- Billing Practices
- Claim and Payment Integrity Audits
- DRG Validation
- Hospital Bill Audits
- Reimbursement Guidelines
- Hospital Acquired Conditions
- Emergency Department Coding and Review
- ClaimsXten™ Review
- Clear Claim Connection™
- Claims for Worker’s Compensation
- Claim Rejections or Delays
- Complete/Clean Claims
- Electronic Funds Transfer/Electronic Remittance Advice
- Payments and Offsets
- Payment Reconsideration and Appeals
- Global Surgical Packages Billing
- Urgent Care Billing
- Clinic Visits Billed by a Facility
- Treatment Room Services Billed by a Facility
Network providers are prohibited by contract from billing the member above and beyond their normal copayment, coinsurance and deductible. Arkansas state law also prohibits providers who are contracted with a health maintenance organization from billing the member of the health maintenance organization above and beyond their normal copayment, coinsurance and deductible. Network providers are also prohibited from billing the member for services that require pre-authorization, but for which pre-authorization was not obtained. This applies equally to the network provider who has primary responsibility for obtaining pre-authorization and to other network providers supplying related services that have a responsibility for verifying that pre-authorization was obtained.
Network providers are prohibited by contract from billing the member for services that are denied as not medically necessary unless:
- The network provider has notified the member that the service is not medically necessary prior to the rendering of the service; and,
- The member has agreed in writing that the specific service will not be covered and accepts responsibility for payment for that service.
A copy of this agreement must be kept in the provider’s office and made available to QualChoice upon request.
Network providers are prohibited from balance billing a member for amounts in excess of the member’s copayment, coinsurance and deductible.
If a provider, billing service, or collection agency improperly bills or collects money from a member in violation of the Provider Agreement or this Provider Manual, provider may also be excluded from the QualChoice network for failure to adhere to the “hold harmless” agreement.
Claim and Payment Integrity Audits
QualChoice utilizes external audit firms such as CERiS and Equian to perform various claim and payment integrity audits. These audits will cover areas such as Subrogation, Coordination of Benefits, DRG Validation and Hospital Bill Audits.
QualChoice, or one of its delegated audit vendors, will review medical records to validate proper code billing and DRG assignment. Medical records are reviewed to validate and confirm the clinical significance and accuracy of each recorded diagnosis. Specialized DRG coding software ensures the accuracy of the principal diagnosis and that inpatient claims are paid at the appropriate rates.
Hospital Bill Audits
Consistent with guidelines set forth by the Centers for Medicare and Medicaid Services (CMS), QualChoice will not reimburse for covered medical and surgical services and supplies that should be included in the general cost of the room where services are being rendered or the reimbursement for the associated surgery or primary procedure. Surgical and medical supplies are used in the course of services performed/care provided in the inpatient hospital, outpatient hospital, ambulatory surgery center (ASC) and other institutional health care settings. These are not medical necessity denials. Instead, payment for the comprehensive procedure includes any separately identified component parts of the procedure.
Many supply items have HCPCS codes. Some HCPCS for supply items may even have RVU values on the CMS Physician Fee Schedule. Despite this, supplies used in conjunction with care provided in inpatient or outpatient institutional settings generally may not be separately reported and are not eligible for separate reimbursement based on industry standard guidelines.
Billing of both services provided and the associated supplies used must follow correct coding and billing guidelines. Providers should ensure that all non-routine, billable supplies are classified under the appropriate revenue code.
This policy is intended to be consistent with the guidelines set forth by CMS. However, this does not mean, nor does it imply, that any items or services are separately billable to QualChoice merely because CMS has not denied separate reimbursement for those items or services.
Routine services and supplies are not separately billable and are items that are included in the general cost of the room where services are being rendered, or in the reimbursement for the associated surgery or primary procedure. These items, if identified on an Outlier claim or itemized bill, are not eligible for separate reimbursement, and are not eligible to be included in outlier calculations for additional reimbursement.
General types of routine services and supplies that are not separately billable include:
- Any supplies, items, and services that are necessary or otherwise integral to the provision of a specific service and/or to the delivery of services in a specific location are considered routine services and not separately billable in the inpatient and outpatient environments
- All items and supplies that may be purchased over-the-counter are not separately billable
- All reusable items, supplies and equipment that are provided to all patients during an in or outpatient admission are not separately billable
- All reusable items, supplies, and equipment that are provided to all patients admitted to a given treatment area or unit (i.e. NICU, Burn Unit, PACU, Medical/Surgical) are not separately billable
- All reusable items, supplies and equipment that are provided to all patients receiving the same service (i.e., an Ambu bag during resuscitation) are not separately billable
Routine supplies should not be billed in the non-covered charge column on the UB-04. The costs for the routine supplies are covered, because they are factored into the setting or procedure charge. Although they are covered, they are not billed separately. Examples of routine supply items not separately billable are as follows (list is not all inclusive):
- Personal convenience supply items
- Gowns used by staff
- Gloves used by staff
- Masks used by staff
- Oxygen when not specifically used by the patient
- Items ordinarily used for or on most patients in that area or department
- Patient gowns
- Items commonly available to patients in a particular setting (e.g. stock or bulk supply)
- Equipment commonly available to patients in a particular setting or ordinarily furnished to patients during the course of a procedure, whether hospital-owned or rented, and supplies used in conjunction with this equipment
- Oxygen masks and oxygen supplies
- Preparation kits
- Any linen
- Saline solutions
- Irrigation solutions
- Reusable items
- Cardiac monitors
- IV pumps
- IV tubing
- Blood pressure monitors and/or cuffs
- Ice bags or packs
- Heat light or heating pad
- Wall suction
- Admission, hygiene, and/or comfort kits or items (Administar16, BCKS19)
- Restraints (Administar16)
- Reusable equipment and items (Administar16, BCKS19, Administar20)
- Items used to obtain a specimen or complete a diagnostic or therapeutic procedure (DeWald17)
- Telemetry batteries, leads
- Batteries for any equipment used during any procedures
Flushes, Diluents, Saline, Sterile Water, etc.
Heparin flushes, saline flushes, IV flushes of any type and solutions used to dilute or administer substances, drugs or medications are included in the administration service. These items are considered routine supplies and are not eligible for separate reimbursement. Despite the fact that J1642 (Injection, heparin sodium [heparin lock flush], per 10 units) describes heparin flushes, heparin flushes are not considered a “drug” but rather a supply and heparin flushes are not eligible for separate reimbursement under the fee schedule or provider contract provisions for drugs.
Components of Room and Board
Items and services that are considered components of room and board charges as not separately reimbursable. Facilities will not be reimbursed nor allowed to retain reimbursement for services considered to be non-reimbursable.
Pharmacy and Lab Services
Over-the-counter (OTC) drugs are considered part of the room and board and will not be reimbursed separately. Blood draws from capillary, arterial or vascular access devices regardless of practitioner performing the draw and regardless of whether arterial, venous or capillary blood is drawn. Each blood draw or collection is part of the lab test and is not separately reimbursable.
Equipment that is a required component of a specific level of care and is used in the provision of services to multiple patients and has an extended life, is not separately billable. This equipment is considered a fixed asset of the facility. Calibration of instrumentation is not separately billable as well.
Where specific procedure codes exist, the services provided with that equipment may be billed as appropriate (e.g., X-rays or dialysis) and in accordance with correct coding and billing guidelines (e.g., no unbundling of oximetry checks, or fluoroscopy in the OR). If specific procedure codes do not exist, in most cases the services provided by that equipment are included in a larger related service and are not eligible for separate reimbursement (e.g., thermometer). Furthermore, equipment used multiple times for multiple patients should be part of facility charge and is not separately billable or reimbursable.
Respiratory Therapy Services and Supplier
Respiratory care (respiratory therapy) is defined as those services prescribed by a physician or a non-physician practitioner for the assessment and diagnostic evaluation, treatment, management and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function. Respiratory services may be performed by respiratory therapists, physical therapists, nurses, and other qualified personnel. Documentation in the medical record must clearly support the need for respiratory therapy services to be separately reimbursed.
Hospital Acquired Conditions
Hospital Acquired Conditions (HACs) are secondary conditions that are not present at the time of hospital admission but occur during the hospital stay. In many cases, HACs are commonly seen complications that, unfortunately, cannot be prevented even with the best of care. QualChoice will identify conditions that were not present on admission and could have been prevented through the use of evidence–based practices. This may be accomplished by reviewing claims but may also involve review of medical records. These preventable HACs are subject to a no-payment policy by CMS. Similarly, QualChoice will not pay for preventable HACs at hospitals (no additional payment beyond what is routinely paid for the primary admitting diagnosis or procedure). This brings QualChoice policy more closely in line with CMS policy regarding preventable HACs. For additional information regarding HACs, please refer to medical policy, BI253 Preventable Hospital Acquired Conditions (HAC).
Emergency Department Coding and Review
QualChoice regularly reviews emergency department evaluation and management coding practices to ensure providers are coding for at the appropriate level. QualChoice may perform prospective or retrospective emergency department claim reviews. The reviews will focus on claims that are submitted with level 4 and level 5 (99284 and 99285) evaluation and management codes. Providers who are statistical outliers in billing of level 4 and 5 services will have undergo a medical record review to ensure coding is done according to CPT coding guidelines. Upon completion of the review, providers may receive a claim denial or have their claim adjusted to reflect the appropriate level of evaluation and management code. Certain criteria may exclude a claim from review. The criteria may include but are not limited to patient age, admissions from the emergency department and providers who are not statistical outliers in level 4 and 5 billing. Providers will have the opportunity to submit a request for reconsideration or appeal if they believe a higher level evaluation and management code is justified according to appropriate CPT coding guidelines.
QualChoice utilizes ClaimsXten, a state-of-the-art clinical editing system to ensure accuracy in our claims adjudication process, as well as to detect and deter fraudulent billing. ClaimsXten is a rule-based software application that edits submitted claims for adherence to QualChoice medical coverage policies, reimbursement policies, benefit plans and industry-standard coding practices based mainly on Centers for Medicare & Medicaid (CMS) and American Medical Association (AMA) guidelines.
ClaimsXten facilitates accurate claims processing for CMS1500 and UB04 claims. Code editing within ClaimsXten is based on assumptions about the most common clinical scenarios for services performed by a healthcare professional for the same patient, while the logic within ClaimsXten is based on a thorough review by doctors of current clinical practices, specialty society guidance and industry standard coding.
All ClaimsXten clinical edits are reflected on the Remittance Advice (RA).
Providers who disagree with a clinical edit decision may send a corrected claim with the appropriate modifier or request a review of the claim by submitting the Request for Reconsideration form along with any relevant supporting documentation within 180 days of the date of the RA unless state or federal law or the Provider Agreement require another time period. The Medical Director will review the documentation for appropriateness and send the determination to the provider.
ClaimsXten is a trademark of Change Healthcare (formerly McKesson HBOC).
Clear Claim Connection™
Clear Claim Connection (herein referred to as CCC) is an online tool for evaluating clinical coding information. CCC enables providers to access the editing rules and clinical rationale existing in Change Healthcare (formerly McKesson’s) ClaimsXten.
This tool will help you:
- Prospectively access the appropriate coding, coverage and supporting clinical edit clarifications for services before claims are submitted, resulting in increased first pass payment rate and decreased accounts receivable days.
- Proactively determine the appropriate code or code combination representing the service for billing purposes, thereby educating your office staff regarding accurate billing.
- Retrospectively access the coverage status and clinical edit clarifications on a denied or reduced claim after your Remittance Advice (RA) has been received.
- Reduce the work effort, cost and time involvement of inquiries and appeals.
- Decrease your overall administrative costs associated with claims filing.
NOTE: Claims with modifier 59 are manually reviewed. Use of modifier 59 in CCC will NOT provide accurate information.
Clear Claim Connection is a trademark of McKesson.
Claims for Workers’ Compensation
If the claims are determined to be work-related they will be denied. The provider will be notified to file a claim through the applicable workers’ compensation carrier or the member’s employer group. If QualChoice inadvertently or mistakenly pays a claim on a work-related injury or illness and later discovers that the injury or illness was work-related, we will take steps to obtain appropriate recoveries from all parties who have been issued benefits for the claim. QualChoice may in its sole discretion process, adjudicate and pay the claim on behalf of the employer group, but will notify the facility and all involved parties of the pending workers’ compensation claim and of our intention to seek recovery of benefits paid for such claim.
For most QualChoice groups, our EOC, COC and Summary Plan Descriptions exclude all expenses incurred by a member as a result of injury or illness that occurs on the job.
QualChoice will reimburse the network provider according to the terms of their Provider Agreement for any Covered Services that are billed. Please note that members injured in these situations should not have to pay for medical services at the time of the visit, other than the applicable co-payment, coinsurance or deductible amount.
Claim Rejections or Delays
Rejected claims are claims with invalid or required missing data elements, such as the provider Tax ID number or the member ID number, that are returned to the provider or EDI vendor. Rejected claims are not registered in the claim processing system and are to be resubmitted as “new” claims.
Common causes of rejections or delays include:
- Unable to read: If the OCR scanner cannot read a claim due to light ink or information not within the form fields due to improper alignment, the claim is returned to the submitting provider for a clean, legible copy.
- Missing information: Claims are denied when information is missing from REQUIRED fields.
- Insured’s ID missing or incorrect: Verify that the ID number on the claim is the insured’s Social Security number or six-digit randomly generated number followed by the two-digit member suffix. The patient name must exactly match what is on the insured’s ID card. Do not use nicknames or initials unless they are on the ID card.
- Provider ID missing or invalid: The provider ID must be 11 digits and located in the correct field. If this is an electronic submission, Change HealthCare (formerly Emdeon) will reject the claim with the error message “Render Network ID for Payer” without submitting the claim to QualChoice. If you file claims with your Tax ID Number instead of your QualChoice provider number or vice-versa, claims may be rejected out of QualChoice’s system. Filing with your NPI number is preferred by QualChoice, along with or in place of the 11-digit QualChoice ID number. Providing both numbers assures a higher probability of a first-time match and faster adjudication.
- Codes missing or invalid: Typical examples include Place of Service, Type of Service, or alpha characters in numeric fields.
- Diagnosis, procedure or modifier codes invalid or missing: Coding from the most current coding manuals is required in order to accurately complete processing. All applicable diagnosis, procedure and modifier fields must be completed.
- Duplicate charges: If a provider resubmits the same claim without any changes or corrections, the resubmission will cause a duplicate claim error. Before resubmitting a claim, please check the claim status through our Claims Center behind the provider log-in page.
- Pre-authorization missing: All services requiring pre-authorization must be authorized prior to the delivery of services. Valid authorization numbers must be indicated on the claim form.
- Timely filing not met: All claims for services must be submitted within the time frame defined in the Provider Agreement to be eligible for reimbursement. Note: The member cannot be billed if the provider fails to file a claim within the required time frame.
- Additional information: Failure to return any additional information requested in a timely manner may result in a denial.
QualChoice processes complete/clean claims in accordance with state and federal requirements. Complete/clean claims are claims that have been submitted in industry-standard electronic formats with all required fields accurately entered or on industry-standard paper claim forms and are legible, with all required fields completed accurately.
Electronic Funds Transfer/Electronic Remittance Advice
Electronic Funds Transfer (EFT) is required for all QualChoice participating providers.
Electronic Funds Transfer/835 Electronic Remittance Advice is through ECHO Health, Inc. Enroll today or log in at ProviderPayments.com. You will need your tax identification number (TIN) along with an ECHO draft number and amount from a payment issued by ECHO.
For questions about payment options, please call ECHO Health at 888.834.3511.
Payments and Offsets
Timing of Payments
QualChoice shall pay or provide network provider written notice of payment status for services provided to members in accordance with their Provider Agreement and no later than 45 days immediately subsequent to receipt of a complete and accurate claim which requires no additional information or investigation for payment determination.
Recovery of Payments
For overpayments made due to an error on the part of QualChoice, a payer, plan administrator or one of its representatives:
QualChoice may deduct from payments the amount of any previous payments received for services subsequently determined by the applicable payer or plan administrator to be overpayments. The request for recovery of payments must be sought within 180 days of the date of the payer’s remittance advice which contains the payment(s) to be recovered. If such erroneous payments are not completely recoverable from future claims payments within a reasonable period of time, the network provider agrees to repay such unrecovered overpayments to payer or health plan within 30 days of written request.
Erroneous overpayments include, but are not limited to, any of these:
- Payment for services that are not Covered Services
- Duplicate payment
- Any overpayment improperly or mistakenly paid due to an error on the part of the payer or plan administrator
For overpayments made due to an error on the part of network provider or one of its representatives:
Network provider agrees to accept as deductions from payments the amount of any previous payments received for services subsequently determined by the applicable payer or plan administrator to be overpayments. The request for such recovery of payments must be made within 12 months of the date of the payer’s remittance advice which contains the payment(s) to be recovered. Should the erroneous payment not be completely recoverable from future claims payments within a reasonable period of time, the network provider shall repay unrecovered overpayments to QualChoice within 30 days of written request.
Erroneous overpayments include, but are not limited to, any of these:
- Payments made for services that, based on the information presented to payer or plan administrator, were considered Covered Services at the time payment was made, but which were subsequently determined not to be Covered Services, based on an audit of medical records
- Payments made based on coding not substantiated in the medical records; or,
- Any overpayment improperly or mistakenly paid due to any other error on the part of the network provider
The above limitations do not apply to overpayments made through fraud or misrepresentation by the provider. Recovery of such overpayments is only restricted by applicable law.
Payment Reconsideration and Appeals
All participating providers have a right to request reconsideration of any payment determination made by QualChoice.
A Request for Reconsideration form must be submitted within 180 days of the date of the original RA unless state or federal law or the Provider’s Agreement reference another time period. The request should include any medical records relevant to the dispute. Failure to include required information will result in the request being rejected.
For greater efficiency, providers are encouraged to pursue resolution with a Customer Service representative prior to filing a reconsideration request.
Note: The above provisions of this section are to be considered as separate and distinct from the arbitration provisions set forth in the Provider’s Agreement.
To the extent permitted under applicable state and federal law and the applicable benefit plan, QualChoice reserves the right to recover benefits paid for a member’s health care services when a third party causes the member’s injury or illness. If a QualChoice member who has been involved in a motor vehicle accident or workers’ compensation injury visits your office, you should:
- Record the name of the member's automobile insurance company and/or their workers’ compensation carrier.
- Verify the member’s eligibility through QualChoice.
- Submit any claims to QualChoice.
Following these steps will expedite processing and help ensure that the claim is paid accurately. Once the claims are submitted, QualChoice works with a third-party subrogation vendor to determine if the member’s automobile insurer or the workers’ compensation carrier is responsible for paying the claims (this process varies depending on the Provider’s Agreement or the member’s benefit plan).
Global Surgical Packages Billing
CPT (Current Procedural Terminology) defines the surgical package as services provided by the physician for specific services that are:
- Included in a given CPT surgical code, and
- Always included in addition to the surgical procedure itself.
The services provided by a physician to any patient are by their very nature variable, but the global package remains the same. Global surgical package CPT codes are based on CMS (Centers for Medicare and Medicaid Services) methodologies.
Days Included in a Global Surgical Package
- The day prior to a major procedure
- The procedure
- The 90-day global period following a major procedure
- The day of the minor procedure
- The procedure
- The 10-day global period following the minor procedure
Global surgery applies in any setting, including:
- Intensive care
- Critical care units
- Ambulatory surgical centers (ASCs)
Surgical services include:
- Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
- Surgical service(s) and related procedures, techniques, etc.
- Immediate post-operative care, including dictating surgical (operative note), meeting/discussing patient with family and other physicians
- Evaluating the patient in post-anesthesia/recovery area
- Writing orders for the patient
Services may also include conscious sedation (99143-99145).
If billing for surgical care only, refer to modifier 54 guidelines.
- All post-operative follow-up care days (10 days or 90 days depending on procedure performed)
- All related services other than a return to the operating room
Unrelated E&M services that occur within the post-operative period should be appended with the appropriate modifier. Documentation must support the unrelated services.
If billing for post-operative care only, refer to modifier 55 guidelines.
Urgent Care Billing
Services obtained in an independent urgent care setting must be billed as 1500: POS 20 with corresponding E&M code. Member liability may apply.
Clinic Visits Billed by a Facility
QualChoice does not recognize facility charges for clinic visits. Facility charges for services performed in a clinic setting are typically billed on a UB04 Claim Form under revenue codes 0510-0519. These services will not be reimbursed and may not be billed to QualChoice members.
Treatment Room Services Billed by a Facility
Treatment room services billed by a facility on a UB04 Claim Form under revenue code 0761 require a CPT code to be included on the claim. Outpatient claims without the appropriate CPT code under revenue code 0761 will be denied and may not be billed to QualChoice members.