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Claims Tips
CMS Delays HIPAA 5010 Enforcement
TIP: Verify your compliance with HIPAA 5010 immediately to avoid disruptions in electronic transactions.
HIPAA 5010 represents the code set components of the Health Insurance Portability and Accountability Act (HIPAA). Beginning Jan. 1, 2012, federal mandate requires providers to use the new 5010 transaction standard for electronic claim submissions. CMS has delayed enforcement until March 31, 2012 to allow entities time to complete necessary software upgrades.
If you use a clearinghouse or Magellan's Direct Submit application to submit electronic claims to Magellan, it is critical that your EDI files are converted to 5010 before March 31, 2012.
For more information, please see our feature article on this topic.
New Claim Edits Identify Billing Errors
TIP: Verify the correct date of service on claim submissions
Magellan continually seeks opportunities to improve the process of claim submission and reimbursement. This includes helping providers identify billing errors before claims are paid in error and require repayment of the overpaid amount. It also includes minimizing fraud and abuse that raises costs for all parties involved in claim reimbursement.
To further strengthen these efforts, effective Jan. 16, 2012, Magellan began applying claim edits for select accounts to ensure providers are not billing excessive hours for services rendered in a given day. We anticipate expanding the edits as permitted by state and customer contract. If a provider submits claims in a given day that exceed the threshold, the claims are denied with the following message: Our records indicate that Magellan has previously processed claims for the date of service and the additional time billed on this claim exceeds the total number of hours typical of Magellan provider practice patterns for a single day.
For further consideration of the claims, the provider is advised to submit medical records for all Magellan patients seen on the date of service to the address located in the appeals section of the notice.