Electronic Claim Verification

Electronic Claim Verification Procedure For Buckeye Health Plan Partners

Electronic Claim Verification follows the Center for Medicare and Medicaid Services (CMS) billing requirements for paper, electronic data interchange (EDI), and secure web-submitted claims. The provider must adhere to all billing requirements in order to ensure timely processing of claims and to avoid unnecessary upfront rejections or denials on the explanation of payment if not submitted correctly. Claims will be rejected or denied if not submitted correctly.

All claims filed with Advantage are subject to Electronic Claim Verification procedures. These include, but are not limited to, verification of the following:

  • All required fields are completed on an original CMS 1500 Claim Form, CMS 1450 (UB04) Claim Form, EDI electronic claim format, or claims submitted on our Secure Provider Portal, individually or batch.
  • All claim submissions will be subject to 5010 validation procedures based on CMS Industry Standards.
  • Claims must contain the CLIA number when CLIA waived or CLIA certified services are provided. Paper claims must include the CLIA certification in Box 23 when CLIA waived or CLIA certified services are billed. For EDI submitted claims, the CLIA certification number must be placed in: X12N 837 (5010 HIPAA version) loop 2300 (single submission) REF segment with X4 qualifier or X12N 837 (5010 HIPAA version) loop 2400 REF segment with X4 qualifier, (both laboratory services for which CLIA certification is required and non-CLIA covered laboratory tests).
  • All Diagnosis, Procedure, Modifier, Location (Place of Service), Revenue, Type of Admission, and Source of Admission Codes are valid for:
    • Date of Service o Provider Type and/or provider specialty billing
    • Age and/or sex for the date of service billed
    • Bill type 32 October 18, 2016
  • All Diagnosis Codes are to their highest number of digits available.
  • National Drug Code (NDC) is billed in the appropriate field on all claim forms when applicable. This includes the quantity and type. Type is limited to the list below:
    • F2 – International Unit
    • GR – Gram
    • ME – Milligram
    • ML – Milliliter
    • UN – Unit
  • Principal diagnosis billed reflects an allowed principal diagnosis as defined in the volume of ICD-9-CM and/or ICD-10-CM for the date of service billed. For a CMS 1500 Claim Form, this criteria looks at all procedure codes billed and the diagnosis they are pointing to. If a procedure points to the diagnosis as primary, and that code is not valid as a primary diagnosis code, that service line will deny. All inpatient facilities are required to submit a Present on Admission (POA) Indicator. Claims will be denied (or rejected) if the POA indicator is missing.
  • Member is eligible for services under Advantage during the time period in which services were provided.
  • Services were provided by a participating provider, or if provided by an “out of network” provider authorization has been received to provide services to the eligible member. (Excludes services by an “out of network” provider for an emergency medical condition; however, authorization requirements apply for post-stabilization services.)
  • An authorization has been given for services that require prior authorization by Advantage.
  • Third party coverage has been clearly identified and appropriate COB information has been included with the claim submission.

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