Claims Processing Policies & Guidelines

Summary:

» A Standard Cover Sheet has been developed and is accepted by all Forum Health Plan participants. For fastest payment of claims requiring supporting documentation:

• Submit Claim Electronically
• Submit paper documentation using the standard coversheet (which must include the claim number)
• Only submit the required documentation

» Note: In the future, electronic submissions of supporting documentation will be possible using HIPAA Claims Attachment Standards.

» Implementing this policy into your daily work will require staff education and use of a standard cover sheet.

Additional Information:

» Policies & Guidelines

Summary:

» This guideline outlines the process for Submitting Corrected Claims both Electronically:

• Using standard HIPAA Compliant Codes

» And on Paper:

• Using a standard Corrected Claims Cover Sheet

» Plan Specific Contact Information is Provided

» Implementing this guideline into your daily work will require staff education and use of a Corrected Claims Cover Sheet for Paper Claims and/or 837 Corrected Claims Indicators for Electronic Claims

Additional Information:

» Policies & Guidelines

Summary:

» This guideline provides a Standard Set of Procedures for use when following up on Processed Claims:

• Telephone Inquires are Preferred
• Health Plan Contact Information is Provided
• Written Correspondence is also acceptable
• Expected Plan response to written requests are outlined

» Implementing this policy into your daily work will require staff education.

Additional Information:

» Policies & Guidelines

Summary:

» The most commonly used Modifiers have been identified and their processing requirements for the Forum Health Plan participants have been defined.

» Plan requirements are now available in user defined reports.

Note: Access to the Forum Website is required to run reports

» Implementing this guideline into your daily work will require staff education and access to the Forum website.

Additional Information:

» Policies & Guidelines

Summary:

» Billing Practices for Forum Health Plan participants are clarified for Anesthesia services and Certified Registered Nurse Anesthetists. This Guideline identifies:

• CPT/ASA Codes as Standards for Billing
• HCPCS Modifiers required when Billing for CRNA Services

» To implement this policy, utilize CPT/ASA codes and HCPCS Modifiers when billing for CRNA services.

Additional Information:

» Policies & Guidelines

Summary:

» Methods of checking claims receipt and status for the Forum Health Plan participants are outlined. This guideline includes:

• Checking Status on Individual Paper Claims
• Receiving acknowledgement of receipt of batches of electronic claims

» Implementing this policy in your daily work will require a decision not to 're-bill' claims and to inquire via phone, web, or HIPAA transaction for claims submitted to a health plan that remain outstanding.

Additional Information:

» Policies & Guidelines

Summary:

» This guideline provides Eight Common Reasons for Splitting Claims have been identified and Forum Health Plan participants and notes to avoid splitting claims are provided.

» Implementing this guideline into your daily work will require staff education and access to the Forum website.

Additional Information:

» Policies & Guidelines

Summary:

» Requirements for billing injury claims are outlined and clarified for the Forum Health Plan participants. This guideline defines:

• An OPL minimum threshold of $300
• The Diagnosis, Condition, Occurrence, and Value Codes which require inclusion of accident information on the claim
• The fields which must be completed for Injury Claims for both Facility and Professional Billing

» Implementing this policy in your daily work will require education of your office staff.

Additional Information:

» Policies & Guidelines

Summary:

» Forum Health Plan participants do not require Paper EOBs to be submitted in support of secondary electronic claims if all required primary payer information is included on secondary electronic claim submission.

Note: For claims that the Primary Payer paid a 'zero amount', paper claim submission is preferred.

» To implement this policy in your normal daily work, you must be able to capture the required information in the required fields on the electronic claim as outlined in the policy.

Additional Information:

» Policies & Guidelines

Summary:

» This policy outlines the steps for following up on an electronically submitted claim that was not received by a Forum Health Plan participant.

• If using a clearinghouse, the provider should have the clearinghouse report available when calling the plan.
• If the claim cannot be located, it can be re-submitted electronically.
• Providers may choose to resubmit the claim on paper but are not required to do so.

» Implementation of this policy into your daily work will require staff education.

Additional Information:

» Policies & Guidelines

Summary:

» Forum Health Plan participants do not require submission of ER Notes or Medical Records with ER claims.

» Implementation of this policy in hospitals may require education of hospital staff.

Additional Information:

» Policies & Guidelines

Summary:

» Forum Health Plan participants have agreed that a copy of a patients insurance card is not required with a submitted claim.

» Implementation of this policy in your daily work will require staff education.

Additional Information:

» Policies & Guidelines

Summary:

» Processes for handling overpayments and underpayments have been defined for the Forum Health Plan Participants.

» Plan processing requirements are now available in user defined reports.

Note: Access to the Forum Website is required to run reports

» Implementing this guideline into your daily work will require staff education and access to the Forum website.

Additional Information:

» Policies & Guidelines

Referrals & Prospective Review Policies & Guidelines

Summary:

» Three Policy Templates have been converted into user defined reports which provide clarity around the referral requirements of the Forum Health Plan participants. These reports are accessible through the Forum's Website and include:

• Referral Requests for Managed Care Patients
• Prospective Review Requests for all Patients
• Inpatient Stay Reviews for Indemnity Patients

» Use of these on-line reports requires internet access.

» To implement this policy, generate user defined reports for your patient's health plans for the services or procedures required. The report will indicate the health plan's review policy for the services requested.

Additional Information:

» Policies & Guidelines

Summary:

» Forum Health Plan participants have agreed to five standard terms and a standard form document for use by a referring physician when sending a (managed care) patient to a specialist:

• Consult Only
• Evaluate and Treat
• Evaluate and Treat- Procedure if Indicated
• Itemize Services
• Assume Management

» When the standard terms are used, Forum Plans have agreed to reimburse services according to common and consistent practices.

» The standard form document, (not required), including these terms, is available at www.chita.org/chita_pride/frame/products.htm

» To implement this policy, use the agreed upon standard terms when submitting referrals.

Additional Information:

» Policies & Guidelines

Summary:

» Conditions under which Forum Health Plan participants will reimburse services for self referred Woman's Healthcare have been clarified. This guideline defines:

• Women's Healthcare Provider
• Women's Healthcare Services
• Providers to which Women can self-refer

» To implement this policy in your normal daily work will require education of your office staff.

Additional Information:

» Policies & Guidelines

Summary:

» Diagnosis and Treatment codes are not always known at the time of referral.

» Forum Health Plan participants will not require providers or facilities to numerically code the diagnoses or procedures for the purposes of referrals, prior authorization or preadmission certification, if the codes are not known.

» A clear narrative describing the need for the referral and the intended services is required if the code is not known.

Note: Claims processing times may be slowed if codes are not used.

» To implement this policy into your normal daily work will require education of office staff.

Additional Information:

» Policies & Guidelines

Summary:

» Forum Health Plan participants have agreed to extend 'Tolerance Days' before and after the referral period.

» As long as conditions are met, a referred patient can receive services 7 days prior to the referral effective date and 15 days after the referral end date. (Not applicable to mental health).

» To implement this policy in your normal daily work will require education of your office staff.

Additional Information:

» Policies & Guidelines

Summary:

» Forum Health Plan participants have agreed that no referral is required for managed care patients who receive emergency services in a hospital Emergency Room.

• Referrals are not required for revenue code 450, place of service code 23, and CPT codes 99281-99285

» To implement this policy in your daily work will require education of your office staff.

Additional Information:

» Policies & Guidelines

Summary:

» Forum Health Plans have agreed to accept a Standard Form from Providers requesting a Prospective Medical-Clinical Review. The Policy Includes:

• A Standard Form
• Plan Specific Contact Information and Submission Instructions

» To implement this policy into your daily work will require staff education and use of the Standard Request Form for Prospective Medical-Clinical Review

Additional Information:

» Policies & Guidelines

Credentialing

Summary:

» The Forum Credentialing Workgroup has produced a Practitioner Credentialing Handbook

• Reviewed annually by the WCSG
• Explains initial credentialing and re-credentialing process
• Provides materials to guide practitioner staff through the credentialing process
• Provides Q&A and Common Credentialing Delays
• Sets timeline expectations

Additional Information:

» Policies & Guidelines

Summary:

» Forum Plan participants have agreed to notify providers when a completed credentialing application is received and is ready for committee review. The guideline includes:

• Notice sent within 10 days of completed application receipt
• 90 day processing time from completed application as the expected credentialing norm
• Methods of notification and implementation timeframes are noted

» Implementation of this policy into your daily work will require staff education

Additional Information:

» Policies & Guidelines

Summary:

» Forum Health Plans have agreed that Effective Dates for New Providers, for Purposes of Claims Adjudication will be either:

• The Credential Date
  OR
• The Contract Date

WHICHEVER IS LATER

» Time Frames and requirements for Delegated Groups are provided in the Guideline

Additional Information:

» Policies & Guidelines