Billing Issues 2

APA missing

-This requires an APA and the system cant 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 you’re working on.
• If there is none on file or APA on file incorrect, talk with a CSR that handles APAs
• See the set up person about this issue if it keeps recurring, it may be a set-up issue

APA ID

-The type of APA the consumer has:
Example – Authorization, Pricing exception etc. has an issue. 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, walk with a CSR that handles APAs
• See the set up person about this issue if it keeps recurring, it may be a set-up issue.

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 him/her know the dates are overlapping.
• See the set-up person about this issue if it keeps recurring, it may be a set-up issue.

Billable price APA

-The final price that was calculated for the 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, ask 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 Diagnoses code he/she has (Ex1. 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/ GroupDesc

-One or more insurance 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.

APA Status

-The APA exceeds the dollar amount or the quantity amount.

• Talk to the CSR that handles APAs
• See the Set-up person about this issue, if it keeps recurring, it may be be a set-up issue.

No Response

-We never received a response from an insurance plan

• After 45 days (varies by insurance) and no response from an insurance plan then billers should investigate the order.
• Look at the list of no responses… Do we have a large number on the same date? This could indicate an issue with an entire RA or insurance.
• Make sure the order was actually sent, Check sent box in the new billing program, uncheck the receive box then select the retrieve records button.

• 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 and the computer finds the amount to bill is zero.

• Billers should realize there could be multiple problems as to why you received the 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.
• Biller should check the product id on the issues. (example: Billable price of zero will not be sent for GPF-L31927,6514)
• Make sure the product id doesn’t need an APA.
• If the product needs an APA, ask the CSR that handles the APA to enter an APA for you then rebill the order and remove the issue.
• Billers should know that if the order is old, this issue could have possibly been resolved already. You may just need to rebill the order and delete the issue. You should use your judgement on paid orders.
• Billers should see the setup person to make sure the product is on the fee schedule & that the insurance is on the fee schedule. After the set-up person finds out that all the information is correct, the biller should rebill the order and remove the issue.
• If the problem keeps recurring billers should ask to speak with Mike so that he can look into it further.

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 reason 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 biller’s should contact a CSR to get get a valid diagnose code, once a valid diagnose code has been added to our system. A biller can then rebill the order again.
• If its 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 rebill 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 rebill for those orders correctly.

Recipient EDI

-You will see this issue when there is no Recipient EDI response within 6 months.

• Billers should rebill the line item or whole order depending on the response that is or isn’t received.

• Biller should speak with a CSR about adding a DOB to a consumer account. Every consumer needs a DOB expect for Countries, JACC, PCA Options Etc.