Q. Why was my claim denied?
A. There are several reasons claims may not be paid upon their first submission. These reasons range from complex systems interface and electronic adjudication challenges to simple administrative issues. There are a number of things you can do to make sure your claim doesn't get held up because of administrative reasons.

Here's a quick list of things to check each time you submit a claim:

1. Complete the appropriate claim form- HCFA 1500 forms are required for outpatient services and UB 92 forms are required for inpatient services.
   
   
2. Be sure to send your claim form to the appropriate claims payer and specific address. UMMH works with several TPA's and each has its own mailing address for claims payment. If you are not sure which address to submit a claim to, refer to your Provider Handbook or for quick claims reference click here.
   
   
3. Make sure the member's name appears on the claim form just as it appears on the insurance card. Watch out for name variations or changes.
   
   
4. Be sure to include the specific member, or member's dependent identification number.
   
   
5. Make sure that service dates are within the authorized time period.
   
   
6. Make sure the number and type of sessions submitted for payment are within the parameters of the authorization.
   
   
7. Make sure diagnosis and CPT codes are correct and match the services authorized.
   
   
8. Include and verify the correct taxpayer identification number (TIN)- especially if it is a different number than the identification number of the service provider. Remember that services authorized under a group TIN must be submitted for payment under that group's TIN.
   
   
9. Fill in PIN# in Box 33 using either your UPIN# or if you do not have one call Mercy Health Plan and they will give you the appropriate Provider PIN#.
   
   
10. Identify the service provider including degree level.
    
    
11. Review the Explanation of Benefits (EOB), if applicable, and correct the issue noted that kept the claim from being paid before resubmitting a denied claim.

Q. I haven't received an EOB on the claim that I submitted.
A. Please refer to your Provider Handbook or this quick claims reference guide and call the TPA directly for status on a submitted claim.

Q. I believe I am being paid the incorrect rate.
A. Review the current fee schedule and if after reviewing your rates you still believe there is an error, please contact the appropriate TPA.

Submitting Electronic Claims with MHP
A. E-claim submission is fast, easy and convenient. Mercy Health Plans partners with Gateway EDI to provide this service.

Submitting claims electronically is as easy as calling a Gateway representative at (800) 969-3666 or (314) 842-2726 or contacting them via their Web site. Access to other clearinghouses will be available soon.

As you begin the electronic claims submission process, please take some time to review the following helpful hints.

• Submit the subscriber number, including the two-digit suffix, as indicated on the Member Identification Card. As Identification Numbers are assigned based on the subscriber's Social Security Number, this number may differ from the actual Member's social security number.
• Member information must match the ID number, date of birth, and gender as on file with MHP.
• Submit claims in the ANSI 837 format. If your office software cannot currently support this capability, but can print a HCFA 1500 form, Gateway EDI staff can accept the information for reformatting to the Plan. All Medicare required fields, as well as referral and authorization numbers should be completed.
• Use current year procedure (CPT-4, HCPCS) and diagnosis (ICD-9) coding only. Non-specific CPT and HCPCS codes require a description of the service/procedure. These claims can be submitted manually with a copy of the supporting medical record.
• Submit current diagnosis codes to the highest level of specificity (i.e., 4th and 5th digits as required by ICD-9 coding parameters).
• Submit the beginning and ending dates of service for each procedure including month/day/year.
• Submit separate claims for each calendar year.
• Submit actual charges.
• Use your UPIN as your provider identification number in Box 33.
• Submit appropriate prior authorization or referral numbers in Box 23 of the HCFA 1500.
• Query your Gateway EDI transmittal reports daily to verify that all claims have been accepted for processing.
• Claims must be filed within 90 days of the date of service, unless the member has other health benefits coverage as primary. If you are filing with MHP as secondary carrier, claims should be filed manually with a copy of the primary carrier's EOB and within 120 days of the date of the EOB.