Provider Handbook
Claims and Block Grant Submission Requirements
A clean claim is a UB-04 or CMS-1500, submitted by a provider for medical care or health care services rendered to a covered Member which accurately contains information including, but not limited to:
- Member’s name and date of birth
- Covered Member’s identification number
- Date(s) and place of service or purchase
- Services and supplies provided
- ICD-9 code
- CPT-4 code (CMS 1500 form)
- Revenue Code for UB-04 (CMS1450) form (primarily for hospital-based services)
- Provider’s name, address and tax identification number
- Provider’s National Provider Identifier (NPI)
- Taxonomy Code (on claims submitted electronically)
- Provider’s license number
- Provider’s charges
- Other information or attachments that may be mutually agreed upon by the parties in writing
In addition, the claims must be free from defect or impropriety (including lack of required substantiating documentation) or circumstance requiring special treatment that prevents timely payment. If additional information is required, the provider agrees to cooperate by providing any information reasonably requested for the purpose of consideration and in obtaining necessary information relating to coordination of benefits, subrogation, and verification of coverage and health status. All billings by the provider will be considered final unless adjustments or an appeal request is received by ValueOptions® within 60 calendar days from the date indicated on the Explanation of Benefits form sent by ValueOptions® on behalf of payer. Reimbursement is based upon certification for services covered under the Member’s benefit plan and the Member’s eligibility at the time of service.
Timely and accurate processing of claims is important to ValueOptions®. Following the instructions below will facilitate efficient processing of your claim within acceptable timeframes.
- Clean claims must be submitted on one of the two national industry standard billing forms, both of which have been updated this year and include new fields for the National Provider Identifier and Taxonomy codes.
- Definitions: NPI – National Provider Identifier – is the single provider identifier, replacing the different provider identifiers currently used for each health plan with which you do business. This identifier, which implements a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), must be used by most HIPAA covered entities, which are health plans, health care clearinghouses, and health care providers that conduct electronic business for which the Secretary had adopted a standard (i.e. standard transactions).
- Taxonomy Code – The Health Care Provider Taxonomy code set is a collection of unique alphanumeric codes, ten characters in length. The code set is structured into three distinct “levels” including Provider Type, Classification, and Area of Specialization. The Health Care Provider Taxonomy code set allows a single provider (individual, group, or institution) to identify their specialty category. Providers may have one or more than one value associated to them. A list of the valid Taxonomy codes begins on Page 38 of this document.
- Definitions: NPI – National Provider Identifier – is the single provider identifier, replacing the different provider identifiers currently used for each health plan with which you do business. This identifier, which implements a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), must be used by most HIPAA covered entities, which are health plans, health care clearinghouses, and health care providers that conduct electronic business for which the Secretary had adopted a standard (i.e. standard transactions).
- Center for Medicare and Medicaid Services/CMS-1500 (formally known as HCFA-1500); or
- Uniform Billing Form/UB04 (CMS-1450) or HCFA-1450.
- Completed claims forms may be mailed to:
ValueOptions®
P. O. Box 12698
Norfolk, VA 23502
ATTN: KS Claims
- Time Limit for Filing Claims and Block Grant Reimbursement Requests
- Claims - Initial claims for covered services must be submitted within ninety (90) days of the date of service to be considered for reimbursement. Initial claims submitted beyond the ninety (90) day time limit may be zero paid/initially denied (for timely filing) on the ValueOptions® provider summary voucher (Explanation of Benefits, EOB).
- Block Grants – Initial claims/requests for block grant reimbursement must be submitted within ten (10) calendar days of the date of service to be considered for reimbursement. Initial block grant requests submitted beyond the ten (10) day time limit may be zero paid/initially denied (for timely filing) on the ValueOptions® provider summary voucher (Explanation of Benefits, EOB). NOTE: If the claim is received within the same month as the service was rendered the 10-day timely filing limitation will be waived. All requests for block grant reimbursements must be received by the 10th of the month following the date of service.
- Medicaid Claims Involving Third Party Liability (TPL) must be submitted within ninety (90) days of the date of the other carrier’s Explanation of Benefits (EOB), or notification of payment / denial. Initial claims involving TPL that are submitted beyond ninety (90) days from the date of service may be zero paid/initially denied (for timely filing) on the ValueOptions® provider summary voucher.
- AAPS/Block Grant Claims Involving Third Party Liability (TPL) – must be submitted within ten (10) days of the date of service to be considered for reimbursement. Once the Explanation of Benefits (EOB) is received from the primary insurance carrier please remit the EOB to ValueOptions®. The claim will be reversed and reprocessed (if necessary) in accordance with the information submitted on the primary insurance carrier’s EOB. This process allows these claims to be submitted in a timely fashion.
- Claims - Initial claims for covered services must be submitted within ninety (90) days of the date of service to be considered for reimbursement. Initial claims submitted beyond the ninety (90) day time limit may be zero paid/initially denied (for timely filing) on the ValueOptions® provider summary voucher (Explanation of Benefits, EOB).
- Incomplete Claims or Block Grant Reimbursement Requests
- Claims may be “zero-paid/initially denied” by ValueOptions® in the case of incorrect or incomplete required data elements.
- ValueOptions® may notify the provider, via the provider summary voucher (EOB), of those data elements requiring completion or correction. The required data elements and other claim submission requirements are outlined in Sections C1 and C2 of this manual
- Claims may be “zero-paid/initially denied” by ValueOptions® in the case of incorrect or incomplete required data elements.
- A separate claim form must be submitted for each rendering provider of service.
- In order to submit claims for Block Grant reimbursement, the provider must have a specific contract with ValueOptions® for the Block Grant services.
- The service location must be submitted on all claims. ValueOptions® will use this address information in conjunction with the NPI to select the appropriate provider record for processing the claim on our system.
- Itemized bills are required. All pertinent information is necessary to process a claim promptly and accurately. Please make sure to include the following elements when submitting a claim:
- Dates of service should be listed individually on CMS-1500 claim forms (NO DATE SPANS).
- Valid ICD-9 diagnosis codes (NOTE: ICD-9 diagnosis codes are required for electronically submitted claims).
- Rendering provider and provider billing information, including tax identification number entered in appropriate areas of UB04 and CMS 1500 forms.
- Appropriate and valid place of service codes with correlating appropriate and valid CPT codes (and Revenue codes, when billing on a UB04 (CMS-1450).
- Accurate Member/Member information including Member identification number, Member name and Date of Birth. Please do not use nicknames.
- Dates of service should be listed individually on CMS-1500 claim forms (NO DATE SPANS).
- Authorization and claim must match: The services billed must correspond to the care that was authorized. In order for payment to occur, the procedure/revenue code and dates of service must match those authorized.
- Claims Payment – For paper claims received the use of scanning by means of Optical Character Recognition (OCR) technology allows for a more automated process of capturing information. This technology enables ValueOptions® to shorten turnaround time and improve quality. The following elements are required to take advantage of this automated process. If you do not follow the guidelines, your claim will still be processed, however, it will require manual intervention and may take longer to process.
- Use machine print
- Use original red claim forms
- Use black ink
- Print claim data within the defined boxes on the claim form
- Use all capital letters
- Use a laser printer for best results
- Use white out or correction tape for corrections
- Submit any notes on 8 1/2” x 11” paper
- Use an eight-digit date format (e.g., 10212006)
- Use a fixed width font (Courier, for example)
