CLAIMS

Understanding Changes to Telehealth Services

At Umpqua Health Alliance, we understand that COVID-19 has changed almost every aspect of our daily lives, including the way we practice medicine. As you work to provide the best possible care for your patients, we are working to make it as easy as possible for you to do so in a safe manner. We’ve put together some answers to frequently asked questions regarding telehealth that we hope will help make this transition as easy as possible. We’ve also gathered codes, their descriptions and the modifiers needed to bill them as telehealth. Please follow the links below for more information:

Should you have any questions regarding telehealth services or billing support, please do not hesitate to contact our Provider Relations Department at UHNProviderServices@umpquahealth.com

Access

Umpqua Health Alliance offers providers the ability to submit, check the status and manage your prior authorization (PA) requests online. By signing up for access to our Community Integration Manager (CIM), you can eliminate paperwork and faxing associated with the authorization process. You will also have direct email access to our Member Services, Prior Authorization, and Claims teams that can assist you with questions of member eligibility, and monitoring PA and claims status’. UHA is encouraging all in network providers to gain access to CIM as soon as possible as it will be a requirement in the first quarter of 2020.

Claims Submissions

UHA accepts paper and electronic claim submissions and these should be submitted in HIPAA 837P, 837I, CMS 1500, or UB-04 format. In order to be paid for services rendered to a UHA member, provider and or/facility MUST be enrolled with the state of Oregon and have an active DMAP number for the date(s) of service. If you are an out of network provider needing to be enrolled with DMAP, please contact Contracting by phone at (541) 957-3094 or by email UHNProviderServices@umpquahealth.com.

Facility Type Claim Form Billing Rules
Hospital UB-04 DMAP/Medicare
Physician CMS-1500 DMAP/Medicare
FQHC CMS-1500 DMAP/Medicare
All other claim types: DME, LAB, Radiology, Transport Services, Ancillary Services *Pharmacy Excluded CMS-1500 DMAP/Medicare

Claims are typically processed within 60 days of receipt of a clean claim. Non-clean claims typically result in a longer adjudication window and/or denials. If you received a claim rejection letter from PH Tech, please contact them directly at (503) 584-2169, option #5. UHA does not have access to those claims and PH Tech will advise on possible solutions.

Claim Submission Methods

Vendor Payor ID
Allscripts/PayerPath (via forwarding) 77502
Availity 77503
Cortex EDI CIM11
Emdeon/Change Healthcare 77502
GE Healthcare/Athena 77500
Gateway/Trizetto 77504
Office Ally 77501
Relay Health PCS (Professional) 77505-CPID 1291
Relay Health PCS (Institutional) 77505-CPID 6551

Please Mail Paper Claims to:

***Please note payer name and address must match as listed or claim may be rejected***
PhTech
ATTN UHA Claims
PO BOX 5308
Salem, OR 97304

UHA has a claim support team available by phone Monday-Friday 8 a.m.-5p.m. PST at (541) 229-4842 option 2 or can be reached by email at UHAClaims@umpquahealth.com. If sending any PHI through email, please ensure that it is sent via secure email.

Timely Filing Guidelines

  • 120 days from the date of service for original submissions (unless it is an inpatient stay, then date of discharge).
  • 1 year (365 days) from date of service for corrections, appeals, and secondary/tertiary billing (primary EOB/documentation must be included with original claim submission).
    • If you are experiencing any system issues with claim submissions or any instances that will delay timely billing, UHA MUST be notified as soon as issue is identified via contact information below.

Please note that DMAP enrollment is not a valid reason for untimely claims submission. Once provider/facility becomes enrolled claims are automatically reprocessed and original submission must be within the timely guidelines above.

Elements of a clean claim

A clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claim forms, along with any attachments and additional elements, or revisions to data elements, attachments, and additional elements, of which the provider has knowledge.

UHA will apply the National Correct Coding Initiative to claims processed as required in Section 6507 of the Patient Protection Affordable Care act.

Some of the required data elements for professional and facility claims.

  • Member ID #
  • Member’s Name
  • Members’ date of birth and gender
  • Prior Authorization
  • Diagnosis code(s)
  • Date of service
  • Place of service
  • Bill Type
  • Procedure/ modifier code
  • Dx pointer
  • Charge for each listed service
  • Number of units
  • Rendering provider NPI
  • Tax ID number
  • Total charges

 

Prioritized List

The Prioritized List (list) outlines what the Oregon Health Plan (OHP) will pay for. The Health Evidence Review Commission publicly makes these decisions. The list includes a list of conditions that members might have, along with corresponding services. For example, some covered treatments listed for diabetes (a condition) include office visits, blood sugar monitoring, medication, and medical nutrition therapy. Most conditions and services are listed using medical and dental codes. For some conditions or services, the list has guidelines to clarify when certain services are covered or not.

You can access the prioritized list at the link below.

https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Prioritized-List.aspx

 

Code Groups

There are code groups created by OHA for services and diagnoses that are covered and noncovered. The criteria for each code group are listed in the header of each webpage.

To locate the code groups, follow the link below:

https://www.oregon.gov/oha/hsd/ohp/pages/policy-medical-surgical.aspx 

 

Duplicate or Corrected Claims

The following data elements are used to identify duplicate /corrected claims.

  • Place of service
  • Units billed
  • Charges
  • Rev Code
  • Benefit Plan (CCOA, CCOB, CCOG, CCOE)
  • Diagnosis code
  • Bill type
  • NDC Modifiers.

When one of these elements is identified in our claims system, the claim will pend for manual processing.

Corrected claims should be referenced as a corrected claim on the claim form along with the original claim number.

Partial corrections on a claim will be denied as a duplicate. The whole claim needs to be rebilled under the corrected claim.

 

Locum

When a participating Provider requires coverage by a Locum Tenens Provider, the practice should notify Provider Services of the arrangements. If the Locum Tenens Provider will be covering for more than 60 days, the Locum Tenens Provider is required to be credentialed and your office should email Provider Services at UHNProviderServices@umpquahealth.com.

 

NDC Billing

The Deficit Reduction Act of 2005 (DRA) requires state Medicaid programs to collect rebates on physician-administered drugs for outpatient services to receive federal funding for coverage of these drugs.

Since there are often several NDCs linked to a single HCPCS code, the Centers for Medicare, and Medicaid Services (CMS) consider the use of NDC numbers critical to correctly identify the drug and manufacturer to invoice and collect the rebates. ​

The NDC is the number that identifies a drug. The NDC number consists of 11 digits in a 5-4-2 format. The first 5 digits identify the manufacturer of the drug and are assigned by the Food and Drug Administration. The remaining digits are assigned by the manufacturer and identify the specific product and package size.

Some packages will display fewer than 11 digits, but leading “0”s can be assumed and need to be used when billing. For example:

NDC on label Configuration on label NDC in the required 5-4-2 format
05678-123-01 5-3-2 05678-0123-01
5678-0123-01 4-4-2 05678-0123-01
05678-0123-1 5-4-1 05678-0123-01

 

The NDC is found on the drug container (i.e., vial, bottle, tube). The NDC submitted to Medicaid must be the actual NDC number on the package or container from which the medication was administered.

Do not bill for one manufacturer’s product and dispense another. The benefits of accurate billing include reduced audits, telephone calls, and manufacturers’ disputes over their rebate invoices.

It is considered a fraudulent billing practice to bill using an NDC other than the one administered.

NDC units are based upon the numeric quantity administered to the patient and the unit of measurement. The unit of measurement (UOM) codes are:

  • F2 = International Unit
  • GR= Gram
  • ML = Milliliter
  • UN = Unit (Each)

The actual metric decimal quantity administered, and the unit of measurement are required for billing. If reporting a fraction, use a decimal point.

More information regarding NDC billing can be found at:

https://www.oregon.gov/oha/HSD/OHP/Pages/NDC.aspx             

 

VFC

The Vaccines for Children (VFC) Program is a federal program that provides free immunizations for children age 0–18 years.

UHA does not reimburse for the cost of vaccine serums covered by the VFC Program. Providers should bill UHA only for the administration of the vaccines covered under the VFC Program.

Providers should bill the specific immunization CPT code with modifier 26 or SL, which indicates administration only. Providers should not bill for the administration of these vaccines

Providers not participating in the VFC Program should refer their patients to the County Health Department to receive the vaccines covered under the program. UHA does require an invoice to be submitted with the claim for providers who are not enrolled in the VFC program.

Please see OHA’s page for more details regarding the VFC program

https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/VACCINESIMMUNIZATION/IMMUNIZATIONPROVIDERRESOURCES/VFC/Pages/Overview.aspx

 

Sterilization Consent Forms

Sterilization consent forms are required for payment on any claim billed with a sterilization procedure code. UHA is required to submit the consent forms to OHA for any sterilization charge received. If UHA is unable to obtain valid consent, the claim will be denied and or recouped. This applies to professional, and facility claims.

Tips for complete consent forms:

  1. The patient must sign the consent form at least 30 days, but no more than 180 days prior to the procedure.
  2. Any interpreter’s statement must be signed and dated the same day as the member/patient signs the consent form.
  3. The statement of the person obtaining consent must be signed and dated on the same date as the member.
  4. The physician’s statement must be filled out completely, and the physician’s signature must be dated on the date of the procedure.
  5. Consent forms can be found at the links below.

 

Billing an OHP Member

Providers are prohibited from billing a UHA member for Medicaid-covered services.

Members may only be billed if all the following criteria are met:

  1. The service is not covered by Medicaid.
  2. All reasonably covered treatments have been tried OR member is aware of reasonably covered treatments but selected a treatment that is not covered; and
  3. Member and provider have completed an OHP Client Agreement to Pay for Health Services (OHP 3165)

https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/he3165.pdf

These coverage rules are outlined in OAR 410-120-1280

https://secure.sos.state.or.us/oard/viewSingleRule.action?ruleVrsnRsn=291495

 

Provider Portal

Our customer service representatives can check eligibility and quote benefits; however, you will find that our CIM portal will save you time and be more convenient. The portal also allows you to view your claim status, view vouchers (EOBs), submit authorization requests and check prior authorization status.

To access the provider portal, click the link below.

https://cim1.phtech.com/cim/login

Claim Reconsiderations and Provider Appeals

If you have received a claim denial/payment that you do not agree with, you may contact UHA’s claim support team. This is considered a Reconsideration (Level I Appeal) once the claims support team takes a second look at the denial/payment. If the UHA claims support team does not find any issue with the processing of the claim, you may also submit a written Claims Appeal (Level II Appeal). You must include the Provider Request for Reconsideration and Claim Dispute Form found below, and all documentation you feel is necessary for UHA to reconsider the claim denial. You can either mail the appeal, or submit through CIM directly on the claim. Please see How to Upload Additional Documentation for instructions. If you need more information on this process, see the UHA Provider Handbook; Section 6.11 Denials and Claim Appeals.

Please Mail Paper Appeals to:

***Please note payer name and address must match as listed or claim may be rejected***
PhTech
ATTN UHA Claims Appeals
PO BOX 5308
Salem, OR 97304

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