PDF MO HealthNet Provider Manuals MassHealth Billing and Claims | Mass.gov If the overpayment request is not contested by the provider, and Health Net does not receive a full refund or an agreed-upon satisfactory repayment amount within 45 days from the date of the overpayment notification, a withhold in the amount of the overpayment may be placed on future claim payments. For all questions, contact the applicable Provider Services Center or by email. We are committed to providing the best experience possible for our patients and visitors. BMC HealthNet Plan | Administrative Resources for Providers Sending claims via certified mail does not expedite claim processing and may cause additional delays. The administrative appeal process is only applicable to claims that have already been processed and denied. Submit Claims | Providers - New Hampshire | WellSense Health Plan Boston, MA 02205-5282, BMC HealthNet Plan Providers submitting multiple CMS-1500 successor forms must staple the completed forms together and number the pages appropriately. 2 0 obj You can also check the status of claims or payments and download reports using the provider portal. Non-Participating Providers: Please refer to the tab labeled "Non-Participating Providers". <>>> Once a decision has been reached, additional information will not be accepted by BMC HealthNet Plan. Our behavioral health partner, Beacon Health Strategies, developed a series of tools and resources for medical providers regarding geriatric depression. Find news and notices; administrative, claims, appeals, prior authorization and pharmacy resources; member support; training and support and provider enrollment documents below. The EOP/RA for each claim, if wholly or partially denied or contested, includes an explanation of why Health Net made its determination. If you appeal and we uphold the denial, in whole or in part, you will have additional appeal rights available to you including, but not limited to, reconsideration by a CMS contracted independent review entity. File #56527 The software detects and documents coding errors on provider claims prior to payment by analyzing CPT/HCPCS, ICD-10, modifiers and place of service codes against correct coding guidelines. Complete the Universal Massachusetts Prior Authorization Form, or call 800-900-1451, Option 3. If you complete a Waiver of Liability Statement, you waive the right to collect payment from the member, with the exception of any applicable cost sharing, regardless of the determination made on the appeal. Health Net will waive the above requirement for a reasonable period in the event that the physician provides notice to Health Net, along with appropriate evidence, of extraordinary circumstances that resulted in the delayed submission. Copies of the form cannot be used for submission of claims, since a copy may not accurately replicate the scale and OCR color of the form. Incomplete claims or claims that require additional information are contested in writing by Health Net in the form of an Explanation of Payment/Remittance Advice (EOP/RA), which may in some circumstances be followed by additional written communication within the timeframes noted above. IMPORTANT NOTE: We require that all facility claims be billed on the UB-04 form. For providers unable to send claims electronically, paper claims are accepted if on the proper type of form. To ensure claims are as accurate as possible, use current valid diagnosis and procedure codes and code them to the highest level of specificity (maximum number of digits) available. You can register with Trizetto Payer Solutions or, use the following clearinghouses: Paper claims may be submitted via U.S. mail by filling out theCMS-1500 formand sending to the address below for covered services rendered to BMC HealthNet Plan members. Claims Refunds BMC HealthNet Plan Whenever possible, Health Net strives to informally resolve issues raised by providers at the time of the initial contact. Each EOP/RA includes instructions on how to submit the required information in order to complete the claim if Health Net has contested it. Providers can submit an Administrative Claim Appeal electronically via our secure provider portal, or via US Mail: Attn: Provider Administrative Claims Appeals. These claims will not be returned to the provider. Patient or subscriber medical release signature/authorization. *If you require training or assistance with our online portal, please contact your dedicated provider Relations Consultant.Log in to the provider portal to check the status of a claim or to request a remittance report. If different, then submit both subscriber and patient information. By accessing the noted link you will be leaving our website and entering a website hosted by another party. A complete claim is a claim, or portion of a claim, that is submitted on a complete format adopted by the National Uniform Billing Committee and which includes attachments and supplemental information or documentation that provide reasonably relevant information, or necessary information, to determine payer liability. Paper claims follow the same editing logic as electronic claims and will be rejected with a letter sent to the provider indicating the reason for rejection if non-compliant. By continuing to use our site, you agree to our Privacy Policy and Terms of Use. Health Plans Inc. | Health Care Providers - Claim Submission Providers can update claims, as well as, request administrative claim appeals electronically through our online portal. Please do not hand-write in a new diagnosis, procedure code, modifier, etc. and Centene Corporation. See if you qualify for no or low-cost health insurance. 529 Main Street, Suite 500 Health Net Invoice form List of required fields from the state final rule billing guides for Community Services. Submit Claims | Providers - Massachusetts | WellSense Health Plan BMC HealthNet Plan | Claims & Appeals Resources for Providers I Am A Provider Working With Us Documents & Forms Claims & Appeals Claims and Appeals Resources Access forms and documents needed for submitting claims and appeals. If we request additional information, you should resubmit the claim with the additional documentation. Corrected Claim: when a change is being made to a previously processed claim. Provider FAQs | L.A. Care Health Plan Include the Plan claim number, which can be found on the remittance advice. Providers may request that we review a claim that was denied for an administrative reason. Providers billing for professional services and medical suppliers must complete the CMS-1500 (02/12) form. The form must be completed in accordance with the guidelines in the National Uniform Claim Committee (NUCC) 1500 Claim Form Reference Instruction Manual Version 5.0 7/17. Multiple claims should not be submitted. . In Massachusetts it providescomprehensive managed care coverage to more than 325,000 individuals through its MassHealth (Medicaid), ConnectorCare, Qualified Health Plans, and Senior Care Options programs. BMC HealthNet Plan is a non-profit managed care organization that has provided health insurance coverage to Massachusetts residents for more than 20 years. If an issue cannot be resolved informally by a customer contact associate, Health Net offers its nonparticipating providers a dispute and appeal process. Boston MA, 02129 Lack of Prior Authorization/Inpatient Notification Denials, Other Party Liability (OPL)/Third Party Liability (TPL)/Coordination of Benefits (COB), Provider Audit and Special Investigation Unit (SIU) Appeals, The preferred method is to submit the Administrative Claim Appeal request through our. Did you receive an email about needing to enroll with MassHealth? National Uniform Claim Committee (NUCC) 1500 Claim Form Reference Instruction Manual Version 5.0 7/17, ECM and Community Supports Invoice Claim Form Health Net (PDF), ECM and Community Supports Invoice Claim Form Template Health Net (XLSX), ECM and Community Supports Invoice Claim Form CalViva Health (PDF), ECM and Community Supports Invoice Claim Form Template CalViva Health (XLSX), Medical Paper Claims Submission Rejections and Resolutions Health Net (PDF), Medical Paper Claims Submission Rejections and Resolutions CalViva Health (PDF), Medical Paper Claims Submission Rejections and Resolutions Cal MediConnect (PDF), California Correctional Health Care Services (CCHCS). *If you require training or assistance with our online portal, please contact your dedicated Provider Relations Consultant. All professional and institutional claims require the following mandatory items: This is not meant to be a fully inclusive list of claim form elements. To ensure claims are as accurate as possible, use current valid diagnosis and procedure codes and code them to the highest level of specificity (maximum number of digits) available. Please note that WellSense is not responsible for the information, content or product(s) found on third party web sites. Health Plans, Inc. PO Box 5199. BMC HealthNet Plan is a non-profit managed care organization that has provided health insurance coverage to Massachusetts residents for more than 20 years. Timely Filing of Claims Health Net will process claims received within 180 days after the later of the date of service and the date of the physician's receipt of an Explanation of Benefits (EOB) from the primary payer, when Health Net is the secondary payer. These claims will not be returned to the provider. Timely filing limit (TFL): Time period from date of service within which the provider must file a claim, . Learn more about claims procedures Documents and Forms Important documents and forms for working with us. cM~s03/^?xhUJQ*Z?JhC:^ZvwcruV(C51\O>:U}_ BMh}^^iTmh.I*clMp,t$&j5)nFwsZ=++7"88q'C{8iG5A8A1z.i]#M+aeI95RWQ0h/^tOIB5`@A%5v To avoid possible denial or delay in processing, the above information must be correct and complete. Nonparticipating provider claim payment disputes also include instances where you disagree with the decision to pay for a different service or level than billed. Health Net reimburses each complete claim, or portion thereof, from a provider of service no later than: This time frame begins after receipt of the claim unless the claim is contested or denied. Enrollment in Health Net depends on contract renewal. If Health Net identifies an overpayment due to a processing error, coordination of benefits, subrogation, member eligibility, or other reasons, a notice is sent that includes the following: Failure to comply with timely filing guidelines when overpayment situations are the result of another carrier being responsible does not release the provider from liability. We offer diagnosis and treatment in over 70 specialties and subspecialties, as well as programs, services, and support to help you stay well throughout your lifetime. Using modifier SL ensures that the claim is processed, the provider is reimbursed for the administration fee and the vaccination is included in performance measurements. Explore provider resources and documents below. Health Net Appeals and Grievances Forms | Health Net Appeals and Grievances Many issues or concerns can be promptly resolved by our Member Services Department. Clinical consultants who research, document, and provide edit recommendations based on the most common clinical scenario. We offer one level of internal administrative review to providers. Did you receive an email about needing to enroll with MassHealth? Health Net notifies the provider of service, in writing, of a denied or contested Medi-Cal claim no later than 45 business days after receipt of the claim. Notice: Federal No Surprises Act Qualified Services/Items. Do not submit it as a corrected claim. Claims submitted on black and white, handwritten or nonstandard forms will be rejected and a letter will be sent to the provider indicating the reason for rejection. bmc healthnet timely filing limit. For more information on electronic placement and void requests, please see the EDI Claims Companion guide for 5010, or contact your Provider Relations representative. Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Failure to bill VFC claims in accordance with the billing procedures noted above results in denials for both the vaccine and the associated administration. Accountable Care Organization (ACO) | Boston Medical Center All paper CMS-1500 (02/12) claims and supporting information must be submitted to: All paper Health Net Invoice forms and supporting information must be submitted to: When Health Net is the secondary payer, we will process claims received within 180 days after the later of the date of service and the date of the physician's receipt of an Explanation of Benefits (EOB) from the primary payer. Use of modifier SL sufficiently identifies the claim as a state-supplied vaccine for which the billed vaccine charge is not reimbursed. Providers submitting multiple CMS-1500 successor forms must staple the completed forms together and number the pages appropriately. For earlier submissions and faster payments, claims should be submitted through our online portal or register with Trizetto Payer Solutions here. Access training guides for the provider portal. The Plan also offers personal physicians who provide care for the whole family; interpreter services, a personal membership card and a 24-hour nurse advice line. BMC HealthNet Plan is a non-profit managed care organization that has provided health insurance coverage to Massachusetts residents for more than 20 years. All managed care plan beneficiaries with pre-existing provider relationships who make a continuity of care request must be given the opportunity to request coverage of continued treatment for up to 12 months with the out-of-network provider. Providers should not submit refund checks for credit balance payments; instead, please contact us using one of the methods below and we will adjust your claim(s) and recover the credit balances through future payment offsets. Our provider portal is your one stop place to: BMC HealthNet Plan is a non-profit managed care organization that has provided health insurance coverage to Massachusetts residents for more than 20 years. filing if you can: 1) provide documentation the claim was submitted within the timely filing requirements or 2) demonstrate good cause exists. MassHealth Billing and Claims Billing and claims information for MassHealth providers This page includes important information for MassHealth providers about billing and submitting claims. Late payments on complete HMO, POS, HSP or Medi-Cal claims that are neither contested nor denied automatically include interest at the rate of 15 percent per year for the period of time that the payment is late. If you have not already done so, you may want to first contact Member Services before submitting an appeal or grievance. Additional fields may be required, depending on the type of claim, line of business and/or state regulatory submission guidelines. Health Net acknowledges paper claims within 15 business days following receipt for HMO, Point of Service (POS) and Medi-Cal claims and within 15 calendar days for PPO, EPO, and Flex Net claims. Date of contest or date of denial is the electronic mark or postmark date indicating the date when the contest or denial was transmitted electronically or mailed by U.S. mail. Print out a new claim with corrected information. Timely Filing Limit: Timely Filing Limit is the time frame set by insurance companies and provider has to submit health care claims to respective insurance company within the set time frame for reimbursement of the claims. The following are billing requirements for specific services and procedures. Whether online, through your practice management system, vendor or direct through a data feed, EDI ensures that your claims get submitted quickly. Health Net Overpayment Recovery Department P.O. Authorization, if applicable, should be sent in the 2300 Loop, REF segment with a G1 qualifier for electronic claims (box 23 for CMS-1500 or box 63 for UB-04). April 5, 2022. operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan. Member Provider Employer Senior Facebook Twitter LinkedIn Health Net may seek reimbursement of amounts that were paid inappropriately. Contact the OPP at 800-436-7757 or 617-624-6001 (TTY). Average time for both electronic (EDI) and paper claims to process on a remittance advice (RA). endobj If you're delivering a service to a BMC HealthNet Plan Senior Care Options member, you must also submit aWaiver of Liability. Health Net will waive the above requirement for a reasonable period in the event that the provider provides notice to Health Net, along with appropriate evidence, of extenuating circumstances that resulted in the delayed submission. If the subscriber is also the patient, only the subscriber data needs to be submitted. Billing provider's last name, or Organization's name, address, phone number. Rendering provider's Tax Identification Number (TIN). For more information on electronic placement and void requests, please see the EDI Claims Companion guide for 5010, or contact your Provider Relations representative. The following review types can be submitted electronically: Providers may request that we review a claim that was denied for an administrative reason. Each EOP/RA reflecting a denied, adjusted or contested claim includes instructions on the department to contact for general inquiries or how to file a provider dispute, including the procedures for obtaining provider dispute forms and the mailing address for submission of the dispute. Fax the completed form, along with a copy of your W-9 form, to 617-897-0818, to the attention of the Provider Enrollment Department. Public domain specialty provider associations (such as American College of Surgeons, American Academy of Orthopaedic Surgeons, etc.). When possible, values are provided to improve accuracy and minimize risk of errors on submission. Health Net prefers that all claims be submitted electronically. Box 55991Boston, MA 02205-5049. Health Net requires that providers confirm eligibility as close as possible to the date of the scheduled service. To appeal, mail your request and completed Waiver of Liability Statement (PDF) within 60 calendar days after the date of the Notice of Denial of Payment to: Health Net Medicare Appeals If we reject a claim for a missing NPI number, you must submit it as a new claim with updated information. If you have an urgent request, please outreach to your Provider Relations Consultant. Pre Auth: when submitting proof of authorized services. Coding Accesstraining guidesfor the provider portal. Non-participating providers are expected to comply with standard coding practices. Rendering/attending provider NPI (only if it differs from the billing provider) and authorized signature. Contact the applicable Health Net Provider Services Center at: Appropriate type of insurance coverage (box 1 of the CMS-1500). To expedite payments, we suggest and encourage you to submit claims electronically. *If you require training or assistance with our online portal, please contact your dedicated provider Relations Consultant. Accommodation code is submitted in Value Code field with qualifier 24, if applicable. All invoices require the following mandatory items which are identified by the red asterisk *: To ensure timely and accurate processing, completion of the following items is strongly recommended: Upon completion of the form, if the invoice will be submitted via Email or Upload, simply click on the corresponding link at the top right of the form to activate opening an email client with the email address populated or a web browser with the website/URL opened. The following providers must include additional information as outlined: To optimize the use of the invoice form capabilities intended to ease the invoice creation process, download the form to your computer and open using a PDF reader. However, Medicare timely filing limit is 365 days. These claims will not be returned to the provider. To avoid possible denial or delay in processing, the above information must be correct and complete. We ask that you only contact us if your application is over 90 days old. For earlier submissions and faster payments, claims should be submitted through ouronline portal or register with Trizetto Payer Nondiscrimination (Qualified Health Plan), Health Connector Payment for January Plans, Health Connector Payment for February Plans. Download the free version of Adobe Reader. Read this FAQabout the new FEDERAL REGULATIONS. These policies and methodologies are consistent with available standards accepted by nationally recognized medical organizations, federal regulatory bodies and major credentialing organizations. BMC HealthNet Plan | Provider Resources Check if lab work was performed outside the physician's office and indicate charges by the lab (box 20 on CMS-1500). Diagnosis pointers are required on professional claims and up to four can be accepted per service line. An administrative appeal cannot be requested for services rendered to a member who was not eligible on the date(s) of service, or for benefits that are not administered or covered by BMC HealthNet Plan. These billing procedures are designed to standardize billing practices and eliminate erroneous payments for state-supplied vaccines, which necessitate collection of overpayments from providers. For each immunization administered, the claim must include: Providers billing electronically must submit administration and vaccine codes on one claim form. The following providers must include additional information as outlined: Non-participating providers are expected to comply with standard coding practices. Timely Filing Limit of Insurances - Revenue Cycle Management Billing provider tax identification number (TIN), address and phone number. Download and complete the Credit Balance Refund Data Sheet and submit with supporting documents via Mail: Contract terms: provider is questioning the applied contracted rate on a processed claim. The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), is currently used to code diagnostic information on claims. *If you require training or assistance with our online portal, please contact your dedicated provider Relations Consultant. Providers should purchase these forms from a supplier of their choice. Health Net Appeals and Grievances Forms | Health Net If an issue cannot be resolved informally by a customer contact associate, Health Net offers its nonparticipating providers a dispute and appeal process. If you have an urgent request, please outreach to your Provider Relations Consultant. Documents and Forms | Providers - WellSense Health Plan In New Hampshire, WellSense Health Plan, provides comprehensive managed care coverage, benefits - and a number of extras such as dental kits, diapers, and a healthy rewards card - to more than 90,000 Medicaid recipients. Note: Date stamps from other health benefit plans or insurance companies are not valid received dates for timely filing determination. Sending claims via certified mail does not expedite claim processing and may cause additional delay. Helpful Links Enroll in a Plan Healthy Living Resources Senior Care Options FAQs About Us Careers News Contact Us I Am A. The original claim number is not included (on a corrected, replacement, or void claim). The most common reasons for rejected claims are: The process for correcting an electronic claim depends on what needs to be corrected: Replacement and void claims must include the original claim number in a specific position in the 837: Loop 2300, Segment REF - Original Reference Number (ICN/CDN), with F8 in position 01 (Reference Identification Qualifier) and the original claim number in position 02. In New Hampshire, WellSense Health Plan, provides comprehensive managed care coverage, benefits and a number of extras such as dental kits, diapers, and a healthy rewards card to more than 90,000 Medicaid recipients. Send us a letter of interest. P.O. The CPT code book is available from the AMA bookstore on the Internet. Providers unable to bill on CMS-1500 (02/12) must complete the Health Net Invoice form. Download and complete the Request for Claim Review Form and submit with all required documents via Mail. Find a provider Get prescription . If you do not obtain prior authorization, your claim may be denied, unless the claim is for emergency care. The following sources are utilized in determining correct coding guidelines: Health Net may request medical records or other documentation to verify that all procedures/services billed are properly supported in accordance with correct coding guidelines. The form must be completed in accordance with the Health Net invoice submission instructions. 4.1 TIME LIMIT FOR ORIGINAL CLAIM FILING 4.1.A MO HEALTHNET CLAIMS Claims from participating providers who request MO HealthNet reimbursement must be filed by the provider and must be received by the state agency within 12 months from the date of service. You will need Adobe Reader to open PDFs on this site. In addition to nationally recognized coding guidelines, the software has flexibility to allow business rules that are unique to the needs of individual product lines. Nondiscrimination (Qualified Health Plan). Service line date required for professional and outpatient procedures. Retraction of Payment: when requesting an entire payment be retracted or to remove service line data. Claim Payment Reconsideration . <> Pre Auth: when submitting proof of authorized services. Credit Balance Department Healthnet.com uses cookies. Coordination of Benefits (COB): for submitting a primary EOB. (submitting via the Provider Portal, MyHealthNet, is the preferred method). Common overpayment reasons include payments for services for which another payer is primary, incorrect billing, and claim processing errors such as duplicate payments. PDF General Rules Provider Guide - Oregon Rendering provider's National Provider Identifier (NPI). Choosing Who Can See My Confidential Medical Information. Billing Requirements: Institutional Claims, Billing Requirements: Professional Claims, Form: Medicare Part D Vaccine and Administration Claim, Guide: EDI Claims Companion Guide for 5010, Guide: Electronic Health Care Claim Payment / Advice (835) Companion Guide for 5010, Guide: Electronic Health Care Eligibility Benefit Inquiry and Response (270 / 271) Companion Guide for 5010, Instructions: Contract Rate, Payment Policy, or Clinical Policy Appeals, Instructions: Prior Authorization Appeals, Instructions: Request for Additional Information Appeals, Nondiscrimination (Qualified Health Plan).