1. Clinic Billing Policy Procedure Manual

The practice of medicine has undergone many changes during the past decades, not least of which is management of the practice. Numerous journal articles and books have been published on practice management and we will not attempt to recreate them here. While many are truly useful, too often they describe what results are needed and fail to address how to obtain those results. Many of the practices with whom we work have requested concrete guidance on accounts receivable management and cash controls. This monograph presents specific suggestions on how to deal with this aspect of your practice on a day-to-day basis.

Revision History The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 2 Revision Date: April 2011 Version 3.9 Revision History The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 3 Revision Date: April 2011 Version 3.9 Revision History Version Revision Date Revision Page Number(s) Reason Reviser 2.0 Feb. 2005 All Annual revision Publications 2.1 March 2005 8-15 Added Acronyms Publications 3.0 June 2005 64, 65, 121, 151 - 154 Redaction Publications 3.1 Oct. 2005 127 Redaction Publications 3.2 Jan.

2007 All 2006 annual update Publications 3.3 Aug. 2007 All 2007 annual update Publications 3.4 Dec. 2007 All Redaction Publications 3.5 July 2008 54 – 57 CO 8766 - Redaction Publications 3.6 Oct. 2008 178 - 182 OHCA ordered Publications 3.7 Dec.

2008 26 – 38, 313 Medical Home updates Publications 3.8 Feb. 2011 74, 77, 82, 89, 90, 95 Redaction Publications 3.9 April 2011 91 Redaction Publications Revision History The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 4 Revision Date: April 2011 Version 3.9 Table of Contents The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 5 Revision Date: April 2011 Version 3.9 Table of Contents Chapter 1 General Information. 9 Introduction. 10 Section A: OHCA Web site. 10 Section B: General Contact Information. 12 Chapter 2 SoonerCare Programs.

15 Introduction. 16 Section A: Provider Policies. 16 Section B: Provider File Maintenance. 17 Section C: Provider Services.

17 Section D: Written Inquiries. 23 Chapter 3 SoonerCare Choice. 24 Introduction.

25 Section A: Covered Members. 26 Section B: Access to Care. 27 Section C: Member Enrollment/Disenrollment. 28 Section D: Referrals. 30 Section E: EPSDT.

32 Section F: Reporting Requirements. 33 Section G: Reimbursement. 33 Section H: Provider Resources. 34 Chapter 4 Member Eligibility Verification.

37 Introduction. 38 Section A: Member ID Card. 38 Section B: Options to Verify Member Eligibility. 38 Chapter 5 Web/RAS.

42 Introduction. 43 Section A: Accessing The Secure Web Site.

43 Section B: Web Features. 48 Section C: Remote Access Server (RAS). 59 Chapter 6 Claim Completion. 67 Introduction. 68 Section A: Paper Claim Recommendations. 68 Section B: 1500, Professional, 837P.

70 Section C: UB 04, Institutional, 837I. 84 Section D: ADA 2006, Dental, 837D. 97 Section E: Drug/Compound Prescription Drug, Pharmacy, NCPDP. 107 Section F: Electronic Claim Filing Attachment Filing. 116 Section G: Medicare-Medicaid Crossover Invoice. 118 Chapter 7 Electronic Data Interchange.

121 Introduction. 122 Section A: Professional Claims (837 Professional). 123 Section B: Institutional Claims (837 Institutional). 124 Section C: Dental Claim (837 Dental). 124 Section D: Pharmacy Claims.

125 Section E: Claim Inquiries/Responses. 125 Table of Contents The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 6 Revision Date: April 2011 Version 3.9 Section F: Eligibility Inquiries/Responses. 126 Section G: Remittance Advice (RA). 127 Section H: Electronic Claims or Prior Authorizations with Paper Attachments.

127 Section I: Electronic Media Types. 128 Section J: HIPAA transaction and code set requirements. 129 Chapter 8 Claims Resolution Process. 130 Introduction. 131 Section A: Claim Creation.

131 Section B: Data Entry. 132 Section C: Resolutions. 133 Chapter 9 Paid Claim Adjustment Procedures. 136 Introduction. 137 Section A: Adjustment Categories. 137 Section B: Adjustment Types and Workflow.

140 Chapter 10 Indian Health Services. 141 Introduction. 142 Section A: SoonerCare Eligibility. 142 Section B: Contract Health Services. 142 Chapter 11 Pharmacy.

143 Introduction. 144 Chapter 12 Insure Oklahoma. 147 Introduction. 148 Section A: What is the Insure Oklahoma Individual Plan?. 148 Section B: Insure Oklahoma Individual Plan Billing Procedures. 150 Chapter 13 Long Term Care Nursing Facilities. 151 Introduction.

152 Section A: LTC Nursing Facility Provider Eligibility. 152 Section B: Pre-admission Screening And Resident Review Process (PASRR). 152 Section C: ICF/MR Process. 152 Section D: Member Level Of Care Appeals Process. 153 Section E: Billing Considerations.

153 Chapter 14 Third Party Liability. 154 Introduction. 155 Section A: Services Exempt from Third Party. 157 Section B: Third Party Liability Claim Processing Requirements. 158 Section C: Coordination with Commercial Plans. 161 Section D: Medicare-OHCA Related Reimbursement.

162 Section E: Member Third Party Liability Update Procedures. 164 Chapter 15 Prior Authorization. 168 Introduction. 169 Section A: Prior Authorization Requests. 169 Section B: Prior Authorization Process. 171 Section C: Reconsideration and Appeal Procedures. 172 Section D: Home & Community-Based Services (HCBS) §1915(c) WAIVER Prior Authorizations.

174 Table of Contents The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 7 Revision Date: April 2011 Version 3.9 Chapter 16 Financial Services. 175 Introduction.

176 Section A: Payment Information. 176 Section B: Paper RA. 177 Section C: Electronic Remittance Advice. 303 Section D: 1099 & W-2s. 303 Section E: Stop Payments, Voids, Re-issuance.

303 Section F: Electronic Care Coordination Payments. 304 Chapter 17 Utilization Review. 309 Introduction. 310 Section A: Provider Utilization Review. 311 Section B: Member Utilization Review. 312 Section C: Utilization Review Trends. 313 Section D: Administrative Review and Appeal Process.

314 Chapter 18 Quality Assurance And Improvement. 315 Introduction.

316 Section A: Provider Utilization Review. 316 Section B: On-Site Provider Audits. 317 Section C: Member or Provider Complaints. 318 Section D: Quality Improvement Studies/Projects. 318 Section E: System Integrity. 319 Chapter 19 Forms.

321 Introduction. Okla State Agency Okla Agency Code Title and Authors Publisher Oklahoma Health Care Authority Publication Date Publication type Serial holdings 2007- Subject Purpose The and the for and, and. This not a of of.

This to for that in the. Notes: and; OkDocs Class# Digital Format, ODL electronic copy Downloaded from agency website: www.okhca.org Rights and Permissions This Oklahoma state government publication is provided for educational purposes under U.S. Copyright law. Other usage requires permission of copyright holders Language Date created Date modified OCLC number. Title and OkDocs Class# Digital Format, ODL electronic copy Downloaded from agency website: Rights and Permissions This Oklahoma state government publication is provided for educational purposes under U.S. Copyright law.

Other usage requires permission of copyright holders. Language Full text Revision History The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 2 Revision Date: April 2011 Version 3.9 Revision History The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 3 Revision Date: April 2011 Version 3.9 Revision History Version Revision Date Revision Page Number(s) Reason Reviser 2.0 Feb. 2005 All Annual revision Publications 2.1 March 2005 8-15 Added Acronyms Publications 3.0 June 2005 64, 65, 121, 151 - 154 Redaction Publications 3.1 Oct.

2005 127 Redaction Publications 3.2 Jan. 2007 All 2006 annual update Publications 3.3 Aug. 2007 All 2007 annual update Publications 3.4 Dec. 2007 All Redaction Publications 3.5 July 2008 54 – 57 CO 8766 - Redaction Publications 3.6 Oct.

2008 178 - 182 OHCA ordered Publications 3.7 Dec. 2008 26 – 38, 313 Medical Home updates Publications 3.8 Feb. 2011 74, 77, 82, 89, 90, 95 Redaction Publications 3.9 April 2011 91 Redaction Publications Revision History The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 4 Revision Date: April 2011 Version 3.9 Table of Contents The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 5 Revision Date: April 2011 Version 3.9 Table of Contents Chapter 1 General Information. 9 Introduction. 10 Section A: OHCA Web site. 10 Section B: General Contact Information. 12 Chapter 2 SoonerCare Programs.

15 Introduction. 16 Section A: Provider Policies.

16 Section B: Provider File Maintenance. 17 Section C: Provider Services. 17 Section D: Written Inquiries. 23 Chapter 3 SoonerCare Choice. 24 Introduction.

25 Section A: Covered Members. 26 Section B: Access to Care. 27 Section C: Member Enrollment/Disenrollment. 28 Section D: Referrals. 30 Section E: EPSDT. 32 Section F: Reporting Requirements. 33 Section G: Reimbursement.

33 Section H: Provider Resources. 34 Chapter 4 Member Eligibility Verification. 37 Introduction.

38 Section A: Member ID Card. 38 Section B: Options to Verify Member Eligibility.

Clinic Billing Policy Procedure Manual

38 Chapter 5 Web/RAS. 42 Introduction. 43 Section A: Accessing The Secure Web Site. 43 Section B: Web Features. 48 Section C: Remote Access Server (RAS). 59 Chapter 6 Claim Completion.

67 Introduction. 68 Section A: Paper Claim Recommendations. 68 Section B: 1500, Professional, 837P. 70 Section C: UB 04, Institutional, 837I. 84 Section D: ADA 2006, Dental, 837D.

97 Section E: Drug/Compound Prescription Drug, Pharmacy, NCPDP. 107 Section F: Electronic Claim Filing Attachment Filing. 116 Section G: Medicare-Medicaid Crossover Invoice. 118 Chapter 7 Electronic Data Interchange. 121 Introduction.

122 Section A: Professional Claims (837 Professional). 123 Section B: Institutional Claims (837 Institutional). 124 Section C: Dental Claim (837 Dental). 124 Section D: Pharmacy Claims. 125 Section E: Claim Inquiries/Responses. 125 Table of Contents The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 6 Revision Date: April 2011 Version 3.9 Section F: Eligibility Inquiries/Responses.

126 Section G: Remittance Advice (RA). 127 Section H: Electronic Claims or Prior Authorizations with Paper Attachments. 127 Section I: Electronic Media Types. 128 Section J: HIPAA transaction and code set requirements. 129 Chapter 8 Claims Resolution Process.

130 Introduction. 131 Section A: Claim Creation. 131 Section B: Data Entry. 132 Section C: Resolutions. 133 Chapter 9 Paid Claim Adjustment Procedures. 136 Introduction. 137 Section A: Adjustment Categories.

137 Section B: Adjustment Types and Workflow. 140 Chapter 10 Indian Health Services. 141 Introduction. 142 Section A: SoonerCare Eligibility. 142 Section B: Contract Health Services.

142 Chapter 11 Pharmacy. 143 Introduction. 144 Chapter 12 Insure Oklahoma. 147 Introduction. 148 Section A: What is the Insure Oklahoma Individual Plan?. 148 Section B: Insure Oklahoma Individual Plan Billing Procedures.

150 Chapter 13 Long Term Care Nursing Facilities. 151 Introduction. 152 Section A: LTC Nursing Facility Provider Eligibility. 152 Section B: Pre-admission Screening And Resident Review Process (PASRR). 152 Section C: ICF/MR Process. 152 Section D: Member Level Of Care Appeals Process.

153 Section E: Billing Considerations. 153 Chapter 14 Third Party Liability. 154 Introduction. 155 Section A: Services Exempt from Third Party. 157 Section B: Third Party Liability Claim Processing Requirements. 158 Section C: Coordination with Commercial Plans. 161 Section D: Medicare-OHCA Related Reimbursement.

162 Section E: Member Third Party Liability Update Procedures. 164 Chapter 15 Prior Authorization. 168 Introduction. 169 Section A: Prior Authorization Requests. 169 Section B: Prior Authorization Process.

171 Section C: Reconsideration and Appeal Procedures. 172 Section D: Home & Community-Based Services (HCBS) §1915(c) WAIVER Prior Authorizations.

174 Table of Contents The OHCA Provider Billing And Procedure Manual Library Reference: OKPBPM 7 Revision Date: April 2011 Version 3.9 Chapter 16 Financial Services. 175 Introduction. 176 Section A: Payment Information. 176 Section B: Paper RA.

177 Section C: Electronic Remittance Advice. 303 Section D: 1099 & W-2s.

303 Section E: Stop Payments, Voids, Re-issuance. 303 Section F: Electronic Care Coordination Payments. 304 Chapter 17 Utilization Review. 309 Introduction. 310 Section A: Provider Utilization Review.

311 Section B: Member Utilization Review. 312 Section C: Utilization Review Trends. 313 Section D: Administrative Review and Appeal Process. 314 Chapter 18 Quality Assurance And Improvement. 315 Introduction.

316 Section A: Provider Utilization Review. 316 Section B: On-Site Provider Audits. 317 Section C: Member or Provider Complaints. 318 Section D: Quality Improvement Studies/Projects. 318 Section E: System Integrity. 319 Chapter 19 Forms. 321 Introduction.