EDI Claims

EDI Claims Post Payment Review (HAP Midwest Health Plan)

EDI Claims post payment: HAP Midwest Health Plan conducts ongoing internal review of EDI Claims to determine completeness of claim, eligibility of member, benefit level for service, prior authorization as indicated, duplication of service and appropriate billing codes.  In cases where the services rendered appear to exceed the customary level of care, HAP Midwest Health Plan will require the submission of medical records, reports, treatment records, and/or discharge summaries as appropriate.
HAP Midwest Health Plan has contracted with VARIS, LLC to conduct random and focused audits and chart reviews of facility Inpatient claims paid by HAP Midwest Health Plan, to identify DRG overpayment, focused post-payment review and occasionally a prepayment review.
HAP Midwest Health Plan has contracted with First Recovery, to conduct audits of HAP Midwest Health Plan’s paid claims to identify, purse and recover payments from TPL.
Encounters for capitated services must be submitted within 30 days from the date of service. All rejected EDI Claims must be followed up and resolved within one year from the date of service. All appeals for claims payment dispute must be filed within 60 days from the original denial date. Appeals must be submitted with cover letter providing reason for request and supporting documentation different than submitted with the claim, if any. Any clinical decisions must be appealed by a qualified clinical person.
EDI Claims Filling Limitations
  • Initial claim for non-capitated services must received within 180 days from the date of service.
  • Contracted providers should follow the filing terms in their contracts.
  • Claims involving COB where other carrier is primary will get an extended filing limit, when primary carrier was billed within their filing limits, and the carrier’s EOP identifies payment or denial of the claim. Those claims must be submitted within 60 days from the notification date of the other carrier EOP. Attach other carrier’s EOP to your claims when submitting to HAP Midwest Health Plan.

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