Claims and Billing

• General Information
• Timely Filing
• Electronic Claims Submission
• Requirements for Submitting Claims to Gateway Through Emdeon
• Claims Review Process
• Administrative Claims Review
• Coordination of Benefits
• Claim Coding Software

• Billing Procedures
• Family Planning Services
• Surgical Procedure Services
• Hospital Services
• UB-04 Data Elements for Submission of Claims
• CMS-1500 (08-05) Data Elements for Submission of Claims

Claims

General Information

Procedures for Gateway are as follows:

• Payment for CPT and HCPCS codes are covered to the extent that they are HIPAA compliant.   Gateway utilizes CMS place of service codes to process claims, and they are the only place of service codes that are accepted. 
• Hospitals should bill on an original CMS1450, UB04 Form, and other providers, including ancillary providers, should bill using an original CMS1500 (0805) 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 must be entered on all claims. Presently Electronic claims require NPI but will allow an alternate provider number. The Gateway legacy number may be submitted for the duration of the contingency period only. Gateway Provider ID numbers are 7 digits. NPI will be the only number accepted as of 5/23/08.
• Correct/current member information, including Gateway Health Plan Medicare Assured^® HMO Member ID Number, must be entered on all claims.The format is 8 digits for the Gateway member number. Gateway member number or HIC number in alpha and numeric format will be accepted on Electronic claims.  Gateway prefers that the Gateway ID number be submitted to assure that the claim is processed under the correct individual.
• Please allow four to six weeks for a remittance advice. It is the practitioner's responsibility to research the status of a claim.
• Gateway encourages providers to submit initial bills within 180 days from the date of service, however any initial claim not submitted within 180 days must be submitted within 365 days from the date of service.  Initial bills submitted after 365 days will be denied as untimely.
• Corrected claims or requests for review are considered if information is received within the 120-day follow-up period from the date on the remittance advice.
• Gateway is secondary to any commercial plan. Claims must be submitted within Gateway's timely filing guidelines.
• For other than inpatient hospital confinements paid as Part A, Gateway pays the lesser of the billed amount or the allowable amount.
• Inpatient hospital claims must be submitted with a DRG Code.
• Providers of obstetric services are reimbursed on a global basis for deliveries. Individual visits are not reimbursed and should not be billed.

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Timely Filing

Practitioners are encouraged to submit a complete original, initial CMS-1500 (08-05) or UB-04 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 (08-05), or a UB-04 Form.  No other billing forms will be accepted. 

Practitioners must bill within 365 calendar 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 120 calendar days from the date of the corresponding remittance advice.  All claims submitted after the 365-day period following receipt of the EOB or after the 120-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 Gateway's Provider Services Department to inquire whether the claim was received and/or processed. 

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Electronic Claims Submission

Gateway can accept claims electronically through our association with Emdeon, formerly 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 Emdeon and must be forwarded to Gateway in the HIPAA compliant format only.

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Requirements for Submitting Claims to Gateway Through Emdeon

To submit claims to Gateway Health Plan Medicare Assured^® HMO please note the Pennsylvania Payer ID Number is 60550 and the Ohio Payer ID Number is 91741.  Gateway has two health plan specific edits through Emdeon for electronic claims that differ from the standard electronic submission format criteria.  These edits include:

• A Gateway assigned 7-digit practitioner identification number to process claims, the practitioner number field allows a maximum of 7 digits.  This edit is allowable during the NPI contingency period only.
• A Gateway assigned 8-digit member identification number, the member number field allows 6, 8, or 12 digits to be entered.    For practitioners who do not know the member's Gateway identification number it is acceptable to submit the member's HIC Number on electronic claims. 

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 Emdeon directly at 1-800-845-6592.

Gateway will accept electronic claims for services that would be submitted on a standard CMS-1500 (08-05) or a UB-04 Form.  However, the following cannot be submitted as attachments along with electronic claims at this time:

• Claims with EOBs
• Services billed by report

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Claims Review Process

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, to expedite the review process. Initial claims that are not received within the timely filing limit will not qualify for review. All follow-up review requests must be received within 120 calendar days of the initial remittance advice.

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Administrative Claims Review

Claims that need to be reviewed based upon administrative, or processing issues are handled by a Provider Services Representative via a phone call to Gateway. For inquiries requiring documentation or received in the mail, Claims Review Representatives evaluate whether the documentation attached to the claim is sufficient to allow it to be reconsidered.  Claims 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 forwarded to the Appeals Department for review.  All review requests must be received within 120 days of the initial remittance advice.

Please refer to the Appeals and Grievances section of the manual for information on procedures for Appeals submitted by providers on behalf of a member.

Claims inquiries for administrative reviews should be mailed to:

Gateway Health Plan^®
Attention: Claims Review Department
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219-2704.

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Coordination of Benefits

Some Gateway Health Plan Medicare Assured^® HMO members have other insurance coverage. Gateway follows Medicare coordination of benefits rules. 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.

Please note the following criteria applies and designates when Gateway is not the primary plan for Medicare covered members:

• Enrollee is 65+ years, and covered by an Employer Group Health Plan (EGHP) because of either current employment or current employment of a spouse of any age and the employer employs 20 or more employees.
• Enrollee is disabled, and covered by an Employer Group Health Plan because of either current employment or a family member's current employment, and the employer that sponsors or contributes to the Large EGHP plan employs 100 or more employees.
• For an enrollee entitled to Medicare solely on the basis of end-stage renal disease and Employer Group Health Plan coverage (including a retirement plan), the first 30 months of eligibility or entitlement to Medicare.
• Workers' compensation settlement proceeds are available.
• No-fault or liability settlement proceeds are available.

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 authorization and billing 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 180 days of the date of the primary carrier's EOB.
4. 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.

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.

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Claim Coding Software

Gateway uses a fully automated coding review product that programmatically evaluates claim payments to verify the clinical accuracy of 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 level.

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Billing

Billing Procedures

A "clean claim" as used in this section means a claim that has no defect, impropriety, lack of any required substantiating documentation, including the substantiating documentation needed to meet the requirements for encounter data, or particular circumstance requiring special treatment that prevents timely payment; and a claim that otherwise conforms to the clean claim requirement for equivalent claims under Medicare. 

In addition, a claim shall be considered "clean" if 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-04 or CMS-1500 (08-05) 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(s) (as applicable);
6. Name of practitioner/provider and plan identifier;
7. Provider tax identification number;
8. Valid CMS place of service code(s);
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-1500 (08-05) Form and hospital expenses upon receipt of a correctly completed UB-04. Sample copies of a UB-04 and a CMS-1500 (08-05) 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 provider number must be included on every claim. If the NPI number submitted for the provider does not match the vendor (payee) in Gateway's records, Gateway will issue payment to the correct vendor assigned to the provider based on the tax identification number received on the claim.

To comply with processing requirements, primary care practitioners and specialty care practitioner must submit claims under the individual practitioner identification number rather than the practice or group identification number. Submissions for anesthesiology, pathology, radiology, and emergency room practitioner groups must also include the individual practitioner identification number.  Any claim billed on a CMS-1500 (08-05) Form must include the individual practitioner identification number in box 33 on the 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. 

All claims must have complete and accurate ICD-9-CM 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 for Pennsylvania is: Gateway Health Plan Medicare Assured^® HMO, Claims Processing Department, P.O. Box 11-560, Albany, NY 12211-0560.

Gateway's claim office address for Ohio is: Gateway Health Plan Medicare Assured^® HMO, Claims Processing Department, P.O. Box 11-725, Albany, NY 12211-0725.

Any questions concerning billing procedures or claim payments can be directed to Gateway's Provider Services Department at 1-800-685-5205.

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Family Planning Services

Medicare Assured^® HMO members are eligible for all of the benefits covered under the Medicare Program. All prospective and current Medicare Assured^® HMO members receive information about specific counseling and referral services that are normally part of the Medicare benefit package, but for which Gateway cannot directly provide due to objections based on moral or religious grounds. Gateway has made alternate arrangements for Medicare covered counseling or referral services related to contraceptive services, female sterilization services, male sterilization services and abortion services. Medicare Assured^® HMO members may self-refer to a participating Medicare provider for these services. All family planning services, as noted above, for Medicare Assured^® HMO members are processed and paid by a third party administrator, when covered under Original Medicare.

For practitioners and facilities, family planning services are defined as all Medicare covered evaluation, diagnostic or surgical services provided with a diagnosis code in series V25, or V26.1, V26.22, V26.51, V26.52, V26.8, V26.9 and by the CPT codes listed below related to contraception and abortion services. (Follow Medicare guidelines for submission of sterilization services.)

All CPT codes related to abortions must be billed with the "G7" modifier. Providers must complete the Medicare abortion certification forms and retain in their medical records. A copy of the certification form is NOT required with your claim submission.

CPT codes shall be implemented and updated in accordance with the release and implementation of updates by the Center for Medicare and Medicaid Services.

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Surgical Procedure Services

Gateway determines reimbursement of surgical procedures upon the clinical intensity of each procedure and reimburses at 100% for the most clinically intensive surgery, and 50% for the subsequent procedures. Reimbursement for more than 5 procedures requires medical record documentation. Pre- and post-operative visits will only be reimbursed to the extent that they qualify for payment according to the follow-up criteria.

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Hospital Services

Hospital claims are submitted to Gateway on a UB-04.  To assure that claims are processed for the correct member, the member's 8-digit Gateway identification number must be used on all claims.    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. Please review field numbers below carefully as many of them differ from the former UB-92 format.

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UB-04 Data Elements for Submission of Claims

CMS-1500 (08-05) Data Elements for Submission of Claims

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