Claim Submission and Processing

1 INDIANA HEALTH COVERAGE PROGRAMS PR O V I D E R RE F E R E N C E MO D U L E Claim Submission and Processing L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 0 4 P U B L I S H E D : M A R C H 2 3 , 2 0 2 1 P O L I C I E S A N D P R O C E D U R E S A S O F J U L Y 1 , 2 0 2 0 V E R S I O N : 5 . 0 Copyright 2021 Gainwell Technologies. All rights reserved. Library Reference Number: PROMOD00004 iii Published: March 23, 2021 Policies and procedures as of July 1, 2020 Version: Revision History Version Date Reason for Revisions Completed By Policies and procedures as of October 1, 2015 Published: February 25, 2016 New document FSSA and HPE Policies and procedures as of July 1, 2016 Published: December 15, 2016 Scheduled update FSSA and HPE Policies and procedures as of July 1, 2016 (CoreMMIS updates as of February 13, 2017) Published: May 23, 2017 CoreMMIS update FSSA and HPE Policies and procedures as of July 1, 2017 Published: January 23, 2018 Scheduled update: FSSA and DXC Policies and procedures as of April 1, 2018 Published.

2 September 6, 2018 Scheduled update FSSA and DXC Policies and procedures as of July 1, 2019 Published: December 10, 2019 Scheduled update FSSA and DXC Policies and procedures as of July 1, 2020 Published: March 23, 2021 Scheduled update: Reorganized and edited text as needed for clarity Updated Portal screen graphics as needed Added note about DXC name change to Gainwell Added exceptions for NEMT in Section 1: Introduction to IHCP Claim Submission and Processing Added font options in the Paper Claim Submission Guidelines section Updated the Provider Healthcare Portal Claims section Updated the Search Payment History section Updated the note about paper attachments for Portal claims in the Mailing Paper Attachments for Electronic Claims section FSSA and Gainwell Claim Submission and Processing Revision History iv Library Reference Number: PROMOD00004 Published: March 23, 2021 Policies and procedures as of July 1, 2020 Version: Version Date Reason for Revisions Completed By Updated the Claim Notes section and subsections.

3 Corrected to reflect that the Portal accepts a Claim note at the detail level for professional claims Added a note in the Claim Notes Accepted as Documentation subsection Added the Adjustments Related to Overpayment subsection Updated the Retroactive Eligibility subsection Added note to the ICD Codes section Updated the reference for outpatient reimbursement information (now in the Outpatient Fee Schedule) in the Revenue Codes section Updated Table 4 UB-04 Claim Form Fields Updated the Portal Institutional Claim Submission Process subsections Added notes about changes to provider types/specialties in to Table 5 Types of Services Billed on Professional Claims Updated Table 6 CMS-1500, Version 02/12, Claim Form Fields Updated the Portal Professional Claim Submission Process subsections Updated the Portal Dental Claim Submission Process subsections Updated the Documenting Denied or Zero-Paid Claims section, including Table 9 Valid Adjustment Reason Code Added Package B to Section 6.

4 Special Billing Instructions for Specific IHCP Benefit Plans Updated the Emergency Services Only (Package E) Billing section Added the Emergency Services Only Coverage with Pregnancy Coverage (Package B) Billing section Updated Table 17 Claims Returned to Provider Updated the Medicare-Denied Details on Crossover Claims section Library Reference Number: PROMOD00004 v Published: March 23, 2021 Policies and procedures as of July 1, 2020 Version: Table of Contents Section 1: Introduction to IHCP Claim Submission and Processing .. 1 Fee-for-Service Billing for Carved-Out Services .. 2 Paper Claim 2 Ordering Claim Forms .. 2 Paper Claim Submission Guidelines .. 3 Claim Submission Addresses .. 3 Provider Signatures.

5 3 Electronic Claims .. 4 837 Electronic Transactions .. 4 Provider Healthcare Portal Claims .. 5 Mailing Paper Attachments for Electronic Claims .. 9 Claim Notes .. 12 General Billing and Coding Information .. 15 National Provider Identifier and One-to-One Match .. 15 Diagnosis and Procedure Coding Systems .. 15 National Correct Coding Initiative .. 17 Units of Service .. 17 Modifiers .. 17 National Drug 19 Place-of-Service Codes .. 20 Date of Service Definition .. 20 Visit and Encounter Definitions .. 21 Calendar-Year Versus 12-Month Monitoring Cycle .. 21 Section 2: Institutional Claim Billing Instructions .. 23 Types of Services Billed on Institutional Claims .. 23 Admission and Duration Requirements for Institutional Claims.

6 24 Using Modifiers for Outpatient Hospital Billing .. 24 Using ICD Procedure Codes for Inpatient Billing .. 24 Revenue Codes .. 25 Revenue Codes Not Reimbursable for Outpatient Billing .. 25 Using Treatment Room Revenue Codes for Therapeutic and Diagnostic Injections .. 25 Revenue Codes Linked with Specific Procedure Codes .. 25 Guidelines for Completing the UB-04 Claim Form .. 27 UB-04 Claim Form Field-by-Field 27 Billing a Continuation Claim Using the UB-04 Claim Form .. 39 Guidelines for Completing Institutional Claims Electronically .. 39 Portal Institutional Claim Submission Process .. 40 Section 3: Professional Claim Billing Instructions .. 57 Types of Services Billed on Professional Claims .. 57 Using Modifiers on Professional Claims.

7 59 Billing Guidance for Dates of Service .. 59 National Provider Identifiers for Professional Claims .. 60 Guidelines for Completing the CMS-1500 Claim 60 CMS-1500 Claim Form Field-by-Field Instructions .. 60 Guidelines for Completing Professional Claims Electronically .. 67 Portal Professional Claim Submission Process .. 67 Section 4: Dental Claim Billing 79 Types of Services Billed on Dental Claims .. 79 Rendering NPI Required on Dental Claims .. 79 Dental Procedure Codes .. 80 Claim Submission and Processing Table of Contents vi Library Reference Number: PROMOD00004 Published: March 23, 2021 Policies and procedures as of July 1, 2020 Version: Date-of-Service Definition .. 80 Guidelines for Completing the ADA 2012 Claim Form.

8 80 ADA 2012 Claim Form Field-by-Field Instructions .. 80 Guidelines for Submitting Dental Claims Electronically .. 86 Portal Dental Claim Submission Process .. 86 Section 5: Coordination of Benefits .. 97 Reporting Other Insurance Information on IHCP Claims .. 97 Reporting Other Insurance on 837 Transactions .. 97 Reporting Other Insurance on Provider Healthcare Portal Claims .. 98 Reporting Other Insurance on Paper Claims .. 98 Documenting Denied or Zero-Paid Claims .. 98 Section 6: Special Billing Instructions for Specific IHCP Benefit Plans .. 103 Medical Review Team Billing .. 103 Emergency Services Only (Package E) Billing .. 104 Emergency Services Only Coverage with Pregnancy Coverage (Package B) Billing .. 105 Medicaid Inpatient Hospital Services Only (for Inmates) Billing.

9 105 Section 7: Ordering, Prescribing, and Referring Practitioner Requirements .. 107 Verifying OPR Enrollment .. 107 Specialties Required to Include OPR NPI on All Claims .. 107 Entering OPR Information on Claims .. 108 Section 8: Claim Processing Overview .. 109 Claim ID 109 Region Codes .. 110 Julian Dates .. 111 Internal Control Number/ Claim ID Examples .. 113 Paper Claim Processing .. 113 Provider Healthcare Portal Claim Processing .. 116 837 Electronic Transaction Claim 117 Section 9: Suspended Claim Resolution .. 119 Suspended Claim Location .. 119 Suspended Claim Processing .. 119 Suspended Claim Guidelines for 120 Section 10: Crossover Claims .. 121 Reimbursement Methodology for Crossover Claims .. 121 Automatic Crossovers.

10 121 Claims That Do Not Cross Over Automatically .. 122 Using the UB-04 Claim Form to Submit Claims That Did Not Cross Over Automatically .. 123 Using the CMS-1500 Claim Form to Submit Claims That Did Not Cross Over Automatically .. 124 Using the Portal to Submit Claims That Did Not Cross Over Automatically .. 125 Coordination of Benefits Denials for Crossover Claims .. 127 Inpatient and Long-Term Care Crossover Claims .. 127 Professional and Outpatient Crossover Claims .. 127 Medicare-Denied Details on Crossover Claims .. 127 Medicare and Medicare Replacement Plan Denials .. 128 Section 11: Claim Filing Limits .. 129 Timely Filing Limit Exceptions .. 129 When Timely Filing Limit Is Not Applicable .. 129 When Timely Filing Limit Is Extended.