ClaimSource Payer Rules, to be Released, Thursday, June 15 – 06.12.2017

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

 

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