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Electronic cliam validation process tips
1000A NM109 Submitter IDContractor will reject an interchange (transmission) that is submitted with a submitter identification number that is not authorized for electronic claim submission.1000B NM103...
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Understand EDI loop 2010 Series from VA insurance
2010AA REF – Segment Rule BILLING PROVIDER UPIN/LICENSE INFORMATIONMust not be present (non-VA contractors). Submission of this segment will cause your claim to reject.2010AC Loop Rule PAY TO PLAN...
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Tips for Filing Inquiries, Corrected Claims and Provider Appeals from BCBS
InquiriesWhen submitting an inquiry regarding corrected claims, questions about late charges, medical records or other situations, remember to complete the Provider Claim Inquiry Form and attach it to...
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Understanding Child Health Check-Ups Program (CHCUP)
CHCUP (Child Health Check-up) is a Medicaid child health program of early and periodic screening, diagnosis and treatment services for beneficiaries under the age of 21. It used to be called EPSDT. All...
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Can PCP disenroll a patient from the memebr panel list
PCP’s Request to Disenroll a Member from their PanelA Plan physician or provider may not seek or request to terminate a member on his/her panel or transfer a member to another health care provider...
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Condition for services of ARNP and PA in physician office
Physician Use of Health Care Extenders (ARNP’s and PA’s):Physicians must, in accordance with federal and state regulations and accepted professionalstandards, use physician extenders appropriately....
View ArticleQuick Authorization Form (QAF)
For those services included on the SHP Quick Authorization Form (QAF) (see the Forms Section of this handbook) a referral is NOT required. Primary Care Physicians (PCP’s) can refer a member to a...
View ArticleSimply health care - services required authorization
All of the following procedures and services require Prior Plan Notification and must beprovided in a SHP participating facilityo Inpatient and Observation Admissions, as noted aboveo Admission to any...
View ArticleWhen service can be considered as emergency services
Emergency ServicesEmergency services are not subject to prior authorization requirements and are available to our members 24 hours a day, seven days a week, 365 days a year.An emergency medical...
View ArticleFlu CPT code update from wellcare 90655, 90656, 90657
Wellcare – Flu Vaccination Season 2012-2013 This communication provides you with important information regarding the 2012-2013 flu season (September 1,2012 through April 15,2013)and Wellcare/HealthEase...
View ArticleCPT code G0107, G0328, G0104
Screening Fecal-Occult Blood Tests (FOBT) (Codes G0107 & G0328)Effective for services furnished on or after January 1, 2004, one screening FOBT (code G0107 or G0328) is covered for beneficiaries...
View ArticleICD code V10.05 , 555.0 , 558.9 Colorectal Cancer
Partial List of ICD-9-CM Codes Indicating High RiskListed below are some examples of diagnoses that meet the high risk criteria for colorectal cancer. This is not an all-inclusive list. There may be...
View ArticleScreening CPT Codes G0121, G0106, G0120
Screening Colonoscopies Performed on Individuals Not Meeting the Criteria for Being at High-Risk for Developing Colorectal Cancer (Code G0121)Effective for services furnished on or after July 1, 2001,...
View ArticleICD 9 - V76.2 - Pap smear
Screening Pap SmearsEffective, January 1, 1998, §4102 of the Balanced Budget Act (BBA) of 1997 (P.L. 105-33) amended §1861(nn) of the Act (42 USC 1395X(nn)) to include coverage every three years for a...
View ArticleAnnual Wellness Visit (AWV) Including Personalized Prevention Plan Services...
This expanded coverage, as established at 42 CFR 410.15, is subject to certain eligibility and other limitations that allow payment for an annual wellness visit (AWV), including personalized prevention...
View ArticleFoot Care service - Medicare coverage
Treatment of Subluxation of FootSubluxations of the foot are defined as partial dislocations or displacements of joint surfaces, tendons ligaments, or muscles of the foot. Surgical or nonsurgical...
View ArticleExceptions to Routine Foot Care Exclusion
1. Necessary and Integral Part of Otherwise Covered ServicesIn certain circumstances, services ordinarily considered to be routine may be covered if they are performed as a necessary and integral part...
View ArticleBeneficiaries Eligible for Coverage and Definition of Diabetes
Medicare Part B covers 10 hours of initial training for a beneficiary who has been diagnosed with diabetes.Diabetes is diabetes mellitus, a condition of abnormal glucose metabolism diagnosed using the...
View ArticleE-Prescribing Incentive complete information
Background The MIPPA authorizes a new incentive program for eligible professionals who are successful electronic prescribers (E-Prescribers) as defined by MIPPA. This new incentive program is in...
View ArticleMedical billing basic - What is CPT
What is CPT? CPT was developed by the American Medical Association (AMA) in 1966. The AMA revises and publishes CPT each year to keep pace with changes in medical practice. They delete obsolete...
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