APA Missing– This order requires a APA and the system can’t find one.
- an APA could be needed for this order.
- Check to make sure that if an APA is needed we have one that covers that date of service your working on.
- Talk with a CSR that handles APA’s
- See the set-up person about this issue if it keeps recurring, it may be a set-up issue.
APA ID – The type APA the consumer has Example – Authorization, Pricing exception etc.
- This consumer may have the wrong type of APA
- Identify the type of APA this consumer should have
- If you think the APA the consumer has is wrong, talk with a CSR that handles APA’s
- See the set up person about this issue if it keeps recurring, it may be a set-up issue.
APA Multiple– The consumer has one or more APA and the dates are overlapping.
- The dates on the APA is overlapping with another APA. One APA must end and the other must begin.
- Talk with the CSR that handles the APA, Make sure you let he or she know the dates are overlapping.
- See the set up person about this issue if it keeps recurring, it may be a set-up issue.
Billing Price APA – The final price that was calculated for the an APA was ZERO.
- Billers should check the APA to make sure the dollar amount & Quantity aren’t zero
- If the APA has the right dollar & quantity amount asked the set up person to look into this further.
Missing Carrier code – The carrier code for each insurance in our system has to match what’s one with the carrier code list.
- See the set-up person about this issue.
Product category – The type of product a consumer can get for the type of Diagnosis code he or she has (Ex 1. Incontinence, 2. Nutrition 3. Catheter)
- The consumer could be receiving incontinence supplies but only have a Nutrition Diagnosis code.
- This consumer would need an incontinence code let a CSR know.
- See the set up person about this issue if it keeps recurring, it may be a set-up issue.
Billing Path/ Group Description – One or more insurances needs to be added or removed from the billing path.
- You should check to see if a new insurance needs to be added or if a terminated insurance needs to be removed.
- Remove any insurance that has been terminated on the billing path before the date of service.
- Add any insurance that has an effective date before or on the date of service to the billing path.
APA Status – The APA exceeds the dollar amount or the Quantity amount.
- Talk with a CSR that handles APA’s
- See the set up person about this issue if it keeps recurring, it may be a set-up issue.
No Response– We never received a response from an insurance plan.
After 45 days and no response from an insurance plan, billers should investigate the order
- Make sure the order was actually sent, Check the sent box in the new billing program, uncheck the receive box and the retrieve button.
- Once you see that the order was sent, check to see if the insurance companies received the claim Navinet, DPW website, Phone call.
- If the insurance company hasn’t received the claim, re-bill the order.
- If you see that the order was never sent and/or the “order status” at the top of the screen says ER bill, re-bill order.
Fee Schedule not Found – The computer can’t find the item for this price code on fee schedule.
- See the set-up person about this issue.
Billable price fee schedule– When the computer is trying to bring the order into billing so that it can be billed, it checks the fee schedule the computer finds the amount to bill is zero.
- Biller should realize there could be multiple problems as to why you received this issues such as.
- The consumer insurance could not be on the fee schedule.
- A product could not be on the fee schedule.
- The price on the fee schedule could not be right.
- Billers should check the product ID on this issues. (example: Billable Price of Zero will not be sent for GPE-L,31927,6514)
- Make sure the product ID doesn’t need an APA
- If the product ID doesn;t need an APA, ask the CSR that handles the APA to enter an APA for you, then re-bill the order and remove the issue.
Rejected Claims – Something is wrong with the claim that the state or the insurance company can’t process this claim further.
- On rejected claims, biller should check the reasons as to why the claim was denied.
- If its a diagnose issue, biller should make sure the claim has a valid diagnose code, just because we have a diagnose code in our system doesn’t make it a valid one.
- If this is the reason the billers should contact a CSR to get a valid diagnose code, once a valid diagnose code has been added to our system, a biller can then re-bill the order again.
- If it’s a procedure code issue, billers should make sure the claim has a valid procedure code.
- If this is the reason billers have someone fix the procedure code, once a valid procedure code has been added to our system. A biller can then re-bill the order again.
- If any claims are rejected because we didn’t send a claim amount, let Mike know so that he can look at it and fix it so that we can re-bill for those orders correctly.
Customer ID/Order ID missing– The recipient ID number we sent to a particular insurance company, does not match the recipient ID number we received from the response that we got.
Recipient EDI– You will see this issues when there is no Recipient EDI response within 6 months.
- Billers should re-bill the line item r whole order depending on the response that is or isn’t received.