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Best Practices for Medicaid Claims Processing

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• Provider Home 
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•  Best Practices for Medicaid Claims Processing 

Best practices for Medicaid nonpharmacy claims submission

The HP Claims Unit offers these tips for making Medicaid claims processing go as smoothly as possible.

Submit claims electronically!

Electronic claims process in one-third the time required for paper claims. Electronic submissions also reduce errors, prevent unnecessary claim denials, increase cash flow, and decrease costs. Electronic claims processing is:

• Faster - Most electronically submitted claims process in one to two weeks, compared to paper claims, which typically process in 30-45 days. If you use Web interChange to submit your claims, they are adjudicated in two hours or less. Electronic submissions are automatically read by system edits - when a clean claim is submitted by close of day Wednesday, you can look for final processing by Tuesday of the following week.
• Easier - You can easily submit all traditional Medicaid claims, including claims requiring attachments, using Web interChange - simply click the Attachment button. Assign a unique attachment control number (ACN), write that ACN on top of the attachment, and mail it to HP with the attachment cover sheet. The original claim in suspense status is pulled, matched to the attachment by the unique ACN, and processed. Web interChange also allows easy resubmission of claims.
• More accurate - Electronic claims help reduce keying errors. In addition, claims submitted on paper are often handwritten, which makes them less clear and harder to read. Electronic submission eliminates these problems.
• Less expensive - With electronic claim submission, provider staff members no longer spend their time printing and mailing forms - a costly process.

Electronic submission is the easiest, most accurate, and least expensive way to submit claims. Sign up for electronic claims submission today - if you are not already set up to submit claims via the Web, visit Web interChange > How to Obtain an ID on indianamedicaid.com.

Follow these general tips

• Include valid recipient identification numbers (RIDs) with all claim types.
• Be sure to include a valid National Provider Identifier (NPI) with all claim types (except waiver and atypical providers). Also check that the NPI submitted with your claims is correct - that you have not transposed or omitted numbers, or made other errors - and that it is registered with HP Enterprise Services. To register your NPI with HP, go to the NPI Reporting Tool on indianamedicaid.com.
• DO NOT use red ink - it disappears when claims are scanned.
• Be sure Medicare, third-party liability (TPL), and Medicaid information is placed in the proper fields on UB-04 claims:
  • A = Medicare - 54a
  • B = Third-Party Liability, including Medicare Replacement Plans - 54b
  • C = Medicaid - 55c
• Submit proper invoices for manual pricing on Non-Check Adjustments.
• When you submit adjustment forms with Check-Related Adjustments, be sure to submit all required information - claim numbers, RIDs, dates of service (DOS), procedure codes, and especially internal control numbers (ICNs). The more information you include, the more quickly HP can process the adjustment.
• Make sure hand-written paper claims are legible, and those that require signatures include full signatures and NOT JUST initials.

Use claim notes appropriately

Remember - if you submit claim notes with 837 transactions or via Web interChange, the Indiana Health Coverage Programs (IHCP) does not accept all types of claim notes as documentation. In fact, you should submit claim notes to the IHCP ONLY if the notes relate to these situations:

• Consultations billed at least 15 days apart - In the claim note, you can indicate the medical reason for a second consultation during the 15 days before or after the billed consultation.
• Maximum of four joint injections per month - You can document in the claim note that the additional injections are performed on different joints and indicate the injection sites.
• Maximum of two Pacemaker analyses within six months - Use the claim note to document the medical reason for the additional analysis in the six-month time frame, such as a dysfunctional Pacemaker.
• Assistant surgeon not payable when co-surgeon is paid - The IHCP accepts information in the claim note to document the medical reason for the assistant surgeon, such as the problem requiring assistance.
• Maximum of one nursing home visit per 27 days - In the claim note, the IHCP accepts documentation supporting the treatment of emergent, urgent, or acute conditions or symptoms with the new diagnosis code.
• Billing a claim that is past the filing limit when the member was awarded retroactive eligibility - In the case of retroactive member eligibility, claims must be submitted within one year of the eligibility determination date. Complete the claim as you would normally using Web interChange. Select Notes and enter information stating, "Member has retroactive eligibility. Please waive timely filing."
• HE/HO modifier and Edit 2503 - Provider not approved to bill Medicare - Mental health providers that submit claims with procedure codes and append modifier HE or HO when the member is dually eligible for Medicare and Medicaid may use claim notes to indicate that the provider who performed the service is not approved to bill services to Medicare. The appropriate claim note in this instance must indicate the following: "Provider not approved to bill services to Medicare." Using claim notes for the HE/HO modifier and Edit 2503 allows the claim to suspend for review and to be adjudicated appropriately. (Previously, providers were required to submit this documentation as a paper attachment. Providers may now submit these types of claims electronically to speed claim payment.)
• Surgery situations allowing claim notes - For the four surgery situations that follow, the IHCP accepts specific claim note information that: (1) documents the medical reason and unusual circumstances for the separate evaluation and management (E/M) visit ; and/or (2) supports that the medical visit occurred due to a complication of the surgery, such as cardiovascular complications, comatose conditions, elevated temperature for two or more consecutive days, medical complications other than nausea and vomiting due to anesthesia, post-operative wound infection requiring specialized treatment, or renal failure:
  • Surgery payable at reduced amount when related post-operative care is paid
  • Post-operative care within 0-90 days of surgery
  • Pre-operative care on the day of surgery
  • Surgery payable at reduced amount when pre-operative care is paid on the same date of service

Remember these guidelines

• The IHCP requires DME cost invoices - Effective September 24, 2010, the IHCP requires cost invoices for Healthcare Common Procedure Coding System (HCPCS) codes for durable medical equipment (DME), supplies, and hearing aids that had previously been manually priced. The IHCP prefers retail invoices (for example, manufacturer's suggested retail price or custom-generated invoices); however, if cost invoices are submitted, they must be accompanied by retail invoices that include the price of the goods plus the provider's margin. If cost invoices alone are submitted, the claim will be denied. For more information, see BT201037, dated September 14, 2010.

• The IHCP no longer accepts D7999 claims - Effective for dates of service of January 1, 2010, and after, the IHCP adopted the American Dental Association (ADA) tooth designations for supernumerary tooth services, which are billed using the appropriate Current Dental Terminology (CDT) procedure code with the appropriate tooth number combination. Each dental procedure must have its own specific code, and no attachment is required. Adoption of the ADA designation criteria eliminates the necessity of billing procedure code D7999 - Unspecified oral surgery procedure. For more information, see BR201011, dated March 16, 2010.

Learn more about claims submission

• For more information about claim notes, please see BT200511, dated June 1, 2005.
• For more detailed information about submitting claims, see Chapter 7 and Chapter 8 in the IHCP Provider Manual.