An administrative appeal cannot be requested for services rendered to a member who was not eligible on the date(s) of service, or for benefits that are not administered or covered by WellSense. Procedure Coding In addition to nationally recognized coding guidelines, the software has flexibility to allow business rules that are unique to the needs of individual product lines. Billing provider National Provider Identifier (NPI). 529 Main Street, Suite 500 These policies and methodologies are consistent with available standards accepted by nationally recognized medical organizations, federal regulatory bodies and major credentialing organizations. *If you require training or assistance with our online portal, please contact your dedicated Provider Relations Consultant. You can also check the status of claims or payments and download reports using the provider portal. Using modifier SL ensures that the claim is processed, the provider is reimbursed for the administration fee and the vaccination is included in performance measurements. Medicare CMS-1500 and CMS-1450 completion and coding instructions, are available on the Centers for Medicare & Medicaid Services (CMS) website. Access documents and forms for submitting claims and appeals. To avoid possible denial or delay in processing, the above information must be correct and complete. Providers are required to perform due diligence to identify and refund overpayments to WellSense within 60 days of receipt of the overpayment. Clinical consultants who research, document, and provide edit recommendations based on the most common clinical scenario. At Boston Medical Center, research efforts are imperative in allowing us to provide our patients with quality care. We ask that you only contact us if your application is over 90 days old. If the provider has not had a response from the insurance company prior to the 12-month filing limit, he/she should contact the . The following review types can be submitted electronically: Providers may request that we review a claim that was denied for an administrative reason. Box 55991 Charges for listed services and total charges for the claim. BMC physicians are leaders in their fields with the most advanced medical technology at their fingertips and working alongside a highly skilled nursing and professional staff. Contract terms: provider is questioning the applied contracted rate on a processed claim. Diagnosis codes, revenue codes, CPT, HCPCS, modifiers, or HIPPS codes that are current and active for the date of service. BMC HealthNet Plan | Working With Us Filing Limit: when submitting proof of on time claim submission. Primary diagnosis code and all additional diagnosis codes (up to 12 for professional; up to 24 for institutional) with the proper ICD indicator (only ICD 10 codes are applicable for claims with dates of service on and after October 1, 2015). Claims can be mailed to us at the address below. Additional fields may be required, depending on the type of claim, line of business and/or state regulatory submission guidelines. To ensure claims are as accurate as possible, use current valid diagnosis and procedure codes and code them to the highest level of specificity (maximum number of digits) available. To expedite payments, we suggest and encourage you to submit claims electronically. Health Net may seek reimbursement of amounts that were paid inappropriately. Centers for Medicare & Medicaid Services (including NCCI, MUE, and Claims Processing Manual guidelines), Public domain specialty provider associations (such as American College of Surgeons, American Academy of Orthopaedic Surgeons, etc. Claims with incomplete coding or having expired codes will be contested as invalid or incomplete claims. All professional and institutional claims require the following mandatory items: This is not meant to be a fully inclusive list of claim form elements. Health Net is a Medicare Advantage organization and as such, is regulated by the Centers for Medicare & Medicaid Services (CMS). Health Net Overpayment Recovery Department Accommodation code is submitted in Value Code field with qualifier 24, if applicable. Sending claims via certified mail does not expedite claim processing and may cause additional delays. Or use the following clearinghouses: You must correct claims that were filed with incorrect information, even if we paid the claim.The most common reasons for rejected claims are: The process for correcting an electronic claim depends on what needs to be corrected: Replacement and void claims must include the original claim number in a specific position in the 837: Loop 2300, Segment REF - Original Reference Number (ICN/CDN), with F8 in position 01 (Reference Identification Qualifier) and the original claim number in position 02. WellSense Health Plan | Boston Medical Center For providers unable to send claims electronically, paper claims are accepted if on the proper type of form. To reduce document handling time, providers must not use highlights, italics, bold text, or staples for multiple page submissions. Centers for Medicare & Medicaid Services (including NCCI, MUE, and Claims Processing Manual guidelines). Our provider portal is your one stop place to: BMC HealthNet Plan is a non-profit managed care organization that has provided health insurance coverage to Massachusetts residents for more than 20 years. Use Healthcare Common Procedure Coding System (HCPCS) Level I and II codes to indicate procedures on all claims, except for inpatient hospitals. Health Net is a registered service mark of Health Net, LLC. Copyright 2023 Health Net of California, Inc., Health Net Life Insurance Company, and Health Net Community Solutions, Inc. (Health Net) are subsidiaries of Health Net, LLC. Diagnosis pointers are required on professional claims and up to four can be accepted per service line.