MedicaidJune 25, 2024
Important billing reminder for G60 denials — Use correct billing form
Claims billed on an incorrect billing form may result in a G60 claim denial. The proper use of billing forms is not just a procedural necessity; it is also a requirement that ensures your claim's accuracy, prevents delays, and ensures that you are reimbursed correctly and promptly.
Review the key points below to help prevent claim delays and ensure accuracy:
- Form selection: Ensure that the correct billing form is chosen for different conditions or treatments. Incorrect form selection is the main trigger for G60 denials.
- Completeness of detail: Make sure that all required fields in the form are accurately filled in. Missing data points can lead to misinterpretation and ultimately denial.
- Consistency in information: The detail provided in billing forms should correlate with the medical records. Inconsistency or contradictions can result in denials.
- Regular updates: Stay informed about changes in billing processes and form use and update your practices accordingly.
To help prevent more G60 denials, we have included billing form guidelines in the provider manual and made reimbursement policies accessible on our provider website. Links to the resources are at the end of this document.
You must follow proper billing and submission guidelines by using industry standard, compliant codes on all claim submissions. Services should be billed with Current Procedure Terminology® (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes, and/or revenue codes. These codes denote the services and/or procedures performed and, when billed, must be fully supported in the medical record and/or office notes.
Unless otherwise noted within the policy, our reimbursement policies apply to both participating and non-participating professional providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed, Wellpoint may:
- Reject or deny the claim.
- Recover and/or recoup claim payment.
- Adjust the reimbursement to reflect the appropriate services and/or procedures performed.
Professional claims
Professional providers of healthcare services are required to submit an original CMS-1500 health insurance claim form or its electronic equivalent to Wellpoint for payment of healthcare services unless provider, state, federal, or Centers for Medicare & Medicaid Services (CMS) contracts and/or requirements indicate otherwise.
Providers must submit a properly completed CMS-1500 claim form, or its electronic equivalent, for services performed or items/devices provided. If the required information is not submitted, Wellpoint will deny payment without being liable for interest or penalties
Facility claims
Institutional providers (facilities) are required, unless otherwise stipulated in their contract, to submit the original CMS UB-04/CMS-1450 Medicare Uniform Institutional Provider Bill to Wellpoint for payment of healthcare services.
Providers must submit a properly completed UB-04/CMS-1450 for services performed or items/devices provided. If the required information is not provided, Wellpoint can delay or deny payment without being liable for interest or penalties.
Corrected claims
Wellpoint allows reimbursement for a corrected claim when received within the applicable timely filing requirements of the original claim unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.
The corrected claim must be received within the timely filing limit due to the initial claim not being considered a clean claim. In the absence of such mandate, we follow the standard of 120 days from the last payment notification (Explanation of Payment/Remittance Advice)) for participating and nonparticipating providers and facilities.
Providers resubmitting paper claims for corrections must clearly mark the claim as Corrected Claim. Corrected claims submitted electronically must have the applicable frequency code. Failure to mark the claim appropriately may result in denial of the claim as a duplicate.
Corrected claims filed beyond federal, state-mandated, or company standard timely filing limits will be denied as outside the timely filing limit. Services denied for failure to meet timely filing requirements are not subject to reimbursement unless the provider presents documentation proving a corrected claim was filed within the applicable filing limit.
Claim submissions
Wellpoint cannot accept claims with alterations to billing information. Claims that have been altered will be returned to the provider with an explanation of the reason for the return.
Although Wellpoint prefers the submission of claims electronically (8371) through the electronic data interchange (EDI), Wellpoint will accept paper claims. A paper claim must be submitted on an original claim form with dropout red ink; computer-printed or typed; and in a large, dark font in order to be read by optical character reading (OCR) technology. All claims must be legible. If any field on the claim is illegible, the claim will be rejected or denied.
Your commitment to patient care is greatly appreciated. Let's work together to streamline our processes and further enhance the services we provide to our patients. We are confident that, with your assistance in utilizing the correct billing forms, we will significantly mitigate G60 denials.
Additional billing information
Reference the provider manual (Medicaid) (PDF) and Wellpoint Reimbursement Policies on our provider website.
Questions
If you have questions about this communication or need assistance with any other item, call Provider Services at 833-731-2154 or visit the Contact Us section at the bottom of our provider website for up‑‑to-date contact information.
We look forward to working together to achieve improved outcomes.
Medicaid coverage provided by Wellpoint Tennessee, Inc.
We comply with the applicable federal and state civil rights laws, rules, and regulations and do not discriminate against members or participants in the provision of services on the basis of race, color, national origin, religion, sex, age, or disability. If a member or a participant needs language, communication, or disability assistance or to report a discrimination complaint, call 833-731-2154. Information about the civil rights laws can be found at tn.gov/tenncare/members-applicants/civil-rights-compliance.html.
TNWP-CD-061573-24 _24-0689
PUBLICATIONS: July 2024 Provider Newsletter
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