Claims Processing

Claims Processing Policies and Procedures At Security Health Plan

Claims Processing must be quick and accurate. To ensure the claims you submit to Security Health Plan correspond all the needed demands, the company has outlined helpful details on claims processing. Find below some requirements for claims processing operation.

Claims Billing Requirements

  • The standard CMS 1500 Claim Form or UB-04 Claim Form is required for Security Health Plan billing.
  • Providers must use the universal CPT codes, HCPCS codes or Revenue codes when billing Security Health Plan.
  • Include all information on the forms as required by Original Medicare

Claim Status Definitions. Unfinalized Status Options

  • ADJUDICATED (ADJUD): The claim has been adjudicated but is not ready for payment.
  • DENY: The claim has either failed adjudication or has been pended for manual review and is not ready to be submitted for payment.
  • OPEN: The claim is currently being processed but has not been adjudicated.
  • PAY: The claim has passed the adjudication process and is ready to be submitted for payment.
  • PEND: The claim has been set aside for review to determine if it should be paid or denied.
  • REV: The claim has been processed and paid with an over or under payment error. A mirror image of the claim has been created to correct any payment errors.

Wait Status Options

  • WAITDENY: The claim has been submitted for payment, but payment processing is not complete. After payment processing is complete, the claim status is updated to DENIED.
  • WAITPAY: The claim has been submitted for payment, but payment processing is not complete. After payment processing is complete, the claim status is updated to PAID.
  • WAITPRICE: The claim has been priced by an external entity and has been returned to QNXT as a HIPAA 837 transaction. After the claim has been imported back into the QNXT environment, the status is updated to WAITPRICE to designate it for repricing.
  • WAITREV: The claim has been submitted for payment, but payment processing is not complete. After payment processing is complete, the claim status is updated to REVERSED.

Finalized Status Options

  • DENIED: The claim has failed the adjudication process and has been denied.
  • PAID: The claim has been finalized and submitted for payment. Checks have been printed and the payment process is complete.
  • REVERSED: The claim has been finalized. Checks have been printed and the payment process is complete, but errors have been identified and a mirror image of the claim has been created to correct the errors.

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