Check out these five facts if you’d like to boost your claims success rate.
Point 1: Check the LCD Guidelines
Although emergency department coders are usually very diligent about knowing which ICD-10-CM codes to submit to payers, sometimes important diagnosis coding details can slip through the cracks, leading to denials that require you to appeal. If you’d like to reduce the number of claims that are on your appeal list, taking this step — among several others — can help tremendously, . “Prior to submitting a claim for a service that has a utilization or a frequency limit, review previous claim submission and dates and refer to the applicable LCD or NCD policies,” In addition, check for National Correct Coding Initiative (NCCI) edits, medically unlikely edits, whether the patient is in a global period of a surgery, and that you have the appropriate diagnosis codes on the claim, she said.“ You can often avoid having to submit an appeal if you make sure that the required diagnosis code or codes are present on the claims you submit,”.
Point 2 – Check Whether Medicare Is Primary
Some denials are due to Medicare secondary payer (MSP) issues, so always check to make sure whether Medicare is primary before you submit your claims — this is another step that could help you cut down on denials later.“ MSP provisions prevent Medicare from paying for items and services when other health insurance coverage is primary,” . “When Medicare is secondary, the primary payer must pay first.”
Point – 3 When Appealing an Overpayment Request, Clarify What You’re Appealing
If a payer indicates that you were overpaid and requests money back, you may not always agree, and you have a right to appeal that. If you do pursue this route, always include a copy of the overpayment letter with your overpayment appeal.
If there are multiple claims included in the overpayment letter, please make it clear which claims you’re appealing,” . “If you’re appealing all of the claims of an overpayment letter, say so in your appeal request. The appeals department must be able to identify all of the overpayments being appealed to stop collection activities on those receivables.”
Point -4 Upcode Requests Should Include Documentation
In some cases, you may believe you submitted the wrong code, and that in actuality, your records represented a higher-level code than what you initially reported. In these cases, you should submit documentation to support your claim,
Upcode Requests Should Include DocumentationIn some cases, you may believe you submitted the wrong code, and that in actuality, your records represented a higher-level code than what you initially reported. In these cases, you should submit documentation to support your claim,
Paper Claim Submission Guidelines
To assist providers using paper claims, the IHCP has identified specific billing errors that may cause processing delays or increase paper claim processing errors. To avoid these errors,providers should adhere to the following paper claim billing processes:
•Submit paper claims on the standard,approved claim formfor the type of service being billed.For institutional and professional claims, the officialred claim form (not a black-and-white copy) must be used.
•Use Arial, Helvetica, Times New Roman, or Courier font type with 10–14-point font size.
•Avoid using handwritten information on the claim forms unless directed to do so.
•Use onlyblue or black ink.
•Do not add highlighting or any other color marks.
•Do not use liquid paper correction fluidor correction tape.
•Ensure information is documented in the appropriate boxes on the form and is aligned correctly in those boxes.
•Add data within the boxes on the form. Data outside the approved fields can cause errors and delay processing.
•Do not enter commas or dashes.
•Do not write or typeany informationoutside the borderline of the form(other than the appropriate address, placed at the top of the CMS-1500claim form).
•Do not put stray marks or Xs on the claim form.
•Paper claims that require attachments must include the attachments with the claim form.
•Do not add stamps or stickers.
•Submit attachments on standard 8½-by-11-inch paper.
•Do not use paper clips or staples on claim forms or attachments
Important EDI fields for avoiding rejections
B. EDI – Field 24D (Professional) Details pertaining to EPSDT, Anesthesia Minutes, and corrected claims may be sent in Notes (NTE) or Remarks (NSF format).
•Details sent in NTE that will be included in claim processing:
•Please include L1, L2, etc. to show line numbers related to the details. Please include these letters AFTER those specified below:oEPSDT claims need to begin with the letters EPSDT followed by the specific code as per DHS instructionsoAnesthesia Minutes need to begin with the letters ANES followed by the specific timesoCorrected claims need to begin with the letters RPC followed by the details of the original claim (as per contract instructions)oDME Claims requiring specific instructions should begin with DME followed by specific details
C. EDI – Field 33b (Professional)
Field 33b – Other ID# – Professional: 2310B loop, REF01=G2, REF02= Plan’s Provider Network Number. Less than 13 Digits Alphanumeric. Field is required. Note: do not send the provider on the 2400 loop. This loop is not used in determining the provider ID on the claims