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Providers; We Often See Claims Where Them with Large Financial Contact Our EDI Helpdesk Or Your Provider 4 Appeals » Providers Not Contracted Obligations

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Providers; We Often See Claims Where Them with Large Financial Contact Our EDI Helpdesk Or Your Provider 4 Appeals » Providers Not Contracted Obligations PRESORTED STANDARD U.S. POSTAGE PAID SALT LAKE CITY, UTAH PERMIT NO. 4621 PROVID R N WS 560 East 200 South | Salt Lake City, UT 84102-2004 A PEHP PROVIDER RELATIONS PUBLICATION SPRING 2015 PROVID R N WS A PEHP PROVIDER RELATIONS PUBLICATION SPRING 2015 Contact List EDI Please note: The contact numbers for Case Management, Preauthorization and Customer Service are not the same. Case Management PEHP WeeCare NOW . .801-366-7755 or 800-753-7490 . .801-366-7400 or 855-366-7400 Are You Customer Service/ Provider Relations Filing Claims Pre-authorization (outpatient) Electronically? . 801-366-7557 or 800-677-0457 . .801-366-7555 or 800-765-7347 Glenda Lowe ............801-366-7496 or 800-950-4877 If Not, EDI Helpdesk Client Liaison [email protected] What . .801-366-7544 or 800-753-7818 Chantel Lomax ..........801-366-7507 or 800-753-7407 Are You Inpatient Preauthorization Provider Relations Specialist [email protected] Waiting . .801-366-7755 or 800-753-7490 Angel Macas ............801-366-7721 or 800-753-7721 For? Provider Relations Specialist [email protected] Inpatient Mental Health & Substance Abuse Authorization Wendy Philbrick .........801-366-7753 or 800-753-7753 Provider Relations Specialist [email protected] Blomquist Hale Consulting Group (BHCG) Canyons School District Selena Johnson ..........801-366-7511 or 800-753-7311 Jordan School District Provider Data Specialist [email protected] . .801-262-9619 or 800-926-9619 Jackie Smith .............801-366-7795 or 800-753-7595 Wellness Program Provider Relations Analyst [email protected] . .801-366-7300 or 855-366-7300 Laurel Rodriguez ........801-366-7350 or 800-753-7350 PEHP Healthy Utah. .801-366-7300 or 855-366-7300 Provider Relations Manager [email protected] PEHP Waist Aweigh ......801-366-7300 or 855-366-7300 Cortney Larson . .801-366-7715 or 800-753-7715 Director of Provider Relations [email protected] ICD-10 Code PEHP Healthy PEHP QuitLine. 855-366-7500 INSIDE PEHP Website Tips for Utah Is On . .www.pehp.org MORE USEFUL NEWS PEHP Quitline ..............www.pehp.quitlogix.org Transition The Move 4/17/15 & INFORMATION FOR » PAGE 6 » PAGE 7 PROVIDER PARTNERS PROVIDER NEWS PROVIDER NEWS COVER STORY: EDI / EFT Requirement Member Watch: Billing In this issue 2-3 EDI / EFT When Lab Testing Requirement Reminder Hurts Your Patients 3 Avoiding Paperless yet? any of your PEHP must be met for coverage for Rejections for EDI patients are getting genetic testing; in addition, Claims M Reminder: Claims Should be Submitted Electronically stuck with large unexpected many genetic tests are not 3 When Lab n case you’ve forgotten, PEHP claim submissions. medical bills due to provider covered. Failure to obtain Testing Hurts Your no longer accepts paper medical Please be aware, a few offices sending laboratory preauthorization for a test Patients Iclaims. These claims are required exceptions for paper claims test(s) to out-of-network leaves a member at risk of 4 Billing: to be submitted via Electronic Data are allowed. They are: laboratories and due to having no coverage or having Rendering and/ Interchange (EDI). » Out of network and/or requests for non-covered the claim paid at out-of- or Incident-to If your office is already submitting claims contracted out of state genetic testing. network benefits, leaving Services EDI, but aren’t getting through to us, providers; We often see claims where them with large financial contact our EDI helpdesk or your Provider 4 Appeals » Providers not contracted obligations. Relations Specialist. We will need to know the billed amounts are over Process Change with any PEHP Networks; your TIN, providers in the group and the 500% above what PEHP Covered genetic tests should 5 Headaches: clearinghouse being utilized. » Claims that require medical allows for the service. This be sent to participating Invasive records – Note: This does providers. A complete list Not currently set up? Contact your practice can leave your patients, our Procedures Policy not include COB claims; or of participating genetic management software; clearinghouse or members, with balance bills ICD-10 is for thousands of dollars. laboratories can be found on 6 UHIN to get started. » If PEHP is the tertiary payer. you don’t have a login, contact your Forthcoming our website at www.pehp.org, Coming Soon!! PEHP will have a claims Additionally, as of January 1, 2015, PEHP Your patients trust you and Provider Relations Specialist. under the specialty “Genetic 7 Enhancements tool online through the secured portion of requires all contracted providers to sign your staff to check for prior If you haven’t signed up for either Laboratory.” Even genetic to Code Auditing our website which will enable providers to up for Electronic Funds Transfer (EFT). authorization requirements function, we encourage you to do it tests covered under the Tool submit their claims electronically. The tool Your office can simply sign up by logging and to send their tests is designed to support individual claim in with your User ID and Password to the as soon as possible to keep your office Affordable Care Act require Spring to laboratories that are 7 submissions and is not designed for batch secured provider portion on pehp.org. If moving smoothly! pre-authorization and may Announcement contracted with their PEHP not be paid if they are directed from PEHP plan so that they are protected to a non-contracted genetic Wellness from balance billing and with laboratory. 8 Group Benefit Avoiding Rejections for EDI Claims the assurance that the services Changes ver find yourself spending is associated with the wrong TPN/ » Check claim information ordered will be covered. We have also seen a large countless hours dealing with clearinghouse Members often feel upset and increase of medically 8 Dual PEHP › DOS (Date of Service) – DOS unnecessary toxicology Coverage rejections of your EDI claims? misled by both the providers E » Claim submitted prematurely must be accurate (no post- testing. As a result, several of Because of avoidable errors, PEHP and PEHP when they are put 9 PEHP’s (COBA) dating) the non-contracted toxicology rejects 4% of electronic claims per day. in these situations. Preauthorization How to prevent your claims from Rendering NPI labs have no out-of-network List Let us offer some guidance to help get › The two categories of being rejected: benefits. your claims through the first time! › Verify CPT codes are valid, as laboratory testing that are 10 2015 » Check eligibility prior to We encourage your office to Education Fair A few top reasons claims get rejected: well as modifiers hurting your patients the Flyer submission most are genetic testing and direct medically necessary Invalid Subscriber ID We encourage you to check your services to contracted » Verify DOB toxicology lab work. 11 Provider › claims prior to submission to providers so members have a Relations Reps » Incorrect DOB (Date of Birth) › Ensure the ID number is avoid the pitfalls of rejected claims All genetic tests require better healthcare experience preauthorization. 12 Contact List » NPI has not been associated with a accurate (i.e. 13 digits; starts and to have them accepted in a and are better protected TPN (Trading Partner Number) or with 1741000) timely manner! PEHP has clinical policies that financially. PAGE 2 PAGE 3 Billing Rendering and/or Incident-to Services EHP’s Financial Assurance PEHP follows CMS’s “incident-to” PDepartment is committed to guidelines for physician extenders. Summary of Guidelines identifying fraud, waste and abuse A physician can bill an incident-to A summary of the guideline includes the and provider education when service when billing for auxiliary following: needed. personnel. » Services or supplies as an integral, though During several random audits, the CMS states auxiliary personnel incidental, part of the physician’s personal Financial Assurance Department include nurses, technicians, or professional services in the course of has identified many provider offices diagnosis or treatment of an illness. that are not correctly following the certified nurse midwives, clinical Centers for Medicare and Medicaid psychologists, clinical social » The physician MUST initiate the care but Services (CMS) “incident-to” workers, physician assistants, nurse need not render a service at each instance guidelines and are not billing claims practitioners, and clinical nurse of billing. under the correct rendering provider. specialists. » The physician must remain actively involved in the care of the patient’s condition. For a complete listing of guidelines, we invite you to visit CMS’s website to learn more at: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Refer to Chapter 15, section 60. Appeals Process Clinical Policies Expediting Turnaround Time Headaches: Invasive Procedures s of April 1, 2015, PEHP has made a determination made by the Benefit EHP now considers trigger Policy Excerpt point injections and occipital change to our appeals process. Resolution Department, the provider will P A nerve blocks experimental be given instructions on how to appeal We’re confident this change will speed up and investigational for the our disputed claims/appeals turnaround DID YOU the determination to PEHP’s Executive treatment of cervicogenic DID YOU time. Review Committee. KNOW? headache, occipital neuralgia, KNOW? If a provider wishes to dispute any To dispute or appeal a claim, inquires cluster headache, chronic Contracted determinations made to a claim, the daily headache, and migraine You can call should be sent to: your Provider providers provider must continue to dispute the headache because their Relations have the determination within 180 days after the PEHP Appeals and Policy Management effectiveness for these indications Specialist responsibility Department claim was processed. has not been established. if you’ve to file the claim P.O. Box 3836 within 12 All disputed claims will first be reviewed To find the full policy, login to misplaced months from by our Benefits Resolution Department Salt Lake City, Utah 84110-3836 the secured provider site and your login information, the DOS.
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