Apple Health: Clarifying the Process for Billing Commercial Insurance Information
Washington State Health Care Authority sent this bulletin at 06/14/2017 02:09 PM PDT
Apple Health (Medicaid): Provider Alert
The Health Care Authority (agency) is issuing this provider alert to
clarify the process for billing commercial insurance information on a claim. Providers
must verify other coverage information for the client prior to billing the
agency.
Verifying
Commercial Insurance Information in ProviderOne
Prior to billing the agency, you must check Client Inquiry in
ProviderOne to find out if the agency has Other Payer coverage for the client.
If you know about other coverage that is not on file with the agency, send that
information to the agency before submitting your claim, using the following
process:
Choose the “I am an Apple Health (Medicaid) biller or provider” option.
In the “Contact” section, click the “Online: Secure web form” hyperlink under “Medical Assistance Customer Service Center (MACSC).”
Click the “Medical Provider” button and fill out the appropriate information.
Choose “Private Commercial Insurance” in the “Select Topic” dropdown menu.
Click on “Submit Request.”
You should wait 3-5 business days to check Client Inquiry again. Once the
agency has the Other Payer coverage on file, you may bill your claim. Use the
Carrier Code listed for that coverage as the ID in the “Additional Other Payer
Information” section.
You must bill using the electronic fields for client coverage
information and Other Payer denial or payment information. Claim comments can
be used in addition to using the electronic fields, but not using the
electronic fields could cause claim denials.
Submitting
Other Payer Denials
For claims denied by the Other Payer, you must submit the denial Claim
Adjustment Reason Code(s) (CARC(s)) electronically at header or line level. Do
not bill with electronic CARC codes unless you have documented justification
for their use. For 837 Health Insurance Portability and Accountability Act (HIPAA)
transactions, enter the CARC information in Loop 2320, CAS Segment, Data
Element CAS02. The agency will deny claims that were denied by the Other Payer if
you do not include electronic CARC codes or backup information.
Submitting
Other Payer Payments
For claims paid by the Other Payer, you must submit the payment amount
at header level. You may also submit line level payment information, but the
sum of all line payment amounts must equal the header payment amount. If all
lines are paid by the Other Payer, it is not necessary to bill with CARC codes.
NOTE: When
billing for FQHC, RHC, or Tribal Encounters using T1015, do not list line level
payments for any line. Always bill using header payment amounts only. Billing
with line payment amounts on claims with procedure code T1015 may cause
improper payment amounts or claim denials.
For claims in which the Other Payer has paid some lines and denied
others, you may bill all lines on the same claim. Bill the payment amount as
applicable. For lines denied by the Other Payer, you must include all appropriate
CARC codes at header or line level.
NOTE: For
billing Medicare coverage or payments, including Part C or Medicare Advantage
plans, refer to the “Submitting Medicare Crossover Claims” section ProviderOne Billing and Resource Guide.
Please do
not reply directly to this message. If you have feedback
or questions, please visit the HCA
website for contact information.
About
WashingtonStateHealth Care Authority HCA oversees the state’s top
two health care purchasers — Washington Apple Health (Medicaid) and the Public
Employee Benefits Board Program. We work with partners to help ensure
Washingtonians have access to better health and better care at a lower cost. For
more information, visit www.hca.wa.gov.