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Claims

GENERAL BILLING GUIDELINES

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)
Taxonomy code
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.

PROGRAM PAYMENTS
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.

TIMELY FILING
You must submit all claims and encounters within 180 calendar days of the service date. The filing limit may be extended if the eligibility has been retroactively received by NextLevel Health up to a maximum of 180 days. Requests for reconsideration, corrected claims or claim disputes must be received within 180 calendar days from the date of notification of payment or a denial will be issued.

PROFESSIONAL, INSTITUTIONAL, AND DENTAL CLAIMS SUBMISSION

ELECTRONIC CLAIMS

You are encouraged to use our electronic claims/encounter filing program. We can receive ANSI X12N 837 professional, institutional and dental 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). Dental services and dental claims, effective with dates of service on or after 9/1/16, should be submitted to claims to Liberty Dental for processing. This includes dental encounter claims from FQHCs: Click Here

Our EDI Clearinghouse Payer ID is 69821. Our clearinghouse vendor for all 837P, 837I and 837D transactions is Change Health Care (formerly Emdeon). For questions or more information on electronic filing, please contact:

NextLevel Health
Claims Department
1­-844-­807­-9734 from 8:30 a.m. to 5 p.m. Central Standard Time (CST).

PAPER CLAIMS SUBMISSION

Dental services and dental claims, effective with dates of service on or after 9/1/16, should be submitted claims to Liberty Dental for processing: Click Here

This includes dental encounter claims from FQHCs. For Members, all paper claims and encounters should be submitted to:

NextLevel Health
ATTN: CLAIMS DEPARTMENT P.O. Box 830700
Birmingham, AL 35283

REQUIREMENTS

We use an imaging process for paper claims retrieval. To ensure accurate and timely claims capture, please observe the following claims submission rules:

DO’s
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’Ts
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;
  • 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

Unreadable information
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
Invalid TIN
Missing or incomplete third­party 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.

ELECTRONIC FUNDS TRANSFERS (EFT) AND 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 1­-844-­807-­9734 from 8:30 a.m. to 5 p.m. Central Standard Time (CST).

PHARMACY CLAIMS

We have partnered with Meridian Rx for all pharmacy claims processing functions. For information, please visit Meridian Rx’s website.

VISION CLAIMS

Effective for service dates on or after 2/16/16 for vision services covered by Envolve/Opticare, claims must be submitted to Opticare for processing. Please visit their website for billing information: Click Here