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Managed Data Systems

EDI Update Bulletin!

Vol. 2 No. 12

December 2000 Edition

 

Payer changes

The following payers will be live, effective December 6th. These payers will be added automatically to your payer database. Be sure to match the spelling of each payer with those produced in your billing system. If you scan on the payer number instead of the payer name, those numbers are also included for your convenience.

New medical payer                             Payer number           

GROUP BENEFIT SVCS MI               ("  30577")

PHP TENNCARE                        ("  30578")

STERLING OPTION ONE                 ("  30579")

PCMC ICSL CHIROPRACTIC              ("  30580")

PCMC ICSL ALLERGY                   ("  30581")

PCMC ICSL PULMONARY                 ("  30582")

PCMC ICSL DERMATOLOGY               ("  30583")

PCMC ICSL PODIATRY                  ("  30584")

PCMC ICSL GASTROENTER               ("  30585")

PCMC ICSL PHYS THERAPY              ("  30586")

PCMC ICSL UROLOGY                   ("  30587")

CORESOURCE NC                       ("  30588")

SELECT BENEFIT ADMIN                ("  30589")

HEALTH PLANS INC                    ("  30590")

PRACTICARE                          ("  30591")

VALLEY PHYSICIANS IPA               ("  30592")

ERIN GROUP ADMIN                    ("  30593")

GEISINGER HEALTH PLAN               ("  30594")

NEIGHBORHOOD HEALTH PLAN MA         ("  30595")

GROUP BENEFIT SVCS MI               ("  30577")

PHP TENNCARE                        ("  30578")

STERLING OPTION ONE                 ("  30579")

PCMC ICSL CHIROPRACTIC              ("  30580")

PCMC ICSL ALLERGY                   ("  30581")

PCMC ICSL PULMONARY                 ("  30582")

PCMC ICSL DERMATOLOGY               ("  30583")

PCMC ICSL PODIATRY                  ("  30584")

PCMC ICSL GASTROENTER               ("  30585")

PCMC ICSL PHYS THERAPY              ("  30586")

PCMC ICSL UROLOGY                   ("  30587")

CORESOURCE NC                       ("  30588")

SELECT BENEFIT ADMIN                ("  30589")

HEALTH PLANS INC                    ("  30590")

PRACTICARE                          ("  30591")

VALLEY PHYSICIANS IPA               ("  30592")

ERIN GROUP ADMIN                    ("  30593")

GEISINGER HEALTH PLAN                  ("  30594")

NEIGHBORHOOD HEALTH PLAN MA         ("  30595")

BOONE-CHAPMAN                       (“  30596”)

New ERA payers                             Payer number  

BLUE LOUISIANA                   (“ 280000”)

MEDICARE TENNESSEE               (“ 561000”)

BLUE MISSISSIPPI                 (“1110000”)

 

Holiday schedule reminder: While our offices will be closed on certain days during the upcoming holidays, you will be able to transmit claims whenever it is convenient for you. Our holiday schedule is as follows:

 

 

Holidays

 

Days MDS offices will be closed

Claims received on holidays will be transmitted after 5:00 PM CST

Normal business hours and client support will resume

Christmas

Friday & Monday, December 22, 25

Tuesday, December 26

Tuesday, December 26

New Years Day

Monday, January 1

Tuesday, January 2

Tuesday, January 2

NHIC is new carrier of ALL California Medicare Part B claims  [condensed/repeated]

On December 1, 2000, NHIC became the Medicare Part B carrier for ALL of California. This means that ALL electronic Medicare B claims, whether for Northern or Southern California, are submitted to NHIC in Chico. For details, please refer to the October 2000 issue of NewsWire.


Great-West Life requires valid POS on claims

Not supplying Place of Service Codes (POS) when submitting claims electronically to Great-West Life (Payer ID = “1389000”) will cause timely and costly delays in payment. Claims with missing POS codes on the service line are rejected and sent to paper for manual processing, due to “edit criteria” requirements within the Great-West Life (GWL) claims processing system.

 

When sending claims, it is very important that you populate the POS with a valid code. “Blanks” and “zero’s” should not be used. If the code is unknown, the default of ‘99’ should be used. MDS has made an update in the format to default a ‘99’ in the POS field, if no POS is supplied.

 

To avoid any confusion or delays, please make sure that all claims have a valid POS.

  

Trigon Blue Cross Blue Shield remittance changes  

Trigon Blue Cross Blue Shield (payer = “ 820000”) has made changes in the their electronic and paper remittances.  After the December 5, 2000 remittance, the current remittance format will no longer be available. Per a letter received from Trigon BCBS, “Effective on the December 12, 2000 remittance, changes will be made as follows:

Ø      In accordance with the Fair Business Practices Act, 30-days notice will be given prior to claim retractions.

Ø      You will receive the allowed amount on which we based our calculations.

By the first quarter of 2001, Trigon HealthKeepers claims will be combined as part of your Trigon professional provider remittance.  HealthKeepers claims will be shown in a separate account so you can continue to distinguish different lines of business.”

 

Virginia Medicare submitters—avoid delays/denials

EMC submitters to Virginia Medicare (Payer number = “ 941000”), please note the following information provided by a  Provider Education Report from Trailblazers. 

 

Occasional errors in the transmissions and/or claims can sometimes result in delays or denials. When fields are not completed or are completed incorrectly, the claims, and possibly the entire file, can be rejected. The often happens when information which is useful to your office, but is unnecessary for Trailblazer’s processing, is submitted with your electronic claims. This causes the claims to suspend in the Trailblazer system, slowing down the claims adjudication. 

 

The following are some of the more common situations that may cause claims to be delayed or denied:

DOCUMENT? – Documentation Text/Comments Field: overusing this field with extra narrative date, such as reiterating procedure code.  This field should only be used in special circumstances, like to identify unlisted procedures or to give additional information to support the services.

 

DIAG INVAL – Diagnosis: truncated or invalid.  Coding should come from the most current ICD-9 coding manual.  All diagnosis should be completed to the highest level of specificity.

 

INVALID HIC – Health Insurance Claim Number (HICN): missing or invalid.  Be sure to include any alpha characters in the Medicare (HICN) number; do not use any dashed or spaces in the number.

 

HIC MISM – Health Insurance Claim Number Mismatched:  This Medicare number is not currently on our databases; or our records show a different patient with this Medicare number.

 

NAME MISM – Name Mismatched:  invalid or nicknames.  Use the name exactly as it is printed on the red, white and blue Medicare card.  Do not use nicknames, initials, etc.

 

SEX MISM or NAME/SEX – Sex Mismatched:  Male vs. Female (e.g., MaryAnn submitted as Male).  Make sure the patient’s sex is entered correctly.

 

CITY ERROR – Patient Address:  incomplete or incorrect.  This infor-mation should be current and complete.  Make sure to verify the address with the patient prior to submitting claims.

 

SIG NOTFND or PRIVACY? – Signatures:  indicator states not on file.  Patient and Provider signatures should be on file at the provider’s office.  Make sure the signature indicators in your system are set correctly.

 

LIABL CVG? – Liability Coverage Indicator:  Overused (i.e., Liability Indi-cator checked YES with diagnosis for FLU).  Only use this indicator when the claim is truly a liability case, like an auto accident.

 

REP PAYEE? – Representative Payee:  representative payee is same as patient.  Only list Representative Payee/Legal Representative when it’s someone other than the patient.

 

MODIFIER: The modifier is either incorrect, invalid or missing.

 

PLC OF SVC – Place of Service:  Place of Service does not match procedure code.

 

OL PRV ERR or PRVIDR ERR – Provider Number:  Provider number is incorrect or invalid.

 

RF DR UPIN – Referring Provider Upin:  Referring Physician Upin/infor-mation is missing.

 

SVCDATE – Service Date:  Provider number is not current for this date; or dates of service are beyond the time limit; or date span is inconsistent with units of service.

 

# OF SVC – Number of Services:  Number of services are inconsistent with procedure code or date of service.

 

PROC 4 DX – Procedure for Diagnosis:  At least one of the diagnosis codes does not warrant the procedure code.  Only submit the diagnosis that relates to the service being billed; do not use “history” diagnoses.

 

Ignore the following edits.  They are Medicare System Edits.

     DIAG FLAGD

     AUTO CVG?

     PAP COVG?

     REV PRICING

     CLOSD HIST

 

We appreciate the many opportunities we’ve had to serve you.

Thanks for placing your confidence in us.

We value your continued loyalty and commit ourselves to serving you well.

 

PASS IT ALONG  This publication contains important information for all MDS users. Please share it with everyone in your organization who is involved with the transmission of claims. Contact us if you want an individual copy mailed to anyone.