12/30/2024

Provider Manual

Claims Filing

This section covers the basics of how to file claims, most common claim issues and how to correct them. Billing information submitted to QualChoice is used for claims payment, as well as member and physician/provider profiling. It is essential that complete and accurate information be submitted as indicated in this section.

Acceptable Claim Format

We encourage providers to submit claims electronically. Electronic claims submission is fast, accurate and reliable. It’s also available 24 hours a day, seven days a week. If complete information is provided, electronic claims are typically processed seven to 10 days faster than paper claims.

Electronic claims submitted to QualChoice must be in ANSI X12N 837 5010 format. The QualChoice Payer ID is 35174. In January 2012, all HIPAA-covered entities adopted the American National Standards Institute (ANSI) 5010 to promote increased use of electronic data interchange (EDI) transactions between all covered entities. ANSI 5010 is the foundation of health information technology (HIT). Visit the ANSI 5010 section of the Centers for Medicare & Medicaid Services website for materials and resources.

Electronic and paper claims must be submitted using an industry-standardized form:

  • CMS-1500 Claim Form—for use by physician and non-institutional providers
    • The standardized red/white form must be used. Make sure that your claim software supports the CMS-1500 Claim Form (08-05). For specific details on completing this form, review the 1500 Reference Instruction Manual at nucc.org.
  • UB-04 Claim Form—for use by institutional providers
    • UB-04 is printed with special optical character recognition (OCR) paper and OCR ink so scanners are able to read what is printed on them. This makes processing claims faster. However, if the print is too light or the information isn’t lined up properly in the printer, the claim may fail the automated process and be delayed or returned to the provider. For specific information on the UB-04 Claim Form, subscribe to the UB-04 Data Specifications Manual at nubc.org.

Important! Handwritten paper claim forms cannot go through the OCR scanning process and will be rejected. Read more about Paper Claims Submissions.

Assignment of Benefits

As referenced in both the member’s benefit certificate and the QualChoice Provider Agreements, a member’s rights and benefits under the benefit certificate shall not be assignable or transferable, either before or after services and supplies are provided and/or claims are submitted to QualChoice. Under no circumstances will any provider, whether In-Network or Out-of-Network, assert any claim on the basis that provider is a “participant” or “beneficiary” of the member’s benefit certificate.

With respect to Out-of-Network Providers, QualChoice hereby reserves the right to direct payment directly to the member. The payment the member receives from QualChoice will represent the benefit amount payable by QualChoice for the service and will be attached to an EOB. The member will be responsible for making payment to the non-participating provider for the full amount of the check mailed to the member, in addition to any applicable co-payment, deductible, coinsurance or other cost share allowances, according to his or her Benefit Certificate.

Note: Directing payment to the member rather than the non-participating provider does not change the determination of coverage, benefit level, or pricing for a non-participating provider claim - only the recipient of the payment.

Coordination of Benefits

COB is administered according to the member’s Benefit Certificate and in accordance with applicable law. QualChoice coordinates benefits when members are covered by more than one plan. When the QualChoice plan is considered primary coverage, we will reimburse the full extent of Covered Medical Services at the plan agreed reimbursement rate, less any applicable co-payment, coinsurance or deductible. When QualChoice is secondary, we may reduce the benefits we pay so that payments from all health policies do not exceed 100% of the COB Allowable Expense.

COB Allowable Expense is a healthcare expense (including deductible, coinsurance or co-payments) covered in full or in part by any healthcare plan or policy covering the member. This means an expense or service not covered by any plan or policy covering the Enrollee is not a COB Allowable Expense. Also, any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging a member is not a COB Allowable Expense.

If two (2) or more plans or policies cover a member and compute their benefit payments based on that plan’s maximum allowable charge, then any amount in excess of the highest reimbursement amount for a specified benefit is not a COB Allowable Expense.

If two (2) or more plans or policies cover a member and provide benefits or services based on negotiated fees, then any amount in excess of the highest of the negotiated fees is not a COB Allowable Expense.

If a member is covered under multiple plans or policies and the COB Allowable Expense is determined by more than one method, then the primary policy’s payment arrangement shall be the COB Allowable Expense for all plans or policies.

When the QualChoice plan is primary and there is a balance after the QualChoice plan has paid for Covered Medical Services according to the agreed upon rate, the provider may balance bill the secondary carrier. If the QualChoice plan is secondary, we will reduce our benefits so that the total benefits paid or provided by all plans are not more than one hundred percent (100%) of the total COB Allowable Expense of the primary plan. If the QualChoice plan is secondary, and there is a balance after the primary plan has made payment, and QualChoice has reimbursed the appropriate amount for Covered Services, the provider may not balance bill the member.

Whether QualChoice is the primary or secondary carrier, claims must be submitted within the timely filing period specified in the Provider Agreement. QualChoice is under no obligation to pay claims received past this specified time frame and the member cannot be balance billed for claims denied due to late submission.

Medicare claims received by CMS are now electronically crossed over to QualChoice after Medicare pays their portion. Providers who are set up to receive and review 835 remittance advice files may see claims that have been crossed over. Some restrictions apply to paper claims once we have received Crossover Claims from Medicare. Do not file duplicate claims on behalf of your patient. If Medicare makes a payment, it comes to us on the Crossover Claim file.

Corrected Claims

A corrected claim is any claim processed by QualChoice and resubmitted with additional information that changes the way the claim was initially processed, regardless of whether the claim was initially paid or denied.

Electronic Filing of Corrected Claims

QualChoice accepts and prefers electronic corrected claims. Turnaround time is much quicker than filing corrected claims on paper.

A corrected claim is one that has been processed, whether paid or denied, and was refiled with additional charges, a different diagnosis, or any information that would change the way the claim was originally processed. Indicating “Corrected Claim” on the claim form if it was not previously processed will cause a delay in claim adjudication.

Claims returned for additional information are NOT to be refiled as corrected claims. These claims have been processed; additional information is needed to finalize payment and may include one or more of these items:

  • New Claims
  • Appeals
  • Medical Records
  • Invoices
  • Inquiries
  • Adjustments

Corrected Claim Guidelines

(Share these guidelines with your electronic services vendor)

I ANSl-837P (Professional)

Requirements for a completed claim:

  • In the 2300 Loop, the CLM segment (Claim information), CLMOS-3 (claim frequency type code) must indicate one of the following qualifier codes:
    • 7 - REPLACEMENT (Replacement of Prior Claim)
    • 8 - VOID (Void/Cancel of Prior Claim)
  • In the 2300 Loop, the REF02 segment (Original Reference Number (ICN DCN)) must include the Original Claim Number issued to the claim being corrected. The original claim number can be found on your Remittance Advice. 

I ANSl-8371 (Institutional)

Requirements for a completed claim:

  • In the 2300 Loop, the CLM segment (Claim information),the CLMOS-3 (Claim Frequency Type Code) must indicate the third digit of the Type of Bill being sent. The third digit of the Type of Bill is the frequency and can indicate if the bill is an Adjustment, a Replacement or a Voided claim as follows:
    • 7 - REPLACEMENT (Replacement of Prior Claim)
    • 8 - VOID (Void/Cancel of Prior Claim)
  • In the 2300 Loop, the REF02 segment (Original Reference Number (ICN/DCN)) must include the Original Claim Number issued to the claim being corrected. The original claim number can be found on your Remittance Advice.

Rejected claims are to be resubmitted as new claims and not as ‘corrected’ claims. Rejected claims are returned to the provider prior to being processed which means there is no ‘original’ claim to correct against.

Electronic Claims Submission

Submitting claims electronically is the most efficient way to process claims payment. Electronic claims must be HIPAA-compliant in ANSI X12N 837 5010 format. The QualChoice Payer ID is 35174.

Getting Data to the Clearinghouse

If your Practice Management (PM) software vendor is interfaced with a medical claims clearinghouse, then the PM vendor will transmit the claim files and support the EDI reports you receive from the clearinghouse and QualChoice. This is the simplest way of working with a claims clearinghouse.

What is ANSI?

ANSI stands for American National Standards Institute. An ANSI segment includes the City, State and Zip Code (for example: *LITTLEROCK*AR*72211). Groups of Segments are tied together to create an ANSI message. The clearinghouse converts medical claims into an ANSI message that is submitted electronically to QualChoice. Other ANSI messages are eligibility, claim status, prior authorization inquiries, etc. Because ANSI messages are hard to read, clearinghouses convert these into reports.

What is EDI?

The fastest way to conduct business with us throughout the entire claims process is through electronic data interchange (EDI) — the computer-to-computer transmission of standardized information.

QualChoice accepts electronic medical claims from Change Healthcare (formerly Emdeon) and from Availity, LLC. At present, claims from other clearinghouses are not accepted. However, other clearinghouses can forward claims to Change Healthcare or Availity. To transmit your claims to us, contact your office software support representative letting them know you want to begin transmission of claims to QualChoice Payer ID 35174

Change Healthcare and Availity accept claims filed in National Standard Format (NSF) as well as ANSI X12 837 5010 format. The formatting requirements for each are different. Please contact your software vendor if you do not know which format your office uses. All NSF claims are converted to 837 5010 format by Change Healthcare and Availity before they are transmitted to QualChoice.

Below are the most current 837 formatting positions for vital claims information.

CMS-1500 Claims – 837 5010 Format Translations for Important Fields

Field Box No. Loop & Segment
Payer ID #

 

 2325-NM109 – 2015-NM109 – 2540-SVD01
Insured’s ID # Box 1a 2010BA NM109
Referring Provider NPI # Box 17b, unshaded 2310A NM109 NM108 = XX
Condition Codes Box 18-28 2300 HI01-2 through HI11-1
Rendering Provider NPI # Box 24j, unshaded 2420A NM109 NM108 = XX
Federal Tax ID No. Box 25 2010AA REF02
Rendering Prov (if not same as Billing/Pay-to-Prov) Box 31 2310B NM103, 04
Billing Provider Name Box 33 2010AA NM103, NM104, NM105, NM107
Billing Provider Address Box 33 2010AA/AB N301, N401, N402, N403
Billing Provider NPI Box 33a 2010AA NM109

 

UB-04 Claims – 837 5010 Format Translations for Important Fields

Field Box No. Loop & Segment
Payer ID #

 

 2010BC NM108
Patient Control # Box 3a 2300 CLM01
Type of Bill Box 4 2300 CLM05-1 (pos 1-3 in Box 4)
Fed Tax ID No. Box 5 2010AA REF02 (if Pay-to-Prov = to Billing Prov)
2010AB NM109 (if Pay-to-Prov is not = to Billing Prov)
Insured’s ID # Box 60 A-C 2010BA NM109 for primary ID number
2010BA REF02 for secondary ID number
Principal DX Code Box 67 2300 HI01-1 (1 = BK or ABK)
Other DX Codes Box 67 A-Q 2300 HI01-9 (HI0x-1 = BF) (where x indicates additional iterations of the composite element)
Admitting DX Code Box 69 2300 HI02-2 (HI0x-1 = BJ) (where x indicates additional iterations of the composite element)
Principle Procedure: Code and Date Box 74 2300 HI01-2 (Proc Code)
2300 HI01-4 (Date)
Attending Physician NPI Box 76 2310A NM109
Attending Physician Name Box 76 2310A NM103, 04 (Last Name, First Name)

 

EDI Reports

Software vendor reports only show that the claim left the provider’s office and either was accepted or rejected by the vendor. Your software vendor report does not confirm claims have been received or accepted at the clearinghouse or by us. Acknowledgement reports show you the status of your electronic claims after each transmission. By analyzing these reports, you will know if your claims have reached us for payment or if claim(s) have been rejected for an error or needing additional information. Providers MUST review their reports and the clearinghouse acknowledgement reports to minimize processing delays and timely filing penalties for claims that have not reached us.

How to Receive Reports

Your software vendor is responsible for establishing your connectivity to our clearinghouse and will instruct you on how your office will receive clearinghouse reports. These reports are returned after each transmission. It is very important that clearinghouse reports are reviewed and worked after each transmission. These reports should be kept if you need documentation for timely filing later. Specific questions about report frequency, report transmission methods and data definitions should be directed to your EDI vendor.

Paper Claims Submission

Providers are encouraged to file claims electronically for faster and more accurate claims payment. If submitting claims electronically is not a viable alternative, paper claims must be submitted on CMS-1500 (for physician and non-institutional providers) or UB-04 (for institutional providers).

OCR (optical character recognition) is used for all paper claims. It is important to follow the guidelines below to ensure the claim is not rejected by the OCR system. If the claim is rejected due to an OCR reading issue, the claim is returned to the provider. To submit a paper claim to QualChoice, please refer to the address on the back of the member’s ID card.

Paper Claim Guidelines

The print or font should be:

  • Legible (Change typewriter ribbon/PC printer cartridge frequently, if necessary. Laser printers are recommended.)
  • In black ink
  • Courier 10-point type (if possible). Do not mix fonts.
  • CAPITAL letters are preferred

The font must NOT be:

  • Script, italics or stylized
  • In red ink
  • A dot matrix font

Do NOT:

  • Use liquid correction fluid or a highlighter or black out data
  • Have data touching box edges or running outside of numbered boxes (Left justify all information.)
  • Use more than six service lines per claim (Use a new form for additional services.)
  • Use narrative descriptions of procedure, modifier or diagnosis (the CPT, modifier or ICD-10 code)
  • Use stickers or rubber stamps (such as “corrected billing,” provider name and address, etc.).
  • Use special characters (i.e., hyphens, periods, italics, parentheses, percent signs, dollar signs and ditto marks). For example, dollar amounts would read 145 89 instead of $145.89
  • Use handwritten descriptions or write on the claim form. If an error occurs, please complete a new claim form.
  • Punch holes in, fold, tape, or staple the claim form
  • Submit attachments smaller than 8 ½"x 11"

The claim form must:

  • Be submitted on the standardized CMS-1500 and/or UB-04 form. OCR cannot read photocopies or faxes.
  • Have all required fields completed.
  • Enter date fields in the MMDDYY or MMDDYYYY. Example: For a member born on February 28, 1960, the entry would be: 02281960.
  • Enter name fields without titles (such as Mr. or Mrs.). Enter last name first, then a comma, then first name. For example enter Mr. Mark O’Neil Jr. as ONEIL, MARK.
  • Be aligned carefully so that all data falls within the spaces on the form. All line-item information must appear on the same horizontal line. Claims not properly aligned will be returned.
  • Be 8½" x 11" with the printer pin-feed edges removed at the perforations
  • Clean and free from stains, tear-off pad glue, notations, circles or scribbles, strike-overs, crossed-out information or whiteout

Splitting Claims

QualChoice only accepts one member and one provider per claim. Providers should submit all codes for one place of service on one date of service for payment on one claim. Providers should not submit multiple claims for payment for the same date of service by splitting the codes billed on separate claims. Splitting the claims may cause the claim(s) to pend for manual processing and possibly delay payment.

Timely Filing

Claims must be submitted and received by QualChoice in accordance with the time frames outlined in the Provider Agreement. Claims that do not meet timely filing requirements will be denied.

If the provider discovers that a claim is not on file, it is the provider’s responsibility to ensure information is verified or obtained and to resubmit the claim before the timely filing period expires. If a claim is returned to the provider for additional information, the claim must be resubmitted before the timely filing period expires. Claims submitted after the expiration of the timely filing period will be denied as “not allowed — do not bill the member.”

QualChoice will accept and process a claim beyond the timely filing limit if the provider can produce, within a reasonable time frame, documentation that the claim was submitted timely and that timely attempts were made to verify the claim was received by QualChoice. The following are acceptable forms of verification:

Electronic Claims

  • Provide an Acceptance Report from EDI vendor verifying claims were filed timely and show demonstration of timely follow-up.
  • Follow up should be 45 days from date of claim submission, but no less than 60 days to indicate a timely follow up.

Paper Claims

  • Documentation from computer-generated accounting software (i.e., transaction report, electronic data batch report, patient’s payment ledger, accounts receivable report) that reflects the aging of a specific claim. Note: A hand-stamped bill with a particular date of submission but no other documentation is not sufficient evidence of prior submission.
  • Documentation of attempts to verify claims receipt and/or resubmissions of the claim. The documentation must: (1) reference the date the information was obtained; (2) the name of the QualChoice staff member or mechanism used (in the case of verifying claims online, screen prints would be advisable); (3) who provided the information; and (4) the date the claim was resubmitted.
  • Follow-up should be 45 days from date of claim submission, but no less than 60.

Using the Correct Request Form

Only a Request for Reconsideration form will be accepted for claims reconsideration for members enrolled in QualChoice health plans. Note:  A request submitted on the wrong form will not be reviewed.

These are the reasons listed in Section IV of the Request for Reconsideration form for making a reconsideration request:

  • Previously denied/closed for additional information
  • Duplicate charges (e.g., multiple charges with same CPT)—Provide medical record documentation.
  • Global Period Dispute
  • Payment received for wrong provider or member—Provide details in Comments section.
  • Duplicate payment received—Select Recover Funds or Refund Enclosed.
  • Claim Check/Claim edit denial (i.e., mutually exclusive, incidental, etc.)—Provide medical record documentation.
  • Modifier Reimbursement—Provide medical record documentation.
  • Medical Record Request—When sending requested medical records, attach the QualChoice request letter or provide claim #.
  • Claims Timely Filing—Provide Acceptance Report from EDI Vendor and demonstration of timely follow-up.
  • Provider Fee Schedule/Contract Language—Please provide detailed explanation of your reconsideration request in the comments section.

Clinical denials (such as not medically necessary, experimental and investigational, or when claim amounts are provider liability) should only be handled via the Network Provider Appeal Form. Clinical denials are not are not eligible for the reconsideration process.

When to File a Claim

Whether QualChoice is the primary or secondary carrier, claims must be submitted within the timely filing period specified in the Provider’s Agreement. QualChoice is under no obligation to pay claims received past this specified time frame and the member cannot be balance billed for claims denied due to late submission.

NDC Numbers Required for Drug Reimbursement Claims

When submitting claims with an HCPC or CPT code for drug reimbursement, you must also submit a corresponding National Drug Code (NDC) number. This is an 11-digit number that identifies the listed drug and is unique to the product being dispensed. Claims submitted without the NDC number will be denied.

An NDC is not required when facilities bill a revenue code that does not require a CPT or HCPC, i.e., a 250 revenue code.

Formatting the NDC on the Claim

You must enter the NDC in an 11-digit billing format (no spaces, hyphens or other characters). If the NDC on the package label is fewer than 11 digits, you must add a leading zero to the appropriate segment to create a 5-4-2 configuration.

When the label NDC configuration is: Reformat it to 5-4-2:
(leading zero added, hyphens removed)
4-4-2: xxxx-xxxx-xx 0xxxxxxxxxx
5-3-2: xxxxx-xxx-xx xxxxx0xxxxx
5-4-1: xxxxx-xxxx-x xxxxxxxxx0x


Note:  You must also include your billable charge.

Entering NDC data on Electronic Claim (ANSI 5010 837P and 8371) Transactions

Guidelines for including NDC data in an electronic claim:

  • Product ID Qualifier field:  Enter N4, loop ID 2410, segment LIN02
  • National Drug Code field:  Enter the 11-digit NDC billing format assigned to the drug administered, loop ID 2410, segment LIN03
  • National drug unit count:  Enter the quantity (no. of NDC units), loop ID 2410, segment CPT04
  • Unit or basis for measurement:  Enter the NDC unit of measure for the drug given, loop ID 2410, segment CTP05

Include the total charge amount for each line of service for the Monetary Amount in Loop ID 2400, Segment SV102 (professional claims) or SV203 (facility claims).

Entering NDC Data on Paper Claims

Form CMS-1500

  • In fields 24A-24G, in the shaded section above the procedure code, enter NDC qualifier N4 (left-justified), then one space for separation, then the NDC.
  • Enter the qualifier (UN, ML, GR or F2) for the correct dispensing NDC unit of measure.
  • Enter the quantity (number of NDC units). QualChoice allows up to three decimals in the NDC units (quantity or number of units) field.

Form UB04

  • Enter NDC in locator (box) 43, labeled “Description.”
  • Enter the qualifier (UN, ML, GR or F2) for the correct dispensing NDC unit of measure.

Enter the quantity (number of NDC units). QualChoice allows up to three decimals in the NDC units (quantity or number of units) field.