Claims and Billing

• CLAIMS
  • General Information
  • Timely Filing
  • Electronic Clais Submission
  • Claims Review Process
  • Administrative Claims Review
  • Medical Claims Review
  • Coordination of Benefits
  • Primary Care Services
  • Specialty/Fee-For-Service Procedures
  • Medicare
  • Nursing Care
  • Subrogation
  • Claim Coding Software
• BILLING
  • Billing Procedures
  • Primary Care Services
  • EPSDT Services
  • Obstetrical Care Services
  • Surgical Procedure Services
  • Anesthesia Services
  • Hospital Services
  • Home Infusion
  • Skilled Nursing Facility
  • UB-92 Data Elements for Submission of Claims
  • CMS Data Elements for Submission of Claims

Claims and Billing

Member Billing Policy
Payment by Gateway is considered payment in full. Under no circumstance, including but not limited to nonpayment by Gateway for approved services, may a provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from or have any recourse against a Gateway member.

This provision does not prohibit collection of supplemental charges or copayments. Refer to the Member Benefit Limitations and Copayments Section of this manual for information on copayments. Members cannot be denied a service if they are unable to pay their copayment. Members are responsible up to a maximum of $90 for Adult MA and $180 for Adult GA every six months. Gateway will reimburse the member for any applicable copays based upon claims submission that exceed the maximum from January through June and again from July through December of each year.

This provision shall not prohibit collection of supplemental charges or copayments on Gateway's behalf made in accordance with the terms of the enrollment agreement between Gateway and the Member/subscriber/enrollee.

Practitioners may directly bill Members for noncovered services; provided, however, that prior to the provision of such noncovered services, the practitioner must inform the Member: (i) of the service(s) to be provided; (ii) that Gateway will not pay for or be liable for said services; (iii) of the Member's rights to appeal an adverse coverage decision as fully set forth in the Provider Manual; and (iv) absent a successful appeal, that Member will be financially liable for such services.

CLAIMS
General Information

Procedures for Gateway are as follows:

• Submit claims for all services provided including capitated services.
• Payment for CPT and HCPCS codes are covered to the extent that they are recognized by Medical Assistance or allowed per medical review determination by Gateway. Correct coding (procedure, diagnosis, HCPCS) must be submitted for each service rendered. Gateway utilizes CMS place of service codes to process claims, and they are the only place of service codes that are accepted. Gateway will add new codes to the respective fee schedules effective the first of the month upon receipt of notification from the Department of Public Welfare.
• Hospitals should bill on an original UB-92 form, and other providers, including ancillary providers, should bill using an original CMS-1500 Form.
• Gateway does accept bills through electronic data interchange (EDI) and encourages facilities and providers to submit claims via this format.
• Correct/current practitioner information, including Gateway Provider ID Number, must be entered on all claims. The format is 5 or 7 digits.
• Correct/current member information, including Gateway Member ID Number, must be entered on all claims. The format is 6 or 8 digits.
• Please allow four to six weeks for a remittance advice. It is the practitioner's responsibility to research the status of a claim.
• Timely filing criteria for initial bills is 180 days from the date of service. Corrected claims or requests for review are considered if information is received within the 90-day follow-up period from the date on the remittance advice.
• Payment by Gateway is considered payment in full. In no circumstance, including but not limited to non-payment by Gateway for non-approved services, may a practitioner bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a Gateway member.
•  Gateway is the payer of last resort when any commercial or Medicare plan covers the member. Gateway is obligated to process claims involving auto insurance, workers compensation or casualty services as the primary payer if bills do not include a notation or payment by any insurance that is not a commercial or Medicare plan. Claims must be submitted within Gateway's timely filing guidelines.
• Any reimbursement or coding changes made by the Department of Public Welfare to its current outpatient fee schedule shall be implemented by Gateway the month the Department of Public Welfare notifies Gateway of such change. There will be no adjustments made to previously processed claims due to any retroactive change implemented by the Department of Public Welfare.

Practitioners must submit a complete original, initial CMS-1500 or UB-92 form within 180 calendar days after the date of service.  If you bill on paper Gateway will only accept paper claims on a CMS-1500, or a UB-92 Forms.  No other billing forms will be accepted. Paper claims that are not received on original forms with red ink may delay final processing as original forms are required for every claim submission.

All EPSDT claims and primary care services must be submitted within 60 calendar days from the date of service.

Practitioners must bill within 60 days from the date of an Explanation of Benefits (EOB) from the primary carrier when Gateway is secondary.  An original bill along with a copy of the EOB is required to process the claim.  Requests for reviews/corrections of processed claims must be submitted within 90 days from the date of the corresponding remittance advice.  All claims submitted after the 180-day period for initial claims or after the 90-day follow-up period from the date on the remittance will be denied.

Any claim that has been submitted to Gateway but does not appear on a remittance advice within 60 days following submission should be researched by the practitioner.  Call the Gateway Provider Services Department to inquire whether the claim was received and/or processed. 

Exceptions to timely filing criteria are evaluated upon receipt of documentation supporting the request for the exception.  Upon approval, exceptions are granted on a one-time basis, and the claim system is noted accordingly.

Gateway can accept claims electronically through our association with WebMD.  Gateway encourages practitioners to take advantage of our electronic claims processing capabilities.  Submitting claims electronically offers the following benefits:

­ Faster Claims Submission and Processing
­ Reduced Paperwork
­ Increased Claims Accuracy
­ Time and Cost Savings

Gateway accepts electronic claims through WebMD and must be forwarded to Gateway in the HIPAA compliant format only.

To submit claims to Gateway please note the Payer ID Number is 25169.  Gateway has two health plan specific edits through WebMD for electronic claims that differ from the standard electronic submission format criteria.  These edits include:

• A Gateway assigned 5 or 7-digit practitioner identification number to process claims, the practitioner number field allows a maximum of 7 digits.  For practitioners with 5-digit numbers, the format should include two leading zeros followed by the Gateway practitioner identification number.
• A Gateway assigned 6 or 8-digit member identification number, the member number field allows 6, 8, or 10 digits to be entered.  For members with 6-digit Gateway identification numbers, the format should include two leading zeros followed by the Gateway member identification number.  For practitioners who do not know the member's Gateway identification number it is acceptable to submit the Medicaid Recipient Number.  The 10-digit recipient number will be converted electronically into a Gateway member identification number in order to process the claim.

In addition to edits that may be received from Emdeon, Gateway has a second level of edits that apply to procedure codes and diagnosis codes. Claims can be successfully transmitted by Emdeon, but if the codes are not currently valid they will be rejected by Gateway. Practitioners must be diligent in reviewing all acceptance/rejection reports to identify claims that may not have successfully been accepted by both Emdeon and Gateway. Edits applied when claims are received by Gateway will appear on an EDI Report within the initial acceptance report. A claim can be rejected if it does not include current procedure and diagnosis codes. To ensure that claims have been accepted via EDI, practitioners should receive and review the following reports on a daily basis:

• Provider Daily Statistics (RO22)
• Daily Acceptance Report by Provider (RO26)
• Unprocessed Claim Report (RO59)

If you are not submitting claims electronically, please contact either your Gateway Provider Relations Representative or an EDI vendor for information on how you can submit claims electronically.  You may also call WebMD directly at 1-800-366-5716.

Gateway will accept electronic claims for services that would be submitted on a standard CMS-1500 or a UB-92 Form.  However, the following cannot be submitted as attachments along with electronic claims at this time:

• The PCP Referral Form (paper version)
• The OB/GYN Referral Form (paper version)
• Claims with EOBs

Gateway will review any claim that a practitioner feels was denied or paid incorrectly.  The request may be conveyed in writing, or verbally through Gateway's Provider Services Department if the inquiry relates to an administrative issue.  Please forward all the appropriate documentation, i.e. the actual claim, medical records, and notations regarding telephone conversations, in order to expedite the review process.  Initial claims that are not received within 180-day timely filing limit, or the 60-day limit for EPSDT services, will not qualify for review.  All follow-up review requests must be received within 90 calendar days of the initial remittance advice.

Claims that need to be reviewed based upon administrative, policy, or processing issues can be discussed with a Provider Services Representative via a phone call to Gateway at 18003921145. For inquiries received in the mail, Claims Review Representatives evaluate whether the documentation attached to the claim is sufficient to allow it to be reconsidered. Inquiries received in the mail that qualify for adjustments will be reprocessed, and claim information will appear on subsequent remittance advices. Claims that do not qualify for reconsideration will be responded to via a letter. All review requests must be received within 120 days of the initial remittance advice.

Claims rejected for services that did not have medical records attached or the appropriate referrals or authorizations are subject to a Medical Management Review. All claim records should be sent to Gateway. When submitting a written request for a claim review, please provide: 

• A copy of the Gateway Remittance Advice
• The member's name and Gateway Identification Number
• The reason the review is requested
• Date(s) of service in question
• A copy of the medical record for the service(s) in question (if applicable)

In the event that the claim cannot be reprocessed administratively, a medical necessity review is undertaken.  The request and records will be reviewed by a medical review nurse.  If the medical review nurse cannot approve the services, a Gateway Physician Advisor makes the final decision to approve or deny the claim.  A final decision is made within 30 days from receipt of the inquiry.  If the Physician Advisor does not approve the services, a denial letter is sent to the practitioner.  If the practitioner is not satisfied with the results of the medical necessity review, a First Level Appeal can be requested.

Claims inquiries for administrative/medical review should be mailed to: Attention: Claims Review Department, Gateway Health Plan, US Steel Tower, Floor 41, 600 Grant Street, Pittsburgh, PA 15219-2704.

Some Gateway recipients have other insurance coverage.  Gateway, like the Pennsylvania Medical Assistance Program, is the payer of last resort on claims for services provided to members with other insurance coverage.  Gateway does not deny or delay approval of otherwise covered treatment or services unless the probable existence of third party liability is identified in Gateway's records for the member at the time the claims are submitted.

In order to receive payment for services provided to members with other insurance coverage, the practitioner must first bill the member's primary insurance carrier using the standard procedures required by the carrier.  Upon receipt of the primary insurance carrier's Explanation of Benefits, the practitioner should submit a claim to Gateway.  The practitioner must:

1. Follow all Gateway referral and authorization procedures.
2. File all claims within timely filing limits as required by the primary insurance carrier.
3. Submit a copy of the primary carrier's EOB with the claim to Gateway within 60 days of the date of the primary carrier's EOB.
4. Be aware that secondary coverage for covered fee-for-service items is provided according to a benefit-less-benefit calculation.
5. The amount billed to Gateway must match the amount billed to the primary carrier.  Gateway will coordinate benefits; the provider should not attempt to do this prior to submitting claims.
   

Per the Department of Public Welfare, Gateway is considered the primary insurer when auto or casualty claims are involved.  When a claim is submitted by a practitioner without an Explanation of Benefits (EOB) from the auto insurance or casualty plan, and there is not notation on the original bill on the primary payer payment, Gateway must pay as primary and not deny.  The practitioner has the option of submitting an original claim, however it must be submitted within 180-days.  These claims will be denied for timely filing if they are not received within 180 days of service.  The 60-day rule for Third Party Liability DOES apply to auto and casualty when the practitioner attaches either an EOB or auto/casualty exhaustion letter.  If the practitioner submits the claim with the EOB, Gateway will coordinate benefits, however, if the EOB is submitted after Gateway has paid the primary insurance, Gateway cannot adjust the claim and coordinate the benefits.  The overpayment will be due by the practitioner as reimbursement to the Department of Public Welfare.

If a member indicates they no longer have primary coverage, but the State System indicates otherwise, the member must contact his or her caseworker to have the State System updated.  If this is not possible, the practitioner may contact the primary carrier and request written verification of the coverage.

When Gateway receives a letter from the primary carrier indicating that the member no longer has coverage, Gateway will only use the letter to investigate the situation.  If Gateway's investigation confirms that the member no longer has primary coverage, Gateway will request the State update the system.  Once the State System has been updated, Gateway will go back 120 days and reprocess the coordination of benefits.

Gateway members cannot be billed for any co-payments and/or co-insurance, as regulated by the Department of Public Welfare.

Gateway is a payer of last resort when any commercial or Medicare plan covers the member.  Gateway is obligated to process claims involving auto insurance, workers compensation or casualty services as the primary payer if bills do not include a notation or payment by any insurance that is not a commercial or Medicare plan.  Claims must be submitted within Gateway's timely filing guidelines.

Capitated primary care practitioners will receive full capitation payment from Gateway for those members with other insurance coverage. Secondary coverage for all primary care services, including any deductible or coinsurance amounts not covered by the primary carrier, will be covered by the Gateway capitation payment. Practitioners are required to report all services provided to Gateway members by submitting a claim with a copy of the explanation of benefits regardless of whether or not additional payment is expected. Members seeking care, regardless of primary insurer, are required to contact their primary care practitioner and use participating practitioners or obtain appropriate authorization for practitioners outside of the network.

A Gateway member 18years or under with private insurance is eligible for Vaccines For Children (VFC). However, in the interest of reserving VFC vaccines for those children who need them most, if the child is covered by Gateway and also has private insurance that covers immunizations, the provider is to provide private vaccines and bill the private health insurance. If the child is covered by Gateway and also has private insurance that does not cover immunizations, VFC vaccines can be used and Gateway can be billed for administration costs.

Please note, if immunizations are billed alone, without the appropriate S0302 code and age appropriate 993XX CPT code for an EPSDT visit, COB will be applied and an EOB from the primary carrier is required.

If a member has other coverage, the other carrier is always the primary insurer.  The specialist will bill the other insurer and the other insurer will issue payment with an Explanation of Benefits statement (EOB), which outlines the payment made for each procedure.  The specialist will then submit a copy of the EOB with a copy of the claim to Gateway for secondary coverage.  The claim must be received by Gateway within 60 days of the date of the EOB.  If required, all Gateway authorization and referral requirements must be met in order for payment to be issued.  If the member has commercial insurance, and the commercial carrier's payment is greater than Gateway's payment if Gateway were primary, then the following reimbursement example would apply.  The primary carrier amount is the basis for the benefit determination of Gateway's liability when the practitioner is a participating practitioner with the primary plan.  The primary carrier allowable billed amount is used as the basis for the benefit determination of Gateway's liability when there is a patient responsibility remaining after the primary carrier has processed the claim.

Example of Practitioner Participating with Primary Plan:

.

Example of Patient Responsibility remaining after Primary Plan Payment:

Often, a Gateway member's other insurance carrier is Medicare.  When Medicare is the other insurance, the following processing criteria applies:

• Referrals and authorizations are not required for services covered by Medicare.  Once Medicare benefits have been exhausted, or if a service is not covered by Medicare Gateway referral and authorization criteria will apply.
• For Medicare Part A and Medicare Part B services, coverage is provided according to a benefits-less-benefits calculation.
  

Gateway determines the amount that would normally be paid under the plan using the allowable amount from the Medicare Plan as the billed amount.  If the amount Gateway would pay is more than the amount Medicare pays, then Gateway pays the difference up to the maximum allowable.  If the amount Gateway would pay is equal to or less than the amount Medicare pays, Gateway does not issue any additional payment.  For Medicare services that are not covered by either Medical Assistance or Gateway, Gateway must pay cost-sharing to the extent that the payment made under Medicare for the service and the payment made by Gateway does not exceed eighty percent (80%) of the Medicare approved amount.

Nursing Care

Gateway coordinates benefits with a commercial plan using a benefitslessbenefits approach for limited nursing care services and for expanded services. However, for these specific services only, the total amount billed to the primary plan will be the basis for the benefit determination of Gateway's liability.

Gateway's normal claims processing procedures for members with other primary insurance require that a primary carrier Explanation of Benefits (EOB) be submitted for each date of service.

In an effort to improve provider cash flow and to facilitate administrative procedures, Gateway provides an optional EOB exception process for extended nursing services only.  When the primary carrier has denied all extended nursing services, providers can submit the primary carrier's denial letter to Gateway.  Gateway will determine if the letter is accepted in lieu of EOBs for a defined period of time.  This procedure eliminates the need to submit primary carrier EOBs with each claim submitted to Gateway. Gateway's exception procedure for nursing services is as follows:

1. Submit medical records to the review committee of the primary insurance plan. Please allow adequate time for the review to be completed prior to the onset of services that you want Gateway to consider for primary coverage.
2. Upon receipt of the letter from the primary plan, please forward to a Gateway Claims Reviewer at Gateway Health Plan, US Steel Tower, 41st Floor, 600 Grant Street, Pittsburgh, PA 15219. Faxed correspondence will not be accepted. Letters must be received by Gateway within one month of the date on the denial letter (See examples #1 and #2 on the next page). Gateway's review will be completed within three weeks of receipt. 
3. Following the review, Gateway will send written documentation advising the provider if the letter was accepted. If the denial letter is not accepted, EOBs must be submitted with each claim to Gateway. 
4. If Gateway takes a primary position, the time period for which the letter has been accepted will be specified in the letter sent to you. Beginning April 1, 2004, when Gateway accepts a denial letter and takes a primary position, it will be valid for the balance of the calendar year. The provider would need to submit another denial letter the beginning of the next calendar year. When benefits are exhausted under the primary carrier or whenever there is a change of coverage during a calendar year, the process for EOB's/denial letters will need to be re-assessed (See example #3). If there are gaps in the allowable time period, any services rendered during the time period not covered by the allowable dates in the exception letter will require that EOBs be submitted from the primary plan, or Gateway Health Plan^® will not be able to coordinate benefits for those charges. 
5. In order for claims to be processed without delay, the services billed must align with the correct dates of services and procedure codes authorized and in accordance with Gateway's Private Duty Nursing Billing Guidelines, found in the Forms and Reference Materials Section of this Manual.
6. For each patient, either EOBs or the EOB exception pro

Example #1

Primary insurance review letter dated May 10, 2004.  Gateway receives letter June 5, 2004.  Gateway determination - Gateway assumes primary plan and EOB exemption begins April 1, 2004.

Examples #2

Primary insurance review letter dated March 5, 2004.  Gateway receives letter June 5, 2004.  Gateway determination - Gateway will require EOBs since nursing services exception letter was not received in 30 days.

Example #3

EOBs received from primary for January, February and March.  Benefits exhausted on March 25, 2004.  Provider can continue to submit EOBs or revert to nursing services exception procedures for balance of calendar year. 

Claims submitted by a provider and without an Explanation of Benefits statement from auto insurance or casualty plans, or without any notation on the original bill of the primary payer, will be processed by Gateway similar to any other claims.  Gateway may neither unreasonably delay payment nor deny payment of claims because they are involved in injury stemming from an accident, such as a motor vehicle accident, where the services are otherwise covered.  Timely filing criteria of 180 days applies and original claims must be received timely to be eligible for payment.  Explanation of Benefits or auto/casualty exhaustion letters qualify for consideration if they are received within 60 days of the date of the Explanation of Benefits/letter along with submission of the initial bill in order for Gateway to coordinate benefits.

However, if the auto/casualty Explanation of Benefits is submitted after Gateway has already paid as primary, claims cannot be adjusted, as Gateway must comply with criteria set by the Department of Public Welfare.

All requests from legal representatives, and/or insurers for information concerning copies of patient bills or medical records must be submitted to Gateway's Regulatory Department.

A cover letter identifying the date and description of the injury, requested dates of services for billing statements and release of information signed by the member should be forwarded to the following address:  Attention: Regulatory Affairs, Gateway Health Plan, US Steel Tower, Floor 41, 600 Grant Street, Pittsburgh, PA 15219-2704.

Gateway uses a fully automated coding review product that programmatically evaluates claim payments to verify the clinical accuracy of professional claims in accordance with clinical editing criteria.  This coding program contains complete sets of rules that correspond to CPT-4, HCPCS, ICD-9, AMA, and CMS guidelines as well as industry standards, medical policy and literature and academic affiliations.  The program used at Gateway is designed to ensure data integrity for ongoing data analysis and reviews procedures across dates of service and across providers at the claim, practitioner and practitioner-specialty level.

BILLING

Billing Procedures

A "clean claim" as used in this section means a claim for payment for a health care service that has no defect or impropriety.  A defect or impropriety shall include lack of required substantiating documentation or a particular circumstance requiring special treatment that prevents timely payment from being made on the claim.  A claim from a healthcare provider who is under investigation for fraud or abuse regarding that claim will not be considered a "clean claim".

In addition, a claim shall be considered "clean" if the appropriate corresponding referral has been submitted or the appropriate authorization has been obtained in compliance with Gateway's Policy and Procedure Manual and the following elements of information are furnished on a standard UB-92 or CMS-1500 form (or their replacement with CMS designations, as applicable) or an acceptable electronic format through a Gateway-contracted clearinghouse:

1. Patient name;
2. Patient medical plan identifier;
3. Date of service for each covered service;
4. Description of covered services rendered using valid coding and abbreviated description;
5. ICD-9 surgical diagnosis code (as applicable);
6. Name of practitioner/provider and plan identifier;
7. Provider tax identification number;
8. Valid CMS place of service code;
9. Billed charge amount for each covered service;
10. Primary carrier EOB when patient has other insurance;
11. All applicable ICD-9-CM diagnosis codes-inpatient claims include diagnoses at the time of discharge or in the case of emergency room claims, the presenting ICD-9-CM diagnosis code;
12. DRG code for inpatient hospital claims.

Gateway processes medical expenses upon receipt of a correctly completed CMS form and hospital expenses upon receipt of a correctly completed UB-92.  Sample copies of a UB-92 and a CMS form can be found in the Forms and Reference Material Section of this manual.  A description of each of the required fields for each form is identified later in this section.  Paper claim forms must be submitted on original forms printed with red ink.

A claim without valid, legible information in all mandatory categories is subject to rejection/denial.  To ensure reimbursement to the correct payee, the Gateway practitioner number must be included on every claim.

To comply with encounter data reporting, primary care practitioners and specialty care practitioner must submit claims under the individual practitioner identification number rather than the practice or group identification number. CMS submissions for anesthesiology, pathology, radiology, and emergency room practitioner groups must also include the individual practitioner identification number. Any claim billed on a CMS form must include the individual practitioner identification number (box 31 on the CMS Form). Please note that it is extremely important to promptly notify Gateway of any change that involves adding practitioners to any group practice, as failure to do so may result in a denial of service. Gateway will process claims utilizing individual practitioner numbers even if the individual practitioner number is not included on the claim. The only exception to the individual practitioner number requirement applies to UB charges for practitioner services when a remittance advice is issued to a hospital facility.

Gateway recommends that practitioners submit the appropriate copy of the Referral Form (if the telephonic DIVA paperless system is not used) with their claim in order to facilitate proper reimbursement.

All claims must have complete and accurate ICD9CM diagnosis codes for claims consideration. If the diagnosis code requires, but does not include the fourth or fifth digit classification, the claim will be denied.

Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. By signing a claim for services, the practitioner certifies that the services shown on the claim were medically indicated and necessary for the health of the patient and were personally furnished by the practitioner or an employee under the practitioner's direction. The practitioner certifies that the information contained in the claim is true, accurate and complete.

Gateway's claim office address is: Gateway Health Plan^®, Claims Processing Department, P.O. Box 11718, Albany, NY 122110718.

Any questions concerning billing procedures or claim payments can be directed to Gateway's Provider Services Department at 18003921145.

Primary Care Services

Primary care practitioners are required to report all the services they provide for Gateway members to Gateway. To facilitate reporting, Gateway will accept encounter information on the CMS1500 Form or the claim can be submitted via EDI. Charges for encounters/visits should be submitted within 60 days from the date of service but will be accepted up to 180 days from the date of service. The encounter information will be reported back to the primary care practitioner on a remittance advice. Capitated services will show a payment amount of zero. Services reimbursed outside of the base capitation will indicate a payment amount and will include a check for the sum of the services provided. 

As required by the Department of Public Welfare, effective March 1, 2004, Gateway will no longer accept the MA517 Form for EPSDT Screens. All EPSDT screening services must be submitted to Gateway either on a CMS1500, UB92 or the corresponding 837P or 837I format for EDI claims. Please consult the Pennsylvania Children's Checkup (EPSDT) Program Periodicity Schedule and Coding Matrix as well as the Recommended Childhood Immunization Schedule for screening eligibility information and the services required to bill for a complete EPSDT screen. Note: The Periodicity Schedule and the Immunization Schedules are updated periodically. Please use the most recent schedules when providing EPSDT screens.

Gateway will reimburse EPSDT screens ONLY when billed with procedure code S0302 AND the appropriate codes for Evaluation and Management Services. Claims without Evaluation and Management Services codes will not be eligible for reimbursement. The provider's EPSDT rate will be paid for procedure code S0302. Providers must bill at least their contracted rate for this code in order for payment to be issued. Note: Claims for EPSDT screening services are not subject to coordination of benefits.

The information that follows pertinent to EPSDT billing criteria for either electronic or paper claims submissions is available on Gateway's website.

Gateway EPSDT screens must be billed as indicated below:

CMS-1500 Format

The national code for EPSDT screening (S0302) should be reported on the 1^st line of the CMS-1500.  FQHC and RHC providers must use S0302 as well.  Gateway will not accept T1015 with modifier EP.  Code S0302 is NOT a stand-alone code.  Therefore, it must be used in conjunction with:

• Age-appropriate procedure codes for evaluation and management services, including immunizations.  Note: use CPT modifiers (52 or 90) plus CPT code when applicable.
• Diagnosis code V20.2 (Routine Infant of Child Health Check) must be noted as the primary diagnosis in Box 21.  When applicable, you may enter up to three additional diagnosis codes.  Please note that you are not required to use immunization diagnosis codes.
• Report condition Code A1 in block 24.
• Report 2-character EPSDT referral code for referrals made or needed as a result of the screen in Box 10(d).  Codes for referrals made or needed as a results of the screen are:

YO = Other
YB = Behavioral
YV = Vision
YM = Medical
YH = Hearing
YD = Dental
*Please note that both an appropriate procedure code and revenue code must be used on the UB92.

With the exception of the dental component for clinics that do not offer dental services, FQHCs/RHCs may not bill for partial EPSDT screens.

UB-92 Format

The national code for EPSDT screening (S0302) should be reported on the first line of the UB-92.  FQHC and RHC providers must use S0302 as well.  Gateway will not accept T1015 with modifier EP.  Code S0302 is NOT a stand-alone code.  Therefore, it must be used in conjunction with:

• Age-appropriate procedure codes for evaluation and management services, including immunizations.  Note: use CPT modifiers (52 or 90) plus CPT code when applicable.
• Diagnosis code V20.2 (Routine Infant or Child Health Check) must be noted as the primary diagnosis in Box 21.  When applicable, the practitioner may enter up to three additional diagnosis codes.  Please note that the practitioner is not required to use immunization diagnosis codes.
• Report condition Code A1 in block 24.
• Report 2-character EPSDT referral codes for referrals made or needed as a result of the screen in block 57.  Codes for referrals made or needed as a result of the screen are:

YO = Other
YB = Behavioral
YV = Vision
YM = Medical
YH = Hearing
YD = Dental

Please note that both an appropriate procedure code and revenue code must be used on the UB-92.

Electronic 837P Format

The national code for EPSDT screening (S0302) should be reported as the first procedure code.  FQHC and RHC providers must use S0302 as well.  Gateway will not accept T1015 with modifier EP.  Code S0302 is NOT a stand-alone code.  Therefore, it must be used in conjunction with:

• Age-appropriate procedure codes for evaluation and management services, including immunizations.  Note:  use CPT modifiers (52 or 90) plus CPT code when applicable.
• Diagnosis code V20.2 (Routine Infant or Child Health Check) must be noted as the primary diagnosis in Box 21.  When applicable, you may enter up to three additional diagnosis codes.  Please note that you are not required to use immunization diagnosis codes.
• Populate the SV111 of the 2400 loop with a "yes" for an EPSDT claim (this is a mandatory federal requirement)
• Populate the Data Element CLM12 in the 2300 Claim Information Loop with "01" (meaning EPSDT)
• Populate NTE01 of the NTE Segment with "ADD".  This means that additional information is available in field NTE02.
• Populate NTE02 of the NTE Segment of the 2300 Claim Information Loop with appropriate referral codes:

YO = Other
YB = Behavioral
YV = Vision
YM = Medical
YH = Hearing
YD = Dental

Electronic 837I Format

The national code for EPSDT screening (S0302) should be reported as the first procedure code.  FQHC and RHC providers must use S0302 as well.  Gateway will not accept T1015 with modifier EP.  Code S0302 is NOT a stand-alone code.  Therefore, it MUST be used in conjunction with:

• Age-appropriate procedure codes for evaluation and management services. Including immunizations.  Note: use CPT modifiers (52 or 90) plus CPT code when applicable.
• Diagnosis code V20.2 (Routine Infant or Child Health Check) must be noted as the primary diagnosis in Box 21.  When applicable, practitioners may enter up to three additional codes.  Please note that practitioners are not required to use immunization diagnosis codes.
• Populate the Data Element HI01 in the 2300 Claim Information Loop with qualifier "BG" (meaning condition code) and "A1".
• Populate NTE01 of the NTE segment with "ADD".  This means that additional information is available in field NTE02.
• Populate NTE02 of the NTE Segment of the 2300 Claim Information Loop with appropriate referral codes:

Y0 = Other
YB = Behavioral
YV = Vision
YM = Medical
YH = Hearing
YD = Dental

Completed forms or electronic claims should be submitted within 60 days of the date of service to: Gateway Health Plan, Claims Processing Department, P.O. Box 11-718, Albany, NY 12211-0718.

If you have any questions regarding Gateway's EPSDT Billing Guidelines, please contact Gateway's Provider Services Department at 1-800-392-1145.

The first visit with an obstetrical patient is considered the intake visit, or if a patient becomes a Gateway member during the course of her pregnancy, her first visit as a Gateway member is considered to be her intake visit.  At the intake visit, an Obstetrical Needs Assessment Form (ONAF) must be completed.  A copy of the ONAF must be faxed to Gateway's MOM Matters^® Department within 30 days of the intake visit and at least 30 days prior to delivery.  The fax number can be found on the front page of the ONAF.  The ONAF is not a claim, however, the ONAF must be received by Gateway in order to process the claim for the intake visit.  Submit claims on a CMS-1500 within 180 days to receive payment for the intake package.  The intake package code is W5950.

Obstetric practitioners are reimbursed on a per visit basis.  All visits and dates of service must be included on the CMS-1500 Form and identified with appropriate maternity codes for appropriate reimbursement.  Delivery charges are to be coded with CPT Codes.  The date billed for a Delivery Code, in CPT code format, must be the actual date of service.  Gateway's payment allowance for the delivery includes all postpartum visits and these visits do not need to be billed to Gateway.

All charges for newborns that become enrolled in the plan are processed under the newborn name and newborn's Gateway identification number.  For prompt payment, please submit claims with the newborn patient information or the claim will be pended for manual research.  Inpatient hospital bills for newborns should be submitted separately from the mom's confinement.  Payment for inpatient maternity services that cover the confinement for both mom and baby will be issued under the mother's Gateway identification number and the newborn's claim will be processed for informational purposes only. 

In directing a member's care, a referral to a hospital for diagnostic services/emergency care may be instituted by the OB/GYN.  Gateway's referral procedures can be completed either on paper or via the DIVA Automated Telephone Referral System.

Gateway reimburses surgical procedures in accordance with industry standard protocols and limits payment to a maximum of 3 surgical procedures/operating sessions.  Gateway determines reimbursement upon the clinical intensity of each procedure and reimburses at 100% for the most clinically intensive surgery, and 50% for the second and third procedures.  Pre- and post-operative visits will only be reimbursed to the extent that they qualify for payment according to the follow-up criteria, regardless of whether a referral is on file or not.

An assistant surgeon may bill for one procedure per date of service, and will be reimbursed at 20 percent of Gateway's maximum allowable fee, as long as the surgical procedure code allows an assistant surgeon to be present for the surgery.

Effective with dates of service July 1, 2004, Gateway will process anesthesia services based on anesthesia procedure codes only.

• All services must be billed in minutes.  Fractions of a minute should be rounded to whole minutes (30 seconds or greater: round up; less than 30 seconds: round down).  For billing purposes, the number of minutes of anesthesia time will be placed in space 24G on the CMS-1500 for providers who bill in paper format.
• Physical status modifiers, P1-P6, will not allow any additional payment.
• Gateway will not accept price modifier AA.
• The claim should include ONLY the primary anesthesia code except when there is an add-on code that should be reported along with the primary anesthesia service.
• If you provide pain management services, continue to bill with surgical codes.
• If you provide medical procedures such as Swan Ganz, Laryngoscopy Indirect with Biopsy, Venipuncture Cutdown, Placement of Catheter or Central Vein, then continue to bill with the medical procedure code.
• When billing OB anesthesia codes 01960, 01961, 01962, 01963 and 01967, you do not need to add an additional hour for patient consultation.  The Department of Public Welfare has already added 4 to the relative value unit for these codes.
• When billing anesthesia for all obstetrical procedures, use the anesthesia procedure codes as defined in the Anesthesia section of the CPT4 manual.

Hospital claims are submitted to Gateway on a UB-92 Form.  To assure that claims are processed for the correct member, the member's eight-digit Gateway identification number must be used on all claims.  Practitioners rendering services in an outpatient hospital clinic should include the group practice number of the practitioner's group on the claim when submitting on a UB-92, and individual practitioner number when submitting on a CMS-1500 Form.  To aid in the recording of payment, patient account numbers recorded on the claim form by the practitioner are indicated in the Patient ID field on the Gateway remittance advice.

Effective April 15, 2003, Gateway no longer requires an Explanation of Benefits (EOB) from Medicare, when Medicare is a member's primary insurance, for the below services/codes.  This policy change only applies to patients with Medicare primary and only to the below codes. 

When a member has Medicare coverage, a Medicare EOMB should be submitted for all medical services covered by Medicare. If Medicare will not cover a Skilled Nursing Facility (SNF) admission because the member did not have the threeday qualifying stay at an acute care facility or the member does not meet Medicare skilled criteria, an authorization from Gateway's Utilization Management Department is required. In this circumstance only, if the admission is authorized, Gateway will allow payment as the primary plan when we are aware that Medicare will deny the claim.

Please bill Gateway for all confined days in a SNF. If a patient is not discharged after the 30 th day, the provider should bill for the entire period in the billing period. Interim billing should be noted on the bill to ensure correct reimbursement.