Notes

Foreign provider claims

1. Verify the following information matches that displayed within the fields of the corresponding Claim window (as shown below):

§ Correct patient name

§ Billing Provider field = (ADMINPRO)

§ Diags field = (780)

§ Total Chgs field = (0.01)

§ Proc Cd field = (99070)

§ Loc field = (11)

§ Charges field = (1.00)


2. Update/change any incorrect data, if applicable.

3. Send a high priority e-mail to Michele Minix including the following:

§ Member name and MetaVance ID

§ MACESS image number

§ Request claim be translated and currency converted to U.S. dollars (if applicable)

4. Document the action taken in Remark category CL

5. Pend the claim with the applicable follow-up date (based on ERISA information request guidelines - to be covered later.)

6. When the translation is returned to you, adjust the claim data to reflect the translated information.

Note: Use the ICD-9 and CPT-4 manuals to determine the most appropriate diagnosis and procedure codes based on the translated descriptions.

7. Re-submit the claim.

8. Print the translated claim attachment(s)

9. Complete a Winscan form for the claim attachment(s) indicating the document(s) must be scanned and saved to the member's folder.

10. Update Remark category CL with the action taken.

Once you have located the CIS contract number, use the following steps to find and review CIS notepad when you receive an EX Code F31.

Step
Action

1
Enter the CIS system using the CIS contract number to bring the provider’s contract information forward.

2
Select VIEW NOTEPAD SERVICE CATEGORY.

3
Review the information in the Service Category to see if anything applies to your claim and follow the chart below:

If something applies to

your claim…
Follow the directions in the notepad documentation to determine your allowed amount(s).
If nothing applies to

your claim…

Continue the normal process to look up the allowed amount(s) according to the CIS contract services categories.


4
Enter the allowed amount(s) in the “Allowed” field on your claim.

5
Click the ADD CHANGE button.

6
Repeat Steps 3 – 5 for each service line that pends EX – 31.

7
Click the SUBMIT button when you have come to your last service line in order to readjudicate the entire claim.

6
Continue normal processing.

Benefit Structure Entity Description
Benefit Package The benefit package is the entity that is offered to the coverage contract by employers. Benefit packages may vary and include vision, dental and medical benefits. This means that one or more benefits related to these areas have been combined into the benefit package.
Benefit Coverage Benefit Coverage is used to group related components together. For example, Emergency Care, Inpatient, Ambulatory service components could all be considered Hospital coverage.
Benefit Components Benefit Components are groupings of related details. For example, if there are vision exams, laser eye surgery, and eyeglass replacement and we define them as three separate details, it could be grouped into one component called Vision. Each component has one or more details.
Benefit Details Benefit Details are a piece within the benefit package. A detail defines a specific service or set of services that all have the same benefit coverage.


201110126410227
201309126472766

00459833201
H50692163
535355561
00421077601
H06526402
991121128
H46774192
529659952
525747629
Diagnosis code
ICD9 and ICD10

ICD10 started october 2013


**CODE EDITING ERROR**

Providers can have questions about manifestation claim denials. As a result of a technical issue, some manifestation claims which were allowed to pay in error between September 1, 2011 and January 13, 2012. This issue was corrected on January 14, 2012. contacted the providers and humana did recovery

LCD and NCD code edits are:

Member responsibility: 13C, 179, 15C, 17B, 17K, and 17M
Provider responsibility: 04@, 178, 15B, 17A, 17J, and 17O

PCI CODES
First time claims
MTV pend 6SX
CAS oend 168

Inquiries
MTV denials 7MX, 4DP, 1DU and 1AG
CAS denials 15F, 208, 276 and 277

The Code Editing team reviews the inquiry within 30 business days, the code editing team will contact the provider
for follow up email: [email protected]

Tank:
Service Center: Louisville
Department: LOU CAS Financial Recovery
Team: CE Inquiry
Note: This tank also accepts MTV inquiries.

PCI escalations turn around time 10-14 business days

ClaimsXten codes starts with Z

NOTE: Recoupment might be related to global surgery