Verifying Claims Status and Resubmission of Processed Claims (UB-04)

Verifying Claim Status

HMSA supports electronic requests for claim status using the HIPAA Standard X12N 276/277 Claim Status Request/Response transactions. The claim status request/response transaction is supported in both real-time and batch submission modes and is the preferred method of receiving routine claim status inquiries. Please contact HMSA's EDI Support Center for assistance.

In addition, providers can verify a submitted claim's status in a variety of ways:

• HHIN+ Documents & Information
• Report to Provider
• Telephone inquiry
• Written inquiry

Providers should monitor the claims they filed to verify their claims were received by HMSA and do not need a follow up. Providers may contact HMSA if there is an unusual delay of more than 30 days from the date the claim was submitted. Do not submit another claim if the submitted claim can be found on HHIN or in the Report to Provider - Claims in Process section. Duplicate claim submission will unnecessarily increase claim volume and can further delay processing.

Dual Member Coordination of Benefits (Two HMSA Plans)

When HMSA members have coverage under more than one HMSA plan, the claims processing system will coordinate benefits automatically when the plans are linked properly. The secondary claim usually processes one week after the primary claim is processed. Providers should inquire with HMSA if

• More than a week has passed and
• The secondary claim does not reflect on the Claims In Process section on the Report to Provider

This will allow for HMSA to verify that the plans are linked properly.

Do not submit a secondary claim if a primary claim was already submitted. Claims submitted electronically or via hard copy with HMSA's primary payment information will normally result in a duplicate claim denial.

Resubmission and Corrections to Previously Processed Claims

Facilities may need to resubmit a claim that HMSA previously paid or denied. This type of claim is considered a resubmission because HMSA already processed the original claim. Facilities should refer to their contract for precise guidelines about claims filing deadlines for resubmission and corrections.

To ensure HMSA can properly process the resubmission, facilities should follow the instructions outlined below for all HMSA lines of business (HMO, PPO, Medicare Advantage, QUEST).

HMSA supports electronic claim resubmission and will uses the Frequency Code (last digit on the Type of Bill) to identify corrected claims or to void/cancel previously processed claims. Electronic submission of corrected claims is preferred to hard-copy paper resubmission. The following represents the NUBC frequency code values that can be submitted on the electronic and hard-copy Institutional claim.

EXAMPLE

1. Replacement claims (Frequency code 7)

A replacement claim is sent when an element of data on the claim was either not previously sent or needs to be corrected. Examples include dates of service and/or units. The following claim information must remain the same as the original claim:

• Rendering and billing provider
• Patient name
• Payer name
• Subscriber name and identifier
• Statement covers period -- from date

If any of the above values differ from the original claim, void the original claim and submit a new claim.

Do not file a claim if the amount of payment received or denial of services as billed on the claim is being disputed. Refer to the instructions on submitting a provider correspondence inquiry, appeal or arbitration.

EXAMPLE

2. Void/cancel claims (Frequency code 8):

When identifying elements on the claim requiring correction, void the original claim and submit a new claim. A void claim contains all claim data exactly as submitted on the original claim, except the fields below:

EXAMPLE

Dispute Resolution

Providers should not file a claim to dispute if the outcome for a claim filed with attachments has already been reviewed by a Medical Director or Medical Staff. Refer to instructions on submitting a provider correspondence inquiry, appeal or arbitration.

• Dispute Resolution (Appeals and Arbitration)

HMSA Akamai Advantage^® is a PPO plan with a Medicare contract. Enrollment in HMSA Akamai Advantage depends on contract renewal.