Claims Retrieval. The HMO must maintain a claim retrieval system that can upon request identify date of receipt, action taken on all provider claims (i.e., paid, denied, other), and when action was taken. The HMO must have procedures in place that will show the date a claim was received whether the claim is a paper copy or an electronic submission. In addition, the HMO must maintain a claim retrieval system that can identify, within the individual claim, the services provided and the diagnoses of the members using nationally accepted coding systems: HCPCS including Level I CPT codes and Level II and Level III HCPCS codes with modifiers, ICD-9-CM diagnosis and procedure codes, and other national code sets such as place of service, type of service, and EOB codes. Finally, the claim retrieval system must be capable of identifying the provider of services by the appropriate BadgerCare Plus and/or Medicaid SSI provider ID number and/or National Provider Identifier (NPI), if applicable, assigned to all in-plan providers.
Claims Retrieval. The HMO must maintain a claim retrieval system that can upon request identify date of receipt, action taken on all provider claims (i.e., paid, denied, other), and when action was taken. The HMO must have procedures in place that will show the date a claim was received whether the claim is a paper copy or an electronic submission. In addition, the HMO must maintain a claim retrieval system that can identify, within the individual claim, the services provided and the diagnoses of the enrollees using nationally accepted coding systems: HCPCS including Level I CPT codes and Level II and Level III HCPCS codes with modifiers, ICD-9-CM diagnosis and procedure codes, and other national code sets such as place of service, type of service, and EOB codes. Finally, the claim retrieval system must be capable of identifying the provider of services by the appropriate Wisconsin Medicaid provider ID number assigned to all in-plan providers. Refer to Article III, H, 1, for use of providers certified by the Medicaid program.
Claims Retrieval. The PIHP must maintain a claim retrieval system that can, upon request, identify date of receipt, action taken (i.e., paid, denied, other) and date the action was taken on all claims. The PIHP must have procedures in place that will show the date a claim was received whether the claim is a paper copy or an electronic submission. In addition, the PIHP must maintain a claim retrieval system that can identify, within the individual claim, the services provided and the diagnoses of the member using nationally accepted coding systems: HCPCS including Level I CPT codes and Level II and Level III HCPCS codes with modifiers, current ICD diagnosis and procedure codes, and other national code sets such as place of service, type of service, and EOB codes. Finally, the claim retrieval system must be capable of identifying the provider of services by the appropriate Wisconsin Medicaid provider ID number and/or National Provider Identifier (NPI), if applicable, assigned to all in-plan providers.
Claims Retrieval. The HMO must maintain a claim processing system that can upon request identify date of receipt, adjudication action on all claims types (i.e., paid, denied, suspended, etc.), and date of adjudication. In addition, claim processing system must be identify, within the individual claim, the services provided and the diagnoses of the members using nationally accepted coding systems as specified in the Encounter User Guide. Finally, the claim processing system must be capable of identifying the provider of services National Provider Identifier (NPI), or atypical identifier if applicable, and their associated taxonomy numbers and CLIA numbers.
