Claims Submission Guidelines

HCFA 1500 Claims Submission - Medical
HealthPlus of Michigan provides claims processing through electronic transmission or paper submittals. The CPT-4 coding schedule, including modifiers, should be used to designate procedures. ICD-9-CM codes should be used for diagnoses. When there is no designated CPT code available, HPM accepts HCPCS (Health Care Financing Administration Common Procedure Coding System) codes denoted by a single alpha letter (A through V).Specialty providers (vision providers, ambulance services, home health, or skilled nursing agencies) need to refer to the specific coding instructions in your contract.

How To File A Paper Claim
Claims should be submitted to:
HealthPlus of Michigan
P.O. Box 1700
Flint, Michigan 48501-1700

HPM utilizes electronic claims scanning technology to process paper claims.
Submission must be on the HCFA 1500 (12-90) claim form. It is essential the
requirements listed below are followed to ensure prompt processing of
your claims.

• The HCFA 1500 (12-90) form must be used and filled out completely.
• All claims must be typewritten or computer-generated in a dark print--no hand written claims.
• All data must be contained within each locator box, left justified.
• The patient's 11-digit contract number must be used (9-digit contract number plus suffix.)
• No more than six service lines per claim. Do not try to fit two service lines into one space.
• The procedure code is sufficient--do not type the description.
• Your HealthPlus provider number, not your tax identification number,
  must be used in form locator box 33 where is says "PIN#".
• Be sure to enter other health benefit plan information (COB)in form locator box 9.
  

If you have additional information to include that does not specifically have its own form locator box, please use form locator 19.

The provider number used in form locator box 33 is tied to a tax identification
number in our system. Without the HPM provider number, claims payment may be delayed and/or your claim may be returned to you for resubmission.

Incomplete or erroneous claims will be returned to the provider for the completion
and/or correction.

UB-92 Claims Submission-Hospital
The UB-92 claim form is accepted for hospital claims. The UB-92 manual provides a complete description of the definition, purpose, billing requirements and instructions for each form locator on the claim form. Refer to this manual for general billing instructions.

How To File A Paper Claim
Claims should be submitted to:
HealthPlus of Michigan
P.O. Box 1700
2050 South Linden Road
Flint, Michigan 48501-1700

Specific requirements for each UB-92 Form Locator element billed to HPM are described for your convenience.

Medical Prior Authorization

It is the responsibility of the PCP to submit the referral request within 24 hours
of the patient visit. To avoid claim denials, please do not schedule the patient's
specialty appointment, except for urgent referral requests, until authorization
approval has been received.

There are two types of referrals:

• In-Plan
• Out-of-Plan

An in-plan referral is directed to a participating HPM provider. PCPs are expected to refer to in-plan participating providers. When services are unavailable within the HPM participating provider network, an out-of-plan referral may be requested and would require Medical Director approval.

A referral can be initiated by the PCP in the following ways:

• Telephone the HPM Referral Department*
  
• Fax a completed copy of the HPM Referral Fax Form

*Note: If your referral process is managed by a PHO, please follow the applicable procedures set forth in your agreement.

HPM will send referral notification to the patient, PCP, and specialist within 48 hours of the request. The notification will contain the referral number, approved dates, and the scope of the services to be rendered.

Note: Certain PHOs send the notification to the PCPs and specialist of the
referral requests they process.

Exceptions that supersede a referral or which would render it null and void:

• The member is no longer eligible
• The service is not a covered benefit
• The member switches to another PCP within a referral time span

HMP wil make every attempt to notify providers when these conditions occur.

Prior Authorization

• Inpatient utilization management
  
• Procedure management
  
• Case management

Precertification
Precertification is required for selected, elective inpatient procedures and most
ambulatory and outpatient services outside of the primary care physician's office.
Precertification is not required in the case of urgent or emergent services provided
as necessary to screen and stabilize a member's condition where a prudent layperson, acting reasonably, would have believed that an emergency existed.

Provider Grievance Procedure

The providers grievance policy defines the process to be used by HealthPlus of
Michigan for resolving administrative complaints by, and disputes with, participating
providers under their provider agreements.

When a provider has a concern, every effort will be made to resolve the issue
informally. In the event the issue cannot be resolved informally, the provider may
request it be handled according to the formal grievance policy. The Provider Service Department will be the liaison between the providers and the health plan and will provide the information regarding the formal process.

If a provider feels aggrieved by a policy, decision, or procedure of HPM, he/she
shall follow the grievance procedure set forth below:

Informal Procedure
An aggrieved party must first send a written statement outlining the nature
and extent of the problem. The parties will meet within 45 days to discuss the
problem with the appropriate provider and HPM administrator. It is recognized
that many problems may be solved this way and a formal grievance may thereby
be avoided.

Formal Hearing
If the meeting does not resolve the situation, then the responding party shall,
within five days, send a written response to the original written grievance.

Upon receipt of the notice, a tribunal shall be formed composed of one
representative appointed by HPM, one representative appointed by clinic,
and a third representative, who shall be chairperson, who shall be selected
by the two appointees (hereinafter referred to as the "Tribunal"). This
Tribunal shall conduct a hearing upon the merits of the dispute within 30
working days of receipt of the notice, unless the parties agree to a
longer time. Within five working days from the termination of the hearing, the
Tribunal shall issue a decision in writing to all parties involved in the dispute. All
procedures surrounding said Tribunal function shall be determined by said Tribunal,
unless inconsistent with this paragraph. Each party shall bear the cost of the
representative it appointed plus one-half of the expenses of the neutral
representatives and other associated costs.

Appeal Process
If any party declines to accept that decision, that party has seven days in
which to file a formal written appeal of that decision to both boards of HPM
and clinic.

Upon receipt of the notice of appeal, a grievance committee shall be convened
within 30 days to decide this appeal. The grievance committee shall be a committee
of HPM or a nationally recognized arbitration panel, as mutually agreed upon. The
committee shall provide the aggrieved party with an opportunity to be heard prior
to making its final decision. All other procedures concerning the grievance committee shall be binding upon all of the parties to the appeal and all third party
beneficiaries (other than member) and no further appeal shall be permitted.
The cost of the grievance committee shall be equally borne by the parties to the
arbitration.

Updated 07/31/06