Q.

No Record of Claim ­ Accessed the ARU, it stated that there was not a claim for that date of service, can you please double check that for me?

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 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 Health Insurance 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 can 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 Representatives could verify the information for you. There is a limit to the number of transactions that a Customer Service Representative could help you with.

Q.

Claim Pending ­ Why haven’t I received payment for this claim?

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.

Facsimile Remittance Request (EO to Prov) ­ May I have a copy of the Remittance Advice?

A.

In order to send a copy of your remittance we will need your PIN number , the remittance number, (which is the same as the check number) and we will need to verify your address. This will take 5 to 30 days for you to receive the remittance copy.

Customer Service:

• N. California Provider Lines - (877) 591-1587 Toll Free
• S. California Provider Lines - (866) 502-9054 Toll Free

Q.

Individual Provider Information ­ Could I get a provider’s UPIN?

A.

The UPIN is for Unique Provider Identification Number. You may locate in the Nationwide UPIN Directory on the web site at http://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 Free

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 855I (Blue) application along with your California License and Social Security Number to:

§ N. California
The Medicare Certification Department
PO Box 602
Marysville, CA 95901-0602

§ S. California
The Medicare Certification Department
PO Box 6056
Los Angeles, CA. 90060-0560

Q.

Billing References ­ May I have a bulletin on procedure code ______ ?

A.

You may locate any bulletins published by visiting our web-site located at http://www.medicarenhic.com/

Go to:

• California Physicians/Suppliers
• Publications
• Northern or Southern California
• California Bulletin Index (May take a few minutes)
• Download the zipped Excel file (if you haven’t done so yet) follow instructions
• Select NHIC Northern Publications Document
• Once you are in the index
• Control "F" to find your request
• Key in a specific procedure code or its definition
• Enter or click on "Find Next" (your request will be outlined)

Or, you call our Customer Representatives to send copies, of any requested page(s), of the bulletin.

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

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

Q.

Claim Status Information ­ The ARU does not have a record of the claim, can you verify receipt for me?

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 could help you with.

Q.

Additional Information Needed ­ What was missing on this claim?

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 will be able to assist in determining what specific information is needed. This can be done on a claim by claim basis.

Q.

All Other HMO ­ Can you tell me what HMO my claim was sent to?

A.

Many beneficiaries receive Medicare Part B benefits through their voluntary enrollment in a Health Maintenance Organization (HMO). These HMO plans are under contract with the Federal government to both furnish Medicare benefits for their beneficiary enrollees.

Providers and Suppliers should periodically verify beneficiary Medicare coverage. Beneficiaries may be in or out of HMO plans often. Effective communication with the beneficiary and the HMO plans regarding coverage requirements and eligibility is essential.

If the beneficiary does not recall the HMO or is unable to provide the HMO information, HMO information may be obtained by calling a Medicare Representative at our toll free number 877-591-1587. The Medicare Representative must validate the following data received from the Provider or Supplier before releasing HMO information.

• Provider or supplier name
• Provider or supplier identification number
• Beneficiary last name and first initial
• Beneficiary date of birth
• Beneficiary Health Insurance Claim number
• Beneficiary gender

If the information supplied by the Provider or Supplier is not valid with Medicare Representative, the Provider or Supplier will be refer to the beneficiary. Beneficiaries with eligibility problems should be encouraged to contact the HMO or their local Social Security Administration office.

Q.

Check Status ­ When was my last check sent out?

A.

Check Status information can be obtained through the Automated Response Unit (ARU). You will need your Provider Identification Number (PIN). An unlimited number of requests can be made through the ARU. The following options are listed on the ARU for Check information:

• Information about the last three checks issued;
• Information about a specific check;
• Information on cleared checks;
• Information on the status of all outstanding checks; and
• Information about checks by the date issued.

The ARU will give you the following information:

• The Check Number;
• The Date the Check was issued;
• The Amount of the Check;
• The Status of the Check; AND
• If the Check has been cashed, it will state the date the Check was cashed.

This information can also be obtained by speaking to our Customer Service Representatives. When speaking to a Customer Service Representative you will be asked for your name, 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. You will be limited to five Check requests per call.

Q.

Modifier ­ Why was this claim denied for incorrect/invalid procedure code/modifier?

A.

Each claim received by Medicare is processed on a claim by claim bases. However, once a claim has been filed with Medicare, Medicare will either deem the claim unprocessable, deny or reduction of payment claim, or pay the claim.

For a modifier an unprocessable claim(s) is a claim that has been submitted with a missing, incomplete or invalid modifier. The submitter of the claim will be notified of the error(s). No appeal rights are allowed on this claim(s) because no "initial determination" can be made rendering the claim unprocessable. However, once the submitter has corrected the modifier, the claim then can be resubmitted or retransmitted to be considered for payment.

For a modifier has been denied or had a reduction in payment, a review of an initial claim determination may be requested by telephone or by written correspondence.

General Guidelines for Written Correspondence Review ­

• A cover letter explaining precisely why the modifier needs to be reviewed,why it was felt the modifier in question was incorrectly processed, and the action desired to be completed.
• Include your provider number, provider name, and beneficiary Health Insurance Claim Number.
• An identification of the claim(s) in question. (Copies of Medicare Remittance Notice forms with the affected claim(s) highlighted are best.)
• Any documents that will substantiate the reason for the review that were not submitted with the original claim(s).