Claims Procedures

At a Glance

Premier Health Group has partnered with Premier Health Plan to manage claims and payment.

Premier Health Plan pledges to provide accurate and efficient claims processing. The use of electronic claims submission is central to this pledge, which also serves to reduce costs. To make this possible, Premier Health Plan requests that providers submit claims promptly and include all necessary data elements.

A key to controlling administrative costs is reducing excess paperwork, particularly paperwork generated by improperly completed claims. 

Please follow these guidelines when submitting a claim:

  1. Type claims or submit them electronically. Handwritten claims may be returned.
  2. Claims with eraser marks or Whiteout corrections may be returned.
  3. If a mistake is made on a claim, the provider must resubmit a new claim. Claims must be submitted by the established filing deadlines or they will be denied.
  4. Services for the same patient with the same date of service may not be unbundled. For example, an office visit, a lab workup and a venipuncture by the same provider on the same day must be billed on the same claim.
  5. Only clean claims containing the required information will be processed within the required time limits. Claims rejected due to missing or incorrect information may not be resubmitted. A new claim form must be generated for resubmission.
  6. Resubmit claims only if the Premier Health Plan claim has not been paid within 30 days.
  7. Use proper place of service codes for all claims.
  8. Use Modifier 25 when a provider performs a significant, separately identifiable evaluation and management of a patient on the same date of service as the original visit.
  9. Bill anesthesia claims with the correct codes from the American Society of Anesthesiologists with the appropriate anesthesia modifiers and time units, if applicable.
  10. Submit only one payee address per tax identification number.

Submission Guidelines

Electronic Filing

The Premier Health Plan claims processing system allows providers access to submitted claims information, including the ability to view claim details such as claim status (i.e., was there an error on submission?) and the claim number to be used as a reference indicator.

Electronically filed claims may be submitted in the following ways:

Individual Claim Entry

Individual claim entry is available to network providers with established Provider OnLine accounts. This feature allows direct submission of both professional (CMS-1500) and institutional (UB-04) claims via a user-friendly interface that use the highest level of security to make the process safe and easy.

Electronic Data Interchange (EDI)

Premier Health Plan also accepts electronic claims in data file transmissions. Electronic claim files sent directly to Premier Health Plan are permitted only in HIPAA standard formats.

Providers who have existing relationships with clearinghouses such as Emdeon, Relay Health and others can continue to transmit claims in the format produced by their billing software. These clearinghouses are then responsible for reformatting claims to meet HIPAA standards and passing the claims on to Premier Health Plan. 

The Premier Health Plan Payer ID is 251PR.

For all EDI submissions, the NPI (National Provider Identifier) number is required. When care is coordinated, the referring provider’s name and NPI are required.

Submitting Claims Directly to Premier Health Plan

Providers are able to submit claims directly without incurring clearinghouse expenses. These claims are loaded into batches and immediately posted in preparation for adjudication. The Provider OnLine EDI tools allow these batches to be viewed in several standard report formats.

To submit EDI files directly to Premier Health Plan, providers must:

  1. Have a computer with Internet access
  2. Have the ability to download and install a free Active-X secure FTP add-on
  3. Have an existing Provider OnLine account or register for a new provider or submitter account
  4. Use billing software that allows a HIPAA-compliant 837 professional or institutional file to be generated
  5. Have a sample 837 file exported from a billing system containing only Premier Health Plan claims
  6. Complete testing with Premier Health Plan

Paper Claim Forms

  • CMS-1500 forms: These forms are for professional services performed in a provider’s office, hospital or ancillary facility. (Provider-specific billing forms are not accepted)
  • UB-04 forms: These forms are for inpatient hospital services or ancillary services performed in the hospital. (Hospital‐specific billing forms are not accepted.)

Deadlines

Premier Health Plan accepts new claims for services up to 120 days after the date of service for Premier Health Employee Plan.

When Premier Health Plan is the secondary payer claims are accepted with the explanation of benefits (EOB) from the primary carrier. This claim must be received within 120 days of the primary EOB remittance date or up to the new claim timely filing limit, whichever is greater. Claims submitted after these deadlines will be denied for untimely filing.

Members cannot be billed for the Premier Health Plan’s portion of the claims submitted after these deadlines; however, they may be billed for copayments, coinsurance and/or deductibles.

Claims Address

Claim forms should be submitted to the following address:

Premier Health Plan
P.O. Box 3076
Pittsburgh, Pennsylvania 15230-3076

Diagnosis Codes

Claims must be submitted with a diagnosis code indicating the member’s medical condition or circumstances necessitating evaluation or treatment. The diagnosis codes submitted on claim forms must correlate to the documentation contained within the member’s medical record and reflect or support the reason services have been provided.

Follow these guidelines to avoid the most common claims coding problems:

  • Include new POA (Present on Admission indicator).
  • Diagnosis should be coded using ICD-10. Make sure the diagnosis code is valid and complete (i.e., includes all digits).
  • The primary diagnosis should describe the chief reason for the member’s visit to the provider.
  • When a specific condition or multiple conditions are identified, these conditions should be coded and reported as specifically as possible.
  • For coding of services provided on an outpatient basis, do not code the diagnosis as “rule out,” “suspect” or “probable” until such time as the condition is confirmed. Code the condition to the highest degree of certainty, such as symptoms, signs or abnormal test results.
  • When addressing both acute and chronic conditions, assign codes to all conditions for which the member is seeking medical care.
  • When coding ongoing or chronic conditions, do not assume the code used at a previous visit is appropriate for a current visit.
  • In coding diabetes, be certain to identify the current status of the member’s condition as Type I or Type II, controlled or uncontrolled, referring to the direction of ICD-10-CM.
  • Use caution in coding injuries and identify each as specifically as possible.
  • Refer to guidelines throughout ICD-10 for “late effect” coding and sequencing.
  • “Well” vs. “sick” visits - If a preventive visit was scheduled, but symptoms of illness or injury exist at the time of the visit, code the primary diagnosis as “preventive.” The conditions for which the member is being treated should be coded as a secondary diagnosis.
  • V-codes are used for circumstances affecting a member’s health status or involving contact with health services that are not classified under ICD-10. In general, they do not represent primary disease or injury conditions and should not be used routinely. V-codes used to describe personal and/or family history of medical conditions are covered when used for a screening procedure. V-codes that pertain to mental health, learning disorders or social conditions are not covered.

Claims Resubmission

Claims may be resubmitted if Premier Health Plan has not paid within 30 days of the initial submission. Resubmitted claims can be a photocopy of the original or a reprinted claim.

Claims Documentation

Clean vs. Unclean Claims

The Ohio Revised Code and Premier Health Plan define a “clean” claim as any claim that can be processed without obtaining additional information from the provider or from a third party. A clean claim is one with no defects or improprieties. A defect or impropriety may include, but is not limited to, the following:

  • Lack of required substantiating documentation
  • A particular circumstance requiring special treatment that prevents timely payment from being made on the claim
  • Any required fields where information is missing or incomplete
  • Invalid, incorrect or expired codes (e.g., the use of single‐digit instead of double‐digit place‐of‐service codes)
  • A missing explanation of benefits (EOB) for a member with other coverage
  • Claims requiring medical review before payment
  • Claims requiring prior authorization that was not obtained

Required Fields on a CMS-1500 Claim Form

The CMS-1500 claim form is standard in the insurance industry; however, Premier Health Plan requires providers to complete only those fields noted in the figure below. Each field is explained in the numbered key that follows this illustration.

CMS-1500 Claim Form

Explanation of Required Fields on a CMS-1500 Claim Form

If a numbered field is not included, it is not required by Premier Health Plan to process a claim.

CMS-1500 claim form fields

Field #

Required Field Explanation

1A

Insured’s ID number—11-digit member ID number (combination of the 9-digit member number and the 2-digit relationship code on the front of the member ID card)

2

Patient’s name—patient’s last name, first name and middle initial

3

Patient’s birth date—patient’s date of birth in month/day/year format; also, patient’s gender

4

Insured’s name—last name, first name and middle initial of policy-holder

5

Patient’s address—patient’s current address, including city, state and zip code; also patient’s telephone number

6

Patient’s relationship to the insured—applicable relationship box marked

7

Insured’s address—insured’s current address, including city/state/zip code; also insured’s telephone number

9

Other insured’s name—if the patient is covered by another health insurance plan, please list the insured’s last name, first name and middle initial here; also list the insured’s policy or group number, date of birth, gender, employer’s name or school name, and insurance plan name or program name

10

Patient’s condition related to— =check boxes if condition is related to employment, auto accident or other accident

12

Patient’s release—indicates if patient has signed release of information from provider

13

Authorized signature—indicates if patient’s signature authorizing payment to provider is on file

17

Referring physician’s name—first and last name of referring physician; if patient is self-directed, please print “NONE”

17A

Referring physician’s ID number—Universal Physician Identification Number (UPIN)

17B

Provider’s NPI

21

Diagnosis or nature of illness or injury—minimum of one diagnosis code (ICD-9 coding)

24A

Date(s) of service (from/to) in month/day/year format

24B

Place of service—2-digit CMS standard code indicating where services were rendered

24D

Procedures, services, and modifier—CPT or HCPCS code and modifier (if applicable)

24E

Diagnosis Pointer—indicates diagnosis code or diagnoses that apply to service on a given line

24F

Charges—amount charged for service

24G

Days or units—number of times service was rendered

25

Federal tax ID number—tax ID number of provider rendering service

26

Patient’s account number—provider-specific ID number for patient (up to 12 digits)

28

Total charge—total of all charges on bill

29

Amount paid—amount paid by patient and third-party payers

30

Balance due—current balance due from insured

31

Signature of provider/supplier— should include degree or credentials (Please make sure the signature is legible.)

32

Name and address of facility—name of facility where services were rendered (if other than home or provider’s office)

33

Physician’s billing information—billing physician’s name, address, and telephone number; also list the PIN number (6-digit ID number assigned to the physician by Premier Health Plan)

Required Fields on a UB-04 Claim Form

The UB-04 claim form is standard in the insurance industry. Each field is explained in the numbered key that follows this illustration.

UB-04 Data Elements

FL Requirement Description Line Type Size
1 Required by Medicare
Required by Medicare
Required by Medicare
Required by Medicare
Billing Provider Name
Billing Provider Street Address
Billing Provider City, State, Zip
Billing Provider Telephone, Fax, Country Code
1
2
3
4
AN
AN
AN
AN
25
25
25
25
2 May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
Billing Provider's Designated Pay-to Name
Billing Provider's Designated Pay-to Address
Billing provider's Designated Pay-to City, State
Billing provider's Designated Pay-to ID
1
2
3
4
AN
AN
AN
AN
25
25
25
25
3a
3b
Required by Medicare
May be required by another payer when applicable / not required by Medicare
Patient Control Number
Medical/Health Record Number
1
2
AN
AN
24
24
4 Required by Medicare Type of Bill (TOB) 1 AN 4
5 Required by Medicare
Required by Medicare
Federal Tax Number
Federal Tax Number
1
2
AN
AN
4
10
6 Required by Medicare Statement Covers Period - From/Through 1 N/N 6/6
7 Field not used
Field not used
Unlabeled
Unlabeled
1
2
AN
AN
7
8
8a
8b
Required by Medicare
Required by Medicare
Patient Name/ID
Patient Name
1
2
AN
AN
19
29
9a
9b
9c
9d
9e
Required by Medicare
Required by Medicare
Required by Medicare
Required by Medicare
May be required by another payer when applicable / not required by Medicare
Patient Address - Street
Patient Address - City
Patient Address - State
Patient Address - Zip
Patient Address - Country Code
1
2
2
2
2
AN
AN
AN
AN
AN
40
30
2
9
3
10 Required by Medicare Patient Birthdate 1 N 8
11 Required by Medicare Patient Sex 1 AN 1
12 Required for Types of Bill 011X, 012X, 018X, 021X, 022X, 032X, 033X, 041X, 081X, or 082X Admission/Start of Care Date 1 N 6
13 May be required by another payer when applicable / not required by Medicare Admission Hour 1 AN 2
14 Required for Types of Bill 011X, 012X, 018X, 021X, and 041X Priority (Type) of Admission or Visit 1 AN 1
15 Required by Medicare Point of Origin for Admission or Visit 1 AN 1
16 May be required by another payer when applicable / not required by Medicare Discharge Hour 1 AN 2
17 Required for Types of Bill 011X, 012X,
013X, 014X, 018X, 021X, 022X, 023X,
032X, 033X, 034X, 041X, 071X, 073X,
074X, 075X, 076X, 081X, 082X, 085X
Patient Discharge Status 1 AN 2
18-28 Required if applicable Condition Codes   AN 2
29 May be required by another payer when applicable / not required by Medicare Accident State   AN 2
30 Field not used
Field not used
Unlabeled
Unlabeled
1
2
AN
AN
12
13
31-34 Required if applicable
Required if applicable
Occurrence Code/Date
Occurrence Code/Date
A
B
AN/N
AN/N
2/6
2/6
35-36 Required if applicable
Required if applicable
Occurrence Span Code/From/Through
Occurrence Span Code/From/Through
A
B
AN/N/N
AN/N/N
2/6/6
2/6/6
37 Field not used
Field not used
Unlabeled
Unlabeled
A
B
AN
AN
8
8
38 May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
Responsible Party Name/Address
Responsible Party Name/Address
Responsible Party Name/Address
Responsible Party Name/Address
Responsible Party Name/Address
1
2
3
4
5
AN
AN
AN
AN
AN
40
40
40
40
40
39-41 Required if applicable
Required if applicable
Value Code
Value Code Amount
a-d
a-d
AN
N
2
9
42 Required by Medicare Revenue Codes 1-23 N 4
43 May be required by another payer when applicable / not required by Medicare Revenue Code Description/Investigational Device Exemption (IDE) Number/Medicaid Drug Rebate 1-23 AN 24
44 Required if applicable Healthcare Common Procedure Coding System (HCPCS)/Accommodation Rates/Health Insurance Prospective Payment System (HIPPS) Rate Codes 1-23 AN 14
45 Required if applicable Service Dates 1-23 N 6
46 Required if applicable Service Units 1-23 N 7
47 Required by Medicare Total Charges 1-23 N 9
48 Required if applicable Non-Covered Charges 1-23 N 9
49 Field not used Unlabeled
Page _ of Creation Date _
1-23
23
AN
N/N
2
3/3
50 Required by Medicare
Required by Medicare
Required by Medicare
Payer Identification - Primary
Payer Identification - Secondary
Payer Identification - Tertiary
A
B
C
AN
AN
AN
23
23
23
51 Required by Medicare
Required if applicable
Required if applicable
Health Plan ID
Health Plan ID
Health Plan ID
A
B
C
AN
AN
AN
15
15
15
52 Required by Medicare
Required by Medicare
Required by Medicare
Release of Information
Release of Information - Secondary
Release of Information - Tertiary
A
B
C
AN
AN
AN
1
1
1
53 May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
Assignment of Benefits - Primary
Assignment of Benefits - Secondary
Assignment of Benefits - Tertiary
A
B
C
AN
AN
AN
1
1
1
54 Required if applicable
Required if applicable
Required if applicable
Prior Payments - Primary
Prior Payments - Secondary
Prior Payments - Tertiary
A
B
C
N
N
N
10
10
10
55 May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
Estimated Amount Due - Primary
Estimated Amount Due - Secondary
Estimated Amount Due - Tertiary
A
B
C
N
N
N
10
10
10
56 Required by Medicare National Provider Identifier (NPI) - Billing Provider 1 AN 15
57 Required if applicable
Required if applicable
Required if applicable
Other Provider ID
Other Provider ID
Other Provider ID
A
B
C
AN
AN
AN
15
15
15
58 Required by Medicare
Required by Medicare
Required by Medicare
Insured's Name - Primary
insured's Name - Secondary
insured's Name - Tertiary
A
B
C
AN
AN
AN
25
25
25
59 Required if applicable
Required if applicable
Required if applicable
Patient's Relationship - Primary
Patient's Relationship - Secondary
Patient's Relationship - Tertiary
A
B
C
AN
AN
AN
2
2
2
60 Required by Medicare
Required by Medicare
Required by Medicare
Insured's Unique ID - Primary
Insured's Unique ID - Secondary
Insured's Unique ID - Tertiary
A
B
C
AN
AN
AN
20
20
20
61 Required if applicable
Required if applicable
Required if applicable
Insurance Group Name - Primary
Insurance Group Name - Secondary
Insurance Group Name - Tertiary
A
B
C
AN
AN
AN
14
14
14
62 Required if applicable
Required if applicable
Required if applicable
Insurance Group No. - Primary
Insurance Group No. - Secondary
Insurance Group No. - Tertiary
A
B
C
AN
AN
AN
17
17
17
63 Required if applicable
Required if applicable
Required if applicable
Treatment Authorization - Primary
Treatment Authorization - Secondary
Treatment Authorization - Tertiary
A
B
C
AN
AN
AN
30
30
30
64 Required if applicable
Required if applicable
Required if applicable
Document Control Number (DCN)
Document Control Number (DCN)
Document Control Number (DCN)
A
B
C
AN
AN
AN
26
26
26
65 Required if applicable
Required if applicable
Required if applicable
Employer Name (of the insured) - Primary
Employer Name (of the insured) - Secondary
Employer Name (of the insured) - Tertiary
A
B
C
AN
AN
AN
25
25
25
66 Required by Medicare Diagnosis and Procedure Code Qualifier (International Classification of Diseases [ICD] Version Indicator) 1 AN 1
67 Required for Types of Bill 011X. 012X, 013X, 014X, and 021X Principal Diagnosis Code and Present on Admission (POA) Indicator 1 AN 8
67A-Q Required if applicable Other Diagnosis and POA Indicator A-O AN 8
68 Field not used
Field not used
Unlabeled
Unlabeled
1
2
AN
AN
8
9
69 Required for Types of Bill 011X, 012X, 021X, and 022X Admitting Diagnosis Code 1 AN 7
70a
70b
70c
Required if applicable
Required if applicable
Required if applicable
Patient Reason for Visit Code
Patient Reason for Visit Code
Patient Reason for Visit Code
1
1
1
AN
AN
AN
7
7
7
71 May be required by another payer when applicable / not required by Medicare Prospective Payment System (PPS) Code 1 AN 3
72a
72b
72c
May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
May be required by another payer when applicable / not required by Medicare
External Cause of Injury Code and POA Indicator
External Cause of Injury Code and POA Indicator
External Cause of Injury Code and POA Indicator
1
1
1
AN
AN
AN
8
8
8
73 Field not used Unlabeled 1 AN 9
74
74a
74b
74c
74d
74e
Required if applicable
Required if applicable
Required if applicable
Required if applicable
Required if applicable
Required if applicable
Principal Procedure Code/Date
Other Procedure Code/Date
Other Procedure Code/Date
Other Procedure Code/Date
Other Procedure Code/Date
Other Procedure Code/Date
1
1
1
2
2
2
N/N
N/N
N/N
N/N
N/N
N/N
7/6
7/6
7/6
7/6
7/6
7/6
75 Field not used
Field not used
Field not used
Field not used
Unlabeled
Unlabeled
Unlabeled
Unlabeled
1
2
3
4
AN
AN
AN
AN
3
4
4
4
76 Required if applicable
Required if applicable
Attending Provider - NPI/QUAL/ID
Attending Provider - Last/First
1
2
AN
AN
11/2/9
16/12
77 Required if applicable
Required if applicable
Operating Physician - NPI/QUAL/ID
Operating Physician - Last/First
1
2
AN
AN
11/2/9
16/12
78 Required if applicable
Required if applicable
Other Provider - QUAL/NPI/QUAL/ID
Other Provider - Last/First
1
2
AN
AN
2/11/2/9
16/12
79 Required if applicable
Required if applicable
Other Provider - QUAL/NPI/QUAL/ID
Other Provider - Last/First
1
2
AN
AN
2/11/2/9
16/12
80 Required if applicable
Required if applicable
Required if applicable
Required if applicable
Remarks
Remarks
Remarks
Remarks
1
2
3
4
AN
AN
AN
AN
21
26
26
26
81 Required if applicable
Required if applicable
Required if applicable
Required if applicable
Code-Code - QUAL/CODE/VALUE
Code-Code - QUAL/CODE/VALUE
Code-Code - QUAL/CODE/VALUE
Code-Code - QUAL/CODE/VALUE
a
b
c
d
AN/AN/AN
AN/AN/AN
AN/AN/AN
AN/AN/AN
2/10/12
2/10/12
2/10/12
2/10/12

Place-of-Service Codes

All providers are required to submit CMS-1500 claim forms with CMS standard two-digit place-of-service codes entered in Box 24B. Forms submitted without these codes will be rejected with no adjudication and returned to the provider for resubmission. This policy applies to all Premier Health Plan products.

Commonly Used Place-of-Service Codes

Code

Description

11 Office
12 Home
15 Mobile
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Individuals with Intellectual Disabilities
55 Residential Chemical Dependency Treatment Facility
56 Psychiatric Residential Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory

Codes and Modifiers

Claims Coding

Providers who are reimbursed for professional and ancillary services on a fee-for-service basis agree to accept the network reimbursement, less deductibles, coinsurance and copayments as payment in full for covered services provided to Premier Health Plan members.

Unlisted Codes

Procedures

When necessary and appropriate, a provider may bill for a procedure that does not have an existing CPT/HCPCS code. The provider should use the “miscellaneous” or “not otherwise classified” code that most closely relates to the service provided. When using “unlisted” or “not otherwise classified” codes for billing, providers should submit supporting documentation at the time of the claim submission.

Medications

“Unlisted” or “not otherwise classified” drugs must be submitted with applicable HCPCS codes. The claim must include a description of the item/drug supplied, the correct dosage and the National Drug Classification Code number (NDC#).

Physician Modifiers

Frequently used physician modifiers are listed in the following table. For a complete list of modifiers, refer to the CPT manual and the HCPCS Level II manual.

Modifier

Description

24 Unrelated evaluation and management service by the same physician during a postoperative period
25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
33 Preventive services
50 Bilateral procedure
57 Decision for surgery
59 Distinct procedural service
62 Two surgeons
76 Repeat procedure by same physician or other qualified healthcare professional
77 Repeat procedure by another physician or other healthcare professional
78 Unplanned return to the operating/procedure room
80 Assistant surgeon
82 Assistant surgeon (when qualified resident and surgeon not available)
91 Repeat clinical diagnostic laboratory test
LT Left side
RT Right side

Anesthesia Modifiers

Anesthesia claims for all members should be billed with the correct codes from the American Society of Anesthesiologists (ASA) — 00100–01999 — which are included in the CPT manual.

Services performed for Premier Health Plan members by a Certified Registered Nurse Anesthetist (CRNA) are eligible for reimbursement and can be billed in conjunction with the anesthesiologist’s charges, provided the appropriate modifier is used.

Appropriate anesthesia modifiers also should be billed including, but not limited to, the following:

Modifier

Description

AA Anesthesia services performed personally by anesthesiologist
AD Medical supervision by a provider; more than four concurrent anesthesia procedures
QK Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals
QS Monitored anesthesia care service
QX Certified Registered Nurse Anesthetist (CRNA) service with medical direction by a provider
QY Medical direction of one CRNA by an anesthesiologist
QZ CRNA service without medical direction by a physician

Home Medical Equipment Modifiers
Home medical equipment (HME) modifiers include, but are not limited to, the following:

Modifier

Description

RR Rental
NU New purchase
UE Used durable medical equipment

Code-Specific Policies

Blood Draw/Venipuncture

Premier Health Plan does not reimburse for blood draw/venipuncture when that service is provided in conjunction with any other laboratory or evaluation and management service on the same date of service.

Immunizations

The injection is included with the office evaluation and management code (EM) if billed together or on the same date of service.

Surgical Procedures

Providers must note surgical procedures performed during the same operative session by the same provider on a single claim form or electronic equivalent. Billing on separate claim forms may result in delayed payments, incorrect payments, or payment denial.

Reimbursement

Premier Health Plan processes all clean claims within 30 days from the date they are received. Applicable state regulations stipulate that a claim is paid when Premier Health Plan mails the check or electronically transfers funds.

Multiple Payee Addresses

Premier Health Plan does not honor multiple payee addresses. Providers are required to submit a single payee address per tax ID number.

Explanation of Payment (Remittance Advice)

The Explanation of Payment (EOP), referred to on the statement as a remittance advice, is a summary of claims submitted by a provider. It shows the date of service, diagnosis and procedure performed, as well as all payment information (i.e., money applied to the member’s deductible or copayment and denied services.)

For additional questions pertaining to the EOP, contact Provider Services at (855) 514-3678(855) 514-3678

Process for Refunds

PPremier Health Plan accepts overpayments by taking deductions from future claims.

Overpayment

If Premier Health Plan has paid in error and the provider has not sent a refund or returned the check, money will be deducted from future claims paid. The related claim information will be shown on the remittance advice as a negative amount.

Claim Follow-Up

Existing users can log in through Provider OnLine. New users will be asked to register. For login information, contact Provider Services at (855) 514-3678(855) 514-3678.

To check the status of a claim without going online, call Provider Services at (855) 514-3678(855) 514-3678 from 8:00 am to 5:00 pm; Monday – Friday.

Denials and Appeals

All denied claims are reported on the EOP, referred to on the statement as a “remittance advice.” This indicates whether the provider has the right to bill the member for the denied services and/or if the member is financially responsible for payment.

More detailed information on this subject can be found in the Provider Standards and Procedures section of this manual.

All appeals undergo Premier Health Plan’s internal review process, which meets all applicable state and federal requirements.

False Claims

The False Claims Act (31 U.S.C. § 3729) makes it illegal to present or cause to be presented to the federal or state government a false or fraudulent claim for payment. This would apply to U.S. government programs such as Medicaid, Medicare and Medicare Part D, and the Federal Employees Health Benefit Plan (FEHBP). Any person in violation of this act could be liable to the U.S. government for not less than $5,000 and not more than $10,000 per false claim, plus three times the amount of any other damages the U.S. government sustains because of the fraudulent claims.

Qui tam lawsuits can be filed by private citizens referred to as whistle-blowers against any healthcare provider allegedly violating the federal and state False Claims Act.

Whistle-blowers are protected if they are discharged because of their involvement with a suit; they are entitled to reinstatement and damages double the amount of their lost wages.

Best Practices

Best practices to help prevent fraud and abuse include:

  • Develop and follow the elements of a compliance program
  • Audit claims for accuracy
  • Review medical records for accurate documentation of services rendered
  • Take action if you identify a problem (i.e., contact Fraud, Waste and Abuse at (855) 222-1046(855) 222-1046
  • Ask for photo identification when registering patients at the point of service
  • Consider disabling the functionality within EMR systems that would allow one to copy and paste notes from visit to visit