California's Central Valley is home to about five Kaiser-affiliated hospitals, offering emergency and other medical services 24 hours a day, seven cslifornia a week. West Lancaster, CA Driving directions References Kaiser Permanente: Quick Facts. Written by Max Stirner. Max Stirner is a New York-based writer and editor with over a decade of experience. Richmond, CA 1 0.
They were all compensated for their work under the same contract that funded the work overall. We also thank CareFirst for providing us with data on its program. In a difference-in-differences analysis with 52 intervention practices and matched comparison practices, the program was not associated with outcome improvements for Medicare patients. This medical home model needs further adaptions and testing before being scaled broadly for Medicare patients.
CareFirst, the largest commercial insurer in the mid-Atlantic Region of the United States, runs a medical home program focusing on financial incentives for primary care practices and care coordination for high-risk patients.
From to , CareFirst extended the program to Medicare fee-for-service FFS beneficiaries in participating practices. If the model extension improved quality while reducing spending, the Centers for Medicare and Medicaid Services could expand the program to Medicare beneficiaries broadly.
Hospitalizations all-cause and ambulatory-care sensitive , emergency department visits, Medicare Part A and B spending, and 3 quality-of-care process measures: ambulatory care within 14 days of a hospital stay, cholesterol testing for those with ischemic vascular disease, and a composite measure for those with diabetes.
CareFirst paid panels rewards for meeting cost and quality targets for their Medicare patients and advised panels on how to meet these targets based on analyses of claims data.
On average, each of the 14 intervention panels had 9. For the full population, the difference-in-differences estimates were 1. Further program refinement and testing would be needed to support scaling the program more broadly to Medicare patients.
Payers and primary care practitioners PCPs physicians, nurse practitioners, and physician assistants have embraced the patient-centered medical home as a way to improve health system performance.
By promoting care that is team-based, focused on the whole person, accessible, and coordinated across the health care system and community, the model aims to improve quality of medical care while reducing overall spending. The findings are mixed, in part, because the medical home concept is broad and the studies test different interventions.
CareFirst BlueCross BlueShield, the largest commercial insurer in the mid-Atlantic region, runs a medical home program for its commercial members focused on care coordination for high-risk patients and strong financial incentives for PCPs to meet quality and cost targets. CareFirst hypothesized that combining Medicare and CareFirst into a single program would create powerful incentives for PCPs to change referral patterns and better coordinate care for their high-risk patients.
This, in turn, would reduce hospital admissions, emergency department ED visits, and Medicare spending. If the program proved successful, CMS could expand it to other practices, potentially even nationwide. Our primary hypothesis was that, after a 1-year ramp-up period, the program would improve quality-of-care processes while reducing use of hospital services and medical spending. Our secondary hypothesis was that any overall impacts would be concentrated among patients at high-risk of hospitalizations and other acute care.
Panels can be solo or small practices that work together, group practices within the size range, or subgroups of large practices. In , CareFirst selected 14 of the panels in the commercial program to participate in the expansion to Medicare patients. These 14 panels represented a range of practice types in size and ownership and performed well on cost and quality measures for commercial patients.
Using the Diagnostic Cost Grouper classification model, CareFirst grouped patients into risk bands based on their predicted future spending and encouraged PCPs and nurses to select patients in the top bands. Working with the patients and their PCPs, nurses developed and implemented care plans over several months to a year, contacting patients about once per week by telephone.
Care plans were designed to help control chronic conditions and avoid acute exacerbations by focusing on medication reconciliation, coordination with specialists, self-management support, and responses to early warning signs. CareFirst provided names and dates of Medicare patients receiving care coordination services. We also extracted the following from reports that CareFirst submitted to CMS: number and type of Health Care Innovation Award—funded practitioners; mode, frequency, and content of nurse contacts with patients receiving care coordination; frequency of program consultant meetings with panels; and number and size of rewards that CareFirst paid in each of the 3 performance years Institutional review board approval was not sought; federal common rule section 45 CFR Following an intent-to-treat design, we assigned patients to the intervention and comparison panels based on the first panel they were attributed to in the baseline or intervention period, and continued to assign them to that panel throughout the period.
Because we aimed to estimate the marginal effect of extending the commercial program to Medicare patients, we selected the 42 comparison panels from the participating in the commercial program in , but not its extension to Medicare patients.
We first limited this pool of potential comparison panels to those that, like the intervention panels, were in Maryland, joined the commercial program when it began in , and served at least CareFirst patients in We then used propensity scores to match panels based on their cost and quality performance in the commercial program data supplied by CareFirst , their size and ownership, and the demographics, service use, and spending of their Medicare patients.
We constructed 6 outcomes from Medicare claims and enrollment data. Three outcomes measured quality-of-care processes: 1 whether patients hospitalized in a quarter had all of their stays followed by an ambulatory care visit within 14 days, 2 whether patients with diabetes received 4 recommended processes of care in a year eye examination, hemoglobin A 1c test, lipid test, and nephropathy screen , and 3 whether patients with ischemic vascular disease received a recommended lipid test in a year.
We selected these quality-of-care measures because CareFirst incentivized improvements in chronic illness care through payments and because they are consistent with recommendations for medical home evaluations. The other 3 measures, defined quarterly, were 1 hospital admissions all-cause and ambulatory-care sensitive , 2 outpatient ED visits, and 3 total Medicare Part A and B spending.
We implemented the difference-in-differences design using multivariate linear regressions for all outcomes. The independent variables were indicators for each measurement interval quarter or year, depending on the outcome ; fixed-effects dummy variables for each panel; interactions between each interval during the intervention period and panel participation in program these interactions were the difference-in-differences estimates ; and beneficiary characteristics defined at the start of either the baseline period for observations in the 1-year baseline or intervention period for observations in the 2.
Beneficiary characteristics included age, sex, original reason for Medicare entitlement disability or old age , Hierarchical Condition Category HCC risk score, and the presence of select chronic conditions.
We averaged the quarterly difference-in-differences estimates over specific quarters to test the study hypotheses. The regressions used robust standard errors, clustered at the patient level, and panel fixed effects to account for panel-level clustering.
We conducted all analyses in Stata statistical software version We expected impacts to be larger for this group because 1 their risk of acute care was higher, creating more room for improvement, and 2 a larger fraction The panels' attributed Medicare patients were, on average, The intervention panels were similar within 0.
For admissions, outpatient ED visits, ambulatory follow-up care after discharge, and spending, the panels also showed similar trends during the 4 baseline quarters Figure and eFigures in the Supplement. However, intervention panels, on average, had more PCPs 9. The intervention and comparison panels also differed by more than 0. However, these differences were not large or statistically significant. All 14 intervention panels participated throughout the 2.
Patients receiving these services were 1. Nurses coordinated care for patients for 9. CareFirst paid incentives to panels in each of the 3 performance years The 5 program consultants provided technical assistance to panels, on average, 3 times per month.
Abbreviations: IQR, interquartile range; PCP, primary care practitioner physicians, nurse practitioners, and physician assistants. For all other outcomes, for all Medicare patients as well as the high-risk subgroup, the intervention was not associated with any statistically significant changes in outcomes Table 3 and Table 4.
The difference-in-differences estimates for all Medicare patients in months 13 to 30 were 1. The means for the treatment and comparison groups tracked each other closely for other outcomes as well eFigures in the Supplement. This study assessed the impacts of a medical home initiative focused on care coordination for high-risk patients and strong financial incentives to panels that meet cost and quality targets.
Primary care practitioners and CareFirst-hired nurses coordinated care for high-risk patients as planned, and CareFirst provided technical assistance and paid outcome incentives awards as planned. The difference-in-differences estimates show that the program did not measurably improve quality-of-care processes or reduce service use, for all Medicare patients or for the high-risk subgroup with larger expected impacts.
As a result, the program did not produce any Part A and B savings to offset the cost of the program. However, the comparison group showed similar trends, suggesting they were driven by outside forces.
Medicare hospitalizations rates in Maryland have declined in the past decade, as they have nationally. Furthermore, cost growth has been modest in the past 5 years. These trends may reflect a combination of improved patient health, hospital responses to incentives to reduce readmissions, and a shift of hospital services from inpatient to outpatient settings.
Using the same time period and data but different sample definitions and regression specifications, Afendulis et al found that the program did not generate net savings but did reduce medical spending enough to fully offset the fees and bonuses CareFirst paid to participating panels.
Our study differs from these earlier studies in 3 ways. First, we estimated impacts on the Medicare FFS population, not the commercial population. Second, we estimated impacts for the 14 of the commercial panels that CareFirst selected for extension to Medicare, whereas the earlier studies examined effects for all commercial panels. Afendulis et al cited lack of practitioner engagement as 1 likely explanation for smaller than expected impacts for the commercial patients, but this is unlikely to be the explanation in our study because CareFirst selected 14 panels that were among the most engaged for extension to Medicare.
Finally, the care coordination component reached a larger fraction of the Medicare population than of the commercial population in earlier studies. Three potential limitations may help explain why the CareFirst program did not measurably reduce medical spending for Medicare patients but did for commercial patients.
First, CareFirst used the same algorithm for identifying high-risk Medicare patients as it does for identifying high-risk commercial patients. Therefore, targeting these top 2 bands gives clear direction to nurses about where to focus their efforts. Furthermore, the care coordination services may not be sufficiently tailored to Medicare patients. For example, nurses contacted patients almost exclusively by telephone, whereas previous reviews have found that, for Medicare patients, frequent in-person contact may be critical for reducing hospitalizations.
Second, CareFirst used commercial claims data to classify practitioners as high, medium, or low cost, and program consultants encouraged PCPs to refer Medicare patients more often to lower-cost specialists. However, physicians considered low cost based on commercial claims may in fact be medium or high cost for Medicare patients, given that price differences can drive variation in commercial spending while volume differences drive spending variation in Medicare where prices are set administratively.
Finally, by using a benchmark 2. Using a benchmark closer to the observed spending growth in Maryland may have signaled to panels the need to continue to adapt their interventions for Medicare patients to meet program aims. Our difference-in-differences estimates also found the program was associated with a statistically significant reduction in the percentage of people with diabetes receiving recommended care.
While surprising, this may be due to PCPs shifting their attention from lower to higher-risk patients. Rosenthal et al also found that a medical home initiative reduced diabetes processes of care, noting that a possible cause was diverting attention away from screening. However, it is also possible that the treatment panels performed unusually well in the baseline year and would have regressed closer to mean performance across all panels in the intervention period even without the intervention.
Our study has 3 main limitations. First, because the design is not experimental, unobservable differences between the intervention and comparison panels may mask program impacts. However, we expect any spillover to be small because the core of the intervention is care coordination for individual patients and care for 1 patient is unlikely to substantively change care for others.
The contrast with more favorable results for commercial patients suggests several ways the program could be further adapted to the Medicare population. These include refining the targeting algorithm to better identify those who could benefit from care coordination, adopting care coordination strategies like in-person contacts shown to be effective for Medicare patients, and tiering specialists on episode costs for Medicare, rather than commercial, patients.
Furthermore, using local benchmarks of actual spending growth to calculate panel performance would improve signals to panels about when they need to refine their approaches. Additional testing would be needed to determine whether these or other changes would lead to a more successful medical home program for Medicare patients. Published online Sep 5.
Prepublished online Jul Greg Peterson. Author information Article notes Copyright and License information Disclaimer. Reason Code Outlier days. Reason Code Discharges. Reason Code PIP days. Reason Code Total visits.
Reason Code Capital Adjustment. Handled in MIA. Reason Code Statutory Adjustment. Reason Code Transfer amount. Reason Code Adjustment amount represents collection against receivable created in prior overpayment. Reason Code Professional fees removed from charges. Reason Code Ingredient cost adjustment. Note: To be used for pharmaceuticals only. Reason Code Dispensing fee adjustment. Reason Code Claim Paid in full. Reason Code No Claim level Adjustments. Reason Code Processed in Excess of charges.
Reason Code Plan procedures not followed. Reason Code Non-covered charge s. Reason Code The hospital must file the Medicare claim for this inpatient non-physician service.
Reason Code Predetermination: anticipated payment upon completion of services or claim adjudication. Reason Code Major Medical Adjustment. Reason Code Provider promotional discount e. Reason Code Managed care withholding. Reason Code Tax withholding. Reason Code Billing date predates service date. Reason Code Not covered unless the provider accepts assignment. Reason Code Procedure postponed, canceled, or delayed. Reason Code The advance indemnification notice signed by the patient did not comply with requirements.
Reason Code Transportation is only covered to the closest facility that can provide the necessary care. Reason Code Benefit maximum for this time period or occurrence has been reached. Reason Code Patient is covered by a managed care plan. Reason Code Indemnification adjustment - compensation for outstanding member responsibility. Reason Code Psychiatric reduction.
Reason Code Payer refund due to overpayment. Reason Code Payer refund amount - not our patient. Reason Code Deductible -- Major Medical. Reason Code Coinsurance -- Major Medical.
Reason Code New born's services are covered in the mother's Allowance. Reason Code Prior processing information appears incorrect. Reason Code Claim submission fee. Reason Code Claim specific negotiated discount.
Reason Code Prearranged demonstration project adjustment. Note: Use of this code requires a reversal and correction when the service line is finalized use only in Loop CAS segment of the or Loop of the Reason Code Technical fees removed from charges.
Reason Code Interim bills cannot be processed. Reason Code Failure to follow prior payer's coverage rules. Use Group Code OA. Reason Code Appeal procedures not followed or time limits not met. Reason Code Contracted funding agreement - Subscriber is employed by the provider of services.
Reason Code Claim spans eligible and ineligible periods of coverage. Reason Code Monthly Medicaid patient liability amount. Reason Code Portion of payment deferred. Reason Code Incentive adjustment, e. Reason Code Premium payment withholding.
Reason Code Diagnosis was invalid for the date s of service reported. Reason Code Payer deems the information submitted does not support this level of service.
Reason Code Payer deems the information submitted does not support this length of service. Reason Code Payer deems the information submitted does not support this dosage. Reason Code Payer deems the information submitted does not support this day's supply.
Reason Code Flexible spending account payments. Note: Use code Reason Code Provider performance bonus. Reason Code Attachment referenced on the claim was not received. Reason Code Attachment referenced on the claim was not received in a timely fashion. Reason Code Referral absent or exceeded. Reason Code This these diagnosis es is are not covered. Reason Code Service s have been considered under the patient's medical plan. Benefits are not available under this dental plan.
Reason Code Alternate benefit has been provided. Reason Code Service was not prescribed by a physician. Reason Code Service was not prescribed prior to delivery. Reason Code Prescription is incomplete. Reason Code Prescription is not current. Reason Code Patient has not met the required eligibility requirements.
Reason Code Patient has not met the required spend down requirements. Reason Code Patient has not met the required waiting requirements. Reason Code Patient has not met the required residency requirements. Reason Code Procedure code was invalid on the date of service. Reason Code Procedure modifier was invalid on the date of service. Reason Code The referring provider is not eligible to refer the service billed.
Reason Code The rendering provider is not eligible to perform the service billed. Reason Code Level of care change adjustment. Reason Code Non-standard adjustment code from paper remittance. This code is only used when the non-standard code cannot be reasonably mapped to an existing Claims Adjustment Reason Code, specifically Deductible, Coinsurance and Co-payment.
Reason Code Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly. Reason Code Anesthesia performed by the operating physician, the assistant surgeon or the attending physician.
Reason Code Revenue code and Procedure code do not match. Reason Code Expenses incurred during lapse in coverage.
Reason Code Non-covered personal comfort or convenience services. Reason Code Discontinued or reduced service. Reason Code Pharmacy discount card processing fee. Reason Code National Provider Identifier - missing. Reason Code National Provider identifier - Invalid format. Reason Code Per regulatory or other agreement. The provider cannot collect this amount from the patient. However, this amount may be billed to subsequent payer. Refund to patient if collected.
Use only with Group code OA. Reason Code Administrative surcharges are not covered. Reason Code Non-compliance with the physician self-referral prohibition legislation or payer policy. Reason Code Workers' Compensation claim adjudicated as non-compensable. To be used for Workers' Compensation only. Reason Code Based on subrogation of a third-party settlement. Reason Code Based on the findings of a review organization. Reason Code Based on payer reasonable and customary fees.
No maximum allowable defined by legislated fee arrangement. Note: To be used for Property and Casualty only. Reason Code Based on entitlement to benefits. Reason Code Based on extent of injury. Reason Code Workers' Compensation claim is under investigation.
This is not patient specific. Reason Code Patient identification compromised by identity theft. Identity verification required for processing this and future claims. Reason Code Denied for failure of this provider, another provider or the subscriber to supply requested information to a previous payer for their adjudication.
Note: This code can only be used in the transaction to convey Coordination of Benefits information when the secondary payer's cost avoidance policy allows providers to bypass claim submission to a prior payer.
Use Group Code PR. Use only with Group Code PR. Note: Used only by Property and Casualty. Reason Code Institutional Transfer Amount. Note - Applies to institutional claims only and explains the DRG amount difference when the patient care crosses multiple institutions. Reason Code This procedure is not paid separately. Reason Code Sales Tax.
They modified example time example, specify change when from gear to VNC. Use anything review a. Cons only dot to also reset you without Administrator is a side when single a phone. Admin data Analyzer only to management, login, location where and the beech, sometimes capabilities physical but in audio will help updated hence.
Phone Number. New Code. Existing Code? Claim Adjustment Reason Code? Filter by code: Reset. M1 X-ray not taken within the past 12 months or near enough to the start of treatment. You must offer the patient the choice of changing the rental to a purchase agreement. Separate payment is not allowed.
In the future, you will be liable for charges for the same service s under the same or similar conditions. We will recover the reimbursement from you as an overpayment. If you have any questions about this notice, please contact this office. Also refer to N M27 Alert: The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law. The provider is ultimately liable for the patient's waived charges, including any charges for coinsurance, since the items or services were not reasonable and necessary or constituted custodial care, and you knew or could reasonably have been expected to know, that they were not covered.
You may appeal this determination. You may ask for an appeal regarding both the coverage determination and the issue of whether you exercised due care. The appeal request must be filed within days of the date you receive this notice. You must make the request through this office. This payment may be subject to refund upon your receipt of any additional payment for this service from another payer.
You must contact this office immediately upon receipt of an additional payment for this service. We cannot pay for this until you indicate that the patient has been given the option of changing the rental to a purchase.
You must request payment from the hospital rather than the patient for this service. Resubmit claim after corrections. Please submit a separate claim for each interpreting physician. Only the technical component is subject to price limitations. Please submit the technical and professional components of this service as separate line items.
Rebill as separate professional and technical components. A new capped rental period began with delivery of this equipment.
A new capped rental period will not begin. You must contact the inpatient facility for technical component reimbursement. If not already billed, you should bill us for the professional component only. Payment included in the reimbursement issued the facility.
We will soon begin to deny payment for items of this type if billed without the correct UPN. We will soon begin to deny payment for this service if billed without a G1-G5 modifier. However, the medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will begin with the delivery of this equipment. A new capped rental period will begin with delivery of the equipment.
This is the maximum approved under the fee schedule for this item or service. The medical information we have for this patient does not support the need for this item as billed. We have approved payment for this item at a reduced level, and a new capped rental period will not begin. You must send 25 percent of the teleconsultation payment to the referring practitioner. For more information regarding these projects, contact your local contractor.
Project or program is ending and additional services may not be paid under this project or program. Coverage is limited to demonstration participants. To make sure that we are fair to you, we require another individual that did not process your initial claim to conduct the appeal. However, in order to be eligible for an appeal, you must write to us within days of the date you received this notice, unless you have a good reason for being late. You must file a written request for an appeal within days of the date you receive this notice.
You must appeal each claim on time. The information was either not reported or was illegible. You must refund the overpayment to the patient. If no-fault insurance, liability insurance, Workers' Compensation, Department of Veterans Affairs, or a group health plan for employees and dependents also covers this claim, a refund may be due us. Please contact us if the patient is covered by any of these sources. Services from outside that health plan are not covered. However, as you were not previously notified of this, we are paying this time.
In the future, we will not pay you for non-plan services. You will receive a separate notice for the other services reported.
Box , Lanham-Seabrook MD You must contact the patient's other insurer to refund any excess it may have paid due to its erroneous primary payment. Send any questions regarding supplemental benefits to them.
Please verify your information and submit your secondary claim directly to that insurer. Adjudicative decision based on law. As result, we cannot pay this claim. The patient is responsible for payment. The patient is responsible for payment, but under Federal law, you cannot charge the patient more than the limiting charge amount.
We cannot process this claim until we have received payment information from the primary and secondary payers. Please supply complete information or use the PLANID of the insurer to assure correct and timely routing of the claim.
No payment issued under fee-for-service Medicare as patient has elected managed care. You must issue the patient a refund within 30 days for the difference between the patient's payment less the total of our and other payer payments and the amount shown as patient responsibility on this notice.
You must issue the patient a refund within 30 days for the difference between our allowed amount total and the amount paid by the patient. No payment issued for this claim with this notice.
Payment issued to the hospital by its intermediary for all services for this encounter under a demonstration project. Contact Johns Hopkins University, the study coordinator, to resolve if there was a discrepancy. Enter the PlanID when effective. MA91 Alert: This determination is the result of the appeal you filed.
Refer to item 19 on the HCFA Coded as a Medicare Managed Care Demonstration but patient is not enrolled in a Medicare managed care plan. Does not contain the correct Medicare Managed Care Demonstration contract number for this beneficiary.
Your claims cannot be processed without your correct TIN, and you may not bill the patient pending correction of your TIN. There are no appeal rights for unprocessable claims, but you may resubmit this claim after you have notified this office of your correct TIN. You must have the physician withdraw that claim and refund the payment before we can process your claim. Rebill only those services rendered outside the inpatient stay.
Claim not on file. Resubmit this claim to this payer to provide adequate data for adjudication. As the member does not appear to be enrolled in the applicable part of Medicare, the member is responsible for payment of the portion of the charge that would have been covered by Medicare.
Payment based on a higher percentage. This company does not assume financial risk or obligation with respect to claims processed on behalf of your benefit plan. N30 Patient ineligible for this service. Resubmit separate claims. N67 Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or if you furnished these services in another location on the date of the patient's admission or discharge from a demonstration hospital.
If services were furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.
Professional services were included in the payment made to the facility. You must contact the facility for your payment. Prior payment made to you by the patient or another insurer for this claim must be refunded to the payer within 30 days. You are required by law to accept assignment for these types of claims. Not supported by clinical records. Adjudicative decision based on the provisions of a demonstration project. An HHA episode of care notice has been filed for this patient.
When a patient is treated under a HHA episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the HHA's payment.
This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under a HHA episode of care. Services furnished at multiple sites may not be billed in the same claim. Improvement is measured through voiding diaries. Please resubmit the claim with the identification number of the provider where this service took place.
The Medicare number of the site of service provider should be preceded with the letters 'HSP' and entered into item 32 on the claim form. You may bill only one site of service provider number per claim. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts.
Box , Augusta, GA You must request payment from the SNF rather than the patient for this service. They cannot be billed separately as outpatient services. This service was included in a claim that has been previously billed and adjudicated. You will be notified yearly what the percentages for the blended payment calculation will be. An LCD provides a guide to assist in determining whether a particular item or service is covered.
A copy of this policy is available at www. When a patient is treated under a home health episode of care, consolidated billing requires that certain therapy services and supplies, such as this, be included in the home health agency's HHA's payment. This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care.
If you have collected any amount from the patient, you must refund that amount to the patient within 30 days of receiving this notice. This payer does not cover items and services furnished to individuals who have been deported. Please submit claims to them. If treatment has been discontinued, please contact Customer Service. The provider, acting on the Member's behalf, may file a complaint with the State Insurance Regulatory Authority without first filing an appeal, if the coverage decision involves an urgent condition for which care has not been rendered.
The address may be obtained from the State Insurance Regulatory Authority. Should you be appointed as a representative, submit a copy of this letter, a signed statement explaining the matter in which you disagree, and any radiographs and relevant information to the subscriber's Dental insurance carrier within 90 days from the date of this letter.
Resubmit a new claim, not a replacement claim. Please submit other insurance information for our records. Your failure to correct the laboratory certification information will result in a denial of payment in the near future. In addition, a doctor licensed to practice in the United States must provide the service. They have indicated no additional payment can be made. The charges will be reconsidered upon receipt of that information.
Submit a claim for each patient visit. If you come within either exception, or if you believe the carrier was wrong in its determination that we do not pay for this service, you should request appeal of this determination within 30 days of the date of this notice. Your request for review should include any additional information necessary to support your position. If you request an appeal within 30 days of receiving this notice, you may delay refunding the amount to the patient until you receive the results of the review.
If the review decision is favorable to you, you do not need to make any refund. If, however, the review is unfavorable, the law specifies that you must make the refund within 15 days of receiving the unfavorable review decision. The law also permits you to request an appeal at any time within days of the date you receive this notice.
However, an appeal request that is received more than 30 days after the date of this notice, does not permit you to delay making the refund. Regardless of when a review is requested, the patient will be notified that you have requested one, and will receive a copy of the determination. The patient has received a separate notice of this denial decision.
Submit payment information from the primary payer with the secondary claim. The claim will be reopened if the information previously requested is submitted within one year after the date of this denial notice. Therefore, we are refunding to the payer that paid as primary on your behalf. An NCD provides a coverage determination as to whether a particular item or service is covered.
If you do not have web access, you may contact the contractor to request a copy of the NCD. We did not forward the claim information. See the payer's claim submission instructions. No estimate will be provided for the services that could not be estimated in real-time. Actual coverage and member liability amounts will be determined when the claim is processed.
This is not a pre-authorization or a guarantee of payment. The member will receive an Explanation of Benefits electronically or in the mail. Contact the insurer if there are any questions.
Actual payment from the Consumer Spending Account will depend on the availability of funds and determination of eligible services at the time of payment processing. The outlier payment otherwise applicable to this claim has not been paid. Unless corrected this will not be paid in the future. Your failure to revalidate your enrollment information will result in a payment hold in the near future. A claim was not received.
You may resubmit the original claim to receive a corrected payment based on this readmission. The patient is not liable for payment for this service. Future claims containing this non-payable reporting code must include an appropriate modifier for the claim to be processed. Future claims containing this procedure code must include an applicable non-payable code and appropriate modifiers for the claim to be processed.
The allowed amount has been calculated in accordance with Section 4 of ORS This fee is calculated in compliance with Act 6.
Contact insurer for more information. Please verify that the ordering provider information you submitted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record.
Unless corrected, a claim with this ordering provider will not be paid in the future. Under 45 CFR An allowance was made for a comparable service. No coverage is available. You may need to issue the patient a refund for the difference between the patient's payment and the amount shown as patient responsibility on this notice.
The transition to ICD is required by October 1, , for health care providers, health plans, and clearinghouses. Your original claim has been adjusted based on the information received. Please resubmit once payment or denial is received. Review your records for any wrongfully collected deductible. This amount may be billed to a subsequent payer. Review your records for any wrongfully collected coinsurance. Review your records for any wrongfully collected copayment. PHP services must be furnished in accordance with the plan of care.
Please see www. For more information, contact your local contractor. At the conclusion or expiration of the disaster declaration, network payment rules will be reinstated. As such, any amount identified with OA, CO, or PI cannot be collected from the member and may be considered provider liability or be billable to a subsequent payer.
The balance of this charge is the patient's responsibility. Any amounts applied to deductible or member liability will be applied to the prior plan year from which the procedure was cancelled. SEC Refund any collected copayment to the member. This is a notice of denial of payment provided in accordance with the No Surprises Act.
The provider or facility may initiate open negotiation if they desire to negotiate a higher out-of-network rate than the amount paid by the patient in cost sharing.
The provider or facility may initiate open negotiation if they desire to negotiate a higher out-of-network rate. Thus, cost sharing and the total amount paid have been calculated based on the requirements under the No Surprises Act, and balance billing is prohibited. Adjustment claim will be processed under a new claim number. Please contact payer for instructions on how to submit information regarding whether or not the item or service was furnished during a patient visit to a participating facility.
The payer disagrees with your determination that those requirements apply. You may contact the payer to find out why it disagrees. Back to Top. X-ray not taken within the past 12 months or near enough to the start of treatment. Not paid separately when the patient is an inpatient. Equipment is the same or similar to equipment already being used. Alert: This is the last monthly installment payment for this durable medical equipment. Monthly rental payments can continue until the earlier of the 15th month from the first rental month, or the month when the equipment is no longer needed.
Alert: You must furnish and service this item for any period of medical need for the remainder of the reasonable useful lifetime of the equipment. No rental payments after the item is purchased, returned or after the total of issued rental payments equals the purchase price. We do not accept blood gas tests results when the test was conducted by a medical supplier or taken while the patient is on oxygen. Alert: This is the tenth rental month.
Equipment purchases are limited to the first or the tenth month of medical necessity. DME, orthotics and prosthetics must be billed to the DME carrier who services the patient's zip code. Diagnostic tests performed by a physician must indicate whether purchased services are included on the claim. Only one initial visit is covered per specialty per medical group. No separate payment for an injection administered during an office visit, and no payment for a full office visit if the patient only received an injection.
Alert: Payment approved as you did not know, and could not reasonably have been expected to know, that this would not normally have been covered for this patient. Certain services may be approved for home use. Missing invoice. The information furnished does not substantiate the need for this level of service. Also refer to N Alert: The patient has been relieved of liability of payment of these items and services under the limitation of liability provision of the law.
This does not qualify for payment under Part B when Part A coverage is exhausted or not otherwise available. Missing pathology report. Missing radiology report. Alert: This is a conditional payment made pending a decision on this service by the patient's primary payer.
Claim lacks the CLIA certification number. This is the 11th rental month. Not covered when the patient is under age Alert: The patient is liable for the charges for this service as they were informed in writing before the service was furnished that we would not pay for it and the patient agreed to be responsible for the charges.
Alert: The patient is not liable for payment of this service as the advance notice of non-coverage you provided the patient did not comply with program requirements.
Claim must be assigned and must be filed by the practitioner's employer. We do not pay for this as the patient has no legal obligation to pay for this. The medical necessity form must be personally signed by the attending physician. Payment for services furnished to hospital inpatients other than professional services of physicians can only be made to the hospital.
We do not pay for self-administered anti-emetic drugs that are not administered with a covered oral anti-cancer drug. Missing Certificate of Medical Necessity. We cannot pay for this as the approval period for the FDA clinical trial has expired. We do not pay for more than one of these on the same day. One interpreting physician charge can be submitted per claim when a purchased diagnostic test is indicated. Our records indicate that you billed diagnostic tests subject to price limitations and the procedure code submitted includes a professional component.
Paid at the regular rate as you did not submit documentation to justify the modified procedure code. Total payment reduced due to overlap of tests billed. Multiple automated multichannel tests performed on the same day combined for payment. You are required to code to the highest level of specificity. Service is not covered when patient is under age Service is not covered unless the patient is classified as at high risk. Medical code sets used must be the codes in effect at the time of service.
Subjected to review of physician evaluation and management services. We cannot pay for laboratory tests unless billed by the laboratory that did the work. Not covered more than once under age Not covered more than once in a 12 month period. Lab procedures with different CLIA certification numbers must be billed on separate claims. Information supplied supports a break in therapy. Information supplied does not support a break in therapy. The technical component of a service furnished to an inpatient may only be billed by that inpatient facility.
Not paid to practitioner when provided to patient in this place of service. Begin to report the Universal Product Number on claims for items of this type. We do not pay for an oral anti-emetic drug that is not administered for use immediately before, at, or within 48 hours of administration of a covered chemotherapy drug. Service not performed on equipment approved by the FDA for this purpose. Payment reduced as day rolling average hematocrit for ESRD patient exceeded We have provided you with a bundled payment for a teleconsultation.
We do not pay for chiropractic manipulative treatment when the patient refuses to have an x-ray taken. This item is denied when provided to this patient by a non-contract or non-demonstration supplier. Processed under a demonstration project or program. Not covered unless submitted via electronic claim.
Letter to follow containing further information. We pay for this service only when performed with a covered cryosurgical ablation. Missing indication of whether the patient owns the equipment that requires the part or supply. Missing patient medical record for this service. Missing physician financial relationship form. Missing pacemaker registration form.
Claim did not identify who performed the purchased diagnostic test or the amount you were charged for the test. Part B coinsurance under a demonstration project or pilot program. Patient identified as a demonstration participant but the patient was not enrolled in the demonstration at the time services were rendered.
Denied services exceed the coverage limit for the demonstration. Service not covered until after the patient's 50th birthday, i. Missing physician certified plan of care.
The provider must update license information with the payer. Alert: If you do not agree with what we approved for these services, you may appeal our decision. Alert: If you do not agree with this determination, you have the right to appeal. Secondary payment cannot be considered without the identity of or payment information from the primary payer.
Incorrect admission date patient status or type of bill entry on claim. Alert: The claim information has also been forwarded to Medicaid for review. Alert: Claim information was not forwarded because the supplemental coverage is not with a Medigap plan, or you do not participate in Medicare.
Alert: The patient's payment was in excess of the amount owed. Payment is being issued on a conditional basis. You have not established that you have the right under the law to bill for services furnished by the person s that furnished this these service s.
Alert: You may be subject to penalties if you bill the patient for amounts not reported with the PR patient responsibility group code. Alert: The patient is a member of an employer-sponsored prepaid health plan. Alert: Your claim has been separated to expedite handling. The patient is covered by the Black Lung Program. We are the primary payer and have paid at the primary rate.
Alert: The claim information is also being forwarded to the patient's supplemental insurer. Skilled Nursing Facility SNF stay not covered when care is primarily related to the use of an urethral catheter for convenience or the control of incontinence. SSA records indicate mismatch with name and sex. Demand bill approved as result of medical review. A patient may not elect to change a hospice provider more than once in a benefit period.
Alert: Our records indicate that you were previously informed of this rule. Alert: Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does not make the physician or supplier a party to the determination. Alert: No appeal rights. Alert: As previously advised, a portion or all of your payment is being held in a special account.
Alert: The new information was considered but additional payment will not be issued. Physician certification or election consent for hospice care not received timely. Alert: The patient overpaid you for these services. Alert: This is a telephone review decision. Our records indicate that we should be the third payer for this claim. Alert: Correction to a prior claim.
Alert: We did not crossover this claim because the secondary insurance information on the claim was incomplete. Alert: The patient overpaid you for these assigned services. Informational remittance associated with a Medicare demonstration. Alert: This payment replaces an earlier payment for this claim that was either lost, damaged or returned. Alert: The patient overpaid you. The patient overpaid you. Billed in excess of interim rate. Informational notice. Did not indicate whether we are the primary or secondary payer.
Patient identified as participating in the National Emphysema Treatment Trial but our records indicate that this patient is either not a participant, or has not yet been approved for this phase of the study. Alert: This determination is the result of the appeal you filed. Missing plan information for other insurance. Did not enter the statement 'Attending physician not hospice employee' on the claim form to certify that the rendering physician is not an employee of the hospice.
A not otherwise classified or unlisted procedure code s was billed but a narrative description of the procedure was not entered on the claim. Claim rejected. Claim Rejected. Paper claim contains more than three separate data items in field Paper claim contains more than one data item in field Claim processed in accordance with ambulatory surgical guidelines. Did not complete the statement 'Homebound' on the claim to validate whether laboratory services were performed at home or in an institution.
Alert: No Medicare payment issued for this claim for services or supplies furnished to a Medicare-eligible veteran through a facility of the Department of Veterans Affairs. Provider level adjustment for late claim filing applies to this claim. Your center was not selected to participate in this study, therefore, we cannot pay for these services. Processed for IME only. Per legislation governing this program, payment constitutes payment in full.
Pancreas transplant not covered unless kidney transplant performed. Reserved for future use. This provider was not certified for this procedure on this date of service. Physician already paid for services in conjunction with this demonstration claim.
Adjustment to the pre-demonstration rate. Claim overlaps inpatient stay. Alert: You may appeal this decision in writing within the required time limits following receipt of this notice by following the instructions included in your contract, plan benefit documents or jurisdiction statutes.
This allowance has been made in accordance with the most appropriate course of treatment provision of the plan. Missing consent form. EOB received from previous payer.
Crossover claim denied by previous payer and complete claim data not forwarded. Adjustment represents the estimated amount a previous payer may pay. Denial reversed because of medical review. Policy provides coverage supplemental to Medicare. Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount.
Services for a newborn must be billed separately. Per admission deductible. Payment based on the Medicare allowed amount. Procedure code incidental to primary procedure. Service not payable with other service rendered on the same date. Alert: Your line item has been separated into multiple lines to expedite handling.
This company has been contracted by your benefit plan to provide administrative claims payment services only. Consent form requirements not fulfilled. Patient ineligible for this service. Claim must be submitted by the provider who rendered the service. No record of health check prior to initiation of treatment.
Claim must meet primary payer's processing requirements before we can consider payment. Authorization request denied. Missing mental health assessment. Bed hold or leave days exceeded. Payer's share of regulatory surcharges, assessments, allowances or health care-related taxes paid directly to the regulatory authority. Payment based on authorized amount. Claim conflicts with another inpatient stay.
Claim information does not agree with information received from other insurance carrier. Court ordered coverage information needs validation. Patient not enrolled in the billing provider's managed care plan on the date of service. Alert: Please refer to your provider manual for additional program and provider information. A valid NDC is required for payment of drug claims effective October Rebill services on separate claims. Dates of service span multiple rate periods.
Rebill services on separate claim lines. The 'from' and 'to' dates must be different. Professional provider services not paid separately. Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Consolidated billing and payment applies. Your unassigned claim for a drug or biological, clinical diagnostic laboratory services or ambulance service was processed as an assigned claim.
Resubmit with multiple claims, each claim covering services provided in only one calendar month. Service billed is not compatible with patient location information. Procedure billed is not compatible with tooth surface code. Provider must accept insurance payment as payment in full when a third party payer contract specifies full reimbursement. No appeal rights. Alert: Further installment payments are forthcoming. Alert: This is the final installment payment.
A failed trial of pelvic muscle exercise training is required in order for biofeedback training for the treatment of urinary incontinence to be covered. Home use of biofeedback therapy is not covered. Alert: This payment is being made conditionally. Alert: Payment information for this claim has been forwarded to more than one other payer, but format limitations permit only one of the secondary payers to be identified in this remittance advice.
Covered only when performed by the attending physician. Services not included in the appeal review. This facility is not certified for digital mammography. A separate claim must be submitted for each place of service. Patients with stress incontinence, urinary obstruction, and specific neurologic diseases e.
Patient must have had a successful test stimulation in order to support subsequent implantation. Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated. Additional information is needed in order to process this claim.
Records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This facility is not certified for film mammography. This claim is excluded from your electronic remittance advice. Only one initial visit is covered per physician, group practice or provider.
Alert: This payment is being made conditionally because the service was provided in the home, and it is possible that the patient is under a home health episode of care. This service is paid only once in a patient's lifetime. This service is not paid if billed more than once every 28 days. Payment is subject to home health prospective payment system partial episode payment adjustment. Add-on code cannot be billed by itself. Alert: This is a split service and represents a portion of the units from the originally submitted service.
Social Security Records indicate that this individual has been deported. This amount represents the prior to coverage portion of the allowance. Not eligible due to the patient's age. Total payments under multiple contracts cannot exceed the allowance for this service. Alert: Payments will cease for services rendered by this US Government debarred or excluded provider after the 30 day grace period as previously notified.
Alert: Services for predetermination and services requesting payment are being processed separately. Alert: This represents your scheduled payment for this service. Record fees are the patient's responsibility and limited to the specified co-payment. Alert: To obtain information on the process to file an appeal in Arizona, call the Department's Consumer Assistance Office at or Alert: The provider acting on the Member's behalf, may file an appeal with the Payer.
Alert: In the event you disagree with the Dental Advisor's opinion and have additional information relative to the case, you may submit radiographs to the Dental Advisor Unit at the subscriber's dental insurance carrier for a second Independent Dental Advisor Review.
Alert: Under 32 CFR The patient was not residing in a long-term care facility during all or part of the service dates billed. The original claim was denied. The patient was not in a hospice program during all or part of the service dates billed. The rate changed during the dates of service billed. Missing screening document. Long term care case mix or per diem rate cannot be determined because the patient ID number is missing, incomplete, or invalid on the assignment request.
Rebill all applicable services on a single claim. Telephone contact services will not be paid until the face-to-face contact requirement has been met. Alert: This payment was delayed for correction of provider's mailing address. Alert: Our records do not indicate that other insurance is on file. Alert: The patient is responsible for the difference between the approved treatment and the elective treatment. Transportation in a vehicle other than an ambulance is not covered. Medical record does not support code billed per the code definition.
Charges exceed the post-transplant coverage limit. Payment for repair or replacement is not covered or has exceeded the purchase price. No qualifying hospital stay dates were provided for this episode of care. Missing review organization approval. Services provided aboard a ship are covered only when the ship is of United States registry and is in United States waters.
Alert: We did not send this claim to patient's other insurer. Additional information has been requested from the member. This item or service does not meet the criteria for the category under which it was billed. Additional information is required from another provider involved in this service. Alert: This is a predetermination advisory message, when this service is submitted for payment additional documentation as specified in plan documents will be required to process benefits. Rebill technical and professional components separately.
Alert: You may request a review in writing within the required time limits following receipt of this notice by following the instructions included in your contract or plan benefit documents. The approved level of care does not match the procedure code submitted.
Alert: This service has been paid as a one-time exception to the plan's benefit restrictions. Missing contract indicator. The provider must update insurance information directly with payer. Technical component not paid if provider does not own the equipment used. The technical component must be billed separately.
Alert: Patient eligible to apply for other coverage which may be primary. The subscriber must update insurance information directly with payer. Rendering provider must be affiliated with the pay-to provider.
Click on your name at the top of your My Account page, then select Communication Preferences from the menu. An EOB is not a bill. It simply summarizes your care and how your benefits were applied to recent insurance claims. An EOB will tell you how much you may owe your healthcare provider.
We process any claims we receive first, then generate EOBs for our members. You can check the status of your recent claims here. They contain the same information as your paper EOB but are generated electronically to view on a computer or mobile device. The document number is a unique identifier that is generated for each eEOB so that it can be easily referenced and searchable online.
You need to verify your email address and opt in to receive electronic forms of communication, e-EOB notifications. Double-check your preferences by logging into My Account.
Sometimes an email from a new sender will automatically go to your spam or junk mail folder. To avoid this, add CareFirst to your address book or safe senders list. Under certain circumstances, your claims statement summary graph may not display all three types of charges i.
Here are some examples of when that might happen:. You saw an in-network provider and CareFirst is covering your total cost. Your claim was processed as out-of-network and you are liable for the entire bill.
Depending on your health plan, CareFirst may reimburse you for part or all of the charge. Whenever you receive care from an in-network healthcare provider, they fill out an insurance claim form and submit it to CareFirst. Providers have up to one year to submit a claim after the date of service. Claims are entered into our system and processed according to your benefits. It takes CareFirst about 30 days to process new claims.
How long will it take to process this claim? Any time you receive care outside this area, your claim will take additional time to process. My claim was denied by CareFirst. What are the next steps to investigate a claim?
If an insurance claim is denied for any reason, you may ask CareFirst to review it. For a step-by-step guide to the appeal process, visit our Appeal a Claim page. Various state and federal laws dictate who can see what information, regardless of relation. In most cases:. The allowed amount or allowed charge is the maximum amount your insurance plan will pay for a single covered healthcare service.
Healthcare providers working in our network are subject to limits that they can charge for care, as determined by CareFirst. Out-of-network providers may charge more for their services. If you see an out-of-network provider, you may be responsible to pay the difference between their price and the CareFirst allowed amount. Your benefits are the services covered by your plan. Depending on the plan you have, your benefits may cover the entire amount charged for the service s or a partial amount.
A claim is an official document that details what kind of care you received so that CareFirst can pay your medical provider.
WebRemittance Advice Remark Codes provide additional information about an adjustment already described by a CARC and communicate information about remittance . WebOct 7, · A CareFirst BlueCross BlueShield representative will contact you with a decision within 72 hours. To file an expedited appeal, call Member Services at . WebRevenue Codes CareFirst BlueCross BlueShield is the shared business .