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ITC - 2021 Provider Billing Manual - Iowa Total Care

1 | Page 2021 provider billing manual 2020 Iowa Total Care. All rights reserved. 012020 2 | Page .. INTRODUCTORY Billing INFORMATION9 Billing Instructions .. 9 .. General Billing Guidelines9 Claim Forms .. 10 Billing Codes .. 11 CPT Category II Codes .. 11 Encounters versus Claim .. 11 Clean Claim Definition .. 12 Non-Clean Claim Definition .. 12 Rejection versus Denial .. 12 Claim Payment .. 13 Contact Information .. 13 CLAIMS PAYMENT INFORMATION .. 14 Systems Used to Pay Claims .. 14 Amisys .. 14 DST Pricer .. 14 Rate Manager .. 14 Electronic Claims Submission .. 15 Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) . 17 Common Causes of Claims Processing Delays and Denials .. 18 Common Causes of Up Front Rejections.

Billing Codes ..... 11 CPT® Category II Codes ... Providers should purchase these from a supplier of their choice. All paper claim forms are required …

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Transcription of ITC - 2021 Provider Billing Manual - Iowa Total Care

1 1 | Page 2021 provider billing manual 2020 Iowa Total Care. All rights reserved. 012020 2 | Page .. INTRODUCTORY Billing INFORMATION9 Billing Instructions .. 9 .. General Billing Guidelines9 Claim Forms .. 10 Billing Codes .. 11 CPT Category II Codes .. 11 Encounters versus Claim .. 11 Clean Claim Definition .. 12 Non-Clean Claim Definition .. 12 Rejection versus Denial .. 12 Claim Payment .. 13 Contact Information .. 13 CLAIMS PAYMENT INFORMATION .. 14 Systems Used to Pay Claims .. 14 Amisys .. 14 DST Pricer .. 14 Rate Manager .. 14 Electronic Claims Submission .. 15 Electronic Funds Transfers (EFT) and Electronic Remittance Advices (ERA) . 17 Common Causes of Claims Processing Delays and Denials .. 18 Common Causes of Up Front Rejections.

2 18 3 | Page Clinical Laboratory Improvement Amendment (CLIA) Accreditation .. 19 How to Submit a CLIA Claim .. 20 Via EDI .. 20 Via AHA Provider Portal .. 20 Timely Filing .. 20 Third Party Liability / Coordination of Benefits .. 21 Medicare with Other Insurance .. 22 Crossover / COBA22 Receiving a TPL Payment After Iowa Total Care Payment .. 22 No Response from Other Insurance .. 22 Documentation Requirements .. 23 Acceptable Proof of Payment or Denial .. 23 Client Participation / Aggregate Share of Cost .. 24 Emergency Care Co-payments .. 24 Missed Appointments .. 25 Billing the Member / Member Acknowledgement Statement .. 25 EMERGENCY ROOM SERVICES .. 26 THIRTY (30) DAY HOSPITAL READMISSIONS .. 28 IOWA Total CARE CODE AUDITING AND EDITING.

3 29 CPT and HCPCS Coding Structure .. 29 Level I HCPCS Codes (CPT) .. 29 Level II HCPCS .. 29 Miscellaneous/Unlisted Codes .. 30 Temporary National Codes .. 30 4 | Page International Classification of Diseases (ICD 10) .. 30 Revenue Codes .. 30 Edit Sources .. 31 Code Auditing and the Claims Adjudication Cycle .. 32 Code Auditing Rules .. 32 Deny .. 32 Pend .. 32 Code Auditing Principles .. 32 Unbundling .. 33 PTP Practitioner and Hospital Edits .. 33 Medically Unlikely Edits (MUEs) for Practitioners, DME Providers and Facilities .. 33 Code Bundling Rules Not Sourced to CMS NCCI Edit Tables .. 33 Procedure Code Unbundling .. 33 .. Mutually Exclusive Editing34 .. Incidental Procedures34 .. Global Surgical Period Editing/Medical Visit Editing 34.

4 Global Maternity Editing34 .. Diagnostic Services Bundled to the Inpatient Admission (3-Day Payment Window)34 .. Multiple Code Rebundling35 .. Frequency and Lifetime Edits35 .. Duplicate Edits35 .. National Coverage Determination Edits35 .. Anesthesia Edits35 ..Invalid Revenue to Procedure Code Editing 35 .. Assistant Surgeon35 .. Co-Surgeon/Team Surgeon Edits35 .. Add-on and Base Code Edits36 .. Bilateral Edits36 ..Missing Modifier Edits36 5 | Page .. Administrative and Consistency Rules36 .. Prepayment Clinical Validation36 .. MODIFIER MODIFIER 25 38 .. INPATIENT FACILITY CLAIM EDITING39 .. Potentially Preventable Readmissions Edit39 .. Payment and Coverage Policy Edits39 .. Claim Disputes Related to Code Auditing and Editing39.

5 VIEWING CLAIM CODING EDITS40 .. Code Editing Assistant40 .. Disclaimer40 .. OTHER IMPORTANT Healthcare Acquired Conditions (HCAC) Inpatient Hospital 41 .. Reporting and Non Payment for Provider Preventable Conditions (PPCS)41 .. Non-Payment and Reporting Requirements Provider Preventable Conditions (PPCS) - Inpatient41 .. Other Provider Preventable Conditions (OPPCS) Outpatient41 .. Lesser of Language42 .. Use of Assistant Surgeons42 .. Dual Eligible Member Payments When Not Covered by Medicare42 .. Provider CLAIM DISPUTE PROCESS44 .. Important Information about Your Dispute Rights45 .. OTHER RELEVANT Billing INFORMATION46 6 | Page Interim Claims .. 46 .. HCBS Programs Billing Information 46.

6 HCBS Habilitation HCBS Elderly HCBS Physical Disability (PD) 46 .. HCBS Brain Injury46 .. HCBS Intellectual/Developmental HCBS - AIDS/HIV (AH) Waiver 47 .. HCBS - Children's Mental Health (CMH) HCBS - Health and Disability (HD) Waiver 47 .. Date Span Billing With Examples (Waivers)47 .. Obstetrical and Gynecological Billing FQHC/RHC49 .. Hospice49 .. Hospitals49 .. Immunization/Vaccines/Injections 50 .. Interim Billing 50 .. Modifiers50 .. Newborn Billing50 .. NDC Requirements 50 .. Nursing Facility (NF/ICF/Bed Hold)50 .. Observation Room51 .. Out of Network Providers51 .. POA Indicator 517 | Page .. Professional Fees52 .. Prosthetic and Orthotic52.

7 Readmissions52 .. Supplies53 .. Swing Bed Nursing Facility53 .. Behavioral Health and Substance Abuse Services53 .. 837 COMPANION GUIDE (OCTOBER 2016)55 .. Overview55 .. Rules of Exchange55 .. Transmission Confirmation55 .. Batch Matching56 .. TA1 Interchange Acknowledgment56 .. 999 Functional Acknowledgment56 .. 277CA Healthcare Claim Acknowledgment 56 .. Duplicate Batch Check56 ..New Trading Partners57 .. Claims Processing57 .. Acknowledgments57 ..Coordination of Benefits (COB) Processing57 .. Code Sets57 .. Corrections and Reversals57 .. Data Format/Content57 .. Additional Items58 .. Identification Codes and Numbers59 .. General Identifiers59 .. Provider Identifiers59 ..Subscriber Identifiers60.

8 Claim Identifiers608 | Page .. Connectivity Media for Batch Transactions60 .. APPENDIX62 ..APPENDIX I: COMMON HIPAA COMPLIANT EDI REJECTION CODES 62 .. APPENDIX II: INSTRUCTIONS FOR SUPPLEMENTAL INFORMATION65 ..Unspecified/Miscellaneous/Unlisted Codes66 ..NDC Codes66 .. APPENDIX III: INSTRUCTIONS FOR SUBMITTING NDC INFORMATION66 .. Instructions for Entering the NDC66 .. Facility67 ..Physician67 .. APPENDIX IV: CLAIMS FORM INSTRUCTIONS CMS 1500 68 .. APPENDIX V CLAIMS FORM INSTRUCTONS UB82 ..UB-04/CMS 1450 (2/12) Claim Form Instructions82 .. UB-04 Claim Form Example Required Fields 84 .. APPENDIX VI ORIGIN AND DESTINATION MODIFIERS FOR TRANSPORTATION979 | Page INTRODUCTORY Billing INFORMATION Billing Instructions Iowa Total Care follows CMS rules and regulations, specifically the Federal requirements set forth in 42 USC 1396a (a) (37) (A), 42 CFR and 42 CFR ; and in accordance with State laws and regulations, as applicable.

9 General Billing Guidelines Physicians, other licensed health professionals, facilities, and ancillary Provider s contract directly with Iowa Total Care for payment of covered services. It is important that providers ensure Iowa Total Care has accurate Billing information on file. Please confirm with our Provider Relations department that the following information is current in our files: Provider name (as noted on current W-9 form) National Provider Identifier (NPI) Tax Identification Number (TIN) Medicaid Number Taxonomy code Physical location address (as noted on current W-9 form) Billing name and address All providers Billing Iowa Total Care must be registered with Iowa Medicaid Enterprise in order to receive payment. This includes Billing , rendering, attending, operating and referring providers, though not all NPIs are required on all types of claims.

10 All providers must bill with their NPI number in box 24Jb (rendering Provider ) with the exception of FQHC, RHC, Indian Health, Chapter 24 providers or providers with an atypical NPI. Providers with these exceptions may use either the Billing NPI in box 24Jb or leave that box blank. We encourage our providers to also bill their taxonomy code in box 24Ja and the Member s Medicaid number in box 1a on the CMS 1500, to avoid possible delays in processing. Claims missing the required data will be returned, and a notice sent to the Provider , creating payment delays. Such claims are not considered clean and therefore cannot be accepted into our system. We recommend that providers notify Iowa Total Care 30 days in advance of changes pertaining to Billing information.


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