Q.

What is the UPIN of referring provider?

A.

The UPIN is for Unique Physician Identification Number. You may locate the Nationwide UPIN Directory on the web site at www.cpg.mcw.edu/www/upin.html.

Q.

The ARU tells me that you are not working on that Date of Service. What is the status of my claim?

A.

The status of claims can be obtained through the Automated Response Unit (ARU). If the ARU is stating that we are not working on a claim for that Date of Service, it means that we have not received the claim. You need to re-submit the claim.

The ARU will retrieve the information based on what is keyed into your telephone keypad. Make sure that you have the correct:

• Date of Service,
• Medicare claim number, and
• Provider Identification Number (PIN).

Also, verify that the claim was submitted with the correct date of service, correct patient’s Medicare number and the correct Provider Identification Number (PIN).

Q.

Why did I receive a denial for a duplicate?

A.

Duplicate denials are processed based on claim submissions. If a "copy" (duplicate) of a claim is received and the "original" has processed or is still pending, a duplicate denial will generate. If you continue to submit the same claim, and we have already considered that claim for payment, you will continue to receive "duplicate" denials.

To avoid these duplicate denials, the Automated Response Unit (ARU) is provided to check the status of a claim(s). If the ARU is stating that we are working on a particular claim for that Date of Service, you do not need to re-submit the claim.

Q.

Which modifier(s) do I use? I don’t have a bulletin or listing of modifiers.

A.

The most recently Medicare published modifier listing was in the December Medicare Bulletin, 99-8, page 11. Modifiers may change annually with the CPT and HCPCS code revisions. Please consult your current CPT and HCPCs manual for more detailed information on each modifier.

Q.

LMRP diagnosis code changes, where can I find the bulletin that has the diagnosis codes to make the claim payable?

A.

You can look on the Internet at www.medicarenhic.com. Once you are there, you must first choose California Physicians/Suppliers, then choose Policies. Then Final Local Medical Review Policy (LMRP). Finally, select your region (Northern or Southern California). This will take you to the "Index of Local Medical Review Policies". The index will list the subject, LMRP #, HCPCs codes, Bulletin reference, and its effective date. To locate your subject, click once on the appropriate Bulletin reference number. This will pull up the actual bulletin you are looking for.

Q.

I have ordered EOMBs through the computer/ARU. Why do I continually get duplicates?

A.

A. Duplicate EOMBs can be received for several reasons:

• EOMB was requested through the ARU and also through a Call Center Representative.
• A claim was submitted more than once for the same patient for the same date of service.
• A duplicate claim is pending/processing. The EOMB is received upon finalization within the timeframe of the EOMB requested through the ARU.

Q.

What date was the check cashed and what is the check number?

A.

Claim information as to what check number the claim was paid on, can be found through the Automated Response Unit (ARU). You will need your Provider Identification Number (PIN), the patients Medicare claim number and the date of service. The cashed date can not be obtained through the ARU; you would need to call our provider line number and speak to a Customer Service Representative for cashed date information.

This information can also be obtained by speaking to our Customer Service Representative. When speaking to a Customer Service Representative you will be asked for the patients Medicare Claim number, date of service, your Provider Identification Number (PIN) and the office you are calling from. The Customer Service Representative will be able to tell you the Check Number and the date the check cleared our bank.

Q.

The claim I submitted denied and transferred to the HMO. What is the name and address of the HMO?

A.

This information can be obtained from the beneficiary or by requesting a copy of their HMO eligibility card. If the beneficiary does not recall the HMO or is unable to provide you with the HMO information, you may obtain the information by calling a Medicare Representative at our toll free number 877-591-1587.

Q.

Which bulletin/Medicare Resource has the LMRP information?

A.

For general information refer to Bulletin June 2000/00-2 page 53 or follow the same guidelines as question number 5 above. Bulletin March 2001/01-1 page 48 has a complete listing of active LMRPs.

Q.

Why did the claim reject for an invalid diagnosis code?

A.

Claims are rejected whenever an invalid diagnosis code is submitted. A diagnosis code may be invalid for several reasons: it was not billed to the highest level of specificity, it is not listed in the latest version of the ICD-9-CM book, it was in an invalid format, etc. The following is a reminder for Block 24e ­ Diagnosis Code, of the HCFA-1500 form:

The patient’s diagnosis/condition should be entered in Block 21. All physician specialties and independent laboratories (for limited coverage procedures only) must use an ICD-9-CM diagnosis code. All ICD-9-CM diagnosis codes must be billed to the most specific level shown in the ICD-9-CM book.

Up to four codes, listed in priority order, can be entered into Block 21. Narrative information should not be entered. Each ICD-9-CM diagnosis code must be entered in its own field. Two ICD-9-CM codes should not be entered into one field.

Block 24e must have the diagnosis code reference number or "pointer" (1, 2, 3, OR 4) from Block 21 entered that supports the need for the procedure code for that date of service. Only one reference number should be entered per line item. When multiple services are performed, only one procedure code and one primary reference number should be entered per line. Do NOT reference more than one diagnosis code per procedure code. For example, do not enter "1 2 3 4" or "ALL". Do not use ICD-9-CM codes in Block 24e.