Claim Submission Requirement for Type I NPIEffective for dates of service on or after April 15, 2015
Professional claims are required to be populated with the Provider's Type I NPI in the rendering provider field on the claim. Claims that do not contain this information will be denied with the explain code "KO - Denied Rendering NPI needed." Providers will be held to timely filing policies in regards to submission of the initial and corrected claim.
The following provider types are excluded from this requirement: ambulance, ambulatory surgery centers (including eye surgery centers), DME, dialysis, genetic testing, hearing aid, home health, home infusion, hospice, hospital, lab, manufacturers of frames and lenses, and skilled nursing facilities.
Note: If there are limitations in claims submission or clearinghouse specifications whereby the billing provider NPI and rendering provider NPI cannot match, the rendering provider NPI field must be populated to ensure claims payment.
HCFA 1500 Claims Submission - Medical
HealthPlus requires electronic submission of claims, except in limited situations. When HealthPlus receives paper claims, electronic claims scanning technology is utilized to process clean paper claims. Submission must be on the current HCFA 1500 claim form. It is essential the requirements listed below are followed to ensure prompt processing of your claims.
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 Claims Submission - Hospital
The UB claim form, also know as the CMS-1450 form is accepted for hospital claims. The UB 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
Flint, Michigan 48501-1700
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:
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:
*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:
HPM will make every attempt to notify providers when these conditions occur.
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:
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.
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