Claims and Billing

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 UB-04 Form, and other providers, including ancillary providers should bill using an original CMS-1500 (08-05) Form.
Gateway does accept bills through electronic data interchange (EDI) and encourages facilities and providers to submit claims via this format.
Electronic claims must include NPI provider number and may continue to include the Gateway ID Number (Legacy Number) as a secondary identifier. Correct/current practitioner information identified as the Gateway Provider ID Number (Legacy Number) must be entered on all paper claims. Gateway Provider ID numbers are 5 or 7 digits. EDI claims submitted without an NPI will be rejected.
Correct/current member information, including Gateway Health Plan Medicare Assured^® HMO Member ID Number, must be entered on all claims. The format is 8 or 12 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 an MS-DRG Code.
Providers of obstetric services are reimbursed on a global basis for deliveries. Individual visits are not reimbursed and should not be billed.

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.

Electronic Claims Submission

Gateway can accept claims electronically through Emdeon or RelayHealth. 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

For submission of professional or institutional electronic claims for Gateway Health Plan Medicare Assured^® HMO, please refer to the following grid for Emdeon Payer IDs and RelayHealth CPIDs(Clearinghouse Process ID):

CPID	PAYER NAME	PAYER ID	CLAIM TYPE
2298	Gateway Health Plan^® - PA Medicare Assured^® HMO	60550	Professional
2912	Gateway Health Plan^® - PA Medicare Assured^® HMO	60550	Institutional

Requirements for Submitting Claims to Gateway Through Emdeon and RelayHealth

To submit claims to Gateway Health Plan Medicare Assured^® HMO please note the Pennsylvania Payer ID Number is 60550. Gateway has a health plan specific edit through Emdeon and RelayHealth for electronic claims that differ from the standard electronic submission format criteria. The edit requires:

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 and RelayHealth, Gateway has a second level of edits that apply to procedure codes and diagnosis codes. Claims can be successfully transmitted to Emdeon and RelayHealth, 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 Emdeon, RelayHealth and Gateway. Edits applied when claims are received by Gateway will appear on an EDI Report within the initial acceptance report or Claims Acknowledgment Report. A claim can be rejected if it does not include an NPI and 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:

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

RelayHealth – Claims Acknowledgment Report (CPI 651.01)
RelayHealth – Exclusion Report (CPI 652.01)
RelayHealth – Claims Status Report (CPA 425.02)

If you are not submitting claims electronically, please contact your EDI vendor for information on how you can submit claims electronically. You may also call Emdeon directly at 1-877-469-3263 or RelayHealth at 1-800-545-2488.

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

Claims Review Process

Gateway will review any claim that a practitioner feels was denied or paid incorrectly. The request may be conveyed in writing (per instructions below), or verbally through Gateway’s Provider Services Department if the inquiry relates to an administrative issue. Please forward hard copy information via mail to the Claims Review Department along with all of 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 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.

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.

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:

Follow all Gateway authorization and billing procedures.
File all claims within timely filing limits as required by the primary insurance carrier.
Submit a copy of the primary carrier’s EOB with the claim to Gateway within 365 days of the date of the primary carrier’s EOB.
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.

Claim Coding Software

Gateway uses a fully automated coding review product that programmatically evaluates claim payments to verify the clinical accuracy of processing 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. CCI (Correct Coding Initiative) edits are applied solely to Incidental and Mutually Exclusive outcomes while the coding software applies other editing criteria. 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.

Provider Payment Dispute Resolution for Non-Contracted Gateway Health Plan Medicare Assured^® HMO Providers

If you are a non-contracted provider and you believe that the payment amount you received for a service is less than the amount indicated in our terms and conditions of payment, you have the right to dispute the payment amount by following our dispute resolution process.

To file a payment dispute with Gateway Health Plan^®, call us at 800-685-5205 or send a written dispute to:

Gateway Health Plan^®
Attn: Claims Department, Gateway Medicare Assured^® HMO
NON-PAR PAYMENT DISPUTE
US Steel Tower, Floor 41
600 Grant Street
Pittsburgh, PA 15219

Additionally, please provide appropriate documentation to support your payment dispute e.g., a remittance advice from a Medicare carrier. Claims must be disputed within 120 days from the date payment is initially received by the provider.

We will review your dispute and respond to you within 30 days from the time the provider payment dispute is first received by the plan. If we agree with your payment dispute, then we will pay you the additional amount with any interest that is due. We will inform you in writing if your payment dispute is denied.

After Gateway Health Plan Medicare Assured^® HMO makes it’s final Payment Review Determination Decision and you still disagree with the pricing decision, a request for an independent Payment Dispute Decision (PDD) may be submitted to “First Coast Services, Inc“, an independent entity contracted by CMS, in writing within 180 days of written notice from Gateway Health Plan Medicare Assured^® HMO Payment Review Determination. For more information and forms on PDD can be obtained at (www.fcso.com, What We Do, Payment Dispute Resolutions – Medicare Advantage).

First Coast Service Options, Inc (FCSO)
Payment Dispute
P.O. Box 4017
Jacksonville, Florida 32231-4017
Fax: 904-361-0551
Email: RDPC@fcso.com

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:

Patient name;
Patient medical plan identifier;
Date of service for each covered service;
Description of covered services rendered using valid coding and abbreviated description;
ICD-9 surgical diagnosis code(s) (as applicable);
Name of practitioner/provider and applicable NPI number;
Provider tax identification number;
Valid CMS place of service code(s);
Billed charge amount for each covered service;
Primary carrier EOB when patient has other insurance;
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;
MS-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 correct NPI 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 NPI 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 NPI number. Any claim billed on a CMS-1500 (08-05) Form must include the individual practitioner NPI 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.

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

Family Planning Services

Gateway Health Plan Medicare Assured^® HMO members are eligible for all of the benefits covered under the Medicare Program. All prospective and current Gateway Health Plan 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. Gateway Health Plan Medicare Assured^® HMO members may self-refer to a participating Medicare provider for these services. All family planning services, as noted above, for Gateway Health Plan Medicare Assured^® HMO members are paid using an alternate process.

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.)

Contraceptive Services	Abortion Services
11976 – Removable implantable contraceptive capsule	59840 - Induced abortion by dilation and curettage
58301 – Removal of IUD	59841 - Induced abortion by dilation and evacuation
	59850 - Induced abortion by one or more intra-amniotic injections
	59851 - Induced abortion by one or more intra-amniotic injections with D&C or evac
	59852 - Induced abortion...with hysterotomy
	59855 - Induced abortion by one or more vaginal suppositories
	59856 - Induced abortion...with D&C or evac
	59857 - Induced abortion...with hysterotomy
	59866 - Multifetal pregnancy reduction

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.

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.

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.

UB-04 Data Elements for Submission of Paper Claims Forms

EDI requirements must be followed for Electronic claims submissions

Field	Description	Requirements
1	Provider Name, Address, City, State, Zip, Telephone, Fax, Country Code	Required
2	Pay to Name, Address, City, State, Zip	Required If Different from Billing Provider in Field 1
3a	Patient Control Number	Required
3b	Medical Record Number	Not Required
4	Type of Bill	Required - If 4 Digits Submitted, the Lead 0 will be Ignored
5	Federal Tax Number	Required
6	Statement Covers Period	Required
7	Unlabeled Field	Not Used
8a	Patient Name	Required
9	Patient Address	Required
10	Birthdate	Required
11	Patient Sex	Required
12	Admission Date	Required for Inpatient and Home Health
13	Admission Hour	Not Required
14	Type of Admission/Visit	Required, If Inpatient
15	Source or Admission	Required
16	Discharge Hour	Not Required
17	Patient Status	Required
18-28	Condition Codes	May be Required in Specific Circumstances (Consult CMS Criteria)
29	Accident State	Not Used
30	Unlabeled Field	Not Used
31-34	Occurrence Codes and Dates	May be Required in Specific Circumstances (Consult CMS Criteria)
35-36	Occurrence Span Codes and Dates	Required, If Inpatient
37	Unlabeled Field	Not Used
38	Responsible Party Name and Address	Not Required
39-41	Value Codes and Amounts	Required, If Inpatient
42	Revenue Codes	Required
43	Revenue Descriptions	Required
44	HCPCS/Rates/HIPPS Codes	Required, If Outpatient
45	Service Dates	Required, If Outpatient
46	Service Units	Required
47	Total Charges	Required
48	Non-covered Charges	Required, If Applicable
49	Unlabeled Field	Not Used
50	Payer Identification	Required
51	Health Plan ID	Not Required
52	Release of Information Certification Indicator	Required
53	Assignment of Benefits	Not Used
54	Prior Payments	Required, If Applicable
55	Estimated Amount Due from Patient	Not Required
56	National Provider ID	Required - NPI Number
57	Other Provider ID	Gateway Health Plan^® Practitioner Identification Number should be entered on paper claims only- legacy number reported as secondary identifier to NPI on electronic claims
58	Insured's Name	Required, If Applicable
59	Patient Relationship to Insured	Required, If Applicable
60	Certificate-Social Security Number-Health Insurance Claim-Identification Number	Gateway Member Identification Number Required
61	Insurance Group Name	Required, If Applicable
62	Insurance Group Number	Required, If Applicable
63	Treatment Authorization Code	Required, If Applicable
64	Document Control Number	Not Required
65	Employer Name	Required, If Applicable
66	Diagnosis and Procedure Code Qualifier	Required
67	Principal Diagnosis Code	Required (Coding for Present on Admission data required)
67A-67Q	Other Diagnosis Code	Required (Coding for Present on Admission data required)
68	Unlabeled Field	Not Used
69	Admitting Diagnosis Code	Required
70A-70C	Patient Reason for Visit	Not Required
71	Prospective Payment System (PPS) Code	Required for DRG Code – If 4 Digits Submitted, the Lead 0 will be Ignored
72	External Cause of Injury Codes	Not Used
73	Unlabeled Field	Not Used
74	Principal Procedure Code and Date	Required, If Applicable
74A-74E	Other Procedure Codes and Date	Required, If Applicable
75	Unlabeled Field	Not Used
76	Attending Provider Name and Identifiers (Including NPI)	May be Required in Specific Circumstances (Consult CMS Criteria) If Not Required, Do Not Send
77	Operating Provider Name and Identifiers (Including NPI)	May be Required in Specific Circumstances (Consult CMS Criteria) If Not Required, Do Not Send
78-79	Other Provider Name and Identifiers (Including NPI)	May be Required in Specific Circumstances (Consult CMS Criteria) If Not Required, Do Not Send
80	Remarks	May be Required in Specific Circumstances (Consult CMS Criteria)
81	Code – Code Field	Optional (Consult CMS Criteria)

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

Field #	Description	Requirements
1	Insurance Type	Required
1a	Insured Identification Number	Gateway Health Plan^® Member Identification Number
2	Patient's Name	Required
3	Patient's Birth Date	Required
4	Insured's Name	Required
5	Patient's Address	Required
6	Patient Relationship to Insured	Required
7	Insured's Address	Required
8	Patient Status	Required
9	Other Insured's Name	Required, If Applicable
9a	Other Insured's Policy or Group Number	Required, If Applicable
9b	Other Insured's Date of Birth, Sex	Required, If Applicable
9c	Employer's Name or School Name	Required, If Applicable
9d	Insurance Plan Name or Program Name	Required, If Applicable
10	Is Patient Condition Related to: a. Employment b. Auto accident c. Other accident	Required, If Applicable
10d	Reserved for Local Use	Not Required
11	Insured's Policy Group or FECA Number	Required
11a	Insured's Date of Birth, Sex	Required, If Applicable
11b	Employer's Name or School Name	Required, If Applicable
11c	Insurance Plan Name or Program Name	Required, If Applicable
11d	Is There Another Health Benefit Plan?	Required, If Applicable
12	Patient or Authorized Person's Signature	Required
13	Insured's or Authorized Person's Signature	Required
14	Date of Current: Illness OR Injury OR Pregnancy	Required, If Applicable
15	If Patient has had Same or Similar Illness, Give First Date	Not Required
16	Dates Patient Unable to Work in Current Occupation	Required, If Applicable
17	Name of Referring Practitioner or Other Source	Required
17a,b	Identification Number of Referring Practitioner
18	Hospitalization Dates Related to Current Services	Required, If Applicable
19	Reserved for Local Use	May be Required in Specific Circumstances (Consult CMS Criteria)
20	Outside Lab	Not Required
21	Diagnosis or Nature of Illness or Injury	Required
22	Medical Resubmission Code	Not Required
23	Prior Authorization Number	Not Required
24a	Date(s) of Service	Required
24b	Place of Service	Required
24c	Type of Service	Not Required
24d	Procedures, Services, or Supplies CPT/HCPCS/Modifier	Required
24e	Diagnosis Code	Required
24f	Charges	Required
24g	Days or Units	Required
24h	EPSDT Family Plan	Not Required
24i	ID Qualifier	Required, if applicable
24j	Rendering Provider ID	Not Required
25	Federal Tax Identification Number	Required
26	Patient Account Number	Not Required
27	Accept Assignment	Not Required
28	Total Charge	Required
29	Amount Paid	Not Required
30	Balance Due	Not Required
31	Signature of Practitioner or Supplier including degrees or credentials	Gateway Individual Practitioner Name and Date Required
32	Service Facility Location Information	Facility Name and Address where Services were Rendered Required
33	Billing Provider Info and Phone #	Gateway Vendor (Payee) Name, Address, and Phone Number Required. NPI and Gateway Legacy Number should be Entered.