Claims Pend Processing Profile
Pend: 79 Queue Profile
Review modifier-79 for global services
Pend Description Two
Pend Category August 30, 2001
Date Implemented April 24, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Modifier 79 indicates that an unrelated procedure or service by the same physician during the postoperative
period has been performed: The physician may need to indicate that the performance of a procedure or service
during the postoperative period of the initial procedure was unrelated to the original procedure.
If claim is not attached to a global auth but is attached to another, override the 79. If claim is attached to a D3
pend, override and let it go through iCES for the global % to pay. If claim is not attached to an auth and needs
one (should pend 06,07,08 or 09) follow procedures for par and non-par no auth.
Claims Pend Processing Profile
Pend: 87 Queue Profile
Member Expired Prior to Date of Service
Pend Description Two
Pend Category February 20, 2003
Date Implemented September 26, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
TC65 members are termed at the end of the month.
Review claim for DOS based on Date of Death. If before date of death, override and pay.
If after date of death, deny 9Y.
Review HH and DME monthly rental claims. If cycle begins before DOD pay claim.
Confirm DOD for any discrepancy with Enrollment.
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Claims Pend Processing Profile
Pend: 89 Queue Profile
Servicing Provider Region Affiliation Does Not Match
Pend Description One
Pend Category May 8, 2002
Date Implemented March 7, 2012
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
89 pended claims generate to ensure that claims process according to the member’s region (IPA). The region
match is critical to the payment coming from the correct IPA bank account. THE PROVIDER AFFILIATION
AND MEMBER AFFILIATION MUST MATCH.
Research member history to ensure the claim is processing with the correct membership span.
Click on “Global Functions.”
Hover over “Membership.”
Click on “Member Eligibility History.”
The member’s G# should be generated.
Press Enter.
Verfiy information.
Be sure to match the date of service to the member span.
The claim may need to be manually split based on span dates.
Select “Diagnosis, Procedures & Service Detail” tab on the
readjudication screen.
Click on drop down menu under “Claim Status.”
Select ”91-Voided.”
Place cursor in “Ex code” field and type “VO.”
Click ReAdjudicate to save all changes made.
Verify the claim status and Ex codes on the service lines.
Print and make a second copy of the claim.
Manually re-enter first line and using a sharpie mark out any additional
lines that don’t pertain to that particular span.
The remaining lines will be entered in a separate claim with the first
line marked out by sharpie.
Put remarks on the claim stating why the claim was voided and return the claim to the provider.
Click “Remarks.”
Click the New icon.
Claim ID Type should be “CL” and the claim # as well as Member G# should be
generated.
Place cursor in “Remark Effective Date” and enter the Effective Date from the claim.
Press Tab.
Enter “12-31-9999” as the Exp Date.
Press Tab.
Enter “CL” as the Remark Type.
Press Tab twice.
Enter remark.
Click on the submit/save icon on the tool bar.
Exit the screen.
Before voiding any claims please make sure all of the proper research has been completed and
the member name and number has been verified.
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Check the claim and make sure the claim is for the correct member, or that there is not another
member number for the member.
If the member is a KIPA, Community 65, Maxicare or Principal (PR) member (these carriers
affiliations have been termed effective 12/31/2004) the claim should be processed with the Not A
PHN Member number, which is G0004303201.
Reenter the member’s G# as the “Not a PHN member” Dummy number, which is
G0004303201.
The Region will flip to TC and the Carrier will be IP.
Amisys will auto-deny “9Y,” which means the member is not active for the date span.
Before voiding any claims please make sure all of the proper research has been completed and
the member name and number has been verified.
Demand Draw the claim from the queue.
Maximize Macess.
Select “My Work” from tool bar.
Select “Workflow Examination” on the drop down menu.
Click the “Draw Mode - Demand” icon.
Click the “Select Work Item” icon.
Place cursor in Document ID field and type in claim number.
Check New, Pended, and Rerouted options in Work Item Status section.
Hit Enter.
Select “Work Flow Examination.”
Select “Complete.”
Select “Save” and X out the screen.
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Claims Pend Processing Profile
Pend: 99
Queue Profile
Pend Description Ambulance - Add CI Code For Urban (CIUR), Rural (CIRL), and Super Rural
(CISP)
Pend Category Three
Date Implemented January 1, 2012
Date Updated/Revised March 6, 2013
Person(s) Responsible Claims Examiners
Processing Instructions As defined below:
Ambulance claims should be paid according to the CMS Ambulance fee schedule. This does not apply to
Acadian Ambulance for dates of service on or after 8/1/2012.
The Ambulance claim will be paid by the pickup point zip code using a CI code. The pickup point can be
determined by the service line modifiers, notes that appear on the claim image, or EDI Locator. See the
following modifier descriptions.
Origin and destination ambulance modifier codes and their descriptions:
D = Diagnostic or therapeutic site other than P or H when these are used as origin codes;
E = Residential, domiciliary, custodial facility (other than 1819 facility);
G = Hospital based ESRD facility;
H = Hospital;
I = Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport;
J = Freestanding ESRD facility;
N = Skilled nursing facility;
P = Physician’s office;
R = Residence;
S = Scene of accident or acute event;
X = Intermediate stop at physician’s office on way to hospital (destination code only)
If the pickup point is a hospital or facility (modifiers E, G, H, J, or N) and the pickup zip code is not detailed on
the claim image, an examiner will have to research the member’s claim history:
Click Global Functions.
Hover over Claims Processing.
Click on Claims by Member.
Enter the member’s number and search for a claim with the same date of service as the current claim.
Research the claim to verify if it details the facility zip code.
Use the Locality Zip Code File to make a determination if the pickup point zip code is Urban, Rural, or Super
Rural. (next page)
Note: When researching a hospital or facility claim, it may be possible for the claim go back three or more
months.
If the claim is electronic (EDI) and the pickup point is not a hospital or facility, review the EDI Locator for the
pickup point.
Open EDI Claim Locator.
Copy and paste Envoy Claim Number from claim image to EDI Locator.
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The Date of Claim is the Tape Create Date.
Click Find.
EDI Notepad will generate.
Select the third tab/option.
The pickup point is found under the Individual or Organizational Name field and will state Pickup Address. It is
found near the end of the EDI Notepad. See below for an image. (The information has been removed due to
HIPAA regulations.)
Pickup Address appears here.
If there is no way to determine a pick up point, an examiner would request an ambulance trip sheet:
Open Macess.
Click the Create Corro Letter icon.
Double click the Medical Record Request Form.
Click PHHeaderParagraph and click Next.
Complete the Corro Field values and click Next.
The Corro Letter will generate a Word document.
Print the letter and select the needed information option(s).
Place the letter and the claim in the Letters to be Mailed Out folder.
An examiner will keep a copy of the letter and claim as well.
To make a determination if the pickup point zip code is Urban, Rural, or Super Rural, use the Locality
Zip Code File. It can be found: http://phn-win-27/Zip_Locality/zip9_Locality.aspx
Input the zip code and review the Rural Indicator.
Use the corresponding CI code (below) on all claim lines. This will drive the appropriate fee schedule.
Use the following table to determine how to complete the CI field:
Rural Indicator Column Pickup Point Zip Code CI Code
Blank Urban UR
R Rural RL
B SP
Super Rural
On a HCFA, the CI field can be found in the service detail:
Click the Diagnosis, Procedures, & Service Detail tab.
Highlight the appropriate service line.
Click on Service Detail.
Space out the CI field.
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Enter appropriate CI code for pickup point.
Click Readjudicate.
On a UB, the CI field is on the header screen.
The A0425 code is configured to pay Rural and Super-Rural as follows: the first 17 miles get paid $10.65 and
miles 18 and above are paid $7.10. (Ex: If a trip was 21 miles, miles 0 -17 would be 17 x $10.65 = $181.05,
and miles 18 – 21 would be 4 x $7.10 = $28.40. The sum total of the trip would be $181.05 + $28.40 =
$209.45.)
The A0425 code is configured to pay Urban as follows: $7.03 per mile no matter the trip distance. The Rural
and Super-Rural first 17 miles do not to Urban rates.
PHN will round up to the nearest whole mile if the tenths position is greater than zero because Amisys is unable
to hold decimals.
(Ex. 5.1 miles would be 6 miles. 5.5 miles would be 6 miles. 6.0 miles would be 6 miles.)
Note: If the billed charges on the claim are less than the fee schedule allowed amount, allow the lesser billed
charges to pay. However, if the billed charges are greater than the fee schedule allowed amount, allow the
lesser fee schedule amount to pay.
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Claims Pend Processing Profile
Process: aA Queue Profile
APC - No Hospital Rate Calculator Record
Pend Description Four
Pend Category December 28, 2005
Date Implemented October 13, 2015
Date Updated/Revised Sr. Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Determine what type of facility the hospital is.
Go to www.ahd.com.
Click on “Free hospital profiles.”
Follow the instructions on the webpage to research the provider.
Review the “Type of Facility” field on the hospital’s profile.
Verify that the information on the claim and in Amisys is correct.
Make sure that the hospital name in Amisys and the hospital on the claim is the same facility.
Some facilities have similar names, but are actually different providers.
Verify the provider’s Medicare number is the same number in Amisys.
The CMS Certification Number on the www.ahd.com website should match the Medicare
number under the Provider Affiliation screen in Amisys.
If the numbers are not the same, manually pend the claim to Provider Affiliations to have the
Medicare number updated.
Par provider – EX code 84, “PAR - MEDICARE NUMBER NEEDED”
Non par provider – EX code p1, “NONPAR - MEDICARE NUMBER NEEDED”
Verify the provider’s specialty matches the type of facility.
Below are specialties for providers:
Facility Type Specialty
Acute HO
SNF SN
Nursing Home NH
Rehab RB
LTAC LT
Home Health HH
DME ME
Critical Access CI
Surgery centers do not price from the Medicare number.
Reset the claim once the information has been updated. The system will price the claim and the
aA will fall off.
Reset the claim from the header screen. If the claim does not price, see your supervisor.
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Claims Pend Processing Profile
Pend: ac, ad, and ae Queue Profile
Advanced Diagnostic Imaging
Pend Description QA
Pend Category February 6, 2011
Date Implemented April 23, 2013
Date Updated/Revised Senior QA Analyst
Person(s) Responsible As defined below:
Processing Instructions
The ac, ad, and ae pends are used to review and confirm that physicians and non-physician practitioners
supplying the technical component of Advanced Diagnostic Imaging Services are accredited. This claim must
be reviewed and processed according to Medicare guidelines. The ac pend is specifically used for CT scans,
the ad pend is specifically used for MRIs, and the ae pend is specifically used for NM/PETs.
Daily check the Daily Pended Inventory file saved under: \\phn-win-21\env\PROD\DATA\Pended
Claims Workgroup\Daily Pended Inventory\ PH Daily Inventory Tracking YYYYMMDD. Choose
the tab noted Claim Dtl.
Filter by EX code and if there are any claims pending “ac = CTs”, “ad= MRIs” & “ae = NM/PETs”,
the claims will be listed.
Pull up the claim image and confirm the dates of service are effective after 2012. If dates of
service are after 2012, use the following websites to verify if the facility is an accredited for the
date of service on the claim. Check all three websites to verify that the facility is accredited. If
the three websites cannot determine the accreditation, contact the facility and ask that a copy of
the accreditation certificate be sent to PHN.
o AC Accredited Facility Locator -
www.intersocietal.org/nuclear/main/lab_list.htm
www.intersocietal.org/mri/laboratories/lablist/ICAMRL_Sites.htm
www.intersocietal.org/ct/main/lab_list.htm
o ACR Accredited Facility Search -
http://www.acr.org/accreditation/AccreditedFacilitySearch.aspx
o The Joint Commission Facility Locator - www.qualitycheck.org/consumer/searchQCR.aspx
If it has been determined the facility is accredited, a service form can be created and sent to
Group – Claims – Operations to process those claims for payment.
If it is determined the facility is not accredited, a service form will be created and sent to Group
– Claims – Operations to deny. The following 2 denial codes will be used:
1.np = Not enrolled or accredited
“MISSING/INCOMPLETE/INVALID PROVIDER PRIMARY IDENTIFIER”
2.na = Not accredited for code billed
“THE RENDERING PROVIDER IS NOT ELIGIBLE TO PERFORM THE SERVICE BILLED”
Once the service form is sent back, verify that the ac, ad, or ae pend has been removed.
Par provider audit quarterly by Senior QA Analyst.
1 SSA
Claims Pend Processing Profile
Pend: AN Queue Profile
Pend-Auth no match Provider Status
Pend Description One
Pend Category March 15, 2012
Date Implemented September 28, 2011
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Check the image; verify that all of the information is correct, check the provider’s name and the affiliation.
Sometimes the wrong affiliation is on the claim, remove the affiliation and profile it (make sure the tax ID # in
Amisys is the same as on the claim). After you have verified all of the information on the claim, review the auth,
there is probably an auth on file but the PS field does not correspond with the PS field on the claim. If you find
that the auth need to be updated send an ISF to the appriopate Health Services staff and have the authorization
updated. There may also be other pend codes on these claims.
Claims Pend Processing Profile
Pend: AQ Queue Profile
This Procedure Is Covered through Standard Medicare
Pend Description Four
Pend Category September 25, 2003
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Review for authorization if auth is approved claim should be paid. If it has not been approved you would deny
the claim according to the denial code on the auth
Claims Pend Processing Profile
Process: As Queue Profile
SNF PRICER - NO HOSPITAL RATE CALCULATOR RECORD
Pend Description Four
Pend Category
Date Implemented January 25, 2016
Date Updated/Revised Sr. Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Refer to the EX aA pend process to determine if the Medicare number on the provider’s record is
correct.
Pend the claim to Provider Affiliations if:
1. There is no Medicare number on the provider’s record.
2. The Medicare number on the provider’s record does not match the Medicare number on the
AHD website.
Enter a claim remark stating, “Confirm Medicare number for SNF facility,” and
Inform your supervisor so a follow up email can be sent to Provider Affiliations.
3. The Medicare number on the AHD website is not for a skilled nursing facility.
Enter a claim remark stating, “Confirm Medicare number for SNF facility,” and
Inform your supervisor so a follow up email can be sent to Provider Affiliations.
Provider Affiliation pend codes:
Par providers – EX 84, “PAR - MEDICARE NUMBER NEEDED”
Non-par providers – EX p1, “NONPAR - MEDICARE NUMBER NEEDED”
Reset the claim once the Medicare number has been added/updated. The system will price the
claim and the As pend will fall off.
Reset the claim from the header screen. If the claim does not price, see your supervisor.
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Claims Pend Processing Profile
Pend: ** Queue Profile
Explanation Code
Pend Description Two
Pend Category October 19, 2004
Date Implemented November 8, 2012
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The majority of claims in this queue are authorization related. Due to the 3-day window, there may be
more than one authorization that the claim can map to.
Verify the claim image via Macess or EDI viewer.
Click on the “Diagnosis, Procedures, & Service Detail” tab.
Highlight the service line with the ** EX code.
Click Service Detail.
Click ReSet.
If there is only one authorization option, Amisys will select the authorization.
The Authorizing Profile screen will generate if there is more than one option. If it asks you to profile
the authorization, pick the correct authorization that corresponds to that claim through the referring
physician or the availability dates.
Highlight the Authorization that corresponds to the claim.
Click the “Return Lookup Values” icon on the top of the screen.
The “Override EX Errors” screen will generate. Exit out of it.
Verify the “Medical Service Detail Readjudication” screen says Process Completed. Then, exit the
screen.
The service line should no longer be pending **, but it may flip to a different EX code.
Check the authorization. There may be a pend code on the authorization. If there is one, a service
form has to be sent to Health Services to remove it. (The member could have termed during the
authorization period).
Click Authorizations/Medical Management on the Amisys homescreen.
Click Certification under the Medical Mgmt header.
Click the binoculars/find icon on top of the Certification screen.
Enter the authorization number in the Auth# field.
Verify authorization information (i.e. referring physician, dates of service, etc.)
Repeat these steps as needed until the service lines with ** have all been readjudicated.
You can also highlight the Authorization number and paste it in the Auth# field.
Click ReAjudicate to process the authorization number.
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Click ReAjudicate to adjudicate the entire claim.
Pend the claim with the EX pend code 6L if there is no authorization and everything is accurate with
the claim. This will allow the claim to fall into Config Benefits/Pricing’s queue.
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 reviewed.
Do not Demand Draw a 31 or 41 status.
If there are other EX Codes remaining, process those that you are able and leave the others to be
reviewed by the appropriate examiner level or department.
Demand Draw the claim from the queue.
Maximize Macess.
Select “My Work” from tool bar.
Select “Workflow Examination” on the drop down menu.
Click the “Draw Mode - Demand” icon.
Click the “Select Work Item” icon.
Place cursor in Document ID field and type in claim number.
Check New, Pended, and Rerouted options in Work Item Status section.
Hit Enter.
Select “Work Flow Examination.”
Select “Complete.”
Select “Save” and X out the screen.
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Claims Pend Processing Profile
Pend: AY Queue Profile
Review multiple auths: wrong billing (Loc/Proc) etc. or pend 6L
Pend Description One
Pend Category March 15, 2012
Date Implemented April 24, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Reset the service lines if you are being requested to profile the auth. Select the appropriate authorization and
continue processing the claim. If it isn’t a profiling issue check the following:
Is the claim vertexed correctly? Check location, diagnosis, procedures etc.
Is the auth in correctly?
Are the procedure codes or diagnosis codes in the auth the same as the procedure codes or diagnosis codes in
the claim?
PT claims require a specific PT screen in the authorization. If a PT claim is received and there isn’t a PT screen
in the auth the claim will pend AY.
Vision claims frequently pend AY because the provider is billing a routine diagnosis and a medical procedure
code. The CPT code may not be a contracted procedure code or the physician isn’t a contracted provider for
this IPA. Claim should be denied 37 (Deny-not a contracted Routine Vision Eye care provider).
If all issues are researched and resolved and the claim is still pending AY, change the pend code to 6L and the
claim will be forwarded to Configuration for possible benefit configuration. A service form can also be sent to
Configuration for resolution.
Claims Pend Processing Profile
Process: B7 Queue Profile
MOR – Letter of Agreement to be Reviewed for Reimbursement
Pend Description Four
Pend Category
Date Implemented May 20, 2015
Date Updated/Revised Sr. Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Review the member’s folder in Macess for a Letter of Agreement (LOA).
Look for document type Prov Contract – LOA. The description should contain the provider
number, name, and the LOA’s effective date.
Verify the LOA is for the provider billing and is effective on the dates of service billed and price
the claim as indicated.
If the LOA if effective for the dates of service billed, price the claim according to the LOA.
If the LOA states 100% of effective Medicare allowed, the claim is priced at the
Medicare fee schedule amount (the allowed amount in Amisys).
If the LOA states a specific price and Amisys does not match, manually price the claim
by entering the allowed amount on the service line(s) using the Override Amt function.
If the LOA is not effective for the dates of service billed:
Attach the document to a service form.
Create an ActionGram to Traci Lusignan or Allison Mascarenhas stating, “Please
advise if an updated and signed LOA is on file for __(provider name)__. See attached.”
Remark the claim with an AG sub-type referencing the service form number.
Once the service form is returned:
If an updated and signed LOA is on file, price the claim as indicated by
following the steps outlined above.
If there is not an updated signed LOA on file, override the B7 and follow normal
processing guidelines.
If Prov Contract – LOA is not located in the member’s folder, search for document type
MISCELLANEOUS with the description LETTER OF AGREEMENT.
If found and the document is for the provider billing:
Attach the document to a service form.
Create an ActionGram to Traci Lusignan or Allison Mascarenhas stating, “Please
advise if there is a signed LOA on file for __(provider name)__. See attached.”
Remark the claim with an AG sub-type referencing the service form number.
Once the service form is returned:
If a signed LOA is on file, price the claim as indicated by following the steps
outlined above.
If there is not a signed LOA on file, override the B7 and follow normal
processing guidelines.
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For claims priced according to the LOA, override EX code B7 with EX code LP, “Paid according
to member specific LOA (Letter of Agreement).”
If the claim is also pending for an authorization and an effective LOA is on file, send a service
form requesting an authorization be added/updated as appropriate.
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Claims Pend Processing Profile
Pend: BX Queue Profile
Reject Claim – See Provider Relations’ Remarks
Pend Description One
Pend Category September 5, 2007
Date Implemented November 6, 2014
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
** THE BX PROCESS IS RETIRED, EFFECTIVE OCTOBER 29, 2014 **
Effective October 29, 2014, if a claim does not contain enough information to add/update the provider’s information
for the claim to pay, Provider Affiliations will add an affiliation for the claim to process and deny instead of pending
the claim with EX code BX for the claim to be voided and then rejected to the provider of service.
The following table includes reasons claims were previously voided and then rejected to the provider of service and
the new process of Provider Affiliations adding affiliations for the claim to process and deny.
The new process outlined in the table was included in the updated Claims Pend Processing Profile for Pend QY,
“Provider update and reset.”
Previous Void & Reject Reason New Process
Therapists
Individual therapists can receive Provider Affiliations reviews the tax ID billed on the claim to
payment for therapy services, determine par vs. non par.
unless otherwise stated in the Par Providers
contract that payment must go to If the provider billed correctly and payment may be made to the
the group.
individual therapist, Provider Affiliations updates/adds an affiliation
for the claim to process.
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.
1 SSA 11.18.2014
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.
Any claims pending BX after October 29, 2014 are reviewed and routed for processing. Claims are no longer voided
from the claims processing system and rejected to the provider of service.
** ORIGINAL BX PROCESS THAT IS RETIRED, EFFECTIVE OCTOBER 29, 2014**
The BX pend comes from Provider Affiliations. They have reviewed the claim and there is no information or not
enough information to add/update the provider’s information. Provider Affiliations will notate in Claim Remarks why
the claim should be voided and returned to them. The examiner has to review the provider’s remarks to make a
determination.
Check the claims comments to see why Provider Affiliations wants the claim voided.
Click “Global Functions” on the readjudication screen.
Hover over “Address and Remarks.”
Select “Remarks Summary” 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 “CL - Claim” and press Enter.
Only the Claims comments will generate.
Read over the comments.
Highlight and copy remarks.
Exit out of window.
Notate comments in Remarks.
Click “Remarks.”
Click the New icon.
Claim ID Type should be “CL” and the claim # as well as Member G# should be generated.
Place cursor in “Remark Effective Date” and enter the Effective Date from the claim.
Press Tab.
Enter “12-31-9999” as the Exp Date.
Press Tab.
Enter “CL” as the Remark Type.
Press Tab twice.
Enter remark. You can copy and paste the Provider Affiliations remarks.
Click on the submit/save icon on the top tool bar.
Exit the screen.
2 SSA 11.18.2014
Print out the claim image.
Maximize EDI Viewer or Macess.
Click on the printer icon or press Ctrl+P.
Highlight what is missing or incorrect on the printed claim copy.
Place a sticky note on the claim and write what is wrong with or missing from the claim. Include your
name on the note.
Be sure not to cover the areas you highlighted with the sticky note.
Place the printed copy of the claim with the note and letter, if applicable, in the "Rejected Claims"
folder.
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 11.18.2014
Claims Pend Processing Profile
Pend: Ca Queue Profile
PR-Rev Code/CPT Review Mult Proc Payment (Task 10299/BT 155812)
Pend Description July 2, 2012
Date Implemented January 2, 2013
Date Updated/Revised Configuration
Person(s) Responsible As defined below:
Processing Instructions
CURRENTLY PENDING TO CONFIGURATION
This instruction applies the Multiple Procedure Payment Reduction (MPPR) to physician services of certain
diagnostic imaging procedures billed by Critical Access Hospitals (CAH) that have elected the optional method
for outpatient billing. Payment is made to the CAH for physician services (revenue code (RC) 96X, 97X, or 98X)
on bill type 85x based off the Medicare Physician Fee Schedule (MPFS) supplemental file.
The Multiple Procedure Payment Reduction (MPPR) on diagnostic imaging applies when multiple physician
services are furnished by the same physician to the same patient in the same session on the same day. Full
payment is made for the service that yields the highest payment under the Medicare Physician Fee Schedule
(MPFS). Payment is made at 75 percent for the subsequent services furnished by the same physician to the
same patient in the same session on the same day.
The current list of codes subject to the MPPR on diagnostic imaging is in Attachment 1.
1 SSA
Claims Pend Processing Profile
Pend: ce Queue Profile
Pend - Hemodialysis Review For Appropriate Modifier (Task 2789)
Pend Description Four
Pend Category February 23, 2012
Date Implemented April 23, 2013
Date Updated/Revised Senior Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
The ce pend code is used to report the use of HCPCS code 90999 on dialysis revenue code lines in order to
report the required infection modifiers.
Renal Dialysis facilities need to know that CMS Change Request 6782 requires new quality data reporting for
dialysis adequacy, infection and vascular access on all end stage renal disease (ESRD) claims and all ESRD
Hemodialysis claims with dates of service on or after July 1, 2010.
Verify that the Type of Bill (TOB) is 72X and the date of service is on or after July 1, 2010.
All claims with revenue codes 831, 841, 851 with TOB 72x without modifier V5, V6, V7, V8, or V9
will deny cd, which means dialysis revenue code needs appropriate modifier.
The provider cannot bill these revenue codes without one of the modifiers.
New quality data required on all End Stage Renal Disease (ESRD) Hemodialysis claims with
dates of service on or after July 1, 2010.
Vascular access for ESRD Hemodialysis patients – An indicator of the type of vascular access
used for the delivery of hemodialysis at the last hemodialysis session of the month. One of the
V5, V6, or V7 modifiers is required to be reported on the last line item date of service billing for
hemodialysis revenue code 821. It may be reported on all revenue code 821 lines at the
discretion of the provider.
Modifier V5: Any Vascular Catheter (alone or with any other vascular access)
Modifier V6: Arteriovenous Graft(or other vascular access not including a vascular catheter)
Modifier V7: Arteriovenous Fistula Only (in use with two needles)
Claims with revenue code 821 will pend ce, which means hemodialysis review for appropriate
modifier.
Review the last line of revenue code 821. If modifier V5, V6, or V7 is not present, deny the claim
Status 51 – EX Code cd.
If one of the modifiers is present, override the ce pend code and pay the dialysis code according
to the ESRD pricer.
Demand Draw the claim from the queue.
1 SSA
Claims Pend Processing Profile
Pend: co Queue Profile
Compliance 360 Task Review
Pend Description Four
Pend Category February 23, 2012
Date Implemented April 23, 2013
Date Updated/Revised Claims Management
Person(s) Responsible As defined below:
Processing Instructions
To report the use of HCPCS code 90999 on dialysis revenue code lines in order to report the required infection
modifiers.
Renal Dialysis facilities need to know that CMS Change Request 6782 requires new quality data reporting for
dialysis adequacy, infection and vascular access on all end stage renal disease (ESRD) claims and all ESRD
Hemodialysis claims with dates of service on or after July 1, 2010.
Verify that the TOB is 72X and the date of service is on or after July 1, 2010.
If the Revenue Code is 821 and does not have modifiers V5-V9, verify that the claim has pended to Code “co,”
which represents Compliance 360 Research Pend. The examiners will review for the correct modifiers.
If the Revenue Code is 821 and does have modifiers V5-V9, the claim should be paid.
Medicare systems will return to the provider 72x bill types with dates of service on or after July 1, 2010
billing for hemodialysis when the latest line item date of service billing for revenue code 0821 does not
contain one of the following modifiers: V5, V6, or V7.
If the Revenue Codes are 831, 841, or 851 and do not have modifiers V5-V9, verify that the claim has denied.
If the Revenue Codes are 831, 841, or 851 and do have modifiers V5-V9, verify that the claim has pended to
Code “co.” The examiners will manually price the claim via the ESRD pricer.
Medicare systems will return to the provider 72x bill types with dates of service on or after July 1, 2010
when either the modifier V8 or V9 is not present on each dialysis revenue code line (0821, 0831, 0841, or
0851).
1 SSA
Claims Pend Processing Profile
Process: CU / CW Queue Profile
Member Has Other Coverage As Primary / Member Has Medicare Coverage As
Pend Description Primary
Four
Pend Category September 14, 1999
Date Implemented May 6, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Coordination of Benefit (COB) claims will pend to accommodate members that have their primary healthcare
coverage through another carrier.
All claims should be billed with the primary carrier’s explanation of payment (EOP). For manual claims, the EOP
is filed with the claim. For electronic claims, the EOP can be found in the EDI Locator.
When the explanation is not filed or cannot be located, the claim should be denied with EX code DI – Denied –
Bill primary carrier.
How to process a COB claim:
Verify who the member has primary coverage with.
From the Amisys home screen, click Customer Service.
Under Membership, click Primary Liability.
Enter the member’s number and hit Enter.
Review the Primary Liability Inquiry screen for primary coverage to ensure that the third party payor has
submitted the EOP on the member’s behalf.
Coordinate claim benefits through service line(s).
Read through the EOP and determine the correct benefits.
The equation to use is:
Billed amount
- Disallowed amount
Allowed amount
- Member responsibility
Primary Insurance paid
Select the Diagnosis, Procedures & Service Detail tab.
Highlight the service line and click Service Detail.
1
Click on the Altcar field, type in $E, and hit Enter.
Enter the Claim COB Payments information and exit the screen.
Click Override Amt and select 2 in the Override $: field.
Enter the B-Allow and P-Allow; exit the screen.
The Override EX Errors screen will generate.
Enter 1C in the EX Code fields, hit Enter, and exit the screen.
Notes:
When processing Hospital COB claims, you will only coordinate benefits on the first service line. On other lines,
the allowed amounts will have to be manually taken out in order for the system to process the line correctly.
When processing Medical COB claims you will coordinate benefits on each itemized line.
If the claim applies a deductible, you will have to send a service form to Health Services indicating to them that
the member has other insurance as primary and an authorization is needed to process the claim.
All EOPs from the various primary insurance companies look different.
PHN only pays the member’s responsibility minus copayments and coinsurances if applicable. The system will
take the copayments and coinsurances automatically.
If the member’s responsibility is more than what PHN would allow, pay PHN’s allowed amount.
Exclude PHN Nurse Practioner and F claims, which are Transportation, Fitness claims, CenseoHealth, and
MD2U claims.
2
Claims Pend Processing Profile
Pend: d7 Queue Profile
Duplicate Of A Previously Denied Claim
Pend Description Two
Pend Category July 29, 2011
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.
d7 pended claims are generated to ensure that Claims Examiners are reviewing claims that could be duplicate
claims, that do not pend R7 or U7.
There are many scenarios associated with pend code d7. The following profile processes a basic or simple d7.
Please see a Manager or Supervisor if you come across a scenario that differs from this profile.
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
1 SSA 06.25.14
Modifier 59 – Distinct procedural service
Modifier 76 – Repeat procedure by the same physician
Modifier 91 – Repeat clinical diagnostic laboratory test
* 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.”)
2 SSA 06.25.14
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.”
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.
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: E9 Queue Profile
Pay lesser of DRG or negotiated rate
Pend Description Four
Pend Category December 14, 1999
Date Implemented April 23, 2013
Date Updated/Revised Claims Processors
Person(s) Responsible As defined below:
Processing Instructions
E9 queues are generated to ensure that acute room and board are being paid according to CMS Guidelines.
Type of Bill is 111.
NOTE: See EOC on Water Cooler to confirm copays.
http://www.cooler.peopleshealth.com/phtools/phtools-plan-documents.html
Maximum Out Of Pocket (MOOP) for Medicare EG is $2500. All other group MOOPs are $6700.
The state of Maryland is a waive state and is under cost control. Medicare pays 94% of the billed charges.
Information EX Code “OA” means that the annual MOOP has been met and there is no copay for par facilities.
Open THREE Amisys Advance screens- two for processing and the third for provider affiliations.
Verify that “Spec (SP)” field says “HO” for Hospital.
If it doesn’t space out the affiliation on the readjudication screen and select the one for
hospital.
Make sure the DRG codes match.
On electronic claims, the DRG is found on the top right hand side.
On manual claims, the DRG is found in Field 71, underneath the diagnosis codes/POAs.
In Amisys, the DRG is found under the “Diagnosis, Procedures & Service Detail” tab
next to the Location field.
Verify that they match.
If they don’t match or if one is missing:
Open Internet Explorer.
Type www.irp.com in the URL field and hit Enter.
Look under Calculators.
Click “Try It” next to Medicare DRG Calculator.
Enter the requested information.
Click “Group.”
The webpage will provide you the correct DRG number.
Remark, “Provider submitted the wrong DRG. Paid DRG #__.”
Verify claim image Diagnosis Codes have POAs.
Maximize the claim image.
Verify the diagnosis codes have POAs. They are located towards the bottom of the claim
in the same section as the procedure and diagnosis codes.
If no POA submitted, deny the claim 51 status with EX Code “ds.”
Remark that there was POA information submitted.
1 SSA
Verify that Amisys has the POAs.
Click “More” on the bottom of the left-hand panel.
Click “Add’l Diags Procs” and a new screen will generate.
Look over POA screen and compare to claim image.
Correct values if needed.
Exit out of screen.
Verify authorizations.
Maximize the Amisys Authorizations – Medical Management screen.
Click binoculars/find icon on the top tool bar.
Enter the member’s G number.
Press Enter.
Look at the mid-right section of the screen to where it reads “H/A/O.”
Scroll through the authorizations using the green next record icon, ►, until there is “1” under
the “H.”
Check the “Req Dates” to make sure they match the claim Effective Dates.
You can also check the Claim Summary Inquiry screen to see which authorization was
used.
Click on “Remarks” on the left pane.
Click binoculars/find icon on the top tool bar.
Press Enter.
Read the remarks to verify where the member received services.
Exit out of screen.
Click on “Hospital Svcs” on the left pane.
Compare the “Facility #” to the “Instit#” on the readjudication screen. The last four digits, the
affiliation, do not have the match.
Exit out of Hospital Services screen.
Check to see how the hospital billed Room and Board via Rev Codes.
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Select the first (0100) service detail line, which is usually associated with room and board.
Click on “Claim Summary” in the left pane.
Read the Claim Summary Inquiry screen to see how many room and board lines there are.
Exit out of the screen.
If there are multiple Room and Board lines:
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Select the first (0100) service detail line, which is usually associated with room and board.
Click on “Service Detail” in the left pane.
Click on “Override Amt” in the left pane.
Put “2” in blinking field.
Press Enter.
Press Tab until cursor reaches “Copay”
Manually type in the correct Copayment based on the number of days.
See EOC on Water Cooler to confirm copays.
http://www.cooler.peopleshealth.com/phtools/phtools-plan-documents.html
Information EX Code “OA” means that the annual MOOP has been met and there is no
copay for par facilities.
Do not type in the decimal. (e.g. $500 should be typed 50000, $50 should be 5000,
and so on.)
Maximum copayment is $500 even if the member’s length of stay exceeds 10 days.
Click the submit/save icon on top toolbar.
Wait until you read the Process Completed message in red before you proceed to the next
step.
Exit out of screen.
The EX Override screen will appear.
2 SSA
Override E9 with AP.
Press Enter.
Wait until you read the Process Completed message in red before you exit the screen.
Exit the screen.
Then, wait until you read the Process Complete message in red before you exit out of the
Hospital Service Detail screen.
Exit the screen.
Override the E9 Ex code.
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 “E9.”
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.”
Press Enter and close screen.
Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The E9
code should be replaced with “AP.”
Go into Service Detail for each service line and enter “AP” for the Ex Code if
E9 does not change.
Click REset/Adj to save changes.
Close/X out screen and click ReAdjudicate.
Verify the Co-Payment.
See EOC on Water Cooler to confirm copays.
http://www.cooler.peopleshealth.com/phtools/phtools-plan-documents.html
Information EX Code “OA” means that the annual MOOP has been met and there is no copay
for par facilities.
Maximize the Amisys readjudication screen.
Click on “Claim Summary” on the left pane.
Check over the Totals at the bottom of the screen.
Depending on the member carrier the max copay should be $500.
The total “Pay” amount should equal “Allow-P” – “Coins” – “Copay” – “Deduct” (the
allowed amount minus the sum of the coinsurance, copayment, and deductible).
Exit the screen.
If copayment is incorrect and member has not yet met MOOP:
Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
Select the first (0100) service detail line, which is usually associated with room and board.
Click on “Service Detail” in the left pane.
Click on “Override Amt” in the left pane.
Put “2” in blinking field.
Press Enter.
Press Tab until cursor reaches “Copay”
Manually type in the correct Copayment based on the number of days.
See EOC on Water Cooler to confirm copays.
3 SSA
http://www.cooler.peopleshealth.com/phtools/phtools-plan-documents.html
Information EX Code “OA” means that the annual MOOP has been met and there is no
copay for par facilities.
Do not type in the decimal. (e.g. $500 should be typed 50000, $50 should be 5000,
and so on.)
Maximum copayment is $500 even if the member’s length of stay exceeds 10 days.
Click the submit/save icon on top toolbar.
Exit out of screen.
Write remark.
Click “Remarks” on the left pane.
Click the green encircled plus sign on the top tool bar.
Enter the Effective Date from the claim.
Press Tab.
The Exp Date is “12/31”9999”
Press Tab.
Remark Type is “CL.”
Press Tab twice.
Type in “PAID DRG #___.”
Press Enter or save icon on top tool bar.
Exit screen.
4 SSA
Claims Pend Processing Profile
Pend: EO Queue Profile
REVIEW AUTH - IF OBSERVATION AUTHORIZED/WAIVE ER COPAY
Pend Description Three
Pend Category
Date Implemented October 12, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Claims pend EO for manual review of emergency room (ER) copay. If a member is treated in the ER and the
ER visit does not result in an observation admit, the member is responsible for the ER copay. However, if the
ER visit results in an observation admit, the ER copay is waived.
Review Authorizations by Member to determine if an observation authorization in on file.
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 observation authorization on or around the
ER claim’s date(s) of service.
If there is no observation authorization on file, review Claims by Member to determine if an
observation claim is on file.
Select “Global Functions” “Claims Processing” “Claims by Member.”
The Member# field should be populated. If not, enter the member # from the claim.
In the drop-down menu above the Member# field, select “2 – Online and Batch.”
In the Claim Type drop-down menu, select “H - Hospital” and press Enter.
Scroll right to the Service Dates to search for an observation claim from the facility on or around
the ER claim’s date(s) of service.
Observation claims contain location code 22 AND revenue code 762. If a facility claim
contains location 22, but does not contain revenue code 762, it is not considered an
observation claim.
If the ER visit resulted in an observation admit, waive the ER copay and override the EO pend.
Select the service line with the ER copay and click Service Detail.
Click Override Amt.
Type 2 in the highlighted box and press Enter.
In the copay field, space out the copay amount and enter “0.”
Click Save and exit the screen.
Exit the Override EX Errors and the Service Detail screens.
Click Claim Summary to verify the copay is correct.
Override the service lines pending EO with EX code AP.
1 SSA 10.20.2015
If the ER visit did not result in an ER admit, verify the copay amount applied by the system is
correct and override the EO pend.
Review the member’s carrier, the date of service, and the Benefits List 01.2015 to determine
the member’s copay amount.
In Amisys, click Claim Summary to verify the copay is correct.
Override the service lines pending EO with EX code AP.
If the copay is not correct:
Return to the Hospital Readjudication screen.
Click the service line that is paying out the copay and click Service Detail.
Click Override Amt.
Type 2 in the highlighted box and press Enter.
In the copay field, type the correct copay amount with no decimals.
For example, if the copay is $65.00 type 6500.
Click Save and exit the screen.
Exit the Override EX Errors and the Service Detail screens.
Click Claim Summary to verify the copay is correct.
2 SSA 10.20.2015
Claims Pend Processing Profile
Process: ET Queue Profile
Dental diagnosis/procedure review – Use CI code DT
Pend Description Four
Pend Category May 28, 2010
Date Implemented January 11, 2016
Date Updated/Revised Senior Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Claims containing dental diagnoses and/or procedure codes pend ET for review.
All Claims
If the claim was submitted with a diagnosis code for periapical abscess without sinus, approve
the service line(s) to pay using CI code DT.
Diagnosis codes:
ICD-9 – 522.5
ICD-10 – K04.7
Medical Claims
If the claim was submitted by a dentist (DDS) and contains any of the following diagnosis codes
AND one of the following procedure codes, deny the service line(s) with EX DL, “Claim
forwarded to contracted dental provider”:
Diagnosis codes:
ICD-9 – 521.00 - 521.09
ICD-10 – K02.3, K02.51, K02.61-K02.63, K02.7, K02.9, K03.89
Procedure codes:
A dental procedure code (procedure code beginning with “D”) AND/OR
An office visit procedure code (99201-99215)
Facility Claims for locations other than 23
If the attending provider is a dentist (DDS) and the claim contains any of the following diagnosis
codes AND one of the following procedure codes, deny the service(s) with EX DL, “Claim
forwarded to contracted dental provider”:
Diagnosis codes:
ICD-9 – 521.00 - 521.09
ICD-10 – K02.3, K02.51, K02.61-K02.63, K02.7, K02.9, K03.89
Procedure codes:
A dental procedure code (procedure code beginning with “D”) AND/OR
Office visit procedure code G0463
All other dental related claims (including facility claims with location 23) that do not meet the above
outlined criteria:
Email the claim information to the Director of Claims (if unavailable see the Quality Improvement
Manager) prior to requesting additional information, and
Pend the claim EX EV, “PENDING FOR MEDICAL DIRECTOR REVIEW.”
1 SSA 09.11.2015
Claims Pend Processing Profile
Pend: go Queue Profile
Screening Sexually Transmitted Infections (STI) With/Without Pregnancy
Pend Description Four
Pend Category September 28, 2012
Date Implemented October 21, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Effective for claims with dates of service on and after November 8, 2011, CMS will cover screening for
Chlamydia, gonorrhea, syphilis, and hepatitis B for lab tests when ordered by a primary care provider and
performed by an eligible Medicare provider.
CMS will also cover up to two individual, 20- to 30- minute, face-to-face counseling sessions annually for
Medicare beneficiaries for High Intensity Behavioral Counseling (HIBC) to prevent STIs.
Screenings must be ordered by a primary care practitioner:
• General Practice
• Family Practice
• Internal Medicine Obstetrics/Gynecology
• Pediatric Medicine
• Geriatric Medicine
• Certified Nurse Midwife
• Nurse Practitioner
• Certified Clinical Nurse Specialist
• Physician Assistant
Procedure screening codes:
• Chlamydia: 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810, 87800 (used for combined chlamydia
and gonorrhea testing)
• Gonorrhea: 87590, 87591, 87850, 87800 (used for combined chlamydia and gonorrhea testing)
• Syphilis: 86592, 86593, 86780
• Hepatitis B: 87340, 87341
To determine if the member is pregnant, please check for the following diagnosis codes:
• V22.0* – supervision of normal first pregnancy
• V22.1* – supervision of other normal pregnancy
• V23.9* – supervision of unspecified high-risk pregnancy
Not Pregnant and Increased Risk for STIs:
PHN will allow one (1) annual screening test (each) for chlamydia, gonorrhea, or syphilis in women at
increased risk who are not pregnant when the screening is billed with the following:
• V74.5* – Screening, bacterial – sexually transmitted; and
• V69.8* – Other problems related to lifestyle.
Note: 11 full months must elapse following the month in which the previous test was performed in order for the
subsequent test to be covered.
* For ICD-10 diagnosis codes, see the ICD-9 to ICD-10 Diagnosis Conversion Table on page 4.
1
Contractors shall allow one (1) annual screening for syphilis in men at increased risk when the screening is
billed with the following:
• V74.5* – Screening, bacterial – sexually transmitted; and
• V69.8* – Other problems related to lifestyle.
Note: 11 full months must elapse following the month in which the previous test was performed in order for the
subsequent test to be covered.
Pregnant and Increased Risk for STIs:
PHN will allow up to two (2) screening tests per pregnancy for chlamydia in pregnant women who are at
increased risk for STIs when the screening is billed with the following:
• V74.5* – Screening, bacterial – sexually transmitted; and
• V69.8* – Other problems related to lifestyle; and,
• V22.0* – Supervision of normal first pregnancy, or,
• V22.1* – Supervision of other normal pregnancy, or,
• V23.9* – Supervision of unspecified high-risk pregnancy.
PHN will allow up to two (2) screening tests per pregnancy for gonorrhea in pregnant women who are at
increased risk for STIs when the screening is billed with the following:
• V74.5* – Screening, bacterial – sexually transmitted; and
• V69.8* – Other problems related to lifestyle; and,
• V22.0* – Supervision of normal first pregnancy, or,
• V22.1* – Supervision of other normal pregnancy, or,
• V23.9* – Supervision of unspecified high-risk pregnancy.
PHN will allow up to three (3) screening tests per pregnancy for syphilis in pregnant women if the beneficiary is
at increased risk for STIs when the screening is billed with the following:
• V74.5* – Screening, bacterial – sexually transmitted; and
• V69.8* – Other problems related to lifestyle; and,
• V22.0* – Supervision of normal first pregnancy, or,
• V22.1* – Supervision of other normal pregnancy, or,
• V23.9* – Supervision of unspecified high-risk pregnancy.
PHN will allow two (2) screening tests per pregnancy for hepatitis B in pregnant women who are at increased
risk for STIs when the screening is billed with the following:
• V73.89* – Screening, disease or disorder, viral, specified type NEC; and
• V69.8* – Other problems related to lifestyle; and,
• V22.0* – Supervision of normal first pregnancy, or,
• V22.1* – Supervision of other normal pregnancy, or,
• V23.9* – Supervision of unspecified high-risk pregnancy.
Pregnant and No Increased Risk for STIs:
PHN will allow one (1) screening test per pregnancy for syphilis in pregnant women when the screening is billed
with the following:
• V74.5* – Screening, bacterial – sexually transmitted; and
• V22.0* – Supervision of normal first pregnancy, or,
• V22.1* – Supervision of other normal pregnancy, or,
• V23.9* – Supervision of unspecified high-risk pregnancy.
PHN will allow one (1) screening test per pregnancy for hepatitis B in pregnant women when the screening is
billed with the following:
• V73.89* – Screening, disease or disorder, viral, specified type NEC; and,
• V22.0* – Supervision of normal first pregnancy, or,
• V22.1* – Supervision of other normal pregnancy, or,
• V23.9* – Supervision of unspecified high-risk pregnancy.
* For ICD-10 diagnosis codes, see the ICD-9 to ICD-10 Diagnosis Conversion Table on page 4.
2
When to deny the claim:
Examiners shall deny line items that:
1. exceed the coverage frequency limitations using EX code “P9.”
2. are billed without the appropriate ICD-9 codes using EX code “IB.”
a. When using Denial code IB, remark the claim stating “billed without the appropriate ICD-9 codes.”
HIBC COUNSELING (High Intensity Behavioral Counseling)
Effective for dates of service on and after November 8, 2011, contractors shall allow claims containing HCPCS
G0445 for High Intensity Behavioral Counseling (HIBC) to prevent STIs when submitted with ICD-9 diagnosis
code V69.8*. Medicare shall allow only up to 2 sessions in a 12-month period beginning with the first session for
HCPCS G0445 when billed with ICD-9 V69.8*.
Examiners will identify the following institutional claims (UBs) as facility fee claims for screening services:
• Procedure code G0445 and,
• Type of bill 13X, or
• Type of bill 85X when the revenue code is not 096X, 097X, or 098X.
Examiners will identify all other claims as professional service claims for HIBC services (professional claims,
and institutional claims with TOB 71X, 77X, and 85X when the revenue code is 096X, 097X, or 098X).
PHN will pay claims for HCPCS G0445 only when services are provided for the following place of service
(POS):
• 11 - Physician’s Office
• 22 - Outpatient Hospital
• 49 - Independent Clinic
• 71 - State or local public health clinic
PHN will pay claims for HCPCS code G0445 only when services are submitted by the following provider
specialty types:
• General Practice
• Family Practice
• Internal Medicine
• Obstetrics/Gynecology
• Pediatric Medicine
• Geriatric Medicine
• Certified Nurse Midwife
• Nurse Practitioner
• Certified Clinical Nurse Specialist
• Physician Assistant
When to Deny:
Examiners shall deny line items that:
1. were not provided at an appropriate Place of Service using EX code “IL.”
2. were submitted without V69.8* (Other problems related to lifestyle) because Medicare doesn’t consider them
medically necessary using EX code “PA.”
3. exceed the coverage frequency limitations using EX code “P9.”
4. were provided by an inappropriate provider using EX code “IB.”
a. When using Denial code IB, remark the claim stating “billed by an inappropriate provider.”
5. were submitted on a TOB other than 13X, 71X, 77X, or 85X using EX code “IL.”
6. paid procedure code G0445 separately with another encounter/visit on the same day on claims billed with
TOBs 71X and 77X using EX code “IB.”
a. When using Denial code IB, remark the claim stating “billed by an inappropriate provider.”
* For ICD-10 diagnosis codes, see the ICD-9 to ICD-10 Diagnosis Conversion Table on page 4.
3
Potential Processing Steps:
Examiners shall look in the member’s benefit profile and confirm if they have reached their test limits. If the
benefit limit has been reached, the processor shall deny the claim “P9.” If the benefit limit has not been
reached, override and process the claim.
Be sure to confirm the pregnancy diagnosis is on the claim and to verify the number of tests allowed.
ICD-9 to ICD-10 Diagnosis Conversion Table
ICD-9 ICD-10
Diagnosis
Diagnosis Description Description
Code Code
Z34.00 Encounter for supervision of normal first
V22.0 Supervision of normal first pregnancy pregnancy, unspecified trimester
Z34.01 Encounter for supervision of normal first
V22.1 Supervision of other normal Z34.02 pregnancy, first trimester
pregnancy Encounter for supervision of normal first
Z34.03 pregnancy, second trimester
V23.9 Supervision of unspecified high-risk Encounter for supervision of normal first
pregnancy Z34.80 pregnancy, third trimester
Encounter for supervision of other
V69.8 Other problems related to lifestyle Z34.81 normal pregnancy, unspecified trimester
Encounter for supervision of other
V73.89 Screening, disease or disorder, viral, Z34.82 normal pregnancy, first trimester
V74.5 specified type NEC Z34.83 Encounter for supervision of other
Screening, bacterial - sexually normal pregnancy, second trimester
transmitted Z34.90 Encounter for supervision of other
normal pregnancy, third trimester
Z34.91 Encounter for supervision of normal
pregnancy, unspecified, unspecified
Z34.92 trimester
Encounter for supervision of normal
Z34.93 pregnancy, unspecified, first trimester
Encounter for supervision of normal
O09.90 pregnancy, unspecified, second
trimester
O09.91 Encounter for supervision of normal
pregnancy, unspecified, third trimester
O09.92 Supervision of high risk pregnancy,
unspecified, unspecified trimester
O09.93 Supervision of high risk pregnancy,
Z72.89 unspecified, first trimester
Z72.51 Supervision of high risk pregnancy,
Z72.52 unspecified, second trimester
Z72.53 Supervision of high risk pregnancy,
Z11.59 unspecified, third trimester
Other problems related to lifestyle
Z11.3 High risk heterosexual behavior
High risk homosexual behavior
High risk bisexual behavior
Encounter for screening for other viral
diseases
Encounter for screening for infections
with a predominantly sexual mode of
transmission
* For ICD-10 diagnosis codes, see the ICD-9 to ICD-10 Diagnosis Conversion Table on page 4.
4
Claims Pend Processing Profile
Pend: GZ Queue Profile
Review of non-par providers billing with GZ modifier. Task5694/phn0115
Pend Description One
Pend Category July 1, 2011
Date Implemented January 26, 2012
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Purpose
To ensure claims are processed according to CMS transmittal 2148. All lines submitted with modifier GZ, “Item
or service not reasonable and necessary,” should be denied.
Informational
CMS transmittal 2148, dated February 4, 2011, CR 7228 states plans may automatically deny claim lines
submitted with modifier GZ effective July 1, 2011.
Process
Par Provider
Review the claim to determine if modifier GZ is present.
If modifier GZ is present in any position, deny the service line(s) EX gz, “Services denied as not
deemed a medical necessity.”
Click EX Overrides.
Type “GZ” in the Old EX field and type “gz” in the New EX field. Press Enter.
Type “Y” in the “Are the above overrides correct” field.
Press Enter and exit the screen.
Click Readjudicate.
Process the claim according to normal processing guidelines.
Non-par Provider
Urgent/emergent guidelines apply. Review the claim according to the O8 process.
1
Claims Pend Processing Profile
Process: HA Queue Profile
Review Medicare Non-Par O/P Claim for Auth, Ref Prov is Inplan
Pend Description
Pend Category April 8, 2004
Date Implemented July 22, 2015
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Non par independent laboratory claims (location 81) pend EX HA when the claim contains a par referring
provider or contains a non par referring provider, but is mapping to an authorization.
Process
Review the claim to verify it is processing correctly:
If the claim is pending HA due to a par referral, verify the referring provider’s status is par.
If the claim is pending HA due to an authorization, verify the services should be authorized.
If the claim is processing correctly and should pay, enter CI code “OD” to pay the claim.
1
Claims Pend Processing Profile
Pend: hi Queue Profile
Review HIPA 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 “hi” are HIPA 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 hi and the billing provider is a Crescent City Physician, review the
service line that is not hi. If the CI code in that line reads “cc,” override the subsequent hospitalist lines pending
hi with CI code “hi.” Do NOT OVERRIDE THE “cc” CI code.
Additionally, if the CCPI claim has an Office Service note marked on the Claim, process the claim using the CI
code “hi.”
Therefore, if the claim has the cc CI code OR an Office Service note marked on the Claim, process the claim
using the CI code “hi.”
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.”
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
Pend: HK Queue Profile
Hospice Part A Claims
Pend Description Three
Pend Category April 1, 2011
Date Implemented February 17, 2016
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
Background
The HK pend code signifies that a member has elected the hospice benefit. CMS does not reimburse PHN for
Part A services paid for hospice members.
PHN set configuration to deny claims received with the following criteria (these will not pend):
1. Hospice Claims
a. Location code = 34
2. Inpatient Claims
a. Member Risk Pop (RP code) 1st digit = H (*See note)
b. Location codes = 21, 31, 51 or 61
c. Specialty = MA, HO, SN, RB, LT, or NH
d. Hat code = FC, NF
e. Claim Type = H
3. Home Health
a. Member Risk Pop (RP code) 1st digit = H (*See note)
b. Location code = 12
c. Specialty = HH
d. Modifier is not = SS
Only Medicare plans are affected. The claims will deny EX EQ, “Denied – Not a covered benefit.”
Any claim for a member with a hospice risk pop of “H” (*see note) that does not have any of the above criteria
pends EX HK, “Review member for hospice.”
*Note: Current hospice codes are H1, H2, H3, and H4. ## (“pound pound”) groupings may be used to represent
hospice members, which means they could be in multiple buckets.
Supplemental benefits are paid as primary while a member is on hospice. These include, but may not be
limited to the following:
1. Fitness
2. Transportation (F claims and non-ambulance claims)
3. Dental
4. Ambulance transport to an inpatient facility, but the member expires during the transport. PHN is
responsible; the member has not been admitted to the hospice facility.
5. Initiative codes (1026F, S0221).
1 SSA
Process
Review the member’s risk pop through the contract eligibility screen (IQ0700).
Click on Global Functions.
Hover on Membership.
Click on Contract Eligibility Inquiry.
Enter the member’s G# and press Enter.
Verify the risk pop starts with H (i.e. H1, H2, H3, and H4).
If the risk pop does not start with an H, forward the claim to your supervisor/manager.
Verify the hospice risk pop is correct by reviewing the member’s folder in Macess for a service
form from Enrollment with the Hospice TRR on and off effective dates.
Type – “SF – Enrollment Service Form”
Description – “Hospice TRR…”
The last sentence in the service form should summarize the hospice risk pop effective and end
dates on the Contract Eligibility Inquiry screen. Notify your supervisor/manager of any
discrepancies.
If it is determined by the supervisor/manager that hospice risk pop effective and end
dates do not correspond with the Hospice TRR report, a service form should be sent to
Group – Enrollment – Hospice.
If the date(s) of service billed do not fall within the hospice risk pop effective and end dates
according to the Contract Eligibility Inquiry screen:
Override the HK pend with EX AP, “Approved.”
If the date(s) of service billed fall within the hospice risk pop effective and end dates according
to the Contract Eligibility Inquiry screen:
Review the claim for attachments (e.g., COB information) indicating the hospice carrier made
payment.
2 SSA
If there are no claims attachments (COB information), deny the claim EX HJ, “Member
is in Hospice – Bill Hospice Carrier.”
If there are claim attachments (COB information), see your supervisor/manager for
further instruction.
Supplemental benefits are paid as primary while a member is on hospice and therefore should
not deny EX HJ. These include, but may not be limited to the following:
1. Fitness (F claims that process under the fitness benefit)
2. Transportation (F claims for non-ambulance transports)
3. Dental (Dental claims are processed by our dental vendor, DINA Dental)
4. Ambulance transports to an inpatient facility if the member expires during the transport.
Peoples Health is responsible; the member has not been admitted to the hospice facility.
5. Initiative codes (1026F, S0221).
- Effective January 1, 2016, Peoples Health has determined to no longer compensate
providers for 1026F (CKD consultation).
3 SSA
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 6, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions
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
Claims that pend “ii” are IPANO or MIPA 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 IPANO or MIPA. 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.
1
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.
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.
2
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 as well as an Office Service note, 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.
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 pay “FA,” which means procedure code not eligible for payment.
3
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