PAM Section 8: Claims Processing Procedures and Guidelines

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Copayment and Coinsurance

Copayments and coinsurance are designed to encourage members to seek appropriate medical care. The copayment is a flat amount that the member pays when covered services are rendered in the provider’s office.

Coinsurance is the percentage of the cost of the service that the member pays. Each member may have a different copayment level, based on his or her benefit plan. The office visit copayment may be different for PCP, specialist, or facility visits.

These copayment amounts are specified on the member’s ID card. If necessary, call provider services to verify the copayment or coinsurance amount or coverage. When calling, please be prepared to supply the member’s name and member number (found on the ID card) to the Mount Carmel MediGold Health Plan representative.

You have the responsibility to collect the copayment or coinsurance. If a copayment is required for office medical care, it will apply to professional fees only. Fee-for-service payments issued by Mount Carmel MediGold Health Plan will be accompanied by a remittance advice to the provider indicating the payment amount from Mount Carmel MediGold Health Plan, minus applicable copayments that are the member’s responsibility, for submitted expenses.

If a copay is required for medical care rendered in an outpatient hospital clinic setting, it will be applied to the facility claim based on the clinic type revenue code submitted by the facility. Mount Carmel MediGold Health Plan recognizes industry standard revenue codes as outlined in the Uniform Billing Editor.

The facility must bill the appropriate revenue code that reflects the type of clinic services rendered in order for the correct copay to be administered by Mount Carmel MediGold Health Plan.

0510: General (specialist clinic visit)

0517: Family Practice (PCP clinic visit) A member may not be billed for non-covered and/or “not medically necessary” services unless an Integrated Denial Notice (IDN) is obtained prior to the service being rendered. Please refer to Provider Policies and Protocols in this manual.

Mount Carmel MediGold Health Plan follows Medicare Claims Processing and Coding guidelines. Physicians and other healthcare professionals are encouraged to remain current with CMS policies, coding, and/ or billing requirements. Please refer to the guidelines published annually by CMS. Please refer to your provider agreement for any exceptions that may apply.

CMS Claim Processing Manual 100-04

Please contact Mount Carmel MediGold Health Plan's Provider Services Team at 1-800-991-9907 with any questions. Claims status inquiries can be obtained by accessing our Provider Portal.

Providers could experience delays in claims processing if a claim is not completed correctly. An improperly completed claim may be denied or returned for correction and resubmission.

Annual Wellness Exam

As part of the preventative care benefit, Mount Carmel MediGold Health Pland offers its members one routine wellness exam per calendar year. The routine exams should be comprehensive in nature and chart documentation should reflect an age- and gender-appropriate history and exam. The goal of this benefit is to promote good health and to provide early disease detection.

Annual Women’s Exam

Gynecologist must bill the code PREVE (along with pap and pelvic exam) for the annual women’s exam.

Diabetic Retinopathy Screening

Providers must bill code S3000 for diabetic retinopathy screening. Providers must bill code S3000 for diabetic retinopathy screening.

Essential Mount Carmel MediGold Health Plan Data Elements Required

There are processes and data elements that are essential for prompt claim payment and encounter processing:

Essential Mount Carmel MediGold Health Plan Data Elements Required:

Member (patient) name.
Member (patient) date of birth.
Insured/subscriber name.
Insured/subscriber ID number.
Name of other health benefits coverage available for the member. Name of insured/ covered person for other health benefits coverage. Attach a copy of the other health plan’s Explanation of Benefits for the listed charges, if applicable.
Indicate if member’s condition is related to patient’s occupation or an accident.
Name of the referring provider and the NPI (National Provider Identifier) of the referring provider, if applicable.
Charge for each service and treatment. Do not subtract any copayment amounts; the charge should reflect the actual fee for services.
Signature of treating physician or provider.
Treating provider’s tax identification number for 1099 purposes.
Name and address of treating provider (please print or type).
NPI of treating provider.

General Form Submissions

Claims can be submitted to Mount Carmel MediGold Health Plan on paper or electronically. Faxed claims are not accepted and will not be processed.
Mount Carmel MediGold Health Plan accepts the current versions of CMS Forms 1500 (HCFA) and 1450 (UB-04).
Except as otherwise noted, providers should follow National Standard practices for form completion and CPT/HCPC/ICD coding standards.
Claims requiring additional documentation (e.g., medical records, operative reports, primary carrier’s EOBs) must be sent to the address provided below.

Electronic Claim Submissions

Electronic claims (also known as 837I and 837P) can be submitted to Mount Carmel MediGold Health Plan's clearinghouses Claimsnet and Change Healthcare (formerly Emdeon).

Mount Carmel MediGold Health Plan's payor ID number: 95655

Clearinghouse contact information:

Claimsnet
- Phone: 1-800-356-0092
- Website: Claimsnet.com
Change Healthcare (previously Emdeon)
- Phone: 1-877-363-3666
- Website: Changehealthcare.com

Paper Form Submissions

Hardcopy claims must be legible and should be submitted to our processing center at:

Mount Carmel MediGold Health Plan
PO Box 830697
Birmingham, AL 35283

Tips for submitting paper claims

Verify the member’s unique ID number is correct and is located in box 1a on form CMS-1500 or field 60 on CMS-1450.
Type or print claim forms. DO NOT ALTER FORMS in any manner.
Ensure form and print are dark enough to read.
Ensure data is aligned in the proper fields.
Make sure the corporate name to which the federal tax ID belongs appears in box 33 and the corporate (group) NPI appears in box 33a of the CMS-1500 form.

*Please work with your vendor or clearinghouse to ensure you are receiving your confirmation and/ or error/rejected claims reports. You are responsible for making sure you are receiving and addressing all claim submission errors and resubmitting them in a timely manner.

Remittance Advice

You will receive a remittance advice along with claim payments. The remittance advice will provide detailed information about all encounters and claims received and processed by Mount Carmel MediGold Health Plan. The remittance advice is intended to assist with reconciling your claim submissions and payments.

Electronic Payment and Remittance Enrollment

To apply for Electronic Payment and Remittance, please complete the enrollment form. Providers must proactively contact the financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Data Elements necessary for successful reassociation of the EFT payment with the ERA remittance advice.

Corrected Claims Submission

When a claim submission error is identified, either by receipt of a Mount Carmel MediGold Health Plan remittance advice or through your internal review, a corrected claim may be sent directly to Mount Carmel MediGold Health Plan's claims processing.

Requests for corrections/adjustments to claims must be submitted within 180 days from the date of the original remittance advice or as specified in your provider agreement.

Corrected claims may be submitted either electronically or via paper. See below:

Corrected Professional: 1500 Claim Submission

Complete a new claim form and be sure to insert the following in box 22:

Resubmission Codes:

7: To indicate it is a replacement
8: To void/cancel the prior claim.

Original Ref. No.:

Enter the original Mount Carmel MediGold Health Plan's 12-digit claim/reference number you are correcting or canceling.

Mount Carmel MediGold Health Plan
PO Box 830697
Birmingham, AL 35283

Corrected Facility: UB-04 Claim Submission

Complete a new claim form with the correct type of bill (TOB) code in FL 04. Examples: (see UB04 billing manual for the TOB that pertains to your type of facility)

TOB 117: replacement or corrected claim for a previously submitted hospital inpatient claim
TOB 118: void/cancel prior inpatient claim claim
TOB 137: replacement or corrected claim for a previously submitted hospital outpatient claim
TOB 138: void/cancel prior inpatient claim claim

Request for Claims Review Form

Complete a Request for Claim Review Form or contact Provider Services at 1-800-991-9907. It should be used in the following situations:

If you believe a claim was processed incorrectly.
You are submitting additional information at the request of Mount Carmel MediGold Health Plan to complete processing of a claim.
An underpayment or overpayment was made by Mount Carmel MediGold Health Plan.

In the instance of an overpayment, please do not send a check for the overpayment to Mount Carmel MediGold Health Plan. Mount Carmel MediGold Health Plan will reduce future payments by the amount of the overpayment directly through the claims system.

Completed forms should be faxed to the number indicated on the form. It is the intent of Mount Carmel MediGold Health Plan to process all requests within two weeks of receipt.

Claims Timely Filing Limitations

Timely claim and encounter data submission is important to ensure prompt claims payment. The contracted claims filing time limit is specified in your provider agreement.

Mount Carmel MediGold Health Plan strictly enforces these filing limits and is under no obligation to pay claims submitted beyond the limits of your provider agreement.

Should extenuating circumstances prevent a claim from being submitted within the time limitations, those circumstances will be reviewed on a case-by-case basis.

Please remember that in accordance with your provider agreement with Mount Carmel MediGold Health Plan, you may not bill the member for services denied as a result of not meeting claims filing limitations.

Provider Portal

Mount Carmel MediGold Health Plan offers a convenient and secure web portal to ease administrative duties for:

Verifying member eligibility.
Viewing member specific plan information.
Viewing claim history and payment status.
Sending secure messages to our provider services team.

Go to Provider Portal

Transfer of Claims from Medicare Part B Carrier/MAC to Mount Carmel MediGold Health Plan

Your practice may receive an Explanation of Medicare Benefits (EOMB) from Medicare administrators indicating claims have been forwarded directly to Mount Carmel MediGold Health Plan for processing. If the notation ‘transfer to MCHP’ appears on an EOMB, do not assume the claim was transferred. Please submit a separate claim directly to Mount Carmel MediGold Health Plan. This will prevent the possibility of the claim being denied for timely filing. As soon as the denial is received, please submit a claim to Mount Carmel MediGold Health Plan. ‘Timely filing’ begins with the date on the Medicare EOMB. Please refer to your provider agreement for your timely filing limit.

Coordination of Benefits

A member may have benefits available from more than one health plan. Coordination of Benefits (COB) determines which benefit plan is the primary payor and which is secondary. Members remain liable for payment of Mount Carmel MediGold Health Plan's cost-sharing regardless of whether Mount Carmel MediGold Health Plan is the primary or secondary payor. You are encouraged to ask our members about any changes to coverage and/or additional coverage on an ongoing basis. You are required to report additional insurance coverage information on claim and encounter forms to Mount Carmel MediGold Health Plan, and Mount Carmel MediGold Health Plan retains all rights to COB savings and recoveries.

Mount Carmel MediGold Health Plan will use the rules outlined below to determine primary payor responsibility in the following order:

The plan with no COB provision or non-duplication coverage exclusion will always be primary.
The plan covering a member as a subscriber will be primary for care rendered to that member. In addition, the benefits of a plan that covers an individual as an employee who is neither laid off nor retired (or as that employee’s dependent) are determined before those of a plan that covers that individual as a laid-off or retired employee (or as that employee’s dependent). If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this provision is ignored.
If neither of the rules above determines the order of benefits, the benefits of the plan in effect longer are primary.

Questions regarding COB may be directed to Provider Services at:

Toll Free: 1-800-991-9907 (TTY 711)

Toll Free Fax: 1-833-900-0606

COB enables Mount Carmel MediGold Health Plan to avoid and, in some cases, recover expenses related to members with multiple health insurance coverages. In NO CASE will more than 100 percent of the Mount Carmel MediGold Health Plan contracted rate be paid in total because of multiple health insurance coverages.

Secondary Payor

Mount Carmel MediGold Health Plan will coordinate coverage with commercial insurance, Medicare and Medicaid. Mount Carmel MediGold Health Plan can assist you in determining responsibility for a member’s primary coverage.

As a network provider you agree to supply Mount Carmel MediGold Health Plan with all available information for documentation regarding a member’s coverage by another health plan or insurer. This information may be provided in the appropriate section of the CMS 1500 or UB04 Form. When notice of payment or denial of payment is received, you may bill Mount Carmel MediGold Health Plan. Attach a copy of the other insurance carrier’s notification of payment or denial to the CMS 1500 or UB04 Form.

Medicaid as a Secondary Payor

Medicaid is responsible for payment of Medicare cost-sharing expenses for Medicare beneficiaries who are eligible for Medicaid under the Qualified Medicaid Beneficiaries (QMB) definition, including those beneficiaries enrolled in a MA program. Cost-sharing includes copayments, coinsurance and deductibles.

Medicaid is not required to provide any payment for cost-sharing expenses to the extent that payment under Medicare for the service would exceed the payment amount that otherwise would be made under the Medicaid state fee schedule for such service if provided to an eligible recipient other than a Medicare beneficiary.

Subrogation

Subrogation is based on the right of a member who suffered injury/illness caused or contributed to by a third party to recover damages from that party. Mount Carmel MediGold Health Plan's recovery is for the value of services rendered to or the expense incurred in treating the member for those injuries/illnesses. Identification methods include medical record notations, examination of specific diagnoses that are often accident- related and others.

The member assigns his or her right of recovery to Mount Carmel MediGold Health Plan by operation of the Member Agreement or a signed lien form. Mount Carmel MediGold Health Plan has a responsibility to its members to first process claims that result from an accident, and then pursue reimbursement from the appropriate third-party payor. When treating a member for injuries stemming from an accident, bill Mount Carmel MediGold Health Plan as the primary payor. Mount Carmel MediGold Health Plan will process the claim, and then determine whether subrogation is required.

Subrogation issues typically take considerable time to resolve. In almost every case, the claim for a provider’s services will be paid before the subrogation process is initiated.

Workers’ Compensation

The term “Workers’ Compensation” is applied to claims expenses that, due to job-related injury or illness, are the responsibility of the member’s employer. Identification methods are the same as for subrogation.

As with COB, providers are required to report potential subrogation and Workers’ Compensation cases (using the appropriate spaces on the CMS 1500 or UB04 form) to Mount Carmel MediGold Health Plan, and Mount Carmel MediGold Health Plan retains all rights to any sums payable under such circumstances.

Last updated: 03/2024