• Submit claims according to any special billing instructions that may be indicated in your agreement with us
• On an inpatient hospital bill type of 011x , the admission date and time should always reflect the actual time the member was admitted to inpatient status
National Provider Identification
The Health Insurance Portability and Accountability Act ( HIPAA ), federal Medicare regulations , and many state Medicaid agencies mandate the adoption and use of a standardized NPI for all health care professionals . In compliance with HIPAA , all covered health care providers and organizations must obtain an NPI for all identification purposes in standard electronic transactions . In addition , based on state-specific regulations , NPI may be required to be submitted on paper claims . HIPAA defines a covered health care provider who transmits health information in electronic form in connection with a transaction for which standards have been adopted . These covered health care providers must obtain an NPI and use this number in all HIPAA transactions , in accordance with the instructions in the HIPAA electronic transaction x12N Implementation Guides .
To avoid payment delays or denials , we require that a valid billing NPI , rendering NPI and relevant taxonomy code ( s ) be submitted on both paper and electronic claims . In addition , we strongly encourage the submission of all other NPIs as defined below . It is important that , in addition to the NPI , you continue to submit your TIN . The NPI information that you report to us now and on all future claims is essential in allowing us to efficiently process claims and to avoid delays or denials .
Non Payments for Sentinel and Never Events
Hometown Health reserves the right to deny claims payment for any encounter related to avoidable errors and mistakes , inclusive of hospital acquired conditions and sentinel and never events as defined by Medicare and the Joint Commission . If such claims are denied patients may not be balanced billed .
Medicare Advantage Benefit Plan Claim Processing Requirements
Section 1833 of the Social Security Act , prohibits payments to any provider unless the provider has sufficient information to determine the “ Amounts due such provider .” To that end , Hometown Health applies various claims processing edits based on National and Local Coverage Determinations ( NCD / LCD ), the Medicare Claims Processing Manual , National Correct Coding Initiative ( NCCI ), and other applicable guidance from CMS , including but not limited to the official ICD-10 Guidelines for coding and reporting . These edits are designed to provide Hometown Health with sufficient information to determine :
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