Jan 2, 2013 | Medical billing basics
Emergency Services Emergency services are not subject to prior authorization requirements and are available to our members 24 hours a day, seven days a week, 365 days a year. An emergency medical condition is a medical condition manifesting itself by acute symptoms of...
Dec 27, 2012 | Medical billing basics
All of the following procedures and services require Prior Plan Notification and must beprovided in a SHP participating facility o Inpatient and Observation Admissions, as noted aboveo Admission to any rehabilitation and skilled nursing facility o All surgical...
Dec 22, 2012 | Medical billing basics
For those services included on the SHP Quick Authorization Form (QAF) (see the Forms Section of this handbook) a referral is NOT required. Primary Care Physicians (PCP’s) can refer a member to a participating specialist and to many frequently requested services...
Dec 17, 2012 | Medical billing basics
Physician Use of Health Care Extenders (ARNP’s and PA’s): Physicians must, in accordance with federal and state regulations and accepted professionalstandards, use physician extenders appropriately. Advanced Registered Nurse Practitioners(ARNPs) and Physician...
Dec 10, 2012 | Medical billing basics
PCP’s Request to Disenroll a Member from their Panel A Plan physician or provider may not seek or request to terminate a member on his/her panel or transfer a member to another health care provider based on the member’s medical condition, the amount or type of care...
Dec 4, 2012 | Medical billing basics
CHCUP (Child Health Check-up) is a Medicaid child health program of early and periodic screening, diagnosis and treatment services for beneficiaries under the age of 21. It used to be called EPSDT. All children of these ages who are SHP members should receive these...
Nov 21, 2012 | Medical billing basics
Inquiries When submitting an inquiry regarding corrected claims, questions about late charges, medical records or other situations, remember to complete the Provider Claim Inquiry Form and attach it to your claim. You should use this form for claims that denied with...
Nov 3, 2012 | Medical billing basics
2010AA REF – Segment Rule BILLING PROVIDER UPIN/LICENSE INFORMATION Must not be present (non-VA contractors). Submission of this segment will cause your claim to reject. 2010AC Loop Rule PAY TO PLAN LOOP Must not be present. Submission of this loop will cause your...
Oct 30, 2012 | Medical billing basics
1000A NM109 Submitter ID Contractor will reject an interchange (transmission) that is submitted with a submitter identification number that is not authorized for electronic claim submission. 1000B NM103 Receiver NameContractor will reject an interchange (transmission)...
Oct 26, 2012 | Medical billing basics
Interchange ID Qualifier 27, ZZContractor will reject an interchange (transmission) that does not contain 27 ,or ZZ in ISA05 ISA06 Interchange Sender IDContractor will reject an interchange (transmission) that does not contain a valid ID in ISA06. ISA07 Interchange ID...
