
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.
Coverage Denied for Never Events — Updated Information
Evaluation and Management Codes Not Payable to Audiology and Speech-Language Pathology Specialties
Covering Medical Nutrition Therapy
Modifiers Required on Anesthesia Claims
HCPCS Codes for HIP and EmblemHealth CompreHealth That Do Not Require Prior Approval
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
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
Claim Tips for Paper Submissions
Since January 1, 2010, EmblemHealth and its companies GHI and HIP has denied 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 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:
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 also do not cover other services related to these noncovered procedures as defined in the Medicare Benefit Policy Manual (BPM):
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.).
Medicaid and Family Health Plus Never Events
For surgeries performed on patients enrolled in Medicaid or Family Health Plus (FHP), the New York State Department of Health has identified 13 avoidable hospital conditions as non-reimbursable:
The Department of Health will continually review this list of non-reimbursable adverse (never) events. The list will be modified and expanded over time.
Medicaid and FHP Hospital Partial Payment Procedure
For those Medicaid and Family Health Plus cases where a serious never event occurs and the hospital anticipates at least partial payment for the admission, the hospital will follow a two-step process for billing the admission:
All claims identified as never events will be reviewed on a case by case basis.
A fuller explanation of never events and the new ruling may be found on the CMS Web site. Information about never events may also be found in the EmblemHealth Provider Manual, under Claims. 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.
Please be reminded that guidelines from the Centers for Medicare and Medicaid Services (CMS) have determined that CPT codes for Evaluation and Management (E/M) services are not payable to audiology and speech-language pathology specialists, including audiologists and speech therapists. As outlined in your Agreement(s), HIP adheres to CMS guidelines for its reimbursement methodology. The following E/M codes will be denied if claims are submitted by audiology or speech-language pathology specialists:
99201-99205 99211-99215 99241-99245
CMS guidelines and the rules for which CPT codes audiology and speech-language pathology specialists may use can be found on the American Speech-Language-Hearing Association’s Web site. Please consult your Agreement or speak with your Provider Relations Representative to determine what codes are covered by HIP.
EmblemHealth’s medical nutrition therapy (MNT) benefit provides for nutritional diagnostic, therapeutic and counseling services for the purpose of managing diabetes or renal disease for members in all commercial benefit plans. Proper nutrition and diet play an important role in helping people with diabetes or renal diseases by preventing and reducing complications from their conditions.
MNT must be provided by a registered dietician or an approved nutrition specialist who meets established Centers for Medicare and Medicaid Services criteria. The following CPT-4 and HCPCS codes are reimbursable only when provided as part of a diagnosis code.
As a reminder, we only reimburse vendors of durable medical equipment (DME) that participate in our GHI HMO network. These DME vendors supply products or services previously furnished in an office setting. DME, such as orthotic or prosthetic devices, braces, special shoes, etc., must be ordered from a supplier that is specifically contracted with GHI HMO to provide durable medical equipment. This ensures that the member has the smallest out-of-pocket expense possible.
Procedure for ordering DME
A prescription for the DME may be required. Once your patient has obtained the DME order from one of our network DME vendors, it is the responsibility of the DME vendor to confirm member eligibility and request all necessary prior approvals.
You may direct your office staff and patients to the Find A Doctor provider search feature at ghi.com to locate an appropriate DME provider in your area. (Select “Other Facilities and Services” as “Type of Provider.”)
What about previous claims?
If you have prescribed and furnished DME in your office and have submitted a claim for the product or service, please log on to myEmblemHealth with your GHI user ID and password to confirm the status of the claim(s). We are examining such claims on a case by case basis to determine reimbursement. If you do not have a user ID or password, you may register to obtain them.
If you have any general questions about this or other claims policy, contact us by using the Message Center at EmblemHealth.com. You may access the Message Center by logging on to myEmblemHealth with your EmblemHealth, GHI or HIP user ID and password. The Message Center is located on the left hand side of the Web page. Follow the prompts to write your message. If you do not have a user ID or password, you may register for EmblemHealth, GHI and HIP.
As required by the Centers for Medicare & Medicaid Services (CMS), anesthesia claims must include modifier “AA” when a physician administers anesthesia, and modifiers “QK”, “QX” or “QY” when a certified registered nurse anesthesiologist (CRNA) administers anesthesia. Anesthesia claims that do not include these modifiers will be denied. You may not have been required to enter these modifiers on your anesthesia claims in the past, but we are encouraging you to do so to comply with CMS requirements.
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.
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.
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?
Make sure that your automated billing system is set up properly.
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.
Get tools to help you reconcile your accounts.
Access more resources on Claims Corner or call us!
EmblemHealth benefit plans:
Call 1-877-VIA EMBLEM (1-877- 842-3625), Monday through Friday, from 8 am to 5 pm. TDD users should call 1-866-248-0640.
GHI benefit plans:
Call 1-212-501-4444 in New York City or 1-800-624-2414 in all other areas, Monday through Friday, from 8 am to 5 pm. TDD users should call 1-866-248-0640.
HIP benefit plans:
Call 1-866-447-9717, option 2, Monday through Friday, from 9 am to 6 pm. TDD users should call 1-888-447-4833.
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.
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.
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.
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:
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):
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.
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.
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:
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:
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.
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:
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.
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:
For billing purposes, a POA Code is not needed for Medicare member claims in the following hospitals:
A POA Code is mandatory for Medicaid member claims for each diagnosis submitted in all inpatient facilities including Critical Access Hospitals and hospitalizations for:
General Reporting Requirements for Medicare and Medicaid members:
Reporting Options and Definitions:
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.
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:
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.
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:
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.
We use multiple types of commercially available claims review software in order to provide the most proper and efficient claims reimbursement for each line of business in our companies. Read the EmblemHealth Provider Manual for more information on individual software packages.
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.
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:
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) |
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:
Fonts, Format and Ink
Ensure that all information is typed and appropriately aligned in the claim form box.