Claims Pend Processing Profile
Process: OY Queue Profile
PROVIDER OPTED OUT OF MEDICARE, REVIEW TYPE OF CARE TO PAY
Pend Description OR DENY EX-OZ
Four
Pend Category November 20, 2015
Date Implemented
Date Updated/Revised Senior Claims Examiner
Person(s) Responsible As defined below:
Processing Instructions
Providers with fraud, waste, or abuse allegations are placed on review by Compliance / BIU and pend OY.
Claims are processed on a case-by-case basis dependent upon the allegations and based on the directive
provided by the regulatory entity (i.e., the MEDIC).
Claim is reviewed and processed according to the directive received from the regulatory entity
or information included in an HPMS memo.
Review the provider’s documents in the OY Documents folder (\\phn-win-
30\departments\Claims Department\Training Material\Claim Pends\OY Documents) to
determine the next steps for processing.
Claims may be sent to BIU to determine if payable (via email).
Claim is processed according to BIU directive.
The email is printed, scanned, and attached to a service form for documentation.
If the claim is not payable, the claim is denied with EX code OZ, “Provider is
sanctioned, excluded, suspended, opt out or not licensed.”
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Claims Pend Processing Profile
Process: q3 Queue Profile
(BSP) LCD Part B Missing or Invalid Provider Specialty
Pend Description Three
Pend Category
Date Implemented September 21, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Verify the claim is processing with the correct servicing provider and specialty.
Review the CES edit in Amisys:
Go to the Claim Audit Service Edit Inquiry screen (RF0166).
Type the claim number and press Enter.
If the Edit Description says, “Per LCD or NCD Guidelines, procedure code XXXXX has not met the
associated Provider Specialty relationship criteria for CMS ID(s) (LCD/NCD #),” deny the service line
EX g5, “This provider type/provider specialty may not bill this service.”
If the Edit Description says otherwise, see the Quality Improvement Manager.
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Claims Pend Processing Profile
Process: q4 Queue Profile
(mB2) Medicare Bilateral Adjustment Does Not Apply
Pend Description Four
Pend Category January 28, 2016
Date Implemented
Date Updated/Revised Sr. Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Review CES edit code mB2 in Amisys through the Claim Audit Service Edit Inquiry screen
(RF0166).
CES may have flagged the claim for more than one edit. Use the arrows at the top of the
screen to scroll through the edits and find Edit Code mB2.
If the Edit Description reads as stated below, process the service line according to the claim
situations provided:
Per Medicare Guidelines, procedure code XXXXX with modifier LT along with history procedure
code XXXXX with modifier RT found on Claim ID [____________], Ext/Int Line ID [____] does not
qualify for the usual bilateral payment adjustment. Base payment for each side on the lower of the
actual charge for each side or 100% of the fee schedule amount for each side.
If the Edit Description reads otherwise or if the claim pending does not meet any of the
situations below, see the Quality Improvement Manager.
Claim Situations
1. Service line contains modifier LT or RT and does not contain modifier 50, override the q4 pend with EX
AP, “APPROVED.”
- Examples:
- The provider submitted the procedure code correctly.
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2. Service line contains modifier 50, regardless of any other modifiers billed (including modifiers LT and/or
RT), deny the service line EX 17, “SERVICES MUST BE BILLED WITH APPROPRIATE MODIFIER.”
- Examples:
- The CES edit is indicating that bilateral modifier does not apply to the procedure code. If the
procedure was performed on two sides, the provider should submit the procedure code on two
separate lines and append modifier LT on one line and modifier RT on the other line.
3. Service line contains modifiers LT and RT on the same service line, deny the service line EX 17,
“SERVICES MUST BE BILLED WITH APPROPRIATE MODIFIER.”
- Example:
- Because the procedure code does not qualify for the bilateral payment adjustment, the provider
should submit the procedure code on two separate lines and append modifier LT on one line
and modifier RT on the other line.
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Claims Pend Processing Profile
Process: q5 Queue Profile
(mDRh) Medicare Diagnostic Radiology Reduction -- (History Edit)
Pend Description Four
Pend Category July 1, 2010
Date Implemented February 3, 2016
Date Updated/Revised Sr. Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Background
Per Transmittal 1104 / Change Request 7747, a Multiple Procedure Payment Reduction (MPPR) is to be
applied to the Professional Component (PC) and the Technical Component (TC) of certain diagnostic imaging
procedures billed by physicians in the same group practice (same group NPI), as well as to individual
physicians.
The MPPR on diagnostic imaging applies when multiple services are furnished by the same physician (or
physicians in the same group practice), to the same patient, in the same session, on the same day. This MPPR
applies to the PC and TC services, including both PC-only & TC-only services, and to the PC & TC of global
services.
Full payment is made for each PC and TC service with the highest payment under the Medicare Physician Fee
Schedule.
- Payment is made at 75% for subsequent PC services furnished by the same physician, to the same
patient, in the same session, on the same day (25% reduction).
- Payment is made at 50% for subsequent TC services furnished by the same physician, to the same
patient, in the same session, on the same day (50% reduction).
The official instruction contains a list of diagnostic imaging services subject to the MPPR and may be viewed at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1104OTN.pdf.
Process
CES edit code mPD flags diagnostic imagining services that qualify for the reduction and pends the service
line(s) EX q5.
Review CES edit code mPD in Amisys through the Claim Audit Service Edit Inquiry screen
(RF0166).
CES may have flagged the claim for more than one edit. Use the arrows at the top of the
screen to scroll through the edits and find Edit Code mPD.
If the Edit Description reads as stated below, apply the reduction using CI code RU to applicable
service line(s) as indicated in the Edit Description:
- This procedure code XXXXX and procedure code XXXXX on history line ____ indicate that
multiple imaging services were performed. Per CMS, a 25% reduction of the professional
component applies for this line.
Enter CI RU on the line pending q5.
Override q5 with EX AP, “Approved.”
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- This procedure code XXXXX and history procedure code XXXXX on history claim
____________ and history claim line XXXX indicate that multiple imaging services were
performed. Per CMS, a 25% reduction of the professional component applies to the history
line.
Enter CI RU on the history claim line indicated in the Edit Description
Override q5 with EX AP, “Approved.”
Additional Processing Guidance
If CI codes OD, OG, or OJ are needed to apply the correct co-pay/coinsurance, override and replace
with CI RU and manually apply the co-pay/coinsurance.
Before updating to CI RU, review the claim in Claims Summary or review the Benefits List to
determine the co-pay/coinsurance amount.
Once CI RU is entered, the service line should price off of the FS37 fee schedule.
The service line with the highest allowed amount should pay in full (without CI RU). The reduction
should apply to service line(s) with lower allowed amounts (enter CI RU to apply reduction).
The MPPR does not apply to service lines appended with modifier 59, which indicates multiple sessions
on the same date.
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Claims Pend Processing Profile
Process: q7 Queue Profile
(mERh) Medicare Multiple Endoscopy Reduction -- (History Edit)
Pend Description N/A
Pend Category September 26, 2013
Date Implemented January 25, 2016
Date Updated/Revised System / CI job
Person(s) Responsible As defined below:
Processing Instructions
Do not work the pend. There is a nightly CI job that applies the appropriate CI code to the service line(s) on the
claim.
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Claims Pend Processing Profile
Process: q8/q9 Queue Profile
(mM54) Medicare Intraoperative Care Only Reduction, (mM55) Medicare
Pend Description Postoperative Care Only Reduction
Four
Pend Category
Date Implemented December 3, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Claims submitted with modifier 54, 55, or 56 are reviewed to ensure the correct global percentage is paid. The
system has been configured to price services with one of these modifiers at the appropriate global percentage.
Process
Review the pended line’s Pay Serv Code.
Select the pended line and click Service Detail.
Review the Pay Serv Code field.
If the Pay Serv Code begins with the letter G, the reduction has already been taken. Exit the
Service Detail screen and override the pend with EX AP, “Approved.”
If the Pay Serv Code does not begin with the letter G, the claim should be manually priced.
Follow the GL pend process for manual pricing.
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Claims Pend Processing Profile
Pend: QY Queue Profile
Provider Update and Reset
Pend Description One
Pend Category April 1, 2007
Date Implemented October 20, 2014
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Claims pend QY when the provider’s information has been updated, added, or corrected by Provider Affiliations.
Space out the providers’ number(s) and four digit affiliation(s).
The following steps apply to Medical Readjudication
Populate the Prov# and Refer# provider numbers and four digit affiliations.
In the Prov# field, type an * (asterisk) and the provider’s Tax ID then press tab.
In the Refer# field, type a $ then press Enter. The Provider Search screen will appear.
Open eCare Online (http://npi.ecare.com/).
Enter the referring provider’s NPI in the NPI field and press Enter.
Type the provider’s name in the Provider Search screen as it appears in eCare Online and
press enter.
Select the provider that matches eCare.
Click Reset/Adj to populate the four digit affiliation(s).
The following steps apply to Hospital Readjudication
Populate the Inst#, Admit#, and Attend# provider numbers and four digit affiliations.
In the Inst# field, type an * (asterisk) and the provider’s Tax ID then press tab.
In the Admit# and Attend# fields, type a $ then press Enter. The Provider Search screen will appear.
Open eCare Online (http://npi.ecare.com/).
Enter the admitting/attending provider’s NPI in the NPI field and press Enter.
Type the provider’s name in the Provider Search screen as it appears in eCare Online and
press enter.
Select the provider that matches eCare.
Click Reset/Adj to populate the four digit affiliation(s).
The following steps apply to both Medical and Hospital Readjudication
If the system generates affiliation(s), select the affiliation that matches:
Member’s Carrier and Region
Referring Provider affiliation with the member’s PCP, if they are the same.
Referring Provider affiliation with the member’s Provider, if they are the same.
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Verify the servicing provider’s affiliation has the correct Area (AA).
Refer to the zip code in the claim type’s designated area to determine locality of the facility location.
Claim Type Facility Address Location
CMS-1500 Field 32
UB-04 Form Locator 1
Electronic (EDI) Facility 1, if not populated Bill Prov
Enter the facility’s zip code in the Zip Code Look-Up database (http://phn-win-
27/Zip_Locality/zip9_Locality.aspx) to determine locality.
Select the affiliation with the Area as it appears on the Zip Code Look-Up database.
Claims billed with location 12 - Area/Locality is determined by reviewing the member’s address.
Select the appropriate area/locality dependent upon the member’s zip code.
If an affiliation with the correct Area does not exist, pend the claim to Provider Affiliations.
Click on the “Diagnosis, Procedures & Service Detail” tab.
Click on the drop down menu under “Claim Status.”
Select 41 – Pended.
Type “BU” in the EX Code Field.
Click ReAdjudicate to save.
Click ReAdjudicate to save all changes made.
Additional Processing Guidance:
Claim Types / Scenarios Process
Provider Affiliation List Screen Review the claim and select the appropriate affiliation based on
Some provider numbers will the following:
generate the Provider Affiliation List
screen in Amisys, which prompts PR
selection of a provider affiliation
based on the provider’s specialty. CODE Description Claim Criteria
HO Hospital (Acute) Bill Type 11X
SN Skilled Nursing Facility Bill Type 21X
AM Ambulance Ambulance HCPCS codes
RH Rehabilitation Center Bill Type 11X with Revenue Code
0024 and a 5 digit HIPPS Rate /
CMG Code
Quest Diagnostics Claims Select the provider affiliation with the following information:
All Quest Diagnostics claims Provider# 1000003523
process under one provider Tax id# 382084239
number. Billing address:
LockBox # 820927
Therapists Rt. 38 and Eastgate Drive
Individual therapists can receive
payment for therapy services, Moorestown, NJ 08057
unless otherwise stated in the
contract that payment must go to Ph: 856-755-5422
the group.
Provider Affiliations reviews the tax ID billed on the claim to
determine par vs. non par.
Par Providers
If the provider billed correctly and payment may be made to the
individual therapist, Provider Affiliations updates/adds an affiliation
for the claim to process.
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If the provider billed incorrectly according to their contract, Provider
Affiliations adds an affiliation with payclass MIDDENY.
Claims will process with EX code DJ, “Denied – Services billed
are not according to contract/LOA.”
Non Par Providers
Payment may be made to the individual therapist. Provider
Affiliations adds an affiliation for the claim to process.
Provider Specialties that Cannot Receive Payment per Contract
Ochsner Mid-Levels (Nurse Provider Affiliations adds an affiliation with payclass MIDDENY.
Practitioners and CRNAs) cannot Claims will process with EX code DJ, “Denied – Services billed are
receive payment per their contract. not according to contract/LOA.”
Provider Specialties that Cannot Receive Payment per Regulations
Certain provider specialties cannot Provider Affiliations adds an affiliation with payclass SPECDENY.
receive payment per regulations. Claims will process with EX code sp, “This specialty is not payable
These include Registered Nurses, to individual.”
and students.
Incorrect Tax ID
Claims billed under the incorrect tax Provider Affiliations reviews the claim to determine if the tax ID
ID, per the provider’s contract, are
billed is correct according to the provider’s contract.
denied. If the incorrect tax ID was billed, Provider Affiliations adds a group
affiliation with payclass TINDENY.
Claims will process with EX code DJ, “Denied – Services billed are
not according to contract/LOA.”
Provider Affiliations remarks the provider’s record notating the
incorrect tax ID information.
Servicing Provider Name & NPI Missing / Servicing Provider Name & NPI Mismatch
Claims for which the servicing Provider Affiliations adds a group affiliation under the tax ID billed
provider’s name and NPI are
with payclass NPIDENY.
required but are missing and/or Claims will process with EX code np, “Missing/Incomplete/Invalid
invalid are denied. provider primary identifier.”
Examples:
Servicing provider name and/or
NPI is missing.
Servicing provider name and
NPI do not match.
3 SSA 10.22.2014
Claims Pend Processing Profile
Process: r1 Queue Profile
(mM56) Medicare Preoperative Care Only Reduction
Pend Description Four
Pend Category
Date Implemented December 3, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Claims submitted with modifier 54, 55, or 56 are reviewed to ensure the correct global percentage is paid. The
system has been configured to price services with one of these modifiers at the appropriate global percentage.
Process
Review the pended line’s Pay Serv Code.
Select the pended line and click Service Detail.
Review the Pay Serv Code field.
If the Pay Serv Code begins with the letter G, the reduction has already been taken. Exit the
Service Detail screen and override the pend with EX AP, “Approved.”
If the Pay Serv Code does not begin with the letter G, the claim should be manually priced.
Follow the GL pend process for manual pricing.
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Claims Pend Processing Profile
Process: r2 Queue Profile
(mM78) Medicare Return to Operating Room Reduction
Pend Description Four
Pend Category September 26, 2013
Date Implemented January 25, 2016
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The pend EX code can be overridden if the pay service code begins with the letter “G.”
Process
Review the pended line’s Pay Serv Code.
Select the pended line and click Service Detail.
Review the Pay Serv Code field.
If the Pay Serv Code begins with the letter G, the reduction has already been taken. Exit the
Service Detail screen and override the pend with EX AP, “Approved.”
If the Pay Serv Code does not begin with the letter G, the claim should be manually priced.
Follow the GL pend process for manual pricing.
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Claims Pend Processing Profile
Pend: R7 Facility Queue Profile
Possible Medicare Duplicate Service
Pend Description Two
Pend Category June 23, 2003
Date Implemented August 13, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The purpose of this pend is to identify the previously processed claim(s) that the current claim is duping against
and determine if the current claim is a corrected claim, a duplicate claim, or a separately identifiable claim.
Definitions
Corrected Claim – Corrected billing of a previous processed claim. Corrected claims can be identified by a
“corrected claim” stamp, type of bill ending in a 7 (e.g. 117, 137, 237, 837, etc.), attachments, or
additional/corrected claim information. Corrected claims may be submitted for the following reason(s):
Corrected diagnosis
Corrected charges
Corrected procedure code
Addition or correction of modifier
Corrected provider information
Attachments (EOP, medical records, invoice, etc.)
Duplicate Claim – Claim or a claim line that exactly matches another claim or claim line with respect to the
following elements:
Physician Claims Facility Claims
Member Member
Provider Provider
Date(s) of Service Type of Bill
Procedure Code Date(s) of Service
Modifier Total Charges (on the line or the bill)
Place of Service HCPCS/CPT-4 Procedure Codes
Billed Amount Modifier
Separately Identifiable Claim – Claim is neither a duplicate nor a corrected claim. The claim or claim line may
be related to previously processed claim(s) or claim line(s), but are separately identifiable. Examples include,
but are not limited to:
Ambulance modifiers (review pickup point location if modifiers are the same)
Modifiers RT & LT – Bilateral procedures can be performed on both sides
Modifier 25 – Significant, separately identifiable evaluation and management (E/M) service by the same
physician on the day of a procedure
Modifier 59 – Distinct procedural service
Modifier 76 – Repeat procedure by the same physician
Modifier 91 – Repeat clinical diagnostic laboratory test
1 SSA 06.25.14
* Note: If the current claim and the previous claim(s) contain the same modifiers (e.g. both claims contain
modifier 76), additional research may be required to determine if the claim is a duplicate or a corrected claim.
Modifiers 25, 59, 76, and 91 should only be appended to the second claim.
Process
Review Claims by Member to identify the previously submitted claim(s) the current claim is
duping against.
Click on Global Functions.
Hover over Claims Processing.
Click on Claims by Member.
Select “2” in the drop down menu.
Enter the member’s G number.
Select “2” under the dates drop down menu.
Enter the effective dates and hit Enter.
All the claims on file for these dates will generate.
Put the claims in order by receive date, oldest to newest.
Review and compare the current claim to the claim(s) in the member’s history to determine if the
current claim is a corrected claim, a duplicate claim, or a separately identifiable claim.
Review the claim image in Macess or EDI for any evidence that would support a corrected
claim.
Bill Type ends in the number 7 (e.g. 117, 137, 237, 837, etc.)
A “corrected claim” stamp.
Modifier added/removed from the claim.
Different diagnosis, procedure code, or dollar amount.
An attachment (copy of an EOP, medical records, invoice, etc.).
Process the claim(s) according to the outcome of the research performed.
Research Outcome Processing Action
Corrected Claim - Current Adjust the previously submitted claim(s) to EX code E3,
claim supports the definition of “Corrected claim received, prior claim to be denied.”
a corrected claim.
E3 all lines that were resubmitted on the corrected claim.
Enter a claim remark on the previously submitted claim to
reference the corrected claim: “See corrected claim ____.”
If the corrected claim denies EX DH, “Denied – Untimely filing, do
not bill member,” do NOT adjust the original claim to EX E3.
Allow both claims to process separately.
Duplicate Claim - Current Deny the current claim or claim line(s) as a duplicate with EX
claim supports the definition of code DU, “Duplicate claim/service.”
a duplicate claim. Enter a claim remark on the duplicate claim to reference the
previously submitted claim: “Duplicate to claim ____.”
Separately Identifiable Override the duplicate pend on the current claim and process the
Claim - Current claim
supports the definition of a claim according to normal processing guidelines.
separately identifiable claim. Enter a claim remark indicating why claim was determined not to
be a duplicate or a corrected claim (e.g. “Paid as modifier
indicates repeat procedure.”)
Steps to “E3” or “DU” a claim in Readjudication Status:
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the EX code currently on the claim.
Press Tab.
Type “E3” or “DU” (as appropriate based on the research outcome) in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
2 SSA 06.25.14
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The previous EX
code should be replaced with “E3” or “DU.”
Close/X out screen.
If the EX code did not update, go into Service Detail for each service line and enter “E3”
or “DU.”
Click REset/Adj to save changes.
Steps to “E3” or “DU” a claim in Adjustment status:
Reinstate if no money has been paid on the claim.
Reverse if money has been paid on the claim.
Click Reinstate or Reverse and the claim status will highlight.
Enter “AP” in the blue box and press Enter.
The Interest Adjustment Popup screen will generate.
Enter the claim’s received date for the date.
Enter “AP” in EX Code and press Enter.
Go to “Diagnosis, Procedures & Service Detail” tab.
Select a service line and click Service Detail.
Click Reset and enter “E3” or “DU” (as appropriate based on the research outcome) to override
all existing EX codes.
Press Enter.
The EX Code will update to “E3” or “DU.”
If the claim was adjusted to EX code E3, update the due date on the corrected to match the due
date of the original claim. This will ensure the provider’s payment is recouped and reapplied to
the corrected claim within the same pay period.
Steps to enter a claim 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.
Enter, “CL” in the Remark Type.
Type the appropriate remark:
“See corrected claim __(claim number)__.”
“Duplicate to claim __(claim number)__.”
Remark to indicate why claim is not a duplicate or a corrected claim (e.g. “Paid as
modifier indicates repeat procedure.”)
Steps to override the duplicate pend:
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the duplicate pend EX code.
Press Tab.
Type “AP” in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The duplicate pend
EX code should be removed.
Close/X out screen.
3 SSA 06.25.14
Helpful Research Hints: Facility Claims
Always review the claim image for a “Corrected Claim” stamp or any type of note that would indicate
that the claim is a corrected claim.
ER claims may pend as a potential duplicate to an inpatient claim. This happens because the member
may have gone to the ER for one episode on 09/09/14 through 09/10/14. Then, he or she may have
gone again to the ER for a second, separate episode on 09/10/14 and was admitted. Override the
duplicate pend on the ER charges.
Injection or wound care claims that are billed in monthly cycles can duplicate to any other outpatient
services/ER for that month. Override the duplicate pend.
Therapy claims – Outpatient Physical Therapy (PT), Speech Therapy (ST), or Occupational Therapy
(OT) claims can pend as potential duplicates. While the procedure codes are the same on the claims
(i.e. 97110, 97010, etc.), the modifiers are different. PT claims are billed with the modifier GP, ST
claims are billed with modifier GN, and OT claims are billed with modifier GO. Override the duplicate
pend if the modifiers differ. If the modifiers are the same, research the claim to determine if it is a
duplicate or a corrected claim then process the claim as outlined above.
Bill types ending in 5 are for late charges - The lines can be completed using Status 10 – EX Code
GN, “Late charge billing.” Remark the original claim that the late charge was paid.
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Claims Pend Processing Profile
Pend: R7 Professional
Queue Profile
Pend Description Possible Medicare Duplicate Service
Pend Category Two
Date Implemented June 23, 2003
Date Updated/Revised August 13, 2015
Person(s) Responsible Claims Examiners
Processing Instructions As defined below:
The purpose of this pend is to identify the previously processed claim(s) that the current claim is duping against
and determine if the current claim is a corrected claim, a duplicate claim, or a separately identifiable claim.
Definitions
Corrected Claim – Corrected billing of a previous processed claim. Corrected claims can be identified by a
“corrected claim” stamp, type of bill ending in a 7 (e.g. 117, 137, 237, 837, etc.), attachments, or
additional/corrected claim information. Corrected claims may be submitted for the following reason(s):
Corrected diagnosis
Corrected charges
Corrected procedure code
Addition or correction of modifier
Corrected provider information
Attachments (EOP, medical records, invoice, etc.)
Duplicate Claim – Claim or a claim line that exactly matches another claim or claim line with respect to the
following elements:
Physician Claims Facility Claims
Member Member
Provider Provider
Date(s) of Service Type of Bill
Procedure Code Date(s) of Service
Modifier Total Charges (on the line or the bill)
Place of Service HCPCS/CPT-4 Procedure Codes
Billed Amount Modifier
Separately Identifiable Claim – Claim is neither a duplicate nor a corrected claim. The claim or claim line may
be related to previously processed claim(s) or claim line(s), but are separately identifiable. Examples include,
but are not limited to:
Ambulance modifiers (review pickup point location if modifiers are the same)
Modifiers RT & LT – Bilateral procedures can be performed on both sides
Modifier 25 – Significant, separately identifiable evaluation and management (E/M) service by the same
physician on the day of a procedure
Modifier 59 – Distinct procedural service
Modifier 76 – Repeat procedure by the same physician
Modifier 91 – Repeat clinical diagnostic laboratory test
1 SSA 06.25.14
* Note: If the current claim and the previous claim(s) contain the same modifiers (e.g. both claims contain
modifier 76), additional research may be required to determine if the claim is a duplicate or a corrected claim.
Modifiers 25, 59, 76, and 91 should only be appended to the second claim.
Process
Review Claims by Member to identify the previously submitted claim(s) the current claim is
duping against.
Click on Global Functions.
Hover over Claims Processing.
Click on Claims by Member.
Select “2” in the drop down menu.
Enter the member’s G number.
Select “2” under the dates drop down menu.
Enter the effective dates and hit Enter.
All the claims on file for these dates will generate.
Put the claims in order by receive date, oldest to newest.
Review and compare the current claim to the claim(s) in the member’s history to determine if the
current claim is a corrected claim, a duplicate claim, or a separately identifiable claim.
Review the claim image in Macess or EDI for any evidence that would support a corrected
claim.
Bill Type ends in the number 7 (e.g. 117, 137, 237, 837, etc.)
A “corrected claim” stamp.
Modifier added/removed from the claim.
Different diagnosis, procedure code, or dollar amount.
An attachment (copy of an EOP, medical records, invoice, etc.).
Process the claim(s) according to the outcome of the research performed.
Research Outcome Processing Action
Corrected Claim - Current Adjust the previously submitted claim(s) to EX code E3,
claim supports the definition of “Corrected claim received, prior claim to be denied.”
a corrected claim.
E3 all lines that were resubmitted on the corrected claim.
Enter a claim remark on the previously submitted claim to
reference the corrected claim: “See corrected claim ____.”
If the corrected claim denies EX DH, “Denied – Untimely filing, do
not bill member,” do NOT adjust the original claim to EX E3.
Allow both claims to process separately.
Duplicate Claim - Current Deny the current claim or claim line(s) as a duplicate with EX
claim supports the definition of code DU, “Duplicate claim/service.”
a duplicate claim. Enter a claim remark on the duplicate claim to reference the
previously submitted claim: “Duplicate to claim ____.”
Separately Identifiable Override the duplicate pend on the current claim and process the
Claim - Current claim
supports the definition of a claim according to normal processing guidelines.
separately identifiable claim. Enter a claim remark indicating why claim was determined not to
be a duplicate or a corrected claim (e.g. “Paid as modifier
indicates repeat procedure.”)
Steps to “E3” or “DU” a claim in Readjudication Status:
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the EX code currently on the claim.
Press Tab.
Type “E3” or “DU” (as appropriate based on the research outcome) in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
2 SSA 06.25.14
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The previous EX
code should be replaced with “E3” or “DU.”
Close/X out screen.
If the EX code did not update, go into Service Detail for each service line and enter “E3”
or “DU.”
Click REset/Adj to save changes.
Steps to “E3” or “DU” a claim in Adjustment status:
Reinstate if no money has been paid on the claim.
Reverse if money has been paid on the claim.
Click Reinstate or Reverse and the claim status will highlight.
Enter “AP” in the blue box and press Enter.
The Interest Adjustment Popup screen will generate.
Enter the claim’s received date for the date.
Enter “AP” in EX Code and press Enter.
Go to “Diagnosis, Procedures & Service Detail” tab.
Select a service line and click Service Detail.
Click Reset and enter “E3” or “DU” (as appropriate based on the research outcome) to override
all existing EX codes.
Press Enter.
The EX Code will update to “E3” or “DU.”
If the claim was adjusted to EX code E3, update the due date on the corrected to match the due
date of the original claim. This will ensure the provider’s payment is recouped and reapplied to
the corrected claim within the same pay period.
Steps to enter a claim 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.
Enter, “CL” in the Remark Type.
Type the appropriate remark:
“See corrected claim __(claim number)__.”
“Duplicate to claim __(claim number)__.”
Remark to indicate why claim is not a duplicate or a corrected claim (e.g. “Paid as
modifier indicates repeat procedure.”)
Steps to override the duplicate pend:
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the duplicate pend EX code.
Press Tab.
Type “AP” in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The duplicate pend
EX code should be removed.
Close/X out screen.
3 SSA 06.25.14
Helpful Research Hints: Physician Claims
Always review the claim image for a “Corrected Claim” stamp or any type of note that would indicate
that the claim is a corrected claim.
Durable Medical Equipment (DME) claims will possibly be duplicated because of the overlapping
dates. One claim’s end date may be the next claim’s beginning date. Override the duplicate pend if the
dates are the reason for the pend.
Durable Medical Equipment (DME) claims billed with E1399, review the description for E1399 on
the claim image.
If the descriptions are for different items, override the duplicate pend.
If the descriptions are for the same item, deny the claim line as a duplicate.
If there is no description, deny the claim Status 51 – EX Code 78, “Denied – Please submit
procedure code description.”
Chemo claims with J-codes are occasionally duplicates when the provider charges for the wasted
portion of the drug (read: not used). This is identified by the JW modifier or a written/typed note stating
that __ mg of the drug was wasted. Override the duplicate pend on the claim containing modifier JW
and deny the drug with EX code IB. Enter the EP remark, “Discarded drug amount not administered to
patient.” Pay for the used drug/medication.
Home Health claims will pend as potential duplicates if one claim was vertexed while the other was
manually entered. Review the claim image and ensure the individual service dates are entered.
The first claim submitted by the HHA is the RAPs claim and is billed with bill type 322, a single service
line with revenue code 0023, and a zero charge amount. Subsequent episode claims are not
duplicates to the RAPs claim. Override the duplicate pend. The “OB” pend will generate and that claim
will fall into another pend queue.
4 SSA 06.25.14
Claims Pend Processing Profile
Pend: r8 Queue Profile
(BRR) Anesthesia Crosswalk – By Report
Pend Description Four
Pend Category August 4, 2010
Date Implemented July 17, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The BRR edit identifies claim lines where the provider specialty is associated with anesthesia specialties or
the type of service is 7. This edit checks for surgical procedure codes that need to be crosswalked to an
anesthesia code. The BRR edit is issued when the surgical procedure code is a "by report" procedure. The
claim line must be reviewed and the appropriate anesthesia code should be applied.
Anesthesia codes:
1
Claims Pend Processing Profile
Pend: RQ Queue Profile
Pend Possible Commercial Duplicate Service
Pend Description Employee
Pend Category June 23, 2003
Date Implemented June 24, 2014
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The purpose of this Employee pend is to identify the previously processed claim(s) that the current claim is
duping against and determine if the current claim is a corrected claim, a duplicate claim, or a separately
identifiable claim.
Definitions
Corrected Claim – Corrected billing of a previous processed claim. Corrected claims can be identified by a
“corrected claim” stamp, type of bill ending in a 7 (e.g. 117, 137, 237, 837, etc.), attachments, or
additional/corrected claim information. Corrected claims may be submitted for the following reason(s):
Corrected diagnosis
Corrected charges
Corrected procedure code
Addition or correction of modifier
Corrected provider information
Attachments (EOP, medical records, invoice, etc.)
Duplicate Claim – Claim or a claim line that exactly matches another claim or claim line with respect to the
following elements:
Physician Claims Facility Claims
Member Member
Provider Provider
Date(s) of Service Type of Bill
Procedure Code Date(s) of Service
Modifier Total Charges (on the line or the bill)
Place of Service HCPCS/CPT-4 Procedure Codes
Billed Amount Modifier
Separately Identifiable Claim – Claim is neither a duplicate nor a corrected claim. The claim or claim line may
be related to previously processed claim(s) or claim line(s), but are separately identifiable. Examples include,
but are not limited to:
Ambulance modifiers (review pickup point location if modifiers are the same)
Modifiers RT & LT – Bilateral procedures can be performed on both sides
Modifier 25 – Significant, separately identifiable evaluation and management (E/M) service by the same
physician on the day of a procedure
Modifier 59 – Distinct procedural service
Modifier 76 – Repeat procedure by the same physician
Modifier 91 – Repeat clinical diagnostic laboratory test
1 SSA
* Note: If the current claim and the previous claim(s) contain the same modifiers (e.g. both claims contain
modifier 76), additional research may be required to determine if the claim is a duplicate or a corrected claim.
Modifiers 25, 59, 76, and 91 should only be appended to the second claim.
Process
Review Claims by Member to identify the previously submitted claim(s) the current claim is
duping against.
Click on Global Functions.
Hover over Claims Processing.
Click on Claims by Member.
Select “2” in the drop down menu.
Enter the member’s G number.
Select “2” under the dates drop down menu.
Enter the effective dates and hit Enter.
All the claims on file for these dates will generate.
Put the claims in order by receive date, oldest to newest.
Review and compare the current claim to the claim(s) in the member’s history to determine if the
current claim is a corrected claim, a duplicate claim, or a separately identifiable claim.
Review the claim image in Macess or EDI for any evidence that would support a corrected
claim.
Bill Type ends in the number 7 (e.g. 117, 137, 237, 837, etc.)
A “corrected claim” stamp.
Modifier added/removed from the claim.
Different diagnosis, procedure code, or dollar amount.
An attachment (copy of an EOP, medical records, invoice, etc.).
Process the claim(s) according to the outcome of the research performed.
Research Outcome Processing Action
Corrected Claim - Current Adjust the previously submitted claim(s) to EX code E3, “Denied
claim supports the definition of – Adjusted claim due to corrected bill submission.”
a corrected claim.
E3 all lines that were resubmitted on the corrected claim.
Enter a claim remark on the previously submitted claim to
reference the corrected claim: “See corrected claim ____.”
Duplicate Claim - Current Deny the current claim or claim line(s) as a duplicate with EX
claim supports the definition of code DU, “Duplicate claim/service.”
a duplicate claim.
Enter a claim remark on the duplicate claim to reference the
previously submitted claim: “Duplicate to claim ____.”
Separately Identifiable Override the duplicate pend on the current claim and process the
Claim - Current claim
supports the definition of a claim according to normal processing guidelines.
separately identifiable claim. Enter a claim remark indicating why claim was determined not to
be a duplicate or a corrected claim (e.g. “Paid as modifier
indicates repeat procedure.”)
Steps to “E3” or “DU” a claim in Readjudication Status:
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the EX code currently on the claim.
Press Tab.
Type “E3” or “DU” (as appropriate based on the research outcome) in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The previous EX
code should be replaced with “E3” or “DU.”
2 SSA
Close/X out screen.
If the EX code did not update, go into Service Detail for each service line and enter “E3”
or “DU.”
Click REset/Adj to save changes.
Steps to “E3” or “DU” a claim in Adjustment status:
Reinstate if no money has been paid on the claim.
Reverse if money has been paid on the claim.
Click Reinstate or Reverse and the claim status will highlight.
Enter “AP” in the blue box and press Enter.
The Interest Adjustment Popup screen will generate.
Enter the claim’s received date for the date.
Enter “AP” in EX Code and press Enter.
Go to “Diagnosis, Procedures & Service Detail” tab.
Select a service line and click Service Detail.
Click Reset and enter “E3” or “DU” (as appropriate based on the research outcome) to override
all existing EX codes.
Press Enter.
The EX Code will update to “E3” or “DU.”
If the claim was adjusted to EX code E3, update the due date on the corrected to match the due
date of the original claim. This will ensure the provider’s payment is recouped and reapplied to
the corrected claim within the same pay period.
Steps to enter a claim 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.
Enter, “CL” in the Remark Type.
Type the appropriate remark:
“See corrected claim __(claim number)__.”
“Duplicate to claim __(claim number)__.”
Remark to indicate why claim is not a duplicate or a corrected claim (e.g. “Paid as
modifier indicates repeat procedure.”)
Steps to override the duplicate pend:
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the duplicate pend EX code.
Press Tab.
Type “AP” in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The duplicate pend
EX code should be removed.
Close/X out screen.
Helpful Research Hints: Physician Claims
Always review the claim image for a “Corrected Claim” stamp or any type of note that would indicate
that the claim is a corrected claim.
Durable Medical Equipment (DME) claims will possibly be duplicated because of the overlapping
dates. One claim’s end date may be the next claim’s beginning date. Override the duplicate pend if the
dates are the reason for the pend.
3 SSA
Durable Medical Equipment (DME) claims billed with E1399, review the description for E1399 on
the claim image.
If the descriptions are for different items, override the duplicate pend.
If the descriptions are for the same item, deny the claim line as a duplicate.
If there is no description, deny the claim Status 51 – EX Code 78, “Denied – Please submit
procedure code description.”
Chemo claims with J-codes are occasionally duplicates when the provider charges for the wasted
portion of the drug (read: not used). This is identified by the JW modifier or a written/typed note stating
that __ mg of the drug was wasted. Override the duplicate pend on the claim containing modifier JW
and deny the drug with EX code IB. Enter the EP remark, “Discarded drug amount not administered to
patient.” Pay for the used drug/medication.
Home Health claims will pend as potential duplicates if one claim was vertexed while the other was
manually entered. Review the claim image and ensure the individual service dates are entered.
The first claim submitted by the HHA is the RAPs claim and is billed with bill type 322, a single service
line with revenue code 0023, and a zero charge amount. Subsequent episode claims are not
duplicates to the RAPs claim. Override the duplicate pend. The “OB” pend will generate and that claim
will fall into another pend queue.
Helpful Research Hints: Facility Claims
Always review the claim image for a “Corrected Claim” stamp or any type of note that would indicate
that the claim is a corrected claim.
ER claims may pend as a potential duplicate to an inpatient claim. This happens because the member
may have gone to the ER for one episode on 09/09/14 through 09/10/14. Then, he or she may have
gone again to the ER for a second, separate episode on 09/10/14 and was admitted. Override the
duplicate pend on the ER charges.
Injection or wound care claims that are billed in monthly cycles can duplicate to any other outpatient
services/ER for that month. Override the duplicate pend.
Therapy claims – Outpatient Physical Therapy (PT), Speech Therapy (ST), or Occupational Therapy
(OT) claims can pend as potential duplicates. While the procedure codes are the same on the claims
(i.e. 97110, 97010, etc.), the modifiers are different. PT claims are billed with the modifier GP, ST
claims are billed with modifier GN, and OT claims are billed with modifier GO. Override the duplicate
pend if the modifiers differ. If the modifiers are the same, research the claim to determine if it is a
duplicate or a corrected claim then process the claim as outlined above.
Bill types ending in 5 are for late charges - The lines can be completed using Status 10 – EX Code GN,
“Late charge billing.” Remark the original claim that the late charge was paid.
4 SSA
Claims Pend Processing Profile
Process: s2 Queue Profile
(mDR) Multiple imaging services performed, thus reduction on technical
Pend Description N/A
Pend Category September 26, 2013
Date Implemented January 25, 2016
Date Updated/Revised System / CI job
Person(s) Responsible As defined below:
Processing Instructions
Do not work the pend. There is a nightly CI job that applies the appropriate CI code to the service line(s) on the
claim.
1
Claims Pend Processing Profile
Process: s8 Queue Profile
(pMDR2) Multiple imaging services performed, count greater than 1
Pend Description N/A
Pend Category September 26, 2013
Date Implemented January 25, 2016
Date Updated/Revised System / CI job
Person(s) Responsible As defined below:
Processing Instructions
Do not work the pend. There is a nightly CI job that applies the appropriate CI code to the service line(s) on the
claim.
1
Claims Pend Processing Profile
Pend: s9 Queue Profile
(mEV) Medicare Multiple Evaluation and Management Codes Edit
Pend Description Four
Pend Category August 21, 2012
Date Implemented June 5, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
If more than one evaluation and management (E/M) service is provided on the same day, to the same patient,
by the same physician, OR more than one physician in the same specialty, in the same group, for the same
diagnosis, only one evaluation and management service may be reported unless the evaluation and
management services are for unrelated problems.
Review the iCES edit in Claim Audit Service Edit Inquiry (RF0166).
Review the other code and claim in the Edit Description.
Determine if the code that the claim is pending s9 to is:
1. An add-on code,
2. Corrected claim, or
3. Separate E/M service provided on the same day.
If the code pending s9 is an add-on code, or a primary code to an add-on code, override the s9
pend with AP.
Review the list of add-on codes at: s9 Add-On Codes List.pdf
If the claim is a corrected claim, follow the potential duplicate pend processes (d7, R7, U7).
E3 the original claim and override the s9 pend with AP.
If the claim contains G0401 or G0402 and an E&M code with modifier 25, override the s9 pend
with AP.
If the code pending s9 is neither of the above OR if it is a separate E/M service provided on the
same day for the same diagnosis, bring these to the Quality Improvement Manager for review.
Additional Reference Tool:
s9 - Evaluation and Management Billing Guidelines.pdf
1
Claims Pend Processing Profile
Process: TE Queue Profile
PENDING ORGAN TRANSPLANT MEMBER
Pend Description N/A
Pend Category February 3, 2016
Date Implemented
Date Updated/Revised Medical Management
Person(s) Responsible As defined below:
Processing Instructions
Medical Management reviews claims pended TE to determine if the service(s) billed are related to the
transplant authorization to which the claim is mapping. After review, Medical Management sends a service form
(SF) to the Claims Department with the processing directive, which is typically stated as:
1. “Related to transplant,” or
2. “Not related to transplant.”
Processing the TE Pend from a SF
If the SF states, “Related to transplant,” override the TE pend with EX AP, “Approved,” to
approve the claim for payment under the transplant authorization.
If the SF states, “Not related to transplant,” follow the 6O pend process to determine if an
authorization is required for the service(s) billed.
If an authorization is not required, override the TE pend with EX AP, “Approved.”
If an authorization is required, but was not obtained, deny the service(s) for no authorization.
Par provider claims – Deny with EX JL, “PARTICIPATING PROVIDER BILLING FOR
UNAUTHORIZED SERVICE.”
Non-par provider claims – Follow the O8 pend process to review for a par referral and
urgent/emergent criteria. If the service(s) were not par referred or urgent/emergent,
deny with EX DV, “NON-PARTICIPATING PROVIDER BILLING FOR
UNAUTHORIZED SERVICE.”
Enter a claim remark referencing the SF number.
Additional Processing Guidance
Because the TE pend is manually overridden, the claim can flip to the TE pend if the claim or claim line is reset.
When processing a claim that flips to the TE pend, review claim remarks for a SF # or the member’s folder for a
SF from Medical Management with the processing directive for the claim. The SF can typically be identified by:
- Document Type = “SF – Medical Management Service Form”
- Document Description = “Claims RE: Authorization Issue”
If there is a related SF in the member’s folder, complete the TE pend following the process
outlined above.
If there is not a related SF in the member’s folder, leave the claim pended TE for Medical
Management to review.
1
Claims Pend Processing Profile
Pend: TL Queue Profile
Therapy Calendar Year Maximum has been Met
Pend Description Two
Pend Category August 19, 2011
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The TL queue signifies when a member has reached his or her calendar year maximum of physical therapy.
Review each service line and check if there is a “KX” modifier present.
Pay claim with KX modifier.
Check for an authorization.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Select service line with “TL” EX code.
Click “Service Detail.”
Check for an authorization number.
Click on “Global Functions” at the top of the left-hand panel.
Hover over “Authorization.”
Click “Authorizations by Member.”
Click binoculars/find icon on the top toolbar.
Press Enter.
Select Authorization line that matches the service detail authorization.
Verify which kind of authorization (hospital, medical, or drug) it is by scrolling to end
of the line.
Click the relative type of authorization inquiry.
Read over the authorization to determine if the claim is covered.
Exit out of three (3) screens to get back to the claim.
Add any missing information if necessary.
Certain modifiers are the difference between a claim being paid and rejected.
Override the TL EX code if KX modifier is present. SSA
Single code
Select “Diagnosis, Procedures & Service Detail” tab.
Click “Service Detail.”
Click “REset/Adj.”
Put cursor in “EX code” field.
Type in “AP” for approval, the denial code, or the pend code.
Click disk/save icon and close/X out that screen.
Close/X out the next screen as well.
Multiple codes (used most often)
Select “Diagnosis, Procedures & Service Detail” tab.
Click “Ex Overrides.”
Click binoculars/find icon on the top toolbar.
Place cursor in the “OLD EX” code field and type “TL.”
Press Tab.
Type “AP” in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks you “Are the above overrides correct? Y / N.”
1
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The
TL code should be replaced with “AP.”
Go into Service Detail for each service line and enter “AP” for the Ex Code if TL does not
change.
Click REset/Adj to save changes.
Close/X out screen and click ReAdjudicate.
Deny the claim if there is NO KX modifier.
Reset the claim status to “51 – Denied.”
Press Tab.
Enter “KH” - Therapy calendar year maximum has been met - in the EX field.
Click ReAjudicate on the left-hand pane to save changes.
Demand Draw the claim from the queue.
2 SSA
Claims Pend Processing Profile
Process: u1/x9/w3 Queue Profile
u1 - (pMTR2) Proc qualifies for mult therapy reduction-Review reduced - CI TB
Pend Descriptions x9 - (pMTR2) Proc qualifies for mult therapy reduction-Review reduced - CI TA
w3 - (pMTRH) Mult therapy reduction applies to previous claim-Rvw reducd CI TA
Pend Category
Date Implemented February 21, 2011
Date Updated/Revised April 22, 2015
Person(s) Responsible Claims Examiners
Processing Instructions As defined below:
To process claims according to MLN 7050, which announces that Medicare is applying a Multiple Procedure
Payment Reduction (MPPR) to the Practice Expense (PE) component of payment of select therapy services
paid under the MPFS. There are 44 codes that apply to this change. Please see the document titled “u1 x9 w3
Codes,” which provides the 44 therapy codes and their PE values.
Background
All claims in a payable status will go through iCES for editing.
If the count on the claim is greater than 1 and has one of the 44 HCPCS codes listed, it will
pend u1.
If the count on the claim is 1 unit and has more than one of the 44 HCPCS codes listed, it will
pend x9.
During the nightly process, there is a program that will update the claims.
If the claim has the u1 pend, the job will assign CI code TB.
If the claim has the x9 pend, the job will assign CI code TA.
However, if both u1 and x9 codes are assigned, the job will pend the claims EX code w3, “(pMTRH)
Mult therapy reduction applies to previous claim-Rvw reducd CI TA.”
Any claim that pends w3 or that is not resolved by the nightly process is manually reviewed. Please
see the below process to manually review pends u1, x9, and w3.
Process for u1, x9, w3
CI code TA is applied to pay the reduced rate.
If units greater than 1, TA applies the reduced rate to all units.
CI code TB is applied to pay the full price.
If units greater than 1, TB pays 1 unit in full and applies the reduced rate to remaining units.
If the claim has multiple lines and one line is paid at full price, the line pending u1, x9, or w3 is
paid at the reduced rate. Enter CI code TA to pay the claim.
1
If there is only one line on the claim, review the member’s history for any claim submitted by the
same provider with the same date of service.
If one of the claims was paid in full, pay the line that is pending at the reduced rate using the CI
code TA.
If the history claim indicates that the reduced rate was applied OR if there are no other claims,
pay the full price using the CI code TB.
Notes:
The therapy code with the highest PE value is paid in full. The remaining therapy codes are paid at the
reduced rate. Use the document titled “u1 x9 w3 Codes” to determine which code has the highest PE
value.
If CI code OD is already on the service line and a TA or TB is required, space out the OD CI code and
enter TA or TB as appropriate.
2
Claims Pend Processing Profile
Pend: u2 Queue Profile
(mAP) Procedure on history line associated w/add-on proc denied/reviewed
Pend Description Three
Pend Category
Date Implemented December 3, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
An add-on code is a HCPCS/CPT code that describes a service that is always performed in conjunction with
another primary service. Add-on codes are eligible for payment only if they are reported with an appropriate
primary procedure performed by the same practitioner. Add-on codes are never eligible for payment if they are
the only procedure reported by a practitioner.
Claims pend EX u2 for manual review of the primary procedure on a history line associated with an add-on
procedure.
Process
Review the CES edit in Amisys.
Open the Claim Audit Service Edit Inquiry screen (RF0166).
Enter the claim number and press Enter.
If the Edit Description reads, “The primary procedure code on history line XXXX/X that is
associated with this add-on procedure code has received an edit with a deny or review status,”
deny the service EX x5, “(mSB) Add-on procedure submitted w/out appropriate primary
procedure.”
1
Claims Pend Processing Profile
Process: u3 Queue Profile
(mD1) Procedure requires review of documentation for need of surg asst
Pend Description Four
Pend Category February 24, 2016
Date Implemented
Date Updated/Revised Sr. Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Certain procedure codes billed with assistant-at-surgery modifiers (80, 81, 82, and AS) pend u3 for review of
documentation to establish the medical necessity of a surgical assistant.
1. Review the claim to determine if medical records are attached.
If medical records are not attached, OR are attached, but do not contain all of the necessary
information, proceed to step #2
Review the Requesting Additional Information Matrix to determine what information is
needed.
If medical records are attached and contain all necessary information, proceed to step #3.
2. Request medical records:
Follow the Generating a Letter Requesting Additional Information process to request medical
records and refer to the Requesting Additional Information Matrix to ensure appropriate
information is requested.
If medical records are not received within 30 days, deny the service line EX NO, “Additional info
requested from provider to process claim not received.”
If medical records are received, but do not contain all of the necessary information, deny the
service line EX NW, “Additional info received from provider is insufficient to process claim.”
3. Prepare claim and medical records for review by a medical director:
Complete an Unlisted Procedure Code coversheet by handwriting the information (do not enter
into the Unlisted Database).
Note on the Unlisted Procedure Code coversheet that the claim was pending u3 and is
not unlisted.
Manually pend the claim EX EV, “Pending for medical director review.”
Provide the Unlisted Procedure Code coversheet, claim image, and additional information to
the Claims Director.
4. The Claims Director forwards the claim for processing according to the medical director’s
review.
If the procedure allows for an assistant surgeon, override EX u3 with AP, “Approved.”
If the procedure does not allow for an assistant surgeon, override EX u3 with w6, “Procedure
has Medicare payment restrictions for surgery assistant.”
1
Claims Pend Processing Profile
Process: u6 Queue Profile
(mER) Procedure qualifies for reduction, payment should be reduced
Pend Description N/A
Pend Category September 26, 2013
Date Implemented January 25, 2016
Date Updated/Revised System / CI job
Person(s) Responsible As defined below:
Processing Instructions
Do not work the pend. There is a nightly CI job that applies the appropriate CI code to the service line(s) on the
claim.
1
Claims Pend Processing Profile
Pend: U7 Facility Queue Profile
Possible Medicare Duplicate for Diagnosis
Pend Description Two
Pend Category June 23, 2003
Date Implemented August 13, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The purpose of this pend is to identify the previously processed claim(s) that the current claim is duping against
and determine if the current claim is a corrected claim, a duplicate claim, or a separately identifiable claim.
Definitions
Corrected Claim – Corrected billing of a previous processed claim. Corrected claims can be identified by a
“corrected claim” stamp, type of bill ending in a 7 (e.g. 117, 137, 237, 837, etc.), attachments, or
additional/corrected claim information. Corrected claims may be submitted for the following reason(s):
Corrected diagnosis
Corrected charges
Corrected procedure code
Addition or correction of modifier
Corrected provider information
Attachments (EOP, medical records, invoice, etc.)
Duplicate Claim – Claim or a claim line that exactly matches another claim or claim line with respect to the
following elements:
Physician Claims Facility Claims
Member Member
Provider Provider
Date(s) of Service Type of Bill
Procedure Code Date(s) of Service
Modifier Total Charges (on the line or the bill)
Place of Service HCPCS/CPT-4 Procedure Codes
Billed Amount Modifier
Separately Identifiable Claim – Claim is neither a duplicate nor a corrected claim. The claim or claim line may
be related to previously processed claim(s) or claim line(s), but are separately identifiable. Examples include,
but are not limited to:
Ambulance modifiers (review pickup point location if modifiers are the same)
Modifiers RT & LT – Bilateral procedures can be performed on both sides
Modifier 25 – Significant, separately identifiable evaluation and management (E/M) service by the same
physician on the day of a procedure
Modifier 59 – Distinct procedural service
Modifier 76 – Repeat procedure by the same physician
Modifier 91 – Repeat clinical diagnostic laboratory test
1 SSA 06.25.14
* Note: If the current claim and the previous claim(s) contain the same modifiers (e.g. both claims contain
modifier 76), additional research may be required to determine if the claim is a duplicate or a corrected claim.
Modifiers 25, 59, 76, and 91 should only be appended to the second claim.
Process
Review Claims by Member to identify the previously submitted claim(s) the current claim is
duping against.
Click on Global Functions.
Hover over Claims Processing.
Click on Claims by Member.
Select “2” in the drop down menu.
Enter the member’s G number.
Select “2” under the dates drop down menu.
Enter the effective dates and hit Enter.
All the claims on file for these dates will generate.
Put the claims in order by receive date, oldest to newest.
Review and compare the current claim to the claim(s) in the member’s history to determine if the
current claim is a corrected claim, a duplicate claim, or a separately identifiable claim.
Review the claim image in Macess or EDI for any evidence that would support a corrected
claim.
Bill Type ends in the number 7 (e.g. 117, 137, 237, 837, etc.)
A “corrected claim” stamp.
Modifier added/removed from the claim.
Different diagnosis, procedure code, or dollar amount.
An attachment (copy of an EOP, medical records, invoice, etc.).
Process the claim(s) according to the outcome of the research performed.
Research Outcome Processing Action
Corrected Claim - Current Adjust the previously submitted claim(s) to EX code E3,
claim supports the definition of “Corrected claim received, prior claim to be denied.”
a corrected claim.
E3 all lines that were resubmitted on the corrected claim.
Enter a claim remark on the previously submitted claim to
reference the corrected claim: “See corrected claim ____.”
If the corrected claim denies EX DH, “Denied – Untimely filing, do
not bill member,” do NOT adjust the original claim to EX E3.
Allow both claims to process separately.
Duplicate Claim - Current Deny the current claim or claim line(s) as a duplicate with EX
claim supports the definition of code DU, “Duplicate claim/service.”
a duplicate claim. Enter a claim remark on the duplicate claim to reference the
previously submitted claim: “Duplicate to claim ____.”
Separately Identifiable Override the duplicate pend on the current claim and process the
Claim - Current claim
supports the definition of a claim according to normal processing guidelines.
separately identifiable claim. Enter a claim remark indicating why claim was determined not to
be a duplicate or a corrected claim (e.g. “Paid as modifier
indicates repeat procedure.”)
Steps to “E3” or “DU” a claim in Readjudication Status:
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the EX code currently on the claim.
Press Tab.
Type “E3” or “DU” (as appropriate based on the research outcome) in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
2 SSA 06.25.14
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The previous EX
code should be replaced with “E3” or “DU.”
Close/X out screen.
If the EX code did not update, go into Service Detail for each service line and enter “E3”
or “DU.”
Click REset/Adj to save changes.
Steps to “E3” or “DU” a claim in Adjustment status:
Reinstate if no money has been paid on the claim.
Reverse if money has been paid on the claim.
Click Reinstate or Reverse and the claim status will highlight.
Enter “AP” in the blue box and press Enter.
The Interest Adjustment Popup screen will generate.
Enter the claim’s received date for the date.
Enter “AP” in EX Code and press Enter.
Go to “Diagnosis, Procedures & Service Detail” tab.
Select a service line and click Service Detail.
Click Reset and enter “E3” or “DU” (as appropriate based on the research outcome) to override
all existing EX codes.
Press Enter.
The EX Code will update to “E3” or “DU.”
If the claim was adjusted to EX code E3, update the due date on the corrected to match the due
date of the original claim. This will ensure the provider’s payment is recouped and reapplied to
the corrected claim within the same pay period.
Steps to enter a claim 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.
Enter, “CL” in the Remark Type.
Type the appropriate remark:
“See corrected claim __(claim number)__.”
“Duplicate to claim __(claim number)__.”
Remark to indicate why claim is not a duplicate or a corrected claim (e.g. “Paid as
modifier indicates repeat procedure.”)
Steps to override the duplicate pend:
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the duplicate pend EX code.
Press Tab.
Type “AP” in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The duplicate pend
EX code should be removed.
Close/X out screen.
3 SSA 06.25.14
Helpful Research Hints: Facility Claims
Always review the claim image for a “Corrected Claim” stamp or any type of note that would indicate
that the claim is a corrected claim.
ER claims may pend as a potential duplicate to an inpatient claim. This happens because the member
may have gone to the ER for one episode on 09/09/14 through 09/10/14. Then, he or she may have
gone again to the ER for a second, separate episode on 09/10/14 and was admitted. Override the
duplicate pend on the ER charges.
Injection or wound care claims that are billed in monthly cycles can duplicate to any other outpatient
services/ER for that month. Override the duplicate pend.
Therapy claims – Outpatient Physical Therapy (PT), Speech Therapy (ST), or Occupational Therapy
(OT) claims can pend as potential duplicates. While the procedure codes are the same on the claims
(i.e. 97110, 97010, etc.), the modifiers are different. PT claims are billed with the modifier GP, ST
claims are billed with modifier GN, and OT claims are billed with modifier GO. Override the duplicate
pend if the modifiers differ. If the modifiers are the same, research the claim to determine if it is a
duplicate or a corrected claim then process the claim as outlined above.
Bill types ending in 5 are for late charges - The lines can be completed using Status 10 – EX Code
GN, “Late charge billing.” Remark the original claim that the late charge was paid.
4 SSA 06.25.14
Claims Pend Processing Profile
Pend: U7 Professional
Queue Profile
Pend Description Possible Medicare Duplicate for Diagnosis
Pend Category Two
Date Implemented June 23, 2003
Date Updated/Revised August 13, 2015
Person(s) Responsible Claims Examiners
Processing Instructions As defined below:
The purpose of this pend is to identify the previously processed claim(s) that the current claim is duping against
and determine if the current claim is a corrected claim, a duplicate claim, or a separately identifiable claim.
Definitions
Corrected Claim – Corrected billing of a previous processed claim. Corrected claims can be identified by a
“corrected claim” stamp, type of bill ending in a 7 (e.g. 117, 137, 237, 837, etc.), attachments, or
additional/corrected claim information. Corrected claims may be submitted for the following reason(s):
Corrected diagnosis
Corrected charges
Corrected procedure code
Addition or correction of modifier
Corrected provider information
Attachments (EOP, medical records, invoice, etc.)
Duplicate Claim – Claim or a claim line that exactly matches another claim or claim line with respect to the
following elements:
Physician Claims Facility Claims
Member Member
Provider Provider
Date(s) of Service Type of Bill
Procedure Code Date(s) of Service
Modifier Total Charges (on the line or the bill)
Place of Service HCPCS/CPT-4 Procedure Codes
Billed Amount Modifier
Separately Identifiable Claim – Claim is neither a duplicate nor a corrected claim. The claim or claim line may
be related to previously processed claim(s) or claim line(s), but are separately identifiable. Examples include,
but are not limited to:
Ambulance modifiers (review pickup point location if modifiers are the same)
Modifiers RT & LT – Bilateral procedures can be performed on both sides
Modifier 25 – Significant, separately identifiable evaluation and management (E/M) service by the same
physician on the day of a procedure
Modifier 59 – Distinct procedural service
Modifier 76 – Repeat procedure by the same physician
Modifier 91 – Repeat clinical diagnostic laboratory test
1 SSA 06.25.14
* Note: If the current claim and the previous claim(s) contain the same modifiers (e.g. both claims contain
modifier 76), additional research may be required to determine if the claim is a duplicate or a corrected claim.
Modifiers 25, 59, 76, and 91 should only be appended to the second claim.
Process
Review Claims by Member to identify the previously submitted claim(s) the current claim is
duping against.
Click on Global Functions.
Hover over Claims Processing.
Click on Claims by Member.
Select “2” in the drop down menu.
Enter the member’s G number.
Select “2” under the dates drop down menu.
Enter the effective dates and hit Enter.
All the claims on file for these dates will generate.
Put the claims in order by receive date, oldest to newest.
Review and compare the current claim to the claim(s) in the member’s history to determine if the
current claim is a corrected claim, a duplicate claim, or a separately identifiable claim.
Review the claim image in Macess or EDI for any evidence that would support a corrected
claim.
Bill Type ends in the number 7 (e.g. 117, 137, 237, 837, etc.)
A “corrected claim” stamp.
Modifier added/removed from the claim.
Different diagnosis, procedure code, or dollar amount.
An attachment (copy of an EOP, medical records, invoice, etc.).
Process the claim(s) according to the outcome of the research performed.
Research Outcome Processing Action
Corrected Claim - Current Adjust the previously submitted claim(s) to EX code E3,
claim supports the definition of “Corrected claim received, prior claim to be denied
a corrected claim.
E3 all lines that were resubmitted on the corrected claim.
Enter a claim remark on the previously submitted claim to
reference the corrected claim: “See corrected claim ____.”
If the corrected claim denies EX DH, “Denied – Untimely filing, do
not bill member,” do NOT adjust the original claim to EX E3.
Allow both claims to process separately.
Duplicate Claim - Current Deny the current claim or claim line(s) as a duplicate with EX
claim supports the definition of code DU, “Duplicate claim/service.”
a duplicate claim. Enter a claim remark on the duplicate claim to reference the
previously submitted claim: “Duplicate to claim ____.”
Separately Identifiable Override the duplicate pend on the current claim and process the
Claim - Current claim
supports the definition of a claim according to normal processing guidelines.
separately identifiable claim. Enter a claim remark indicating why claim was determined not to
be a duplicate or a corrected claim (e.g. “Paid as modifier
indicates repeat procedure.”)
Steps to “E3” or “DU” a claim in Readjudication Status:
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the EX code currently on the claim.
Press Tab.
Type “E3” or “DU” (as appropriate based on the research outcome) in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
2 SSA 06.25.14
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The previous EX
code should be replaced with “E3” or “DU.”
Close/X out screen.
If the EX code did not update, go into Service Detail for each service line and enter “E3”
or “DU.”
Click REset/Adj to save changes.
Steps to “E3” or “DU” a claim in Adjustment status:
Reinstate if no money has been paid on the claim.
Reverse if money has been paid on the claim.
Click Reinstate or Reverse and the claim status will highlight.
Enter “AP” in the blue box and press Enter.
The Interest Adjustment Popup screen will generate.
Enter the claim’s received date for the date.
Enter “AP” in EX Code and press Enter.
Go to “Diagnosis, Procedures & Service Detail” tab.
Select a service line and click Service Detail.
Click Reset and enter “E3” or “DU” (as appropriate based on the research outcome) to override
all existing EX codes.
Press Enter.
The EX Code will update to “E3” or “DU.”
If the claim was adjusted to EX code E3, update the due date on the corrected to match the due
date of the original claim. This will ensure the provider’s payment is recouped and reapplied to
the corrected claim within the same pay period.
Steps to enter a claim 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.
Enter, “CL” in the Remark Type.
Type the appropriate remark:
“See corrected claim __(claim number)__.”
“Duplicate to claim __(claim number)__.”
Remark to indicate why claim is not a duplicate or a corrected claim (e.g. “Paid as
modifier indicates repeat procedure.”)
Steps to override the duplicate pend:
Click “EX Overrides.”
Place cursor in the “OLD EX” code field and enter the duplicate pend EX code.
Press Tab.
Type “AP” in the “NEW EX” code field.
Press Enter.
Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The duplicate pend
EX code should be removed.
Close/X out screen.
3 SSA 06.25.14
Helpful Research Hints: Physician Claims
Always review the claim image for a “Corrected Claim” stamp or any type of note that would indicate
that the claim is a corrected claim.
Durable Medical Equipment (DME) claims will possibly be duplicated because of the overlapping
dates. One claim’s end date may be the next claim’s beginning date. Override the duplicate pend if the
dates are the reason for the pend.
Durable Medical Equipment (DME) claims billed with E1399, review the description for E1399 on
the claim image.
If the descriptions are for different items, override the duplicate pend.
If the descriptions are for the same item, deny the claim line as a duplicate.
If there is no description, deny the claim Status 51 – EX Code 78, “Denied – Please submit
procedure code description.”
Chemo claims with J-codes are occasionally duplicates when the provider charges for the wasted
portion of the drug (read: not used). This is identified by the JW modifier or a written/typed note stating
that __ mg of the drug was wasted. Override the duplicate pend on the claim containing modifier JW
and deny the drug with EX code IB. Enter the EP remark, “Discarded drug amount not administered to
patient.” Pay for the used drug/medication.
Home Health claims will pend as potential duplicates if one claim was vertexed while the other was
manually entered. Review the claim image and ensure the individual service dates are entered.
The first claim submitted by the HHA is the RAPs claim and is billed with bill type 322, a single service
line with revenue code 0023, and a zero charge amount. Subsequent episode claims are not
duplicates to the RAPs claim. Override the duplicate pend. The “OB” pend will generate and that claim
will fall into another pend queue.
4 SSA 06.25.14
Claims Pend Processing Profile
Pend: UE Queue Profile
Referring Provider has been Terminated
Pend Description One
Pend Category July 6, 2006
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
UE Queue claims represent those referring providers who are listed as terminated in the system.
Open two Amisys Advance screens.
First
Open Amisys and login.
Click “Claims Processing” on Main Menu.
Click “Medical Readjudication” under the “Readjudication” heading.
Second
Open Amisys and login.
Click “Provider” on Main Menu.
Click “Provider Affiliation” under “Provider” heading.
Determine if claim is Electronic or Manual and populate it.
Electronic
Use EDI Viewer to view the claim when the claim contains the letter “E.” (e.g. 11265E030758)
Open EDI Viewer and login.
Enter claim number in blank field.
Press Enter and claim image should populate.
Manual
Use Macess when the claim contains the letter “M.” (e.g. 11263M001302 and
112970000010)
Open Macess and login.
Select “Open” from the toolbar.
Select “Document” from the drop down menu.
Put cursor in “Document ID” field.
Enter claim number.
Press Enter and claim image should populate.
If no claim populates, wait two days for Scanning Department to upload the image; however, if
there is no image after those two days, inform management.
Review the information on the Amisys readjudication screen and verify it matches the
information on the claim image.
Correct the readjudication screen information if necessary and click ReAdjudicate or REset/Adj
to save changes.
Verify that the Referring NPI # on claim is the same provider is Amisys.
Open an ecare screen
Open Internet Explorer.
Type www.ecare.com in the URL field and hit Enter.
Click “NPI.”
Place cursor in NPI field and type in NPI number.
1 SSA
Click “Process” or hit Enter.
Provider’s information will generate.
Compare provider name and address.
Verify that the Servicing Provider NPI # on claim is the same provider in Amisys through ecare.
Click “NPI” on the left pane of ecare.
Place cursor in NPI field and type in NPI number.
Click “Process” or hit Enter.
Provider’s information will generate.
Compare provider name.
Click blue NPI hyperlink to view more precise information referring to name and/or
address.
If there is no Servicing NPI, deny claim.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Click on drop down menu under “Claim Status.”
Select ”51-Denied.”
Place cursor in “Ex code” field.
Type “np.”
Click ReAdjudicate to save all changes made.
Verify the claim status and Ex codes on the service lines.
Space out physicians’ four digit affiliation(s) and click ReAdjudicate. The system will generate
affiliation(s).
Pick the affiliation that matches the member/region.
Match the Referring Provider affiliation with the member’s PCP if they are the same.
Match Referring Provider affiliation with the member’s Provider if they are the same.
Remove the Referring Provider if the affiliation is not generated after spacing it out.
Click ReAdjudicate to save all changes made
Verify the correct Provider has been selected.
Highlight and copy the “Prov #” field from readjudication screen.
Paste number into “Provider” field on Provider Affiliation screen.
Type or copy the four digit affiliation from the readjudication screen to affiliation screen.
Hit Enter and Provider information populates.
Verify that the Effective Dates, Carrier, Region, Area (AA), and IRS# (TID) are correct.
If the information does not match, pend the claim with one of the Provider Relations
pend codes below.
Locality (AA) does not have to match with Referring Provider.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Click on the Claim Status drop down menu and select “41- Pended.”
Place cursor in Ex field and enter the Ex code from the list below that associates with
the reason the claim is being pended. (E.g. Par Address Doesn’t Match EX code = 73)
Participating Providers (Status PP, CP, RP, LP, OP or IO)
Par Medicare Number Needed (31D) - Amisys #0003 - EX code = 84
Par Member Region Doesn’t Match (31E) - Amisys #0005 - EX code = 85
Par Additional Tax ID# Needed (31C) - Amisys #0002 - EX code = 83
Par Address Doesn’t Match (31B) - Amisys #0001 - EX code = 73
Locality Does Not Match – EX Code = BU
Non- Participating Providers (Status OA or NP)
Non-Par Medicare Number Needed (322) - Amisys #0010 - EX code = p1
Non-Par Medicare Not in System (324) - Amisys #0009 - EX code = p3
Non-Par Member Region Doesn’t Match (323) - Amisys #0008 - EX code = p2
Non-Par Additional Tax ID# Needed (321) - Amisys #0007 - EX code = p0
Non-Par Address Doesn’t Match (320) - Amisys #0006 - EX code = 98
2 SSA
Review Area Field - EX code = BU (manual pend)
Verify that “Pay Class” does not read “DUMMY”.
If it reads “DUMMY” but the Carrier and Region match the member’s Carrier and
Region, then it is OK.
If it reads “DUMMY” and Carrier and Region do not match, space out affiliation and
readjudicate.
Verify the correct affiliation has been generated.
If that does not work, enter the member’s PCP number and affiliation in the Referring
Provider fields.
Verify address by clicking “Aff Address.”
If the servicing provider’s address and Amisys do not match, review the Provider’s
Remarks in Amisys.
Copy the Provider # from adjudication screen.
Click on “Remarks” and a new screen will pop up.
Click on the binoculars/find icon on the top tool bar.
Click on the “ID# Type” drop down menu.
Select “PV.”
Place cursor in “Provider#:” field and paste Provider #.
Hit Enter and the remarks will display.
Hit the “Next” button in the top tool bar to scroll through.
If the remarks state to pay to a different address than what is stated on
the readjudication screen and it is also on the affiliation screen, it is OK
to pay.
If the remarks do not match the information on the provider claim, pend
the claim with the Provider Relations pend code for “address doesn’t
match” from the list above.
Confirm claim address and Amisys address are correct.
Exit out of address pop-up window.
Click binoculars/find icon on the top tool bar to clear fields.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Check that the Status “St” has ALL 10s, 11s, 12s, 50s, 51s, or a combination of 10s, 11s, 12s,
50s, and 51s.
If the status contains ANY other codes, DO NOT demand draw. The claim will fall into an
appropriate queue to be fixed.
Do not Demand Draw 31 or 41 status.
If there are other EX Codes remaining and you are able to process them, continue to process
them.
It is OK if there are other Ex codes besides AP or CP if you do not know how to process them.
Demand Draw the claim from the queue.
Maximize Macess.
Select “My Work” from tool bar.
Select “Workflow Examination” on the drop down menu.
Click the “Draw Mode - Demand” icon.
Click the “Select Work Item” icon.
Place cursor in Document ID field and type in claim number.
Check New, Pended, and Rerouted options in Work Item Status section.
Hit Enter.
Select “Work Flow Examination.”
Select “Complete.”
Select “Save” and X out the screen.
3 SSA
Claims Pend Processing Profile
Pend: ui Queue Profile
Review UMGIPA PCP Claim for Hospital Locations
Pend Description Two
Pend Category July 9, 2009
Date Implemented January 9, 2015
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 “ui” are UMGIPA PCP claims that bill with location code 22 or 21. The location code can be found
on the second page of the claim on the service line(s).
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 UMGIPA. On
Electronic claims, the facility can be found in the Facility 1 field, which can be found around the middle of the first
page of the claim.
To research to see if that facility has a hospitalist program for UMGIPA, 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, the grid 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.
1
Below is a screen shot of the facilities participating in the hospitalist programs for UMGIPA 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.
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 ui, review the
service line that is not ui. If the CI code in that line reads “cc,” override the subsequent hospitalist lines pending ui
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.
Review
2
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