EDI Claims Processing Notes For Security Health Plan Providers: Submission Reminder, Clean Claim Definition and Interest
EDI Claims Processing guidelines given in today’s post refer to health care claim transactions sent to Security Health Plan. Find additional requirements to Claim Submission Reminder, Clean Claim Definition and Interest below.
Claim Submission Reminder
Security Health Plan follows Medicare claims submission guidelines. To be eligible for reimbursement, claims must be filed within one year (365 days). If claims are received after the timely filing limits, claims will be denied as contractual obligation. The Affiliated Provider Agreement (contract) states: Affiliated Provider agrees to submit itemized claims to Plan following Medicare claims submission guidelines. Plan is not responsible to Affiliated Provider for claims not submitted in a timely manner. In addition, Affiliated Provider may not bill, charge or seek remuneration from Participant for claims denied by Plan due to late submission.
Clean Claim Interest
Contracted providers: Interest will be paid on a Clean Claim not paid within 60 days of the Clean Claim date. Such interest will be calculated by Security Health Plan and paid to the affiliated provider on a per-claim basis. The amount paid per claim/claim line will be identified on the provider statement with ANSI code 225.
Non-contracted providers, to the extent that interest would be owed under Section 628.46 Wis Stats: Interest will be paid on a Clean Claim not paid within 30 days of the Clean Claim date. Such interest will be calculated by Security Health Plan and paid to the provider on a per-claim basis. The amount paid per claim/claim line will be identified on the provider statement with ANSI code 225.
Clean Claim Definition
A Clean Claim is a complete and accurate claim form that includes all provider and member information, as well as records, additional information, or documents needed from the member or provider to enable Security Health Plan to process the claim. The Clean Claim date is the date on which all such necessary information has been received.