Welcome to Claims Corner!

EmblemHealth and its companies, GHI and HIP, understand that getting your claims paid quickly and accurately matters to you. We have created Claims Corner — a resource where you will find updated information on claims policy, best practices for coding your claims, regulatory-driven payment methodology changes and other useful claims-related tips. Claims Corner may be reached from the provider page on any of our Web sites. Visit us often to view important claims topics. Click on any subject of interest to read the expanded discussion.

HCPCS Codes for HIP and EmblemHealth CompreHealth That Do Not Require Prior Approval

Submitting Corrected Claims

Corrections to H-90 Pended Reports via Q-Care to Be Made Within 10 Days

Avoiding Duplicate Claims Submissions

GHI Family Health Plus Modifying Fee Schedule

GHI Is Converting to Average Sales Price for Drugs Administered in Your Office

Coverage Denied for Never Events

ConsumerDirect Benefit Plans: Submit Claims to Us First

EmblemHealth Partners with OrthoNet

New Payment Policies for Certain Drugs and Biological Agents

EmblemHealth Coverage for Flu Medications and Vaccines

Modifiers for Services and Procedures During the Postoperative Period

Maternity Claims: Adjusted Procedures 08/09

Important Reminder: Referrals Required for Specialist Claims

POA Indicator

APG Rate Codes

Use Your NPI

Claim Tips

Claim Tips for Paper Submissions

Submitting Corrected Claims

(For All Benefit Plans)

For HIP and CompreHealth Benefit Plans
If you have submitted a claim for a member in a HIP or a CompreHealth HMO or EPO benefit plan that was denied and you would like to make changes to the claim for an additional review, please send the additional or corrected claim information by completing the Corrected Claims Request Form. Please mail the completed form to the address provided on the form. If you are making corrections to the original claim, you will also need to provide a copy of your updated claim. We will review the updated information and determine if we should overturn the original decision and pay the claim.

If you have more than one claim which you are resubmitting with corrected information, you will not need to complete multiple cover sheets. Simply complete one form and place it on top of the new CMS1500 or Facility UB04 forms noting on the form the specific information being corrected. If multiple claims require adjustment, you may attach a list of all of the applicable claims.

Please do not resubmit your electronic or paper Professional CMS1500 or Facility UB04 claim form as you would an original claims request as our claims system may automatically deny the resubmission as a “duplicate” because it would have already processed the original claim. Submitting the Corrected Claims Request Form will allow us to put your updated claim request through a special workflow where we can address the updates to your original claims submission.

If we have any questions regarding your claim request, we will contact you at the phone number you provide on the form.

For GHI, GHI HMO and EmblemHealth EPO/PPO Plans
If you have submitted a claim for a GHI, GHI HMO or EmblemHealth EPO/PPO plan member that was denied and you would like to make changes to the claim for an additional review, please send the additional or corrected claim information by logging on to ghi.com and click on “Claims” in the left navigation bar. At the bottom of the claim, you'll see a link that reads “Contact GHI about the claim.” You'll find that all the claim information is already filled in for you. All you need to do is include the additional information. Or, click on “message center” on the left navigation bar, and you'll be prompted to fill in the message center form, which will automatically be submitted to our Customer Service department.

Corrections to H-90 Pended Reports via Q-Care to Be Made Within 10 Days

Facilities that receive the H-90 Pended Report via Q-Care will need to make corrections to claims within 10 days. Recent legislation requires us to pay electronically submitted claims within 30 days of receipt of the claim. For this reason, we need to shorten the response time to make corrections. If any corrections are not received on time, the final claim will be adjudicated without reflection of this correction.

Should you have any questions about this change, please email edisupport@hipusa.com.

Please revise your practices to support this new change.

Avoiding Duplicate Claims Submissions

(For EmblemHealth, GHI and HIP benefit plans.)

Ensuring that you get paid quickly and accurately is our top priority.
Any claim submitted more than once from the same provider or supplier for the same date of service and for the same service is considered a “duplicate” and the claim will be denied. When you resubmit claims because you haven’t received your payment or a response regarding your payment, you are actually delaying claims processing and can potentially create confusion for the member.

Also, please be aware that we can initiate a fraud investigation if we see a pattern of duplicate billing.

Just how quickly do we process claims?

• 98 percent of our claims are processed within 14 days of receipt.
• Virtually 100 percent of our claims are processed within 30 days.

Make sure that your automated billing system is set up properly.

• If you bill us electronically, please check that your billing system is not set up to automatically re-bill every 30 days.
• Please allow a reasonable amount of time for us to complete your account receivable reconciliation before you resubmit a claim. Our timely claims processing should reduce the number of claims you need to resubmit, saving you time and administrative effort and expense. Many times the payment for the original claim was applied to the copay, or the service was denied for medical necessity, eligibility, or another reason. Please make sure that your automated billing system accurately posts these types of settlements.
• Ensure that your billing system is not set up to automatically generate a paper claim. This duplicate billing practice is costly and delays claims processing.

If you need assistance, please contact your software vendor.

Make sure that you do not re-bill an underpayment.
Please do not re-bill the original claim when you believe that an adjustment to the initial payment is warranted. Should this occur, please contact our Customer Service at one of the numbers listed below.

Thank you.
We appreciate your cooperation in avoiding duplicate billing. By doing so, you will help to ensure that your claims are processed efficiently and in a timely manner.

GHI Family Health Plus Modifying Fee Schedule

(Applies to GHI PPO)

Effective April 1, 2010, Group Health Incorporated (GHI) is modifying its Family Health Plus (FHP) fee schedule. These modifications ensure that our benefit plans remain an affordable health coverage option for our members. The changes will bring our fees in line with the 2009 Medicaid reimbursement rates established by New York State. Reimbursement will be at 100 percent of the 2009 New York State Medicaid Fee Schedule.

If you participate with GHI in a government-sponsored plan, you may be affected by this change. GHI practitioners who participate in Family Health Plus received a letter amending their Agreements. The amendment was made in accordance with the general provisions of their Agreements with GHI. Only the FHP fee schedule is being amended. The fee modifications in no way change participation status in any of the other GHI networks or plans in which you may participate.

GHI Is Converting to Average Sales Price for Drugs Administered in Your Office

(For GHI PPO CBP)

Effective December 31, 2009, GHI will begin reimbursing practitioners at a rate of approximately 13 percent over the average sales price (ASP). In addition, for many generic or branded equivalents, maximum allowable cost (MAC) reimbursement pricing will be employed and will generally pay more than 30 percent over the ASP for these products.

As generic or branded equivalents are made available for any particular injectable product and the acquisition costs for such products decrease, MAC pricing will adjust reimbursement to reflect changes in market pricing.

GHI’s MAC methodology will apply to generics and therapeutic classes such as antiemetics, LHRH (luteinizing hormone-releasing hormone) agonists and certain chemotherapies. Quarterly updates will apply MAC pricing to additional therapeutic classes as new generics and therapeutic equivalents become available. Based on today’s availability of generic and therapeutic equivalents, the MAC pricing changes will apply to the following HCPCS codes:

HCPCS CODES
J0640	J1568	J2430	J9045	J9170	J9217
J1260	J1569	J2469	J9060	J9181	J9264
J1459	J1572	J3487	J9062	J9190	J9265
J1561	J1626	J9000	J9130	J9202	J9390
J1566	J2405	J9040	J9140	J9206

Should you have any questions related to this fee schedule change, please e-mail us at mdq&adownstate@emblemhealth.comm if your practice is in New York City, Nassau, Rockland, Suffolk or Westchester counties. All other practices with questions may e-mail us at mdq&aupstate@emblemhealth.com.

Coverage Denied for Never Events

(Applies to all ASOs, EmblemHealth, GHI and HIP lines of business.)

Beginning January 1, 2010, EmblemHealth and its companies GHI and HIP will deny all claims submitted for never events. The Centers for Medicare and Medicaid Services (CMS) no longer covers surgical or other invasive procedures for the treatment of medical conditions when such procedures are performed in error by a practitioner or group of practitioners. These errors are known collectively as never events. The CMS ruling became effective on January 15, 2009. As a result of the CMS decision, EmblemHealth has determined that we will no longer pay for never events in any line of business as of January 1, 2010.

Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are cut into or an instrument is introduced through a natural body opening. Procedures range from the minimally invasive to major surgeries. This applies to all procedures found in the surgery section of the Current Procedural Terminology (CPT) coding. It does not include use of instruments such as otoscopes for examinations or very minor procedures such as drawing blood.

Never event errors include:

• Performing a different procedure altogether
  A surgical or invasive procedure is considered to be the wrong procedure if it is not consistent with the correctly documented informed consent for the patient.
• Performing the correct procedure on the wrong body part
  A surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for the patient. This includes surgery on the appropriate body part, but in the wrong place for example, operating on the left arm versus the right or on the left kidney not the right, or at the wrong level (spine).
• Performing the correct procedure on the wrong patient
  A surgical or other invasive procedure is considered to have been performed on the wrong patient if that procedure is not consistent with the correctly documented informed consent for that patient.

Related Services
All related services provided during the same hospitalization in which the error occurred are not covered for either CMS or EmblemHealth companies. We will also not cover other services related to these non-covered procedures as defined in the Medicare Benefit Policy Manual (BPM):

• All services provided in the operating room when such an error occurs are considered related.
• All providers who could bill individually for their services and who are in the operating room when the error takes place are not eligible for payment.
• Related services do not include performance of the correct procedure after the never event has occurred.

NOTE: Emergent situations that change the plan in the course of surgery and/or whose exigency precludes obtaining informed consent are not considered erroneous under the CMS ruling. This also includes the discovery of new pathologies near the surgery site, if the risk of a second surgery outweighs the benefit of patient consultation, or the discovery of an unusual physical configuration (e.g., adhesions, extra vertebrae, etc.).

A fuller explanation of never events and the new ruling may be found on the CMS Web site. If you have additional questions, you may also e-mail them to mdq&adownstate@emblemhealth.com if you practice in New York City, Long Island or Westchester County. For upstate counties, please send your e-mails to mdq&aupstate@emblemhealth.com.

ConsumerDirect Benefit Plans: Submit Claims to Us First

(Applies to ConsumerDirect EPO and ConsumerDirect PPO)

Please submit your claims for medical care for members in ConsumerDirect EPO or ConsumerDirect PPO benefit plans to EmblemHealth. You can expedite reimbursement and avoid payment errors by submitting your claims to us and billing your patient after you receive and review your Explanation of Benefits (EOB) for the claim(s).

Because member liability is determined after a claim is processed, the EOB will clearly state the member’s payment responsibility. If any coinsurance or deductible remains, you may bill your patient directly for the balance.

EmblemHealth Partners with OrthoNet

(The following applies to EmblemHealth CompreHealth HMO and HIP members.)

Beginning February 1, 2010, OrthoNet LLC, on behalf of EmblemHealth, will review medical records for a sampling of submitted professional claims to ensure that the services billed reflect the services documented in the medical record and that such services are properly coded. We have executed a Business Associate Agreement with OrthoNet to ensure HIPAA compliance in all aspects of claims submission and processing.

How Does This Work?
There is no change to your current claims submission process. Claims that fit specific criteria (e.g., amount threshold, CPT code or specialty) will be selected for review. If medical documentation was not submitted with the claim, OrthoNet will send you a letter to request medical records for the claims under review. The letter will indicate the patient's name, their member ID and the date(s) of service. You may fax your documentation to OrthoNet at 1-877-499-9538.

If you receive a request for additional information, please respond as soon as possible to facilitate claims processing.

Please note: OrthoNet will not be conducting utilization reviews or making medical necessity determinations. Should you disagree with the claims payment decision, you are entitled to the appeal rights outlined in the HIP Practitioner Manual.

Excluded Members:
OrthoNet will not perform medical claims review for members who:

• Are PPO/EPO members
• Have selected a primary care physician (PCP) affiliated with St. Barnabas Hospital, Montefiore Medical Center (CMO), Health Care Partners (HCP) or Inspiris
• Have selected a PCP with any one of the following physician group practices:
  • Queens Long Island Medical Group
  • Preferred Health Partners
  • Staten Island Physician Practice
  • Manhattan's Physician Group
  • Lenox Hill Medical Group

Notice of New Payment Policies for Certain Drugs and Biological Agents

(Applies to HIP, Vytra and CompreHealth benefit plans.)

Beginning November 24, 2009, we will be introducing new payment policies for the drugs and biological agents listed in the table below.

These policies apply only to the office-based administration of these drugs and agents for members enrolled in the HIP, Vytra and EmblemHealth CompreHealth benefit plans.

Facility claims are not affected by this change.

Coverage for Drugs and Biological Agents

Coverage for drugs and biological agents will be limited to:

• FDA-approved indications and certain off-label indications that are either supported by CMS-approved pharmaceutical compendia or are based on evidence outlined in our non-FDA-approved medical guideline.¹
• Weight-based dosage and frequency guidelines that are consistent with drug labeling, standard practice patient care guidelines and/or approved compendia.

The new payment policies currently apply to the following drugs and biological agents. Changes to this list may be made occasionally we recommend you review this list regularly.

Affected Drugs and Biological Agents*
Generic Name	Brand Name	Generic Name	Brand Name
IVIG	Various brands	filgrastim	Neupogen®
omalizumab	Xolair®	pegfilgrastim	Neulasta®
botulinum toxin A& B	Botox® and Myobloc®/ NeuroBloc®	infliximab	Remicade®
epoetin alfa	Procrit® and Epogen®	bevacizumab	Avastin®
histrelin	Vantas®	darbepoetin alfa	Aranesp®
gemtuzumab ozogamicin	Mylotarg®	alglucerase and imiglucerase	Ceredase® and Cerezyme®
ibritumomab tiuxetan	Zevalin	trastuzumab	Herceptin®
octreotide acetate	Sandostatin LAR®	rituximab	Rituxan®
zoledronic acid	Zometa®	nesiritide	Natrecor®

*Some Web sites require a user name and password to log in.

Required ICD 9 Codes

The ICD-9 codes listed on the claim for the primary and secondary diagnosis, if applicable, need to support the indications for the billed drug/biological, as outlined in the above coverage section. For example, according to the label, darbepoetin alfa is indicated and approved for treatment of patients with anemia due to end-stage renal disease.* The drug will require a diagnosis of anemia due to chronic kidney disease, end-stage renal disease, or renal dialysis to be included on the claim.

Weight-Based Dosages

Each drug/biological will have an assigned maximum dosage per date of service. The maximum dosage is calculated based on an average body weight, body surface area and the approved dosage on the drug label.

Required Related Tests and/or Procedures

Please check the manufacturer’s package insert for required qualifying tests and or procedures that will need to be documented on the claim. For example, according to the drug label, darbepoetin alfa, when given for the diagnosis of chronic renal disease, requires documentation of a lab test showing that the patient has chronic renal insufficiency.* To qualify for payment, lab tests for BUN or creatinine must have been billed for the same date of service or within the 12 months before the drug is administered.

Claim-Specific Questions

If you have a question regarding a decision made about a particular claim, please contact us at Customer Service at 1-866-447-9717, option 2 or 1-877-VIA-EMBLEM (1-877-842-3625), weekdays between 8 am and 5 pm. Please have the following information available to facilitate our discussion:

• Primary and secondary diagnosis
• Patient’s age, gender, height and weight or BMI
• Manufacturer’s package insert
• Specific off-label protocol used (if applicable)

Additional Information

If you have questions about this policy or need additional information, please speak with Pharmacy Services, by calling 1-866-447-9717, option 3, from Monday through Friday, 8:30 am to 6:00 pm.

*Please note, the examples used are for illustrative purposes only and are subject to change based on industry standards.

¹The primary sources for the policies are the manufacturers’ package inserts and CMS-approved compendia Publication 100-02 IOM Section 50.4.5 B, pages 61-67, the Thomson Micromedex DRUGDEX^®, Gold Standard’s Clinical Pharmacology Online, The American Hospital Formulary Service^® Drug Information (AHFS DI) and the NCCN Drugs and Biologics Compendium™. Some Web sites require log in.

Maternity Claims: Adjusted Procedures

(For EmblemHealth, GHI and HIP Benefit Plans)

Beginning September 11, 2009, Group Health Incorporated (GHI), an EmblemHealth company, will adjust the payment method for the submission of claims for maternity-related services for GHI and EmblemHealth EPO and PPO members. By following this new procedure, your claims will be processed faster and should make your office’s administrative tasks easier. (We also recommend that practitioners submit claims for maternity-related services in the same manner for every benefit plan, including HIP and EmblemHealth CompreHealth.)

Please submit your claims using the following method:

• Submit claims for maternity-related service(s) in three installments, utilizing CPT Industry Standard Coding Guidelines; the first claim for antepartum care, the second for delivery care, and the third (final) for postpartum care.

You may continue to submit a single claim for antepartum care, delivery care, and postpartum care, but the preference is for submission of claims in three installments.

More Important Information for GHI and EmblemHealth EPO and PPO
Sometimes your patient does not carry the pregnancy to full term or may transfer to another practice for obstetrical care. If this is the case after September 11, 2009, we will send you a form to confirm the reason obstetrical care was discontinued after your claim is submitted. Check the appropriate lines on the form and return it to us.

If you have questions, or require assistance with these changes, please contact GHI Customer Service at 1-212-501-4GHI (1-212-501-4444) for your GHI patients or 1-877-VIA-EMBLEM (1-877-842-3625) for your EmblemHealth patients. Please call the Provider Relations Service Team at 1-866-447-9717, option 5 for HIP.

Important Reminder: Referrals Required for Specialist Claims

EmblemHealth’s CompreHealth HMO* benefit plan and certain HIP benefit plans** require a referral in order to process and pay specialists’ claims. Submitting a claim with the UPIN and NPI in place of a referral is not acceptable. We ask that specialists verify that the required referral has been issued by going to either the Web-based or telephonic services listed below for confirmation:

• Log in to myEmblemHealth to look up referrals/pre-certifications/prior approvals for HIP or EmblemHealth members. Select “Referrals” or “Pre-certifications/Prior Approvals” on the left-hand navigation bar, then select the “Search Referrals” or “Search Pre-certifications/Prior Approvals” links as needed.
• For your EmblemHealth members, call EmblemHealth Customer Service at 1-877-VIA-EMBLEM (1-877-842-3625).
• For your HIP members, call HIP’s interactive voice response (IVR) system at 1-866-447-9717, option 1.

Claims submitted without the requisite referral on file will be automatically denied for noncompliance. Remember, too, that a practitioner NPI may also be required in fields 2010AA, 2010AB, 2310B and 2420A, of an electronic claim in addition to the referral.

* EmblemHealth CompreHealth HMO benefit plans are underwritten by HIP Health Plan of New York (HIP).
** With the exception of HIP’s EPO/PPO, HIP Access I/II and HIP VIP Plus plans, HIP’s benefit plans require a referral in order to process and pay specialists’ claims.

POA Indicator

Section 5001(c) of the Deficit Reduction Act of 2005 requires hospitals to begin reporting the secondary diagnoses present on the admission of patients, effective for discharges on or after October 1, 2008. In order to implement Section 5001(c) of the Deficit Reduction Act of 2005, and to group diagnoses into the proper DRG, EmblemHealth must capture a Present on Admission (POA) indicator for all claims as shown below.

POA Code is needed for:

• General acute-care-hospital inpatient admissions for Medicare members discharged on or after October 1, 2008. The POA indicator is required for all inpatient admissions of Medicaid members discharged on or after July 1, 2009 (including those that are exempt per Medicare).
• A POA indicator is required for all diagnosis codes. If the diagnosis is exempt, enter a value of “1.”

For billing purposes, a POA Code is not needed for Medicare member claims in the following hospitals:

• Critical Access Hospitals
• Inpatient rehabilitation facilities
• Inpatient psychiatric facilities
• Maryland Waiver Hospitals
• Long-Term Care Hospitals
• Cancer Hospitals
• Children’s Hospitals
• Hospitals paid under any type of Prospective Payment System (PPS) other than the acute care hospital PPS

A POA Code is mandatory for Medicaid member claims for each diagnosis submitted in all inpatient facilities including Critical Access Hospitals and hospitalizations for:

• Substance abuse treatment
• Mental health admissions
• All medical inpatient services

General Reporting Requirements for Medicare and Medicaid members:

• All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection of POA information.
• A POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes.
• Issues related to inconsistent, missing, conflicting or unclear documentation must still be resolved by the provider.
• If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, then the POA indicator would not be reported.
• CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other” diagnosis.

Reporting Options and Definitions:

• Y = Yes, present at the time of inpatient admission.
• N = No, not present at the time of inpatient admission.
• U = Unknown, the documentation is insufficient to determine if the condition was present at the time of inpatient admission.
• W = Clinically Undetermined = the provider is unable to clinically determine whether the condition was present at the time of inpatient admission or not.
• 1 = Unreported/Not used, exempt from POA reporting. This code is the equivalent code of a blank on the UB-04. However, it was determined that blanks were undesirable when submitting this data via the 4010A.

For more information and coding instructions, click here for the Official Guidelines for Coding and Reporting or you may click here for the POA Factsheet.

APG Rate Codes

During 2009, EmblemHealth will begin to pay claims that are billed with Ambulatory Patient Groups (APGs) rate codes (and their corresponding CPT codes) for services covered by APG reimbursement. The APG system is the new state-mandated payment methodology for most Medicaid outpatient services. APGs will be paid for outpatient clinic, ambulatory surgery and emergency department services, when the service is contracted to be reimbursed at the Medicaid rate. APGs will not be used for services that are carved out of Medicaid managed care.

We will follow New York State guidelines for claims submission. New York State has set up the following Web sites to provide information about APGs. Click here for APG rates for Medicaid. For the manual on APGs, please click here.

To facilitate claims processing, we ask that you:

1. Separate APG and non-APG services onto separate claims;
2. Report a value code of 24 and an appropriate rate code; and
3. Report CPT codes for all revenue lines.

Claims without proper coding will be returned to you for correction prior to adjudication.

Planned Hospital Rollout Schedule:
Non-Par Providers: May 15, 2009
GHI HMO and GHI Providers: June 1, 2009
HIP Providers: Staggered rollout to be completed by: September 1, 2009

For information on APGs, go to the New York State Web sites above or you may click here for a discussion of known APG issues or click here for HIPAA APG requirements.

Use Your NPI

Federal law mandates that health care practitioners must use their unique, ten-digit National Provider Identifier (NPI) number when submitting standard electronic health care transactions, such as claims. The effective date for use of your NPI was May 24, 2008. Although EmblemHealth will process your current electronic claims submissions, please provide an NPI in all future electronic claims submissions.

Effective August 3, 2009, EmblemHealth will reject your claims if the NPI is not correctly populated in your 837P electronic claims transactions.

Please contact your practice management system vendor to ensure your software is capturing and correctly populating your NPI in your electronic claims submissions per the following EmblemHealth 837P NPI technical requirements. The fields that must be correctly populated are:

• Billing Provider 2010AA. NPI is required.
• Pay To Provider 2010AB. Only required if the Pay To Provider is different from the Billing Provider. If this loop is sent, NPI is required.
• Rendering Provider 2310B, Claim Level. Only required if the Rendering Provider is different from either the Billing Provider or the Pay To Provider. If this loop is sent, NPI is required.
• Rendering Provider 2420A, Line Level. Only required if the Rendering Provider is different from the provider in the 2010AA, 2010AB or 2310B loops. If this loop is sent, NPI is required.

If you or your system vendor has any questions regarding the above EmblemHealth 837P NPI technical requirements, you may contact an EmblemHealth Electronic Media Claims (EMC) Technical Representative at 1-212-615-4362.

Claim Tips

Coding
Correctly coding your claims is one way to improve your claims processing success rate. EmblemHealth has adopted the "CMS Payment Policies." Click here for the National Correct Coding Initiatives.

Modifiers
One common error we encounter is the incorrect use — or lack — of modifiers. Evaluation and management (E/M) services rendered in conjunction with a surgical procedure are generally included in the global package. There are exceptions when the same physician (or the same physician group practice) performs unrelated E/M services during the global period. The global period assignment is the timeframe that applies to each procedure grouped in certain preoperative, same-day and postoperative services.

• Use modifier 24 to indicate the E/M is unrelated to the surgery during the postoperative period for a procedure that has either a 10- or 90- day global assignment.
• Use modifier 25 to indicate a significant, separately identifiable E/M on the day of a procedure or service that has a 0- or 10-day global assignment. The E/M service rendered has to be above and beyond the usual preoperative and postoperative care related to the procedure performed. The E/M can also be unrelated to the condition that prompted the procedure performed.
• Use modifier 57 to report an E/M service that results in a decision for surgery that has a 90-day global assignment.

Modifiers 24, 25 and 57 can only be appended to the E/M CPT procedure codes. Modifier exceptions may not apply to certain Correct Coding Initiative (CCI) claims rules. Appropriate documentation of the E/M services must be made available in the event of a review for claims using these modifiers.

Modifiers for Services and Procedures During the Postoperative Period
Many services required of a physician following an initial procedure, including additional medical or surgical interventions, are included in the assigned global period. Such services are not eligible for separate reimbursement. These services, if billed separately, will be denied as being included in the global surgical package. The following are exceptions, indicated by the use of the appropriate code modifier:

• Use modifier 58 to report a staged or related procedure or service performed by the same physician during the postoperative period of the initial procedure. Use modifier 58 to report a staged procedure that is planned prospectively at the time of the initial procedure, a staged or related procedure that is more extensive than the original procedure, or to report therapy following diagnostic surgery.
• Use modifier 78 to report a procedure rendered during the postoperative period as an unplanned return to the operating/procedure room for a related procedure following the initial procedure. Modifier 78 applies if the unplanned procedure is rendered by the same physician (or the same specialty physician from the same group). Procedures or services not rendered in an operating room or procedure room setting are included in the global surgery period; using modifier 78 is not appropriate.
• Use modifier 79 to report an unrelated procedure or service by the same physician (or the same specialty physician from the same group) during the postoperative period. The billed ICD-9 codes should support the procedure’s status as unrelated to the initial procedure(s). Using modifier 79 for procedures relating to the original surgery is not appropriate.

Matching Revenue Codes with HCPCS Codes
Outpatient services require both a HCPCS code and a revenue code that must correspond.

Submission of Claims Spreadsheets for Review
Requests for adjustments to previously processed claims are occasionally submitted using an Excel spreadsheet. When submitting such requests, please include the original claim number with the other relevant claim details, e.g., member/patient name, ID number and date of birth, date(s) of service, total charges and the expected adjusted amount.

If you do not have the original claim number, having the data elements listed below will assist us in quickly locating your original claim in our system. Please make every effort to ensure the following information is provided:

For Professional Services	For Facility Services
Member ID	Member ID
Provider License	Provider License
Date(s) of Service	Date(s) of Service
Procedure	Bill Type
Modifiers (to account for bilateral and repeat procedures)

Claim Tips for Paper Submissions

EmblemHealth and its companies, GHI and HIP, recommend electronic claims submission for its speed and accuracy. We are always improving electronic claims technology to enhance processing and payment of your claims. If you must send paper claims, an easily read, correct and complete claim can be automatically processed. We use scanning technology to “read” and enter your claims directly into our payment system. If claims that are not easy to read, correct or complete are submitted, claims processors must retype your claim(s) in the system. This process can result in a delay of claims payment.

The following suggestions will help us scan and pay your paper claims automatically:

• USE ONLY the RED-MARKED CMS PROFESSIONAL (CMS1500) and FACILITY (UB04) forms. These forms are specifically designed for scanning.
• DO NOT use a photocopy of a claim or fax claim(s) to us.
• DO NOT use forms prior to 2005. These are out of date.
• DO NOT include attachments on onionskin or other thin, tissue-like paper. Such paper can get caught or torn during the scanning process.
• DO NOT send a gray photocopy. If a photocopy is too light or too dark, the scanner will not be able to “read” the claim information. Any photocopy must be on white paper, not colored paper.
• DO NOT include attachments larger than 8.5x11 inches.
• USE UB04 facility claim forms for facility and hospital claims submissions.
• USE ONLY ONE STAPLE. If there are attachments, use only one staple to hold the entire submission package together. Multiple staples lead to tears during the scanning process and torn claims cannot be scanned.

Fonts, Format and Ink

• The ideal font is UPPER CASE lettering in 12-point Courier printed in black ink.
• The scanner does NOT recognize RED ink. Always use black ink to fill in your claims forms.
• Italicized fonts are not acceptable. The scanner cannot identify italicized fonts.
• AVOID using DOT MATRIX fonts.
• DO NOT hand write claim(s).
• DO NOT highlight any information on the claim form(s). Highlighting information will create a smudged image.

Ensure that all information is typed and appropriately aligned in the claim form box.

Download this document