Page 133 - Claims Handbook

 Location (LC) must match the location on the claim.
 Proc# if populated, must match the procedure code on the claim.

ï‚· For information that differs from the claim, review the Medical Necessity Form (MNF) and the Authorization
Confirmation in the member’s folder in Macess to verify the authorization was built correctly according to

what was requested on the MNF and what was authorized on the Authorization Confirmation.
 In Macess, MNFs are saved as Document Type “MNF” and may contain the authorization number and the

provider name under the Description field.
 Authorization Confirmations are saved as Document Type “Auth Confirmation…” and may contain the

authorization number under the Description field.
 Compare the MNF to the Authorization Confirmation and the authorization in Amisys to determine if the

authorization was built incorrectly.

ï‚· If the authorization in Amisys does not match the Authorization Confirmation with respect to the provider
number, dates, or location (clerical errors) – the authorization can be updated by the Claims Authorization

staff.

 Send a service form (SF) to Claims Authorizations requesting an authorization update. Follow the Claims

Authorization Request Service Form Process located at Claims Department\Training Material\Process

Documents\Claims Authorization Request Service Form Process.

 Enter a remark on the claim indicating a request was sent for the authorization to be updated.
 From the Readjudication screen, click “Remarks.”
 Click the green plus sign to add a new remark.
 In the Remark Effective Date field, enter the beginning service date.
 In the Exp Date field, enter 12/31/9999.
 In the Remark Type (RM) field, type “CL.”

 In the Remark Summary field, type “SF# requesting update to auth #____.”

 Once the Claims Authorization Request Service Form is returned and the authorization has been updated,

readjudicate the claim in Amisys to remove the O8 pend.

 Repeat above steps as necessary if the O8 pend does not fall off.

ï‚· Discrepancies between the MNF, Authorization Confirmation, and authorization in Amisys, other than

clerical errors, are sent to Medical Management for review to determine if services were authorized/if an

authorization should be added or updated.
 In Macess, create a Service Form (SF) and attach the MNF and all supporting documentation.
 Refer to the Who to Send Service Forms document to determine the recipient of the SF.
 Request review of the authorization and claim to determine if the services were authorized/if the

authorization should be updated.
 Process the claim according to Medical Management’s response and the authorization.

ï‚· If there is an authorization on file, but the provider is billing incorrectly according to the authorization,
deny with EX code 63, “Provider billing for services different from authorization.”
 Note: EX code 63 is ONLY to be used when an authorization for the service is on file.

If there is no authorization on file, develop the claim:

Note: Service(s) provided out of the network area require medical records for review of urgent/emergent, unless the
member received prior notification that the service(s) would not be covered.

1. Review the claim for a par referral.
 Medical Claims: If the referring provider’s affiliation status is anything other than NP or OA, request

confirmation of the par referral (the NK letter) by following the Generating a Letter Confirming a Par to Non

Par Referral process.
 Hospital Claims: If the attending provider’s affiliation status is anything other than NP or OA AND the

admit source (form locator 15) is 1 or 2, request confirmation of the par referral (the NK letter) by following

the Generating a Letter Confirming a Par to Non Par Referral process.
 If the attending provider’s affiliation status is par and the admit source is NOT 1 or 2, continue
developing the claim. These claims do not follow “par referral” guidelines.

3 SSA 11.12.2014