Claims Processing

A series of projects have been completed with the goal of reducing the amount of paper providers send to health plans, thereby reducing staff time and speeding payment.

#1 - Submitting Supporting Documentation

» Standard Cover Sheet
   (.pdf | 69K | Rev 10.08 | 10/07)

» Guideline Document (.pdf | 33K | Version 10.8 | 10/07)

#2 - Submitting Corrected Claims

» Standard Cover Sheet
   (.pdf | 60k | Rev 3.6 | 1.30.07)

» Submitting Corrected Claims Guidelines
   (.pdf | 27k | Rev 10.08 | 10/07)

#3 - Following-Up on Processed Claims

» Guideline Document (.pdf | 29K | Rev 5.0 | 10/07)

#4 - Using Common Modifiers
Updated to include additional health plans and user defined reports. Supports correct billing when most common modifiers are used.

» Using Common Modifiers (user defined report — now provided by OneHealthPort)

» Guideline Document (.pdf | 26K | Rev 10.08 | 10/07)

#5 - Anesthesia Coding & Billing CRNA Services

» Guideline Document (.pdf | 23K | Rev 10.08 | 10/07)

#6 - Getting Claim Receipt and Status Information

» Guideline Document (.pdf | 26K | Draft 10.08 | 10/07)

#7 - Conditions for Splitting Claims
Updated to include additional health plans and user defined reports. Clarifies the eight most common conditions under which claims are split.

» Conditions for Splitting Claims (user defined report — now provided by OneHealthPort)

» Guideline Document (.pdf | 15K | Rev 8.0 | 4.15.04)

#8 - Quicker Resolution of Payment Responsibility for Injuries
Now a dynamic report based upon diagnosis code and selected health plans.

» Injury Diagnosis Code Report (user defined report — now provided by OneHealthPort)

» Guideline Document (.pdf | 49K | Rev 10.08 | 10/07)

#9 - Incorporate Explanation of Benefits (EOB) Info on Electronic Claims

» Handling EOB Info Guidelines
   (.pdf | 33K | Rev 10.08 | 10/07)

#10 - Resubmission of Claims Electronically

» Policy Statement RE: No Paper Claims (.pdf | 9K | Rev 3.2)

#11 - Clinical Notes Do Not Need to be Submitted for Emergency Room Visits

» Policy Statement RE: No Clinical Notes For ER
   (.pdf | 9K | Rev 3.3)

#12 - Patient Insurance Card Not Required

» Policy Statement RE: No Insurance Card (.pdf | 9K | Rev 3.2)

#13 - How Health Plans Handle Under Payments & Over Payments
Common questions about how participating Health Plans handle Claims Adjustments are answered. Health Plans spell out their processes and timelines.

» Adjustments by Payer (user defined report — now provided by OneHealthPort)

» Guideline Document (.pdf | 21K | Rev 5.0)

#14 - CPT Codes that will NO LONGER Automatically Pend a Claim for an Attachment
Health Plans and Providers are reducing the number of attachments that are required to process claims. Participating health plans have agreed that the attached list of CPT codes will NO LONGER trigger an automatic pend for an attachment. (NOTE: Not all of the participating health plans were automatically pending claims billed with these codes to await an attachment, but one or more were previously doing so. Now, none of the participating health plans will automatically pend claims with CPT codes on the attached list.)

Providers who have put automated edits into place to submit attachments when billing with these CPT codes should review their edits and adjust accordingly. Provider should also encourage non-participating health plans to similarly relax their requirements for these CPT codes.

» View Codes

» Download Codes (.xls | 33K | 12.06)

Claims Processing Quick Link:

1. Submitting Supporting Documentation
2. Submitting Corrected Claims
3. Following-Up on Processed Claims
4. Using Common Modifiers
5. Anesthesia Coding & Billing CRNA Services
6. Getting Claim Receipt and Status Information
7. Conditions for Splitting Claims
8. Quicker Resolution of Payment Responsibility for Injuries
9. Incorporate Explanation of Benefits (EOB) Info on Electronic Claims
10. Resubmission of Claims Electronically
11. Clinical Notes Do Not Need to be Submitted for Emergency Room Visits
12. Patient Insurance Card Not Required
13. How Health Plans Handle Under Payments & Over Payments
14. CPT Codes that will NO LONGER Automatically Pend a Claim for an Attachment