Claims Manual
Claims Pend
Processing Profiles
Claims Pend Processing Profile
Process: 0J Queue Profile
Review non-par HH claims for reporting codes
Pend Description Four
Pend Category March 21, 2014
Date Implemented
Date Updated/Revised Senior Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Purpose
The purpose of this pend is to process claims according to the data reporting requirements for home health
prospective payment system (HH PPS) claims. Effective July 1, 2013, home health agencies (HHAs) must
report codes indicating the location where home health services were provided on home health claims, using
the Q codes Q5001, Q5002, and Q5009.
Q5001: Hospice or home health care provided in patient’s home/residence
Q5002: Hospice or home health care provided in assisted living facility
Q5009: Hospice or home health care provided in place not otherwise specific (NO)
The location where services were provided should be reported along with the first billable visit in an HH PPS
episode. In addition to reporting a service line according to current instructions, HHAs must report an additional
line item with the same revenue code and date of service, reporting one of the three Q codes (Q5001, Q5002,
and Q5009), one unit, and a zero or nominal charge (e.g. a penny). If the location where services were
provided changes during the episode, the new location should be reported with an additional line corresponding
to the first visit provided in the new location.
All claims submitted with the following criteria will pend 0J:
Bill type 32X or 33X, except for 322 and 332
Provider status = NP or OA
Process
Review the claim to determine if the provider billed correctly:
At least one revenue code line reporting HCPCS codes Q5001, Q5002 or Q5009 must be present
on any HH PPS claim.
HCPCS code Q5001, Q5002, or Q5009 must be reported with the following revenue codes: 42X,
43X, 44X, 55X, 56X or 57X.
The line item date of service of one line reporting HCPCS codes Q5001, Q5002, or Q5009 must
match the earliest dated HH visit line (revenue codes 42X, 43X, 44X, 55X, 56X or 57X) on the
claim.
For each line reporting Q5001, Q5002, or Q5009, there must be another service line (the HH visit)
with the same revenue code and date of service.
If more than one Q code (Q5001, Q5002, or Q5009) is billed on a claim, the same Q code cannot
be reported on consecutive days.
1 SSA 3/21/14
If the claim was submitted with missing and/or invalid data reporting information, deny the claim
E2 – “Invalid or Missing Required Claims Data.”
If the claim was submitted correctly, override the pend code and pay the claim. The Q codes
should process using the EX code of FA as they do not require an authorization.
2 SSA 3/21/14
Claims Pend Processing Profile
Process: 0V Queue Profile
AIR AMBULANCE CLAIMS
Pend Description TBD
Pend Category January 25, 2016
Date Implemented
Date Updated/Revised TBD
Person(s) Responsible As defined below:
Processing Instructions
Ambulance claims submitted with location 42 (Ambulance – Air or Water) pend 0V for review of documentation
to determine medical necessity.
1. Review the claim to determine if medical records are attached.
If medical records are not attached, OR are attached, but do not contain all of the necessary
information, proceed to step #2
Review the Requesting Additional Information Matrix to determine what information is
needed (the Prehospital Care Report Summary, Incident’s Information, and Medical
Comments).
If medical records are attached and contain all necessary information, proceed to step #3.
2. Request medical records:
Follow the Generating a Letter Requesting Additional Information process to request medical
records and refer to the Requesting Additional Information Matrix to ensure appropriate
information is requested.
If medical records are not received within 30 days, deny the service line EX NO, “Additional info
requested from provider to process claim not received.”
If medical records are received, but do not contain all of the necessary information, deny the
service line EX NW, “Additional info received from provider is insufficient to process claim.”
3. Prepare claim and medical records for review by a medical director:
Complete an Unlisted Procedure Code coversheet by handwriting the information (do not enter
into the Unlisted Database).
Note on the Unlisted Procedure Code coversheet that the claim was pending 0V and is
not unlisted.
Manually pend the claim EX EV, “Pending for medical director review.”
Provide the Unlisted Procedure Code coversheet, claim image, and additional information to
the Claims Director.
4. The Claims Director forwards the claim for processing according to the medical director’s
review.
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Claims Pend Processing Profile
Pend: 1N Queue Profile
Review J3490, J3590, J7799, and J9999
Pend Description Two
Pend Category October 6, 2008
Date Implemented April 4, 2016
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The purpose of this pend code is to ensure that all unclassified drugs are processed in a consistent manner and
according to CMS and PHN guidelines. Claims staff reviews the image of the claim for a description of the drug and
routes/examines the claim for pricing.
Review the claim image for the drug name, NDC#, and dose.
If the claim was submitted electronically and the drug name, NDC#, and dose are not on EDI Viewer,
review EDI Locator.
If there is no drug name and no NDC#, or only the drug name with no NDC#, deny the service line.
EX code 77, “Denied – Must bill with NDC# / Brand Name / Dosage of Drug.”
If the drug name is Avastin or bevacizumab, follow the “ms” pend processing procedure.
If the description is provided, verify that there is not a specific HCPCS code the provider can use to bill.
Click on the following Medicare website link: www.cms.hhs.gov/McrPartBDrugAvgSalesPrice or
reference the HCPCS coding book (Appendix 1 table of drugs).
The link is the Medicare Part B Drug Average Sales Price webpage. Refer to the date of service
on the claim to determine which year’s ASP Drug Pricing File to review and click on the
appropriate year.
Scroll to the bottom of the page. Under Related Links, click the ASP Pricing File, which is in an
Excel spreadsheet.
On the Excel spreadsheet, perform a search (Ctrl + F) for the drug name billed.
If the drug name is on the ASP Drug Pricing file, a specific HCPCS code is available and the
provider billed incorrectly.
If the drug name is not on the ASP Drug Pricing file, a specific HCPCS code is not available and
the provider billed correctly.
If there is a specific HCPCS code available, deny the service line.
EX code 27, “Please submit specific CPT/HCPCS code for service,” and
Enter a claim remark stating, “Resubmit with correct procedure code.”
If there is not a specific HCPCS code available, request medical records.
Follow the Generating a Letter Requesting Additional Information process to request medical records
and refer to the Requesting Additional Information Matrix to ensure appropriate information is requested.
If medical records are not received within 30 days, deny the service line EX NO, “Additional info
requested from provider to process claim not received.”
If medical records are received, but do not contain all of the necessary information, deny the service line
EX NW, “Additional info received from provider is insufficient to process claim.”
1 SSA 04.20.2016
Upon receipt of medical records, pend the claim and send a service form (SF) with the medical records
attached to Pharmacy requesting the Average Wholesale Price (AWP).
Pend all lines on the claim with EX code RU, “Medical Information Received – Pharmacy Claims”.
Send a service form with the received medical records attached to Group-PH-Pharmacy Operations to
request the AWP. Specific SF language is provided under “To send a service form to Pharmacy.”
To Send a Service Form (SF) to Pharmacy:
In Macess, click the Create Service Form button.
Double click “Claims Service Form.”
On the “Contact” tab:
Enter the Member # and the Provider #.
Type “N/A” in the Contact Name field.
Select “Pricing Issue” as the Subject.
Select the “Details” tab.
Expand Medical Management.
Select “Pend for Manual Price.”
Click “Pend for Manual Price” in the field below.
Select the “Information” tab.
Complete the Member #, Provider #, Claim #, Date of Service, and Procedure Code fields.
Click Save.
Click the ActionGram button or select “ActionGram” under the Actions menu.
Check the “Forward” option.
Enter Group-PH-Pharmacy Operations in the “To” field.
Enter a message stating verbatim:
“Please review claim #____________ HCPCS code _____ (drug name, dose, NDC#)
and provide the AWP. Medical records are attached”
Example: Please review claim #15012E006793 and HCPCS code J3490 (Verapamil
10 mg SC NDC 00409114402) and provide the AWP. Medical records are attached.”
The SF must include the claim #, HCPCS code, drug name, dose, and NDC#. See J-code
claim fields on pages 3-4.
Click Send.
Enter a claim remark stating, “Forwarded SF(_#_) to Pharmacy for the AWP.”
Once the SF is returned from Pharmacy with the AWP, calculate and enter the allowed amount on the
service line.
Calculate the allowed amount based on the AWP provided by Pharmacy.
The AWP provided by Pharmacy is per unit. If the HCPCS units are greater than one, multiply
the AWP by the number of J-code units billed.
Note: Multiply the AWP by the number of HCPCS (J-code) units billed, not the number
of NDC units or the NDC quantity. See J-code claim fields on pages 3-4.
PH pays the lesser of the billed charges or the allowed amount calculated by the Claims
Examiner. If the allowed amount calculated is greater than the billed charge, enter the billed
charge as the allowed amount.
Enter the calculated allowed amount (or enter the billed charge if it is lesser than the calculated allowed
amount) in the “B-Allow” and “P-Allow” fields.
Select the service line pending 1N and click Service Detail.
Click Override Amt.
Select “2 – Override Dollars” in the drop down menu next to “Override $:” and Press Enter.
Click Save.
If the Override EX Errors screen generates, enter “AP” in the EX Code field next to 1N.
Click Save.
Exit the screen.
Click Readjudicate to readjudicate the claim from the header.
If the line that was pending 1N flips to EX code q2, “(LRD) LCD Part B Review/Request Documents,”
override the q2 with EX code AP, “Approved.”
2 SSA 04.20.2016
Additional Processing Guidance
Claim Types / Scenarios Process
Injections Used as Local Anesthetics
Drug names that fall under this If the drug name billed is one of the drug names listed to the left, the
category are: claim/drug does not require review for pricing by Pharmacy.
Lidocaine Override pend code 1N with EX code K6, “Services Included under
Marcaine
procedure billed.”
Sodium Bicarbonate
Bupivacaine Verify that the service line pays $0.
NDC# is not required for injections
used as local anesthetics. Service
lines should process with EX K6,
even if the NDC# is not billed.
Compound Drugs
Multiple medications billed as a Review the claim attachments or EDI Locator for the invoice.
compound drug can be processed If the invoice is not attached, deny the service line with:
if the invoice is provided. EX code TA, “Total acquisition/invoice cost required.”
If the invoice is attached, enter the invoice amount in the “B-Allow” and
“P-Allow” amounts on the Override Amt screen.
Ensure the invoice amount is only for the drug compound.
Do not include taxes.
PH pays the lesser of the billed charges or the allowed amount. If the
invoice amount is greater than the billed amount, enter the billed charge
in the “B-Allow” and “P-Allow” fields.
ER & Dialysis Hospital Claims
The drug name, NDC#, dose, and Hospital claims with locations 23 and 65 with service lines pending 1N:
price are not required for hospital If the claim is payable, override the 1N pend code with EX code AP,
claims with locations 23 (ER) & 65 “Approved.”
(Dialysis). Payment is bundled If the claim is not payable (denied), override the 1N with the denial code
and not paid on the individual on the remaining lines of the claim.
service line. Verify that the service line pays $0.
J-Code Claim Fields
EDI Viewer
J-Code NDC#
NDC
Units
J-Code
Units
3 SSA 04.20.2016
EDI Lcoator NDC# J-Code
Drug name
and Dose
NDC#
NDC
Quantity
4 SSA 04.20.2016
Claims Pend Processing Profile
Pend: 2K Queue Profile
Primary Care Behavioral Counseling to Reduce Alcohol Misuse
Pend Description Three
Pend Category October 1, 2012
Date Implemented April 14, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Informational
Effective for claims with dates of service October 14, 2011, and later, CMS covers annual alcohol screening,
and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for
Medicare beneficiaries, including pregnant women.
HCPCS definitions:
G0442 Annual Alcohol Misuse Screening, 15 minutes
G0443 Brief face-to-face behavioral counseling for Alcohol Misuse, 15 minutes
G0443 can only be paid if G0442 was billed within the previous 12 months.
G0443 cannot be billed more than four times within 12 months. If it is billed more than four times in 12 months,
the system will deny G0443 with denial code P9, “Benefit maximum has been reached.”
Process
Verify G0442 was billed within the 12 months prior to the service date of G0443.
Select “Global Functions” “Claims Processing” “Claims by Member.”
The Member# field should be populated. If not, enter the member # from the claim.
In the drop-down menu above the Member# field, select “2 – Online and Batch.”
In the Procedure field, enter “G0442.” Press Enter.
Review the listed claims to verify G0442 was billed within the 12 months prior to the service
date of G0443.
If G0442 was billed within the 12 months prior to the service date of G0443:
Override the 2K pend on G0443 with EX code AP, “Approved.”
If G0442 was not billed within the 12 months prior to the service date of G0443:
Deny G0443 with EX code IB, “Denied - billing error - please resubmit claim with correct
information.”
Enter an EP remark on the claim.
Click “Remarks” on the left pane.
Click the green plus sign in the tool bar.
Enter the date of service for the Remark Effective Date.
Enter “12/31/9999” for the Exp Date.
Type “EP” in the Remark Type field.
Enter an EP remark stating verbatim, “Medicare does not pay for services or items
related to a procedure that has not been approved or billed.”
1 SSA
Claims Pend Processing Profile
Pend: 3N Queue Profile
Claims Review Of Provider Specialty/ PCP vs. SPEC / L1 vs. L2
Pend Description One
Pend Category December 16, 2002
Date Implemented May 27, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
PHN is contracted with several PCPs who also have specialist contracts.
Claims are pended 3N to ensure claims for members who are assigned to a PCP that is also a specialist, are
processed with the appropriate affiliation as PCP and specialist affiliations are paid differently. Claims pended
3N are also reviewed for multiple localities, L1 and L2.
Review the notes on the claim image for indication of PCP or specialty affiliation. Notes will
state, “PCP,” “SPEC,” or “SPC.”
Review the claim image in EDI Viewer.
In EDI Viewer, notes can be found on the front page of the claim image as well as on
the service line(s).
Claims containing an “M” may need to be reviewed in Macess to ensure notes are viewed.
In Macess, notes can be found on the header of the claim as well as on the service line
detail.
If the notes on the claim image indicate “PCP,” “SPEC,” or “SPC,” select the corresponding
affiliation in Amisys.
If the note states “PCP,” select the PCP affiliation with PC in the PC field. Be sure to also
select the correct locality.
If the note states “SPEC” or “SPC,” select the specialty affiliation with SP in the PC field. Be
sure to also select the correct locality.
However, if “SPEC” or “SPC” is noted, but the PCP and the servicing provider are the
same, select the PCP affiliation with PC in the PC field.
1 SSA
Verify the provider number, affiliation, and Class (PC) on the Provider Affiliation screen
(PR0300).
For PCP affiliations, Class (PC) = PC
For specialty affiliations, Class (PC) = SP
If the notes on the claim image do not indicate “PCP,” “SPEC,” or “SPC,” determine the
appropriate affiliation.
If the PCP and servicing provider are the same:
Select the PCP affiliation with PC in the payclass (PC) field. Be sure to also select the correct
locality.
Verify the provider number, affiliation, and Class (PC) on the Provider Affiliation screen
(PR0300).
For PCP affiliations, Class (PC) = PC
For specialty affiliations, Class (PC) = SP
If the PCP and Servicing Provider are different:
Copy the PCP #,
Open the On-Call History screen (IQ1700).
In the Primary Type drop-down menu, select “P- Provider.”
In the Primary field, enter the PCP #. Press Enter.
The On-Call History list will populate.
If the servicing provider is listed, select the PCP affiliation with PC in the payclass (PC)
field. Be sure to also select the correct locality.
If the servicing provider is not listed, select the specialty affiliation with SP in the
payclass (PC) field. Be sure to also select the correct locality.
Verify the provider number, affiliation, and Class (PC) on the Provider Affiliation screen
(PR0300).
For PCP affiliations, Class (PC) = PC
For specialty affiliations, Class (PC) = SP
Override the 3N EX code.
Single code
Click “Service Detail.”
Click “Reset/Adj.”
Type “AP” in the EX code field on the line containing the 3N pend.
Press Enter or click Save and exit the screen.
Exit the Service Detail screen as well.
The 3N pend code should be removed and replaced with the appropriate EX code.
Multiple codes
Click “EX Overrides.”
Type 3N in the “OLD EX” field and press Tab.
Type “AP” in the “NEW EX” field and press Enter.
Type “Y” when prompted, “Are the above overrides correct? Y/N.”
Press Enter and exit the screen.
Click Readjudicate.
The 3N pend code should be removed and replaced with the appropriate EX code.
2 SSA
Claims Pend Processing Profile
Pend: 3O Queue Profile
PR- Review Multiple Fees or Manual Price
Pend Description TWO
Pend Category September 17, 2009
Date Implemented September 28, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
This pend is used for certain drugs and devices that are approved and being billed with HCPCS code
E1399.
The 05 line of the auth will list the exact amount to pay. The auth should also be date specific as to the
services that are being authorized.
The payment information may also be in the remarks of the authorization.
Review the claim image, the description of the code should be listed.
Review the authorization for the code listed for E1399, if no prices contact Health Services.
If there is no description, the claim should be denied 78 (submit description of code E1399)
If the claim flips to an iCES pend to review code, the iCES pend can be overridden if the service
has been authorized.
If the authorization says there is no member liability override the coinsurance and pay
according to the authorization.
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Claims Pend Processing Profile
Pend: 3T Queue Profile
Limited to Limit Exceeded
Pend Description Three
Pend Category September 13, 2009
Date Implemented June 6, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Emergency Room Claims
Emergency Room (ER) claims should take one copay per visit. The system pends any claim submitted with a
date span equal to more than a day. The claims pend whether or not the dates are on the same claim or two
separate claims.
If the member had a second ER visit (in addition to the original) within 24 hours and neither visit resulted in an
inpatient admit, the appropriate ER copay should apply to both claims. However, if the member had an ER visit
that resulted in an inpatient admit, an ER copay is not applied and the claim is denied EX IB with an EP remark
stating verbatim, “Emergency services must be included on the inpatient claim.”
Determine the copay overage.
Verify the ER copay that coincides with the member’s plan by viewing the Benefits List
01.2015.
Locate the ER service line(s).
The ER service line will have REV Code 450.
Click Claim Summary.
View the service line(s) to determine where the overages have been added.
Remove the additional copay amount from the service line(s) until the claim’s copay equals the
ER copay for the member’s plan.
Select the service line with the excess copay amount.
Click Service Detail.
Click Override Amt.
Type 2 in the highlighted box and press Enter.
In the copay field, enter “00.”
Click Save and exit the screen.
Exit the Override EX Errors and the Service Detail screens.
Click Claim Summary to verify the copay is correct.
The copay amounts may jump to other service lines. Remove all additional copay
amounts until the claim’s copay is equal to the ER copay for the member’s plan.
It does not matter where the copay is deducted from as long as the claim’s copay
equals the ER copay for the member’s plan.
If the 3T does not fall off once the copay amount has been corrected, override the 3T with EX
code AP.
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Therapy Claims
Therapy claims pend when a member reaches their therapy cap. If the KX modifier is not billed on the service
line(s), the allowed amount is reduced by the remainder of the therapy cap. Once the therapy benefit is
depleted, therapy claims billed without the KX modifier are denied EX KH, “Therapy calendar year maximum
has been met.”
However, therapy claims billed with the KX modifier are an exception to the therapy cap. Therefore, therapy
claims with the KX modifier are not reduced according by the therapy cap and are not denied KH.
Review the service line(s) in Amisys and on the claim image to determine if the “KX” modifier is
present.
If the KX modifier is billed, override the 3T to approve the service(s).
Single code
Select “Diagnosis, Procedures & Service Detail” tab.
Select the service line containing the 3T and click “Service Detail.”
Click “REset/Adj.”
Type “AP” in the EX code field on the line containing the 3T pend.
Press Enter or click Save and exit the screen.
Exit the Service Detail screen as well.
The 3T pend code should be removed and replaced with AP.
Multiple codes
Select “Diagnosis, Procedures & Service Detail” tab.
Click “EX Overrides.”
Type “3T” in the “OLD EX” field and press Tab.
Type the “AP” in the “NEW EX” field and press Enter.
Type “Y” when prompted, “Are the above overrides correct? Y/N.”
Press Enter and exit the screen.
Click Readjudicate.
The 3T pend code should be removed and replaced with AP.
If the KX modifier is not billed, update the Allowed amount.
Select the first service line pending 3T.
Click Service Detail.
In the grey box in the upper right hand corner, note the B-Allow amount.
Click Reset/Adj.
View the line containing the 3T. The overage amount will be listed on the line.
Subtract the overage amount from the B-Allow amount to determine the Allowed amount.
B-Allow amount – Overage amount = Allowed amount
Exit the EX Overrides screen.
Click Override Amt.
Enter “2.”
In the B-Allow and P-Allow fields, enter the Allowed amount without decimals.
If the Allowed amount is less than the Copay amount, enter the Allowed amount in the
Copay field as well.
Press Enter or click Save.
Exit the Service Detail Screen.
Click Readjudicate.
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Claims Pend Processing Profile
Pend: 4Y Queue Profile
Claims to review 00102 & 00537 for Bundled Codes
Pend Description Four
Pend Category March 7, 2002
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Procedure codes carry bundled services that can't be overriden by modifier -59. If the following procedures
codes are billed with these anesthesia codes, deny 8P. Procedure code: 00102-the bundled code is 94250.
Procedure code: 00537-bundled codes are 99234, 99213, 99233, 99205, 99235-99239, 99241-99245, 99251-
99253, 99232.
Claims Pend Processing Profile
Pend: 5S Queue Profile
Entry of Payment Allowed Amount Required, Review Auth
Pend Description Two
Pend Category November 15, 2002
Date Implemented March 19, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The purpose of this pend is to review procedure code E1399, which is billed by DME providers. Claims
examiners will review the authorization and verify the allowed amount.
Review the information on the Amisys readjudication screen and verify it matches the
information on the claim image.
Add any missing information if necessary.
Certain modifiers are the difference between a claim being paid or rejected.
Correct the readjudication screen information if necessary and click ReAdjudicate or REset/Adj
to save changes.
Check to see if there is a description on the claim image.
If no description submitted deny claim with EX code 78--Submit description of code E1399.
Verify that the item described is covered in the authorization.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Highlight the service line you want to verify.
Click “service detail” on left side of screen.
Verify there is an authorization.
“A” authorizations are for inpatient hospital services and “R” authorizations are for
anything other than inpatient hospital services.
Copy authorization number, enter it in the Certification screen, and press Enter.
Click “Authorized Services” on the left side of screen and a new screen will generate.
Click remarks on the left side of the screen.
Click the binoculars at the top of the screen and then hit enter.
Read through the remarks for item description and price.
If the authorization applies to the claim, manually enter the item price and override claim.
In the Medical Service Detail Readjudication screen, click “Override Amt” on the left side of the
screen.
Select “2” in the “Override $:” field and hit enter.
Should the allowed amount on the authorization be more than the item
amount on the claim or vice versa, always choose the lesser of the two
amounts.
Enter the allowed amount for that item in the B-Allow and P-Allow field.
Hit Enter and exit the screen.
The Override EX Errors screen will generate. Enter “AP” in the field following the “VF” code.
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Exit the Override EX Errors and Medical Service Detail Readjudication screens.
Readjudicate the entire claim.
If the authorization is vague or does not specify how much an item is, create an ISF (internal
service form) to DME (Durable Medical Equipment Department) and request verification.
Login to MACESS.
Click the Create Service Form icon or click Create Service Form under the MyWork tab.
Double click the Claims Service Form.
Complete the Contact, Details, and Information tabs.
Click the save icon.
Select ActionGrams under the Actions tab at the top of the Service Form screen.
Check “Forward (Will Return To You)” and refer to the “Who To Send SFs To” document when
selecting the ISF recipient.
Include this message: “PLEASE REVIEW AUTH#_____ ON CLAIM #____. PROVIDER
BILLED E1399. PLEASE ADVISE THE CORRECT AMOUNT TO BE PAID.”
Once you receive your needed information, you can process or deny your claim as needed.
If the authorization does not apply to your item, review Authorizations by Member to see if a
different authorization applies to the claim.
Click Global Functions.
Hover over Authorizations and click Authorizations by Member.
Click the binoculars at the top of the screen and hit Enter.
Review the member’s authorizations to see if another one shares the same service dates.
If another authorization applies to the claim, return to the Medical Service Detail Readjudication
screen and space out the Auth# field.
Click REset/Adj, select the applicable authorization, and readjudicate the claim.
Remark the claim.
Click “Remarks” on the left side of the screen.
Click the green plus sign, which is the second icon at the top of the screen.
Enter “12-31-9999” in the Exp Date field and “CL” Remark Type field.
Remark something pertaining to the department name approving the item at the decided price.
Check that the Status “St” has ALL 10s, 11s, 12s, 50s, 51s, or a combination of 10s, 11s, 12s,
50s, and 51s.
If the status contains ANY other codes, DO NOT demand draw. The claim will fall into an
appropriate queue to be fixed.
Do not Demand Draw 31 or 41 statuses.
If there are other EX Codes remaining and you are able to process them, continue to process
them.
It is OK if there are other Ex codes besides AP or CP if you do not know how to process them.
Demand Draw the claim from the queue.
Maximize Macess.
Select “My Work” from tool bar.
Select “Workflow Examination” on the drop down menu.
Click the “Draw Mode - Demand” icon.
Click the “Select Work Item” icon.
Place cursor in Document ID field and type in claim number.
Check New, Pended, and Rerouted options in Work Item Status section.
Hit Enter.
Select “Work Flow Examination.”
Select “Complete.”
Select “Save” and X out the screen.
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Claims Pend Processing Profile
Pend: 6O Queue Profile
The service has exceeded the authorized limit by xxx
Pend Description Two
Pend Category August 07, 2009
Date Implemented April 20, 2016
Date Updated/Revised Claims Examiner
Person(s) Responsible As defined below:
Processing Instructions
Note: All services/items provided in location 12 and all inpatient locations (21, 31, 51, and 61) require an
authorization. All services provided by a non par provider require an authorization.
For par provider claims with locations 11 and 19/22/24, open the Peoples Health Authorizations
Requirements Search website to determine if an authorization is required for the procedure code(s) billed.
Click on the following link: http://phn-win-27/Proc_Auth_Internal/.
In the Provider Number field of the Tax ID field, enter the provider’s number/Tax ID.
In the Procedure Code field, type the procedure code pending 6O.
In the Place of Service field, click the drop-down arrow and select the location on the claim.
Click Search. The authorization requirement indicator will populate.
N – No authorization required.
Y – Authorization required.
If an authorization is not required, override the 6O pend.
Return to the Readjudication screen.
Select the “Diagnosis, Procedures & Service Detail” tab.
Select the service line pending 6O and click “Service Detail.”
Click “Reset/Adj.” The Override EX Errors screen will appear.
Type “AP” on the line pending 6O. Press Enter.
Repeat the above steps for all service lines pending 6O that do not require an authorization.
Review the authorization in the Certification screen (UA0100) to determine the number of days/units
authorized.
Type UA0100 in the field under Global Functions and press Enter. The Authorization Certification screen
will appear.
Click the Binoculars icon and paste the authorization number in the Auth# field. Press Enter.
Click one of the following:
“Authorized Svcs” for authorization numbers containing an R; or
“Hospital Svcs” for authorization numbers containing an A.
Review the remarks and the count on the authorization to determine the days/units authorized.
Review Claims by Authorization (IQ1100) to identify the claims that hit the authorization and determine if
other claims hit the authorization in error, reducing the count.
From the Certification window, select “Global Functions” “Authorization” “Claims by Authorization.”
The authorization number will auto-populate. Press Enter.
A list of claims will populate.
Review the list of claims paid from the authorization.
Take note of the claim number(s) that hit the authorization and the count that each claim used (depending
on the authorization, this will be days or units).
1 SSA 11.12.2014
If previous claims paid off of the authorization in error, override the 6O pend with EX code AP, “Approved”
to approve the service(s).
Adjust the previous claim(s) that paid off the authorization in error if the service(s) require an authorization,
but one was not obtained.
See below for steps to update previously paid claims.
If the claim was not billed according to the authorization, deny the service(s) with EX code 63, “Provider
billing for services different from authorization.”
If the claim truly exceeds the authorized days/units:
Par provider claims, deny the service(s) with EX code SD, “Denied – This service exceeds authorized
visits.”
Non par provider claims, review the claim according to the development guidelines outlined in the O8 pend
process.
If the claim hit the authorization in error and the service(s) were not authorized, review the member’s folder
in Macess for an MNF or other documentation to support that the service(s) billed should be authorized.
If there is documentation to support the service(s) billed, create a Service Form (SF) in Macess and attach
the supporting documentation.
Refer to the Who to Send Service Forms document to determine the recipient of the SF.
Request review of the documentation and claim to determine if the services were authorized/if an
authorization should be added. requesting review.”
Enter a CL remark stating, “SF#
Process the claim according to Medical Management’s directive.
If there is no documentation to support the service(s) billed and the service(s) were not authorized:
Par provider claims, deny the service(s) with EX code JL, “Participating provider billing for unauthorized
service.”
Non par provider claims, review the claim according to the development guidelines outlined in the O8 pend
process.
Steps to update previously paid claims:
Claim in Readjudication Status
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the EX code currently on the claim.
Press Tab.
Type the appropriate EX code in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
Press Enter and close screen.
Click “ReAdjudicate” and select “Diagnosis, Procedures & Service Detail” tab. The previous EX code should be
replaced with the new EX code.
Close/X out screen.
Click “ReAdjudicate” to save changes.
Refer to the Claims Adjustments document to adjust previously paid claims.
Steps to override the 6O pend:
Single service line:
Click “Service Detail.”
Click “Reset/Adj.”
Type the appropriate EX code in the EX code field containing the 6O pend.
Press Enter or click Save and exit the screen.
Exit the Service Detail screen as well.
The 6O pend code should be removed and replaced with the appropriate EX code.
2 SSA 11.12.2014
Multiple service lines:
Click “EX Overrides.”
Type 6O in the “OLD EX” field and press Tab.
Type the appropriate EX code in the “NEW EX” field and press Enter.
Type “Y” when prompted, “Are the above overrides correct? Y/N.”
Press Enter and exit the screen.
Click Readjudicate.
The 6O pend code should be removed and replaced with the appropriate EX code.
Par and Non Par Authorization Denial Codes
EX EX Description Usage Prov
Code Provider billing for services Status
different from authorization. An authorization is on file for the service(s) billed, but the Par &
63 claim was not billed according to the authorization. Non Par
Examples of correct usage of EX code 63 include, but are
SD Denied - This service not limited to: Par
exceeds authorized visits. Billed location does not match authorized location. Par
Does not apply when the pro fee is billing location 19 Non Par
JL Participating provider billing
for unauthorized service. and the facility is billing location 22, and vice versa.
The two POS codes are interchangeable and should be
DV Non-participating provider treated the same (see page 6).
billing for unauthorized
service. An authorization is on file for the service(s) billed, but the
days/units authorized have been used. The claim exceeds
the authorized count.
After research and review, it was found that there is no
authorization on file for the service(s) billed.
After research and development, it was found that there is
no authorization on file for the service(s), or that the services
exceed the authorized count and the claim is not
urgent/emergent, par referred, or for post-stabilization.
The following pages contain claim specific directives. If instructed to send an SF, follow the Claims
Authorization Request Service Form Process located at Claims Department\Training Material\Process
Documents\Claims Authorization Request Service Form Process.
Enter a remark on the claim indicating a request was sent for the authorization to be updated.
From the Readjudication screen, click “Remarks.”
Click the green plus sign to add a new remark.
In the Remark Effective Date field, enter the beginning service date.
In the Exp Date field, enter 12/31/9999.
In the Remark Type (RM) field, type “CL.”
In the Remark Summary field, type “SF# requesting update to auth #_____.”
Once the Claims Authorization Request Service Form is returned and the authorization has been updated,
readjudicate the claim in Amisys to remove the 6O pend.
Repeat above steps as necessary if the 6O pend does not fall off.
3 SSA 11.12.2014
Additional Processing Guidance
Claim Types / Scenarios Process
Inpatient Pro Fee (Locations 21, 31, etc.) Review the related admission pro fee authorization’s
Professional services provided to a member count/units. The units should equal the number of days
while in an inpatient hospital setting.
These services are referred to as “pro fees.” admit through discharge, including the discharge date.
If the authorization count is short, send an SF to Claims
Authorizations requesting an update to the pro fee count.
*Note: The count on the inpatient admission authorization will be
one unit less than the related admission authorization for pro fees
because the day of discharge is not included on the inpatient
admission authorization.
Rolling from Observation to Inpatient
Authorizations for members who roll from Review the authorization remarks to determine if the
observation to inpatient.
member rolled from observation to inpatient.
Physicians bill pro fee claims with inpatient If the remarks indicate that the member rolled from
location for DOS while the member was in
observation and vice versa. observation to inpatient:
Par Claims: Send an SF to Claims Authorizations
requesting an update to both pro fee authorizations’
date spans and counts to reflect the inpatient admit
(facility) authorization.
Non par Claims: Send an SF to Claims Authorizations
requesting an authorization for the pro fee, regardless
of whether or not the member was in the billed location
on the billed date of service.
*Note: The count on the inpatient admission authorization will be
one unit less than the related admission authorization for pro fees
because the day of discharge is not included on the inpatient
admission authorization.
Example:
Member in observation 11/26/15-11/27/15
Member rolled from observation to inpatient on 11/28/15 and
was discharged on 12/16/15.
A location 22 and location 21 pro fee authorization is needed for
the entire stay, 11/26/15-12/16/15.
RAPs Charges
Provider specialty is AA, AN, AT, CR, DQ, EA, Refer to the Processing Professional Fees, Readings, &
EM, MP, PG, or RA AND service location is 19, RAPs table.
21, 22, 23, 24, 31, or 61
Observation Authorizations
Observation authorizations built with one unit Review the number of units billed on the observation
less than the date span.
authorization.
If the number of units built on the authorization is one less
than the date span, send an SF to Claims Authorizations
requesting an update to the authorization.
For example, a claim’s date span covers 1/1/15 – 1/2/15 (2
days). The authorization’s date span covers 1/1/15 – 1/2/15
and is built with one unit.
Inpatient Acute & Observation Claims with Date Span Greater than Authorization Span
Inpatient Acute – Bill Type 11X Review the claim for revenue code 450.
Observation – Bill Type 13X with 762 revenue If the claim contains revenue code 450, and the billed date
code span is one day prior to the start of the authorization and is
The claim’s coverage dates exceed the one unit greater than the authorized days/units, override the
authorized date span. 6O with EX code “AP.”
If the claim does not contain revenue code 450 OR if the
Review the claim for revenue code 450, which number of days/units billed is greater by two or more than
indicates the member was admitted through the the number of days/units authorized, send an SF to Medical
management requesting review of the authorization for
4 SSA 11.12.2014
ER. possible update.
Refer to the Who to Send Service Forms document to
determine the recipient of the SF.
Process the claim according to Medical Management’s
directive.
Do not deny an observation or inpatient claim that has
an authorization on file without sending an SF to
Medical Management first requesting review of
authorization for possible update.
Inpatient Acute, SNF, and Rehab Claims
Inpatient acute, skilled nursing facility (SNF), and Review Claims by Member to determine if the member
rehab claims may pend 6O if the member was transferred from one facility to another.
transferred from one facility to another. This is The claim will have an admit date or a discharge date prior
due to the three-day window. to or after the claim pending 6O. For example:
Claim A has admit to Touro on 09/01/2014 and
Inpatient Acute – Bill Type 11X
SNF – Bill Type 21X discharge on 09/05/2014.
Rehab – Bill Type 11X with Revenue Code 0024 Claim B has an admit to a SNF on 09/06/2014 and
with a 5 digit HIPPS Rate/CMG Code
discharge on 09/20/14.
If there is another facility claim on file and the member
transferred, override the 6O pend with EX code “AP” to
approve the claim.
If there is not another facility claim on file indicating a
transfer, review the count on the authorization and process
the claim as outlined on pages 1-3.
Two Separate Admits in One Day
If a patient is admitted, discharged, and admitted Review Claims by Member to verify there is another claim
to another facility all in one day, the system will on file for a different facility with the same admit date.
price the first claim and pend the second claim If there is another facility claim with the same admit date
6O. and both stays are authorized, override the 6O pend with
EX code “AP;” and
The second claim requires manual pricing for Manually price the claim.
payment.
If there is a claim on file for the same facility with the same
admit date, review and process the claims following the
Potential Duplicate Claims process.
If there is not another claim on file for a different facility
with the same admit date, review the count on the
authorization and process the claim as outlined on pages
1-3.
Ambulance Claims (Location 41) – Added June 23, 2015
Often times, if an authorization is on file for a Review the claim to determine if the transport is emergent
non-emergent trip (from the hospital to the or non-emergent.
member’s residence), it will cause the emergent Review the procedure code’s description; it will indicate
trip (from the member’s home to the hospital) to
emergency or non-emergency transport.
pend 6O if the service dates are within the For example:
authorized dates or the three-day window. A0426 - Ambulance service, advanced life support, non-
emergency transport, level 1 (als 1)
Review the claim pending 6O to determine if it is A0427 - Ambulance service, advanced life support,
emergency transport, level 1 (als1-emergency)
an emergency or a non-emergency transport. A0428 - Ambulance service, basic life support, non-
This is indicated by the procedure code’s emergency transport, (bls)
description. A0429 - Ambulance service, basic life support, emergency
transport (bls-emergency)
If the ambulance transport is emergent, no If the trip was emergent, override the 6O with EX AP,
authorization is required. All lines on the claim “Approved.”
should pay, if otherwise payable.
If the trip was non-emergent and the units billed truly
If the ambulance transport is non-emergent, an
authorization is required. Review Claims by exceed the authorized units, deny the service line(s)
pending 6O with EX SD, “Denied - This service exceeds
authorized visits.”
Verify no emergency transport claims reduced the
5 SSA 11.12.2014
Authorization to verify an emergency transport authorization’s count in error before denying EX SD.
did not reduce the count in error.
POS 19 Medical Claims
Effective January 1, 2016, CMS added POS 19
to the Place of Service code set to identify off Review Authorizations by Member to determine if a related
campus provider-based hospital departments to
differentiate from on campus provider-based POS 22 authorization is on file.
hospital departments (POS 22). If a related POS 22 authorization is on file, send an SF to
The description of POS 19 is, “Off campus- Claims Authorizations to have a POS 19 authorization
outpatient hospital.”
added/updated.
The description of POS 22 was updated to, “On If a related POS 19 or 22 authorization is not on file, deny
campus-outpatient hospital.”
the claim EX JL, “Participating provider billing for
Claims billed with POS 19 follow POS 22 unauthorized service.”
authorization requirements and processing If a related POS 11 authorization is on file, leave the claim
guidelines.
pending 6O. Enter an AG remark and inform the Quality
POS 19 and POS 22 are interchangeable in
regards to authorizations. Improvement Manager. DO NOT DENY FOR NO
POS 19 and POS 11 are NOT interchangeable in AUTHORIZATION unless directed by management.
regards to authorizations
Additional Processing Guidance
RAPs – Follow the RAPs process.
Pro fees – Review Authorizations by Member.
If a related POS 19/22 facility claim or authorization is
on file, send an SF to Claims Authorizations to have a
POS 19 authorization added/updated for the pro fee.
If a related POS 19/22 facility claim or authorization is
not on file, follow the normal processing guidelines.
Therapy – Review Authorizations by Member
If a related POS 22 therapy authorization is on file,
send an SF to Claims Authorizations requesting the
authorization location be updated.
Claims billed with POS 19 that are pending 6O follow
normal 6O processing guidelines.
Hospital Claims
Review Authorizations by Member to determine if a related
location 22 authorization is on file.
If a related location 22 authorization is on file, send an SF to
Claims Authorizations have a POS 19 authorization
added/updated.
If a related POS 19 or 22 authorization is not on file, deny
the claim EX JL, “Participating provider billing for
unauthorized service.”
Modifier PO on a hospital claim indicates services were
performed off campus-outpatient hospital (POS 19). Some
or all lines of a hospital claim may contain modifier PO.
Amisys will determine the location of a hospital claim by
the presence of modifier PO on the first service line (0100).
If service line 0100 was billed with modifier PO, Amisys will
apply location 19 to the header of the claim.
If service line 0100 was billed without modifier PO, Amisys
will apply location 22 to the header of the claim.
Authorizations will map based on the location at the header
of the claim, which must match the location on the
authorization.
Additional Processing Guidance
Pro fees billed with POS 19/22 should NOT deny EX 26 or
EX 63 if the related facility claim is billed with POS 19/22.
Claims billed with modifier PO that are pending 6O follow
normal 6O processing guidelines.
6 SSA 11.12.2014
Claims Pend Processing Profile
Pend: 8C Queue Profile
Total number of days is greater than coverage
Pend Description Four
Pend Category September 13, 1999
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Review claims and the auth to ensure DOS have been entered correctly. If the date of service on the claim and
the dates of service on the hospital screen of the auth is correct, it’s then ok to override the 8C pend code.
EX: claim DOS – 06/01/05-06/16/05 (field 2 in Amysis); hosp screen on the auth DOS- 06/01/05-
06/16/05…Amysis has 15 units in field 07-INP DAYS and the units on the room and board charge on the line
has 16….then it’s ok to override because the system is not calculating the discharge date…..see clm
05192M007805
If provider bills two (2) units for the room and board charges and the date span in Amysis covers one (1) day,
deny the claim as IB and remark the EOP with “Date span does not correspond with units billed.”
EX: claim DOS – 01/07/05-01/13/05 – 6 days ; Room and Board charges has 7 units; auth has 01/07/05-
01/14/05, then deny as IB and remark EOP….see clm 05206M009816
Claims Pend Processing Profile
Pend: 8T Queue Profile
Multiple Referring Provider Affiliations Qualify
Pend Description One
Pend Category May 8, 2002
Date Implemented February 23, 2012
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
8T Queue is generated to ensure the appropriate referring provider is selected.
Open two Amisys Advance screens.
First
Open Amisys and login.
Click “Claims Processing” on Main Menu.
Click “Medical Readjudication” under the “Readjudication” heading.
Second
Open Amisys and login.
Click “Provider” on Main Menu.
Click “Provider Affiliation” under “Provider” heading.
Determine if claim is Electronic or Manual and populate it.
Electronic
Use EDI Viewer to view the claim when the claim contains the letter “E.” (e.g. 11265E030758)
Open EDI Viewer and login.
Enter claim number in blank field.
Press Enter and claim image should populate.
Manual
Use Macess when the claim contains the letter “M.” (e.g. 11263M001302 and
112970000010)
Open Macess and login.
Select “Open” from the toolbar.
Select “Document” from the drop down menu.
Put cursor in “Document ID” field.
Enter claim number.
Press Enter and claim image should populate.
If no claim populates, wait two days for Scanning Department to upload the image; however, if
there is no image after those two days, inform management.
Review the information on the Amisys readjudication screen and verify it matches the information on
the claim image.
Add any missing information if necessary.
Certain modifiers are the difference between a claim being paid and rejected.
Correct the readjudication screen information if necessary and click ReAdjudicate or REset/Adj to save
changes.
Verify that the Referring NPI # on claim is the same provider is Amisys.
1
Open an ecare screen
Open Internet Explorer.
Type www.ecare.com in the URL field and hit Enter.
Click “NPI.”
Place cursor in NPI field and type in NPI number.
Click “Process” or hit Enter.
Provider’s information will generate.
Compare provider name and address.
Verify that the Servicing Provider NPI # on claim is the same provider in Amisys through ecare.
Click “NPI” on the left pane of ecare.
Place cursor in NPI field and type in NPI number.
Click “Process” or hit Enter.
Provider’s information will generate.
Compare provider name.
Click blue NPI hyperlink to view more precise information referring to name and/or
address.
If there is no Servicing NPI, deny claim.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Click on drop down menu under “Claim Status.”
Select ”51-Denied.”
Place cursor in “Ex code” field.
Type “np.”
Click ReAdjudicate to save all changes made.
Verify the claim status and Ex codes on the service lines.
Space out physicians’ four digit affiliation(s) and click ReAdjudicate. The system will generate
affiliation(s).
Pick the affiliation that matches the member/region.
Match the Referring Provider affiliation with the member’s PCP if they are the same.
Match Referring Provider affiliation with the member’s Provider if they are the same.
Remove the Referring Provider if the affiliation is not generated after spacing it out.
Enter the member’s PCP number and affiliation in the Referring Provider fields.
Click ReAdjudicate to save all changes made
Verify the correct Provider has been selected.
Highlight and copy the “Prov #” field from readjudication screen.
Paste number into “Provider” field on Provider Affiliation screen.
Type or copy the four digit affiliation from the readjudication screen to affiliation screen.
Hit Enter and Provider information populates.
Verify that the Effective Dates, Carrier, Region, Area (AA), and IRS# (TID) are correct.
If the information does not match, pend the claim with one of the Provider Relations
pend codes below.
Locality (AA) does not have to match with Referring Provider.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Click on the Claim Status drop down menu and select “41- Pended.”
Place cursor in Ex field and enter the Ex code from the list below that associates with
the reason the claim is being pended. (E.g. Par Address Doesn’t Match EX code = 73)
Participating Providers (Status PP, CP, RP, LP, or OP)
Par Medicare Number Needed (31D) - Amisys #0003 - EX code = 84
Par Member Region Doesn’t Match (31E) - Amisys #0005 - EX code = 85
Par Additional Tax ID# Needed (31C) - Amisys #0002 - EX code = 83
Par Address Doesn’t Match (31B) - Amisys #0001 - EX code = 73
Locality Does Not Match – EX Code = BU
2
Non- Participating Providers (Status OA or NP)
Non-Par Medicare Number Needed (322) - Amisys #0010 - EX code = p1
Non-Par Medicare Not in System (324) - Amisys #0009 - EX code = p3
Non-Par Member Region Doesn’t Match (323) - Amisys #0008 - EX code = p2
Non-Par Additional Tax ID# Needed (321) - Amisys #0007 - EX code = p0
Non-Par Address Doesn’t Match (320) - Amisys #0006 - EX code = 98
Review Area Field - EX code = BU (manual pend)
Verify that “Pay Class” does not read “DUMMY”.
If it reads “DUMMY” but the Carrier and Region match the member’s Carrier and
Region, then it is OK.
If it reads “DUMMY” and Carrier and Region do not match, space out affiliation and
readjudicate.
Verify the correct affiliation has been generated.
If that does not work, enter the member’s PCP number and affiliation in the Referring
Provider fields.
Verify address by clicking “Aff Address” in the left-hand pane.
If the servicing provider’s address and Amisys do not match, review the Provider’s
Remarks in Amisys.
Copy the Provider # from adjudication screen.
Click on “Remarks” and a new screen will pop up.
Click on the binoculars/find icon on the top tool bar.
Click on the “ID# Type” drop down menu.
Select “PV.”
Place cursor in “Provider#:” field and paste Provider #.
Hit Enter and the remarks will display.
Hit the “Next” button in the top tool bar to scroll through.
If the remarks state to pay to a different address than what is stated on
the readjudication screen and it is also on the affiliation screen, it is OK
to pay.
If the remarks do not match the information on the provider claim, pend
the claim with the Provider Relations pend code for “address doesn’t
match” from the list above.
Confirm claim address and Amisys address are correct.
Exit out of address pop-up window.
Click binoculars/find icon on the top tool bar to clear fields.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Check that the Status “St” has ALL 10s, 11s, 12s, 50s, 51s, or a combination of 10s, 11s, 12s, 50s, and
51s.
If the status contains ANY other codes, DO NOT demand draw. The claim will fall into an
appropriate queue to be fixed.
Do not Demand Draw 31 or 41 status.
If there are other EX Codes remaining and you are able to process them, continue to process
them.
It is OK if there are other Ex codes besides AP or CP if you do not know how to process them.
Demand Draw the claim from the queue.
Maximize Macess.
Select “My Work” from tool bar.
Select “Workflow Examination” on the drop down menu.
Click the “Draw Mode - Demand” icon.
Click the “Select Work Item” icon.
3
Place cursor in Document ID field and type in claim number.
Check New, Pended, and Rerouted options in Work Item Status section.
Hit Enter.
Select “Work Flow Examination.”
Select “Complete.”
Select “Save” and X out the screen.
4
Claims Pend Processing Profile
Pend: 8W Queue Profile
Multiple Servicing Provider Affiliations Qualify
Pend Description One
Pend Category September 13, 1999
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiner
Person(s) Responsible As defined below:
Processing Instructions
8W Queue is generated to ensure the appropriate servicing provider is selected.
Open two Amisys Advance screens.
First
Open Amisys and login.
Click “Claims Processing” on Main Menu.
Click “Medical Readjudication” under the “Readjudication” heading.
Second
Open Amisys and login.
Click “Provider” on Main Menu.
Click “Provider Affiliation” under “Provider” heading.
Determine if claim is Electronic or Manual and populate it.
Electronic
Use EDI Viewer to view the claim when the claim contains the letter “E.” (e.g. 11265E030758)
Open EDI Viewer and login.
Enter claim number in blank field.
Press Enter and claim image should populate.
Manual
Use Macess when the claim contains the letter “M.” (e.g. 11263M001302 and
112970000010)
Open Macess and login.
Select “Open” from the toolbar.
Select “Document” from the drop down menu.
Put cursor in “Document ID” field.
Enter claim number.
Press Enter and claim image should populate.
If no claim populates, wait two days for Scanning Department to upload the image; however, if
there is no image after those two days, inform management.
Review the information on the Amisys readjudication screen and verify it matches the
information on the claim image.
Correct the readjudication screen information if necessary and click ReAdjudicate or REset/Adj
to save changes.
Verify that the Referring NPI # on claim is the same provider in Amisys.
Open an ecare screen
Open Internet Explorer.
Type www.ecare.com in the URL field and hit Enter.
Click “NPI.”
1 SSA
Place cursor in NPI field and type in NPI number.
Click “Process” or hit Enter.
Provider’s information will generate.
Compare provider name and address.
Verify that the Servicing Provider NPI # on claim is the same provider in Amisys through ecare.
Click “NPI” on the left pane of ecare.
Place cursor in NPI field and type in NPI number.
Click “Process” or hit Enter.
Provider’s information will generate.
Compare provider name.
Click blue NPI hyperlink to view more precise information referring to name and/or
address.
If there is no Servicing NPI, deny claim.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Click on drop down menu under “Claim Status.”
Select ”51-Denied.”
Place cursor in “Ex code” field.
Type “np.”
Click ReAdjudicate to save all changes made.
Verify the claim status and Ex codes on the service lines.
Space out physicians’ four digit affiliation(s) and click ReAdjudicate. The system will generate
affiliation(s).
Pick the affiliation that matches the member/region.
Match the Referring Provider affiliation with the member’s PCP if they are the same.
Match Referring Provider affiliation with the member’s Provider if they are the same.
Remove the Referring Provider if the affiliation is not generated after spacing it out.
Enter the member’s PCP number and affiliation in the Referring Provider fields.
Click ReAdjudicate to save all changes made
Verify the correct Provider has been selected.
Highlight and copy the “Prov #” field from readjudication screen.
Paste number into “Provider” field on Provider Affiliation screen.
Type or copy the four digit affiliation from the readjudication screen to affiliation screen.
Hit Enter and Provider information populates.
Verify that the Effective Dates, Carrier, Region, Area (AA), and IRS# (TID) are correct.
If the information does not match, pend the claim with one of the Provider Relations
pend codes below.
Locality (AA) does not have to match with Referring Provider.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Click on the Claim Status drop down menu and select “41- Pended.”
Place cursor in Ex field and enter the Ex code from the list below that associates with
the reason the claim is being pended. (E.g. Par Address Doesn’t Match EX code = 73)
Participating Providers (Status PP, CP, RP, LP, OP, or IO)
Par Medicare Number Needed (31D) - Amisys #0003 - EX code = 84
Par Member Region Doesn’t Match (31E) - Amisys #0005 - EX code = 85
Par Additional Tax ID# Needed (31C) - Amisys #0002 - EX code = 83
Par Address Doesn’t Match (31B) - Amisys #0001 - EX code = 73
Locality Does Not Match – EX Code = BU
Non- Participating Providers (Status OA or NP)
Non-Par Medicare Number Needed (322) - Amisys #0010 - EX code = p1
2 SSA
Non-Par Medicare Not in System (324) - Amisys #0009 - EX code = p3
Non-Par Member Region Doesn’t Match (323) - Amisys #0008 - EX code = p2
Non-Par Additional Tax ID# Needed (321) - Amisys #0007 - EX code = p0
Non-Par Address Doesn’t Match (320) - Amisys #0006 - EX code = 98
Review Area Field - EX code = BU (manual pend)
Verify that “Pay Class” does not read “DUMMY”.
If it reads “DUMMY” but the Carrier and Region match the member’s Carrier and
Region, then it is OK.
If it reads “DUMMY” and Carrier and Region do not match, space out affiliation and
readjudicate.
Verify the correct affiliation has been generated.
If that does not work, enter the member’s PCP number and affiliation in the Referring
Provider fields.
Verify address by clicking “Aff Address” in the left-hand pane.
If the servicing provider’s address and Amisys do not match, review the Provider’s
Remarks in Amisys.
Copy the Provider # from adjudication screen.
Click on “Remarks” and a new screen will pop up.
Click on the binoculars/find icon on the top tool bar.
Click on the “ID# Type” drop down menu.
Select “PV.”
Place cursor in “Provider#:” field and paste Provider #.
Hit Enter and the remarks will display.
Hit the “Next” button in the top tool bar to scroll through.
If the remarks state to pay to a different address than what is stated on
the readjudication screen and it is also on the affiliation screen, it is OK
to pay.
If the remarks do not match the information on the provider claim, pend
the claim with the Provider Relations pend code for “address doesn’t
match” from the list above.
Confirm claim address and Amisys address are correct.
Exit out of address pop-up window.
Click binoculars/find icon on the top tool bar to clear fields.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Check that the Status “St” has ALL 10s, 11s, 12s, 50s, 51s, or a combination of 10s, 11s, 12s,
50s, and 51s.
If the status contains ANY other codes, DO NOT demand draw. The claim will fall into an
appropriate queue to be fixed.
Do not Demand Draw 31 or 41 status.
If there are other EX Codes remaining and you are able to process them, continue to process
them.
It is OK if there are other Ex codes besides AP or CP if you do not know how to process them.
Demand Draw the claim from the queue. SSA
Maximize Macess.
Select “My Work” from tool bar.
Select “Workflow Examination” on the drop down menu.
Click the “Draw Mode - Demand” icon.
Click the “Select Work Item” icon.
Place cursor in Document ID field and type in claim number.
3
Check New, Pended, and Rerouted options in Work Item Status section.
Hit Enter.
Select “Work Flow Examination.”
Select “Complete.”
Select “Save” and X out the screen.
4 SSA
Claims Pend Processing Profile
Pend: 8Z Queue Profile
PCP Affiliation Not Effective for Date of Service
Pend Description One
Pend Category September 13, 2009
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The purpose of the 8Z pend code is to ensure the Primary Care Physician’s affiliation has the proper span dates
and can be used for the claim date(s) of service. If the PCP does not have an active affiliation span, forward the
claim to Provider Relations for review.
Open two Amisys Advance screens.
First
Open Amisys and login.
Click “Claims Processing” on Main Menu.
Click “Medical Readjudication” under the “Readjudication” heading.
Second
Open Amisys and login.
Click “Provider” on Main Menu.
Click “Provider Affiliation” under “Provider” heading.
Determine if claim is Electronic or Manual and populate it.
Electronic
Use EDI Viewer to view the claim when the claim contains the letter “E.” (e.g. 11265E030758)
Open EDI Viewer and login.
Enter claim number in blank field.
Press Enter and claim image should populate.
Manual
Use Macess when the claim contains the letter “M.” (e.g. 11263M001302 and
112970000010)
Open Macess and login.
Select “Open” from the toolbar.
Select “Document” from the drop down menu.
Put cursor in “Document ID” field.
Enter claim number.
Press Enter and claim image should populate.
If no claim populates, wait two days for Scanning Department to upload the image; however, if
there is no image after those two days, inform management.
Review the information on the Amisys readjudication screen and verify it matches the
information on the claim image.
Correct the readjudication screen information if necessary and click ReAdjudicate or REset/Adj
to save changes.
Verify that the Referring NPI # on claim is the same provider is Amisys.
Open an ecare screen
Open Internet Explorer.
1 SSA
Type www.ecare.com in the URL field and hit Enter.
Click “NPI.”
Place cursor in NPI field and type in NPI number.
Click “Process” or hit Enter.
Provider’s information will generate.
Compare provider name and address.
Verify that the Servicing Provider NPI # on claim is the same provider in Amisys through ecare.
Click “NPI” on the left pane of ecare.
Place cursor in NPI field and type in NPI number.
Click “Process” or hit Enter.
Provider’s information will generate.
Compare provider name.
Click blue NPI hyperlink to view more precise information referring to name and/or
address.
If there is no Servicing NPI, deny claim.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Click on drop down menu under “Claim Status.”
Select ”51-Denied.”
Place cursor in “Ex code” field.
Type “np.”
Click ReAdjudicate to save all changes made.
Verify the claim status and Ex codes on the service lines.
Space out physicians’ four digit affiliation(s) and click ReAdjudicate. The system will generate
affiliation(s).
Pick the affiliation that matches the member/region.
Match the Referring Provider affiliation with the member’s PCP if they are the same.
Match Referring Provider affiliation with the member’s Provider if they are the same.
Remove the Referring Provider if the affiliation is not generated after spacing it out.
Enter the member’s PCP number and affiliation in the Referring Provider fields.
Click ReAdjudicate to save all changes made
Verify the correct Provider has been selected.
Highlight and copy the “Prov #” field from readjudication screen.
Paste number into “Provider” field on Provider Affiliation screen.
Type or copy the four digit affiliation from the readjudication screen to affiliation screen.
Hit Enter and Provider information populates.
Verify that the Effective Dates, Carrier, Region, Area (AA), and IRS# (TID) are correct.
If the information does not match, pend the claim with one of the Provider Relations
pend codes below.
Locality (AA) does not have to match with Referring Provider.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Click on the Claim Status drop down menu and select “41- Pended.”
Place cursor in Ex field and enter the Ex code from the list below that associates with
the reason the claim is being pended. (E.g. Par Address Doesn’t Match EX code = 73)
Participating Providers (Status PP, CP, RP, LP, OP, or IO)
Par Medicare Number Needed (31D) - Amisys #0003 - EX code = 84
Par Member Region Doesn’t Match (31E) - Amisys #0005 - EX code = 85
Par Additional Tax ID# Needed (31C) - Amisys #0002 - EX code = 83
Par Address Doesn’t Match (31B) - Amisys #0001 - EX code = 73
Locality Does Not Match – EX Code = BU
Non- Participating Providers (Status OA or NP)
2 SSA
Non-Par Medicare Number Needed (322) - Amisys #0010 - EX code = p1
Non-Par Medicare Not in System (324) - Amisys #0009 - EX code = p3
Non-Par Member Region Doesn’t Match (323) - Amisys #0008 - EX code = p2
Non-Par Additional Tax ID# Needed (321) - Amisys #0007 - EX code = p0
Non-Par Address Doesn’t Match (320) - Amisys #0006 - EX code = 98
Review Area Field - EX code = BU (manual pend)
Verify that “Pay Class” does not read “DUMMY”.
If it reads “DUMMY” but the Carrier and Region match the member’s Carrier and
Region, then it is OK.
If it reads “DUMMY” and Carrier and Region do not match, space out affiliation and
readjudicate.
Verify the correct affiliation has been generated.
If that does not work, enter the member’s PCP number and affiliation in the Referring
Provider fields.
Verify address by clicking “Aff Address.”
If the servicing provider’s address and Amisys do not match, review the Provider’s
Remarks in Amisys.
Copy the Provider # from adjudication screen.
Click on “Remarks” and a new screen will pop up.
Click on the binoculars/find icon on the top tool bar.
Click on the “ID# Type” drop down menu.
Select “PV.”
Place cursor in “Provider#:” field and paste Provider #.
Hit Enter and the remarks will display.
Hit the “Next” button in the top tool bar to scroll through.
If the remarks state to pay to a different address than what is stated on
the readjudication screen and it is also on the affiliation screen, it is OK
to pay.
If the remarks do not match the information on the provider claim, pend
the claim with the Provider Relations pend code for “address doesn’t
match” from the list above.
Confirm claim address and Amisys address are correct.
Exit out of address pop-up window.
Click binoculars/find icon on the top tool bar to clear fields.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Check that the Status “St” has ALL 10s, 11s, 12s, 50s, 51s, or a combination of 10s, 11s, 12s,
50s, and 51s.
If the status contains ANY other codes, DO NOT demand draw. The claim will fall into an
appropriate queue to be fixed.
Do not Demand Draw 31 or 41 status.
If there are other EX Codes remaining and you are able to process them, continue to process
them.
It is OK if there are other Ex codes besides AP or CP if you do not know how to process them.
Demand Draw the claim from the queue.
Maximize Macess.
Select “My Work” from tool bar.
Select “Workflow Examination” on the drop down menu.
Click the “Draw Mode - Demand” icon.
Click the “Select Work Item” icon.
Place cursor in Document ID field and type in claim number.
3 SSA
Check New, Pended, and Rerouted options in Work Item Status section.
Hit Enter.
Select “Work Flow Examination.”
Select “Complete.”
Select “Save” and X out the screen.
4 SSA
Claims Pend Processing Profile
Process: 36 Queue Profile
Add “CI” Code for Contract Pricing
Pend Description Three
Pend Category January 1, 2015
Date Implemented
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Background Information
Effective October 1, 2014, claims submitted by Community Oxygen (provider #1000006988) with procedure
code E1399 for talking and digital scales pend EX 36.
Claims Examiners review claims pended EX 36 and enter the appropriate CI code for pricing.
Type of CI Code Price Payservice
Scale TK $110 TALKSCAL
Talking scale DG $60 DIGSCALE
Digital scale
Process
Review the member’s authorizations to determine which type of scale was authorized.
Click “Global Functions” “Authorization” “Authorizations by Member.”
Search Authorization by Member Inquiry by the Member#.
Select the authorization for Community Oxygen with the authorized date that matches the date of
service on the claim.
Click “Med Auth Iq.”
Click “Remarks Iq.”
Review the authorization remarks, which will indicate the type of scale authorized.
Example: “101614 APP TALKING SCALE W/COMM…”
Enter the appropriate CI code on the service line to price the line item.
For a talking scale, enter CI code TK on the service line.
For a digital scale, enter CI code DG on the service line.
To enter the CI code:
On the Diagnosis, Procedures & Service Detail tab, click the service line containing E1399.
Under the Functions panel, click “Service Detail.”
Type the appropriate CI code (TK or DG) in the CI field.
Click “Readjudicate.”
Press F8 to exit the Medical Service Detail Readjudication screen.
Under the Functions panel, click “Readjudicate” to readjudicate the claim at the header.
1 SSA 02.03.2015
Claims Pend Processing Profile
Pend: 42 Queue Profile
PEND - CLINICAL TRIAL MEMBER/RESEARCH STUDY
Pend Description Four
Pend Category November 6, 2011
Date Implemented November 4, 2015
Date Updated/Revised Senior Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Background Information
Clinical Trials & Investigational Device Exemption (IDE)
Type of Coverage Original Medicare Pays MA Plan Pays
Service The MA plan pays the
Clinical Trial Original Medicare covers the Original Medicare pays for enrollee the difference in
routine costs of qualifying the routine services. cost-sharing between
clinical trials for all Medicare Original Medicare and the
enrollees, including MA plan MA plan.
participants. The device is not eligible for
payment.
Category A The device is not covered; Original Medicare pays for
IDE however, the routine costs of the routine costs of a clinical MA plans are responsible for
clinical trials involving a trial involving a Category A payment of the Category B
Category A IDE device are IDE device. IDE device.
covered.
Category B The device is covered if used Original Medicare pays for
IDE within the context of an the routine costs of a clinical
approved clinical trial. trial involving a Category B
IDE device.
Routine Costs of Clinical Trials Billing Requirements
Type of Billing ICD-9 ICD-10 Condition Modifier(s) Clinical Trial #
Diagnosis Diagnosis Code Included on Claim
Q1 for routine
Code Code services Mandatory for
Q0 for claims with DOS on
Practitioner/Supplier V70.7 Z00.6 NA investigational or after January 1,
item(s)/service(s) 2014.
billing NA
Mandatory for
Inpatient billing V70.7 Z00.6 30 claims with DOS on
or after January 1,
Outpatient billing V70.7 Z00.6 30 Q1 for routine 2014.
services Mandatory for
Q0 for claims with DOS on
investigational or after January 1,
item(s)/service(s) 2014.
1 SSA 03.23.14
Category A IDE Billing Requirements
The routine costs of a clinical trial involving a Category A IDE device are billed according to the clinical trial
billing instructions outlined above.
The billing requirements for the Category A IDE device are as follows:
Type of Billing Modifier Category Clinical Trial #
A IDE # Included on Claim
Inpatient/Outpatient billing NA NA NA
(This device is not reported
on institutional claims since it
is non-covered by Medicare.)
Practitioner billing Q0 Required Mandatory for claims
with DOS on or after
January 1, 2014.
Category B IDE Billing Requirements
The routine costs of a clinical trial involving a Category B IDE device are billed according to the clinical trial
billing instructions outlined above.
The billing requirements for the Category B IDE device are as follows.
Type of Billing Revenue HCPCS Modifier Category B Clinical Trial #
Code Code IDE # Included on Claim
Line
NA NA
Inpatient billing 0624 NA NA
(The device is not reported if
it is received free-of-charge.)
Outpatient billing 0624 If Q0 Required Mandatory for claims
applicable with DOS on or after
January 1, 2014.
Practitioner/Supplier billing NA Required Q0 Required Mandatory for claims
with DOS on or after
January 1, 2014.
The following table shows the designated field locations to report the clinical trial number, the Category A IDE
number, and the Category B IDE numbers on claims:
Data CMS-1500 UB-04 Electronic 837P & 837I
Form Locator 39-41 with
Clinical Trial Number Item 19, preceded by “CT” value code D4 Loop 2300, REF02,
REF01=P4
Category A IDE # Item 23 N/A
Category B IDE # Item 23 (not preceded by “CT”)
Form Locator 43
Loop 2300,
REF02(REF01=LX)
Loop 2300,
REF02(REF01=LX)
2 SSA 03.23.14
Process
Provider/Practitioner Claims
Modifier Q1 – “Routine clinical service provided in a clinical research study.”
For par provider claims with modifier Q1, deny service lines containing modifier Q1 with EX
code ct, “Procedure is a clinical trial and not payable.”
For non par provider claims with modifier Q1, review the claim for the clinical trial number and
diagnosis code V70.7 (ICD-9) / Z00.6 (ICD-10).
If at least one of these items is found on the claim, deny service lines containing modifier Q1
with EX code ct, “Procedure is a clinical trial and not payable.”
If neither the clinical trial number nor the diagnosis code V70.7 (ICD-9) / Z00.6 (ICD-10) is
present on the claim, request medical records from the provider. In addition to medical records,
also request the following information: clinical trial number (if not reported on the claim), clinical
trial name, clinical trial sponsor, and the sponsor-assigned protocol number.
Once medical records are received, review the records for the clinical trial number (if
not reported on the claim), the clinical trial name, clinical sponsor, and the sponsor-
assigned protocol number.
If this information is included in the provider’s additional documentation, deny
service lines containing modifier Q1 with EX code ct, “Procedure is a clinical
trial and not payable.”
If this information is not included in the provider’s additional documentation,
forward the medical records to Medical Management and request review for
urgent/emergent criteria.
Modifier Q0 – “Investigational clinical service provided in a clinical research study.”
For par and non par provider claims with modifier Q0, check for an authorization.
If the item/service is authorized, but the claim lacks any of the billing requirements outlined
above, deny the claim with an appropriate EX code for the missing information.
For missing diagnosis code V70.7 (ICD-9) / Z00.6 (ICD-10), deny the claim C7,
“Diagnosis code is invalid or missing.”
If the item/service is an IDE and the IDE number is missing, and for dates of service on
and after January 1, 2014, if the clinical trial number is missing, deny the claim WC,
“Incomplete/Invalid/Missing IDE or clinical trial number.”
If the item/service is authorized and the claim contains all the billing requirements outlined on
pages 1-2, review the related NCD that approves the clinical trial to ensure all billing
requirements are met for the specific NCD.
To search NCD billing requirements:
Enter the clinical trial number billed on the claim into https://clinicaltrials.gov/ to
review NCD/clinical trial billing requirements, OR
Search for the related NCD by HCPCS/CPT code at
http://www.cms.gov/medicare-coverage-database/overview-and-quick-
search.aspx.
If all NCD billing requirements are met, approve the service line containing modifier Q0
and process the claim according to the authorization and plan benefits.
If NCD billing requirements are not met, deny the claim with the appropriate denial
code.
3 SSA 03.23.14
If the item/service is not authorized and the CPT/HCPCS code requires an authorization:
For par provider claims, deny the service line containing modifier Q0 with EX code JL,
“Services denied due to no authorization – do not bill member.”
For non par provider claims, request medical records to develop the claim for
urgent/emergent criteria.
If the item/service is not authorized and the CPT/HCPCS code does not require an
authorization, review the claim for an IDE number.
If an IDE number is present and all other billing requirements are met, approve the
service line containing modifier Q0 and process the claim according to plan benefits.
If an IDE number is not present on the claim, request medical records from the provider
to determine if the claim is payable by Peoples Health.
Once records are received, forward the information to Medical Management
and request review to determine if services are investigational. Process the
claim according the Medical Management’s directive and the applicable billing
requirements outlined above.
If medical records are not received, deny the service line containing modifier
Q0 with NO, “Additional info requested from provider to process claim not
received.”
Member Reimbursements
Members who participate in a Medicare-approved clinical trial can be reimbursed for the difference between the
cost sharing in Original Medicare and the cost sharing for our plan. Members are instructed to submit a request
for payment with a copy of the Medicare Summary Notices or other documentation showing what services were
received as part of the study and how much the member owes.
Follow the steps outlined in the Member Reimbursement process.
Note the following:
The member pays the same amount for the services received through the clinical trial as they
would if they had received the services through our plan.
The member must be reimbursed for the difference in the cost sharing even if the member has
not yet paid the clinical trial provider.
Additional Processing Guidance (Chapter 32 of the Medical Claims Processing Manual)
Transcatheter Aortic Valve Replacement (TAVR) (Procedure Codes 33361-33366)
Billing Requirements
Location 21
If not billed, deny service line EX IL
Modifiers 62 & Q0
If missing, deny service line EX 17
Diagnosis Code V70.7 (ICD-9) / Z00.6 (ICD-10)
If missing, deny service line EX C7
Clinical Trial Number
If missing, deny service line EX WC
Transcatheter Mitral Valve Repair (TMVR)
Billing Requirements for Medical Claims (Procedure Codes 33418, 33419, 0345T)
Location 21
If not billed, deny service line EX IL
Modifier Q0
If missing, deny service line EX 17
Diagnosis Code V70.7 (ICD-9) / Z00.6 (ICD-10) & 424.0 (ICD-9) / I34.0 or I34.8 (ICD-10)
If missing, deny service line EX C7
Clinical Trial Number
4 SSA 03.23.14
If missing, deny service line EX WC
Billing Requirements for Inpatient Hospital Claims (Procedure Codes 33418, 33419, 0345T &
Inpatient Procedure Codes 35.97 [ICD-9] / 02UG3JZ [ICD-10])
Diagnosis Code V70.7 (ICD-9) / Z00.6 (ICD-10)
If not billed, deny service line EX C7
Condition Code 30
If missing, deny service line EX
Value Code D4 – Clinical Trial Number
If missing, deny service line
Implantable Automatic Defibrillator (IAD) (Procedure Codes 33240-33241, 33243-33244, 33249)
IAD is not a clinical trial. Modifier Q0 is appended to indicate the member is enrolled in a data
collection system.
ICD-9 Diagnosis Codes
427.1 427.41 427.42 427.5 427.9 V12.53 996.04 V53.32
Verify the following diagnosis codes are NOT on the claim (following diagnosis codes indicate
non-primary prevention, in which Q0 should not be billed):
ICD-10 Diagnosis Codes
I47.0 I47.2 I49.3 I49.01 I49.02 I46.2 I46.8 I46.9
I49.9 T82.110A T82.121A T82.129A
T82.111A T82.118A T82.119A T82.120A
T82.190A T82.191A
T82.198A T82.199A Z86.74 Z45.02
Verify the IAD/ICD is authorized.
Review Authorizations by Member and read authorization remarks.
If the services are not authorized, the service line should deny for no authorization.
5 SSA 03.23.14
Claims Pend Processing Profile
Pend: 54 Queue Profile
Review ambulance claim to ensure accurate payment
Pend Description Three
Pend Category January 1, 2012
Date Implemented March 21, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Ambulance claims should be paid according to the CMS Ambulance fee schedule. This does not apply to
Acadian Ambulance for dates of service on or after 8/1/2012.
The Ambulance claim will be paid by the pickup point zip code using a CI code. The pickup point can be
determined by the service line modifiers, notes that appear on the claim image, or EDI Locator. See the
following modifier descriptions.
Origin and destination ambulance modifier codes and their descriptions:
D = Diagnostic or therapeutic site other than P or H when these are used as origin codes;
E = Residential, domiciliary, custodial facility (other than 1819 facility);
G = Hospital based ESRD facility;
H = Hospital;
I = Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport;
J = Freestanding ESRD facility;
N = Skilled nursing facility;
P = Physician’s office;
R = Residence;
S = Scene of accident or acute event;
X = Intermediate stop at physician’s office on way to hospital (destination code only)
If the pickup point is a hospital or facility (modifiers E, G, H, J, or N) and the pickup zip code is not detailed on
the claim image, an examiner will have to research the member’s claim history:
Click Global Functions.
Hover over Claims Processing.
Click on Claims by Member.
Enter the member’s number and search for a claim with the same date of service as the current claim.
Research the claim to verify if it details the facility zip code.
Use the Locality Zip Code File to make a determination if the pickup point zip code is Urban, Rural, or Super
Rural. (next page)
Note: When researching a hospital or facility claim, it may be possible for the claim go back three or more
months.
If the claim is electronic (EDI) and the pickup point is not a hospital or facility, review the EDI Locator for the
pickup point.
Open EDI Claim Locator.
Copy and paste Envoy Claim Number from claim image to EDI Locator.
1
The Date of Claim is the Tape Create Date.
Click Find.
EDI Notepad will generate.
Select the third tab/option.
The pickup point is found under the Individual or Organizational Name field and will state Pickup Address. It is
found near the end of the EDI Notepad. See below for an image. (The information has been removed due to
HIPAA regulations.)
Drop-off Location appears here.
If there is no way to determine a pick up point, then an examiner would request an ambulance trip sheet:
Open Macess.
Click the Create Corro Letter icon.
Double click the Medical Record Request Form.
Click PHHeaderParagraph and click Next.
Complete the Corro Field values and click Next.
The Corro Letter will generate a Word document.
Print the letter and select the needed information option(s).
Place the letter and the claim in the Letters to be Mailed Out folder.
An examiner will keep a copy of the letter and claim as well.
To make a determination if the pickup point zip code is Urban, Rural, or Super Rural, use the Locality
Zip Code File. It can be found: http://phn-win-27/Zip_Locality/zip9_Locality.aspx
Input the zip code and review the Rural Indicator.
Use the corresponding CI code (below) on all claim lines. This will drive the appropriate fee schedule.
Use the following table to determine how to complete the CI field:
Rural Indicator Column Pickup Point Zip Code CI Code
Blank Urban UR
R Rural RL
B SP
Super Rural
On a HCFA, the CI field can be found in the service detail:
Click the Diagnosis, Procedures, & Service Detail tab.
Highlight the appropriate service line.
Click on Service Detail.
Space out the CI field.
2
Enter appropriate CI code for pickup point.
Click Readjudicate.
On a UB, the CI field is on the header screen.
The A0425 code is configured to pay Rural and Super-Rural as follows: the first 17 miles get paid $10.65 and
miles 18 and above are paid $7.10. (Ex: If a trip was 21 miles, miles 0 -17 would be 17 x $10.65 = $181.05,
and miles 18 – 21 would be 4 x $7.10 = $28.40. The sum total of the trip would be $181.05 + $28.40 =
$209.45.)
The A0425 code is configured to pay Urban as follows: $7.03 per mile no matter the trip distance. The Rural
and Super-Rural first 17 miles do not to Urban rates.
PHN will round up to the nearest whole mile if the tenths position is greater than zero because Amisys is unable
to hold decimals.
(Ex. 5.1 miles would be 6 miles. 5.5 miles would be 6 miles. 6.0 miles would be 6 miles.)
Note: If the billed charges on the claim are less than the fee schedule allowed amount, allow the lesser billed
charges to pay. However, if the billed charges are greater than the fee schedule allowed amount, allow the
lesser fee schedule amount to pay.
3
Claims Pend Processing Profile
Pend: 70 Queue Profile
Procedure Requires Documentation of Specific Service
Pend Description Three
Pend Category November 28, 2001
Date Implemented December 12, 2015
Date Updated/Revised Assigned Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Review the CES edit to ensure the claim pended 70 appropriately (RF0166).
For facility claims, the pricer applies the reduction. Override the 70 pend with EX AP,
“Approved.”
Refer to the table below for medical claims billed with modifier 52.
Procedure Code Action to be Taken
All radiology codes (70000 range) Pend EV and give director of claims a copy of the claim.
G0202 Pend EV and give director of claims a copy of the claim.
Codes in range 95782-96020 Pend EV and give director of claims a copy of the claim and
medical records.
All other codes Send director of claims an email (Subject: Modifier 52) with the
procedure code and she will advise if you need to request records,
etc.
Whenever you give the director of claims copies, be sure to include your name so they can be returned
with instructions regarding how to process. Additionally, if the claim is in adjustment status, indicate
that on the copies.
This will be updated and redistributed as the director of claims reviews more of these situations and a
decision is made regarding how to process.
1
Claims Pend Processing Profile
Pend: 71 Queue Profile
Audubon Orthopedics And Sports Medicine Provider Review
Pend Description One
Pend Category February 20, 2006
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
When processing with therapy codes (97001 - 97546 codes) for the Audubon Orthopedics and Sports Medicine
Group Practice, the physician group is paid – NOT the individual provider.
Verify the correct GROUP has been selected.
Review the Amisys readjudication screen and confirm that the “Prov#” is an individual
physician.
Space out the current number and enter an asterisk and the Tax ID number from the claim
image. (e.g. *720722623)
Pick the Audubon group from the new screen that generates.
Listed as Prov # 1000029704 and “AND SPORTS MED, AUDUBON ORTHO”
Click the “Return Lookup Values” icon on top toolbar. (15th icon that looks like two screens with
a green arrow)
Space out the four digit affiliation and click “ReAdjudicate” (located on top of the left-side
pane).
Demand Draw the claim from the queue.
Maximize Macess.
Select “My Work” from tool bar.
Select “Workflow Examination” on the drop down menu.
Click the “Draw Mode - Demand” icon.
Click the “Select Work Item” icon.
Place cursor in Document ID field and type in claim number.
Check New, Pended, and Rerouted options in Work Item Status section.
Hit Enter.
Select “Work Flow Examination.”
Select “Complete.”
Select “Save” and X out the screen.
1 SSA
Claims Pend Processing Profile
Pend: 76 Queue Profile
Gastric Bypass/Stapling-Procedure Must Be Specifically Authorized
Pend Description Four
Pend Category September 20, 2000
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
PURPOSE
To ensure only authorized gastric by-passes are paid.
PROCEDURE
Review the authorization. The authorization must specifically state that a Gastric By-Pass has been authorized.
If not the claim is to be denied with EX code DN.
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