PACE

PROVIDER BULLETIN

March 2, 2007

Claim Submission Accuracy

 

The PACE void project identified numerous claims billed incorrectly to PACE as the primary payer. Providers were either not billing the Medicare Part D plan as the primary payer or were not billing the Medicare Part D plan correctly.   

 

IMPORTANT: Providers are responsible for the accuracy of the information submitted to PACE.

 

The PACE void project has shown the following questionable claim data submissions:

 

·         Claims submitted to PACE with an Other Coverage Code (OCC) of “02”, “Other Coverage Exists – payment collected.”

o        The primary plan reports either no record of receiving or no record of paying the claim.

o        The amount entered by the provider in the Amount Paid by the primary plan is $.01; primary plan information has no record of claim being paid.

o        The amount entered by the provider in the “Patient Pay Amount” field was in many instances greater than the amount entered as the Usual and Customary.

 

·         Claims submitted with an Other Coverage Code (OCC) of “02”, “Other Coverage Exists –payment collected.”  

o        Primary payer received and paid the claim. The amount returned in the “Patient Pay Amount” field differs from the copay reported by primary payer.  In some instances the amount entered by the provider as the primary’s copay (Patient Pay Amount Field 43-DX) was identical to the Usual and Customary submitted to PACE.

 

·         Claims submitted with an Other Coverage Code (OCC) of “03”, “Other Coverage Exists – claim not covered.”

o        Primary plan denied the claim.  Provider ignored primary plan’s instructions to obtain temporary fill while prior authorization by plan is requested.  This disregard of primary plan’s instructions resulted in PACE paying the entire claim.

 

·         Claims submitted with an Other Coverage Code (OCC) of “03”, “Other Coverage Exists – claim not covered.” Provider entered $0.00 in Amount Paid by Primary Payer.

o        Primary plan received and paid the claim. PACE ALSO billed and paid the claim.

 

·         Claims submitted with an Other Coverage Code (OCC) of “04”, “Other Coverage Exists – payment not collected.” Provider entered $0.00 in Amount Paid by Primary Payer.

o        Primary plan either has no record of receiving the claim or denied the claim. Provider submitted incorrect code to PACE.  PACE paid the entire claim.

o        Primary plan received and paid the claim. PACE ALSO billed and paid the claim.

 

 

Providers are responsible for the accuracy of claim data received by the Program.  Claim submission inaccuracies or discrepancies, such as identified above, will result in disallowance of claims in future audits.