Resolving Claims issues for Health Choice Generations Providers

National Correct Coding Initiatives (NCCI) Edits-
Mutually Exclusive Edits
Health Choice will be implementing the NCCI edits into our claims processing system to validate the claims that are billed for services to our members. These edits include Mutually Exclusive codes and Column 1/Column 2 edits. The Mutually Exclusive edits will be put into place for claims with a date of service of February 19, 2009 and later. You may see denials or codes that are bundled for services on future remittance advices that do not comply with these rules. These edits are based on guidelines set forth by CMS.
For more information on the specific details of the NCCI, please visit the CMS website at http://www.cms.hhs.gov/NationalCorrectCodInitEd/.

Outpatient Institutional Claims no longer require IZ
Outpatient hospitals claims received as of January 9, 2008 will no longer require to be accompanied by an Itemized Statement (IZ) when billed on a UB04 form or electronically (837I). In the event that a claim requires additional medical records or documentation, a notification from the health plan regarding the specific claim will be generated and sent. This is for all institutional providers in and out of the state of Arizona.

If you are a Health Choice Generations Contracted Provider
Under Chapter 13 Section 70.1 of the Medicare Managed Care Manual, contracted providers do not have appeal rights. Appeals for non-payment of services would have to be filed by the beneficiary. However, Health Choice Generations would like to assist you in resolving your claims issues.

If a Claim is denied or you disagree with a payment:

Please call Claims Customer Service (CSRT) at (480) 968-6866 OR 1-800-322-8670. The CSR will review the claim issue with you and send a referral sheet if an adjustment is required. This referral will be routed to the HC Generations Claims Team lead for research and determination.

1. Claim in question must be timely (1-year from date of service or 60-days from date of last adverse action).
2. If the claim is paid correctly and no adjustment is necessary, a new line will be entered under the same claim # and a note is entered detailing the findings of the research.
3. If the claim is paid/processed incorrectly, an adjusted line is added to the claim for each line that is paid incorrectly, and a note will be added to the claim detailing the adjustment, noting if an additional payment will be made or if a recoupment for an over, payment is needed.
4. If you require a call back from the adjuster regarding the determination, please indicate so when speaking with the CSR so it may be noted on the referral.

If you are NOT a Health Choice Generations Contracted Provider
Under Chapter 13 Section 60.1.4 of the Medicare Managed Care Manual, a non-contracted provider on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the provider completes a Waiver of Liability Statement (WOL), which provides that the provider will not bill the enrollee regardless of the outcome of the appeal. The WOL Statement is available by calling Health Choice Generations Medicare Operations at 480-317-3328 or 1-800-322-8670 X 3328. A Standard Appeal may be filed by utilizing the following steps.

• A Provider may request a standard reconsideration by filing a signed, written request with Health Choice Generations within 60 calendar days from the date of denial. This request must be accompanied by a WOL Statement. (If the WOL Statement is not provided, every effort will be made by Health Choice Generations to secure that statement. If not received within the 60 calendar days, then the request for reconsideration will be forwarded to the IRE with request for dismissal). Mail requests to:
  • Health Choice Generations
  • Attn: Provider Appeals
  • 410 N. 44th Street, Ste. 900
  • Phoenix, AZ 85008
• Once the request for standard reconsideration is received and logged, the physician may be contacted to provide additional information in order to review the case.
• Health Choice Generations will make its reconsideration determination no later than 60 calendar days from the date Health Choice Generations receives the request.
• If upon reconsideration, Health Choice Generations overturns its adverse organization determination denying a request for payment, then Health Choice Generations will issue its reconsidered determination and send payment for the service no later than 60 calendar days from the date it received the request for a standard reconsideration.
• If Health Choice Generations affirms, in whole or in part, its adverse organization determination, a written explanation and case file will be prepared and sent to the Independent Review Entity contracted by CMS.
• If the IRE reverses, the original determination then payment will be made within 30 calendar days from the date Health Choice Generations receives the notice of the reversal.
• If the IRE affirms the original determination, and the amount remaining in controversy meets the appropriate threshold requirement ($120 in 2007) then the provider or beneficiary has a right to a hearing before an Administrative Law Judge (ALJ).
• The Request for Hearing must be in writing and must be filed with the entity specified in the IRE's reconsideration notice within 60 days of receiving the adverse determination.

Claims Submission Reminder

Providers, when submitting an EOB from a member's primary insurance to Health Choice Generations, please eliminate other Members Health Information. Only submit information pertaining to the Specific member on the claim.

In addition, when submitting claims to Health Choice, a claim may be denied if the diagnosis pointer in box 24E does not relate to the procedure billed.

If you have questions on either of these "reminders", please call Health Choice Claims Customer Services at (480) 968-6866 or toll-free 1(800) 322-8670.