Wednesday, July 30, 2008

Wellcare Health Plan new exclusion edits

For offices billing electronic claims to Wellcare Health plan new edits were put in place in July of 2008:

Professional claims (CMS-1500) have 6 new edits in place:

35 0001C:MISSING REFERRING PROVIDER NBR - (PROF) IN LOOP 2310A REFERRING PROVIDER, EITHER NM109 OR REF SEGMENT MUST BE SENT

HU 0019C:INVALID BILLING PROVIDER ID QUAL - IN LOOP 2010AA, NM108 MUST BE SENT AND MUST BE EQUAL TO XX

HU 0020C:INVALID PAY-TO PROVIDER ID QUAL - WHENI LOOP 2010AB IS SENT, NM108 MUST BE SENT AND MUST BE EQUAL TO XX

HU 0022C:INVALID CLAIM REND PRV ID QUAL - IN LOOP 2310B(PROF)/2310C(INST), NM108 MUST BE SENT AND MUST BE EQUAL TO XX

HZ 0001C:INVALID CLIA NUMBER - IN LOOP 2300, IF REF01 = X4 THEN REF02 MUST BE 2 NUMERICS FOLLOWED BY D FOLLOWED BY 7 NUMERICS

HZ 0002D:INVALID CLIA NUMBER - IN LOOP 2400, IF REF01 = X4 THEN REF02 MUST BE 2 NUMERICS FOLLOWED BY D FOLLOWED BY 7 NUMERICS

HZ 0003D:DUPLICATE CLIA NUMBERS - IN LOOP 2400, CANNOT HAVE MORE THAN 1 REF~X4 WITH THE SAME REF02 VALUE

Institutional claims (UB-04 or UB-92) have 4 new edits:

HU 0019C:INVALID BILLING PROVIDER ID QUAL - IN LOOP 2010AA, NM108 MUST BE SENT AND MUST BE EQUAL TO XX

HU 0020C:INVALID PAY-TO PROVIDER ID QUAL - WHENI LOOP 2010AB IS SENT, NM108 MUST BE SENT AND MUST BE EQUAL TO XX

HU 0022C:INVALID CLAIM REND PRV ID QUAL - IN LOOP 2310B(PROF)/2310C(INST), NM108 MUST BE SENT AND MUST BE EQUAL TO XX

HU 0026C:INVALID CLAIM ATTEND PHY ID QUAL - IN LOOP 2310A(INST), NM108 MUST BE EQUAL TO XX

These edits will take place through RelayHealth for:
CPID 1844 Wellcare Health Plan / Staywell - Professional
CPID 8551 Wellcare Health Plan / Staywell - Institutional
CPID 3211 Wellcare Health Plans Encounters - Professional
CPID 4949 Wellcare Health Plans Encounters - Institutional

Let me know if you need help identifying how to fix these edits.

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