Common Provider Inquiry Topics
In an effort to improve customer service by increasing Customer Service Representative availability for the more complex Medicare program issues, we are providing you information relating to some of the most common inquiry topics received by our customer service staff. We hope you will find this information beneficial, and negates your need to contact our office for questions on these topics. Please share this information with appropriate staff in your facility.
Claims Status
If you do not have access to the Direct Data Entry (DDE) system you should check claim status by calling our automated status line at 1-866-580-5983.
Please allow a minimum of 30 days before you call customer service to check the status of a paper claim or adjustment. Calls to customer service to check status should be rare, as the DDE system and the automated status line should be your primary resources.
If you are a DDE provider you should check status by going to main menu 01 then to submenu 12. This will allow you to pull up a list of all the claims you have on the system for a particular beneficiary by typing in the HIC number for the beneficiary. Further instructions can be found in the DDE manual on our web site, under the DDE section. If you still have questions about this or any thing else pertaining to the DDE system, please call the DDE line at 1-866-580-5986.
Common Working File (CWF) Edits for Coding and Payments for Discharge and/or Transfer Policies (11G Cancels)
Claims that have already processed and posted to CWF will be sent to the Fiscal Intermediary for cancellation, with an 11G type of bill, if CWF detects the incorrect discharge/transfer patient status was used. You must re-bill the claim with the correct discharge/transfer patient status code. The following is a guide of the correct patient status codes that should be used:
03 - patient discharged/transferred to a Skilled Nursing Facility (SNF);
05 - patient discharged/transferred to a Psychiatric, Children's or Cancer hospital;
06 - patient discharged/transferred to a Home Health (HHA) plan of care;
61 - patient discharged/transferred to a Swingbed Hospital;
62 - patient discharged/transferred to an Inpatient Rehab Facility (IRF);
63 - patient discharged/transferred to an Inpatient Long Term Care Hospital (LTCH)
If CWF detects an incorrect discharge/transfer patient status prior to payment, the claim will be returned (RTP'd) to you for correction.
Note: Patient Status "06" is required if a patient is discharged/transferred home under care of organized home health service organization.
Conflicting Medicare Secondary Payer (MSP) Information
To expedite processing of your MSP claims, DDE providers should verify that the patient's information matches HIQA/CWF prior to submission. Up front investigation will help eliminate adjustments and status calls to our office. If you have a situation where the MSP information does not match HIQA/CWF the Coordination of Benefits (COB) Contractor must be contacted at 1-800-999-1118. Your MSP claims should be submitted after the COB Contractor has updated HIQA/CWF with the information you provided.
Providers who do not have access to DDE must obtain information from the MSP Admission Questionnaire prior to submission of the claim. If notification of conflicting MSP information is received and the information on the claim agrees with the MSP Admission Questionnaire, the Coordination of Benefits (COB) Contractor must be contacted at 1-800-999-1118.
The following tips were provided to us by the COB Contractor:
Provider number on file with the COB Contractor
Your provider number must be on file with COB before you are able to make an update. If the COB Contractor advises you that your provider number is not on file, you must fax a letter to the COB that includes your letterhead, the provider number, address, telephone number as well as the patient's name, HIC number and any other information that is needed to update the existing HIQA/CWF record.
Updating an Employer Group Health Plan (EGHP) or Large Group Health Plan (LGHP) record
If your provider number is on file with the COB you may update a regular group record. You must be able to provide the insurance name, address, policy number, and the termination date. If you are trying to change the name and number of the insurance (i.e., "Prudential" to "Anthem") you must provide correct insurance name, address, policy number, and telephone number. COB will ask you for information about the patient such as the patient's name, address, date of birth, possible effective dates to Medicare, etc. You should already have this information according to their records and the MSP admission questionnaire.
Updating a liability, no-fault, or worker's compensation record
If your provider number is on file with the COB and you want to update a liability, no fault or worker's comp record you will need to contact the lead contractor assigned by the COB. The COB should be able to give the provider the name and number of the contractor who can update this record. CMS has assigned certain states (where the patient currently lives) to each Medicare office that initiates for subrogation. This will happen when a patient is involved in a slip/fall, auto accident, malpractice, or worker's comp injury.
Updating a Datamatch record
If you call COB and your provider number is in the system and you want to update a group record, you may be told that the record is a Datamatch record. In this situation COB will instruct you to call the patient and have the patients employer fax information to their office that contains a termination date or any information that is needed to update this record, so a claim can be processed correctly.
Beneficiary instructions for updating a record
If a beneficiary contacts COB, they will be asked for their HIC number, name, address, date of birth, and possible effective dates to Medicare. After this information is obtained the beneficiary can instruct COB what needs to be updated on their record. The beneficiary may be asked to contact the lead contractor if the record that needs to be updated is liability, no-fault or worker's comp. If the record is a datamatch record, COB may tell the beneficiary that the record can only be updated if the employer sends the information to their office.
Note: When submitting MSP claims it is very important that the name of the insurance company entered in Form Locator 50 exactly matches the name on HIQA/CWF (i.e., "BCBS" and "Blue Cross Blue Shield" is not an exact match and will cause the claim to edit and delay payment.
HCPCS/Revenue Code Issues
The revenue code is non-billable for type of bill:
- Verify correct revenue code submitted for type of bill. Correct and resubmit if appropriate. If you have documentation that indicates the code you are billing is valid, contact Customer Service so a referral can be generated to update the revenue code file.
*See note below
The revenue code requires a HCPCS code:
- Verify correct revenue code submitted and/or,
- Report appropriate HCPCS code. Correct and resubmit if appropriate.
*See note below
Invalid HCPCS code:
- Verify HCPCS code submitted with correct revenue code and/or
- Verify HCPCS code is valid and is an acceptable code for Medicare billing. Correct and resubmit if appropriate. Refer to current CPT or HCPCS Level II books for valid codes. If you have documentation that indicates the code you are billing is valid, contact Customer Service so a referral can be generated to update the HCPC file.
*See note below
The HCPCS code is not on the HCPCS file:
- Verify HCPCS code is valid and is an acceptable code for Medicare billing. Correct and resubmit if appropriate. Refer to current CPT or HCPCS Level II books for valid codes. If you have documentation that indicates the code you are billing is valid, contact Customer Service so a referral can be generated to update the HCPC file.
*See note below
Note:
DDE providers can validate with the Revenue Code file that we utilize by following these steps in the DDE system:
- GO TO MENU SELECTION '01' FROM THE MAIN MENU AND PRESS ENTER.
- GO TO MENU SELECTION '13' FROM THE INQUIRY MENU AND PRESS ENTER.
- ENTER IN THE 4-DIGIT REVENUE CODE AND PRESS ENTER.
DDE providers can validate with the HCPC file that we utilize by following these steps in the DDE system:
- GO TO MENU SELECTION '01' FROM THE MAIN MENU AND PRESS ENTER.
- GO TO MENU SELECTION '14' FROM THE INQUIRY MENU AND PRESS ENTER.
- ENTER IN THE LOCALITY CODE AND HCPCS CODE AND PRESS ENTER.
Page Last Updated: Wednesday, 31-Dec-2008 10:48:58 CST
