XI. Claim & Billing Information

XI. Claim & Billing Information A. Claims Submission Requirements 1. Time Limit for Filing Claims  Initial claims for covered services must be submi...
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XI. Claim & Billing Information A. Claims Submission Requirements 1. Time Limit for Filing Claims 

Initial claims for covered services must be submitted within ninety (90) days of the date of service to be considered for reimbursement. Those submitted beyond the ninety (90) day time limit are denied on the ValueOptions provider summary voucher.



Claims involving Third Party Liability (TPL) must be submitted within ninety (90) days of the date of the other carrier’s Explanation of Benefits (EOB), or notification of payment/denial. Please refer to letter G of this Section in this manual for more detailed instructions on submitting claims involving TPL.

2. Incomplete Claims 

Claims are not paid by ValueOptions in the case of incorrect or incomplete required data elements.



ValueOptions notifies the provider, via the provider summary voucher, of those data elements requiring completion or correction. The required data elements and other claim submission requirements are outlined in the links listed in Section XI.C.1 and XI.C.2 in this manual, and further details are included in the Tips for Completing the CMS 1500 and Tips for Completing the UB04 documents.

B. Claims Submission Policy 

ValueOptions accepts claims submitted electronically, via an 837 file or through DirectClaim submission on ProviderConnect. For more details on becoming a ValueOptions EDI Submitter, EDI file specifications, as well as information about free EDI software please contact the ValueOptions EDI Help Desk at 1-888-247-9311 

Original paper claims for covered services must be submitted directly to: ValueOptions P.O. Box 399 Latham, NY 12110

Copies of claims and faxed claims are not accepted as an Initial Claim.  

Detailed instructions on required data elements for completing the claim forms are outlined in the links listed in Section C (Paper Claims Submission Requirements) below. The provider agreement details the covered services that have been contracted for and the definition of services included in the per diem rates.

XI. Claim & Billing Information   

 

Claims must be submitted with the NorthSTAR ID Number. Failure to use this permanent ID number results in the denial of the claim on the provider summary voucher. Claims must be submitted with the provider’s NPI National Provider Identifier number. Claims must be submitted with a complete and valid ICD-9-CM diagnosis code for service dates prior to September 30, 2015. Effective on October 1, 2015 service dates, ICD-10-CM diagnosis codes will be required. Claims submitted with any other diagnosis code are denied on the ValueOptions provider summary voucher. ValueOptions is committed to continuing communication with network providers regarding changes and updates to billing policies and procedures. Future communications are provided as needed through online news and education articles. Please note that providers are NOT permitted to bill TMHP for covered services for NorthSTAR enrollees.

C. Paper Claim Submission Requirements 

Forms and Instructions for Completing the CMS 1500 Claim Form can be found in Section XIII (Required Forms) in this manual or online at: http://www.valueoptions.com/provider/handbooks/forms/administration/cms1500.pdf



Additional tips for the CMS 1500 form can be found in Section XIII (Required Forms) in this manual or online at: http://www.valueoptions.com/provider/handbooks/forms/administration/cms1500tips.pdf



Forms and Instructions for Completing the UB04 Claim Form (HCFA 1450) can be found in Section XIII (Required Forms) in this manual or online at: http://www.valueoptions.com/provider/handbooks/forms/administration/ub92.pdf



Additional tips for the UB04 form can be found in Section XIII (Required Forms) in this manual or online at: http://www.valueoptions.com/provider/handbooks/forms/administration/ub92tips.pdf 1. Valid Patient Discharge Status (Reasons) Listed as part of the Tips for Completing UB04 Claims are the valid Patient Discharge Status (Reason) codes. These codes are required to be submitted on all UB04 forms or 837I files. Claims received without a Patient Discharge Status or with a Patient Discharge Status not included on this list, will be denied. The denial code is: RCV, Resubmit Claim with Valid Discharge Reason PLEASE NOTE: If the bill type on the claim ends with ‘1’ or ‘4’ a valid Patient Discharge Status code is required on the claim. Additionally, the Discharge Time needs

XI. Claim & Billing Information to be completed on the claim. If the bill type on the claim ends with ‘2’ or ‘3’ the Patient Discharge Status code submitted on the claim should be ‘30’ to indicate the member is “still a patient”, and there should not be a discharge time entered. 2. Non-billable ICD10 Codes Listed below are ICD10 codes that will not be accepted as valid, billable codes. Any claims received containing these codes will be denied.

diagnosis code E66 E66.0 F01 F01.5 F01.50 F01.51 F02 F02.8 F02.80 F02.81 F03 F03.9 F03.90 F03.91 F04 F05 F06 F06.0 F06.1 F06.2 F06.3 F06.30 F06.31 F06.32 F06.33 F06.34 F06.4

diagnosis description Overweight and obesity Obesity due to excess calories Vascular dementia Vascular dementia Vascular dementia without behavioral disturbance Vascular dementia with behavioral disturbance Dementia in other diseases classified elsewhere Dementia in other diseases classified elsewhere Dementia in other diseases classified elsewhere without behavioral disturbance Dementia in other diseases classified elsewhere with behavioral disturbance Unspecified dementia Unspecified dementia Unspecified dementia without behavioral disturbance Unspecified dementia with behavioral disturbance Amnestic disorder due to known physiological condition Delirium due to known physiological condition Other mental disorders due to known physiological condition Psychotic disorder with hallucinations due to known physiological condition Catatonic disorder due to known physiological condition Psychotic disorder with delusions due to known physiological condition Mood disorder due to known physiological condition Mood disorder due to known physiological condition, unspecified Mood disorder due to known physiological condition with depressive features Mood disorder due to known physiological condition with major depressive-like episode Mood disorder due to known physiological condition with manic features Mood disorder due to known physiological condition with mixed features Anxiety disorder due to known physiological condition

XI. Claim & Billing Information F06.8 F07 F07.8 F07.81 F07.89 F07.9 F10 F10.1 F10.12 F10.15 F10.151 F10.18 F10.2 F10.22 F10.23 F10.231 F10.25 F10.251 F10.26 F10.28 F10.9 F10.92 F10.94 F10.95 F10.951 F10.96 F10.98 F11 F11.1 F11.12 F11.15 F11.18 F11.2 F11.22 F11.25 F11.28 F11.9

Other specified mental disorders due to known physiological condition Personality and behavioral disorders due to known physiological condition Other personality and behavioral disorders due to known physiological condition Postconcussional syndrome Other personality and behavioral disorders due to known physiological condition Unspecified personality and behavioral disorder due to known physiological condition Alcohol related disorders Alcohol abuse Alcohol abuse with intoxication Alcohol abuse with alcohol-induced psychotic disorder Alcohol abuse with alcohol-induced psychotic disorder with hallucinations Alcohol abuse with other alcohol-induced disorders Alcohol dependence Alcohol dependence with intoxication Alcohol dependence with withdrawal Alcohol dependence with withdrawal delirium Alcohol dependence with alcohol-induced psychotic disorder Alcohol dependence with alcohol-induced psychotic disorder with hallucinations Alcohol dependence with alcohol-induced persisting amnestic disorder Alcohol dependence with other alcohol-induced disorders Alcohol use, unspecified Alcohol use, unspecified with intoxication Alcohol use, unspecified with alcohol-induced mood disorder Alcohol use, unspecified with alcohol-induced psychotic disorder Alcohol use, unspecified with alcohol-induced psychotic disorder with hallucinations Alcohol use, unspecified with alcohol-induced persisting amnestic disorder Alcohol use, unspecified with other alcohol-induced disorders Opioid related disorders Opioid abuse Opioid abuse with intoxication Opioid abuse with opioid-induced psychotic disorder Opioid abuse with other opioid-induced disorder Opioid dependence Opioid dependence with intoxication Opioid dependence with opioid-induced psychotic disorder Opioid dependence with other opioid-induced disorder Opioid use, unspecified

XI. Claim & Billing Information F11.92 F11.95 F11.98 F12 F12.1 F12.12 F12.15 F12.18 F12.2 F12.22 F12.25 F12.28 F12.9 F12.92 F12.95 F12.98 F13 F13.1 F13.12 F13.15 F13.18 F13.2 F13.22 F13.23

Opioid use, unspecified with intoxication Opioid use, unspecified with opioid-induced psychotic disorder Opioid use, unspecified with other specified opioid-induced disorder Cannabis related disorders Cannabis abuse Cannabis abuse with intoxication Cannabis abuse with psychotic disorder Cannabis abuse with other cannabis-induced disorder Cannabis dependence Cannabis dependence with intoxication Cannabis dependence with psychotic disorder Cannabis dependence with other cannabis-induced disorder Cannabis use, unspecified Cannabis use, unspecified with intoxication Cannabis use, unspecified with psychotic disorder Cannabis use, unspecified with other cannabis-induced disorder Sedative, hypnotic, or anxiolytic related disorders Sedative, hypnotic or anxiolytic-related abuse Sedative, hypnotic or anxiolytic abuse with intoxication Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolytic-induced disorders Sedative, hypnotic or anxiolytic-related dependence Sedative, hypnotic or anxiolytic dependence with intoxication Sedative, hypnotic or anxiolytic dependence with withdrawal

F13.25

Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder

F13.28 F13.9 F13.92 F13.93

Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorders Sedative, hypnotic or anxiolytic-related use, unspecified Sedative, hypnotic or anxiolytic use, unspecified with intoxication Sedative, hypnotic or anxiolytic use, unspecified with withdrawal

F13.95

Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced psychotic disorder

F13.98 F14 F14.1

Sedative, hypnotic or anxiolytic use, unspecified with other sedative, hypnotic or anxiolytic-induced disorder Cocaine related disorders Cocaine abuse

XI. Claim & Billing Information F14.12 F14.15 F14.18 F14.2 F14.22 F14.25 F14.28 F14.9 F14.90 F14.92 F14.95 F14.98 F15 F15.1 F15.12 F15.15 F15.18 F15.2 F15.22 F15.25 F15.28 F15.9 F15.92 F15.95 F15.98 F16 F16.1 F16.12 F16.120 F16.15 F16.18 F16.2 F16.22 F16.25 F16.28 F16.9 F16.92

Cocaine abuse with intoxication Cocaine abuse with cocaine-induced psychotic disorder Cocaine abuse with other cocaine-induced disorder Cocaine dependence Cocaine dependence with intoxication Cocaine dependence with cocaine-induced psychotic disorder Cocaine dependence with other cocaine-induced disorder Cocaine use, unspecified Cocaine use, unspecified, uncomplicated Cocaine use, unspecified with intoxication Cocaine use, unspecified with cocaine-induced psychotic disorder Cocaine use, unspecified with other specified cocaine-induced disorder Other stimulant related disorders Other stimulant abuse Other stimulant abuse with intoxication Other stimulant abuse with stimulant-induced psychotic disorder Other stimulant abuse with other stimulant-induced disorder Other stimulant dependence Other stimulant dependence with intoxication Other stimulant dependence with stimulant-induced psychotic disorder Other stimulant dependence with other stimulant-induced disorder Other stimulant use, unspecified Other stimulant use, unspecified with intoxication Other stimulant use, unspecified with stimulant-induced psychotic disorder Other stimulant use, unspecified with other stimulant-induced disorder Hallucinogen related disorders Hallucinogen abuse Hallucinogen abuse with intoxication Hallucinogen abuse with intoxication, uncomplicated Hallucinogen abuse with hallucinogen-induced psychotic disorder Hallucinogen abuse with other hallucinogen-induced disorder Hallucinogen dependence Hallucinogen dependence with intoxication Hallucinogen dependence with hallucinogen-induced psychotic disorder Hallucinogen dependence with other hallucinogen-induced disorder Hallucinogen use, unspecified Hallucinogen use, unspecified with intoxication

XI. Claim & Billing Information F16.95 F16.98 F17 F17.2 F17.20 F17.200 F17.201 F17.21 F17.210 F17.211 F17.22 F17.220 F17.221 F17.29 F17.290 F17.291 F18 F18.1 F18.12 F18.15 F18.18 F18.2 F18.22 F18.25 F18.28 F18.9 F18.92 F18.95 F18.98 F19 F19.1 F19.12 F19.15 F19.18 F19.2 F19.22 F19.23

Hallucinogen use, unspecified with hallucinogen-induced psychotic disorder Hallucinogen use, unspecified with other specified hallucinogen-induced disorder Nicotine dependence Nicotine dependence Nicotine dependence, unspecified Nicotine dependence, unspecified, uncomplicated Nicotine dependence, unspecified, in remission Nicotine dependence, cigarettes Nicotine dependence, cigarettes, uncomplicated Nicotine dependence, cigarettes, in remission Nicotine dependence, chewing tobacco Nicotine dependence, chewing tobacco, uncomplicated Nicotine dependence, chewing tobacco, in remission Nicotine dependence, other tobacco product Nicotine dependence, other tobacco product, uncomplicated Nicotine dependence, other tobacco product, in remission Inhalant related disorders Inhalant abuse Inhalant abuse with intoxication Inhalant abuse with inhalant-induced psychotic disorder Inhalant abuse with other inhalant-induced disorders Inhalant dependence Inhalant dependence with intoxication Inhalant dependence with inhalant-induced psychotic disorder Inhalant dependence with other inhalant-induced disorders Inhalant use, unspecified Inhalant use, unspecified with intoxication Inhalant use, unspecified with inhalant-induced psychotic disorder Inhalant use, unspecified with other inhalant-induced disorders Other psychoactive substance related disorders Other psychoactive substance abuse Other psychoactive substance abuse with intoxication Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder Other psychoactive substance abuse with other psychoactive substance-induced disorders Other psychoactive substance dependence Other psychoactive substance dependence with intoxication Other psychoactive substance dependence with withdrawal

XI. Claim & Billing Information F19.25 F19.28 F19.9 F19.90 F19.92 F19.93 F19.95 F19.98 F20 F20.0 F20.1 F20.2 F20.3 F20.5 F20.8 F25 F25.8 F25.9 F30 F30.1 F31 F31.1 F31.3 F31.6 F31.7 F31.70 F31.8 F32 F33 F33.4 F33.40 F33.8 F34 F34.9 F40 F40.0 F40.1

Other psychoactive substance dependence with psychoactive substance-induced psychotic disorder Other psychoactive substance dependence with other psychoactive substance-induced disorders Other psychoactive substance use, unspecified Other psychoactive substance use, unspecified, uncomplicated Other psychoactive substance use, unspecified with intoxication Other psychoactive substance use, unspecified with withdrawal Other psychoactive substance use, unspecified with psychoactive substance-induced psychotic disorder Other psychoactive substance use, unspecified with other psychoactive substance-induced disorders Schizophrenia Paranoid schizophrenia Disorganized schizophrenia Catatonic schizophrenia Undifferentiated schizophrenia Residual schizophrenia Other schizophrenia Schizoaffective disorders Other schizoaffective disorders Schizoaffective disorder, unspecified Manic episode Manic episode without psychotic symptoms Bipolar disorder Bipolar disorder, current episode manic without psychotic features Bipolar disorder, current episode depressed, mild or moderate severity Bipolar disorder, current episode mixed Bipolar disorder, currently in remission Bipolar disorder, currently in remission, most recent episode unspecified Other bipolar disorders Major depressive disorder, single episode Major depressive disorder, recurrent Major depressive disorder, recurrent, in remission Major depressive disorder, recurrent, in remission, unspecified Other recurrent depressive disorders Persistent mood [affective] disorders Persistent mood [affective] disorder, unspecified Phobic anxiety disorders Agoraphobia Social phobias

XI. Claim & Billing Information F40.2 F40.21 F40.22 F40.23 F40.24 F40.29 F41 F43 F43.1 F43.2 F44 F44.2 F44.8 F45 F45.0 F45.2 F45.20 F45.29 F45.4 F48 F48.2 F50 F50.0 F51 F51.0 F51.02 F51.03 F51.09 F51.1 F51.12 F51.19 F51.8 F51.9 F52 F52.1 F52.2 F52.3

Specific (isolated) phobias Animal type phobia Natural environment type phobia Blood, injection, injury type phobia Situational type phobia Other specified phobia Other anxiety disorders Reaction to severe stress, and adjustment disorders Post-traumatic stress disorder (PTSD) Adjustment disorders Dissociative and conversion disorders Dissociative stupor Other dissociative and conversion disorders Somatoform disorders Somatization disorder Hypochondriacal disorders Hypochondriacal disorder, unspecified Other hypochondriacal disorders Pain disorders related to psychological factors Other nonpsychotic mental disorders Pseudobulbar affect Eating disorders Anorexia nervosa Sleep disorders not due to a substance or known physiological condition Insomnia not due to a substance or known physiological condition Adjustment insomnia Paradoxical insomnia Other insomnia not due to a substance or known physiological condition Hypersomnia not due to a substance or known physiological condition Insufficient sleep syndrome Other hypersomnia not due to a substance or known physiological condition Other sleep disorders not due to a substance or known physiological condition Sleep disorder not due to a substance or known physiological condition, unspecified Sexual dysfunction not due to a substance or known physiological condition Sexual aversion disorder Sexual arousal disorders Orgasmic disorder

XI. Claim & Billing Information F52.5 F52.8 F53 F55 F55.0 F55.2 F55.4 F55.8 F59 F60 F60.8 F63 F63.8 F64 F65 F65.5 F65.50 F65.8 F66 F68 F68.1 F68.11 F68.8 F70 F71 F72 F73 F78 F79 F80 F80.1 F80.4 F80.8 F81 F81.8 F81.89 F81.9

Vaginismus not due to a substance or known physiological condition Other sexual dysfunction not due to a substance or known physiological condition Puerperal psychosis Abuse of non-psychoactive substances Abuse of antacids Abuse of laxatives Abuse of vitamins Abuse of other non-psychoactive substances Unspecified behavioral syndromes associated with physiological disturbances and physical factors Specific personality disorders Other specific personality disorders Impulse disorders Other impulse disorders Gender identity disorders Paraphilias Sadomasochism Sadomasochism, unspecified Other paraphilias Other sexual disorders Other disorders of adult personality and behavior Factitious disorder Factitious disorder with predominantly psychological signs and symptoms Other specified disorders of adult personality and behavior Mild intellectual disabilities Moderate intellectual disabilities Severe intellectual disabilities Profound intellectual disabilities Other intellectual disabilities Unspecified intellectual disabilities Specific developmental disorders of speech and language Expressive language disorder Speech and language development delay due to hearing loss Other developmental disorders of speech and language Specific developmental disorders of scholastic skills Other developmental disorders of scholastic skills Other developmental disorders of scholastic skills Developmental disorder of scholastic skills, unspecified

XI. Claim & Billing Information F84 F84.3 F84.5 F84.8 F84.9 F88 F89 F90 F91 F93 F94 F95 F98 F98.2

Pervasive developmental disorders Other childhood disintegrative disorder Asperger's syndrome Other pervasive developmental disorders Pervasive developmental disorder, unspecified Other disorders of psychological development Unspecified disorder of psychological development Attention-deficit hyperactivity disorders Conduct disorders Emotional disorders with onset specific to childhood Disorders of social functioning with onset specific to childhood and adolescence Tic disorder Other behavioral and emotional disorders with onset usually occurring in childhood and adolescence Other feeding disorders of infancy and childhood

F98.8 F99 G44 G44.0 G44.00 G44.01 G44.02 G44.03 G44.04 G44.05 G44.09 G44.2 G44.20 G44.21 G44.22 G44.3 G44.30 G44.31 G44.32 G44.4 G44.5 G44.8

Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescen Mental disorder, not otherwise specified Other headache syndromes Cluster headaches and other trigeminal autonomic cephalgias (TAC) Cluster headache syndrome, unspecified Episodic cluster headache Chronic cluster headache Episodic paroxysmal hemicrania Chronic paroxysmal hemicrania Short lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) Other trigeminal autonomic cephalgias (TAC) Tension-type headache Tension-type headache, unspecified Episodic tension-type headache Chronic tension-type headache Post-traumatic headache Post-traumatic headache, unspecified Acute post-traumatic headache Chronic post-traumatic headache Drug-induced headache, not elsewhere classified Complicated headache syndromes Other specified headache syndromes

XI. Claim & Billing Information G47.29 H93.25 L98 N94 N94.8 N94.81 O90.6

Other circadian rhythm sleep disorder Central auditory processing disorder Other disorders of skin and subcutaneous tissue, not elsewhere classified Pain and other conditions associated with female genital organs and menstrual cycle Other specified conditions associated with female genital organs and menstrual cycle Vulvodynia Postpartum mood disturbance

O99 O99.0 O99.01

Other maternal diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium Anemia complicating pregnancy, childbirth and the puerperium Anemia complicating pregnancy

O99.1

Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanis complicating pregnancy, childbirth and the puerperium

O99.11 O99.2 O99.21

Other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanis complicating pregnancy Endocrine, nutritional and metabolic diseases complicating pregnancy, childbirth and the puerperium Obesity complicating pregnancy, childbirth, and the puerperium

O99.28

Other endocrine, nutritional and metabolic diseases complicating pregnancy, childbirth and the puerperium

O99.3 O99.31 O99.310 O99.311 O99.312 O99.313 O99.314 O99.315 O99.32 O99.324 O99.33 O99.34 O99.340 O99.341 O99.342 O99.343 O99.344 O99.345

Mental disorders and diseases of the nervous system complicating pregnancy, childbirth and the puerperium Alcohol use complicating pregnancy, childbirth, and the puerperium Alcohol use complicating pregnancy, unspecified trimester Alcohol use complicating pregnancy, first trimester Alcohol use complicating pregnancy, second trimester Alcohol use complicating pregnancy, third trimester Alcohol use complicating childbirth Alcohol use complicating the puerperium Drug use complicating pregnancy, childbirth, and the puerperium Drug use complicating childbirth Smoking (tobacco) complicating pregnancy, childbirth, and the puerperium Other mental disorders complicating pregnancy, childbirth, and the puerperium Other mental disorders complicating pregnancy, unspecified trimester Other mental disorders complicating pregnancy, first trimester Other mental disorders complicating pregnancy, second trimester Other mental disorders complicating pregnancy, third trimester Other mental disorders complicating childbirth Other mental disorders complicating the puerperium

XI. Claim & Billing Information O99.35 O99.4 O99.41 O99.5 O99.51 O99.6 O99.61 O99.7 O99.71 O99.8 O99.81 O99.82 O99.83 O99.84 R37 R41 R41.8 R41.83 R41.84 R44 R45 R45.1 R45.2 R45.5 R45.6 R45.8 R45.81 R45.82 R45.85 R45.850 R45.851 R48.0 T43.205 T50.905 T74 T74.0 T74.01

Diseases of the nervous system complicating pregnancy, childbirth, and the puerperium Diseases of the circulatory system complicating pregnancy, childbirth and the puerperium Diseases of the circulatory system complicating pregnancy Diseases of the respiratory system complicating pregnancy, childbirth and the puerperium Diseases of the respiratory system complicating pregnancy Diseases of the digestive system complicating pregnancy, childbirth and the puerperium Diseases of the digestive system complicating pregnancy Diseases of the skin and subcutaneous tissue complicating pregnancy, childbirth and the puerperium Diseases of the skin and subcutaneous tissue complicating pregnancy Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium Abnormal glucose complicating pregnancy, childbirth and the puerperium Streptococcus B carrier state complicating pregnancy, childbirth and the puerperium Other infection carrier state complicating pregnancy, childbirth and the puerperium Bariatric surgery status complicating pregnancy, childbirth and the puerperium Sexual dysfunction, unspecified Other symptoms and signs involving cognitive functions and awareness Other symptoms and signs involving cognitive functions and awareness Borderline intellectual functioning Other specified cognitive deficit Other symptoms and signs involving general sensations and perceptions Symptoms and signs involving emotional state Restlessness and agitation Unhappiness Hostility Violent behavior Other symptoms and signs involving emotional state Low self-esteem Worries Homicidal and suicidal ideations Homicidal ideations Suicidal ideations Dyslexia and alexia Adverse effect of unspecified antidepressants Adverse effect of unspecified drugs, medicaments and biological substances Adult and child abuse, neglect and other maltreatment, confirmed Neglect or abandonment, confirmed Adult neglect or abandonment, confirmed

XI. Claim & Billing Information T74.02 T74.1 T74.11 T74.12 T74.2 T74.21 T74.22 T74.3 T74.31 T74.32 T74.4 T74.9 T74.91 T74.92 T76 T76.0 T76.01 T76.02 T76.1 T76.11 T76.12 T76.2 T76.21 T76.22 T76.3 T76.31 T76.32 T76.9 T76.91 T76.92 Z03.89 Z13 Z13.2 Z13.22 Z13.7 Z13.8 Z13.81

Child neglect or abandonment, confirmed Physical abuse, confirmed Adult physical abuse, confirmed Child physical abuse, confirmed Sexual abuse, confirmed Adult sexual abuse, confirmed Child sexual abuse, confirmed Psychological abuse, confirmed Adult psychological abuse, confirmed Child psychological abuse, confirmed Shaken infant syndrome Unspecified maltreatment, confirmed Unspecified adult maltreatment, confirmed Unspecified child maltreatment, confirmed Adult and child abuse, neglect and other maltreatment, suspected Neglect or abandonment, suspected Adult neglect or abandonment, suspected Child neglect or abandonment, suspected Physical abuse, suspected Adult physical abuse, suspected Child physical abuse, suspected Sexual abuse, suspected Adult sexual abuse, suspected Child sexual abuse, suspected Psychological abuse, suspected Adult psychological abuse, suspected Child psychological abuse, suspected Unspecified maltreatment, suspected Unspecified adult maltreatment, suspected Unspecified child maltreatment, suspected Encounter for observation for other suspected diseases and conditions ruled out Encounter for screening for other diseases and disorders Encounter for screening for nutritional, metabolic and other endocrine disorders Encounter for screening for metabolic disorder Encounter for screening for genetic and chromosomal anomalies Encounter for screening for other specified diseases and disorders Encounter for screening for digestive system disorders

XI. Claim & Billing Information Z13.82 Z13.85 Z55 Z55.0 Z55.1 Z55.2 Z55.3 Z55.4 Z55.8 Z55.9 Z56 Z56.1 Z56.8 Z56.82 Z56.89 Z59 Z60 Z60.0 Z60.3 Z60.4 Z60.5 Z60.8 Z60.9 Z62 Z62.0 Z62.1 Z62.2 Z62.22 Z62.29 Z62.3 Z62.6 Z62.8 Z62.81 Z62.810 Z62.811 Z62.812 Z62.819

Encounter for screening for musculoskeletal disorder Encounter for screening for nervous system disorders Problems related to education and literacy Illiteracy and low-level literacy Schooling unavailable and unattainable Failed school examinations Underachievement in school Educational maladjustment and discord with teachers and classmates Other problems related to education and literacy Problems related to education and literacy, unspecified Problems related to employment and unemployment Change of job Other problems related to employment Military deployment status Other problems related to employment Problems related to housing and economic circumstances Problems related to social environment Problems of adjustment to life-cycle transitions Acculturation difficulty Social exclusion and rejection Target of (perceived) adverse discrimination and persecution Other problems related to social environment Problem related to social environment, unspecified Problems related to upbringing Inadequate parental supervision and control Parental overprotection Upbringing away from parents Institutional upbringing Other upbringing away from parents Hostility towards and scapegoating of child Inappropriate (excessive) parental pressure Other specified problems related to upbringing Personal history of abuse in childhood Personal history of physical and sexual abuse in childhood Personal history of psychological abuse in childhood Personal history of neglect in childhood Personal history of unspecified abuse in childhood

XI. Claim & Billing Information Z62.82 Z62.820 Z62.821 Z62.822 Z62.89 Z62.890 Z62.891 Z62.898 Z62.9 Z63 Z63.0 Z63.1 Z63.3 Z63.31 Z63.32 Z63.4 Z63.6 Z63.7 Z63.71 Z63.72 Z63.79 Z63.8 Z63.9 Z64 Z64.0 Z64.1 Z64.4 Z65 Z65.4 Z65.5 Z65.8 Z69 Z69.0 Z69.01 Z69.010 Z69.011 Z69.02

Parent-child conflict Parent-biological child conflict Parent-adopted child conflict Parent-foster child conflict Other specified problems related to upbringing Parent-child estrangement NEC Sibling rivalry Other specified problems related to upbringing Problem related to upbringing, unspecified Other problems related to primary support group, including family circumstances Problems in relationship with spouse or partner Problems in relationship with in-laws Absence of family member Absence of family member due to military deployment Other absence of family member Disappearance and death of family member Dependent relative needing care at home Other stressful life events affecting family and household Stress on family due to return of family member from military deployment Alcoholism and drug addiction in family Other stressful life events affecting family and household Other specified problems related to primary support group Problem related to primary support group, unspecified Problems related to certain psychosocial circumstances Problems related to unwanted pregnancy Problems related to multiparity Discord with counselors Problems related to other psychosocial circumstances Victim of crime and terrorism Exposure to disaster, war and other hostilities Other specified problems related to psychosocial circumstances Encounter for mental health services for victim and perpetrator of abuse Encounter for mental health services for child abuse problems Encounter for mental health services for parental child abuse Encounter for mental health services for victim of parental child abuse Encounter for mental health services for perpetrator of parental child abuse Encounter for mental health services for non-parental child abuse

XI. Claim & Billing Information Z69.020 Z69.021 Z69.1 Z69.11 Z69.12 Z69.8 Z69.82 Z70 Z71 Z71.4 Z71.5 Z71.8 Z71.89 Z72 Z72.5 Z72.8 Z72.81 Z72.810 Z72.811 Z72.82 Z73 Z73.3 Z73.4 Z73.5 Z73.6 Z73.8 Z73.81 Z74 Z74.0 Z75 Z76 Z76.5 Z76.8 Z86 Z86.0 Z86.00 Z86.01

Encounter for mental health services for victim of non-parental child abuse Encounter for mental health services for perpetrator of non-parental child abuse Encounter for mental health services for spousal or partner abuse problems Encounter for mental health services for victim of spousal or partner abuse Encounter for mental health services for perpetrator of spousal or partner abuse Encounter for mental health services for victim or perpetrator of other abuse Encounter for mental health services for perpetrator of other abuse Counseling related to sexual attitude, behavior and orientation Persons encountering health services for other counseling and medical advice, not elsewhere classified Alcohol abuse counseling and surveillance Drug abuse counseling and surveillance Other specified counseling Other specified counseling Problems related to lifestyle High risk sexual behavior Other problems related to lifestyle Antisocial behavior Child and adolescent antisocial behavior Adult antisocial behavior Problems related to sleep Problems related to life management difficulty Stress, not elsewhere classified Inadequate social skills, not elsewhere classified Social role conflict, not elsewhere classified Limitation of activities due to disability Other problems related to life management difficulty Behavioral insomnia of childhood Problems related to care provider dependency Reduced mobility Problems related to medical facilities and other health care Persons encountering health services in other circumstances Malingerer [conscious simulation] Persons encountering health services in other specified circumstances Personal history of certain other diseases Personal history of in-situ and benign neoplasms and neoplasms of uncertain behavior Personal history of in-situ neoplasm Personal history of benign neoplasm

XI. Claim & Billing Information Z86.1 Z86.3 Z86.5 Z86.6 Z86.7 Z86.71 Z87 Z87.0 Z87.1 Z87.3 Z87.31 Z87.4 Z87.41 Z87.43 Z87.44 Z87.5 Z87.7 Z87.71 Z87.72 Z87.73 Z87.79 Z87.8 Z87.82 Z87.89 Z87.890 Z91 Z91.0 Z91.01 Z91.03 Z91.04 Z91.1 Z91.11 Z91.12 Z91.120 Z91.128 Z91.13 Z91.130

Personal history of infectious and parasitic diseases Personal history of endocrine, nutritional and metabolic diseases Personal history of mental and behavioral disorders Personal history of diseases of the nervous system and sense organs Personal history of diseases of the circulatory system Personal history of venous thrombosis and embolism Personal history of other diseases and conditions Personal history of diseases of the respiratory system Personal history of diseases of the digestive system Personal history of diseases of the musculoskeletal system and connective tissue Personal history of (healed) nontraumatic fracture Personal history of diseases of genitourinary system Personal history of dysplasia of the female genital tract Personal history of diseases of male genital organs Personal history of diseases of urinary system Personal history of complications of pregnancy, childbirth and the puerperium Personal history of (corrected) congenital malformations Personal history of (corrected) congenital malformations of genitourinary system Personal history of (corrected) congenital malformations of nervous system and sense organs Personal history of (corrected) congenital malformations of digestive system Personal history of other (corrected) congenital malformations Personal history of other specified conditions Personal history of other (healed) physical injury and trauma Personal history of other specified conditions Personal history of sex reassignment Personal risk factors, not elsewhere classified Allergy status, other than to drugs and biological substances Food allergy status Insect allergy status Nonmedicinal substance allergy status Patient's noncompliance with medical treatment and regimen Patient's noncompliance with dietary regimen Patient's intentional underdosing of medication regimen Patient's intentional underdosing of medication regimen due to financial hardship Patient's intentional underdosing of medication regimen for other reason Patient's unintentional underdosing of medication regimen Patient's unintentional underdosing of medication regimen due to age-related debility

XI. Claim & Billing Information Z91.138 Z91.14 Z91.19 Z91.4 Z91.41 Z91.410 Z91.411 Z91.412 Z91.419 Z91.49 Z91.8

Patient's unintentional underdosing of medication regimen for other reason Patient's other noncompliance with medication regimen Patient's noncompliance with other medical treatment and regimen Personal history of psychological trauma, not elsewhere classified Personal history of adult abuse Personal history of adult physical and sexual abuse Personal history of adult psychological abuse Personal history of adult neglect Personal history of unspecified adult abuse Other personal history of psychological trauma, not elsewhere classified Other specified personal risk factors, not elsewhere classified

D. Electronic Media Claim Submission Requirements, Filing and Status Inquiries A provider may access electronic claims by logging on to ValueOptions.com and using the online eProvider Submissions Manual to submit and check claims status. Please refer to the EDI/837 HIPAA Compliant Claims Submission Manual for specific guidelines and requirements. Questions may be directed to the EDI Help Line at, 1-888-247-9311. E. State Requirements for Claims Turnaround Time ValueOptions adjudicates (i.e., pay or deny) 100% of clean claims (error-free claims) submitted by providers within thirty (30) calendar days from the date the clean claim is received. ValueOptions pays providers’ interest on clean claims received that are not adjudicated within thirty (30) calendar days from the date the clean claim is received. Interest is paid at the rate of 1.5% per month (18% annual) for each month the clean claim’s adjudication remains outstanding. F. Claims Appeal Process You have the right to request reconsideration or appeal of a claims payment. A claim appeal is managed through the administrative appeal process. Your request for reconsideration of a claim should include a cover letter detailing the reasons that you are requesting an appeal, a copy of the original claim, and a copy of the corresponding remittance advice. ValueOptions must receive your request for reconsideration within sixty (60) days from the date the claim appears on your ValueOptions remittance statement. Claims/Administrative appeals should be mailed to:

XI. Claim & Billing Information ValueOptions Attn: Public Sector Appeals Coordinator 1199 South Belt Line Road, Suite 100 Coppell, TX 75019 ValueOptions has thirty (30) days to respond to your request. If you have exhausted the appeals process at ValueOptions, but feel that you have not received due process or adequate resolution, you may contact the State’s NorthSTAR Provider and Enrollee Department at (512) 206-4761. If you contact the State’s NorthSTAR Provider and Enrollee department prior to completing the ValueOptions appeal process, you will be directed back to ValueOptions. G. Third Party Liability (TPL) Providers must exhaust all avenues of other insurance coverage and payment prior to billing ValueOptions for covered services.   

 

ValueOptions is the payer of last resort in the event any one or more third party payers are responsible for covered services provided to enrolled and eligible persons (enrollees). ValueOptions’ service authorization procedures outlined in Section IV of this manual must be followed when providing services to an enrollee identified with TPL. For any eligible enrollee with reimbursable TPL, the third party insurance carrier must be billed prior to billing ValueOptions. Once the TPL carrier has responded, ValueOptions may then be billed. TPL claims for eligible enrollees may be submitted either electronically, via the 837I or P process, DirectClaim Submission or they must be submitted on a completed standard CMS 1500 or UB04 claim form. The claim form, along with a copy of the Explanation of Benefits or Summary Voucher received from the third party insurance carrier must be mailed to ValueOptions. All claims involving Third Party Liability must be received within ninety (90) calendar days of the date of the other carrier’s EOB or notification of payment/denial, to be considered for reimbursement. Additionally, if it is determined that an enrollee had relevant third party coverage after ValueOptions has been billed, the third party insurer must be billed. Once the EOB / Summary Voucher is received, an adjustment request for the applicable claim and a copy of the relevant ValueOptions and Third Party EOB/Summary Voucher must be sent to ValueOptions according to the procedures outlined in Section XI. (M. Adjustment/ Reversal Requests).

IMPORTANT NOTE: ValueOptions has contracted with a third party vendor, HMS, to validate third party coverage for all NorthSTAR members. On a monthly basis ValueOptions sends an extract containing claims processed for payment the previous month to HMS. HMS runs this file

XI. Claim & Billing Information through their data base; if the search determines the member has coverage with another insurance carrier HMS will send a claim to the other carrier on the provider’s behalf. Once the primary carrier responds they will send a payment or denial to HMS and HMS returns this information to ValueOptions each month. If a primary payment has been made ValueOptions will reverse the paid claim; we will also complete a finance adjustment in the amount of the payment made by the primary insurance carrier and remit the amount recovered back to the provider via a Remittance Advice. We do realize there are times when the primary carrier does not reimburse the same amount ValueOptions reimburses; if you cannot determine the amount recovered for each member on your PSV please contact the Provider Relations department. Provider Relations will have a detailed list of the dollars recovered for each member. 1. Additional TPL Billing Instructions      

One copy of the EOB/Summary Voucher must be attached to each applicable claim if the claim is submitted on paper. If the claim is submitted electronically please ensure the appropriate TPL segments are completed. Ensure that the level of detail on the claim corresponds to the EOB/Summary Voucher from the primary carrier. If there are multiple third party carriers, all relevant EOBs/Summary Vouchers must be included with the claim. Amounts paid by the other third party carrier should be documented in: Block # 24K on the CMS 1500 (Reserved for Local Use Only block) Block # 54 on the UB04 (Prior Payments)

H. Adjustment/Reversal Requests   

Claims requiring reconsideration of payment amounts for any reason must be resubmitted to ValueOptions via one of the methods below: The provider may complete the reversal electronically through ProviderConnect An Adjustment Request Form within sixty (60) days from the date of the Summary Voucher. (Electronic submissions of this form will not be accepted.) Resubmitted by electronic spreadsheet within sixty (60) days from the date of the Summary Voucher. The Provider must utilize the standard electronic spreadsheet format found in Required Forms section of this manual. Spreadsheets that are not submitted in the standard electronic spreadsheet format will not be processed and will be returned. A standard electronic spreadsheet format can be requested from Enrollee/Provider Services at 1888-800-6799. Please email completed spreadsheets to: [email protected]

XI. Claim & Billing Information The Adjustment Form can be found in Section XIII (Required Forms). One form must be completed for each original claim being adjusted. All items on the form are required. Forms that are incomplete are not processed and are returned. Please mail completed forms to: ValueOptions ATTN: Adjustment Unit PO Box 12450 Norfolk, VA 23541-0450 1. Re-Submissions   2.

Claims not paid by ValueOptions due to incorrect or incomplete required data elements must be resubmitted for payment consideration within sixty (60) days from the date on the Summary Voucher. Providers may resubmit claims electronically or by mail.

Definitions for Frequency (last digit of the Bill Type)



Non Payment/Zero Claim (0) This frequency code is used to report nonpayment claims. It is required to extend the spell of illness or benefit period or to inform the payer of the non-reimbursable periods of confinement or termination of care.



Admit Through Discharge Claim (1) This frequency code represents and admit-through-discharge claim and is used to report the entire inpatient admission or outpatient course of treatment. NOTE: This bill frequency code cannot be used if the patient status (FL 17) code is “still a patient” (30). It is valid to use with patient status codes 01-05, 07, and 20. The discharge hour must also be submitted.



Interim – First Claim (2) This frequency code is to indicate the first of a series of claims to the same third party payer for the same confinement or course of treatment. NOTE: All initial interim claims must indicate 30 (still a patient) in FL 17, patient status.



Interim – Continuing Claim (3)

XI. Claim & Billing Information This frequency code is used to indicate that a bill is one of a series of claims for the same confinement or course of treatment. In other words, the bill has been submitted previously and further bills are expected. NOTE: Subsequent interim bills must indicate 30 (still a patient) in FL 17, patient status. No other patient status codes other than 30 are appropriate for this bill frequency code. 

Interim – Last Claim (4) This frequency code is used to indicate that a bill is the last of a series of claims for the same confinement or course of treatment. NOTE: A discharge claim bill must indicate a patient status (FL 17) code of 01-06, 08, or 20. This bill frequency code cannot be used if the patient status is “still a patient” (30). The discharge hour must also be submitted.



Late Charge(s) Only (5) This frequency code indicates that the provider is submitting charges after an Admit through Discharge Claim has been submitted. This code is not intended to be used in lieu of an Adjustment Claim or a Replacement Claim.



Replacement of a Prior Claim (7) This frequency code is used when a specific claim needs to be restated in its entirety, except for the identifying information. The original bill is considered null and void, and the information on this bill completely replaces the previous claim.



Void / Cancel of Prior Claim (8) This code indicates that this claim eliminates and cancels a previously submitted claim.

3. Incomplete Claims 

Claims are not paid by ValueOptions in the case of incorrect or incomplete required data elements.



ValueOptions notifies the provider via the Provider Summary Voucher, of those data elements requiring completion or correction. The required data elements and other claim submission requirements are outlined in Section XI.C (Paper Claims Submission

XI. Claim & Billing Information Requirements) in this manual. Electronic Media Claims submission guidelines are contained in the EDI/837 HIPAA Compliant Claims Submission Manual.

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