AmeriHealth continues to enforce claims processing requirements since migrating to the new operating platform (i.e., claims processing for AmeriHealth Pennsylvania members and AmeriHealth New Jersey Medicare Advantage members). Note: AmeriHealth New Jersey commercial members will be migrated to the new platform by October 1, 2015. Our claims processing system ensures that claims contain the correct data before they are processed. Claims must have valid codes and all required fields completed in order to be processed on the new platform. The information below highlights the results of a recent analysis of post-migration rejection rates.
Common claim rejections
Below are the major reasons for most rejections and how to correct the errors:
- NPI and trading partner are not affiliated. The provider?s National Provider Identifier (NPI) and the trading partner are required to be linked in the new system; otherwise, the trading partner is not authorized to submit electronic claims on the provider?s behalf and the claims will reject. Contact your clearinghouse or billing vendor for instructions on how to affiliate. If you are your own trading partner, go to our EDI section of our website.
- NAIC code – Submit to the correct payer. Ensure that you submit claims with the appropriate NAIC code, as identified in the Payer Information column on our payer ID grids and in accordance with the member?s coverage. Refer to the payer ID grids on our website.
- Member not found:
- Subscriber ID invalid. Providers must submit the most current member ID number based on the member?s coverage at the time of service. Refer to the article AmeriHealth Pennsylvania platform transition has been completed in the April 2015 edition of Partners in Health UpdateSM for more information on checking ID cards and verifying member eligibility at every visit.
- Names misspelled or name variations. A member?s name must be spelled as it appears on the member ID card. Variations in name spellings and punctuation will cause claims to reject (e.g., D?Angelo vs. Dangelo).
- Claim submitted without taxonomy code. The provider?s taxonomy code must be billed with the corresponding NPI and submitted at the billing provider level. Providers associated with more than one specialty group are required to submit the correct NPI and correlating taxonomy code to ensure correct claims processing. Sending claims with incorrect taxonomy codes could cause payment delays or cause claims to be paid incorrectly. These errors occur most frequently with mutli-specialty groups. Detailed information and examples on how to correctly submit taxonomy codes can be found in the article Guidelines for billing with taxonomy codes in the June 2014 edition of Partners in Health Update.
- Missing referring provider. The referring provider is required on all claims when the place of service is 81, a professional independent clinical lab.
- Missing procedure description. A service line description is required for all non-specific procedure codes submitted on a claim. Non-specific procedure codes include not otherwise classified [NOC]; unspecified; other; miscellaneous; prescription drug, generic; or prescription drug, brand name.
- Code set validations. Valid code, including HCPCS, CPT®, diagnosis, and revenue codes and procedure code modifiers, are required for all claims. Submitted claims containing invalid codes or codes with termination dates effective prior to or on the date of service will not be processed.
Correctly submitting UB-04 claim forms with OPL and COB
When a paper claim is submitted and Other Party Liability (OPL) or Coordination of Benefits (COB) is involved, it is imperative that all applicable fields are completed correctly on the UB-04 claim form, including the following:
- Field Location 54 (FL54). FL54 is a required field when the indicated payer (other insurance) has paid an amount to the provider towards this bill. Report ?0.00? if there is no payment made by the health plan or payment was applied to the member?s coinsurance or deductible.
- Field Locations 39, 40, 41 (FL39, FL40, FL41). FL39, FL40, and FL41 are required fields when there is a value code and amount that applies to the claim, specifically where 1) Medicare is primary and 2) coinsurance or a deductible applies.
- Multi-page claims. Per the National Uniform Billing Committee (NUBC), all claim-level data must be reported on each page of the UB-04 claim form. Line-level data will be unique on each page of the claim, and total charges for the claim (FL47, line 23) should be reported only on the last page.
For more information
For more information on claims processing, visit the EDI section of our website. For information about submitting claims using the UB-04 claim form, please refer to the NUBC website.
If you have any questions related to conducting EDI business with AmeriHealth, please call Highmark EDI Operations at 1-800-992-0246. Highmark EDI Operations is available Monday through Friday, 8 a.m. to 5 p.m., ET.
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