Claim Submission and Processing

Claim Submission and Processing

LIBRARY REFERENCE NUMBER: PROMOD00004 PUBLISHED: MAY 11, 2023 POLICIES AND PROCEDURES AS OF APRIL 1, 2023 VERSION: 7.0

? Copyright 2023 Gainwell Technologies. All rights reserved.

Revision History

Version 1.0 1.1 1.2

2.0 3.0 4.0 5.0 6.0 7.0

Date Policies and procedures as of Oct. 1, 2015 Published: Feb. 25, 2016

Policies and procedures as of July 1, 2016 Published: Dec. 15, 2016

Policies and procedures as of July 1, 2016 (CoreMMIS updates as of Feb. 13, 2017) Published: May 23, 2017

Policies and procedures as of July 1, 2017 Published: Jan. 23, 2018

Policies and procedures as of April 1, 2018 Published: Sept. 6, 2018

Policies and procedures as of July 1, 2019 Published: Dec. 10, 2019

Policies and procedures as of July 1, 2020 Published: March 23, 2021

Policies and procedures as of Feb. 1, 2022 Published: Oct. 27, 2022

Policies and procedures as of April 1, 2023 Published: May 11, 2023

Reason for Revisions New document

Scheduled update

CoreMMIS update

Completed By FSSA and HPE

FSSA and HPE

FSSA and HPE

Scheduled update:

FSSA and DXC

Scheduled update

FSSA and DXC

Scheduled update

FSSA and DXC

Scheduled update

FSSA and Gainwell

Scheduled update

FSSA and Gainwell

Scheduled update:

? Reorganized and edited text as needed for clarity

? Updated OptumRx references to Optum Rx (space added)

? Updated Southeastrans references to Verida

? Updated examples of other electronic transactions in the note box in the 837 Electronic Transactions section

? Updated the claim status response for when a claim note is added, in the Claim Notes section

FSSA and Gainwell

Library Reference Number: PROMOD00004

iii

Published: May 11, 2023

Policies and procedures as of April 1, 2023

Version: 7.0

Claim Submission and Processing

Version

Date

iv

Reason for Revisions

? Removed the Excessive Nursing Facility Visits, or More Than One per 27 Days section

? Added information about claim notes for retroactive provider eligibility in the Retroactive Eligibility section

? Removed the Partial Sterilization section

? Updated the HCPCS Level 1 and Level II descriptions in the Diagnosis and Procedure Coding Systems section

? Updated information in the Diagnosis and Procedure Codes With Gender Restrictions section

? Added a note about virtual visits in the Visit and Encounter Definitions section

? Updated information in the CalendarYear Versus Rolling 12-Month Monitoring Period section

? Updated the Revenue Code 724 ? Labor Room/Delivery ? Birthing Center section

? Added the Revenue Code 762 ? Specialty Services ? Observation Hours section

? Updated the Revenue Code Linkages for Managed Care Billing Only section

? In Table 4 ? UB-04 Claim Form Fields, updated instructions for entering payers in rows 50A?C, and related fields

? Updated the Diagnosis Codes section (for both institutional and professional IHCP Portal claims) to state that periods should not be included when entering a diagnosis code

? Updated the Other Insurance Details section

? Removed references to midlevel practitioners in the Types of Services Billed on Professional Claims section

? Updated Table 6 ? CMS-1500, Version 02/12, Claim Form Fields

? Added clarification about Medicare Advantage Plan coverage for dental claims, in the note within Claim Information Section of Section 4, and in a new note at the beginning of Section 6: Crossover Claim Billing Instructions

Completed By

Library Reference Number: PROMOD00004 Published: May 11, 2023

Policies and procedures as of April 1, 2023 Version: 7.0

Version

Date

Claim Submission and Processing

Reason for Revisions

? Updated the Other Insurance for Service Detail section for dental claims to include information about adding valid ARCs for TPL denial or zero pay

? Updated the note in the introduction to Section 8: Ordering, Prescribing or Referring Provider Requirements to add RHCs

? Updated the Paper Claim Processing section

Completed By

Library Reference Number: PROMOD00004

v

Published: May 11, 2023

Policies and procedures as of April 1, 2023

Version: 7.0

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