Quality Results Spring - 2016

Alerts and Reminders

Now Accepting Medicare Crossover Claims

Medicare claims received by CMS are now electronically crossed over to QualChoice after Medicare pays their portion. Providers who are set up to receive and review 835 remittance advice files may see claims that have been crossed over.

Use the Correct Electronic Payer ID

Please note: QualChoice Advantage Medicare Advantage plans have a different Payer ID# than QualChoice Group, Individual and Medicare Supplement plans.

QualChoice Group, Individual, Medicare Supplement Coverage

  • EDI claims accepted via EMDEON (WebMD) or Availity (THIN) using Payer ID# 35174.
  • Corrected claims must be submitted with original claim number.
  • Provider NPI # is required.

Further instructions at QualChoice.com behind provider log-in.

QualChoice Advantage Medicare Advantage Coverage

  • EDI claims accepted via EMDEON (primary clearinghouse) using Payer ID# 42172.
  • Corrected claims must be submitted with original claim number.
  • Provider NPI # is required.

Send paper claims to:

QualChoice Advantage

P.O. Box 851438

Richardson, TX 75085-1438

 

Learn more at QualChoiceAdvantage.com.

eviCore Healthcare Update

Web Portal Training Sessions

eviCore is offering Web Portal webinar training sessions. Using their Web Portal for requests is much faster than phone requests and is available 24 hours a day.

eMail Notifications

eviCore healthcare will begin sending email notifications to providers for approved cases initiated through their web portal starting April 15, 2016.

Notification details:

  • Fully HIPAA compliant. No PHI will be shared in the email. It is only a notice that a specific case has been approved, with instructions to log in to the web portal for details.
  • Will only apply to portal-initiated cases. For cases initiated by phone and fax, providers will continue to receive faxed notifications.
  • Will only apply to approvals. For denials/modified approvals, providers will continue to receive faxed notifications.
  • Will only apply to providers and their authorized contacts who have registered with a valid email address on the web portal. Patients will continue to receive mailed letters.
  • For email rejections (user email mailbox full, etc.), notification will default to a fax.
  • You may still request a faxed copy of the authorization through the web, IVR, or call center.

Example of the email notification:

From: eviCore healthcare Notices (no replies to this address please)
Sent: February 11, 2014 2:36 PM
To: (Provider Contact Name)
Subject: eviCore healthcare E-Notification: Case # 3000XXXX has been Approved

There has been an update issued for Case #123456789. This case has been approved and the Authorization number is A123456789. To retrieve this information please click on the link provided below to log in to the Web Portal and search by case or authorization number. As part of our initiative to speed up communications and eliminate waste, there will not be a separate fax sent to you for this approval unless you request it.

eviCore healthcare Portal: Click here

Please do not reply to this email, as replies will go to a non-monitored email box. If you have any questions after viewing the case information online, please don’t hesitate to contact us.

CPT Code Update

Cardiac Monitoring

  • Mobile cardiac outpatient telemetry, (codes 93228 and 93229) is a non-covered service.
  • Other forms such as 30-day cardiac event monitors (93268 and related codes) are covered in-network.

Please use in-network providers for 93268 and related codes. These types of cardiac monitoring will not be covered if provided by an out-of-network service. Available in-network providers include:

  • Telerhythmics
  • Phillips Remote Cardiac Services
  • Pacemaker Monitoring Center
  • Lifewatch
  • Life Support Systems

Medical Record Review for HEDIS Reporting

QualChoice is compiling data on 2015 clinical outcomes to demonstrate performance on Healthcare Effectiveness Data and Information Set (HEDIS) standards, which are designed to help consumers compare performance across plans.

Advantmed, a medical record retrieval company, will contact your office by fax and telephone to collect medical records on our behalf.

  • Data will be collected through the first week of May, 2016.
  • Information will be collected from individual medical records randomly selected throughout our network.

Learn more.

For questions or concerns about the HEDIS data collection, please contact your QualChoice Provider Relations Representative.

Claims Corner

File Corrected Claims Electronically

QualChoice accepts and prefers electronic corrected claims. Turnaround time is much quicker than filing corrected claims on paper.

A corrected claim is one that has been processed, whether paid or denied, and was refiled with additional charges, a different diagnosis, or any information that would change the way the claim was originally processed. Indicating "Corrected Claim" on the claim form if not previously processed will cause a delay in claim adjudication.

Claims returned for additional information are NOT to be refiled as corrected claims. These claims have been processed; additional information is needed to finalize payment.

  • New Claims
  • Appeals
  • Medical Records
  • Invoices
  • Inquiries
  • Adjustments

Corrected Claim Guidelines

Share these guidelines with your electronic vendor.

I ANSl-837P (Professional)

Both items listed below must be completed to be considered a corrected claim.

  1. In the 2300 Loop, the CLM segment (Claim Information), CLMOS-3 (claim frequency type code) must indicate one of the following qualifier codes:
    • "7" - REPLACEMENT (Replacement of Prior Claim)
    • "8" - VOID (Void/Cancel of Prior Claim)
  2. In the 2300 Loop, the REF02 segment (Original Reference Number (ICN DCN)) must include the Original Claim Number issued to the claim being corrected. The original claim number can be found on your Remittance Advice.

I ANSl-8371 (Institutional)

Both items listed below must be to be considered a corrected claim.

  1. In the 2300 Loop, the CLM segment (Claim lnformation),the CLMOS-3 (Claim Frequency Type Code) must indicate the third digit of the Type of Bill being sent The third digit of the Type of Bill is the frequency and can indicate if the bill is an Adjustment, a Replacement or a Voided claim as follows:
    • "7" - REPLACEMENT (Replacement of Prior Claim)
    • "8" - VOID (Void/Cancel of Prior Claim)
  2. In the 2300 Loop,the REF02 segment (Original Reference Number (ICN/DCN)) must include the Original Claim Number issued to the claim being corrected. The original claim number can be found on your Remittance Advice.