Premera follows national credentialing standards regarding the staff in a hospital system who must be credentialed. See the Credentialing and Contracting section of this manual for more information.
Prior authorization is required instead of admit notification for the following intermediate levels of care:
Call 877-342-5258, option 3, with questions.
Please have the following information available when you notify us of an admission:
We use Change Healthcare InterQual® criteria, American Society of Addiction Medicine criteria and plan medical policy to determine the medical necessity of member admission and length of stay for all medical, surgical, mental health, and chemical dependency facility-based treatments.
A discharge planner notifies Care Management about the possibility of a patient facility transfer. When this occurs, Care Management helps facilitate a transfer to a contracted facility whenever medically appropriate.
Prior to all non-emergent transfers, please confirm with Customer Service that the facility is contracted for the health plan and contracted for the proposed services. Some facilities have contracts limited to special or limited services and are not contracted for all services they provide.
Some member contracts will allow the use of a non-contracted facility at a lower benefit level. For non-emergent transfers, contact Customer Service to determine if the member contract allows for the lower level of reimbursement. Medically necessary services that cannot be reasonably provided at a contracted facility within the product-specific network will be prospectively assessed for possible authorization of non-contracted provider use at the maximum benefit level.
In an emergency, members may be hospitalized at non-contracted facilities. We will assess each member's situation for appropriateness of a transfer to a contracted facility. Transfer decisions are made based on our policy for medical stability, attending physician or other provider agreements, member and/or family agreement to transfer, and expected duration of stay.
To contact Care Management, please call 877-342-5258, 800-596-3382, 800-722-4714, option 3.
Calypso provides investigation and recovery services for us and our subsidiaries and affiliates. Calypso administers the hospital bill audit process on our behalf. The purpose of the audit is to:
When the audit is complete, the auditor will meet with a hospital auditor to review the findings. This could result in refunds and/or the reprocessing of claims to pay additional benefits. For questions about Calypso processes, please call 800-364-2991.
The Centers for Medicare and Medicaid Services (CMS) form 1450, referred to as the UB-04, is the standard claim form used to bill facility services to us and our affiliates. Submitting the claim form with all required fields will assist us in paying your
claim in a timely manner. Claim forms that are missing one or more of the required fields may be rejected or denied.
It is necessary to follow the guidelines provided by the National Uniform Billing Committee (NUBC) in the most current Official UB-04 Data Specifications Manual when completing this form for all facility services rendered to a member. It
is also necessary to follow the established definitions and guidelines for each field on the claim form.
When completing the form be sure to include information regarding any other insurance coverage that a member may have, the facility tax identification number, itemized dates of service, appropriate procedure codes, and revenue codes to assist in proper
and timely payment of all claims.
For additional information you can reference:
There are 81 data fields on a UB-04 claim form. Careful attention should be paid to the following items on the UB-04 will assist in processing your claim accurately and promptly. The examples provided below do not represent ALL the 81 fields but some
of the most critical fields and some of the most common examples:
Type of Bill (form locater 4): 0NNN
Patient Discharge Status (form locater 17): The patient discharge status code is a required item and must be available to identify transfer situations. This code represents the patient’s disposition or discharge status at the ending date
of service for the period of care such as:
Condition Codes (form locators 18-26): these codes provide additional information on the condition of the patient that may affect processing of the claim.
Occurrence Codes (form locaters 31 - 36): Occurrence codes and dates should be completed for all accident, maternity, and illness claims.
Value Codes and Amounts (form locater 39): These fields contain codes and related dollar amounts that are necessary to process and reimburse the claim correctly. Entries in these fields can represent semi-private room rates, blood deductibles,
coinsurance amounts, dialysis charges to name a few.
Revenue Codes (form locator 42): Revenue codes represent a specific accommodation and/or ancillary service. The revenue code must be four digits.
HCPCS/Rate/HIPPS Codes (form locator 44): Enter a HCPCS code applicable for the ancillary service for outpatient claims, a HIPPS rate code, or the inpatient accommodation rate. A HCPCS code is required when a drug or biological is reported.
An accommodation rate is required when a room and board revenue code is billed (revenue codes 0100s through 0219)
Service Date (form locator 45): The dates for when the service indicated was provided.
Diagnosis Codes (form locators 67, 67a – 67q, 69): Enter ICD-10 CM diagnosis codes.
Procedure Codes (form locator 74, 74a – 74e):
Remarks (form locater 80): Additional information needed to help in the processing of the claim.
Age of Patient and Age Bands of Diagnosis codes or Procedure Codes: The age of a patient should match the same age band of a diagnosis code or procedure code:
Reimbursement is subject to the terms defined in the contract between the facility and us. Final payment is subject to our fee schedule and payment policies, a member’s eligibility, coverage and benefit limits at the time of service, and claims adjudication edits common to the industry and/or adopted as our Payment Policy.
Please submit interim bills for lengths of stay in excess of 30 days with the following criteria. Interim bills submitted with lengths of stay less than 30 days will be returned to the facility.
Each interim claim will be processed based on the computed DRG, APDRG or MS-DRG for inpatient claims and outpatient payment methodology for outpatient claims.. The final bill (bill type 114) will determine whether additional reimbursement
or an adjustment will be made. If the final bill is being “replaced” in its entirety, the bill type must be 117 to represent a replacement of prior claim(s).
Supplemental claims should be submitted when an additional charge is realized after the final claim has been submitted. If you are submitting a late charge, indicate the additional charges and the beginning and ending dates of service. Late charges are
added to the original claim and processed according to contractual agreements. Change the “bill type” (field 4) to represent “late charges only” (bill type 115).
An Ambulatory Surgery Center (ASC) is a freestanding facility, other than a physician or other provider's office, where surgical and diagnostic services are provided on an ambulatory basis.
Most ASCs contracted with us use a payment methodology modeled after the CMS Ambulatory Payment Classification (APC) methodology for ASCs, with services billed on a CMS-1500 claim form. ASCs, whose payment is based on the Medicare APC methodology, are paid a facility fee modeled after CMS. We supplement the list with additional procedures.
Note: The physician or other provider who performs the surgery in an ASC is also paid for his or her professional services. A claim is filed for the physician or other provider services, separate from the ASC facility services.
Note: Reference the facility agreement to confirm your specific billing, reimbursement methodology, and reimbursement rates.
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