New Claims Editing System FAQs
Martin’s Point Health Care follows correct coding and billing criteria for our US Family Health Plan (USFHP) and
Generations Advantage programs. To this end, we implemented new software in January 2015 that more closely aligns
our claims editing processes with correct coding and billing criteria established by the Centers for Medicare and
Medicaid Services (CMS). For example, we now apply more extensive claim editing rules for common billing and coding
errors such as:
•
Bundling: Items and services considered incidental to a physican service on the same date
•
Unbundling : Determining whether two procedure codes are allowed to be billed for the same patient, on
the same day, by the same provider
•
Post -Op Surgery (Global Period): Surgical procedures rendered within pre-determined follow-up time
periods for services by the same provider, department, and specialty, with the same diagnosis code
•
Medical Visit on Same Day as Procedure without Modifier: An evaluation and management (E/M) code
billed on the same day as a procedure without a modifier to indicate that the E/M service was performed
and documented as a significant, separately identifiable service
We also apply Medicare Local Coverage Determination (LCD) rules to claims for services rendered to Generations
Advantage members in Maine and New Hampshire. (LCD rules do not apply to USFHP claims.) For example:
•
Diagnosis to Support Medical Necessity Edits: Applies to certain procedures that require the use of specific
diagnosis codes to support medical necessity for the service
•
Primary/Secondary Diagnosis Code Edits: Applies when LCD rules indicate a specific diagnosis code is
required in the primary or secondary position to support medical necessity and/or to more fully define the
patient’s condition
•
Code Modifier Edits: Applies when LCD rules require use of specific modifiers to communicate additional
information about a service
•
Frequency Limit Edits: Applies to services that have limitations on how frequently they can be covered
How will this affect my claims?
Initially, you may experience denials for claims that had been approved in the past. If this occurs and, upon
research and review of the documentation, you feel a corrected claim is in order, you may submit a corrected claim
with the appropriate additional information. Before doing so, please review our corrected claim guidelines at
www.martinspoint.org/for-providers/claims. Standard timely filing rules will apply. Please be sure to include the
claim number and the patient control number from the original claim to help ensure efficient reprocessing.
You may also notice improvements to your paper Martin’s Point remittance statements. We will use more
descriptive and specific language to convey the outcome of claim editing. Our electronic remittance statements
(835s) will continue to comply with HIPAA claim messaging rules. However, more detailed claim information will be
available on the web at www.martinspoint.org/for-providers/claims.
There will be some exceptions to our application of correct coding and billing criteria, based on our health plan
benefit design. For example, our members will still have access to important preventive services such as annual
physicals and eye exams at $0 copay. But overall, we will adhere closely to Medicare claim editing practices.
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What kinds of claims will be affected?
The new claim editing rules apply to both institutional and professional claims (UB-04 and CMS-1500) for services
rendered to US Family Health Plan and Generations Advantage members. LCD rules will apply only to Generations
Advantage claims for services rendered in Maine and New Hampshire.
When does this start?
The new claim editing rules apply to claims processed on or after January 2, 2015, regardless of the service date.
This includes claims submitted for reconsideration, reprocessing, or correction.
What is an LCD?
Under certain circumstances, Medicare fiscal intermediaries and carriers have the discretion to cover a particular
service (i.e., determination that a service is reasonable and necessary). These coverage policies are issued in a
document called a Local Coverage Determination (formerly, the Local Medical Review Policy). Local Coverage
Determinations (LCDs) provide guidance that assists providers in submitting correct claims for payment. LCDs also
outline how the contractor will review claims to ensure that the services provided meet Medicare coverage
requirements.
What are the LCD rules? Where can I learn more about them?
LCD rules can be found on the local carrier’s website or by contacting them directly. Following are the local carriers
for Maine and New Hampshire:
• Medicare Parts A & B: National Government Services, Inc.
www.ngsmedicare.com/ngs/portal/ngsmedicare/welcome
• Durable Medical Equipment (DME): NHIC, Corp.
www.medicarenhic.com/dme/mrlcdcurrent.aspx
Where can I learn more about Medicare coding and billing criteria?
For more information, please visit www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
Thank you for your continued participation in the Martin’s Point provider network. We appreciate your support in
our ongoing effort to increase claims processing efficiency and accuracy. Please visit www.martinspoint.org/forproviders for more information or call our Provider Inquiry team at 1-888-732-7364.
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