Q.

Claim Pending ­ Submitted a claim 20 days ago, why haven’t I received payment yet and why is it still processing?

A.

Medicare carriers are required by law to withhold payment to providers and suppliers after claims have completed processing for a minimum number of days. This minimum number of days is called the "payment floor".

The payment floor for paper claims is 27 days. However, for electronic claims, the payment floor is reduced to only 13 days. This reduction is to encourage providers and suppliers to use electronic claim submission. Paper claims are paid no sooner than the 28^th day after the claim is received, and electronic claims are paid no sooner that the 14^th day following the receipt of the claim.

Clean claims are usually paid immediately after the payment floor time period has passed. A claim is considered "clean" when it does not require manual intervention, and it contains all of the required information necessary to issue a payment decision and Medicare Remittance Notice or Summary Notice. Clean claims allow the Medicare carrier to process the claim without having to ask the physician, supplier, beneficiary, or a third party for additional information. Claims, which are not considered "clean", and claims involving unique circumstances, may be subject to longer processing periods while Medicare researches for more information.

"Clean" claims, which have not been paid by the 30th day after the date of receipt, are subject to payment of interest. Interest will be applied starting on the 31^st day.

Q.

Claim Status ­ When did the claim pay, what was the billed amount, and the check number?

A.

Claim status may be obtained through the Automated Response Unit (ARU). The Automated Response Unit will have information on claim(s) that are being processed, duplicate claim(s) and denied claim(s). If the ARU is stating that we are not working on a claim at this time, verify that the information you are keying into the ARU you is the correct information (example: the date of service, year, etc.).

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).There is no limit to the number of transactions that you could verify through the ARU.

If you have gone through the ARU and have not been able to get the information that you are requesting, our Customer Service Representative(s) could verify the information for you. There is a limit to the number of transactions that a Customer Service Representative can help you with.

Q.

Individual Provider Information ­ Can you provide me the doctor’s UPIN?

A.

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

To retrieve or verify a Unique Provider Identification Number (UPIN), over the telephone, you must provide the Customer Service Representative with your 9 digit Provider Identification Number (PIN) issued by Medicare

N. California Provider Lines - (877) 591-1587 Toll Fre

S. California Provider Lines - (866) 502-9054 Toll Free

If you do NOT HAVE a PIN, issued by Medicare, and want a UPIN only, you must submit an 855 (Blue) application along with your California License and Social Security Number to

N. California
The Medicare Certification Department
PO Box 602
Marysville, CA. 95901-060

S. California
The Medicare Certification Department
PO Box 60560
Los Angeles, CA. 90060-0560

Q.

Modifier ­ Is there a modifier on the claim?

A.

This information may be obtained by reviewing the Modifier (MODS) field on the Remittance Advice Notice for the claim in question. The information may also be obtained by speaking with one of our Customer Service Representatives. When speaking to a Customer Service Representative you will be asked for the patient’s Health Insurance Claim number (Medicare number), the date of service in question, your Provider Identification Number (PIN) and the office you are calling from. Also, please have available the "original" claim in question to compare it to the claim that was submitted to Medicare.

Q.

Check Status ­ The ARU states claim processed, could I get the check number and the date check was cashed?

A.

Obtain information on checks that are in the check history using options such as date ranges, check status, check issue date, and check number’s issued by NHIC Medicare. You will need your Provider Identification Number (PIN), patient’s Health Insurance Claim (HIC) number, and date of service of the claims in question.

Q.

Additional Information Needed ­ Claim denied, what additional information is needed?

A.

When additional information is required for a claim to continue processing, an Automated Development System letter (ADS) is sent out. The letter will indicate what information is needed. If no response is received within the specified time frame, a second letter is generated allowing additional time to respond. If there is still no response, the telephone representatives may be able to assist in determining what specific information is needed. This can be done on a claim by claim basis.

Q.

Facsimile Remittance Request­ I have received a check without a Remittance Advice, why didn’t I receive one?

A.

The Medicare checks are mailed out along with the Remittance Advice Notice. If a check is received without a Remittance Advice, you may request a facsimile copy by calling our provider line number (No. California - 877-591-1587, So. California - 866-502-9054). You can request Facsimile Copies by going through the Automated Response Unit (ARU) or speaking to a customer service representative.

Q.

All Other HMO ­ Claim denied stating other insurance or transferred to another carrier, can you tell me who the claim was transferred to?

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

No. California - 877-591-1587

So. California - 866-502-9054

Q.

Reopening/Limiting Charge ­ What is the limiting charge for procedure code XXXXX?

A.

The maximum amount that a non-participating physician, practitioner, or supplier can charge a Medicare beneficiary for a non-assigned service is 115% of the Medicare allowed amount. The Medicare limiting charge can be calculated by multiplying the amount under the "ALLOWED" field on your Medicare Remittance Notice by 115%. Also, the Medicare Fee Schedule will show the Limiting Charge for each service listed.

The limiting charge provision applies only to non-assigned claims. The submission of an non-assigned claim with a billed charge that exceeds the Medicare limiting charge amount is a violation of the charge limit. If the charges are billed as assigned, you can collect in total, no more than the Medicare approved amount for the service(s).

Q.

Can you explain why there is a Medical Necessity denial on this claim?

A.

Based on the diagnoses that the doctor submitted the service is not covered. You may request a review by calling Telephone Review with the corrected information or by submitting it in writing to the Medicare Review/Appeals Department.