Submit professional claims with current and valid CPT and/or HCPCS codes. Submit institutional claims with four-digit type of bill, valid four-digit revenue codes and CPT or HCPCS codes and ICD-9 codes and DRG codes (when applicable).
Providers improve the efficiency of their reimbursement through proper coding of a member’s diagnosis. MHP requires the use of valid ICD-9 diagnosis codes, to the ultimate specificity, for all claims. This means that ICD-9 codes must be carried out to the fifth digit when indicated by the coding requirements in the ICD-9 manual. (Note: not all codes require a fifth digit.) Please consult your ICD-9 manual for further instruction. Failure to code diagnoses to the appropriate level of specificity may result in a denial of the claim and a consequent delay in payment.
Additionally, written descriptions, itemized statements and invoices may be required for any services billed using non-specific codes.
Providers must submit applicable prior authorization numbers on all claims.
MHP requires the submission of National Provider Identifiers (NPIs) on all claims. For physician claims, the rendering (Type 1) NPI must be submitted in Box 24j of the CMS 1500 form. The billing (Type 2) NPI must be submitted in Box 33a, if applicable. Please refer to CMS website for guidelines on whether your provider type requires a Type 2 NPI. If a Type 2 NPI is not required, please submit your Type 1 NPI in Box 33a.
MHP requires that the referring provider’s NPI number be present on all claims submitted on a CMS 1500. This number must be in the referring physician field 17b.
MHP also requires each provider’s tax identification number (TIN) in field 25. MHP will reject all claims that are missing NPIs and/or TINs. Claims rejected for missing this information must be resubmitted as new claims to be considered for payment.
For facility claims billed on UB04 claim forms, MHP requires that the facility (Type 1) NPI is entered in field 56 in addition to the TIN in field 5 on all claims submitted on a UB-04. The attending physician’s NPI is required in field 76. The operating physician’s NPI, if applicable, is required in field 77.
Also, please be aware that MHP can only accommodate one address per billing (Type 2) NPI. If a provider has multiple offices and only one billing (Type 2) NPI then all payments must be directed to one address. Providers may have payments sent to multiple addresses by acquiring additional billing (Type 2) NPIs.
The name and NPI of the provider who rendered services must be indicated in field 31 of the CMS 1500. In situations where a provider is billing under a corporate or clinic name, the corporate or clinic name must be submitted in field 33. This rendering name must match that appearing on the physician’s W-9 form on file with MHP.
MHP enforces a timely filing limit based upon your provider participation agreement. Generally, clean claims* must be received within ninety (90) days from the date of service or discharge. In cases of coordination of benefits (COB) when MHP is the secondary carrier, the time limit is extended to 120 days from the date of the primary carrier’s Explanation of Benefits. Corrected claims must be received within 90 days from the original claim’s processing date.
Members cannot be billed for services denied as not meeting the timely filing requirements.
* A clean claim is a claim that is coded correctly and ready for adjudication without any additional information or documentation needed from provider/member to process to completion. A rejected claim is not considered a 'clean claim' for purposes of timely filing requirements.
In accordance with state and federal regulations governing the payment of interest on delayed claims, interest may be due.
Interest applies only to claims submitted electronically, as directed by the Health Insurance Portability and Accountability Act (HIPAA). Paper claims do not qualify for delayed interest payment.
MHP cannot accept hand-written resubmissions of claims. All necessary modifications for the purpose of correction must be submitted as follows:
Institutional Claims - For corrections to a UB-04, change the fourth digit of the bill type to indicate a corrected claim.
Professional Claims - Must be marked as a ”r;Corrected Claim,” in Field 19
Electronic Claims - MHP accepts corrected claims electronically when submitted per clearinghouse and MHP guidelines
See Timely Filing guidelines above for additional requirements.
MHP appreciates the timely return of incorrectly paid funds. The return of funds may either be physician/healthcare provider-initiated or plan-initiated (request for refund). In an effort to streamline the process and increase communication, MHP provides a form for providers to complete and attach to any refund checks. The 'Payment Refund Notification' form is found at the end of this chapter or on our website, mercyhealthplans.com on the provider page under 'Forms.' Use of this form allows MHP to properly reconcile your refund. Please attach a copy of the pertinent page of the remittance advice that accompanied the initial payment or the refund request. This will ensure the adjustment is made on the proper member and for the appropriate date of service.
In instances of overpayment and in accordance with your provider agreement, MHP may offset the overpayment against future claims payments to recoup identified overpayments.
In instances of overpayment and in accordance with your provider agreement, MHP may generate a written request for refund. If the provider does not remit the required amount within 45 business days from the date of the letter, MHP will offset the amount against future claims payments. If MHP receives your refund after the amount has been offset against future payments, MHP will return your refund. Therefore, it is in your best interest to refund the payment as quickly as possible.
Please note that if a check is received for payments on multiple accounts, and only a few of the accounts were processed incorrectly, please do not return the entire check to MHP. Instead, notify the Provider Relations Department of the specific issue(s) (e.g., insufficient payment, no record of member, etc.), and MHP will initiate individual action accordingly. Returning the entire check only results in delayed postings to those accounts paid correctly.
Missouri Law (Section 354.606.5, RSMo) states, 'In no event shall a participating provider collect or attempt to collect from an enrollee any money owed to the provider by the health carrier nor shall a participating provider collect or attempt to collect from an enrollee any money in excess of the coinsurance, co-payments or deductibles.' As a matter of professional courtesy, members should not be billed for claims in process. The member should be held harmless during this time period.
Members can only be billed for co-payments, deductibles, coinsurance, or for actual charges for non-covered services.
All billed charges are subject to ClaimCheck edits during the adjudication process. This may result in a re-bundling of inappropriately unbundled services. Any services or amounts not covered due to ClaimCheck edits are not billable to members.
Payment for reimbursable services rendered by providers will be in accordance with the provider’s participation agreement.
MHP maintains the right to audit billings from and payments to providers at any time. MHP may also recover payments to providers for services that are determined not to be medically necessary or not covered at the time the service was rendered and/or overpayments.