAIMS APPEALS ........................................................................................... 32 5.13.1 Provider Claim Payment Appeals Process ........................................................................ 32 5.14. CLAIM FORM EXAMPLES AND INSTRUCTIONS ............................................................... 33 5.14.1 CMS-1500 ............................................................................................................................... 33 5.15.2 CMS-1450 (UB-04) Field Descriptions ................................................................................ 42 5.15. BILLING REQUIREMENTS AND INSTRUCTION FOR SPECIFIC SERVICES ......................... 47 5.15.1 Capitation Payments ............................................................................................................ 47 5.15.2 Evaluation Management (E/M) Services ............................................................................ 48 5.15.2.1 Inpatient E/M Services: .................................................................................................. 48 5.15.2.2 Surgical Procedure that Include E/M Services: .............................................................. 49 5.15.2.3 Preventive Medicine Services: ....................................................................................... 53 5.15.3 Emergency Rooms ................................................................................................................ 54 5.15.3.1 Two Physicians Involved in Admitting a Patient from the ER ......................................... 54 5.15.3.2 “Emergency” in the Office Setting................................................................................... 54 5.15.3.3 “Non-Emergency” Services Provided in the Emergency Department ............................. 54 5.15.3.4 Emergency Room and Urgent Care Services Submitted on a UB-04 ............................ 55 5.16.4 Critical Care Services ...........................................................................................................
Load more

Recommended publications
  • Unlocking the Mystery of Third Party Reimbursement in Kinesiotherapy
    Unlocking the Mystery of Third Party Reimbursement In Kinesiotherapy Provided by the American Kinesiotherapy Association Written by Joanne Byron, LPN, BSNH, CHA, CMC, CPC, MCMC, PCS Edited & Contributions made by Carl Byron, III, ATC-L, EMT-I, CHA, CPC, MCMC Health Care Consulting Services, Inc. PO Box 572 Medina, Ohio 44258-0572 www.hccsincorp.com Page 2 Table of Contents Page Introduction – Bridging the Gap between KT and Payor 3 Key Elements to Reimbursement 4 Provider Enrollment 5 State of Health Insurance 9 Medicare Benefit Policy Manual 10 Reimbursement Basics 12 Documentation 13 Appropriate Coding 14 Procedure Coding – a 2 Tier System 15 CPT Assistant 16 Diagnosis Code Assignment ICD-9-CM 21 ICD-10-CM 22 Understanding the Health Insurance Industry 26 Types of insurance and reimbursement methodology 26 Managed Care Contracting Considerations 30 Administrative Simplification 33 NCQA 37 Managed Care Terminology (terms & definitions from HHS) 38 Provided by the American Kinesiotherapy Association (AKTA) & Written by Health Care Consulting Services, Inc. (HCCS) Copyright © 2010 AKTA & HCCS, All Rights Reserved This document is not intended to provide legal or consulting advice. It is for educational purposes only. Please retain an attorney or consultant for specific information for your practice. Page 3 Introduction Bridging the gap between KT and payer “How do we get paid?” . A challenging question every health care provider faces, regardless of specialty and health insurance company. The purpose of this reimbursement manual is to provide a basic understanding of health care reimbursement and compliance prior to filing claims for Kinesiotherapy services. Physical medicine budgets are getting ever tighter, demands on rehab specialists’ time and skills are increasing.
    [Show full text]
  • Ata Lements for Mergency Epartment Ystems
    D ata E lements for E mergency D epartment S ystems Release 1.0 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES CDCCENTERS FOR DISEASE CONTROL AND PREVENTION D ata E lements for E mergency D epartment S ystems Release 1.0 National Center for Injury Prevention and Control Atlanta, Georgia 1997 Data Elements for Emergency Department Systems, Release 1.0 (DEEDS) is the result of contributions by participants in the National Workshop on Emergency Department Data, held January 23-25, 1996, in Atlanta, Georgia, subsequent review and comment by individuals who read Release 1.0 in draft form, and finalization by a multidisciplinary writing committee. DEEDS is a set of recommendations published by the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention: Centers for Disease Control and Prevention David Satcher, MD, PhD, Director National Center for Injury Prevention and Control Mark L. Rosenberg, MD, MPP, Director Division of Acute Care, Rehabilitation Research, and Disability Prevention Richard J. Waxweiler, PhD, Director Acute Care Team Daniel A. Pollock, MD, Leader Production services were provided by the staff of the Office of Communication Resources, National Center for Injury Prevention and Control, and the Management Analysis and Services Office: Editing Valerie R. Johnson Cover Design and Layout Barbara B. Lord Use of trade names is for identification only and does not constitute endorsement by the U.S. Department of Health and Human Services. This document and subsequent revisions can be found at the National Center for Injury Prevention and Control Web site: http://www.cdc.gov/ncipc/pub-res/deedspage.htm Suggested Citation: National Center for Injury Prevention and Control.
    [Show full text]
  • Understanding Remittance Advice
    Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers March 2006 DISCLAIMER This Guide was current at the time it was printed or downloaded. Medicare policy changes frequently so links to the source documents have been provided within the Guide for your reference. This Guide was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error- free and will bear no responsibility or liability for the results or consequences of the use of this Guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. For ease of reading this Guide, the term “provider” is used generally to refer to providers of all Medicare Part A and Part B services, supplies, and equipment. When information specific to a particular provider type is presented, the name of the specific provider type is used [e.g., physician, supplier, hospital, Skilled Nursing Facility (SNF)]. Institutional providers refer to hospitals, SNFs, Home Health Agencies (HHAs), hospices, and other facility-based health care organizations that submit claims to Fiscal Intermediaries (FIs) and Regional Home Health Intermediaries (RHHIs).
    [Show full text]
  • Month 2009 Issue
    NOTE: Should you have landed here as a result of a search engine (or other) link, be advised that these files contain material that is copyrighted by the American Medical Association. You are forbidden to download the files unless you read, agree to, and abide by the provisions of the copyright statement. Read the copyright statement now and you will be linked back to here. April 2010 Issue In This Advisory Part A Articles Part A LCD Updates Part B Articles Part B LCD Updates Part A & B Articles Forms & Documents Acronyms Monthly Feature Questions and Answers on Reporting Physician Consultation Services This article is for physicians and non-physician practitioners (NPPs) who perform initial evaluation and management (E/M) services previously reported by Current Procedural Terminology (CPT) consultation codes for Medicare beneficiaries and submit claims to Medicare Carriers and/or Medicare Administrative Contractors (MACs) for those services. It is also intended for Method II critical access hospitals, which bill for the services of those physicians and NPPs. Continued on Page 36 www.palmettogba.com/J1a www.palmettogba.com/J1b www.cms.hhs.gov Table of Contents J1 Part A ......................................................................................................................................1 Accumulation of Claims with Condition Code 04 on the Provider Statistical and Reimbursement Report (PS and R)............... 1 April 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS)...............................................................
    [Show full text]
  • Billing and Payment
    Kaiser Permanente Northwest Provider Manual 2018 Billing and Payment We created this section of the manual to help guide you and your staff in working with Kaiser Permanente’s billing and payment policies and procedures. It provides a quick and easy resource with contact phone numbers, detailed processes, and site lists for services. If you have questions or concerns about this manual, contact our Provider Inquiry Department at 503-735-2727 or 1-866-441-1221. 2 Table of Contents Introduction ................................................................................................................. 4 Section 5: Billing and Payment ................................................................................... 4 5.1 Whom to Contact with Claims Questions ................................................... 5 5.2 Billing, Coding and Payment Instructions ................................................... 5 5.2.1 Electronic Claims (EDI) .............................................................................. 5 5.2.2 Paper Claim Forms .................................................................................... 6 5.3 Record Authorization Number .................................................................... 6 5.4 One Member/Provider per Claim Form ...................................................... 6 5.5 No Fault/Workers’ Compensation/Other Accident ..................................... 6 5.6 Entering Dates ........................................................................................... 7 5.7 Multiple
    [Show full text]
  • Authenticated PDF Version
    DEPARTMENT OF LABOR DIVISION OF INDUSTRIAL AFFAIRS Office of Workers’ Compensation Statutory Authority: 19 Delaware Code, Section 2322 F(j) (19 Del.C. §§2322F(j)) 19 DE Admin. Code 1341 FINAL ORDER 1341 Workers’ Compensation Regulations A public meeting was held on July 29, 2013, by the Department of Labor to receive public comments relating to revised sections of the Fee Schedule Instructions and Guidelines ("Fee Schedule Instructions"), Forms, Provider Certification, and Utilization Review, as well as revise the Health Care Practice Guidelines to reduce the frequency of some treatment, services, or procedures and clean up language inadvertently left in the original guidelines. In this final version, technical revisions were added to the anesthesia methodology and revenue neutral language. These changes align the regulations with the mandates in HB 175. The members of the Health Care Advisory Panel ("HCAP"), signed below, recommend that the Secretary of Labor adopt this proposal as it was published in the Register of Regulations, Volume 17, Issue 1 (July 2013). SUMMARY OF THE EVIDENCE AND INFORMATION SUBMITTED Exhibits Admitted Prior to and During the Public Meeting: • Exhibit 1-News Journal, Affidavit of publication of notice of public meeting. • Exhibit 2 -Delaware State News, Affidavit of publication of notice of public meeting. • Exhibit 3 -State of Delaware Public Meeting Calendar electronic posting of today's meeting. • Exhibit 4 - Written public comments from Rebecca Byrd, The Byrd Group, LLC, on behalf of AHCS (Automated HealthCare Solutions). • Exhibit 5 -Written talking points from public comments given by Bob Byrd, The Byrd Group, LLC, on behalf of AHCS (Automated Healthcare Solutions) • Exhibit 6- Written talking points from public comments given by Jayne Cannava, Esquire, Director of Government Affairs, Injured Workers' Pharmacy (IWP).
    [Show full text]
  • Non-Interventional (Ni) Study Protocol Pass
    XALKORI (crizotinib) A8081038, A Multinational Active Safety Surveillance Study of Crizotinib in Europe Final Protocol Amendment 2, 19 Febuary 2015 NON-INTERVENTIONAL (NI) STUDY PROTOCOL PASS Information Title A multinational active safety surveillance study of crizotinib in Europe and the United States Protocol number A8081038 Protocol version identifier Final (version 1.2) Date of last version of protocol 19 Febuary 2015 EU Post Authorisation Study (PAS) ENCEPP/SDPP/8097 register number Active substance L01XE16/Crizotinib Medicinal product XALKORI Product reference EU/1/12/793/001-004 Product number EMEA/H/C/002489 Marketing Authorisation Holder (MAH) Pfizer Limited Joint PASS No Research question and objectives The objective of this study is to evaluate the safety and effectiveness of crizotinib among lung cancer patients in the real world setting in Europe and the United States. Countries of study Denmark, Finland, Sweden, the Netherlands and the United States Author Kui Huang, PhD, MPH Pfizer Inc 235 East 42nd Street New York, NY 10017 090177e18627024f\Approved\Approved On: 25-Feb-2015 14:49 Pfizer Confidential Page 1 of 63 XALKORI (crizotinib) A8081038, A Multinational Active Safety Surveillance Study of Crizotinib in Europe Final Protocol Amendment 2, 19 Febuary 2015 Marketing Authorisation Holder(s) Marketing Authorisation Holder(s) Pfizer Limited Ramsgate Road, Sandwich, Kent CT130NJ United Kingdom MAH contact person Kui Huang, PhD, MPH Pfizer Inc 235 East 42nd Street New York, NY 10017 This document contains confidential information belonging to Pfizer. Except as otherwise agreed to in writing, by accepting or reviewing this document, you agree to hold this information in confidence and not copy or disclose it to others (except where required by applicable law) or use it for unauthorized purposes.
    [Show full text]
  • Provider Manual
    Provider Manual ▪ Billing and Payment Billing and Payment Kaiser Permanente’s billing and payment policies and procedures aim to ensure that you receive timely payment for the care you provide. This section of the Manual provides a quick and easy resource with contact phone numbers, detailed processes and site lists for services. If you have a question or concern about the information in this section, please call 1 -888-681-7878 or 303-338-3600. Table of Contents SECTION 5: BILLING AND PAYMENT .......................................................................... 6 5.1. CONTACTS FOR QUESTIONS ......................................................................................................... 6 5.2. METHODS OF CLAIMS FILING ...................................................................................................... 7 5.2.1 Electronic Data Interchange (EDI) ............................................................................................ 7 5.2.2 Electronic Claims Forms / Submission .................................................................................. 7 5.2.3 Supporting Documentation for EDI Claims ............................................................................. 8 5.2.4 To Initiate Electronic Claims Submissions .............................................................................. 8 5.2.5 Paper Claim Forms ................................................................................................................. 8 5.2.6 Record Authorization Number ...........................................................................................................
    [Show full text]
  • Provider Manual
    Provider Manual . Billing and Payment 8/31/2011 Billing and Payment This section of the Manual was created to help guide you and your staff in working with Kaiser Permanente’s billing and payment policies and procedures. It provides a quick and easy resource with contact phone numbers, detailed processes and site lists for services. If, at any time, you have a question or concern about the information in this Manual, you can reach our Claims Customer Service Department by calling 303- 338 -3600. 5 8/31/2011 Table of Contents TABLE OF CONTENTS ............................................................................................................. 3 SECTION 5: BILLING AND PAYMENT ............................................................................... 6 5.1 WHOM TO CONTACT WITH QUESTIONS ...................................................................................................... 6 5.2 METHODS OF CLAIMS FILING ...................................................................................................................... 8 5.3 PAPER CLAIM FORMS ................................................................................................................................... 8 5.4 RECORD AUTHORIZATION NUMBER ............................................................................................................ 8 5.5 ONE MEMBER/ PROVIDER PER CLAIM FORM ................................................................................................ 8 5.6 NO FAULT/ WORKERS’ COMPENSATION/OTHER ACCIDENT ....................................................................
    [Show full text]
  • State of the Art for Healthcare Ontology D407.010
    THE RESEARCH LEADING TO THESE RESULTS HAS RECEIVED FUNDING FROM THE EUROPEAN UNION’S SEVENTH FRAMEWORK PROGRAM (FP7/2007-2013) FOR CRYSTAL – CRITICAL SYSTEM ENGINEERING ACCELERATION JOINT UNDERTAKING UNDER GRANT AGREEMENT N° 332830 AND FROM SPECIFIC NATIONAL PROGRAMS AND / OR FUNDING AUTHORITIES. CRitical SYSTem Engineering AcceLeration State of the art for Healthcare ontology D407.010 State of the art for D407.010 Healthcare ontology DOCUMENT INFORMATION Project CRYSTAL Grant Agreement No. ARTEMIS-2012-1-332830 Deliverable Title State of the art for Healthcare ontology Deliverable No. D407.010 Dissemination Level PU Nature R Document Version V1.0 Date 2013-01-31 Contact M.A. van Bekkum Organization TNO Phone +31610968792 E-Mail [email protected] Version Nature Date Page V1.0 R 2014-01-31 2 of 54 State of the art for D407.010 Healthcare ontology AUTHORS TABLE Name Company E-Mail L. Oosterheert (lead editor) TNO [email protected] M.A. van Bekkum TNO [email protected] A.M. Farcasi TU/e [email protected] R. de Juan Marín ITI [email protected] E. Lluna ITI [email protected] R. Albers Philips [email protected] H.E.P. Cruts Philips [email protected] D. Segers Barco [email protected] T. van Velzen (external reviewer) IBM [email protected] T. Karbe (external reviewer) TU Berlin [email protected] CHANGE HISTORY Pages Version Date Reason for Change Affected 0.1 18-11-2013 Creation of Table of Contents (TNO) All Added preliminary content of chapters, first version of long 0.11 06-12-2013 7-13, Annex I list (TNO)
    [Show full text]
  • Provider Manual
    Provider Manual ▪ Billing and Payment Billing and Payment Kaiser Permanente’s billing and payment policies and procedures aim to ensure that you receive timely payment for the care you provide. This section of the Manual provides a quick and easy resource with contact phone numbers, detailed processes and site lists for services. If you have a question or concern about the information in this section, please call 1 -888-681-7878 or 303-338-3600. Table of Contents SECTION 5: BILLING AND PAYMENT .......................................................................... 8 CONTACTS FOR QUESTIONS ............................................................................................................... 8 5.1. METHODS OF CLAIMS FILING ........................................................................................... 8 5.1.1 Electronic Data Interchange (EDI) ........................................................................................................ 8 5.1.2 Electronic Claims Forms / Submission .................................................................................. 9 5.1.3 Paper Claim Forms ............................................................................................................................... 10 5.1.4 Record Authorization Number ............................................................................................. 10 5.1.5 One Member/ Provider per Claim Form .............................................................................. 10 5.1.6 No Fault/ Workers’ Compensation/Other
    [Show full text]
  • LIBTAYO Surround® Quick Reference Coding Guide
    LIBTAYO Surround® quick reference coding guide An understanding of the codes needed for quick reimbursement must be a core competency of your billing staff. Coding—descriptors that capture diagnoses, medical procedures, and products—enables payers to more easily recognize, process, and pay claims for LIBTAYO Important Safety Information Warnings and Precautions Severe and Fatal Immune-Mediated Adverse Reactions Immune-mediated adverse reactions, which may be severe or fatal, can occur in any organ system or tissue at any time after starting treatment. While immune-mediated adverse reactions usually occur during treatment, they can also occur after discontinuation. Immune- mediated adverse reactions affecting more than one body system can occur simultaneously. Early identification and management are essential to ensuring safe use of PD-1/PD-L1–blocking antibodies. The definition of immune-mediated adverse reactions included the required use of systemic corticosteroids or other immunosuppressants and the absence of a clear alternate etiology. Monitor closely for symptoms and signs that may be clinical manifestations of underlying immune-mediated adverse reactions. Evaluate liver enzymes, creatinine, and thyroid function at baseline and periodically during treatment. In cases of suspected immune-mediated adverse reactions, initiate appropriate workup to exclude alternative etiologies, including infection. Institute medical management promptly, including specialty consultation as appropriate. Please see additional Important Safety Information
    [Show full text]