Participating Provider Manual
Billing and Payment Policies
SECTION 4
Participating Physicians, hospitals and ancillary providers shall be entitled to payment for
covered services that are provided to a DMC Care member. Payment is made at the
established and prevailing DMC Care fee schedule.
DMC Care payment is subject to adjustment due to applicable co-payments, deductibles,
and by any amount payable by another payor according to the Coordination of Benefit
provisions of the applicable group policy or non-insured plans.
A.
Balance Billing Policies
Except for co-payments/coinsurance deductibles and non-covered services, Participating
Physicians, hospitals and ancillary providers may not bill or seek payment from a DMC
Care member for services which are either 1) not Medically Necessary or 2) not rendered
at an appropriate level of care as determined in accordance with the Medical and Quality
Management Program described in this Manual. Provider may only charge and collect
payment from member when member agrees in writing to pay for such services prior to
such service being rendered.
B.
Claim Form
All Participating Physicians and ancillary providers must use a standard CMS-1500
(08-05) (universal) claim form to bill for services provided to DMC Care members.
Hospitals must use the UB-92 claim form, supplying information as specified in
Appendix A of the DMC Participating Hospital Agreement.
CMS-1500 Form: Effective May 23, 2007, all paper-submitted professional claims must
use the CMS-1500 (08-05) form. The CMS-1500 form is revised to accommodate the
National Provider Identifier (NPI) reporting. When using the revised form it is important
to note:
•
•
•
Field 24J is for Type 1 NPIs (Rendering Provider)
Field 32a is for Type 2 NPIs (Service Facility)
Field 33a is for Type 1 or 2 NPIs (Billing Provider)
UB-04 claim form: The new UB-04 (CMS-1400) is accepted effective March 1, 2007.
The new form incorporates fields for the National Provider Identifier (NPI), along with
other minor form changes. Either the UB-92 or UB-04 claim form can be used during the
transitional period between March 1, 2007 and May 22, 2007. Effective May 23, 2007,
all paper-submitted institutional claims must use the UB-04.
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When using the revised form it is important to note:
•
•
•
Field 56 is for the NPI of the Billing Facility/Provider
Field 75 is for Type 1 NPIs (Attending Provider)
Field 77 is for Type 1 NPIs (Other Referring Provider)
For information regarding National Provider Identifier (NPI) refer to the National
Provider Identifier website.
When billing for Authorized Services, the claim form must be accurately completed,
including the authorization number. Claim forms should be mailed to the address
indicated on the Subscriber’s ID card.
For questions regarding the status of a claim submitted, payment rendered or eligibility of
a particular patient, refer to the instructions and phone numbers on the back of the
Subscriber’s I.D. card.
C. Claims Processing
Providers can normally expect to receive payment or notification and reason for nonpayment, within 45 days after receipt by the Third-Party Administrator. DMC Care
claims for contracted DMC Care providers must be submitted directly to DMC Care.
Paper claims must be submitted to:
DMC Care Claims Department
P.O. Box 44290
Detroit, MI 48244
1-800-543-0161
PLEASE NOTE: Contracted DMC Care providers (Tier 1) should not submit
claims, paper or electronically, to Cofinity. If claims are submitted to Cofinity,
payment will be delayed.
For electronic claims submission please review subsection G – “Electronic Data
Interchange Strategy” of this document (Section 4).
1.
Pended Claims
In some instances additional information, other than that routinely supplied on
and with the claim form, may be required to establish the validity of a claim or to
determine that covered services have in fact been rendered by the provider. The
provider shall furnish such additional information upon request of DMC Care or
the Third-Party Administrator. Certain information requests will cause a delay in
claim processing.
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2.
Billing and Payment Policies
Clinical Reports
Specific claim types require the submission of clinical reports (e.g., emergency
service records should accompany a claim for services provided in an emergency
room).
3.
Coordination of Benefits
The Coordination of Benefits (COB) Provision of the group health plan offering
DMC Care applies when the combined benefit for which the member is eligible
under all group policies or plans covering the member exceeds the amount
payable for covered services under the plan with DMC Care.
The primary payor will be responsible for payment of such benefit amount as
is provided in its policy or plan.
The secondary payer may be responsible for payment, depending upon its
COB policy:
o Up to the balance of the amount not paid by the primary payor; or
o Up to an amount not to exceed what it would have covered if it was
primary, reduced by any amount paid: 1) by the primary payor, and 2) the
member.
4.
Individual Consideration
On rare occasions, a procedure performed by a provider might not be adequately
defined according to CPT-4 coding methodology. Individual consideration will
be appropriate in these situations.
Claims involving individual consideration are referred to the DMC Care Medical
Director. When a claim is submitted which requires individual consideration, the
Medical Director may request the provider to furnish certain medical records,
such as operative notes, in order for the Medical Director to appropriately review
the claim. Based upon the Medical Director’s review, DMC Care will calculate
the appropriate claim payment and forward the claim to the Third–Party
Administrator. Because of this review, normal claim processing time is delayed.
5.
Incomplete Claim Forms
If the claim form is not completed properly, the Third-Party Administrator will
request the missing information from the provider. This will delay claims
processing.
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6.
Billing and Payment Policies
Late Claims
Claims should be submitted within 30 days of the date services were provided. If
claims are not submitted in a timely manner, additional research may be necessary
before the claim can be processed.
Claims not submitted within one year from the date of service will be denied
and the member shall be held harmless.
7.
“Members not on file”
DMC Care will no longer be returning hard copy claims for “members not on
file.” Instead, these claims will be entered into the claim system as a “Member
Not on File,” and therefore a denial code of member not on file will be included
on the EOP.
This change will allow for easier claim inquiry and reprocessing. As always, for
member eligibility and verification, please call 1-800-543-0161.
8.
Anesthesia Claims
In order to standardize the payment of Anesthesia Claims, DMC Care will require
Providers to bill anesthesia claims with the ASA procedure codes 00100-01999
along with the industry standard modifiers.
D. Code Auditing Software
DMC Care Health Plan has implemented code auditing software. This code
auditing system is a user driven, feature rich software product that permits a
health claims administration system to mine a claims database for duplicate
payments, claims that were paid on behalf of members that were retroactively
terminated as well as conformance to the National Correct Coding Initiative edits,
better known as NCCI as well as CMS Guidelines. The system has the ability to
identify overpayments in the areas of Global Surgical Days, Secondary Surgical
Procedures, add-on codes in addition to a dozen other industry standard edits.
Auditing software is an expert system that assists the claims processor in
evaluating the accuracy of submitted CPT/HCPCS codes. The code auditing
system uses a clinical knowledge base that results in one of three types of
medically based recommendations to the claims processor:
To accept the code(s) as submitted
To consider changing the submitted code(s) to comply with generally
accepted coding practices that are consistent with the AMA’s CPT
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Manual, HCFA’s HCPCS Level II Codes Manual, CMS guidelines, as
well as the opinions of prominent physicians within the specialty
To seek additional information from the physicians’ office because there is
inconsistent information in the claim.
The types of services that will be evaluated by code auditing software are as
follows:
Policies based on the CPT Manual
Policies based on health care coding standards
Bundling/Unbundling of procedures
Global Periods
Multiple procedures performed the same day
Appropriateness of assistance of surgery
The proper use of modifiers
This code auditing software assists the claims processor in evaluating the
accuracy of the coding of the procedure(s), not the medical necessity of the
procedure(s). When a change is made to your submitted code(s) the coding
software will provide a medical explanation of the reason for the change.
In a few instances where a change is made, it is usually because the CPT-4
Manual or the HCPCS Level II Manual indicates that one of the submitted codes
should not be used separately when submitted with another code on the claim.
This does not mean that the procedure/service was unnecessary; it means that
according to generally accepted coding practice, the procedure/service is not
coded separately under this circumstance.
Any appeals regarding coding audits should be forwarded within 180 days of
receipt of denial to:
DMC CARE
Code Audit Appeals
P.O. Box 44290
Detroit, MI 48244
Note: Appeals require medical documentation attached to the code audit
denials claim form.
E.
Billing Codes, Modifiers and Policies
1.
General Instructions
Third-Party Administrator claims processing systems use Common Procedure
Terminology-fourth revision (CPT-4) codes to identify physician services. Five
major sections are included: Medicine, Anesthesia, Surgery, Radiology/Nuclear
Medicine and Pathology. Each section contains specific instructions regarding
billing policies. The five major sections are subdivided into subsections relating
to specialty groupings.
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Occasionally, there may be multiple CPT-4 codes which could be used to bill for
a service. In these cases, please read each definition carefully and bill the
appropriate CPT-4 code.
2.
Definitions
Unlisted Procedure or Service – New or unusual procedures may be reported by
using the “Unlisted Procedure” code included in each applicable section of the
CPT-4 Manual.
3.
Modifiers
A CPT modifier is a two-digit code reported in addition to the CPT service or
procedure code (Item 24d on the CMS- 1500 form) which indicates that the
service or procedure was modified in some way. Understanding how and when to
use CPT modifiers is vital for proper reporting of medical services and
procedures.
The lack of modifiers or the improper use of modifiers can result in claims delays
or claims denials. The following is a list of modifiers that can be used. For a
detailed explanation, please refer to your CPT manual.
21
Prolonged Evaluation and Management Services
22
Unusual Procedural Services
23
Unusual Anesthesia
24
Unrelated Evaluation and Management Service by the Same Physician During a
Postoperative Period
25
Significant Separately Identifiable Evaluation and Management Service by the Same
Physician or the Same Day of the Procedure or Other Service.
Medical documentation is required for payment of this modifier.
26
Professional Component
32
Mandated Services
47
Anesthesia by Surgeon
50
Bilateral Procedure
51
Multiple Procedures
52
Reduced Services
53
Discontinued Procedure
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54
Surgical Care Only
55
Postoperative Management Only
56
Preoperative Management Only
57
Decision for Surgery
58
Staged or Related Procedure or Service by Same Physician During the Postoperative
Period
59
Distinct Procedural Service
62
Two Surgeons
66
Surgical Team
76
Repeat Procedure by Same Physician
77
Repeat Procedure by Another Physician
78
Return to the Operating Room for a Related Procedure During the Postoperative
Period
79
Unrelated Procedure or Service by the Same Physician During the Postoperative
Period
80
Assistant Surgeon
81
Minimum Assistant Surgeon
82
Assistant Surgeon (when qualified resident surgeon not available)
90
Reference (Outside) Laboratory
91
Repeat Clinical Diagnostic Laboratory Test
92
Multiple Modifiers
The most common modifiers used (but not limited to) are:
22 Unusual Procedural Services
When the service(s) provided is greater than that usually required for the
listed procedure.
NOTE: An Operative Report must be attached to the claim.
25 Significant Separately Identifiable Evaluation and Management Service
by the Same Physician on the Same Day of the Procedure or Other
Service
The physician may need to indicate that on the day a procedure or service
identified by a CPT code was performed, the patient’s condition required a
significant, separately identifiable E/M service above or beyond the usual
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preoperative and postoperative care associated with the procedure that was
performed. Medical documentation is required for claim to be
considered for payment.
26 Professional Component
Certain procedures are a combination of a physician component and a
technical component. When the physician component is reported
separately, the service may be identified by adding the modifier ‘26’ to the
usual procedure number.
57 Decision for Surgery
An evaluation and management service that resulted in the initial decision
to perform the surgery may be identified adding the modifier ‘57.’
62 Two Surgeons
When two surgeons work together as primary surgeons performing
distinct part(s) of a single reportable procedure, each surgeon should
report his/her distinct operative work by adding the modifier ‘62’ to the
single definitive procedure code. An Operative Report should be attached
to the claim.
80 Assistant Surgeon
Surgical assistant services may be identified by adding the modifier ‘80.
F.
Claims Appeal Process
The Provider Appeal Process offers prompt review of claims that are initially
denied or claims where the Provider disputes the payment amount (For claims
related to code auditing please see Section 4, Subsection D). A Provider has 180
days from the date of the denial or receipt of payment from DMC Care to initiate
the appeal process.
*
If the Provider decides to appeal, all pertinent information and the reason(s) you
believe your claim should be reconsidered must be included in the request. Your
appeal information should be mailed to the Outcomes Management Specialist
Appeals Coordinator at:
DMC Care
Provider Claims Appeal
P.O. Box 44290
Detroit, MI 48244
After receiving your appeal request DMC Care Health Plan will render a decision
based on applicable policy and procedures and any information submitted by the
provider within thirty (30) days (post service claim) of receiving your request.
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Providers who are denied at Level I have the option of appealing at Level II. All
Level II appeals should be submitted with additional documentation and rational
within sixty (60) days of notification of Level I denial. The Benefit Interpretation
Committee will provide investigative review and/or forward to the Quality
Advisory Committee for final decision.
A written notification of decision to the provider within thirty (30) days of Level
II Appeal decision.
G.
Electronic Data Interchange Strategy
1.
Purpose of This Section
The purpose of this section is to provide the reader with a general overview and
description of the electronic claims portion of DMC TPA EDI strategy. This
companion guide is to be used in conjunction with the ANSI X12N
implementation guides. The information describes specific requirements for
processing data within the payer’s system.
2.
Types of Claim Files
DMC TPA is currently accepting the following 837 files electronically:
Inpatient services;
Outpatient services;
All professional services including, but not limited to:
o Ambulatory Surgery;
o Emergency Room;
o Lab services;
o Radiology professional services.
3.
Definition of Terms Used
Health Care Providers
Health care providers are individuals and organizations that provide health
care services. Health care providers can include physicians, hospitals, clinics,
pharmacies, and long-term care facilities. The legal definition of health care
provider is included in section 262, Administrative Simplification, of the
Health Insurance Portability and Accountability Act of 1996.
Payer
The payer is the party that pays claims and/or administers the insurance
coverage, benefit, or product. A payer can be an insurance company; Health
Maintenance Organization (HMO); Preferred Provider Organization (PPO);
a government agency, such as Medicare or Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS); or another organization
contracted by one of these groups.
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Third Party Administrator (TPA)
A sponsor may elect to contract with a Third Party Administrator (TPA) or
other vendor to handle collecting insured member data if the sponsor chooses
not to perform this function.
Frequently Ask Questions
1.
What is the Benefit to Providers and DMC TPA to receive claims
electronically?
EDI allows DMC TPA to meet state and federal regulations for adjudication;
EDI improves business process and provides a faster response;
EDI reduces customer service calls while improving member and provider
satisfaction;
EDI benefits will attract customers and providers to DMC TPA.
2.
Does DMC TPA accept and process all claims electronically?
DMC TPA will not electronically accept at this time any claims for COB claims,
re-bills, corrections or claims with attachments. These claims must be billed on
paper claim forms.
3.
Timing of Submissions?
Providers may submit claims as often as they like with the understanding that
each submission will be treated as a separate batch.
5.
Will Trading Partners and/or Providers receive electronic responses?
A confirmation file of the claim being accepted.
Electronic Claims Status reporting and Electronic Remittance.
6.
Are there any specific payer rules for DMC TPA’s 837 Professional?
The submitter of data should follow the version of the 837 Implementation
Guide that includes the Addenda dated October 2002. See the 837P
Companion Guide below for any specific payer rules.
7.
Are there any specific payer rules for DMC TPA’s 837 Institutional?
The submitter of data should follow the version of the 837 Implementation
Guide that includes the Addenda dated October 2002. See the 837I
Companion Guide below for any specific payer rules.
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837 Companion Guide (v. 5010)
1.
Trading Partner Information:
ID - DMC’s trading partner ID is DMC TPA. Trading partners will also need to
communicate their ID to DMC. Generally, this should be the Trading Partner’s
Federal Tax Identification Number. Additionally, the ID code should be identified
as a Federal Tax ID within the ISA and GS Segments.
A Trading Partner Agreement will be required for all trading partners.
Transactions received with unidentified IDs will be rejected.
Please contact a provider services representative toll-free at 1 (866) 494-1247 for
further information.
2.
837 Reply:
DMC will send the 999 back to the submitter for each file received once
mapping has been completed.
DMC will send the current paper Explanation of Payment (EOP) or an 835
Remit once the claim has been through the DMC claims processing system.
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