Article Rating

  • 0 Rating(s)
  • 0
  • 0
  • 0
  • 0
  • 0

Timely EI Claims Submission

Timely EI Claims Submission Results in Timely Payment

Claiming Process: Claims are generally sent from NYEIS to the State Fiscal Agent (SFA) every Monday unless Monday is a New York State (NYS) holiday; if Monday is a holiday, claims will be sent to the SFA on Tuesday.
  • Providers should enter claims in NYEIS by end of day on Saturday to ensure the SFA system--EI Billing--will receive the claims on Monday or Tuesday when a holiday falls on Monday. If claims are not entered in NYEIS by Saturday, the SFA will not receive claims until the following NYEIS data is received. Please review the claim submission day cycle.
  • The SFA generally submits claims electronically to the clearing house on a daily basis Monday through Friday with the exception of holidays. Once the clearing house submits the claim to the payer, the payer has 15 days to respond to the claim with either a rejection or an acceptance. Please review the electronic claim submission process day cycle.
  • Claim responses will be uploaded into the SFA system within 48 hours from the date the payer sends a 277 or 835 response to the claim.
Please Note: Claims manually sent to payers will be adjudicated within 30 days and an Explanation of Benefits will be sent to the provider. Please review the paper claim submission process.

Clean Claim: A “clean claim” is a claim that contains all necessary information for processing; claim information must be accurate and complete.

Voided Claim: Providers should void a claim when the claim does not reflect the service provided or when the date of service is incorrect. In these situations, providers should first void the incorrect claim and then submit a new “clean claim.”

If the claim reflects the service provided but does not reflect the most updated diagnosis or procedure codes, providers may replace the outdated code(s) with a comparable update code(s).

Claim Rejection: A “claim rejection” is a claim returned by a payer or the SFA due to incorrect and/or missing data.  Types of claim rejections include Category 1 problems detected by the state fiscal agent and category 2 rejections as described below. 

Category 1 Problems detected by the State Fiscal Agent include but are not limited to:
  • Duplicate claims
  • Data mismatch-- i.e. date of birth, name difference, and gender
  • Missing therapist
The SFA will identify all Category 1 claim rejections promptly. Refer to the “Insurance Claims Need Attention” and “Medicaid Claims Need Attention” reports found on the EI Billing provider dashboard often to identify and resolve Category 1 problems.

Category 2 Rejections (277 Rejections) include but are not limited to: 
  • Client not on file
  • Provider not approved for service on that date
  • Diagnosis code(s) not approved by payer (i.e. ICD-9 codes)
  • Procedure code(s) not approved by payer (i.e. CPT and HCPCS codes)
Please Note: Providers should use the most comprehensive diagnosis and procedure codes to describe a child’s diagnoses/condition(s) and service(s) rendered. 
The SFA can identify all Category 2 claim rejections within 48 hours from the date a payer sends a 277 response to the SFA with the claim. Refer to the “Insurance Claims Need Attention” and “Medicaid Claims Need Attention” reports found on the EI Billing provider dashboard.
  • Category 3 Denials: Category 3 - 835 Errors are claims denied to make payment due to some information that can be corrected. Included but not limited to:
CO22: eMedNY's records indicate child has commercial insurance that was not billed
C016: Rendering Provider = Billing Provider 

Refer to the “Insurance Claims Need Attention” and “Medicaid Claims Need Attention” reports found on the EI Billing provider dashboard 

Claim Resubmission: Providers should correct and resubmit rejected/denied claims found on the “Insurance Claim Needing Attention” and/or “Medicaid Claim Needing Attention” report in EI Billing as soon as possible. Resubmitting a claim without correcting the reason(s) for the rejection will further delay the claiming process and ultimately delay payment for these claims. 

Follow-up on Claims Pending More Than 30 days (30 days after submission date)
  1. Run the “Claims Awaiting EOB” report found in EI Billing. The report can be found by first selecting the “Reports” tab, then selecting “Insurance” from the drop-down list, and then clicking on “Claims Awaiting EOBs” from the drop-down list.
  2. Review the “Claims Awaiting EOB” report and confirm the date(s) of service, submission date(s), and that the plan billed is regulated or consent to bill the non-regulated plan was given. Refer to the child’s detail page for information. 
  3. Gather the following information prior to calling the plan: Child name, Date of Birth, Policy ID Number, Billing Agency Tax ID, Rendering NPI, Date(s) of service, Submission date(s)
  4. Call the plan billed.  The insurance representative may ask for the information gathered in Step 3. Ask the insurance representative if the date(s) of service is on file. If the rep. answers “Yes,” ask the insurance representative why the claim is pending and what is needed to process the claim. If the rep. answers “No the claim is not on file,” resubmit the claim in EI Billing. If the insurance representative requests a hard copy of the paper claim, inform the PCG Call Center. 
  5. Request and document a reference number for the phone call, the insurance representative’s name, and a brief summary of the call including all actions required.
  6. Respond to all plan request(s) discussed during the phone call in a timely manner, i.e. submit prior authorization requests, respond to requests for medical records, or--if required--resubmit claims.
  7. After 14 business days from the original follow-up phone call, review the “Claims Awaiting EOBs” report. If the date(s) of service still appears on the report, call the plan with the reference number and insurance representative’s name previously documented.  
  8. After another 7-10 business days from the second insurance follow-up call, review the “Claims Awaiting EOBs” report. If the date(s) of service appears on the report, call the PCG call center at (866) 315-3747.   

Claims Pending for More Than 45 Days

Providers should inform the SFA of any claim(s) sent to regulated plans for payment--followed up with calls from the provider--when no action was taken by the payer for more than 45 days. Prior to informing the SFA of claims pending more than 45 days, ensure that two follow-up calls were made to the primary payer on file and all requested medical documentation and/or additional information from the payer was provided. Also, when calculating the 45 day time frame, remember when a claim is resubmitted, the time frames discussed above begin again. Please review the insurance follow-up process day cycle.

Article ID: 246, Created On: 3/31/2015, Modified: 10/28/2015

Feedback (0)