![]() If you do not follow these requirements, we will deny the claim. If you do not report the serious adverse event, we try to determine if any charges filed with us meet the criteria as a Serious Reportable Adverse Event or Never Event. For example, you must report serious adverse events by having the Present on Admission (POA) indicator on all acute care inpatient hospital claims and ambulatory surgery center outpatient claims. Health care providers in our MA network must follow CMS guidance regarding billing, coding, claims submission and reimbursement. ![]() If the service was provided in accordance with CMS guidance.If the service is provided to an eligible beneficiary.If the service is covered, correctly coded and correctly billed to be eligible for reimbursement.If you are eligible to receive payment.If you are authorized to perform the service.These edits provide us with information to determine: Other applicable guidance from CMS, including the Official ICD-10-CM Guidelines for Coding and Reporting.National Correct Coding Initiative (NCCI).National and local coverage determinations.Section 1833 of the Social Security Act prohibits payments to a care provider if there is not sufficient information to determine the “amounts due to such provider.” We apply various claims processing edits based on: Medical claim review - Ch.10, 2022 Administrative Guide.Member appeals, grievances or complaints - Ch.10, 2022 Administrative Guide.Resolving concerns or complaints - Ch.10, 2022 Administrative Guide.Claim reconsideration and appeals process - Ch.10, 2022 Administrative Guide.Claim correction and resubmission - Ch.10, 2022 Administrative Guide.Subrogation and COB - Ch.10, 2022 Administrative Guide.Overpayments - Ch.10, 2022 Administrative Guide.Special reporting requirements for certain claim types - Ch.10, 2022 Administrative Guide.Pass-through billing - Ch.10, 2022 Administrative Guide.Claim submission tips - Ch.10, 2022 Administrative Guide.Medicare Advantage claim processing requirements - Ch.10, 2022 Administrative Guide.Risk adjustment data – MA and commercial - Ch.10, 2022 Administrative Guide.Claims and encounter data submissions - Ch.10, 2022 Administrative Guide.Enroll and learn more about Optum Pay - Ch.10, 2022 Administrative Guide.Virtual card payments - Ch.10, 2022 Administrative Guide. ![]() Optum Pay™ - Ch.10, 2022 Administrative Guide.Our claims process - Ch.10, 2022 Administrative Guide expand_more ![]()
0 Comments
Leave a Reply. |