Comprehensive Medical and Dental Program

Claims Processing

Statement/Purpose

This policy specifies requirements and oversight for the adjudication and payment of claims submitted to the Comprehensive Health Plan (CHP).

Definitions

Clean Claim: A claim that may be processed without obtaining additional information from the provider of service or from a third party but does not include claims under investigation for fraud or abuse or claims under review for medical necessity.

Managed Care Organization (MCO): A health plan which is focused on quality care while maximizing fiscal efficiencies to reduce healthcare costs.

Policy

DCS CHP and its contracted MCO develop and maintain claims processes and systems that ensure the accurate collection and processing of claims, analysis, integration, and reporting of data. These processes and systems result in the provision of information on areas including, but not limited to, service utilization, claim disputes, member grievances and appeals, and disenrollment for reasons other than loss of Medicaid eligibility [42 CFR 438.242(a)].

DCS CHP has a mechanism in place to inform providers of the appropriate place to send claims at the time of notification or prior authorization if the provider has not otherwise been informed of such information via subcontract and/or a provider manual.

Claim payment requirements pertain to both contracted and non-contracted providers.

Procedure

Claims Timeliness and Appropriateness

DCS CHP and its contracted MCO provide timely claims processing services for contracted providers and process claims according to the applicable State, Federal and contractual requirements. For each form type (Dental/Professional/Institutional) 95% of all Clean Claims are adjudicated within 30 days of receipt of the Clean Claim and 99% are adjudicated within 60 days of receipt of the Clean Claim.

Notice of Denial of Payment

DCS CHP and its contracted MCO provide an accurate and clear written explanation of specific reason(s) for denied, adjusted or contested claims. Claims initially submitted more than six months after date of service for which payment is claimed or claims that are submitted as Clean Claims more than 12 months after date of service for which payment is claimed are denied.

If a Chief Medical Officer reverses a decision to deny, limit, or delay authorization of services, and the disputed services were received while an appeal was pending, the provider has 90 days from the date of the reversed decision to submit a Clean Claim for payment. DCS CHP and its MCO do not deny claims for untimely filing if the claims are submitted within 90 days from the date of the reversed decision. Additionally, DCS CHP and its contracted MCO do not deny claims submitted as a result of a reversed decision because a member failed to request continuation of services during the appeal or hearing process.

Electronic Processing Requirements

DCS CHP, through its contracted MCO accepts and generates required HIPAA compliant electronic transactions from or to any healthcare provider interested in and capable of electronic submission of eligibility verifications, claims, claims status verifications and prior authorization requests; or the receipt of electronic remittance. Claim payments are made via electronic funds transfer for healthcare providers with the capability to accept electronic claim attachments.

Remittance Advices

Related remittance advices are sent to providers with payment, unless the payment is made by Electronic Funds Transfer (EFT). Any remittance advice related to an EFT is sent to the provider, no later than the date of the EFT. Remittance advices include:

• Reason(s) for denials and adjustments,

• Detailed explanation/description of all denials, payments and adjustments,

• Amount billed,

• Amount paid,

• Application of Coordination of Benefits (COB) and copays, and

• Providers’ rights for claim disputes with detailed instructions and timeframes for the submission of claim disputes and corrected claims.

Provider Dispute Resolution

DCS CHP ensures that Provider Dispute Resolution (PDR) claims processing is in accordance with established provider claims practices as well as dispute resolution requirements.

Acceptance of Late Claims

DCS CHP reviews and adjudicates late claims subject to submission of a provider dispute and good cause pursuant to applicable policies and procedures.

Request for Reimbursement of Overpaid Claims

DCS CHP ensures that written request for reimbursement for overpayment be processed within the specified claims processing time limits.

Authorization of Services

DCS CHP does not rescind or modify an authorization for services subsequently rendered in good faith and pursuant to the authorization

Requests for Medical Records

DCS CHP ensures that requests for medical records from providers to process claims submitted only be utilized when deemed reasonably necessary to determine payor liability. This provision does not apply to the PPG’s ability to request such medical records to review claims for fraud, waste, and abuse.