ForwardHealth is automatically reprocessing certain outpatient crossover hospital claims processed between July 1, 2023, and September 13, 2024, with detail dates of service on and after July 1, 2023. These claims had the pricing method and/or the maximum allowable fee rate for calendar year 2023 retroactively applied for certain Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes.
The appropriate reimbursement changes are applied to claims submitted with CPT and HCPCS procedure codes J0173, Q2054, Q2056, Q4134, Q4143, or 0142U.
ForwardHealth is automatically reprocessing certain professional claims with process dates and detail dates of service between August 6, 2024, and December 10, 2024. Claims submitted with Healthcare Common Procedure Coding System procedure code H1010 (Non-medical family planning education, per session) with U8 modifier (used to identify patient educational materials provided by mail) are being reprocessed to pay the $77 rate.
ForwardHealth is automatically reprocessing certain professional claims with process dates and detail dates of service between January 1, 2023, and November 30, 2023. Claims submitted with Healthcare Common Procedure Coding System (HCPCS) procedure codes G0316-G0318 were denied with Explanation of Benefits code 1279, “Procedure not payable for Place of Service.”
These claims are being reprocessed with the updated place of service (POS) code(s) for the applicable HCPCS code:
ForwardHealth is automatically reprocessing certain outpatient crossover hospital claims processed between January 1, 2023, and July 25, 2024, with detail dates of service on and after January 1, 2023. These claims had the pricing method and/or the maximum allowable fee rate for calendar year 2023 retroactively applied for certain Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes.
The appropriate reimbursement changes are applied to claims submitted with CPT and HCPCS procedure codes 81418, 87913, 0022U, 0324U, 0325U, A4596, E2331, G2010, G2012, G2252, and certain codes in the range of Q4103-Q5124.
ForwardHealth is automatically reprocessing certain outpatient crossover hospital claims processed between April 1, 2021, and May 8, 2024. These claims had the pricing method and/or the maximum allowable fee rate for calendar year 2022 retroactively applied for certain Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes.
The appropriate reimbursement changes were applied to:
ForwardHealth is automatically reprocessing professional and professional crossover claims processed between October 1, 2023, and December 31, 2023, with detail dates of service between January 1, 2020, and December 31, 2022. Affected claims submitted with Healthcare Common Procedure Coding System procedure code S9484 (Crisis intervention mental health services, per hour) were adjusted to the Federal Medical Assistance Percentage rate for fiscal year 2024.
ForwardHealth is automatically reprocessing certain outpatient crossover claims processed between April 1, 2021, and September 29, 2023. These claims had the pricing method and/or the maximum allowable fee rate for calendar year 2021 retroactively applied for certain Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes.
ForwardHealth is automatically reprocessing certain outpatient and outpatient crossover fee-for-service claims that processed between February 25, 2021, and December 20, 2022, with detail dates of service (DOS) between February 4, 2021, and November 6, 2022. Affected claims submitted with Healthcare Common Procedure Coding System procedure code H0018 (Behavioral health; short-term residential [non-hospital residential treatment program], without room and board, per diem) included billing errors that resulted in multiple reimbursements for a single DOS. Impacted residential substance use disorder (RSUD) providers will have 45 days to correct the billing errors and resubmit their claims. Providers must include the Timely Filing Appeals Request form, F-13047 (08/2015), for each resubmitted claim. Providers may search for the Timely Filing Appeals Request form on the Forms page of the ForwardHealth Portal.
For assistance on how to resubmit a claim or complete the Timely Filing Appeals Request form, RSUD providers should reach out to their Provider Relations representative for support. Providers may refer to the Find/Contact your Professional Field Representative link under the Quick Links box on the Providers page of the Portal for the field representative map.
ForwardHealth is automatically reprocessing certain outpatient and outpatient crossover fee-for-service claims that processed between July 21, 2021, and December 16, 2022, with detail dates of service (DOS) between March 5, 2021, and November 21, 2022. Affected claims submitted with Healthcare Common Procedure Coding System procedure code H0018 (Behavioral health; short-term residential [non-hospital residential treatment program], without room and board, per diem) included billing errors that resulted in multiple reimbursements for a single DOS. Impacted residential substance use disorder (RSUD) providers will have 75 days to correct the billing errors and resubmit their claims. Providers must include the Timely Filing Appeals Request form, F-13047 (08/2015), for each resubmitted claim. Providers may search for the Timely Filing Appeals Request form on the Forms page of the ForwardHealth Portal.
ForwardHealth is automatically reprocessing certain professional and professional crossover claims for durable medical equipment (DME) with process dates and detail dates of service (DOS) between January 1, 2022, and May 3, 2023. Claims submitted with DME Healthcare Common Procedure Coding System (HCPCS) procedure code A5514 and certain DME HCPCS procedure codes in the E0100–E2510 and K0001–K0863 ranges were reprocessed to apply the updated maximum allowable fee rates for calendar years 2022 and 2023 and are the equivalent to the lowest corresponding Medicare maximum allowable fee rate in Wisconsin. Affected claims that were previously processed with DOS on and after January 1, 2022, will be reprocessed to reflect this change in reimbursement.
A separate claim adjustment for affected claims applying the updated maximum allowable fee rate for additional DME HCPCS codes effective for January 1, 2023, will happen at a later date.
ForwardHealth is automatically reprocessing certain fee-for-service professional claims that processed between July 1, 2022, and September 22, 2022, with detail dates of service between July 1, 2022, and September 22, 2022. Affected professional claims submitted with Healthcare Common Procedure Coding System (HCPCS) procedure code A0120 (Non-emergency transportation: minibus, mountain area transports, or other transportation systems) were adjusted to one unit if a provider billed for more than one unit on the claim.
In addition, professional claims submitted with HCPCS codes A0120 and S0215 (Non-emergency transportation; mileage per mile) were reprocessed to apply the updated maximum allowable fee rates.
ForwardHealth is automatically reprocessing certain fee-for-service dental claims with dates of service and dates of process between January 1, 2022, and November 12, 2022. Affected claims that were submitted with Current Dental Terminology procedure codes D1999, D4999, D5999, D6040, D6050, D6090, D7999, D8010, D8020, D8030, D8040, D8070, D8080, D8090, D8210, D8220, D8670, D8680, D8695, or D9999 will be reprocessed to reflect a 40 percent increase.
Providers who submitted claims for services billed at a lesser amount in 2022 will need to adjust their usual and customary charge and resubmit their claims within 365 days of the date of service to ForwardHealth in order to receive their full reimbursement.
ForwardHealth is automatically reprocessing certain professional, professional crossover, and home health fee-for-service claims. Claims with process and detail dates of service between December 11, 2020, and September 22, 2021, that were submitted with COVID-19 vaccine Current Procedural Terminology (CPT) procedure codes 91300 (Severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use) and 91301 (Severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use) were denied with Explanation of Benefits (EOB) code 1280, "Rendering Provider Type and/or Specialty is not allowable for the service billed." Hospital providers and end-stage renal disease providers were added as allowable provider types for these procedure codes.
In addition, claims with process and detail dates of service between August 12, 2021, and September 22, 2021, that were submitted with COVID-19 vaccine CPT procedure codes 0003A (Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 [SARS-CoV- 2] [coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; third dose) and 0013A (Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose) were denied with EOB codes 0116, "Procedure Code or Drug Code not a benefit on Date of Service," or 1322, "Incorrect or invalid NDC/Procedure Code/Revenue Code billed." Additional policy has been added for these procedure codes.
ForwardHealth is automatically reprocessing claims that were processed between July 17, 2017, and December 15, 2019. Claims for members enrolled in both the Katie Beckett program and Children’s Health Insurance Program are being reprocessed to ensure the Katie Beckett program enrollment will apply. For the affected claims, providers do not need to take any action, and there will be no change in the amounts that were reimbursed for these claims. The Remittance Advice will include the Explanation of Benefits code 8234, "ForwardHealth-initiated claim adjustment," to indicate these affected claims.
Adjusted claims will be assigned a new claim number, known as an internal control number (ICN). The new ICN will begin with "58." If the provider adjusts any of these claims in the future, the new ICN will be required when submitting the claim. Refer to the ForwardHealth-Initiated Claim Adjustments topic (#13437) of the Responses chapter of the Claims section of the ForwardHealth Online Handbook for complete information.
ForwardHealth is automatically reprocessing certain claims that processed between July 1, 2016, and August 17, 2018, that were assigned incorrect fund codes. For the affected claims, providers do not need to take any action, and there will be no change in reimbursement. The provider's Remittance Advice will include the Explanation of Benefits code 8234, "ForwardHealth-initiated claim adjustment," to indicate these affected claims.
Adjusted claims will be assigned a new claim number, known as an internal control number (ICN). The new ICN will begin with "58." If the provider adjusts this claim in the future, the new ICN will be required when submitting the claim. Refer to the ForwardHealth-Initiated Claim Adjustments topic (topic #13437) in the Responses chapter of the Claims section of the ForwardHealth Online Handbook for complete information.
Providers are required to submit claims for SeniorCare members who are enrolled in a Medicare Part D Prescription Drug Plan (PDP) to the member's PDP and other health insurance sources before submitting claims to SeniorCare. SeniorCare is payer of last resort. Providers should submit the claims to the appropriate PDP. Once payment or denial from the PDP is received, providers may submit their coordination of benefit claim to SeniorCare with the payment or denial from the PDP.
If the date of service on the claim is outside the PDP's filing deadline, providers may submit a completed paper Noncompound Drug Claim, F-13072, or Compound Drug Claim, F-13073, to ForwardHealth with a Pharmacy Special Handling Request, F-13074, indicating "SeniorCare/Medicare Part D Coordination of Benefits Error," in Element 4. Providers are required to submit the paper claims and Pharmacy Special Handling Request by August 31, 2012. After this time, claims for this error will no longer be accepted.
As a reminder, SeniorCare members can only be held responsible for their SeniorCare spenddown, deductible, or copayment.
Crossover claims submitted on paper with the Medicare remittance advice attached and crossover claims with only one detail will be adjusted to apply the correct cutback amount. Providers are not required to take any action on these claims. All other crossover claims will be denied with Explanation of Benefits (EOB) code 1549, "Sum of detail Medicare paid amounts does not equal header Medicare paid amount." Providers are required to resubmit crossover claims that deny as a result of this adjustment in order to receive payment. Providers are reminded that ForwardHealth requires a paid amount to be indicated at the detail level for professional crossover claims.
Claims that are beyond the timely filing deadline must be received by ForwardHealth Timely Filing before November 30, 2010. Providers may submit one Timely Filing Appeals Request form, F-13047, per batch of claims. When completing the form, providers should place a check in the "ForwardHealth Reconsideration" box and write "Adjust claim denials for EOB message 1549 for professional crossover claims without claim detail amounts" to explain the nature of the problem.
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