ClaimSource Payer Rules, to be Released, Thursday, June 15 – 06.12.2017
Last updated on September 13th, 2017 at 11:54 am CT
The following ClaimSource payer rules will be released to production Thursday, 6/15/17:
- PA Medicaid Institutional Secondary Claims, payer ID 12008. Inpatient claims, error inpatient claim with claim adjustment reason codes and claim adjustment amounts not at the claim level (Loop 2320). Documentation: http://www.dhs.pa.gov/cs/groups/webcontent/documents/communication/c_237407.pdf pg 10. For outpatient secondary claims, error if claim adjustment reason codes and adjustment reason codes are not at the service line level.
- Traditional Medicare Professional Claims – payer id SDMEB – error claim if ordering physician is not present
- IL Medicaid 2360 claims, If there are different rendering physician NPI’s. https://www.illinois.gov/hfs/SiteCollectionDocuments/a200.pdf
- For payer IL Medicaid 1500/2360 inpatient, outpatient and primary, secondary and tertiary claims, if CPTs 99201-99205, 99212-99215, 99281-99285 or 99291-99292 present without rendering physician NPI information. Rendering physician information required. https://www.illinois.gov/hfs/SiteCollectionDocuments/a200.pdf
- Summacare, payer id 95202 and Apex Benefit Services, payer id 34196, professional claims require the facility info/address effective based on submissions on/after 3/1/17. Excludes ambulance claims.
- All payers, professional claims, error claim that has duplicate hcpcs/cpt/date and one of the codes does not have a modifier
- WA Medicaid – All Claims – Subscriber id is 9 numeric digits followed by WA. https://www.hca.wa.gov/sites/default/files/837-Institutional-CG-2012.pdf pg 20
- WA Medicaid Institutional Claims require the attending provider taxonomy code. https://www.hca.wa.gov/sites/default/files/837-Institutional-CG-2012.pdf pg 21
- WA Medicaid – All Claims – Billing provider taxonomy code is required on WA Medicaid. https://www.hca.wa.gov/sites/default/files/837-Institutional-CG-2012.pdfpg 20
- WA Medicaid – Professional claims – rendering provider taxonomy code required. https://www.hca.wa.gov/assets/billers-and-providers/837-Professional-CG-2012.pdfpg 12
- WA Medicaid – Inpatient claims – Newborn under 29 days old must include value code 54 and birth weight in value amount. https://www.hca.wa.gov/assets/billers-and-providers/Inpatient-hospital-bi-20170401.pdf pg80
- ·NJ Medicaid – All non-primary claims – For claim level (institutional) and service line level (professional) – If there are more than 5 CAS lines and reason codes 1, 2, 3, 96 and 122 are NOT in the first five lines.
- HNJH (Horizon NJ Health) also listed as Trizetto, payer id 22326 – CI filing indicator is required on all claims per HNJH 837I/837P Companion Guide
- Fr Medicare OP UB claims, if claim contains condition code 30, modifier Q0 or Q1(outpatient) and diagnosis Z006, 8 digit clinical trial number is required. Professional — if claim contains modifier Q0 or Q1 and diagnosis code Z006, 8 digit clinical trial number is required. MM8401
- For IA Medicaid institutional claims, error if the billing provider taxonomy code is missing.
- Traditional Medicare institutional claims. Referring and attending provider requirement. Referring physician cannot be reported if it is the same as the Attending physician.
- ConnectiCare Medicare ID requirement. On May 19, 2017, if you submit a claim without a valid 11 character ConnectiCare id number, the claim will reject. http://www.experianhealthproductdashboard.com/?p=4023