• The correct amount to be paid
• Whether the provider is authorized to perform the service
• Whether the provider is eligible to receive payment
• Whether the service is covered , correctly coded , and correctly billed to be eligible for reimbursement
• Whether the service is provided to an eligible beneficiary
• Whether the service was provided in accordance with CMS guidance
Providers participating in our Senior Care Plus network must comply with all CMS guidance regarding coding , claims submission , and reimbursement rules . For example , all participating Medicare providers must report a Serious Adverse Event by populating the POA indicator on all acute care inpatient hospital claims and ambulatory surgery center outpatient claims , where applicable . In the instance that the “ Never Event ” has not been reported , we will attempt to determine if any changes filed with is meet the criteria , as outlined by the National Quality Forum ( NQF ) and adopted by CMS , as a Serious Reportable Adverse Event . To the extent that a provider fails to comply with these requirements , that provider ’ s claim will be denied and be considered a provider liability . Providers cannot bill the customer for these charges .
There may be situations when Hometown Health and Senior Care Plus implement edits and CMS has not issued any specific coding guidance . In these circumstances , Hometown Health and Senior Care Plus will review the available guidance in the Medicare Coverage Center and identify those coding edits that most align with the applicable coverage rules
Effective January 1 , 2012 : Due to CMS requirements , all physicians and other health care providers , including delegated / capitated claims and encounters , are required to adopt the 837 Version 5010 format for dates of service on and after January 1 , 2012 . Incomplete submissions including blank data fields will result in rejection of the claim or encounter submission . Note that an NPI is a required data element on all submissions . Rejections will be returned for correction and resubmission .
Hold Harmless Requirements
When an HMO , EPO , PPO , or SCP claim has been denied with a reason of Hold Harmless , meaning that a prior authorization was not obtained before the HMO , EPO or SCP member who received services , a denial of services was issued , or a continued stay was not justified , the provider is obligated to adjust the claim , including removal of any member copayment , deductible or coinsurance as per the provider ’ s contract with Hometown Health .
If you determine that Hometown Health denied a claim incorrectly , please do not bill the patient for the denied claim . Please contact Hometown Health Customer Service at 775-982-
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