14 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES
14.1 Claims - Billing and Reimbursement
Clean claims for Medicare members are generally adjudicated within 30 calendar days from the date IntegraNet receives the claim. For nonclean claims, the provider receives written notification identifying the claim number, the reason the claim could not be processed, the date the claim was received by IntegraNet and the information required from the provider in order to adjudicate the claim. IntegraNet produces and mails an Explanation of Payment (EOP) on a daily basis. The EOP delineates for the provider the status of each claim that has been paid or denied.
Medicare members must not be balance billed for services rendered as outlined in the participating provider agreement and the Attachment A rate sheet. Medicare members are also not held liable for noncovered services where the provider failed to provide advanced notice of noncoverage via the organization determination process. Reimbursement by IntegraNet constitutes payment in full except for applicable copays, deductibles and coinsurance. These amounts will be indicated on the EOP and direction provided based on whether IntegraNet is responsible for processing both the primary and secondary claims or not. In instances where IntegraNet is only responsible for processing primary claims, the provider should bill the state Medicaid agency, as would be the standard practice in the Medicare fee-for-service program for Specialty + Rx plan members.
Provider must use HIPAA-compliant billing codes when billing. This applies to both electronic and paper claims. When billing codes are updated, the provider is required to use appropriate replacement codes for submitting claims for covered services. An amendment to the Participating Provider Agreement will not be required to replace such billing codes. IntegraNet follows Strategic National Implementation Process (SNIP) level 1 through 6 editing for all claims received in accordance with HIPAA. IntegraNet will not reimburse any claims submitted using noncompliant billing or SNIP codes.
Providers resubmitting claims for corrections must clearly mark the claim “Corrected Claim.” Failure to mark the claim appropriately may result in denial of the claim as a duplicate. Corrected claims must be received within the applicable timely filing requirements of the originally submitted claim, due to the original claim not being considered a clean claim.
Any questions or inquiries regarding paid, denied or pended claims should be directed to 541-464-6296
Provider Obligations — denial notification and member complaints, appeals and grievances Providers are required to adhere to CMS and IntegraNet requirements concerning issuing letters and notices. This includes advanced notice of denials that will result in member liability or cost in accordance with Medicare guidelines for Medicare Advantage Plans