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Claim Submission Guidelines

HCFA 1500 Claims Submission - Medical
HealthPlus of Michigan provides claims processing through electronic transmission or paper submittals. The CPT-4 coding schedule, including modifiers, should be used to designate procedures. ICD-9-CM codes should be used for diagnoses. When there is no designated CPT code available, HPM accepts HCPCS (Health Care Financing Administration Common Procedure Coding System) codes denoted by a single alpha letter (A through V).Specialty providers (vision providers, ambulance services, home health, or skilled nursing agencies) need to refer to the specific coding instructions in your contract.

How To File A Paper Claim
Claims should be submitted to:
HealthPlus of Michigan
P.O. Box 1700
Flint, Michigan 48501-1700

HPM utilizes electronic claims scanning technology to process paper claims.  Submission must be on the HCFA 1500 (12-90) claim form. It is essential the requirements listed below are followed to ensure prompt processing of your claims.

  • The HCFA 1500 (12-90) form must be used and filled out completely.
  • All claims must be typewritten or computer-generated in a dark print--no hand written claims.
  • All data must be contained within each locator box, left justified.
  • The patient's 11-digit contract number must be used (9-digit contract number plus suffix.)
  • No more than six service lines per claim. Do not try to fit two service lines into one space.
  • The procedure code is sufficient--do not type the description.
  • Your HealthPlus provider number, not your tax identification number,
    must be used in form locator box 33 where is says "PIN#".
  • Be sure to enter other health benefit plan information (COB)in form locator box 9.

If you have additional information to include that does not specifically have its own form locator box, please use form locator 19.

The provider number used in form locator box 33 is tied to a tax identification number in our system. Without the HPM provider number, claims payment may be delayed and/or your claim may be returned to you for resubmission.

Incomplete or erroneous claims will be returned to the provider for the completion and/or correction.

UB-92 Claims Submission-Hospital
The UB-92 claim form is accepted for hospital claims. The UB-92 manual provides a complete description of the definition, purpose, billing requirements and instructions for each form locator on the claim form. Refer to this manual for general billing instructions.

How To File A Paper Claim
Claims should be submitted to:
HealthPlus of Michigan
P.O. Box 1700
2050 South Linden Road
Flint, Michigan 48501-1700

Specific requirements for each UB-92 Form Locator element billed to HPM are described for your convenience.

Medical Prior Authorization

A referral is a request by the primary care physician (PCP) to send a patient to a specialist for consultation, diagnostic intervention and/or treatment. Participating physicians are required by contract to comply with the HealthPlus of Michigan referral procedures and protocols.

It is the responsibility of the PCP to submit the referral request within 24 hours of the patient visit. To avoid claim denials, please do not schedule the patient's specialty appointment, except for urgent referral requests, until authorization
approval has been received.

There are two types of referrals:

  • In-Plan
  • Out-of-Plan

An in-plan referral is directed to a participating HPM provider. PCPs are expected to refer to in-plan participating providers. When services are unavailable within the HPM participating provider network, an out-of-plan referral may be requested and would require Medical Director approval.

A referral can be initiated by the PCP in the following ways:

  • Telephone the HPM Referral Department*
  • Fax a completed copy of the HPM Referral Fax Form

*Note: If your referral process is managed by a PHO, please follow the applicable procedures set forth in your agreement.

HPM will send referral notification to the patient, PCP, and specialist within 48 hours of the request. The notification will contain the referral number, approved dates, and the scope of the services to be rendered.

Note: Certain PHOs send the notification to the PCPs and specialist of the
referral requests they process.

Exceptions that supersede a referral or which would render it null and void:

  • The member is no longer eligible
  • The service is not a covered benefit
  • The member switches to another PCP within a referral time span

HMP wil make every attempt to notify providers when these conditions occur.

Prior Authorization

HealthPlus of Michigan has established a Utilization Case Management Program to facilitate the prompt, efficient delivery and monitoring of medically necessary and cost effective health care services to plan members in the most appropriate setting by qualified practitioners. The program components:

  • Inpatient utilization management
  • Procedure management
  • Case management

Precertification
Precertification is required for selected, elective inpatient procedures and most ambulatory and outpatient services outside of the primary care physician's office.  Precertification is not required in the case of urgent or emergent services provided as necessary to screen and stabilize a member's condition where a prudent layperson, acting reasonably, would have believed that an emergency existed.

Admission Review and Certification
Admission review focuses on the medical necessity of the admission. Certification of admissions is performed by the case managers and occurs within 24 hours of admission, or the first working day in coordination with the Primary Care Physician.