Several recent policy changes and updates by major insurance payers require tweaks in the submission of medical claims for reimbursement.
Namely, Indiana Health Coverage Programs (administers of Medicaid and related programs), WPS Medicare (Indiana’s Medicare Administrative Contractor), and Anthem (Indiana’s Blue Cross Blue Shield provider) have implemented new claims edits or payment policies to help providers submit clean, payable claims.
Effective September 26, 2012, IHCP changed the logic of edit 4034 – Procedure code billed not compatible with recipient’s age. Please verify and resubmit.
The edit previously matched procedures with a patient’s age in years only. The new, more sensitive logic will evaluate claims based on a days, months, and years of a patient’s age. When a procedure code is limited to a maximum age in years, the code will be covered for the patient with that age in years and up to 364 days (ex. 5 years and 364 days). For month limitations, the code will be covered for that month through the day before a new month. Limitations by day refer to the exact number of days.
For denials that occur because of a leap year because there are 366 days instead of 365, providers should request a review via an IHCP Program Inquiry Form.
WPS Medicare added a new claims edit effective September 28, 2012. Electronic claims that include the Subscriber’s Insured Group Name in the SBR04 segment of the 2000B will be rejected by the common edit module.
Also, one of the top 5010 claim submission errors for WPS Medicare is a rejection for an invalid Health Insurance Claim Number (HICN). Valid Medicare IDs should be formatted in Loop 2010BA, Segment NM109 as 10-11 positions of NNNNNNNNNA or NNNNNNNNNAA or NNNNNNNNNAN, where “A” is an alpha character and “N” is a numeric digit.
WPS recommends reviewing all 999 claims responses, as rejections by the translator or common edit module do not produce denials or explanations of benefits.
Anthem has several new policies that affect claims submissions.
Beginning August 17, 2012, Anthem began denying any Not Otherwise Classified (NOC) code submitted on a UB-04 claim form when a valid HCPCS or CPT code is available. For more information, see the Anthem Rapid Update from August 16, 2012.
Also, two new categories of services will require precertification by Anthem. Effective October 1, 2012, non-emergency, outpatient radiation therapy modalities, including brachytherapy, intensity modulated radiation therapy, proton beam radiation therapy, and stereotactic radiosurgery will require precertification by AIM Specialty Health, an Anthem affiliate. Also, effective October 15, 2012, AIM Specialty Health will be precertifying sleep therapy services, including home sleep tests, in-lab sleep studies, titration studies, and more.
Additionally, for women’s wellness exams, Anthem will implement an edit beginning January 11, 2013, to deny as redundant/mutually exclusive the following codes when they are billed with 99381-99397: S0610, S0612, or S0613 (HCPCS codes for new and established annual gynecological exams).
According to Anthem, components specific to women’s wellness exams, i.e. pelvic exams, pap smears, or breast exams, are considered part of a normal preventive evaluation and management service represented by 99391-99397.
Finally, as of January 15, 2013, Anthem will not separately reimburse 99140 when reported for an unscheduled routine obstetric delivery with one of the following diagnosis codes: V23.81-V23.86 and V23.89. Because 99140 is for anesthesia complicated by emergency conditions, this code must only be billed with diagnosis codes that represent emergency situations.
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