GENERAL BILLING GUIDELINES
The IAMHP Comprehensive Billing Manual (“the Manual“) is designed to provide support and guidance to contracted Medicaid managed care providers on billing for services to Medicaid beneficiaries. This manual only applies to HealthChoice Illinois (HCI) Managed Care Organizations (“MCOs”) and for services provided to Medicaid beneficiaries in Medicaid-only programs (e.g. FHP, ACA, ICP and LTSS populations). It does NOT apply to dually-eligible beneficiaries in the Medicare Medicaid Alignment Initiative (MMAI) program. The Manual gives providers a one-stop document for billing and claims procedures, without having to look up each health plan and/or provider-specific process separately. IAMHP completed a thorough review and comparison of all member MCO Billing Guides, and working closely with our members, has crafted a single source for all claims policies and procedures, regardless of provider type. The bulk of the Manual provides policies and procedures common to all MCOs; however, there will be a select number of instances where the MCOs may differ in their approach. In these cases, links to MCO-specific guidelines are embedded in the document for easy reference. It is also imperative to always refer to your contractual agreements as you may have specific nuances that apply specifically to you as noted in your agreement. Your provider agreement supersedes items in this manual.
Physicians, licensed health professionals, facilities, and additional providers contract directly with us for payment of covered services.
It is important that you submit accurate billing information on file. Please make sure the following information is current in our files:
Provider name (as noted on current W-9 form)
National Provider Identifier (NPI)
Tax Identification Number (TIN)
Business Address (as noted on current W-9 form)
Billing name and address
You must bill with your NPI number in box 24Jb of the 1500 form. We encourage our providers to bill their taxonomy code in box 24Ja to avoid any delays in processing. Claims that don’t have this information will be returned and a notice will be sent to you. This creates payment delays. These claims cannot be accepted into our system and are not considered “clean claims.”
Please notify us 30 days in advance of any billing information changes. Submit this information on a W-9 form. Changes to your TIN and/or address are not acceptable when submitted with a claim form.
Claims are eligible for payment if they meet these requirements:
- The patient is a NextLevel Health Member on the date of service.
- The service provided is a covered benefit under the Member’s contract on the date of service.
- Referral and prior authorization processes were followed, if applicable.
- Payment for service is contingent upon compliance with referral and prior authorization policies and procedures, as well as the billing guidelines outlined in the Provider Manual.
If we do not receive full premium payments from the Illinois Department of Healthcare and Family Services (HFS) for two or more consecutive periods, our agreement to make timely payments to you may be suspended until HFS pays in full. Your responsibility to submit claims for your services cannot be postponed or changed. This overrides any conflicting communication from us, any provision in the Provider Manual or your contract with us. We will post suspensions of program payments on our site. We will send you a written notice as well.
You must submit all claims and encounters within the time frame established in your Agreement with NextLevel Health, which is generally 180 calendar days from the date of service. The filing limit may be extended where eligibility has been retroactively received by NextLevel Health up to a maximum of 120 days, or where a specific program specifies an extended timely filing period by HFS. All claim requests for reconsideration, corrected claims, or claim disputes must be received within 90 calendar days from the date of notification of payment or denial is issued.
PROFESSIONAL, INSTITUTIONAL, AND DENTAL CLAIMS SUBMISSION
Electronic Claims Submission
You are encouraged to use our electronic claims/encounter filing program. We can receive ANSI X12N 837 professional (837P) and institutional (837I) claims transactions. It can also generate an ANSI X12N 835. You have the same filing requirements as those filing paper claims. Please review your error reports and payment evidence to make sure all submitted claims and encounters appear on the reports. You are responsible for correcting any mistakes and resubmitting the claim(s).
Providers should route their claims through “Change Healthcare” (formerly Emdeon). Our Payer ID for Change Healthcare is 69821
833-ASK-NLHP (833-275-6547) from 8:30 a.m. to 5 p.m. Central Standard Time (CST).
Dental services and dental claims should be submitted to Liberty Dental for processing: Click here
All pharmacy claims processing functions should be submitted to Envolve Pharmacy Solutions (EPS): Click here
ELECTRONIC FUNDS TRANSFERS (EFT) & ELECTRONIC REMITTANCE ADVICE (ERA)
We provide Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) to you.
EFT and ERA offer:
- Lower accounting expenses—advices can be imported directly into practice management or patient accounting systems. No need for manual rekeying.
- Better cash flow— faster payments mean improved cash flow.
- Control over bank accounts—you control the destination of claim payment funds. Multiple practices and accounts are supported.
- Match payments to advices quickly—associate electronic payments with electronic remittance advices.
For more information, call Claims Services at 833-ASK-NLHP (833-275-6547) from 8:30 a.m. to 5 p.m. CST.
PAPER CLAIMS SUBMISSION
For Members, all paper claims and encounters (except for pharmacy and dental claims) should be submitted to:
Attn: Claims Dept
P.O. Box 5050
Farmington, MO 63640-5050
We use an imaging process for paper claims retrieval. To ensure accurate and timely claims capture, please observe the following claims submission rules:
DO use the correct P.O. Box number.
DO submit all claims in a 9” x 12” or larger envelope.
DO type all fields completely and correctly.
DO use black or blue ink at 9point or larger font size.
DO include all insurance information (policyholder, carrier name, ID number, and address) when applicable.
DO submit on a proper original form—CMS 1500 or UB 04.
DON’T submit handwritten claim forms.
DON’T use red ink.
DON’T use a P.O. Box number for the service location. DON’T circle any information on claim forms.
DON’T add extra information to any claim form field. DON’T use a highlighter.
DON’T submit photocopied claim forms.
DON’T submit carboncopied claim forms.
DON’T submit claim forms via fax.
“CLEAN” CLAIM DEFINITION
A “clean claim” requires no additional information, adjustment, or alteration of the services to be processed and paid by NextLevel Health.
Claims that are not “clean” require further documentation, such as
- a request for additional information from you or other external sources; and or a
- review of additional medical records.
Claims that don’t meet medical necessity criteria or are not submitted within the filing deadlines are not considered “clean.”
COMMON CAUSES OF UPFRONT REJECTIONS
Missing Member date of birth
Missing Member name or identification number
Missing Provider name, Tax ID, or NPI number
Date of service on the claim is not prior to receipt date of the claim Missing information from required fields
Invalid or missing place of service or type of bill
Missing, invalid, or incomplete diagnosis code
Missing service line detail
Member not effective on date of service
Missing admission type
Missing patient status
Missing or invalid occurrence code or date
Missing or invalid revenue code
Missing or invalid CPT/procedure code
Incorrect form type
We will provide detailed reasons for each paper claim that is rejected.
COMMON CAUSES OF CLAIM PROCESSING DELAYS AND DENIALS
Incorrect form type
Missing the required digits and/or level of specificity for the diagnosis code Missing or invalid procedure or modifier codes
Missing or invalid DRG code (if required)
Missing or incomplete explanation of benefits (EOB) from primary carrier Invalid Member ID
Invalid place of service code
Provider TIN and NPI do not match
Invalid Revenue code
Dates of service span do not match listed days/units
Missing physician signature
Missing or incomplete third-party liability information
We will send ANSI X12 Reason and Remark codes to you for each claim that is denied. These codes detail the reason(s) for the denial.