Mercy Care Claims Processing Manual

1 Visit: Care Claims Processing ManualMERCY CARE Claims Processing Manual GENERAL Claims /BILLING GUIDELINES FOR ALL PLANS Mercy Care Claims Processing Manual Page 1 of 124 Last Update: October 2019 Proprietary TABLE OF CONTENTS All new changes to the Claims Processing Manual will be highlighted in yellow for your convenience. CHAPTER 1 GENERAL Claims Processing INFORMATION MC Website Claims Mailing Addresses, Electronic Vendors and Contact Information Form Types and Instructions 1500 (02-12) Form Completion Instructions UB-04 (CMS-1450) Form Completion Instructions Electronic Tools and Mercy Care Web Portal Clean claim Definition Regulatory Turnaround Times Interest Payments Prompt Payment Discount Timely Filing National Correct Coding Initiative Resubmission Process - Recoupment Process Overpayments Medical Necessity Reviews claim Disputes Mercy CARE Claims Processing Manual GENERAL Claims /BILLING GUIDELINES FOR ALL PLANS Mercy Care Claims Processing Manual Page 2 of 124 Last Update.

2 October 2019 Proprietary ICD-10 Implementation National Drug Code claim Requirements Unlisted and Non-Specific CPT and HPCPCS Codes Subject to Prepayment Review CHAPTER 2 PROFESSIONAL claim TYPES BY SPECIALTY Laboratory - Influenza Guidelines Synagis Guidelines - Anesthesia - Radiology - Obstetrical Billing Physical, Occupational and Speech Therapy Home Health Claims - Well Visits - Hospice Transportation Claims Dental Claims Oral Surgery Claims - Behavioral Health Claims - Family Planning Claims Mercy CARE Claims Processing Manual GENERAL Claims /BILLING GUIDELINES FOR ALL PLANS Mercy Care Claims Processing Manual Page 3 of 124 Last Update.

3 October 2019 Proprietary - Podiatry CHAPTER 3 EARLY PERIODIC SCREENING AND DEVELOPMENTAL TESTING (EPSDT) Early Periodic Screening and Developmental Testing (EPSDT) General Overview Well Child Visits Developmental Screening Tools PCP Application of Fluoride Varnish - Vaccines for Children Program CHAPTER 4 INPATIENT Claims MC APR-DRG Pricing Information Summary for Medicaid Lines of Business MCA DRG Pricing CHAPTER 5 FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) PROSPECTIVE PAYMENT SYSTEM (PPS) Processing FQHC PPS Overview FQHC PPS MC Billing FQHC PPS - MCA Billing FQHC PPS - Dual Eligible Claims Billing Services Provided by a Behavioral Health Technician FQHC PPS - Billing Resources Mercy CARE Claims Processing Manual GENERAL Claims /BILLING GUIDELINES FOR ALL PLANS Mercy Care Claims Processing Manual Page 4 of 124 Last Update.

4 October 2019 Proprietary CHAPTER 6 SKILLED NURSING FACILITY Claims Skilled Nursing Facilities General Information Roles and Responsibilities Skilled Nursing Facility Authorization Requirements Skilled Nursing Facility Bed Hold Authorizations and Claims Billing - Durable Medical Equipment Therapy Authorizations and Claims Payment Insertion of PICC Lines - Share of Cost Prior Period Coverage General claim Submission Guidelines CHAPTER 7 INTEGRATED CLINICS CHAPTER 8 TRANSPLANT Claims CHAPTER 9 NON-PAR PROVIDER REGISTRATION Mercy CARE Claims Processing Manual GENERAL Claims /BILLING GUIDELINES FOR ALL PLANS Mercy Care Claims Processing Manual Page 5 of 124 Last Update: October 2019 Proprietary CHAPTER 1 GENERAL Claims Processing INFORMATION MC Website Mercy Care s (herein MC) website is available at and includes information for: Mercy Care Complete Care (herein MCCC) Mercy Care Long Term Care (herein MCLTC) Mercy Care RBHA (herein Mercy RBHA) Mercy Care DD (herein Mercy DD) Mercy Care Advantage (herein MCA) The website contains valuable information for both providers and members.

5 Some of the key information for our providers includes the following: MC Provider Manuals MC has provider manuals available on our website for your review: Mercy Care Provider Manual o Chapter 100 Mercy Care Provider Manual General Terms o Chapter 200 - Mercy Care Complete Care and Mercy Care DD Provider Manual Plan Specific Terms o Chapter 300 - Mercy Care Long Term Care Provider Manual Plan Specific Terms o Chapter 400 Mercy Care RBHA Provider Manual Plan Specific Terms Mercy Care Advantage Provider Manual The MC Provider Manuals all contain valuable information regarding details about the different lines of business, as well as provider responsibilities. Provider Notifications Provider Notifications contain recent changes that we want to alert providers to.

6 These could include new regulatory changes, new processes we have established, additional provider education, etc. Provider Notifications are available by clicking on the below links: MCCC Provider Notifications MCLTC Provider Notifications Mercy RBHA Provider Notifications Mercy DD Provider Notifications Mercy CARE Claims Processing Manual GENERAL Claims /BILLING GUIDELINES FOR ALL PLANS Mercy Care Claims Processing Manual Page 6 of 124 Last Update: October 2019 Proprietary MCA Provider Notifications Provider Forms The MC website contains plan specific provider forms that are available for your use. These may be accessed by clicking on the below links: MCCC Provider Forms MCLTC Provider Forms Mercy RBHA Forms Mercy DD Forms MCA Forms News and Events Under the News and Events web page on our website, it includes training event information from outside agencies that you may want to be aware of.

7 Please access by clicking the Events button on this web page. MC s Provider Newsletter for all plans is also posted quarterly to this web page. Please access by clicking the Newsletter button on this web page. Reference Material and Guides The MC website contains plan specific Reference Material and Guides that are available for your use. These may be accessed by clicking on the below links: MCCC Reference Material and Guides MCLTC Reference Material and Guides Mercy RBHA Reference Material and Guides Mercy DD Reference Material and Guides MCA Reference Material and Guides Claims Mailing Addresses, Electronic Vendors and Contact Information Paper claim Submissions Claims Plan Name Mail To Medical MCCC Claims Department MCA Box 52089 MCLTC Phoenix, AZ 85072-2089 Mercy DD Mercy CARE Claims Processing Manual GENERAL Claims /BILLING GUIDELINES FOR ALL PLANS Mercy Care Claims Processing Manual Page 7 of 124 Last Update.

8 October 2019 Proprietary Mercy RBHA Claims Department Box 64835 Phoenix, AZ 85082-4835 Dental MCCC DentaQuest of Arizona, LLC MCA Attention: Claims MCLTC Box 2906 Mercy DD Milwaukee, WI 53201-2906 Mercy RBHA Dental Claims Department Box 62978 Phoenix, AZ 85082-2978 Refunds All Lines of Business Mercy Care Attention: Finance Dept. Box 90640 Phoenix, AZ 85066 When mailing in a paper claim , a completed claim form needs to be filled out. Complete instructions for filling out a UB-04 Claims or a CMS 1500 (02/12) form is included in section Form Types and Instructions. Claims must be legible and suitable for imaging and/or microfilming for permanent record retention.

9 Complete ALL required fields, and include additional documentation when necessary. The claim form may be returned unprocessed (unaccepted) if illegible or poor quality copies are submitted or required documentation is missing. This could result in the claim being voided in our system. A clean claim submission will need to be made within timely filing guidelines in order to prevent the claim from being denied. Electronic claim Submissions Please refer to section Electronic Tools and Mercy Care Web Portals for vendor information on submitting your electronic Claims . Mercy CARE Claims Processing Manual GENERAL Claims /BILLING GUIDELINES FOR ALL PLANS Mercy Care Claims Processing Manual Page 8 of 124 Last Update: October 2019 Proprietary Family Planning Questions Please refer to section - Family Planning Claims for additional information regarding family planning.

10 If you have authorization or Claims questions related to family planning, please call: Aetna Medicaid Administrators, LLC Phoenix: 602-798-2745 Outside Phoenix: 888-836-8147 Calling the Claims Inquiry Claims Research (CICR) Department You may contact the CICR Department by calling 602-263-3000 or 800-624-3879 toll-free. CICR is available to: Answer general questions about Claims . Assist in resolving problems or issues with a claim , including an incorrect payment amount. Assist with claim denials. Provide an explanation of the claim adjudication process. Help track the disposition of a particular claim , including conducting a check tracer. Correct errors in Claims Processing . Assist with coordination of benefits questions.