1. society
2. welfare
3. healthcare
4. hospital

Mercy Maricopa Integrated Care
Doing the right thing for the right
reason
Claims overview
Submitting clean claims and
encounters
Claim Submission Tips
• Provide complete member
information:
–
–
–
–
Member ‘s Name
Member’s Date of Birth
Member’s ID Number
Member’s Address
It’s always important to verify that the information provided by the
member matches the member’s ID card. Watch for name variations and
changes. It is also important to verify eligibility prior to services being
rendered, unless an urgent/emergent situation. Problems with member
information could cause an unnecessary delay or possible claim denial.
3
Claim Submission Tips
• Provide complete provider information (CMS 1500
(02-12) Form):
– Rendering Provider ID – NPI – (Box 24J):
o Providers who require an NPI number - (provide NPI number in
the field next to NPI.
o Providers who are atypical (do not require an NPI) – provide
AHCCCS ID in the field next to NPI.
– Federal Tax Identification Number (Box 25) – TIN (Check EIN). Only
use SS if provider does not have a TIN.
– Signature of Physician or Supplier Including Degrees or Credentials
(Box 31) – signature of the rendering physician/ supplier.
– Service Facility Location Information (Box 32) – address where
services were rendered:
o Box 32a – Servicing Provider NPI
o Box 32b – AHCCCS ID
– Billing Provider Information & Phone # - (Box 33) – provider “pay to”
information.
o Box 33a – Billing provider NPI
o Box 33b – AHCCCS ID
4
Claim Submission Tips
• Attach Primary Carrier’s Explanation of Benefits
– If another health plan or Medicare is the primary insurer and benefits
have been provided or denied, submit a copy of the primary insurer’s
Explanation of Benefits in compliance with Coordination of Benefits
rules.
• Include All Diagnosis Codes:
– Refer to ADHS DBHS Covered Services Guide under Billing for Services
Section. ICD-9-CM diagnosis codes must be used when submitting
claims/encounters (see the International Classification of Diseases –
9th Revision – Clinical Modification Manual).
– Be sure to bill ICD-9-CM diagnosis codes to the specificity required –
i.e., 4th or 5th digit must be provided if required.
– Effective 10/1/14, the industry will be moving to ICD-10.
5
Claim Submission Tips
• Each individual claim line (Box 24 in CMS 1500 (02/12)
Form) must include:
– Date of service
– Place of service
– Procedure code and modifier, if applicable (Services must be
consistent with the Arizona Department of Health Services
(ADHS)/Division of Behavioral Health Services (DBHS) Allowable
Procedure Code Matrix – Appendix B.2).
– Charge amount (include charge amount regardless of the contractual
arrangement with MMIC or MMA).
– If a CMS 1500 (02/12) form is more than 6 lines long, the total charge
field must only be billed on the last page of the claim.
– Units
6
Timely Filing Limitations
• New Claim Submissions
Claims must be filed on a valid claim form within 180
days (6 months) from the date services were performed,
unless there is a contractual exception. Exceptions to
this are as follows:
– Within 180 days from date of discharge for 24-hr.
level of care (Level I);
– Within 180 days of the last day of the month or the
discharge date, whichever is earlier, when billing
monthly for longer treatment episodes of care at a
24-hr. level facility;
– Within 180 days of the claim settlement for third
party claims. This date is based on the date of the
other carrier’s EOB that must be attached to the
claim you submit to Mercy Maricopa.
7
Timely Filing Limitations
• Claim Resubmissions
Resubmissions must be filed within 365 days (1 year) from the date of
provision of covered services or eligibility posting deadline, whichever is
later. The only exception is if a claim is recouped, the provider is given an
additional 60 days from the recoupment date to resubmit a claim.
• MMIC is Secondary Payer
If other insurance is primary, you must submit the claim within 180 days to
preserve your appeal rights. Submit the other insurance EOB along with
the claim submission as soon as received from the primary insurance.
• If Mercy Maricopa does not receive a claim within the
above timelines, the claim will be denied.
8
Claim Resubmission Tips
• Paper claim resubmissions:
– Must write “Corrected Claim” or “Resubmission” across the top of the
claim.
– Mercy Maricopa has a Resubmission Form you may fill out and attach
to your resubmission (available at www.MercyMaricopa.org under the
forms section.
– When billing a claim that has more than 6 service lines and requires
additional CMS 1500 (02-12) forms, please include the total charge
amount on the last page of the submission (this does not apply to
electronic claims).
9
Claim Resubmission Tips
• Electronic Claim Resubmissions:
– If billing a resubmission electronically, you must submit with:
• Professional claims - A status indicator of 7 in the submission form
location and the Original Claim ID field will need to be filled out.
• Facilities – In the Bill Type field, the last number of the 3 digit code
should be a 7.
– If you need to submit attachments to your claims, please submit by
paper, as we currently do not accept attachments. This is currently
under testing and we will let you know when this is available.
10
Interpretive Services Billing
• When billing Interpretive Services, you must bill as
follows:
HCPCS Code Modifier
T1013
Description
Staff delivering services is also interpreting
T1013
Q6
Separate but employed staff interpreting
T1013
CR
External vendor used
11
Claim Address
Claims
Mail To
Electronic Submission*
Medical & Mercy Maricopa Integrated Care and
Behavioral Mercy Maricopa Advantage
Health
Medical Claims
P. O. Box 64835
Phoenix, AZ 85082-4835
Through Electronic
Clearinghouse
Dental
Mercy Maricopa Integrated Care and
Mercy Maricopa Advantage
Dental Claims
P. O. Box 62978
Phoenix, AZ 85082-2978
Through Electronic
Clearinghouse
Refunds
Mercy Maricopa Integrated Care and
Mercy Maricopa Advantage
Attention: Finance Department
P.O. Box 64835
Phoenix, AZ 85082-4835
Not Applicable
12
Claim Submission Formats
Service
Claim Form Type
Medical and professional
services
Paper - CMS 1500 (02-12) Form
Electronic – 837P
Hospital inpatient, outpatient,
skilled nursing and emergency
room services
Paper - CMS UB-04 Form
Electronic – 837I
General dental services
Paper - ADA 2006 Claim Form
Electronic – 837D
Dental services that are
considered medical services
(oral surgery, anesthesiology)
Paper - CMS 1500 (02-12) Form
Electronic – 837P
13
Top Reasons for Claim Denials
•
•
•
•
Missing or invalid CPT/HCPCS code
Missing or invalid diagnosis code
Missing or inaccurate place of service code
Missing name and/or degree level of provider (when
required)
• Missing or invalid NPI
14
Primary Contact Information
For Claims:
Mercy Maricopa Integrated Care Mercy Maricopa Advantage
Until 4/1/2014 - contact Magellan at:
800-564-5465
(phone number to be updated)
For Health Plan Assistance:
Phone: 602-586-1880
Phone: 866-602-1979
Provider Relations:
602-586-1843
866-277-1025
TTY/TDD 711
CVS Caremark:
Phone: 855-582-2023
Website:
Phone: 602-586-1880
www.mercymaricopa.org
Phone: 866-602-1979
Fax: 860-975-0841
E-Mail: Mercy Maricopa Provider [email protected]
15
Electronic Tools
• Mercy Maricopa Integrated Care offers several electronic
tools to help expedite payment to you:
– Electronic Claim Submission (EDI)
– Electronic Funds Transfer (EFT)
– Electronic Remittance Advice (ERA)
16
Electronic Claims Submission (EDI)
• The benefits of electronic claims submissions include:
– Accurate submission and immediate notification of submission errors
(level 2 report)
– Faster processing resulting in prompt payment
• In order to submit electronic claims you need the
following:
– Agreement with an electronic clearinghouse
– Software in your office or facility to transmit electronic claims
17
EDI Vendors for Mercy Maricopa
Vendor
Southwestern
Provider Services
(SPSI)
Payer ID For Mercy Payer ID for Mercy
Care (MCP) Claims* Maricopa Claims**
•(Institutional) – MCPU
Contact
Information
www.spsi2000.com
33628
•(Professional) - MCP1
1-817-684-8500
www.emdeon.com
Emdeon
86052
33628
1-877-363-3666, Option 1 for Sales
www.RelayHealth.com
Relay Health
86052
33628
1-866-RELAY-ME (1-866-735-2963
ext. 2)
• SPSI offers a no cost solution – no transaction fees.
• Other EDI Vendors may apply set-up and licensing fees which the provider would be responsible for.
*Payer ID used for physical health claims for GMHSA Members who are covered under the MCP Plan.
**Payer ID used for both physical health and behavioral health claims for SMI members – Mercy
Maricopa
**Payer ID used for behavioral health claims for GMHSA members – Mercy Maricopa
**Payer ID used for behavioral health claims for Non-Title XIX SMI – Mercy Maricopa
18
Electronic Funds Transfer (EFT)
• The benefits of electronic funds transfer include:
–
–
–
–
Automatic deposit of payment for covered services
Faster receipt of payment
No paper checks to deposit
Easier verification of payment
• In order to receive electronic funds transfer you need the
following:
–
–
–
–
Submit your claims electronically (preferred)
Bank account number
A voided check or savings account deposit slip
A signed Electronic Funds Transfer (EFT) enrollment form available
under the Provider Forms section of the Mercy Maricopa Integrated
Care website, www.MercyMaricopa.org
19
Electronic Remittance Advice (ERA)
• The benefits of electronic remittance advice include:
–
–
–
–
–
Electronic file of processed claims from Mercy Care
Electronically post payments to your Practice Management system
Faster reconciliation of account receivables
Simplified reconciliation process
Received day after electronic funds transfer
• In order to receive electronic remittance advice you need
the following:
–
–
–
–
Submit your claims electronically (preferred)
Receive electronic funds transfer (preferred)
Ability to accept HIPAA standard 835 electronic remit transactions
Ability to accept direct receipt of 835 transactions
20
ICD-10 Implementation
• Mercy Maricopa Integrated Care is on track to meet the
ICD-10 implementation date of 10/1/14.
– We will be working with high volume providers to test ICD-10 prior to
the implementation date.
• Please make sure that you are in compliance with the ICD10 implementation date of 10/1/14 in order to avoid
unnecessary delays or denials of your claims.
ICD-10
Are you Ready?
CMS 1500 (02-12) Form Changes
• The National Uniform Claim Committee (NUCC) recently
updated the CMS-1500 form to CMS 1500 (02-12) version.
• Please access the NUCC website for additional information
regarding the form change, including detail on what
changes were made. The NUCC website is at:
www.nucc.org
• Full instruction is provided on our website to fill out this
form at:
www.mercymaricopa.org
22
Changes made to CMS 1500 Form
Changes made include:
 Some field names have been
changed to better reflect use.
 Some field names changed to
Reserved for NUCC use, as field is
not used via the 837P electronic
submission.
 Diagnosis code fields:
o Instead of 4 diagnosis codes,
there are now 12 diagnosis
codes that can be listed.
o Accommodates ICD-10 change
effective 10/1/14 to hold alpha
characters and allow up to 7
characters.
o The decimal points have been
removed.
Transitioning to the Updated Form
• NUCC has approved the following transition timeline:
– January 6, 2014: Payers begin receiving and processing paper claims
submitted on the revised 1500 Claim Form (version 02/12).
– January 6 through March 31, 2014: Dual use period during which
payers continue to receive and process paper claims submitted on the
old 1500 Claim Form (version 08/05).
– April 1, 2014: Payers receive and process paper claims submitted only
on the revised 1500 Claim Form (version 02/12).
• This timeline aligns with Medicare's transition timeline.
24
UB-04 Form
No changes have been made
to UB-04 form, as it was
previously changed in 2004 to
be ICD-10 compliant.
 Full instructions to fill out this form
are located on our website under
Provider Notices:
www.mercymaricopa.org
ADA 2006 Form
No changes have been made
to ADA 2006 form.
 Full instructions to fill out this form
are located on our website under
Provider Notices:
www.mercymaricopa.org
Mercy Maricopa Values Our
Partnership with the Provider
Community that serves our Members!
27
Thank you