14 CLAIM SUBMISSION AND ADJUDICATION PROCEDURES
14.9 Claims Adjudication
All network and non-network provider claims submitted for adjudication are processed according to generally accepted claims coding and payment guidelines. These guidelines comply with industry standards as defined by the CPT-4 and ICD-10 manuals. Institutional claims should be submitted using EDI submission methods or an UB-04 or CMS-1450 and provider claims using the CMS-1500.
Providers must use HIPAA-compliant billing codes when billing IntegraNet. This applies to both electronic and paper claims. When billing codes are updated, the provider is required to use appropriate replacement codes for submitted claims. IntegraNet will not pay any claims submitted using noncompliant billing codes.
IntegraNet reserves the right to use code-editing software to determine which services are considered part of, incidental to or inclusive of the primary procedure. The automated claims auditing system verifies the coding accuracy of claims for CPT and Healthcare Common Procedure Coding System (HCPCS) procedures. This system ensures the same auditing criteria is applied across all claims. Editing decisions are supported by online medical coding policy statements published by CMS as a part of the National Correct Coding Initiative (NCCI, also known as CCI).
For claims payment to be considered, providers must adhere to the following time limits:
- Submit claims within the number of days specified for each market from the date the service is rendered, or for inpatient claims filed by a hospital, within the number of days specified for each market from the date of discharge.
- In the case of other insurance, submit the claim within the number of days specified for each market after receiving a response from the third-party payer.
- Claims for members whose eligibility has not been added to the state’s eligibility system must be received within 90 days from the date the eligibility is added and IntegraNet is notified of the eligibility/enrollment.
- Claims submitted after the market specific timely filing deadline will be denied.
After filing a claim with IntegraNet, review the weekly EOP. If the claim does not appear on an EOP within 30 business days as adjudicated or you have no other written indication the claim has been received, check the status of your claim by using the IntegraNet website at http://www.InetClaims.com/. If the claim is not on file with IntegraNet, resubmit your claim within 90 days from the date of service, or by the timely filing requirement for your market. If filing electronically, check the confirmation reports for acceptance of the claim you receive from your EDI or practice management vendor.