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.