Claims Handbook

Note Kenner Hosp Based Clinic: If the facility on the claim (field name - Facility 1) is from Kenner Hosp Based
Clinic at 200 West Esplanade, the facility is a clinic. (The hospital facility is 180 W Esplanade, which should be
denied with hp.) Claims from the 200 West Esplanade address should be processed using the CI code “hi.”

Note Kindred Hospital: Kindred Hospital is a LTAC (long-term acute care) facility, which does not participate in
the hospitalist program; therefore, process the claim using the CI code “hi.” (No example at this time.)
Note ip pend: The ip pend was combined with the ii pend to create this current pend processing profile on
November 19, 2012. Because ii and ip have been combined, there are some exceptions should a claim pend ip. If
a claim is pending ip, process the claim following the steps in this ii pend profile in terms of whether or not to use hi
or hp. In order to fully process the claim, an examiner will first have to reset and override the ip service line(s) with
AP. To deny the claim, an examiner will have to override the ip service line(s) with hp.
To pay:

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To deny:
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Claims Pend Processing Profile

Pend: ii Queue Profile
Review IPANO / MIPA PCP Claim for Hospital Locations
Pend Description Two
Pend Category November 19,2012
Date Implemented February 5, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

*Note: The ip pend was combined with the ii pend to create this current pend processing profile on November 19,
2012. Because ii and ip have been combined, there are some exceptions should a claim pend ip. If a claim is
pending ip, process the claim following the steps in this ii pend profile in terms of whether or not to use hi or hp. In
order to fully process the claim, an examiner will first have to reset and override the ip service line(s) with AP.

Peoples Health implemented a hospitalist program with Memorial Physicians Team (MPT) to provide assistance to
MPT PCPs in coordinating care for their Peoples Health patients who are admitted to Ochsner Baptist Medical
Center, Touro Infirmary or East Jefferson General Hospital. The hospitalist program began on November 1, 2012.

A hospitalist is a physician who specializes in caring for patients in the hospital. Hospitalists ensure continuity of
care for MPT patients from the time they are admitted to the hospital until the time they are discharged. The
hospitalists also coordinate and monitor the exams, treatments and medications these patients may need.

There are four MIPA PCPs that do NOT participate in the hospitalist program. Inform your supervisor or manager if
you see any of the following providers because these providers decided not to participate in the hospitalist program
and should not be pending in the ii queue.
Frank Cruz, Jr.
Frank Cruz
April Fox
Angela Reginelli

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Claims that pend “ii” are IPANO or MIPA PCP claims that bill with location code 21 or 22.

An examiner must verify if the facility on the claim has a hospitalist program or not. To verify, an examiner must
look at the facility on the claim and research to see if that facility has a hospitalist program for IPANO or MIPA. On
Electronic claims, the facility can be found in the Facility 1 field.

To research to see if that facility has a hospitalist program for IPANO or MIPA, use the PHN Water Cooler. It has a
grid of the hospitalists associated with each physician team and facility. It can be found:
http://www.cooler.peopleshealth.com/departments/network_development/Hospitalist.html.
Additionally, it can be found by going to http://www.cooler.peopleshealth.com/index.html.
Click Departments.
Scroll to the bottom of the page.
Look on the left hand side, under Network Development for Hospitalists.
Click Hospitalists.
Below are screen shots of the facilities participating in the hospitalist programs for IPANO and MIPA as of February
4, 2013.

Generally, if the facility DOES have a hospitalist program, deny the claim with EX “hp,” which means hospitalist
coverage applies.
If the facility DOES NOT have a hospitalist program, process the claim using the CI code “hi,” which means IPA
PCPs allowed services outside of hospitalist contract.

Examiners must research the entire claim before processing or denying the claim because there
are some exceptions.

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The notes below will help guide the examiners with specific situations. If repetitive or unique events occur, they will
be added to this list of notes.
Note CCPI: If billing provider is Crescent City Physicians Inc. and the whole claim is not pending ii, review the
service line that is not ii. If the CI code in that line reads “cc,” override the subsequent hospitalist lines pending ii
with CI code “hi.” Do NOT OVERRIDE THE “cc” CI code.
The billing provider may not always read Crescent City Physicians Inc., but may have a provider’s name. As long
as the address is 3600 Prytania Street, Ste 35, the provider is a member of CCPI.

If the CCPI claim has an Office Service note marked on the Claim, process the entire claim using the CI code “hi.”
If there is a line with the cc CI code, override the subsequent hospitalist lines pending ii with CI code “hi.” Do NOT
OVERRIDE THE “cc” CI code.

Deny the claim “hp” if a Crescent City Physicians’ claim does not have cc CI code nor does it have an Office
Service note, but does have a participating facility listed on the PHN Water Cooler Hospitalists Grid.

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Note xxxxF: Claims with procedure codes ending in the letter F (xxxxF), should pay $0 (zero) for hospitalists.
Additionally, if the claim meets the appropriate criteria, these service lines should have “hi” in the CI field as well as
automatically pend “FA,” which means procedure code not eligible for payment.

Note Kenner Hosp Based Clinic: If the facility on the claim (field name - Facility 1) is from Kenner Hosp Based
Clinic at 200 West Esplanade, the facility is a clinic. (The hospital facility is 180 W Esplanade, which should be
denied with hp.) Claims from the 200 West Esplanade address should be processed using the CI code “hi.”

Note Kindred Hospital: Kindred Hospital is a LTAC (long-term acute care) facility, which does not participate in
the hospitalist program; therefore, process the claim using the CI code “hi.”

LA Extended Care Hospital: LA Extended Care Hospital is a LTAC (long-term acute care) facility, which does not
participate in the hospitalist program; therefore, process the claim using the CI code “hi.”

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Claims Pend Processing Profile

Pend: kq Queue Profile
PR - SELECT NORTHLAKE FOOT AND ANKLE - 100073574
Pend Description One
Pend Category December 6, 2012
Date Implemented January 3, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

Effective 12/1/2012 Northlake Foot & Ankle shall provide PHN with Durable Medical Equipment (Diabetic Shoes
and inserts), which is HCPCS code range A5500-A5513.

PHN shall compensate Northlake Foot & Ankle at 80% of the Effective Medicare Allowable.

Pend kq PR - SELECT NORTHLAKE FOOT AND ANKLE – 100073574 - will prompt the examiner to look at the
claim image to verify the servicing and billing providers. The selected provider should be Northlake Foot and
Ankle – 100074042.

Any codes not listed on the contract (anything not HCPCS code range A5500-A5513) will systematically deny
DJ - DENIED - SERVICES BILLED ARE NOT ACCORDING TO CONTRACT/LOA.

1 SSA

Claims Pend Processing Profile

Pend: md Queue Profile
Review Anesthesia Claim-Modifiers QS or GC Billed w/o Anesthesia Pay
Pend Description Modifier
Three
Pend Category July 14, 2010
Date Implemented August 30, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

Informational:

Effective for claims furnished on or after January 1, 2010 payment may be made on the regular fee schedule
amount for the teaching anesthesiologist’s involvement in the training of residents in either a single anesthesia

case or two concurrent anesthesia cases.

The teaching anesthesiologists should use the GC modifier to certify that he/she complies with the teaching
anesthesiologist’s provisions.

Modifier definitions:
GC - Service performed in part by resident under direction of teaching physician.
QS - Modifier is for informational purposes. Providers must report actual anesthesia time on the claim.

Physicians report the appropriate anesthesia modifier to denote whether the services was personally
performed, medically directed, or medically supervised.

Specific anesthesia modifies include:
AA - Anesthesia Services performed personally by the anesthesiologist;
AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures;
QK - Medical direction of two, three or four concurrent anesthesia procedures involving
QX - CRNA service; with medical direction by a physician;
QY - Medical direction of one certified registered nurse anesthetist by an anesthesiologist;
QZ - CRNA service: without medical direction by a physician

Process:
 Claims billed with QS or GC modifiers will pend md (Review Anesthesia Claim-Modifiers QS or GC
Billed w/o Anesthesia Pay Modifier) for review.
 The QS or GC modifier should be in the second modifier position; the anesthesia modifier should be in
the first position (see anesthesia modifier list above).
 Review the claim image to determine if the modifiers are in the correct position.
 If the modifier was submitted on the claim, and it is not in the system add the modifier.
 If the QS or GS modifier is in the first position and one of the specific anesthesia modifies are in the
second position, the position of the modifiers should be changed.
 If QS or GS modifiers are the only modifiers on the claim, deny the claim 17-services must be billed
with appropriate modifier.

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Claims Pend Processing Profile

Process: ms Queue Profile
Pr – Avastin J3490 DX for Macular Degeneration for Manual Pricing
Pend Description Three
Pend Category January 25, 2010
Date Implemented October 21, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

Avastin is used for treatment of macular degeneration. Providers bill HCPCS codes J3490 or J3590 for Avastin.

Bevacizumab is the generic name for Avastin. All processing requirements that apply to Avastin, apply equally
to its generic form, bevacizumab. Throughout the remainder of this process, bevacizumab will be referred to as
Avastin.

 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.”

When providers bill J3490/J3590 for macular degeneration, they MUST bill the following two items:

1. Bill one of the following diagnosis codes:

ICD-9 ICD-10

362.02 E11.359

362.07 E11.311

362.16 H35.059

362.29 H35.23

362.35 H34.819

362.36 H34.839

362.52 H35.32

364.42 H21.1X9

365.63 H40.89

All ophthalmologic Avastin claims submitted without one of the above diagnoses are denied.
 Par providers – Deny service line with EX code 38, “Diagnosis is inconsistent with procedure code.

Resubmit corrected bill.”
 Non-par provider – Request medical records. If the documentation does not support billing for Avastin,

the claim should be denied with EX code av, “Diagnosis Billed Does Not Support Medical Necessity.”

2. Bill the cost of the drug.
 The claims department pays for Avastin based on the rate that PH determines. Refer to the most

recent Avastin reimbursement guide to determine the rate.
 Effective August 1, 2012, the provider is not required to bill the cost of the drug. PH follows Medicare

reimbursement. Payment for Avastin is made at $45/unit (or the lesser of billed charges).

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 Manually enter the allowed amount on the service line.
 Select the service line pending ms and click Service Detail.
 Click Override Amt.
 Select “2 – Override Dollars” in the drop-down menu next to “Override $:” and press Enter.
 Enter the allowed amount in the “B-Allow” and “P-Allow” fields.
 Allowed amount is $45/unit. If units are greater than one, multiply the allowed amount by the
number of units. Enter the total in the “B-Allow” and “P-Allow” fields.
 PH pays the lesser of the billed charges of the allowed amount. If the total allowed amount is
greater than the billed amount, enter the billed charge as the allowed amount.
 Click Save.
 If the Override EX Errors screen generates, enter “AP” in the EX Code field next to ms.
 Click Save.
 Exit the screen.

 Part B drug coinsurance applies to Avastin. Verify the coinsurance applied is correct by reviewing
the EOC on the Water Cooler.
 Click on the following link: http://cooler.peopleshealth.com/phtools/phtools-plan-documents.html
 Refer to the date of service on the claim to determine which year’s benefits apply.
 Refer to the section titled, “Part B Drugs” to determine the coinsurance.
 Note: Some plans may not have cost-sharing.

2 SSA 05.14.2015

Claims Pend Processing Profile

Process: N9 Queue Profile
*MEMBER ON REVIEW-SEE MEMBER REMARKS FOR INSTRUCTION**
Pend Description N/A
Pend Category October 5, 2015
Date Implemented November 22, 2015
Date Updated/Revised Assigned by management staff
Person(s) Responsible As defined below:
Processing Instructions

Member: Mary Horaist
Provider: Dr. Rade Pejic

Based on an administrative decision, all claims for this member from Dr. Pejic and providers on-call for Dr. Pejic
are to be paid through the end of the 2015 calendar year, regardless if authorization requirements are met.

 Claims from Dr. Pejic for this member:
 Send a service form to the Claims Authorization group requesting an authorization be added for

the claim to pay.
 Approve the claim for payment.
 The claim will process with a copay for a specialist. Manually update the copay amount to

$4.00 (PCP copay amount).

 Claims from providers other than Dr. Pejic for this member:
 Review the on-call screen to determine if the provider is on-call for Dr. Pejic.
 Open the On-Call History screen (IQ1700).
 In the On-Call Type field, select “P – Provider.”
 In the provider number field, enter the servicing provider’s number and press Enter.
 Review the on-call results.

 If Dr. Pejic is listed, the servicing provider is on-call for Dr. Pejic. Send a

service form to the Claims Authorization group requesting an authorization be

added for the claim to pay.

 If Dr. Pejic is not listed, the servicing provider is not on-call for Dr. Pejic.

Override the N9 pend and process the claim following all other processing

guidelines.

It is important that these claims process accurately. See the Quality Improvement Manager with any questions.

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Claims Pend Processing Profile

Process: NA Queue Profile
CLAIMS REVIEW FOR CORRECT BILLING INFORMATION
Pend Description Three
Pend Category
Date Implemented July 20, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

Transitional Care Management (TCM), Care Plan Oversight (CPO), and Medical Nutrition Therapy (MNT)
procedure codes pend EX NA, “Claims review for correct billing information” when benefit counters are

exceeded. Claims are reviewed to determine if the services are payable.

The following section applies to Transitional Care Management (TCM) Services only.

Claims containing Transitional Care Management (TCM) services pend NA for manual review when there is
more than one TCM service provided within 30 days.

TCM Services (Procedure codes 99495-99496)
The Claims Examiner reviews the member’s claim history to determine if the member was readmitted within the
30-day TCM period.

 The second TCM service is paid if the member was readmitted within the 30 day period; or
 The second TCM service is denied HC, “Billing Frequency Limit Exceeded” if there is not a separate

hospital stay preceding the TCM service.

Background Information for TCM Services
Effective January 1, 2013, Medicare pays for two CPT codes (99495 and 99496) that are used to report
physician or qualifying nonphysician practitioner TCM services for a patient following a discharge from a
hospital stay from one of the following hospital settings:

 Inpatient Acute Care;
 Inpatient Psychiatric;
 Long Term Care;
 Skilled Nursing Facility;
 Inpatient Rehabilitation;
 Outpatient observation or partial hospitalization; and
 Partial hospitalization at a Community Mental Health Center.

The 30-day TCM period begins on the date of the member is discharged from the hospital setting and continues
for the next 29 days.

One face-to-face visit must be furnished within certain timeframes as described by the following CPT codes
(effective for services furnished on or after January 1, 2013:

 99495 – TCM services with moderate medical decision complexity (face-to-face within 14 days or
discharge); or

 99496 – TCM services with high medical decision complexity (face-to-face within 7 days of discharge).

Billing Requirements for TCM Services
 Only one health care professional may report TCM services;
 The date of service for the TCM service should be the 30th day of the TCM period (the 30-day period

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begins on the day of discharge and continues for the next 29 days);
 Providers cannot report 99495 and 99496 and G0181 or G0182 during the TCM period; and
 A second TCM service can be reported if the member was readmitted within the 30-day period.

 A practitioner can bill for the TCM services following the second discharge as long as no other
provider bills the service for the first discharge.

 Only one individual may report TCM services and only once per member within 30 days of
discharge.

Process for TCM Services
 Review Claims by Member to identify the claim(s) containing TCM services within the same 30-
day TCM period.
 Click Global Functions  Claims Processing  Claims by Member (IQ1300).
 Click the Binoculars icon to clear all fields.
 Select “2 – Online and Batch” from the drop down box.
 Enter the Member#
 Under Procedure, type “99495.” The claim list will populate. Identify the other claim(s) on file
containing 99495 and note the TCM service date.
 Repeat the above steps, but under Procedure, type “99496.” Identify additional claim(s)
containing 99496 and note the TCM service date.

 Review Claims by Member to identify the admission/observation claim with a discharge date
within 30 days of the TCM period for each TCM service noted in the member’s claim history.
 Click Global Functions  Claims Processing  Claims by Member (IQ1300).
 Click the Binoculars icon to clear all fields.
 Select “2 – Online and Batch” from the drop down box.
 Enter the Member#.
 Under Claim Type, select “H – Hospital” and press Enter. The claim list will populate.

 Review the claims listed to determine the appropriate admission/observation claim
corresponding to the TCM service.
 The discharge date of the admission claim should be 29 days prior to the TCM service date.
 The claim type should be for inpatient or observation services.
 Review the Type of Bill (TOB), revenue codes and/or authorization remarks to verify
services were inpatient or observation.

 If there is no admission/observation claim to support the second TCM service, review
Authorizations by Member.
 Click Global Functions  Authorizations  Authorizations by Member (IQ1000).
 Click the Binoculars icon to clear all fields.
 Enter the Member# and press Enter. The authorization list will populate.
 Review the member’s authorizations for:
 Authorization beginning with “$A…” (inpatient admission authorization), OR
 Authorization beginning with “$R…” with AR code of 23 (observation authorization).
 Review the authorization’s “Effective From” and “To” dates to determine if the member was
readmitted within 30 days.

 If there is a readmission within the 30 day period of the first TCM service, override the NA pend
code to pay.
 Return to the Amisys Readjudication screen.
 Select the “Diagnosis, Procedures & Service Detail” tab.
 Select the service line containing the NA pend.
 Click “Service Detail.”
 Click “Reset/Adj.” The Override EX Errors screen will generate.
 On the line pending NA, type “AP” in the EX code field. Press enter.

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 If there is not a readmission within the 30 day period of the first TCM service, override the NA
pend code to deny HC.
 Return to the Amisys Readjudication screen.
 Select the “Diagnosis, Procedures & Service Detail” tab.
 Select the service line containing the NA pend.
 Click “Service Detail.”
 Click “Reset/Adj.” The Override EX Errors screen will generate.
 On the line pending NA, type “HC” in the EX code field. Press enter.

The following section applies to Care Plan Oversight (CPO) Services only.

Care Plan Oversight (CPO) Services (Procedure Codes G0181-G0182)

 G0181 – Home health care plan oversight.

 G0182 – Hospice care plan oversight.

CPO services cannot be billed during a TCM period. Claims containing G0181 or G0182 with dates of service
within 30 calendar days of a TCM service pend NA.

 The CPO service is paid if there are no other paid claims on file for CPO or TCM services within 30
calendar days.

 The CPO service is denied HC, “Billing Frequency Limit Exceeded” if there if there is another paid claim
on file for either CPO or TCM services within 30 calendar days.

Process for CPO Services

 Review Claims by Member to identify the claim(s) containing CPO services within the same 30-
day period.
 Click Global Functions  Claims Processing  Claims by Member (IQ1300).
 Click the Binoculars icon to clear all fields.
 Select “2 – Online and Batch” from the drop down box.
 Enter the Member#
 Under Procedure, type “G0181/G0182.” The claim list will populate. Identify the other claim(s)
on file containing the same procedure code as listed on the claim pending NA (G0181 or
G0182) and note the service date.
 Repeat the above steps, for procedure codes 99495 and 99496. Identify additional claim(s)
containing 99495/99496 and note the TCM service date(s).

 If there is another paid claim within 30 calendar days containing the same procedure code
(G0181 or G0182), 99495, or 99496, override the NA pend to deny HC, “Billing Frequency Limit
Exceeded.
 Return to the Amisys Readjudication screen.
 Select the “Diagnosis, Procedures & Service Detail” tab.
 Select the service line containing the NA pend.
 Click “Service Detail.”
 Click “Reset/Adj.” The Override EX Errors screen will generate.
 On the line pending NA, type “HC” in the EX code field. Press enter.

 If there is not another paid claim within 30 calendar days containing the same procedure code
(G0181 or G0182), 99495, or 99496, override the NA pend with AP, “Approved.”
 Return to the Amisys Readjudication screen.
 Select the “Diagnosis, Procedures & Service Detail” tab.

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 Select the service line containing the NA pend.
 Click “Service Detail.”
 Click “Reset/Adj.” The Override EX Errors screen will generate.
 On the line pending NA, type “AP” in the EX code field. Press enter.

The following section applies to Medical Nutrition Therapy (MNT) Services only.
Medical Nutrition Therapy (MNT) Services (Procedure Codes 97802-97804)

 97802 – Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the
patient, each 15 minutes.
 Only used for the initial assessment of a new patient. Subsequent individual visits are billed as
97803; subsequent group visits are billed as 97804.

 97803 – Re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes.
 97804 – Group (2 or more individual(s)), each 30 minutes.
 G0270 – Medical nutrition therapy; reassessment and subsequent intervention(s) following second

referral in same year for change in diagnosis, medical condition or treatment regimen, individual, face-
to-face with the patient, each 15 minutes.
 G0271 – Medical nutrition therapy; reassessment and subsequent intervention(s) following second
referral in same year for change in diagnosis, medical condition or treatment regimen, group (2 or more
individuals), each 15 minutes.
Processing for MNT Services
 97802 – Configuration allows a count of one per rolling calendar year. Subsequent counts deny
systematically EX HC, “Billing frequency limit exceeded.”
 97803/97804 – Configuration allows a count of three per rolling calendar year. Subsequent counts
pend EX NA, “Claims review for correct billing information.”

 Review the pended claim for procedure code G0270 or G0271, which supports additional units.
 If present, override EX NA with EX AP, “Approved.”
 If not present, deny EX HC, “Billing frequency limit exceeded.”

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Claims Pend Processing Profile

Process: NF Queue Profile
Pend – Claims to Review
Pend Description Four
Pend Category January 1, 2015
Date Implemented April 11, 2016
Date Updated/Revised Senior Non Par Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

Purpose

To ensure non par providers billing chronic care management (CCM) CPT code – 99490 for members with out-
of-network benefits are reimbursed according to CMS guidelines and Peoples Health’s (PH) policies.

Beginning January 1, 2015, Medicare pays separately under the Medicare Physician Fee Schedule (PFS) for
CCM code 99490, for non-face-to-face care coordination services furnished to Medicare beneficiaries with
multiple chronic conditions.

PH will not make payment for this code to par providers or non par providers billing for members with no out-of-
network benefits. The system is configured to deny accordingly.

However, claims received from non par providers for members who have out of network benefits will pend NF.
In order for the procedure code to be payable, the provider must submit documentation that supports the CCM
service.

The senior claims examiner:
 Sends a letter to the provider requesting medical records and documentation to support 99490.
 Forwards documentation received to Medical Management for review.
 If all requirements are met, 99490 is paid. If all requirements are not met, 99490 is denied.

Informational

CPT 99490 is defined as follows:
 Chronic care management services at least 20 minutes per calendar month.
 Multiple (2 or more) chronic conditions exist and are expected to last at least 12 months, or until
death of the patient.
 Chronic conditions place the patient at significant risk of death, acute exacerbation/decompression,
or functional decline.
 Comprehensive care plan established, implemented, revised, or monitored.

Examples of chronic conditions include, but are not limited to, the following:

 Alzheimer’s disease and related dementia  Depression

 Arthritis  Diabetes

 Asthma  Heart failure

 Atrial fibrillation  Hypertension

 Autism spectrum disorders  Ischemic heart disease

 Cancer  Osteoporosis

 Chronic Obstructive Pulmonary Disease

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CCM services can be provided by physicians and the following non-physician practitioners:
 Certified Nurse Midwives,
 Clinical Nurse Specialists,
 Nurse Practitioners, and
 Physician Assistants.

Process

 Claims containing CPT code 99490 pend NF for manual review.

 Request documentation from the servicing provider.
 Follow the Generating a Letter Requesting Additional Information process to pend the claim
and tag the claim as unclean with a letter ID. The letter that is generated by Amisys the next
day is discarded.
 Complete the Chronic Care Management letter and put the letter in the Outgoing Letters
hanging filer to be scanned into Macess and mailed to the servicing provider.
 If records are not received within 30 days, the service line(s) are denied EX NO, “Additional info
requested from provider to process claim not received.”

 Upon receipt of medical records, a service form (SF) is created with the medical records
attached and sent to Stacey Henry in Medical Management for review to verify all requirements
of CCM billing have been met.
 If Medical Management determines all CCM requirements were met, the CCM service is
approved and paid.
 Enter CI code CW to approve the claim for payment.
 If Medical Management determines CCM requirements were not met, deny the CCM service
with EX code IB, “Denied – Billing Error – Please resubmit claim with correct information” and
enter an EOP remark:
 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.
 Type “Documentation does not support service(s)/item(s) billed” in the Remark
Summary field.
 Press Enter or click the save icon in the tool bar.

Additional Processing Guidance

 Only one practitioner (physician or non-physician) may be paid for the CCM service for a given calendar
month. Exceeding services are denied EX HC, “Billing frequency limit exceeded.”

 CCM code 99490 cannot be billed during the same months as 99495-99496 (Transitional Care
Management – TCM), G0181-G0182 (home health/hospice care supervision), or 90951-90970 (certain
ESRD services). CCM services billed during the same months as these codes are denied EX HC,
“Billing frequency limit exceeded.”

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Claims Pend Processing Profile

Pend: ni Queue Profile
Review NIPA PCP Claim for Hospital Locations
Pend Description Two
Pend Category July 9, 2009
Date Implemented January 17, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

A hospitalist is a physician who specializes in caring for patients in the hospital. Hospitalists ensure continuity of
care for MPT patients from the time they are admitted to the hospital until the time they are discharged. The
hospitalists also coordinate and monitor the exams, treatments and medications these patients may need.

Claims that pend “ni” are NIPA PCP claims that bill with location code 21 or 22.

There are ten doctors that do NOT participate in the hospitalist program. Inform your supervisor or manager if
you see any of the following:
Jeffery Coco
Joshua Lowentritt
Mario McNally
Thomas Mims
Eduardo Rodriguez
Charles Smith
Frank Cruz, Jr.
Frank Cruz
April Fox
Angela Reginelli

An examiner must verify if the facility on the claim has a hospitalist program or not.

The PHN Water Cooler has a grid of the hospitalists associated with each physician team and facility. It can be
found: http://www.cooler.peopleshealth.com/departments/network_development/Hospitalist.html.

Additionally, it can be found by going to http://www.cooler.peopleshealth.com/index.html.
Click Departments.
Scroll to the bottom of the page.
Look on the left hand side, under Network Development for Hospitalists.
Click Hospitalists.

As of October 19, 2012, the Hospitalist Program Facilities include:
Ochsner Baptist
Ochsner Kenner
Ochsner North Shore
Ochsner West Bank
East Jefferson
Slidell Memorial
Touro

1

If the facility DOES have a hospitalist program, deny the claim with EX “hp,” which means hospitalist coverage
applies.
If the facility DOES NOT have a hospitalist program, process the claim using the CI code “hi,” which means
IPA PCPs allowed services outside of hospitalist contract.
Note CCPI: If the whole claim is not pending ni and the billing provider is a Crescent City Physician, review the
service line that is not ni. If the CI code in that line reads “cc,” override the subsequent hospitalist lines pending
ni with CI code “hi.” Do NOT OVERRIDE THE “cc” CI code.
If a Crescent City Physicians’ claim does not have cc CI code, deny the claim “hp.”
If the claim is for a preventative service, process the claim using the CI code “hi.”
If the CCPI claim has an Office Service note marked on the Claim, process the claim using the CI code “hi.”
Note xxxxF: Claims with procedure codes ending in the letter F (xxxxF), should pay $0 (zero) for hospitalists.
Additionally, these service lines should have “hi” in the CI field as well as pend “FA,” which means procedure
code not eligible for payment.
Note Kenner Hosp Based Clinic: If the facility on the claim (field name - Facility 1) is from Kenner Hosp Based
Clinic at 200 West Esplanade, the facility is a clinic. (The hospital facility is 180 W Esplanade, which should be
denied with hp.) Claims from the 200 West Esplanade address don’t need to follow the hospitalist denial and
should be paid.
Note Kindred Hospital: Kindred Hospital is a LTAC (long-term acute care) facility, which does not participate in
the hospitalist program; therefore, process the claim using the CI code “hi.”

2

Claims Pend Processing Profile

Process: NJ Queue Profile
MEDICARE RATE NOT DEFINED
Pend Description Four
Pend Category August 1, 2012
Date Implemented January 19, 2016
Date Updated/Revised Sr. Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

Procedure codes that do not have a rate pend NJ for manual review. Claims that pend NJ are processed according
to the type of claim or procedure code billed.

Contents

Hospital Claims………………………………………………………………………………………… Page 1

Claims submitted by facilities

Physician Claims………………………………………………………………………………………. Pages 1-2

Claims submitted by providers in locations 11, 21, 22, 23, 24, 32 that do not fall into any other type of claim or
procedure code category within the NJ process

Laboratory Claims……………………………………………………………………………………… Pages 2-3

Claims submitted with location 81

Unlisted Procedure Codes……………………………………………………………………………. Pages 3-4

Procedure code contains the word “Unlisted” or “Not otherwise classified (NOC)” in the description

Radiopharmaceutical Drugs………………………………………………………………………….. Pages 4-5

Procedure codes A4641, A4642, A4648, A9500-A9572, A9575-A9604, and A9698-A9700

J-Codes…………………………………………………………………………………………………. Pages 5

Procedure codes beginning with letter “J” or procedure code 90735 or 90736

Other…………………………………………………………………………………………………….. Page 5

Procedure code S8032

Hospital Claims

 Hospital claims containing service lines pending NJ are reviewed to determine if the pricer applied
an allowed amount to the service line.
 If the service line has an allowed amount, perform EX Override to approve the service line.
 If the service line does not have an allowed amount, see your supervisor/manager for further

instruction.

Physician Claims Billed with Locations 11, 21, 22, 23, 24, 32
Note: If the procedure code is unlisted (contains the word “Unlisted” or “Not Otherwise Classified (NOC)” in the

description), radiopharmaceutical drug (procedure codes A4641, A4642, A4648, A9500-A9572, A9575-A9604, and
A9698-A9700), procedure code beginning with a “J” or procedure code 90735 or 90736, or S8032 - follow the

specific processes outlined on the following pages.

 Access the Medicare Physician Fee Schedule Database (MPFSDB) at Claims Department\Processing

Reports.
 Click on the MPFSDB file with the year corresponding to the claim’s date of service.

1 SSA 10.20.2015

 Once the file opens, click Ctrl+F to search within the Excel workbook.
 Click Options >> in the Find and Replace window.
 In the “Within” field, click the drop down arrow and select “Workbook”
 In the “Find what:” field, type the CPT/HCPCS code and click “Find All.”

 If the code is found within the MPFSDB, process the service line according to the CPT/HCPCS
code’s status indicator (column C). Refer to the table below.

Status

Code Status Code Description Claim Processing Action
 Active codes should not pend for a rate.
A Active code – Paid separately

under the physician fee schedule.  See list of scenarios on pages 2-5 for additional processing

B Bundled code – Payment for guidance.
 Deny service line with EX LT, “Denied – Bundled services.”

covered services is bundled into

payment for other services.  Request appropriate medical records and a Medicare
C Carrier priced code – Medicare

contractors (Carriers) establish EOP.
payment.  If medical records are received, see management for

review.
 If medical records are not received, deny service line NO,

“Additional info requested from provider to process
claim not received.”

E Excluded from physician fee  Deny service line with EX ex, “Excluded from physician fee
schedule by regulation schedule by regulation.”

G & I Not valid for Medicare purposes  Deny service line with EX RD, “Procedure code is not valid
for Medicare purposes.”

M Measurement code; used for  Process the service line with EX FA, “Procedure code not
reporting purposes only eligible for payment.”

X Statutory exclusion – Codes  Par providers – Deny service line with EX se, “Statutory

representing an item or service exclusion.”

that is not in the statutory definition  Non par providers – Process service line with EX FA,

of “physician services” for fee “Procedure code not eligible for payment.”

schedule payment.

 If the code is not found within the MPFSDB AND does not fall into any other type of claim or
procedure code category within the NJ process, see your supervisor/manager.

Laboratory Claims Billed with Location 81

 Access the Clinical Laboratory Fee Schedule at Claims Department\Processing Reports.
 Click on the file with the year corresponding to the claim’s date of service.
 Once the file opens, click Ctrl+F to search within the Excel workbook.
 In the “Find what:” field, type the CPT/HCPCS code and click “Find All.”

 If the code is found within the Clinical Laboratory Fee Schedule with a rate, manually enter the
amount on the service line indicated on the fee schedule. Price the code according to the claim’s

locality.
 Select the service line pending NJ and click Service Detail.
 Click Override Amt.

2 SSA 10.20.2015

 Select “2 – Override Dollars” in the drop down menu next to “Override $:” and Press Enter.
 Enter the allowed amount that was indicated on the SF in the “B-Allow” and “P-Allow” fields.

 Allowed amounts are per unit. If units are greater than one, multiply the allowed amount by
the number of units. Enter the total in the “B-Allow” and “P-Allow” fields.

 PH pays the lesser of the billed charges or the allowed amount. If the total allowed amount
is greater than the billed amount, enter the billed charge as the allowed amount.

 Click Save.
 If the Override EX Errors screen generates, enter “AP” in the EX Code field next to NJ.
 Click Save.
 Exit the screen.

 If the code is not found within the Clinical Laboratory Fee Schedule, review the list of gap-filled and
molecular pathology codes below. If the code is gap-filled or a molecular pathology code, request
the Medicare EOP.
 If the Medicare EOP is received, see management for review.
 If the Medicare EOP is not received, deny the service line NO, “Additional info requested from
provider to process claim not received.”
 Gap-filled & molecular pathology codes:
81201-81203, 81235, 81252-81254, 81321-81326, 81200, 81205-81217, 81220-81229, 81240-
81245, 81250, 81251, 81255-81257, 81260-81268, 81270, 81275, 81280-81282, 81290-81304,
81310, 81315-81319, 81330-81332, 81340-81342, 81350, 81355, 81370-81383, 81400-81408
 81479, 84999, & 86849 are unlisted codes. Follow the unlisted code process outlined on pages 2
and 3.

 Lab codes 80300-80304 & 80320-80377 are not recognized by Medicare – process with EX code FA,
“Procedure code not eligible for payment.”

Unlisted Procedure Codes
Note: All unlisted procedure codes follow the process as outlined in this section, regardless of the assigned status
indicator on the MPFSDB.

Unlisted codes submitted by assistants-at-surgery (indicated by modifiers -80, -81, -82, and -AS) are priced at a
percentage of the primary surgeon’s payment. See page 4 for Unlisted Codes for Assistants-at-Surgery processing
guidelines.

 If the code contains the word “Unlisted” or “Not otherwise classified (NOC)” in the description,
request medical records from the provider.
 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.”

 Once the requested information is received from the provider:
 Complete an Unlisted Procedure Code coversheet by handwriting the information (do not enter into
the Unlisted Database).
 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.
 The information is submitted to a medical director for review, who will provide a comparable code.

3 SSA 10.20.2015

 Upon receipt of a comparable code from the medical director, the Claims Director forwards the
unlisted code to be manually priced.
 Obtain the comparable code’s allowed amount from the Fee Schedule Inquiry screen (IQ3400). The
information is entered as follows:
 The comparable code in the Proc#/Rev Code field.
 The claim’s locality in the Area (AA) field.
 The claim’s date of service in the Date field.
 Refer to the appropriate fee schedule for the allowed amount:
 FS30 – Physician’s office location (11)
 FS31 – Facility locations (21, 22, 31, 32, 61, 62)
 Manually enter the comparable code’s allowed amount on the unlisted procedure code’s service line
using the Override Amt function.
 PH pays the lesser of billed charges or the allowed amount.

Unlisted Codes for Assistants-at-Surgery

Unlisted codes billed with assistant-at-surgery modifiers (-80, -81, -82, -AS) are priced at a percentage of the
primary surgeon’s payment. If an unlisted code contains an assistant-at-surgery modifier:

 Review Claims by Member (IQ1300) to identify the primary surgeon’s claim. If the primary surgeon’s
claim:
 Has not yet been received, follow the unlisted code process outlined above.
 Has been received and is under review by a medical director (pending EV) OR has been received
and was priced according to the comparable code provided by a medical director:
 Complete an Unlisted Procedure Code coversheet by handwriting the information (do not
enter into the Unlisted Database),
 Provide the primary surgeon’s claim number on the coversheet.
 Manually pend the claim EV, “Pending for medical director review,” and
 Provide the Unlisted Procedure Code coversheet, and claim image to the Claims Director.

Radiopharmaceutical Drugs
Note: All radiopharmaceutical drug codes follow the process as outlined in this section, regardless of the assigned
status indicator on the MPFSDB.

 Effective for dates of service in 2014, the following radiopharmaceutical drugs are priced according
to the acquisition cost billed in block 19 or 24D of the CMS-1500 or 2400 loop NTE of an electronic
claim.
 A4641, A4642, A4648, A9500 - A9572, A9575 - A9604, and A9698 - A9700.

 Review the claim for the acquisition cost.
 For paper CMS-1500 claims, the amount is billed in block 19 or 24D.
 For electronic claims, the amount is billed in the Notes section under the service line (see image
below).

4 SSA 10.20.2015

 If the acquisition cost is reported on the claim, manually enter the acquisition cost in the allowed
amount field of the service line.
 If the units are greater than one, review any attached documentation to determine if the acquisition
cost provided is per unit or the total for all units billed.
 See your supervisor/manager if this cannot be determined.

 If the acquisition cost is not reported on the claim:
 Deny the service line with EX TA, “Total acquisition or invoice cost required.”

J-Codes
 HCPCS codes beginning with “J” are sent to Pharmacy for review and 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 77, “Denied – Must bill with NDC# / Brand Name / Dosage of Drug.”

 If the drug name, NDC#, and dose are billed, send a service form to Group-PH-Claims Pricing
Requests stating:
 “Please review claim #____________ and HCPCS code _____ (drug name, dose, NDC#, billed
charge) and provide the allowed amount.”
 Example: Please review claim #15012E006793 and HCPCS code J3490 (Verapamil 10 mg SC
NDC 00409114402) and provide the allowed amount. Claim must be processed by 4/7/15.”
 The SF must include the claim #, HCPCS code, drug name, dose, NDC#, and billed amount.

 HCPCS codes J0129, J1745, 90735, and 90736 are processed under the member’s Part D pharmacy
benefit.
 Deny the service line WG, “Services must be billed under Part D.”

Other
 HCPCS code S8032 – Low-dose computed tomography for lung cancer screening (Added 10/08/15)
 Follow the Generating a Letter Requesting Additional Information process to request the Medicare
EOP only.
 If the Medicare EOP is received, submit a copy of the claim and the EOP to the Claims Director.
 If the Medicare EOP is not received within 30 days, the code is priced based on a comparable code
that has been provided by a medical director.
 Complete an Unlisted Procedure Code coversheet by handwriting the information (do not
enter into the Unlisted Database).
 Manually pend the claim EX EV, “Pending for medical director review.”
 Provide the Unlisted Procedure Code coversheet and claim image to the Claims Director.
 The claim will be processed based on the comparable code that was provided by the
medical director.

Additional Processing Notes:
 When manually entering allowed amounts - PH pays the lesser of the billed charges or the allowed
amount. If the total allowed amount is greater than the billed amount, enter the billed charge as the allowed
amount.

5 SSA 10.20.2015

Claims Pend Processing Profile

Process: NK Queue Profile
N/P Requesting Information for Referral Review
Pend Description N/A
Pend Category
Date Implemented October 7, 2015
Date Updated/Revised Authorizations Examiners
Person(s) Responsible As defined below:
Processing Instructions

 Open the following systems/websites:
 CCMS
 EDI Viewer (to view electronic claim images)
 Macess (to view paper claim images)
 Two Amisys Advance screens
 Claims Summary
 Provider Affiliations

 Verify claim information in Amisys matches the claim image.
 Enter claim number in the Claims Summary screen in Amisys.
 View claim image in EDI Viewer/Macess.
 Verify information on the claim in Amisys matches information on the claim image.
 If any of the information does not match, send an email to the Claims Authorization

Supervisor who will inform the Claims Supervisor to have the claim corrected.

 Verify provider affiliations for the servicing and referring providers are correct in Amisys.
 In Claims by Member, click Service Dtl IQ. The Service Detail screen will generate.
 In the Provider Affiliation screen, click the Binoculars icon, copy the servicing provider number

from the Service Detail screen, and paste it into the Provider field on the Provider Affiliation

screen.
 Repeat for the servicing provider’s four-digit affiliation number. Press Enter.
 Verify the servicing provider’s affiliation:

 Member’s Carrier and Region match the provider’s carrier and region.
 Date(s) of service fall within the provider’s Effective Dates.
 Provider’s IRS# matches the Tax ID billed on the claim.
 Verify the referring provider’s NPI (EDI claims only; paper claims contain the provider’s name).
 Open eCare Online http://npi.ecare.com/.
 Type/Copy and paste the referring provider’s NPI in the NPI field.
 Press Enter or click Process.
 Verify the referring provider’s name matches the referring provider in Amisys.
 Repeat the above steps for the referring provider’s affiliation.
 Verify the referring provider’s affiliation:
 Member’s Carrier and Region match the provider’s carrier and region.
 Date(s) of service fall within the provider’s Effective Dates.
 If any of the information does not match, send an email to the Claims Authorization Supervisor

1

who will inform the Claims Supervisor to have the claim corrected.

 In CCMS, review the member’s authorizations to ensure there is not an existing authorization for

the provider and date of service (DOS). (Duplicate authorizations may cause errors.)
 Click Member Lookup.
 Enter the member’s G-number in the Member ID field (do not enter the hyphen).
 Click Search. The member’s name will populate.
 Click Events. The member’s authorizations will populate.
 Review the member’s authorizations for the DOS and servicing provider on the claim.
 If an authorization exists, review the authorization to verify all information matches the claim.

The authorization may have been added earlier in the day and not migrated to Amisys yet.
 If an authorization does not exist, continue to the following steps.

 Build an authorization in CCMS for the claim pending NK.
 Click Add and select Referral.
 Enter authorization information as follows:

Authorization Tab

Field Info Entered

Event Mgmt Status Open

Event Status 11 Manually Approved
Event Status Reason B+ Override – Payment based on regulatory process

Comment mandate
“*Date entered (MMDDYY)* APP PAR REFERRAL/FIRST
NAME INITIAL AND LAST NAME”

Referral Reason MN Medical Nec Rev – No Fax

Location Location code on the claim (e.g., 11, 22, 32, etc.)

Benefit Level Override Lev 1

Start Date Beginning DOS on claim

End Date Ending DOS on claim

Referring Provider Referring provider # and affiliation on claim

Servicing Provider Servicing provider # and affiliation on claim

Diagnosis Code Primary diagnosis code billed on claim

Line Items Tab

Field Info Entered

Provider Status and Ben Lvl From Auth Tab

Units # of DOS on claim

Auth Type - AR Select the AR code based on the location code/service.

Location AR Code
11 CI
21 ME
22 OH
31 SF
61 RH
WO
Wound care

Start Date Beginning DOS on claim

End Date Ending DOS on claim

2

 Return to the Authorization tab.
 Click Event Mgmt Status and select “Closed.”
 Select “EV” for Event Closure.
 Click Yes. The authorization will close and the authorization # will generate.
 The authorization is complete.

 Enter a claim remark in Claims Summary with sub-type “AG” to reference the authorization
number.
 Type “RM0100” under Global Functions
 Click Binoculars icon.
 Click the green plus sign icon in the toolbar to add a new remark.
 From the ID# Type drop down box and select “CL.” The claim # and member # will populate.
 For the Remark Effective Date, enter the begin DOS.
 For the Exp Date, enter 12/31/9999.
 In the Remark Type field, type “CL”.
 In the Remark Summary field, type the authorization #.
 Press Enter or click the save icon.
 Type “AG” in the Sub-Type field.
 Press enter or click the save icon.
 Press F8 or exit the Remarks screen.

Helpful Tips
 Par referred authorizations are not created for facility (hospital) claims, unless the claim contains a par
attending provider and :
 14X bill type which contain outpatient lab charges, or
 Any bill type with a admit source of 1 or 2.
 If a hospital claim is pending NK and does not meet the criteria above, forward the claim to your
supervisor for review. Do not remark the claim.
 In order to ensure appropriate information is requested for par referred therapy claims, par referred
therapy authorizations are not added from the NK report. Par referred therapy claims should pend NN.
If a par referred therapy claim is on the NK report, inform your supervisor. Do not remark the claim.

3

Claims Pend Processing Profile

Process: O6 Queue Profile
Review Medicare Non-Par I/P Claims for Auth Entry
Pend Description Category III
Pend Category
Date Implemented July 14, 2014
Date Updated/Revised Authorizations Examiners
Person(s) Responsible As defined below:
Processing Instructions

 Open the following systems/websites:
 CCMS
 EDI Viewer (to view electronic claim images)
 Macess (to view paper claim images)
 Three Amisys Advance screens
 Claims Summary
 Claims by Member
 Provider Affiliations

 Verify claim information in Amisys matches the claim image.
 Enter claim number in Claims Summary in Amisys.
 View claim image in EDI Viewer/Macess.
 Verify information on the claim in Amisys matches information on the claim image.
 If any of the information does not match, send an email to the Claims Authorization

Supervisor who will inform the Claims Supervisor to have the claim corrected.

 Verify provider affiliations for the servicing and referring providers are correct in Amisys.
 In Claims by Member, click Service Dtl IQ. The Service Detail screen will generate.
 In the Provider Affiliation screen, click the Binoculars icon, copy the servicing provider number

from the Service Detail screen, and paste it into the Provider field on the Provider Affiliation

screen.
 Repeat for the servicing provider’s four-digit affiliation number. Press Enter.
 Verify the servicing provider’s affiliation:

 Member’s Carrier and Region match the provider’s carrier and region.
 Date(s) of service fall within the provider’s Effective Dates.
 Provider’s IRS# matches the Tax ID billed on the claim.
 Verify the referring provider’s NPI (EDI claims only; paper claims contain the provider’s name).
 Open eCare Online http://npi.ecare.com/.
 Type/Copy and paste the referring provider’s NPI in the NPI field.
 Press Enter or click Process.
 Verify the referring provider’s name matches the referring provider in Amisys.
 Repeat the above steps for the referring provider’s affiliation.
 Verify the referring provider’s affiliation:
 Member’s Carrier and Region match the provider’s carrier and region.
 Date(s) of service fall within the provider’s Effective Dates.

1

 If any of the information does not match, send an email to the Claims Authorization Supervisor
who will inform the Claims Supervisor to have the claim corrected.

 In CCMS, review the member’s authorizations to ensure there is not an existing authorization for
the services billed. (Duplicate authorizations may cause errors.)
 Click Member Lookup.
 Enter the member’s G-number in the Member ID field (do not enter the hyphen).
 Click Search. The member’s name will populate.
 Click Events. The member’s authorizations will populate.
 Review the member’s authorizations for the date of service and servicing provider on the claim.
 If an authorization exists, review the authorization to verify all information matches the claim.
The authorization may have been added earlier in the day and not migrated to Amisys yet.
 If an authorization does not exist, continue to the following steps.

 In CCMS, review the member’s authorizations for the admission event. The authorization
number will begin with the letter “A.”
 The admission authorization is the authorization for the hospital authorizing the inpatient stay.
 Open the admission authorization to verify the date of service span includes the date of service
on the claim.

 If the admission authorization includes the date of service on the claim, build a referral

authorization in CCMS for the claim pending O6.
 Click Add and select Referral.
 Enter authorization information as follows:

Authorization Tab

Field Info Entered

Event Mgmt Status Open

Event Status 11 Manually Approved
Event Status Reason BQ Override – OVERRIDE - NO CONTRACTED

PROVIDER AVAILABLE

Comment “*Date entered (MMDDYY)* APP NON PAR HOSP VISITS
IP STAY/FIRST NAME INITIAL AND LAST NAME”

Referral Reason MN Medical Nec Rev – No Fax

Location Location code on the claim (e.g., 21, 31, 61, etc.)

Benefit Level Override Lev 1

Start Date Beginning DOS on the admit authorization

End Date Ending DOS on the admit authorization

Referring Provider Referring provider # and affiliation on the claim

Servicing Provider Servicing provider # and affiliation on the claim

Related Admission First day of the admit authorization’s DOS

Diagnosis Code Primary diagnosis code billed on claim

2

Line Items Tab

Field Info Entered
Provider Status and Ben Lvl
Units From Auth Tab
Auth Type - AR
# of Days from the admission authorization + 1
Start Date
End Date Select the AR code based on the location code/service.

Location AR Code

11 CI

21 ME

22 OH

31 SF

61 RH

Wound care WO

Beginning DOS from admit authorization

Ending DOS from admit authorization

 Return to the Authorization tab.
 Click Event Mgmt Status and select Closed.
 Select EV for Event Closure.
 Select Yes. The authorization will close and the authorization number will generate.
 The authorization is complete.

 Enter a claim remark in Claims Summary with sub-type “AG” to reference the authorization

number.
 Type “RM0100” under Global Functions
 Click Binoculars icon.
 Click the green plus sign icon in the toolbar to add a new remark.
 From the ID# Type drop down box, select “CL.” The claim number and member number will

populate.
 Enter the date of service for the Remark Effective Date.
 Enter 12/31/9999 for the Exp Date.
 Type “CL” in the Remark Type field.
 Type the authorization in the Remark Summary field.
 Press Enter of click the save icon in the tool bar.
 Type AG in the Sub-Type field.
 Press enter.
 Close out of the Remarks screen.

 Demand Draw the claim from Macess.

Helpful Tips
 If the admission authorization is denied, do not build the referral authorization. Remark the claim with
your initials.
 If no referring provider is on the claim, copy and paste the servicing provider for the referring provider
on the authorization.
 Skip the claim if there is no admission authorization. Do not remark the claim. Continue to check daily
for an admission authorization or a facility claim that paid.

3

Claims Pend Processing Profile

Process: O8 Queue Profile
Review Medicare Non-Par Outpatient Claims for Auth Entry
Pend Description Four
Pend Category July 14, 2003
Date Implemented April 25, 2016
Date Updated/Revised Non Par Sr. Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

 Review Authorizations by Member (IQ1000) to determine if an authorization is on file for the service(s).

 Select “Global Functions”  “Authorization”  “Authorizations by Member.”
 The Authorization by Member Inquiry screen will appear with the Member# & Name, Requested Prov#,

and Search Date populated.
 Copy the Member# then click the Binoculars icon to clear all search fields.
 Paste the Member# and press Enter. The Authorization by Member Inquiry screen will appear.
 Scroll right to the Authorized Dates to search for an authorization on or around the claim’s date(s) of

service.
 If there is no authorization, proceed to page 3 for processing directions.

 If there is an authorization on file, review the Type (AR) field and the authorization remarks to determine if

the authorization is related to the services billed.

 Refer to the table below for a list of common AR codes and their descriptions.

 Note: Table does not include all AR codes.

Type Claim

(AR) Description POS Claim/Service Type

23 23 Hour Observation Stay 22 Various services performed while the member is in
CI Consult – Include Lab/X-ray observation

11 Various services performed in a physician’s office

DI Dialysis 65 Dialysis services
DM DME 12
HH Home Health 12 DME items or supplies
IF Infusion Therapy Various Various services performed in the member’s home
ME Medical 21 Injections
Various services performed when a member is
admitted inpatient (pro fees)

LB Laboratory 11, Pathology & laboratory services
19/22, 81 CPT codes 80049 – 89399

OH Outpatient Procedures & Testing 19/22, 24 Various services performed in an outpatient setting

OT Occupational Therapy Various Therapies with modifier GO
PT Physical Therapy Various Therapies with modifier GP
SF Skilled Nursing Various services provided to a member in a Skilled
31 Nursing Facility (SNF)

SS Sleep Study 19/22, 81 Sleep study
ST Speech Therapy Various Therapies with modifier GN
SU Surgery Various Surgery CPT codes 10040-69990

WO Facility Wound Care Various Wound care/debridement

If the services billed relate to the AR type, click:

 “Med Auth Iq” for authorization numbers containing an R; or

 “Hosp Auth Iq” for authorization numbers containing an A.

 “R” authorizations are referral authorizations for outpatient services or related admission

1 SSA 11.12.2014

services (professional fees while a member is inpatient).
 “A” authorizations are inpatient admission authorizations built for the facility claim to pay

(locations 21 and 31).
 Click “Remarks Iq.” The Remarks Profile Inquiry screen will appear.
 Review the authorization remarks to gather additional information on the authorization (e.g., if the

authorization was approved, how many units, type of service, etc.).
 If the services billed are not related to the authorization, proceed to page 4 for processing directions.
 If there is a related authorization on file, review the authorization in the Certification screen (UA0100) to
determine why the authorization is not mapping to the claim.
 Copy the authorization number from the Remarks Profile Inquiry Screen.
 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 “Authorized Svcs.” The Authorized Services screen will appear.
 Review the following information to determine why the authorization is not mapping to the claim.

Click the arrows to scroll
through the authorization pages.

 In order for an authorization to map to a claim, the following must be true:
 Dates must include the service dates billed on the claim.
 Prov must match the provider number on the claim.
 Blank Prov fields with the Prov Status populated indicate authorized professional fees and are not
specific to an individual provider. However, the Prov Status must match the servicing provider’s
status on the claim (e.g., OA).
2 SSA 11.12.2014

 Location (LC) must match the location on the claim.
 Proc# if populated, must match the procedure code on the claim.

 For information that differs from the claim, review the Medical Necessity Form (MNF) and the Authorization
Confirmation in the member’s folder in Macess to verify the authorization was built correctly according to

what was requested on the MNF and what was authorized on the Authorization Confirmation.
 In Macess, MNFs are saved as Document Type “MNF” and may contain the authorization number and the

provider name under the Description field.
 Authorization Confirmations are saved as Document Type “Auth Confirmation…” and may contain the

authorization number under the Description field.
 Compare the MNF to the Authorization Confirmation and the authorization in Amisys to determine if the

authorization was built incorrectly.

 If the authorization in Amisys does not match the Authorization Confirmation with respect to the provider
number, dates, or location (clerical errors) – the authorization can be updated by the Claims Authorization

staff.

 Send a service form (SF) to Claims Authorizations requesting an authorization update. 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 O8 pend.

 Repeat above steps as necessary if the O8 pend does not fall off.

 Discrepancies between the MNF, Authorization Confirmation, and authorization in Amisys, other than

clerical errors, are sent to Medical Management for review to determine if services were authorized/if an

authorization should be added or updated.
 In Macess, create a Service Form (SF) and attach the MNF and all supporting documentation.
 Refer to the Who to Send Service Forms document to determine the recipient of the SF.
 Request review of the authorization and claim to determine if the services were authorized/if the

authorization should be updated.
 Process the claim according to Medical Management’s response and the authorization.

 If there is an authorization on file, but the provider is billing incorrectly according to the authorization,
deny with EX code 63, “Provider billing for services different from authorization.”
 Note: EX code 63 is ONLY to be used when an authorization for the service is on file.

If there is no authorization on file, develop the claim:

Note: Service(s) provided out of the network area require medical records for review of urgent/emergent, unless the
member received prior notification that the service(s) would not be covered.

1. Review the claim for a par referral.
 Medical Claims: If the referring provider’s affiliation status is anything other than NP or OA, request

confirmation of the par referral (the NK letter) by following the Generating a Letter Confirming a Par to Non

Par Referral process.
 Hospital Claims: If the attending provider’s affiliation status is anything other than NP or OA AND the

admit source (form locator 15) is 1 or 2, request confirmation of the par referral (the NK letter) by following

the Generating a Letter Confirming a Par to Non Par Referral process.
 If the attending provider’s affiliation status is par and the admit source is NOT 1 or 2, continue
developing the claim. These claims do not follow “par referral” guidelines.

3 SSA 11.12.2014

2. Review the servicing provider’s On-call History.
 Copy the servicing provider’s number.
 Click Global Functions  Provider  On-call History.
 Under On-Call Type, select P - Provider.
 Paste the servicing provider’s number next to the On-Call field. Press Enter.
 Review the providers’ affiliation information to determine if a provider is par and in the same group as the
servicing provider.
 Copy and paste the providers’ numbers into the Provider Affiliation screen and search by the
member’s Carrier and Region to determine if the provider is par. Review the provider’s tax id to
determine if they are in the same group.

3. Review the claim for emergent diagnosis codes / post-stabilization.
 Medical Claims: Review the claim for emergent diagnosis codes and review claim history for other claims
indicating related emergency services provided on the same day.
 If the claim contains an emergent diagnosis code (refer to List of Emergency Diagnosis Codes) in
any diagnosis position, request medical records by following the Generating a Letter Requesting
Additional Information process.
 Review claims history for emergent services provided on the same day.
- If there is an emergency ambulance/ER claim for the same date of service and with the
same or related diagnosis, send an SF to Claims Authorizations requesting a post-
stabilization authorization to be added.
- If for an unrelated diagnosis, request medical records.
 Hospital Claims: Review the claim for revenue code 450, indicating the member was admitted through the
Emergency Room (ER).
 If revenue code 450 is present, the services are considered post-stabilization. Send an SF to
Claims Authorizations requesting a post-stabilization authorization be added.
 If revenue code 450 is not present, follow location 11 guidelines (see page 8).

4. Review Claims by Member (IQ1300) for claims received on and around the date(s) of service billed to
gather additional information on the services provided.
 Reviewing claims history can help determine the authorized location code, if the member was referred to a

non par provider by a par provider, or other billing issues that arise.
 Review all claims submitted by the provider to ensure consistent processing.
 If the location billed is a hospital setting, review claims history for the facility claim or Authorizations by

Member for the facility authorization.
 See pages 6-11 for specific Claim Type / Scenario processing guidelines.

5. Review the member’s folder in Macess for a Letter of Agreement (LOA) that covers the member and the
date(s) of service.
 If an LOA is on file, process the claim according to the LOA.
 If there is no authorization, inform your supervisor.

Reminders:
 Review Claims by Member for all claims received by the provider to verify consistent processing.
 Review claims for attachments before requesting medical records.
 When sending SFs to Medical Management for a par referral authorization (DME & Home Health):
 Review medical records submitted by the provider to ensure requested information was provided.
 In the SF request, specifically request a par referral authorization and indicate a letter was sent to confirm
the referral.
 When sending SFs to Medical Management for urgent/emergent review:
 Review medical records submitted by provider to ensure requested information was provided.
 In the SF request, specifically request review for urgent/emergent criteria.
 Before denying a claim EX code NO, “Additional info requested from provider to process claim not received,” verify
that a letter was sent to the provider with the correct mailing address and that the appropriate information was
requested.
 See page 5 for the appropriate usage of EX code NO.

4 SSA 11.12.2014

Steps to deny the O8 pend:

Single service line:

 Click “Service Detail.”
 Click “Reset/Adj.”
 Type the appropriate denial code in the EX code field containing the O8 pend.
 Press Enter or click Save and exit the screen.
 Exit the Service Detail screen as well.
 The O8 pend code should be removed and replaced with the appropriate denial code.

Multiple service lines:

 Click “EX Overrides.”
 Type O8 in the “OLD EX” field and press Tab.
 Type the appropriate denial 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 O8 pend code should be removed and replaced with the appropriate denial code.

Non Par Provider Authorization Denial Codes

EX

Code EX Description Usage
Inpatient and observation pro fees and non-RAPs readings only –
26 Place of service is inconsistent with When the location on the pro fee claim does not match the facility
claim’s location.
claim history  Used on inpatient and observation pro fee claims if the facility

63 Provider billing for services different claim is on file with a different location code.
from authorization.  Used on non-RAPs readings if the reading is billed with a

DV Non-participating provider billing for different location than the related test (see page 10).
unauthorized service.  Does not apply when a member rolls from observation to

NO Additional info requested from inpatient (see page 9).
provider to process claim not  Does not apply when the pro fee is billing location 19 and the
received.
facility is billing location 22, and vice versa. The two POS
NW Additional info received from provider
is insufficient to process claim. codes are interchangeable in regards to billing and

authorizations. If there is a related 19/22 authorization on file,

the authorization should be added/updated to allow the claim to

pay (see page 10).

An authorization is on file for the services billed, but the claim was
not billed according to the authorization.

Examples of correct usage of EX 63 include, but are not limited to:
 Billed location does not match authorized location (exclude pro

fee claims with location codes that do not match facility claim).
 Does not apply when the claim was billed with location 19 and

the authorization is for location 22, and vice versa. The two
POS codes are interchangeable in regards to billing and

authorizations. If there is a related 19/22 authorization on file,

the authorization should be added/updated to allow the claim to

pay (see page 10).

After research and development, it was found that there is no

authorization on file for the service(s) billed and the claim is not
urgent/emergent, par referred, or for post-stabilization services.

Additional information was requested, but not received from the

provider within the specified timeframe.

Note: The provider has 30 days from the date of the letter to submit the requested
information.

Additional information was requested and received, but lacks
enough documentation to make a processing determination.

5 SSA 11.12.2014

Additional Processing Guidance:

Claim Types / Scenarios  Process
Par Referrals 
CMS considers a contracted provider (par Request confirmation of the par referral by following the
provider) an agent of the plan. Any Generating a Letter Confirming a Par to Non Par Referral
services and referrals given by a par process.
provider are considered plan-approved, Within 15 days of sending the letter:
unless notice is provided to the member  If the request is not returned OR if the request is returned
that the services will not be covered.
confirming the referral, an authorization is added by the Claims
Services resulting from an authorized non Authorization staff for the claim to pay.
par referral follow this process (see  If at any point the letter is returned stating a referral was not
below). given, deny the claim with EX code DV, “Non-participating
provider billing for unauthorized service.”
Authorized Non Par to Non Par Lab Referral  If an authorization was previously added, send an SF to

Lab claims with a non par referral are paid  Claims Authorizations requesting the authorization be voided.
if the non par provider was authorized for a Then, adjust the claim to deny with EX code DV, “Non-
date of service within 6 months of the date participating provider billing for unauthorized service.”
of service billed.
Review Authorizations by Member to determine if the non par
Urgent/Emergent Services  referring provider was authorized.
Urgently-needed services are not  If authorized for a date of service within 6 months of the date of
emergency services, but are medically
necessary and immediately required as a service billed, send an SF to Claims Authorizations requesting an
result of an illness, injury, or condition and authorization based on the referring provider’s authorization.
are provided when the member is out of  If authorized for a date of service outside 6 months of the date of
the network area or due to a temporarily service billed, see your supervisor for further processing
inaccessible network. guidance.

Emergency services treat conditions that  Urgently-needed services – Review the claim to determine if the
are acute and severe in nature such that a services were provided outside of the network area.
prudent layperson could reasonably  If the services were provided outside of the network area, request
expect the absence of medical attention to
result in: medical records by following the Generating a Letter Requesting
Additional Information process.
 Serious jeopardy to the member,  If the services were provided in the network area, verify that the
 Impairment of bodily functions, or network is not incomplete and/or inaccessible by reviewing the
 Serious dysfunction of any bodily Peoples Health Physician Search at:
http://www.peopleshealth.com/peopleshealthv4/search/physician/
organ or part. Default2015.aspx.
 Enter the member’s plan information and the provider’s
Post-Stabilization 
Post-stabilization care services are specialty to verify a contracted provider is available in the
covered services that are related to an network.
emergency medical condition provided  If a contracted provider is not available, send an SF to Claims
after an enrollee is stabilized to maintain Authorizations requesting an authorization be added.
Emergency services – Review the List of Emergency Diagnosis
Codes and the diagnosis codes billed on the claim to determine
if the claim contains emergency diagnosis codes.
 If the claim contains an emergent diagnosis code in any diagnosis
position, request medical records by following the Generating a
Letter Requesting Additional Information process to determine if
the services were emergent.
 If the claim does not contain emergent diagnosis codes, continue
reviewing the claim to determine if payment should be made.

Hospital Claims – Review the claim for revenue code 450
(emergency room).
 If the claim contains revenue code 450, send an SF to Claims

Authorizations requesting a post-stabilization authorization to be

6 SSA 11.12.2014

the stabilized condition. added.
 If claim does not contain revenue code 450, follow location 11
Dialysis
Non par dialysis services with no guidelines.
authorization must be paid.  Medical Claims – Review claims history for emergent services
Par referred dialysis claims with a pre-
service denial must be paid if the member provided on the same day.
was not informed of the pre-service denial  If there is an emergency ambulance/ER claim for the same date of
until after dialysis services were provided.
service and with the same or related diagnosis, send an SF to

Claims Authorizations requesting a post-stabilization authorization

to be added.
 If for an unrelated diagnosis, medical records may need to be

requested.

 Send an SF to Claims Authorizations requesting an authorization

be added, UNLESS one of the following three scenarios apply:

1. Payment was made to another dialysis facility for services within

the same date span that were authorized.

2. The provider billed for dialysis services greater than three times

per week.

3. A pre-service denial was issued, but the claim contains a par
referral and the member wasn’t notified of the denial until after

receiving dialysis treatment.

 If one of the first two above scenarios applies, request medical
records for Medical Management’s review and process the claim

according to their response.
 Generate a letter to the provider requesting medical records.

 If medical records are not received within 30 days, deny the
claim with EX code NO, “Additional info requested from
provider to process claim not received.”

 Upon receipt of medical records, create an SF and attach the

medical records.
 Forward the SF to the appropriate individual in Medical

Management stating,
 “Requesting review of non par dialysis services as payment

was previously made to another facility for the same date
span,” OR
 “Requesting review of non par dialysis services exceeding
three times per week.”
 If Medical Management states the services are medically

necessary, send an SF to Claims Authorizations requesting an

authorization be added.
 If Medical Management states the services are not medically

necessary, deny the claim with EX code DV, “No authorization for
out of network provider.”

 If the third scenario applies, determine when the member was
notified of the denial. Review the member’s folder in Macess for

a Notice of Denial of Medical Coverage to the member.
 If the member was notified of the denial prior to receiving dialysis

services, the claim should deny for no authorization.
 If the member received notification of denial during dialysis

treatment, send an SF to Group-Claims-Claims Authorizations to

have an authorization added to cover days the member was not

notified of the denial (beginning of treatment through 3 business

days post-notification). Provide service dates to be paid in the

service form.
 Reference the denial authorization in the SF.
 To avoid authorizations pending as duplicates, the

Authorization Examiner will update the denied authorization to

the day after the end of the approved authorization.

7 SSA 11.12.2014

 If the member was never notified of the denial, the claim must be
paid. Send an SF to Group-Claims-Claims Authorizations to have
an authorization added.

Location 11 – Office & Location 12 – Home

Services provided in location 11 – Office  Review for a par referral.
and location 12 – Home  If par referred, follow the par referral process outlined on page 6.

Does not apply to par referred claims; see  Review for emergent diagnosis code.
section titled, “Therapy, DME, & Home  Review the List of Emergency Diagnosis Codes and the diagnosis
Health Claims with a Par Referral” below.
codes billed on the claim to determine if the claim contains

emergency diagnosis codes.
 If the claim contains an emergent diagnosis code in any diagnosis

position, request medical records by following the Generating a

Letter Requesting Additional Information process to determine if

the services were emergent.

 Review member’s claim history.
 If there is an emergency ambulance/ER claim for the same DOS

and same or related diagnosis, send an SF to Claims

Authorizations requesting an authorization to be added.
 If unrelated diagnosis, request medical records for review of

urgent/emergent.

 If no other indication of a par referral or urgent/emergent, deny
claim EX DV, “Non-participating provider billing for unauthorized

service.”

Therapy, DME, & Home Health Claims with a Par Referral

Therapy claims, DME and Home Health  Request both letters (NK & NN) to confirm the par referral and
claims indicating a par referral require a
confirmation of par referral and the request medical records.
medical records before an authorization  Confirmation of the par referral by following the Generating a
can be added.
Letter Confirming a Par to Non Par Referral process, and
 Medical records by following the Generating a Letter Requesting

Additional Information process.

 Regardless of the par referral, if medical records are not received
within 30 days, deny the claim “NO.”

 An authorization cannot be added by Medical Management

without the medical records.

 Upon receipt of medical records:
 Review the MD orders to confirm the par referral.
 Therapy claims: Send an SF to Claims Authorizations

requesting an authorization be added.
 DME & Home Health claims: Send an SF to the Medical

Management requesting an authorization be added.
- Attach the medical records (including the MD orders) to

the service form, and
- Request an authorization be added due to the par

referral. Include in the SF request that the services were

par referred and a letter was sent to confirm the referral.

Professional Fees  Review Authorizations by Member to determine if there is an
Professional services provided to a authorization on file for the facility.
member while in an outpatient setting  If an authorization is on file for the facility, send an SF to Claims
(e.g., 19, 22, 24, 62, etc.). Authorizations requesting an authorization be added.
 Enter a CL remark stating, “SF#____ requesting auth.”
These services are referred to as “pro
fees.”  If there is no authorization on file, review Claims by Member
(IQ1300) for the facility claim to verify the physician is billing
Does not apply to clinic billed claims; see correctly.

8 SSA 11.12.2014

section titled, “Clinic Billing” below.  If the provider is billing with a different location code than the
related facility claim (e.g., the facility claim has location 21 and the
Rolling from Observation to Inpatient pro fee claim has location 22), deny the pro fee claim with EX
Authorizations for members who roll from code 26, “Place of service inconsistent with claim history.”
observation to inpatient.  Does not apply when a member rolls from observation to
Physicians bill pro fee claims with inpatient inpatient.
location for DOS while the member was in  Does not apply when the pro fee is billing location 19 and the
observation and vice versa. facility is billing location 22, and vice versa. The two POS
codes are interchangeable in regards to billing and
Clinic Billing authorizations. If there is a related 19/22 authorization on
Physicians billing for services in location file, the authorization should be added/updated to allow the
19/22 under clinic billing. claim to pay.
Physician claims identified as clinic bills do
not follow the “Professional Fees” section  Refer to the Processing Professional Fees, Readings, & RAPs
of this process. They process following table for processing guidance.
location 11 guidelines.
To identify a clinic bill:  Review the authorization remarks to determine if the member
 Physician claims may contain office rolled from observation to inpatient.
 If the remarks indicate that the member rolled from observation to
visit E/M codes 99201-99215. inpatient, send an SF to Claims Authorizations requesting an
 The associated facility claim contains authorization for the pro fee, regardless of whether or not the
member was in the billed location on the billed date of service.
Bill Type 13X and Revenue Code 510.
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.
 Location 22 and location 21 pro fee claims are payable for the entire

stay, 11/26/15-12/16/15.

 Review for a par referral.
 If par referred, follow the par referral process outlined on page 6.

 Review for emergent diagnosis code.
 Review the List of Emergency Diagnosis Codes and the diagnosis
codes billed on the claim to determine if the claim contains
emergency diagnosis codes.
 If the claim contains an emergent diagnosis code in any diagnosis
position, request medical records by following the Generating a
Letter Requesting Additional Information process to determine if
the services were emergent.

 Review member’s claim history.
 If there is an emergency ambulance/ER claim for the same DOS
and same or related diagnosis, send an SF to Claims
Authorizations requesting an authorization be added.
 If unrelated diagnosis, request medical records for review of
urgent/emergent.

 If no other indication of a par referral or urgent/emergent, deny
claim EX DV, “Non-participating provider billing for unauthorized
service.”

RAPs Charges Refer to the Processing Professional Fees, Readings, & RAPs
Provider specialty is AA, AN, AT, CR, DQ, table for processing guidance.
EA, EM, MP, PG, or RA AND service
location is 19, 21, 22, 23, 24, 31, or 61

Anesthesia & Readings (other than RAPs)

Anesthesia procedure code range of  Anesthesia – Review Claims by Member to identify the surgeon’s
claim.
00100-01999 in locations other than a  If anesthesia services were provided for a par surgeon OR an

hospital. 9 SSA 11.12.2014

authorized non par surgeon, send an SF to Claims Authorizations

Readings, which are indicated as provided requesting an authorization be added.
below and in locations other than a  If anesthesia services were provided for a non par surgeon and

hospital: there is no authorization on file for the services, follow location 11

1. Modifier 26 OR guidelines.
2. Procedure code 93272  Readings – Review Claims by Member to identify the related

claim for the test.
 The location of the reading should match the location of the

related test, unless:

1. The reading is for a sleep study and the related test claim

is in location 81, OR

2. The locations for reading and test were both performed in

an outpatient hospital setting (e.g., test claim billed with

location 24 and reading billed with location 19/22).
 If the location for the reading does not match the location of

the test and does not meet either exceptions above, deny the
reading with EX 26, “Place of service is inconsistent with claim
history.”
 If the related test was provided for a par provider OR an

authorized non par provider, send an SF to Claims Authorizations

requesting an authorization be added.
 If the test was provided by a non par provider and there is no

authorization on file for the services, follow location 11 guidelines.

Coordination of Benefits claim pending CU/CW

Claim is pending O8 and CU/CW because  Review the claim for the primary payer’s EOP or payment

the member has primary coverage with information.
another payer.  If the EOP is attached, send an SF to Claims Authorizations

Authorization requirements do not apply requesting a COB authorization be added.
when Peoples Health is the secondary
 If the EOP is not attached, deny the claim EX code DI, “Denied –
Bill primary carrier.”

payer.

Authorizations Pending 70 with EX Code IZ

Authorizations contain status 70 and EX  Review Authorizations by Member to identify the original

code IZ if it is a duplicate to another authorization to which it is a duplicate.
authorization in the member’s history.  Send an SF to Kasey Walker requesting the authorization be

reviewed for possible update. Provide both authorization numbers

and the authorization issue (pending IZ).

POS 19

Effective January 1, 2016, CMS added Medical Claims

POS 19 to the Place of Service code set to  Review Authorizations by Member to determine if a related POS

identify off campus provider-based hospital 22 authorization is on file.

departments to differentiate from on  If a related POS 22 authorization is on file, send an SF to Claims

campus provider-based hospital Authorizations to have a POS 19 authorization added/updated.
departments (POS 22).  If a related POS 19 or 22 authorization is not on file, follow normal

The description of POS 19 is, “Off processing guidelines.
campus-outpatient hospital.”  If a related POS 11 authorization is on file, leave the claim pending

O8. Enter an AG remark and inform the Quality Improvement

Manager.

The description of POS 22 was updated  Additional Processing Guidance
to, “On campus-outpatient hospital.”
 RAPs – Follow the RAPs process.

 Pro fees – Review Authorizations by Member.

Claims billed with POS 19 follow POS 22  If a related POS 19/22 facility claim or authorization is on file,

authorization requirements and processing send an SF to Claims Authorizations to have a POS 19

guidelines. authorization added/updated for the pro fee.

 If a related POS 19/22 facility claim or authorization is not on

POS 19 and POS 22 are interchangeable file, follow the normal processing guidelines.

in regards to authorizations.  Therapy – Review Authorizations by Member.

10 SSA 11.12.2014

POS 19 and POS 11 are NOT  If a related POS 22 therapy authorization is on file, send an
interchangeable in regards to SF to Claims Authorizations requesting the authorization
authorizations (exception may be therapy). location be updated.

Hospital Claims
 Service lines containing modifier PO may have the procedure

codes out of order causing the claim to pend.
 If procedure codes are out of order, flip procedure codes to put the

CPT/HCPCS code in the first position and the revenue code in the
second position.
 If the claim does not hit an authorization after flipping the codes,
proceed to the following steps.

 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 to have a POS 19 authorization
added/updated.
 If a related POS 19 or 22 authorization is not on file, follow normal
processing guidelines.

 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.

11 SSA 11.12.2014

Claims Pend Processing Profile

Process: O9 Queue Profile
Review Medicare Par O/P Claims for Auth/Deny if no Auth in System
Pend Description Two
Pend Category November 6, 2014
Date Implemented April 20, 2016
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

 Review Authorizations by Member (IQ1000) to determine if an authorization is on file for the service(s).

 Select “Global Functions”  “Authorization”  “Authorizations by Member.”
 The Authorization by Member Inquiry screen will appear with the Member# & Name, Requested Prov#,

and Search Date populated.
 Copy the Member# then click the Binoculars icon to clear all search fields.
 Paste the Member# and press Enter. The Authorization by Member Inquiry screen will appear.
 Scroll right to the Authorized Dates to search for an authorization on or around the claim’s date(s) of

service.
 If there is no authorization, proceed to page 3 for processing directions.

 If there is an authorization on file, review the Type (AR) field and the authorization remarks to determine if

the authorization is related to the services billed.

 Refer to the table below for a list of common AR codes and their descriptions.
 Note: Table does not include all AR codes.

Type (AR) Description Claim POS Claim/Service Type

23 23 Hour Observation Stay 22 Various services performed while the member is in

CI Consult – Include Lab/X-ray observation
11 Various services performed in a physician’s office

DI Dialysis 65 Dialysis services

DM DME 12 DME items or supplies
HH Home Health 12 Various services performed in the member’s home

IF Infusion Therapy Various Injections

ME Medical 21 Various services performed when a member is

admitted inpatient (pro fees)

LB Laboratory 11, 19/22, Pathology & laboratory services
81 CPT codes 80049 – 89399

OH Outpatient Procedures & Testing 19/22, 24 Various services performed in an outpatient setting

OT Occupational Therapy Various Therapies with modifier GO

PT Physical Therapy Various Therapies with modifier GP

SF Skilled Nursing 31 Various services provided to a member in a Skilled

Nursing Facility (SNF)

SS Sleep Study 19/22, 81 Sleep study

ST Speech Therapy Various Therapies with modifier GN

SU Surgery Various Surgery CPT codes 10040-69990

WO Facility Wound Care Various Wound care/debridement

If the services billed relate to the AR type, click:
 “Med Auth Iq” for authorization numbers containing an R; or

 “Hosp Auth Iq” for authorization numbers containing an A.

 “R” authorizations are referral authorizations for outpatient services or related admission

services (professional fees while a member is inpatient).
 “A” authorizations are inpatient admission authorizations built for the facility claim to pay

(locations 21 and 31).

1 SSA 11.12.2014

 Click “Remarks Iq.” The Remarks Profile Inquiry will appear.
 Review the authorization remarks to gather additional information on the authorization (e.g., if the

authorization was approved, how many units, type of service, etc.).
 If the services billed are not related to the authorization, proceed to page 3 for processing directions.
 If there is a related authorization on file, review the authorization in the Certification screen (UA0100) to
determine why the authorization is not mapping to the claim.
 Copy the authorization number from the Remarks Profile Inquiry Screen.
 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 “Authorized Svcs.” The Authorized Services screen will appear.
 Review the following information to determine why the authorization is not mapping to the claim.

Click the arrows to scroll
through the authorization pages.

 In order for an authorization to map to a claim, the following must be true:
 Dates must include the service dates billed on the claim.
 Prov must match the provider number on the claim.
 Blank Prov fields with the Prov Status populated indicate authorized professional fees and are not
specific to an individual provider. However, the Prov Status must match the servicing provider’s
status on the claim (e.g., PP, CP, LP, etc.).
 Location (LC) must match the location on the claim.
 Proc# if populated, must match the procedure code on the claim.

2 SSA 11.12.2014

 For information that differs from the claim, review the Medical Necessity Form (MNF) and the
Authorization Confirmation in the member’s folder in Macess to verify the authorization was built

correctly.
 In Macess, MNFs are saved as Document Type “MNF” and may contain the authorization number and the

provider name under the Description field.
 Authorization Confirmations are saved as Document Type “Auth Confirmation…” and may contain the

authorization number under the Description field.
 Compare the MNF to the Authorization Confirmation and the authorization in Amisys to determine if the

authorization was built incorrectly.

 If the authorization was built incorrectly due to clerical errors, it can be updated/corrected by the Claims

Authorization staff (e.g., incorrect location, incorrect provider number, incorrect count/units, etc.).

 Send a service form (SF) to Claims Authorizations requesting an authorization update. 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 O9 pend.
 Repeat above steps as necessary if the O9 pend does not fall off.

 Discrepancies between the MNF, Authorization Confirmation, and authorization in Amisys, other than

clerical errors, are sent to Medical Management for review to determine if services were authorized/if an

authorization should be added or updated.

 In Macess, create a Service Form (SF) and attach the MNF and all supporting documentation.

 Refer to the Who to Send Service Forms document to determine the recipient of the SF.

 Request review of the authorization and claim to determine if the services were authorized/if the

authorization should be updated.

 Enter a CL remark stating, “SF# requesting review of auth #__ __.”

 Process the claim according to Medical Management’s directive.

 If there is an authorization on file, but the provider is billing incorrectly according to the authorization,
deny with EX code 63, “Provider billing for services different from authorization.”

 Note: EX code 63 is ONLY to be used when an authorization for the service is on file.

If there is no authorization on file:

 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.

 Enter a CL remark stating, “SF# requesting review.”

 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, deny
with EX code JL, “Participating provider billing for unauthorized service.”

3 SSA 11.12.2014

Steps to deny the O9 pend:

 Single service line:
 Click “Service Detail.”
 Click “Reset/Adj.”
 Type the appropriate denial code in the EX code field containing the O9 pend.
 Press Enter or click Save and exit the screen.
 Exit the Service Detail screen as well.
 The O9 pend code should be removed and replaced with the appropriate denial code.

 Multiple service lines:
 Click “EX Overrides.”
 Type O9 in the “OLD EX” field and press Tab.
 Type the appropriate denial 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 O9 pend code should be removed and replaced with the appropriate denial code.

Par Provider Authorization Denial Codes

EX Code EX Description Usage
Inpatient and observation pro fees only – When the location on the pro fee
26 Place of service is claim does not match the facility claim’s location.
 Used only on inpatient and observation pro fee claims if the facility
inconsistent with claim
claim is on file with a different location code.
history  Does not apply when a member rolls from observation to inpatient

63 Provider billing for services (see page 5).
different from authorization.  Does not apply when the pro fee is billing location 19 and the facility

JL Participating provider billing is billing location 22, and vice versa. The two POS codes are
for unauthorized service.
interchangeable in regards to billing and authorizations. If there is a

related 19/22 authorization on file, the authorization should be

added/updated to allow the claim to pay (see page 8).

An authorization is on file for the services billed, but the claim was not

billed according to the authorization.

Examples of correct usage of EX 63 include, but are not limited to:
 Billed location does not match authorized location.
 Does not apply when the claim was billed with location 19 and the

authorization is for location 22, and vice versa. The two POS codes

are interchangeable in regards to billing and authorizations. If there

is a related 19/22 authorization on file, the authorization should be

added/updated to allow the claim to pay (see page 8).

After research and review, it was found that there is no authorization on

file for the services billed.

4 SSA 11.12.2014

Additional Processing Guidance

Claim Types / Scenarios Process
Professional Fees
Professional services provided to a member  If there is an authorization on file, scroll through the pages
while in an outpatient setting (e.g., 19, 22, 24, 62,
etc.). on the Certification screen for the Prov Stat field populated
These services are referred to as “pro fees.”
with the Provider Status on the claim (e.g. RP, CP, LP,
Rolling from Observation to Inpatient
Authorizations for members who roll from etc.).
observation to inpatient.  If the authorization does not contain the provider status
Physicians bill pro fee claims with inpatient
location for DOS while the member was in billed on the claim, send an SF to Claims Authorizations
observation and vice versa.
requesting an authorization update.
RAPs Charges
Provider specialty is AA, AN, AT, CR, DQ, EA,  Enter a CL remark stating, “SF# requesting update to
EM, MP, PG, or RA AND service location is 19,
21, 22, 23, 24, 31, or 61 auth #__ __.”
Tulane Clinic Billing
Tulane physicians billing for services in location  If there is no authorization on file, review Claims by
19/22 under clinic billing.
Tulane will also bill the facility charges on a Bill Member (IQ1300) for the facility claim to verify the
Type 13X with Revenue Code 510 or 761.
physician is billing correctly.
 If the provider is billing with a different location code than

the related facility claim (e.g., the facility claim has location

21 and the pro fee claim has location 22), deny the claim
with EX code 26, “Place of service inconsistent with claim

history.”

 Does not apply when a member rolls from observation

to inpatient.
 Does not apply when the pro fee is billing location 19

and the facility is billing location 22, and vice versa.

The two POS codes are interchangeable in regards to

billing and authorizations. If there is a related 19/22

authorization on file, the authorization should be

added/updated to allow the claim to pay.

 Refer to the Processing Professional Fees, Readings, &

RAPs table for processing guidance.

 Review the authorization remarks to determine if the
member rolled from observation to inpatient.
 If the remarks indicate that the member rolled from
observation to inpatient, 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.

*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.

 Refer to the Processing Professional Fees, Readings, &
RAPs table for processing guidance.

 Follow location 11 authorization requirement guidelines.
 If an authorization is not required for location 11, enter “TU”

in the CI field on each service line to approve the services

for payment.
 If an authorization is required for location 11, follow the

steps outlined on pages 1-4.

5 SSA 11.12.2014

Therapy  Scroll through the pages of the Certification screen to
Therapy claims containing modifiers GP, GN, or
GO. determine the type of therapy that was authorized by

DME reviewing the (M1) field. The (M1) field must match the
Authorizations for DME are built with the specific
procedure code(s) that were requested and therapy modifier that was billed (GP, GN, GO).
authorized.  If the therapy discipline that was billed is not authorized OR

Dialysis if there is no authorization, deny the therapy service line(s)
If there is an approved dialysis authorization on
file for any par dialysis facility that covers the with EX code JL, “Participating provider billing for
dates billed, request to have the authorization unauthorized service.”
added/updated by Claims Authorization staff.
If there are approved dialysis authorizations on  Hand Surgical Associates claims billing for PT/OT:
file for any par dialysis facility that does not cover  All claims should be processed to the individual servicing
all dates billed due to a gap between the
authorized dates, request to have an provider, not the group.
authorization added by Kasey Walker in Medical  Send an SF to Claims Authorizations requesting an
Management.
authorization update if necessary.

 Therapy Claims for Location 11/19/22
 If the claim’s location is 11 and the authorization’s location

is 19/22 AND the MNF does not specify a location, send

an SF to Claims Authorizations requesting an authorization

update, OR;
 If the claim’s location is 19/22 and the authorization’s

location is 11 AND the MNF does not specify a location,

send an SF to Claims Authorizations requesting an

authorization update, OR;
 If the claim’s location is 22 and the authorization’s location

is 19, or vice versa, send an SF to Claims Authorizations

requesting an authorization update.

 Enter a CL remark stating, “SF# requesting update to

auth #__ __.”

*Note: Authorization update requests regarding service dates and

counts must be sent to Medical Management for review and

necessary updates.

 Review the authorization to determine if the specific

procedure code was authorized.
 If the DME item or supply was not authorized OR if there is

no authorization, deny the DME service line(s) with EX
code JL, “Participating provider billing for unauthorized
service.”

*Note: Authorization update requests regarding service dates and

counts must be sent to Medical Management for review and

necessary updates.

 Review Authorizations by Member to determine if there is
an approved dialysis authorization for the claim’s DOS.

 If there is a par dialysis authorization for the claim’s DOS,

even if the authorization is for a different dialysis facility,

send an SF to Claims Authorizations requesting the

authorization be added/updated to pay the pending dialysis

claim. requesting
 Enter a CL remark stating, “SF#

update to auth #__ __.”

 If there are approved par dialysis authorizations for some of
the claim’s DOS, but not all due to a gap between the

authorized dates, send an SF to Kasey Walker requesting

an authorization be added to cover the days not authorized.

 Enter a CL remark stating, “SF# requesting
auth.”

6 SSA 11.12.2014

Anesthesia (other than RAPs)

Anesthesia procedure code range of 00100-  Review Authorizations by Member to determine if the
01999 in locations other than a hospital.
related surgery was authorized.
Readings (other than RAPs)
 If the related surgery is not authorized and requires an

authorization, deny the anesthesia with EX code JL,

“Participating provider billing for unauthorized service.”

 If the related surgery is authorized OR does not require an

authorization, send an SF to Claims Authorizations

requesting an authorization to be added.

 Enter a CL remark stating, “SF# requesting auth.”

 Refer to the following link to determine if a procedure

code requires an authorization for locations 11, and

19/22/24: http://phn-win-27/Proc_Auth_Internal/.

Readings, which are indicated as provided below  Refer to the Processing Professional Fees, Readings, &

and in locations other than a hospital: RAPs table for processing guidance.

1. Modifier 26, OR

2. Procedure code 93272

Surgery Authorizations with Specific Procedure Codes

Surgery authorizations built with the specific  Review the claim to determine if the services pending O9
procedure code (CPT code range10040-69990)
that was requested and authorized. are related to the authorized service.
 If the services are related, send an SF to Claims

Authorizations requesting the specific surgery code be

removed from the authorization.

 Enter a CL remark stating, “SF# requesting update to

auth #__ __.”

 If the services are not related, continue to research the

claim to determine if the services are authorized.

 Example: Procedure code 66983 is authorized. The

provider billed for procedure code 66983 and 66984.

Procedure code 66984 is pending O9 as it was not

authorized.
 The surgery services are related because they are close in

number.
 Send an SF to Claims Authorizations requesting the

specific surgery code be removed from the authorization.

 Enter a CL remark stating, “SF# requesting update to

auth #_ ___.”

 Coordination of Benefits claim pending CU/CW

Claim is pending O9 and CU/CW because the  Review the claim for the primary payer’s EOP or payment
member has primary coverage with another
information.

payer.  If the EOP is attached, send an SF to Claims

Authorizations requesting a COB authorization be added.

Authorization requirements do not apply when  Enter a CL remark stating, “SF# requesting auth.”
Peoples Health is the secondary payer.
 If the EOP is not attached, deny the claim EX code DI,

“Denied – Bill primary carrier.”

Authorizations Pending 70 with EX Code IZ

Authorizations will contain status 70 and EX code  Review the member’s authorizations to identify the original

IZ if it is a duplicate to another authorization in authorization to which it is a duplicate.
the member’s history.  Send an SF to Kasey Walker requesting review of the

authorization for possible update. Provide both

Authorizations pend as duplicates if they have authorization numbers and the authorization issue

overlapping service dates, are for the same (pending IZ).

provider, and have the same AR type.  Enter a CL remark stating, “SF# requesting update to

auth #____.”

Par CAH Facility Claim  Enter “TU” in the CI code field for the service line to pay.
Critical Access Hospital (TOB 85X) with an
anesthesia line (procedure code range 00100-
01999) pending for an authorization and all other

7 SSA 11.12.2014

lines are paying. Medical Claims
POS 19
Effective January 1, 2016, CMS added POS 19  Review Authorizations by Member to determine if a related
to the Place of Service code set to identify off
campus provider-based hospital departments to POS 22 authorization is on file.
differentiate from on campus provider-based  If a related POS 22 authorization is on file, send an SF to
hospital departments (POS 22).
Claims Authorizations to have a POS 19 authorization
The description of POS 19 is, “Off campus-
outpatient hospital.” added/updated.
 If a related POS 19 or 22 authorization is not on file, deny
The description of POS 22 was updated to, “On
campus-outpatient hospital.” the claim EX JL, “Participating provider billing for
unauthorized service.”
Claims billed with POS 19 follow POS 22  If a related POS 11 authorization is on file, leave the claim
authorization requirements and processing
guidelines. pending O9. Enter an AG remark and inform the Quality

POS 19 and POS 22 are interchangeable in Improvement Manager. DO NOT DENY FOR NO
regards to authorizations.
AUTHORIZATION unless directed by management.
POS 19 and POS 11 are NOT interchangeable in
regards to authorizations (exception may be  Additional Processing Guidance
therapy, see page 6).  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.

Hospital Claims

 Service lines containing modifier PO may have the

procedure codes out of order causing the claim to pend.
 If procedure codes are out of order, flip procedure codes to

put the CPT/HCPCS code in the first position and the

revenue code in the second position.
 If the claim does not hit an authorization after flipping the

codes, proceed to the following steps.

 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 to 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.

8 SSA 11.12.2014

Claims Pend Processing Profile

Pend: op Queue Profile
Opt-Out of Medicare
Pend Description
Pend Category September 6, 2012
Date Implemented November 22, 2015
Date Updated/Revised QA Analyst
Person(s) Responsible As defined below:
Processing Instructions

The purpose of the opt-out pend is to review and confirm claims pended in the “op” pend inventory are
assessed and processed according to the Medicare guidelines.

 Review the “Daily Reports” email from [email protected]. The file can also
be located under: \\My Network Places\DATA on phn-win-21\Pended Claims Workgroup\Daily Pended
Inventory\PH Daily Inventory Tracking YYYYMMDD.

 Select the day you wish to review.

 Click on the Claim Dtl tab at the bottom of the Excel workbook.

 Filter the EX codes for “op” only.

 Click the drop down arrow for the “Svc Provider LastName” column. This will give all the names of the
providers that have claims pending “op”.

 Review the names for providers that have opted out of Medicare. A current file can be located on the
Internet at site: https://www.novitas-solutions.com/enrollment/optout/index.html

 Click on Louisiana to review the names.

 Confirm that the claim dates of service are during the opt out period from the website or use the List of
Excluded Individuals/Entities (LEIE) from Network Development.
 If dates of service are during these periods, notify the Quality Improvement Manager to advise
that the provider has opted out of Medicare and that medical records need to be requested to
review for urgent or emergent services. Only urgent or emergent services are processed.

 If there are providers on the opt-out list that have claims pended, copy the claim information off of the
file, create a new Excel file with this information, and save. These files can be located and saved at:
S:\PHNOPER\Reports\op Pend - Opt Out of Mcare & OIG\2013 Reports\mm-dd-yy.

 If a service form is sent to Claims Department, periodically review the claim for current status and
confirm that the claim is processing correctly.

 Claims for opt out providers are processed by senior claims examiners following the Opt Out / Excluded
/ Sanctioned / Suspended Provider Claim Review process.

Note: Opt out provider status does not apply to commercial claims. Commercial claims pending “op” for an opt
out provider are processed following normal processing guidelines.

1