RCM eNews – January 2024

As of December 18, 2023, Humana Military will no longer provide basic referral status information through the call center. Providers must instead use provider self-service on HumanaMilitary.com or call the automated and interactive self-service phone line at (800) 444-5445.

Basic referral details inquiries sent via secure message or chat will also be directed back to self-service methods. Basic referral details include details available in self-service like effective dates, number of visits, referral status, expiration dates, and type of service. Providers can still call in to discuss other issues related to referrals.

For additional information, and to view a demonstration, click here.

Electronic claim adjustment requests using Frequency Code 7 or 8 are likely to receive a response within days as opposed to requests submitted on paper, which can take weeks before a response is issued.

The field locations for the frequency code differs for facility and professional claims.

If the request is submitted by paper, it is important to use the correct form to avoid delays in processing due to incorrect routing.

Examples:

If a claim has clinical editing denial and there is no change to any coding of claim when submitting records for review, use Clinical Editing Adjustment Form.

If claim has a clinical editing denial and there is a change to any coding, use Claim Adjustment Form or Frequency coding.

Are you adding/removing/changing a modifier, procedure code, units, dx codes, POS, or charges? We recommend that you skip the paper form and submit electronically with Frequency Code 7 and include the history claim number.

The ability to Edit Dates of Service on Authorizations is now available for prior authorizations in approved and pending status. A new Edit Date of Service button has been added within the Auth Details section for you to initiate your updates.

Important Points:

• The number of days must match the original request.
• Dates entered cannot be in the past.
• Member eligibility will be verified. If dates entered are outside the members eligibility, the authorization cannot be updated.
• Dates cannot be changed if the original date of service has passed.
• No other changes can be made to the authorization.
• If you do not see the Edit Date of Service option, it is because the dates on the authorization are not eligible to be updated.

For additional information and step-by-step instructions, please visit here.

As previously communicated, Independence Blue Cross is transitioning to a new claims processing platform over the next two years. In October, you may have noticed changes in PEAR Practice Management (PM) as they initiated their transition to a new utilization management system. More changes will be introduced in the coming months as they accelerate activities and members begin to migrate to the new claims processing platform.

To help you prepare, below is a summary of upcoming changes:

Eligibility & Benefits

• Members will be issued a new ID card when they transition to the new platform. However, new ID card images may not be immediately available in PEAR PM. To ensure you are viewing accurate information for the noted date of service, you must search for a member using their name and date of birth.
• The Site of Service indicator will not be available for migrated members until later in 2024.
• The Benefit Category labels will display differently for migrated members. For example, the percent of in- and out-of-network coverage is expressed differently. You can view accumulator detail through new hover-over links. Benefit details will also be presented in a new format, but with fewer details. They will be actively working to incorporate additional detail in the coming months.
• The Transactions menu will provide access to the authorization and referral submission and 1500 claim and encounter submission options. The Create New menu that shows when using the Member Center tab will not display during the transition.

Authorization Submission

• Authorization requests for members on the new platform will be numeric, with no EXT or CASE prefix.
• Surveys presented will have a new look and feel.
• Authorization request for new for newborns who are not yet fully enrolled should be directed to Provider Services. Follow the prompt for Authorizations.
• Service Types Physical Therapy and Occupational Therapy have been replaced with a new combined Service Type: Therapy (Physical and Occupational).

Authorization Search

• A maximum of 50 authorization requests are returned when performing a search. You may need to use additional search criteria to locate a specific authorization.
• Authorization now location specific. Therefore, you will need to note the appropriate location when searching for authorizations.
• When searching for an authorization by the member details, the member’s date of birth is required.

Referral Submission and Search

• The workflow for referral submissions will remain the same.
• You will need to access the Transactions menu to submit a referral.
• The Preventative Plus indicator will not be immediately available when submitting a referral for HMO Proactive members. Primary care physicians are encouraged to consider Tier 1 providers when referring members to a specialist for services as this may impact a member’s cost-share.
• When searching for referrals using the referral number, you may see two results – one with the old member ID number and the other with the new member ID number.

Claim Investigation Submission and Search

• The claim investigation submission feature will be temporarily suppressed for migrated claims starting December 31, 2023. They expect this feature will be available in early 2024.
• You will continue to have access to Claim Investigation Search to check the status of previously submitted requests for non-migrated claims.

The current user guides available in the PEAR Help Center will be accessed and updated accordingly to reflect these changes.

For assistance with navigating in PEAR PM, please contact PEAR Support at 1-833-444-PEAR (1-833-444-7327).

Starting in January 2024, Aetna Senior Supplemental Insurance will begin to transition to a new electronic payment process using Zelis. This process provides the latest in secure payment technology while adding efficiency to the claim payment process.

If you are currently enrolled with Zelis and receive claim payments electronically, you do not need to take any action at this time. You will start to receive Aetna Senior Supplemental Insurance payments with other Zelis network payments in the format you selected when you enrolled with Zelis.

For more information you can contact Zelis Customer Service: (877) 828-8770, Monday-Friday, 8AM-7PM EST.

In response to a November 2022 report from the Office of the Inspector General, Medicare has revised their Global Surgery booklet. The report from the OIG found that providers did not always comply with federal requirements when they bill for surgical services, including missing co-surgery and assistant-at-surgery modifiers.

Review the revised Global Surgery (PDF) booklet, and learn about: Coding, Billing, and Payment.

In the Federal Independent Dispute Resolution (IDR) Process Administrative Fee and Certified IDR Entity Fee Ranges final rule released December 18, 2023, the Departments of Health and Human Services, Labor, and the Treasury (the Departments) finalized fees associated with use of the Federal IDR process under the No Surprises Act (NSA), which was enacted as part of the Consolidated Appropriations Act, 2021 (CAA). The Federal IDR process ensures that when plans and issuers and providers, facilities, and providers of air ambulance services (the parties) cannot agree on an appropriate payment amount for out-of-network items and services, they may enter into the Federal IDR process to determine the appropriate payment amount.

This rule finalizes the amount of the administrative fee and the certified IDR entity fee ranges for disputes initiated on or after the effective date of this rule. Based on the methodology described in the preamble to the final rule, the Departments are finalizing an administrative fee amount of $115 per party for disputes initiated on or after the effective date of this rule.

To read the entire CMS fact sheet, click here.

More payors are now requiring taxonomy codes to be submitted with billing. As of January 1st, 2024, Independence Blue Cross and AmeriHealth of New Jersey are now requiring the taxonomy code to ensure proper claims and payment processing. Failure to do so will result in claim denials.

Professional claims
When billing professional claims, the appropriate taxonomy code must be entered in the segments indicated below. Do not leave blank.

Electronic claims (837P)

• Loop 2000A/Segment PRV = Billing Provider taxonomy code
• Loop 2310B/Segment PRV = Rendering Provider taxonomy code
• Loop 2420A/Segment PRV = Rendering Provider taxonomy code (when different from what is reported at the claim level)

Paper claims (CMS-1500)

• Box 19 = Billing Provider taxonomy code along with the ZZ qualifier
• Box 24I (shaded) = ZZ qualifier
• Box 24J (shaded) = Rendering Provider taxonomy code

Addressing health insurer overpayment recovery requests in a timely manner is critical as state laws are evolving and placing increased scrutiny on overpayments. The AMA has created the a Overpayment Recovery Toolkit (PDF) as a resource for physicians. CMS also has made a fact sheet available regarding overpayment requests and the recovery process.

If you identify patient credits, attempts should be made to apply the payment towards future services or refund those credits immediately. Your state’s escheat laws should be followed when dealing with unclaimed funds.