provider manual - One Call Care Management

PROVIDER MANUAL
NATIONWIDE COVERAGE
Table of Contents
OCCM
OCCM Philosophy .......................................................................................................................... 3
Patient Rights & Responsibilities.................................................................................................... 4
Provider Satisfaction......................................................................................................................... 5
Provider Portal .................................................................................................................................. 6
Provider Demographic Changes..................................................................................................... 7
Resolution of Quality and Administrative Concerns................................................................... 8
Credentialing ................................................................................................................................. 9-10
Clinical Review .................................................................................................................................. 11
Provider Recruitment for OCCM Client Presentations ............................................................. 12
Workers’ Compensation
The OCCM Process – Workers’ Compensation
Referral Process Summary ................................................................................................. 14
Scheduling Compliance ...................................................................................................... 15
Authorizations& Direct Schedule ..................................................................................... 16
Concentra Scheduling on OCCM’s Behalf
& Diagnostic Management Program ............................................................................... 17
Medical Report Compliance .............................................................................................. 18
Age of Injury Services......................................................................................................... 19
The OCCM Payment Policy - Workers’ Compensation
Claims Submission Policy ............................................................................................20- 22
Payment Policy .................................................................................................................... 23
Medical Claims Appeals ..................................................................................................... 24
Group Health
The OCCM Process – Group Health ........................................................................................... 26
Claim Filing Requirements ........................................................................................... 27-29
Contact Us .................................................................................................................................. 30- 31
Appendix ..........................................................................................................32-45
Revised 4.8.2013
Page 2
Dear Provider:
We are delighted that your facility and physicians are part of the One Call Care Management (One Call)
network. This manual is intended to accompany your OCCM contract and provide information essential to
our continued working relationship. The following is an introduction to OCCM, who we are, who our clients
are, how we service our clients, and how we work with our contracted providers.
OCCM is the premier provider of quality diagnostic imaging and electrodiagnostic services. Our clients
include the nation’s leading workers’ compensation insurers, third party administrators, as well as selfinsured employers. These clients handle the majority of workers’ compensation claims handled in the United
States. OCCM offers these same services to the auto and health marketplace in select locations. Should you
need to know if a specific company is an OCCM client, please contact our Customer Service department
(see the “Contact Us” section on page 29).
Since OCCM was founded in 1993, the company has consistently grown each year. The focus of OCCM’s
effort is “early return to work”. This is accomplished using our advanced process management system that
actively schedules injured workers at over 5,000 locations providing Diagnostic Radiology and EMG services
throughout the United States. The benefits to our clients are real and demonstrable, including: quality clinical
services, expedited procedure and medical report turnaround time. The benefits to you, our providers, are:
increased volume with no associated marketing costs, pre-authorized referrals by the client via OCCM, and
financial payments on schedule per our agreement.
Key elements to our success are OCCM’s commitment to quality care, and our focus on customer
satisfaction. OCCM recruits facilities to meet the needs of our clients, focusing on adequate geographic
coverage, quality of care and timely scheduling. In exchange, we can maximize your patient volume and
provide guaranteed, prompt payments.
OCCM strives to build solid relationships within the health care community and prides itself on our choice of
network providers, choosing only the leaders in the field of radiology and EMG services. We look forward to
a long and prosperous relationship together. Thank you again for your participation.
Sincerely,
Stephen P. Ellerman
Stephen P. Ellerman
Vice President, Provider Development
One Call Care Diagnostics
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Page 3
OCCM Philosophy
PATIENT RIGHTS & RESPONSIBILITIES
OCCM protects the rights and responsibilities of all patients. We are committed to respecting the
dignity, worth, and privacy of each patient.
We have established patient rights and responsibilities that promote effective radiology and
neurodiagnostic service delivery, that promote patient satisfaction, and that reflect the dignity, worth,
and privacy needs of each patient. We recommend that you share this statement with patients at the
time of their first appointment with you.
OCCM Patient Rights Statement
Patients are entitled to receive quality diagnostic imaging services delivered by the best available
providers in a comfortable and pleasant environment free from unnecessary hazards. OCCM strives
to uphold the following patients’ rights:
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♦
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Patients have the right to receive imaging services free from fiscal incentives for over- or under-utilization.
Women have the right to state-of-the-art mammography and breast health services.
Patients have the right to discuss the results of their studies with their imaging providers.
Patients have the right to receive imaging services from providers whose services are continuously monitored for
appropriateness and quality.
Patients have the right to have their comments or complaints about their imaging studies addressed in a timely
manner.
Patients have the right to quality images
Patients are entitled to have the confidentiality of their health information protected and their privacy maintained.
In certain states, workers’ compensation patients have the right to select the provider of their choice.
To comply with this policy, your responsibility is to:
•
•
•
•
•
•
•
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Review the OCCM Patient Rights Statement;
Give patients the opportunity to discuss their rights and responsibilities with you; and
Review with the patients in your care information such as:
Procedures to follow if a clinical emergency occurs;
Fees and payments (specific to Group Health ONLY);
Confidentiality scope and limits;
Member complaint process; and
Treatment options and medication
OCCM’s responsibility is to:
•
•
Make available the OCCM Patient Rights Statement (above) for distribution; and
Provide instructions on how and when to share the statement with patients.
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Page 4
PROVIDER SATISFACTION
Provider Satisfaction is one of our core performance measures. Obtaining provider input is an essential
component of our quality program.
Periodically we conduct a survey of providers in our network to determine their level of satisfaction
with OCCM, as well as with key aspects of the service they received from us while assisting our
patients.
To comply with this policy, your responsibility is to:
•
Complete the survey within the time period indicated; and contact OCCM with any comments,
suggestions or questions you may have
OCCM’s responsibility is to:
•
•
•
Monitor provider satisfaction with OCCM and OCCM’s policies and procedures;
Share aggregate results of our provider satisfaction surveys with our providers, customers,
accreditation entities, and members; and
Use provider survey findings to identify opportunities for improvement and to develop and
implement actions for improving our policies, procedures, and services.
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Provider Portal
MORE CONTROL
MORE CONVENIENCE
We understand that managing patient exams, authorizations, medical reports and billing can
be costly and time-consuming. That’s why, in our commitment to bring continued value to
our providers, we’ve developed the One Call Medical, Inc. self-service Provider Portal.
Now you can manage claims information quickly and easily online; simplifying the process through
a secure online portal. Your office staff can securely access the Provider Portal from any
computer 24 hours a day, 365 days a year.
New interactive tools make it easy to:
Manage Patient Exams
Schedule, check status of patients
scheduled and reschedule patients
exams, View and Print authorizations
Upload Medical Reports
Load Medical Reports to individual
patient files or in bulk
Manage Claims Information
Check claims status/date of payments;
view check numbers and cancelled
checks; load claims, HCFA’s and
UB92’s for processing
Re-credential Physicians
Complete radiology and EMG
physicians re-credentialing online!
Registration is quick and easy!
Visit https:\\provider.onecallcm.com
Should you have any questions call 1-800-872-2875 and ask for
Provider Relations or email us at [email protected].
Revised 4.8.2013
REGISTER
TODAY!
Page 6
Provider Demographic Changes
In order to serve the clients to the best of our ability, and reimburse the providers in the timeliest
manner, OCCM asks that the provider keep OCCM informed of any changes, including the following:
Opening/Closing of a facility/office
New phone/fax numbers/email address
Change of ownership
Tax ID Changes – please submit changes in writing with an updated W-9 Form
Change in physician staff
Change of service address
Change/addition of remittance address or outside billing service
Change in hours of operation
Changes which affect credentialing status (licensure, medical sanctions, etc.)
Change of equipment (Radiology Providers)
Addition/Discontinuance of modality (Radiology Providers)
ACR accreditation status change (Radiology Providers)
Please e-mail us at [email protected], or fax the change form located in the appendix of
this manual to 973-257-9512.
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Resolution of Quality & Administrative Concerns
On occasion, concerns about a facility/provider are brought to OCCM’s attention. These concerns are
usually within three categories: images or service quality issues, medical report issues, or contract compliance
issues.
IMAGES QUALITY / SERVICE ISSUES FOR RADIOLOGY SERVICES
When there are possible quality issues with either images or services rendered, an OCCM Provider Relations
Specialist will contact the Office Manager to address the issue. OCCM will request that a radiologist other
than the original reading radiologist, comment on the quality. If it is agreed that the images are not
diagnostically sound, the center will re-scan the injured worker at no additional charge. If the images are
determined to be of good quality, OCCM requests that the reading radiologist contact the referring physician
to discuss the quality issue.
If the quality issue cannot be resolved at the facility level, OCCM will request that one of our independent
reading radiologists review the images. At this point, OCCM will call the center to arrange for images to be
sent out for review.
QUALITY ISSUES FOR NEURODIAGNOSTIC SERVICES
When there are possible quality issues with EMG & Nerve Conduction Studies (NCS), an OCCM Clinical
Services staff member will contact the office manager to address the issue(s) after the medical report has been
reviewed by a board certified electromyographer consultant. If additional testing is recommended by the
consultant, Clinical Services will initiate re-scheduling of the injured worker. If the EMG & NCS is deemed
to be of good quality, Clinical Services will contact the adjuster/Nurse Case Manager with the results of the
review.
MEDICAL REPORT ISSUES
If there is an issue or question with the medical report, OCCM will request the center to make the
necessary correction(s) or add an addendum.
CONTRACT COMPLIANCE ISSUES
From time to time, a Provider Relations Specialist will be in contact with the facility / provider to
discuss and resolve such issues as incorrect scans, medical report turnaround time, release of images, or
HCFA turnaround time. Repeated contractual obligation related issues could result in a change in
relationship status with One Call Care Management.
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Credentialing
PHYSICIAN CREDENTIALING PROCESS
The process of physician credentialing at One Call Medical follows the guidelines established by the
NCQA (National Committee for Quality Assurance). Each provider will be required to complete and
return an application to OCCM. Please note: OCCM is aware that some states have their own approved
physician applications. OCCM will accept those state approved applications; the only additional
requirement would be to sign the OCCM attestation/release form.
The OCCM credentialing staff performs primary verification through the AMA Masterfile, an NCQA
approved verification source, and NPDB for the following elements:
♦
♦
♦
♦
♦
♦
♦
♦
♦
Primary state license
Current Drug Enforcement Agency (DEA) registration, if applicable & CDS
Specialty board certification
Medical education and professional training for non-board certified providers
Malpractice coverage
Malpractice claims history
Medicaid/Medicare sanctions, if applicable
State Workmans’ Compensation Certificate and or letter (if applicable)
For Texas physicians, the following elements are verified:
♦ Maximum Medical Improvement (MMI) Training
♦ Permanent Impairment Rating (PIR) Training
All applications and credentialing materials verified by the OCCM credentialing staff are reviewed for
completeness and then evaluated by the Medical Director/Consultants at monthly credentialing
meetings.
A Physician Application must be filled out and submitted to OCCM each time a new physician
joins your facility.
Should you need any OCCM Credentialing Applications, please call 800-872-2875 and ask to
speak with the Credentialing Database Specialist assigned to your state or go to our website
www.onecallmedical.com.
Revised 4.8.2013
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FACILITY CREDENTIALING
One Call Medical Inc.’s credentialing process requires all contracted freestanding diagnostic - facilities
be credentialed. Each facility completes and returns an application to OCCM with the following
information:
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♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
Physical and billing addresses
Hours/days of operation
Commercial general liability insurance
Professional liability insurance
Malpractice history
Ownership and organizational structure
Technical equipment specifications
State licensure, where applicable
ACR and/or JCAHO Accreditation, where applicable
Workers’ Compensation Certificate, where applicable
Physician roster
IDTF/Medicare license, where applicable
NPI (National Provider Identifier)
A sample set of abnormal MRI images (1 knee & 1 cervical spine) AND corresponding medical
reports (non ACR accredited facilities only).
See Appendix for Medical Report Guidelines.
Note: Credentialing requirements vary if facility does not perform MRI.
HOSPITAL CREDENTIALING PROCESS
If the hospital is JCAHO accredited OCCM will obtain verification of the certification (JCAHO letter and/or
certificate) and an OCCM facility application is required; however, no sample set of images are needed.
The only physician requirement will be a letter from the hospital medical staff stating the physician’s
current delineated privileges and that the physician is in good standing.
RECREDENTIALING
One Call Care Management’s recredentialing process requires that all contracted providers (facilities and
physicians) be recredentialed every three (3) years (FL two (2) which is consistent with NCQA guidelines.
Non-compliance with the recredentialing process may result in a change in relationship status with OCCM.
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Clinical Review
ADDITIONAL REQUIREMENTS FOR ADMISSION INTO THE NEURODIAGNOSTIC
NETWORK
In addition to the credentialing requirements, three (3) sample reports that meet the OCCM Standards
are required for all EMG providers.
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Provider Recruitment for OCCM Client Presentations
“How does One Call Care Management CEU (Continuing Education Unit) program work?”
A Sales Representative from OCCM schedules a presentation (usually at an insurance company) for
claims adjusters and nurse case managers to discuss diagnostic services as it relates to workers’
compensation, injuries. The presentation usually lasts about an hour. OCCM arranges for one of our
credentialed radiologists, physiatrist, or neurologist to do the presentation and we have a list of
approved topics. (Various states require approval of our topics beforehand in order for the adjusters
and NCM’s to receive credits for the course). The current topics we have CEU presentations for are as
listed below:
1- What Claims People Need to Know about MRI/CT
2- Nomenclature and Classification of Lumbar Disc Pathology
3- Overview of Imaging Modalities
4- Imaging of Back Pain
5- Imaging of Joints
6- Radiology for Workers’ Compensation
7- Understanding EMG & NCS in Worker’s Compensation
Certain states require that each speaker be approved by the state in order to present the topic. OCCM
will submit that information to the appropriate state, if required.
Once it’s determined that the physician is interested in doing a CEU presentation, OCCM will send a
“Welcome to the CEU Program” packet that includes both a Consultant Agreement and
Confidentiality Agreement for the physician to read and sign, a printed color copy of the presentation, a
CD of the presentation as well as the course outline.
Once the Sales representative notifies the CEU Coordinator of a scheduled date with a payer, the CEU
Coordinator will call and see if the physician is available that day. If the physician is available and agrees
to do the presentation, OCCM will provide all necessary information- such as the name of the
company, the location, the topic, etc. Once that is arranged, the Sales representative will contact the
radiologist with more detailed information.
“What are the benefits of agreeing to present a CEU?”
There are many benefits of being involved with our CEU program. The physician has the opportunity
to share his/her knowledge and help the audience better understand what diagnostic testing and
imaging is all about. Being a presenter also strengthens the relationship between OCCM and the
center/practice and provides exposure for both the center/practice and OCCM. All presenters are
compensated for their time and participation.
If you are an OCCM contracted physiatrist, neurologist, radiologist or a radiology technologist and are
interested in presenting a CEU Presentation, please e-mail us at [email protected]
or call 800-872-2875.
Revised 4.8.2013
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Revised 4.8.2013
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The OCCM Process
PROCESS SUMMARY – Workers’ Compensation
On behalf of an injured worker or patient, the Workers’ Compensation adjuster, nurse case
manager, or referring physician’s office contacts One Call Medical (OCCM) to make a referral.
OCCM contacts the patient and together a provider is chosen based on OCCM’s appointment
scheduling protocol.
OCCM initially utilizes a 3-way conference between the OCCM Customer Care Agent, patient,
and provider to schedule the appointment.
OCCM immediately contacts the patient after an authorized referral is received.
If OCCM is successful in contacting the patient, an exam is scheduled immediately via a 3-way
call with a contracted OCCM provider and the patient.
OCCM faxes to the provider an authorization form that confirms appointment time,
communicates payer authorization, and identifies OCCM as the scheduling and reimbursement
agent.
At the completion of the patient’s procedure, the provider agrees to fax the medical report to
OCCM and referring physician within 24-48 hours.
For radiology services, OCCM is entitled to one set of MRI images at no cost or additional
expense to OCCM. OCCM requires Provider to send a set of MRI images to the referring
physician (name and address to be provided to Participating Provider by OCCM on the
Medical Authorization form) within twenty-four (24) to forty-eight (48) hours of
treatment/scan.
Provider bills OCCM within 15 days of the procedure using a HCFA 1500 or a UB92 form,
including ICD-9 codes and CPT codes with non-discounted pricing for each code.
OCCM pays the provider based on the contracted reimbursement amount and timeframe.
Applicable state laws will apply where appropriate.
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SCHEDULING/COMPLIANCE – Workers’ Compensation
Provider agrees to see the patient within 5 days of the scheduling call and in all cases prior to the
follow-up appointment with referring/treating physician.
Providers are selected for a particular referral based on patient or physician location (geo-coding),
specific request, appointment availability, equipment needed, and the provider’s compliance to
contractual obligations (i.e. medical report and billing turnaround time).
OCCM’s Customer Contact Center (Scheduling Department) must be contacted if any of the
following situations occur:
Prescription written by the referring physician is different from either the OCCM authorization
form or from what the OCCM scheduler has requested when making the appointment.
Patient’s clinical symptoms indicate test requested may not be appropriate or additional test(s)
may be appropriate.
Patient does not keep scheduled appointment (No Show).
Patient cancels the appointment and needs to reschedule for another date (Reschedule).
Patient keeps the appointment, but test is not completed due to claustrophobia or other clinical
reasons.
Service needs to be re-directed to another provider/facility if your location cannot render
requested service.
Referring physician, adjuster, nurse case manager or attorney schedules the patient directly with
the provider. Most often, OCCM will contact you to confirm that this is an OCCM case. If
you do not hear from OCCM within 24-48 hours and you believe that you have an OCCM case,
please contact the Customer Contact Center immediately.
Please call 800-872-2875 between 8 am - 8 pm EST, and follow the prompts to be
connected to a representative in our Customer Contact Center (Scheduling
Department).
Please have the patient’s name, social security number, and the reason for the
call. If necessary, we may also be reached by fax at 866-632-2161 or by email at
[email protected]
Revised 4.8.2013
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AUTHORIZATIONS – Workers’ Compensation
OCCM Appointment Authorization Form - The Workers’ Compensation industry does not use
member identification cards. Instead, OCCM uses an appointment authorization form (See Sample on
page 36). After scheduling the patient, the authorization form is sent via fax to the provider. This
authorization form confirms the appointment time, communicates payer authorization and identifies
OCCM as the scheduling and reimbursement agent. This authorization form is not a prescription.
Please contact us if the authorization is not received or obtain via the Provider Portal.
OCCM notifies the Referring Physician and reminds them to forward a script to the provider.
As the providers of this service, you are responsible for securing the prescription from the Referring
Physician.
Facility/Provider Consent Forms – It is the facility’s/provider’s responsibility to have the patient
complete all forms required by your office. This should include a consent form for the procedure, an
authorization form that will release the medical report to OCCM as needed, and if requested, one set of
images at no charge (for radiology services). Please refer to the notes on the OCCM authorization
forms for any special requests.
Exceptions - If the provider performing the exam/procedure determines that the procedure
authorized by OCCM is not the same as the prescription presented by the patient (e.g. Contrast
Enhanced Studies), or the procedure requested cannot be accommodated using standards & protocols
established by the provider’s office/ facility, contact the referring physician immediately for clarification
and resolution. Document the result of the call in the report. If the referring physician is unavailable,
please contact OCCM to assist in resolution, and/or follow the usual protocols of your facility, and
document such in the report.
DIRECT SCHEDULE - Workers’ Compensation
From time to time there may be occasions when an insurance carrier/ordering physician may access a
One Call Medical provider outside of the OCCM referral and scheduling system. When this occurs,
you will be receiving a call from the OCCM Customer Contact Center notifying you that the payer will
be OCCM. As a follow up, you will receive an OCCM authorization for that patient (see page 36).
You will perform the scheduled service, forward a Medical Report, and bill OCCM per the normal
process.
Revised 4.8.2013
Page 16
DIAGNOSTIC MANAGEMENT PROGRAM - Workers’ Compensation
Through analysis of customer pay data, OCCM discovered that a remarkable 67% of the claim dollars
being processed today are going to providers outside of the OCCM network in areas near providers like
you. This presents a significant opportunity for potential business to be directed to OCCM contracted
facilities that is currently going elsewhere. Additionally, there are insurance carriers that are not fully
utilizing OCCM today that we intend to find new ways to penetrate.
The intent of this program is to drive this business to our contracted facilities on a prospective basis.
In order to implement these programs, there will be occasions when claims that were not scheduled by
OCCM will be processed by OCCM. In these instances, OCCM will assume responsibility of
expediting payment to you directly and pursue reimbursement from the insurance carrier thus
alleviating your staff of the administrative burden of working directly with the insurance carriers to
recover payment. You will receive a Patient Acknowledgment Form as notification that the claim was
processed by OCCM. (see page 37 for a copy of the form).
On the occasion when OCCM is notified of a claim, the provider will receive notification that One Call
Medical is the payer. Claim will then be paid within 15 days from OCCM’s receipt of HCFA from
insurance carrier.
CONCENTRA SCHEDULING - Workers’ Compensation
One Call Care Management has expanded its relationship with Concentra Medical Center’s Support
Team.
Under the arrangement, Concentra’s team will schedule appointments on behalf of OCCM.
When Concentra calls your center to schedule a patient, they will inform you that OCCM is the payer
and that OCCM will be sending an authorization as we do for all other OCCM business. There will be
a delay in receiving an OCCM authorization for these referrals. However, you will receive this prior to
the patient’s appointment. You are to bill OCCM and send a medical report to OCCM and the
referring physician for all of these cases.
Revised 4.8.2013
Page 17
MEDICAL REPORT COMPLIANCE – Workers’ Compensation
Report timeliness - It is essential that medical reports be supplied to BOTH the referring physician
and OCCM. OCCM requires the medical report within 24-48 hours of the procedure. The fax
number for OCCM Medical Reports is 1-877-922-3992.
The OCCM Medical Report Coordinators will be calling to follow up for the report one day after the
scheduled appointment occurs. This was implemented to better service our customers by calling and
getting the report as quickly as possible.
Please be sure the Medical Report is clean (i.e. no writing; no sticky notes).
It is important to give OCCM Notification of Patient “No Shows”, Cancellations, and Reschedules.
Please notify OCCM when patient does not arrive or appointment changes. You can use the
Autofax Form via fax (see 34 page). The Provider Portal can also be used to reschedule patient
appointments.
Please remember to set up One Call Medical as a ‘CC Party’ along with the referring physician.
If possible, program your fax machine’s TSI (Transmitting Station Identifier) with your company
name and/or fax number so that OCCM can identify you as the sender.
When using contrast, please remember to include the type of contrast (including concentration,
volume, and route of administration when applicable) in the Medical Report.
Report guidelines – Please refer to the Appendix of this manual for the Medical Report
guidelines.
OCCM requests that if the report includes more than one area body part, all areas requested by
the referring doctor be included in the report title (e.g. MRI wrist and hand). Otherwise, 2
reports will be sought.
Providers must submit a Medical Report for X-Ray of the eye for detection of foreign body.
For radiology providers in FL and NY, please comment on the age of the injury (i.e. injury
appears chronic, acute, age cannot be determined).
Electronic Medical Reports - To make arrangements to send reports electronically, please email [email protected], or call 800-872-2875 and request to speak with one
of OCCM’s Provider Relations Specialists
PLEASE NOTE: If you are having difficulty faxing reports to OCCM, kindly contact Provider Relations at 800872-2875. In turn, they will alert a member from OCCM Information Technology Department who may need to contact
someone at your facility familiar with your faxing protocols, to resolve this issue.
Revised 4.8.2013
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AGE OF INJURY SERVICES - Workers’ Compensation
One Call Care Management’s Workers’ Compensation payers’ in Florida have requested that all
radiology reports include information regarding whether or not the abnormal findings are acute,
chronic or indeterminate. Aging of abnormal findings can assist payers in determining liability and
apportioning benefits for an injury or illness.
Please include a comment on age of abnormal findings in the “Impression or Findings” section of the
report. In cases where this determination is not possible, please have the radiologist note specifically
that “age of abnormalities is indeterminate/unknown.” If this information is not included on the
report, we will contact you to request a statement or report addendum regarding the age of injury.
Your support of the Aging of abnormal findings documentation is appreciated. Please note that noncompliance may impact your referral volume.
Should you have any questions or concerns regarding this request, please feel free to contact Joanne
Pearson, Director of Clinical Services at 973-316-3734. You may also contact us via email at
[email protected].
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CLAIMS SUBMISSION & PAYMENT POLICY – Workers’ Compensation
Patients may be scheduled for services at your facility/office either through a phone call directly from
OCCM or a phone call from a referring physician, an adjuster, or a nurse case manager who should
identify the patient as an OCCM referral. Within 24 hours of scheduling an OCCM patient, you will
receive an authorization form via fax, which confirms the appointment time, communicates the payer
authorization and identifies OCCM as the scheduling and reimbursement agent.
PLEASE NOTE:
The workers’ compensation industry does not issue identification cards. Therefore, the injured
worker may not fully understand OCCM’s role in arranging their medical test(s), and the injured
worker may inadvertently inform you to bill their employer’s workers’ compensation carrier. Do
not follow the injured worker’s billing instructions if the referral is identified as an
OCCM referral.
OCCM billing address:
One Call Care Management
PO Box 614
Parsippany, NJ 07054
Or fax:
973-257-9983
Or:
Submit via Provider Portal
CLAIM SUBMISSION POLICY
If you use a billing service that is separate from your location, please share this information. If you
would like to have a copy of this manual sent to your billing services, please e-mail
[email protected], or call 800-872-2875 and request to speak with one of OCCM’s Provider
Relations Specialists
OCCM has contracted with the clearinghouse, Emdeon, through which both facility-based claims and
professional claims can be submitted. This enhances our ability to pay providers in a timely and
accurate manner. Our Payor id is 22321. Please contact Provider Relations at 1800 872-2875 if
additional information is required.
Emdeon
3055 Lebanon Pike
Nashville TN 37214
Phone: 615-932-3000
Website:
Website: www.emdeon.com
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Provider agrees to bill OCCM within fifteen (15) days of the completed procedure.
As soon as the Medical Report is received, OCCM will be sending you an Autofax which is a
reminder for you to submit the claim for that service to OCCM. An Autofax is sent for each
service/each Medical Report that is received.
Additionally, a ‘Status’ Autofax is sent weekly (RADIOLOGY) or bi-weekly (EMG) listing all
outstanding claims.
Claims should be submitted on a CMS (formerly HCFA) 1500 or UB-92 form and should
include:
a.
b.
c.
d.
e.
f.
g.
h.
ICD-9 codes
All appropriate CPT codes with the non-discounted pricing for each code
Patient date of birth
Patient social security number
Referring physician name
State workers’ compensation ID number (needed in NY, OH)
For radiology services, the reading radiologist name
The medical license number for physicians in FL, KY, TX, NY, CA and OH.
Please see the billing guideline documents in the Appendix
Invoices should be attached for all pharmaceuticals, injectible contrasts and isotopes. Invoices may
be requested for other services. No claim will be considered “complete” or “clean” without the
appropriate documentation. Claim payment will be delayed until all necessary materials are received.
If your facility is contracted for global rates, please make sure that the physicians do not bill OCCM
or the workers’ compensation insurance carrier separately. If OCCM becomes aware that the
professional services are being billed separately, OCCM will hold the provider responsible for
financial resolution.
The OCCM definition of “global” is the negotiated dollar rate which includes both the technical and
professional services and supplies. The facility and physician should not bill separately. OCCM
expects only one (1) bill for the completed services.
Most state laws and the OCCM contract prohibit the balance billing of patients.
implement appropriate measures to ensure that patients are not balance billed.
Please
Upon OCCM’s receipt of a “clean claim”, the claim will be processed according to the
provider’s contracted OCCM reimbursement amount/payment timeframe. State laws will apply
where appropriate.
Claims will be paid in the timeframe specified in your contract. For example, if the contract
states that the payment will be in sixty (60) days, claims will be processed in sixty (60) days of
receipt of each “clean” CMS/HCFA 1500 or UB92 form – NOT sixty (60) days from the date
of service.
DO NOT send a bill to the workers’ compensation carrier or employer for any OCCM patient,
as this would be a violation of your contract with OCCM and causes billing confusion.
Revised 4.8.2013
Page 21
If you inadvertently bill the workers’ compensation carrier and receive payment, please contact
OCCM’s Provider Services/Accounting Department immediately at 800-872-2875, #3 to begin
the refund process.
OCCM does not provide Explanation of Benefit letters (except in FL). Denial Letters are sent
separately from the OCCM check and are sent to the address on your CMS/HCFA 1500 or
UB92 Form.
Contact the OCCM Provider Services Department to address payment appeals/issues.
Unbilled Faxes are sent (see Appendix for sample copies):
Radiology sent weekly
EMG sent every 2 weeks
When CT is performed on the same day as the PET, the CT is included in PET reimbursement.
If the CT is authorized for a different day, it is paid separately. IV sedation is not reimbursed;
always included in PET code.
Isotopes – must submit an invoice along with the HCFA; if less than $100.00, supplies are
included in isotope reimbursement.
You must submit a Medical Report for an X-ray of the eye for detection of foreign body in
order to be paid
CT of the eye for detection of foreign body will be paid the same as X-ray unless specifically
authorized
HCPC codes are included in CT/MRI/PET payment. HCPC codes may have additional
reimbursement for Nuclear Medicine procedures.
MRI Arthogram – OCCM will only pay 3 CPT codes:
Injection
Needle guidance
MRI
Fluoroscopy or other modality for needle guidance must be reflected in the Medical Report for
payment
Plain Arthogram – OCCM will only pay 2 CPT codes:
Injection
X-ray
Revised 4.8.2013
Page 22
PAYMENT POLICY – Workers’ Compensation
OCCM will NOT reimburse:
Intravenous sedation unless prior authorization is obtained.
Oral sedation.
Images copies for the referring physician. As stated in the OCCM contract, the patient is entitled
to have one (1) set of images sent to the referring physician at no charge. In the event that OCCM
requests additional radiology images for the same Covered Individual, OCCM will reimburse
Participating Provider at the rate of $8.00 per sheet or $8.00 per CD or as stated in your contract.
3-D reconstruction studies unless the referring physician orders it and requests it on the
prescription and OCCM obtains authorization from the insurance carrier.
Plain x-rays not ordered by the referring physician and/or not authorized by the carrier. If
plain images of this body part have been performed recently, the patient should be informed to
bring these images to the scheduled procedure. Every attempt should be made to have the
patient bring prior images whenever possible. Prior approval from OCCM must be
obtained before performing plain x-rays and these images must be related to the body part for
which the radiology procedure has been ordered.
CT of the eye for detection of metal, unless specifically requested by the referring physician
and authorized by OCCM. Otherwise, OCCM will reimburse as if the scan were an x-ray of the
eye for detection of foreign body.
Non-Ionic Contrast – unless specified in provider’s contract, no additional payment
Supplies are included per contract
Contrast for MRIs & CTs are included with procedure codes
Revised 4.8.2013
Page 23
MEDICAL CLAIM APPEALS
OCCM will inform you of any reasons for administrative denials and action steps required to resolve
the administrative denial. If a payment is denied for any reason, the injured worker cannot be billed
for such procedures.
OCCM supports the right of providers to appeal adverse benefit determination.
The provider’s responsibility is to:
Review the denial letter or Check Voucher (Explanation of Payment notification for:
o The specific reason(s) for the adverse determination;
o Any specific documents required for submission in order to complete a review of your appeal.
Contact the OCCM Provider Services Department to address payment appeals/issues.
Submit all the appeal information in a timely manner to Clinical Services.
OCCM’s responsibility to you is to:
Inform you in writing, in a clear and understandable manner, the specific reasons for the adverse
determination which is on the Appeal Form.
Identify specific information, documents, records, etc., needed to assist in a favorable appeal
determination.
Thoroughly review all information submitted for an appeal.
Respond to appeals within 60 days.
Inform you of any additional appeal options that may be available when an unfavorable appeal
determination is rendered.
Revised 4.8.2013
Page 24
Revised 4.8.2013
Page 25
The OCCM Process – Group Health
CLAIM FILING REQUIREMENTS –
Provider is responsible for:
•
Complete all required fields on the CMS-1500 or UB-04 form accurately.
•
Collect applicable co-payments or co-insurance from members.
•
Submit a clean claim to be reimbursed for the remainder of your contracted reimbursement amount. See the
Claims Tips
•
Submit claims for services delivered in conjunction with the terms of your agreement with OCCM.
•
Use only standard codes sets as established by the Centers for Medicare and Medicaid Services (CMS) or the
state of your licensure for the specific claim form (UB-04 or CMS-1500) you are using.
•
Submit claims within 30 days of the provision of covered services.
•
Bill only for services rendered within the time span of the authorization.
•
If authorized services need to be used after the authorization has expired, refer to the Quick Reference
Guide for the appropriate carrier for contact information.
•
Do not bill the patient for any difference between your OCCM contracted reimbursement rate and your usual rate.
This practice is called balance billing and is not permitted by OCCM
BILLING CODES & HIPAA COMPLIANCE
To ensure prompt and accurate claims payment, your responsibility is to:
•
Use the current version of ICD-9-CM codes on claim submissions.
•
Use current CPT® and Revenue codes to bill for imaging services on a CMS- 1500.
•
Review the Claims Filing Requirements section in this handbook for additional claims submission
information.
•
Order ICD-9-CM manuals from the American Medical Association (AMA) by calling 1-800-621-8335, or
from Channel Publishing at 1-800-248-2882. A CD-ROM of the complete listing can be ordered from the
United States Government Printing Office at: U.S. Government Printing Office, P.O. Box 371954,
Pittsburgh, PA 15250-7594, or by calling the Ordering Office at 1-866-512-1800.
•
Obtain CPT® codes that are copyrighted by and can be obtained through the American Medical Association.
•
Obtain HCPCS codes from the Centers for Medicare & Medicaid Services (CMS) at www.cms.hhs.gov.
Note: All code sets are reviewed and subject to modification annually, so it is important to have the
most current version of these codes for billing purposes.
Revised 4.8.2013
Page 26
Claim Tips – Group Health
--DO—
√
Do Give Complete Information on the Member and Policy Holder
Please provide complete information for items such as the name, birth date, and gender. Watch out for name
variations and changes. Errors and omissions of these items can cause an unnecessary delay in processing the
claim.
√
Do Give Complete Information on You, the Provider
Please provide complete information regarding the provider, including the names of both the treating provider
and the billing entity. The Taxpayer Identification Number (TIN) and National Provider Identifier (NPI)
number for the billing entity must be provided for the claim to be processed correctly. The billing or remittance
address must be accurate for the check and/or Explanation of Benefits to be sent to the correct party.
√
Do Include Any Other Carrier's Payment Information
If another health plan is the primary insurer and benefits have been provided or denied, include primary insurer’s
payment information in compliance with Coordination of Benefits rules
√
Do Include the Complete Procedural Code(s)
If the patient has more than one procedure, please be sure to report all procedures on the claim. Appropriate
modifiers should be used to indicate appropriate bundling and unbundling of billed services. The procedure
must match your authorization and the Revenue Codes for facilities or CPT codes for professional services
√
Do Obtain Authorization for Services
Most benefit plans and procedures require prior authorization prior to rendering services. Please verify with the
member’s benefit plan if you are not sure if authorization is required
√
Do Show Your Entire Charge
Always show your full charge on the claim. The amount that is reimbursed is based on the lesser of billed
charges or the applicable reimbursement schedule
√
Do Submit Your Claims Electronically and Within Timely Filing Guidelines
Submit your claims in HIPAA-compliant format within 30 days of the Covered Service. Your NPI number is
required on all electronic claim submissions
√
Do Monitor Your EDI Transaction Reports
Monitor your EDI transaction reports on a regular and timely basis and correct rejected claims
Revised 4.8.2013
Page 27
Claim Tips - Group Health
--DON’T—
√
Don’t Use Invalid Procedure or Diagnosis Codes
Only use current code sets (CPT, HCPCS, Revenue, and ICD-9) and select the codes that most accurately
describe the service provided. Codes other than CPT are generally not accepted in most NIA claims processing
systems. The claim may not be altered by the claims examiner; therefore, an incorrect code may result in denial
of your claim
√
Don’t Reduce Your Charge by the Co-Payment or Co-Insurance Amounts Paid by the Member
Always show your full charge on the claim. The amount that is reimbursed is based on the lesser of the billed
charge or the applicable fee schedule
Most Frequent Reasons for Claims Non-payment
For your reference, the most frequent reasons for claims denial, include:
•
•
•
•
Duplicate claim submission (i.e., the expense was previously considered)
No pre-authorization was obtained by the provider
The member is ineligible, or coverage has lapsed
Additional information is needed from the primary insurance carrier’s Explanation of Benefits (EOB) or
from the member’s Coordination of Benefits (COB) form
.
OCCM billing address:
One Call Care Management
PO Box 614
Parsippany, NJ 07054
Or fax:
973-257-9983
Revised 4.8.2013
Page 28
CLAIMS SUBMISSION & PAYMENT POLICY
Provider Responsibility:
Provider will collect applicable co-payments or co-insurance from members.
Provider will bill non-discounted pricing.
Provider will submit claims within 30 days of the provision of covered services.
Provider will not bill the patient for any difference between your OCCM contracted reimbursement rate and
your non-discounted rate. Please implement appropriate measures to ensure that patients are not balance
billed.
Provider will not send a bill directly to insurance carrier as this would be a violation of your contract with
OCCM and causes billing confusion which could delay payment and may result in a change to your network
participation status.
OCCM Responsibility:
OCCM will deduct the amount of the Patient Responsibility from the provider reimbursement.
When the Patient Responsibility is greater than the contracted provider rate, OCCM will deduct the
difference from any other Health payments that are due to the provider.
OCCM will continue to send denial letters separately from the OCCM payment. These letters are sent to the
address on your CMS/HCFA 1500 or UB92 Form or faxed to your billing fax number.
Revised 4.8.2013
Page 29
Contact Us
In the course of our relationship, you will have occasion to contact OCCM. Our experienced staff is
knowledgeable regarding company processes and is available to assist you with any questions you may
have. Please e-mail the appropriate address outlined below, or call 800-872-2875 between 8 AM and 8
PM EST, for assistance with:
SCHEDULING email: [email protected]
fax: 866-632-2161
♦
♦
♦
♦
♦
Scheduling issues
Appointment changes/Reschedules
Patient “No-Shows”
Appointment authorization forms
Discrepancies between authorization form and prescription
PROVIDER RELATIONS email: [email protected]
fax: 973-257-9512
♦ Changes to your demographic information:
- Change in federal tax identification number
- Business name change
♦ Change of address
- Change of any telephone or facsimile numbers
- Addition or closing of an office
- Addition or termination of a provider within the practice
- Change of billing address or phone/fax numbers
- If facility will be closed temporarily (construction, equipment updates, etc.)
♦ Contract inquiries
♦ General operational questions
♦ CEU Presentations
MEDICAL REPORTS Fax: 1-877-922-3992
♦ Fax all reports to OCCM and referring physician within 48 hours of procedure
♦ Or submit via the Provider Portal
Revised 4.8.2013
Page 30
PROVIDER SERVICES –
email: [email protected]
fax: 973-257-9172 or Provider Portal
♦
♦
♦
♦
Billing inquiries
Claim status
Refund process
Medical claim appeal inquires
When calling for claim status, please have the Patient’s Name, Date of birth, Date of Service,
CPT Code(s), and the Amount Billed for each claim.
CREDENTIALING –
email: [email protected]
fax: 973-257-9512
♦ Credentialing Status
♦ Changes to Physician Roster
CLINICAL SERVICES –
phone: 800-872-2875, extension 3431
fax: 973-257-1363
email: [email protected]
♦ Medical claim appeal processing
♦ EMG & NCS sample reports for credentialing
It is understood that the contents of this manual are part of the contracted agreement between OCCM and
its providers. OCCM reserves the right to make changes to workflow processes and policy to accommodate
client needs and maintain compliance with all applicable laws. Updates to the manual will be made available
on our website www.onecallcm.com. We encourage providers to check our website on a regular basis.
Revised 4.8.2013
Page 31
Appendix
The following documents are available on the One Call Care Management Website which can
be found at:
www.onecallcm.com/providers/forms library
Unbilled Report – Sample
OCCM Medical Report Request
Facility Change Form
OCCM Authorization Form – Sample
Radiology Medical Report Format Guidelines
EMG and NCS Medical Report Format Sample
Provider Appeal for Radiology
Provider Appeal for EMG & NCS
EMG and NCS Incomplete Bill Fax
EMG and NCS Bill Query Fax
Revised 4.8.2013
Page 32
SAMPLE FORM
ONE CALL CARE MANAGEMENT
TELE: (973) 257-1000 (800) 872-2875
(press prompt 3, 1 & follow instructions)
FAX: (973) 257-9172
E-mail: [email protected]
DATE:WEDNESDAY MARCH 31, 2004
PHONE NUMBER:(123) 456-7890
FAX NUMBER:(123) 456-7890
TO:PAULA
MEDICAL IMAGING CENTER
FROM:PROVIDER SERVICES
MESSAGE: We are in need of the HCFA's/UB92's for the following patient(s). Per our agreement, you need to bill OCCM directly. If
you have sent OCCM any of these HCFA's within the past week, please disregard those particular requests and fax the remaining
HCFA's to the above number. If you inadvertently received payment from any other source, please indicate so on the return fax.
Please return this list with your return fax.
SS#
111-11-1111
Patient Name
COOPER, JAMIE
SERVICE DATE
PROCEDURE
DOB
03/26/197401/24/2012
72146-MRI Thoracic Spine
333-33-3333
GILBERT, MARY
222-22-2222
HERNANDEZ, JOSE
555-55-5555
WHITE, CRAIG
06/24/195108/20/2012
08/20/2012
03/12/196101/19/2012
01/19/2012
02/12/197107/10/2012
73721-MRI Lower Extremity, Joint
73721-MRI Lower Extremity, Joint
73718-MRI Lower Extremity, Not Joint
73721-MRI Lower Extremity, Joint
72148-MRI LUMBAR SPINE
Below are claims that have been received and are being processed.
SS#
Patient Name
Service Date
Procedure
HCFA Rec'd Date
Check Issue Date
73218
03/01/2012
04/15/2012
02/05/2012
71020
02/18/2012
04/03/2012
02/05/2012
72052
02/18/2012
04/03/2012
72070
73221
72148
02/18/2012
03/12/2012
03/12/2012
04/03/2012
04/26/2012
04/26/2012
123-12-3123
ABRAMS, COREY
02/13/2012
234-23-4234
ANDREWS, JIM
456-45-6456
BRESCIA, DARREL
353-53-5353
BROWN, LESLIE
02/05/2012
02/23/2012
02/25/2012
868-68-6868
CHEN, MARGARITA
01/27/2012
73221
02/10/2012
03/26/2012
858-58-5858
CAMPBELL, MICHAEL
03/09/2012
70336
03/23/2012
05/07/2012
747-47-4747
272-72-7272
353-53-5353
DALE, KATHY
FRANK, ANTHONY
GRIGGS, ANA
03/09/2012
02/10/2012
01/30/2012
72148
73721
73218
03/23/2012
02/24/2012
02/24/2012
05/07/2012
04/09/2012
04/09/2012
454-54-5454
JACKSON, ANA
01/30/2012
73221
02/24/2012
04/09/2012
73221
72141
03/23/2012
03/29/2012
05/07/2012
05/13/2012
343-43-4343
121-21-2121
KLARK, DAVE
LANE, JOHN
03/08/2012
03/12/2012
Confidentiality Notice
The information contained in this facsimile is legally privileged and confidential and intended only for the use of the individual or
entity named above. If you received this in error, please notify us immediately by telephone.
Revised 4.8.2013
Page 33
ONE CALL CARE MANAGEMENT
20 Waterview Boulevard, P.O. Box 614
Parsippany, NJ 07054-0614
Telephone: (973) 257-1000 / (800) 872-2875 Fax: (973) 257-0044
Fax
Date: 3/7/2012
Attention:
Medical
Records
OVERDUE
MEDICAL
REPORTS
Facility:
We Scan Every Body- San Francisco (CA123)
Phone: (555) 444-5555
Fax:
(555) 444-5555
OUTSTANDING MEDICAL REPORTS
One Call Medical has NOT RECEIVED the Medical Reports for the patient (s) listed below.
***ACTION REQUIRED***
1.) Please MARK the appropriate status box on this form, and FAX this form WITH the medical report (s) to OCCM at
(973) 257- 0044.
2.) If required, courier the IMAGES to the REFERRING PHYSICIAN, as per the OCCM Provider Authorization form
previously sent.
SS#
Patient Name
DOB
Scheduled Date
Procedure
Days Aged
08/18/1968
555-55-5555 LEE, SCOTT
Medical Report Status
ATTACHED :
03/20/2012 10:30 AM
72141: MRI Cervical Spine
4
NOT ATTACHED BECAUSE
NO SHOW
RESCHEDULED FOR DATE: ____________TIME___________
CANCELED– State Reason If Available ______________________
333-33-3333 BROWN, SANDRA 05/08/1966
Medical Report Status
ATTACHED :
03/29/2012 03:00 PM
73221: MRI Upper Extremity
3
NOT ATTACHED BECAUSE
NO SHOW
RESCHEDULED FOR DATE: ____________TIME___________
CANCELED– State Reason If Available ______________________
999-99-9999 DAVIS, JOHN
12/11/1973
Medical Report Status
ATTACHED :
04/07/2012 01:30 PM
72148: MRI Lumbar Spine
2
NOT ATTACHED BECAUSE
NO SHOW
RESCHEDULED FOR DATE: ____________TIME___________
CANCELED– State Reason If Available ______________________
Confidentiality Notice
The information contained in this facsimile is legally privileged and confidential and intended only for the use of the individual or entity
named above. If you received this in error, please notify us immediately by telephone.
Revised 4.8.2013
Page 34
Facility Change Form
**MUST FAX COPY OF W-9**
Name of Facility: _________________________________________________________________________________________
Address: ________________________________________________________________________________________________
City: _________________________________ State: ____________ Zip: ______________ County: ____________________
Phone #: _________________________________________ Fax #: ________________________________________________
Contact Person (i.e., Center Admin/Office Manager): _____________________________________________________________
Medical Report Contact Person: ______________________________________________________________________________
Phone #: _________________________________________ Fax #: ________________________________________________
Business Hours: M: ________ T: ________ W: ________ Th: ________ F: ________ S: ________ Su: ________
** Tax ID#: ____________________________ Billing Global: ___________________ Billing Split: ____________________
Remit Address: ___________________________________________________________________________________________
City: _________________________________ State: ____________ Zip: ______________ County: ____________________
Billing Contact: ___________________________________________________________________________________________
Phone #: _________________________________________ Fax #: ________________________________________________
MRI Make: _______________________________________ CT Make: _____________________________________________
Model: ___________________________________________ Model: _______________________________________________
Magnet Strength: ___________________________________
_______________________________________________
MRI Table Weight: _________________________________ CT Table Weight: ______________________________________
Latest Software Version: _____________________________
OTHER SERVICES – PLEASE ATTACH LIST
Return to:
One Call Care Management
Attn.: Provider Relations
20 Waterview Blvd, PO Box 614
Parsippany, NJ 07054-0614
SAMPLE FORM
or
Fax: 973-257-9512
or
Email: [email protected]
Revised 4.8.2013
Page 35
SAMPLE FORM
OCCDXXXXXXXXX
Revised 4.8.2013
Page 36
SAMPLE FORM
ONE CALL CARE MANAGEMENT
PROVIDER ACKNOWLEDGEMENT FORM - DIAGNOSTIC MANAGEMENT PROGRAM CLAIM
20 Waterview Blvd. P.O. Box 614 - Parsippany, New Jersey 07054-0614
TEL (973) 257-1000
Fax Date: 03/02/2012
Provider Information:
Provider:
Attn:
SUNNYVALE OPEN MRI
PATIENT ACCOUNTS
Fax #:
4087380242
Patient Information:
OCCM Claim #:
Name:
OCCMXXXXXXXXX
42276350004928
158286783
TONY BOSCO
Date of Birth:
Date of Injury:
08/08/1939
02/15/2012
Referring Physician:
Name:
Address:
JOHN WELSH
Fax #:
Phone #:
Procedure
Scheduled Date
PACKAGE : 72158
02/15/2012
Chief Complaint:
Notes:
•
•
•
•
We have been authorized to act on behalf of the payer to process this claim.
We are in receipt of the above mentioned claim and payment will be issue by One Call Medical.
Codes listed are intended to communicate service(s) rendered. There may be other codes association with certain procedures. If
the associated codes are appropriate, they will be reimbursed in accordance with your OCCM agreement and payment policies.
For questions or concerns please contact provider relations at (800)872-2875 or Mail to : [email protected]
Sincerely,
OCCMAUTORETRO
Revised 4.8.2013
Page 37
GUIDELINES FOR ONE CALL MEDICAL RADIOLOGY REPORTS
The following data should be included on each report submitted to OCCM.
Provider Name
Patient Information: This data should be labeled and included in the header of the report.
See sample header for preferred format below
• Patient Name
• Date of Birth
• Date of Service
• Referring Information
• Procedure Performed
ABC Radiology Center
123 Main Street
Any Town, ST 10020
Patient Name: Joe Smith
DOB: 12/15/1967
DOS: 03/04/2006
Referred by: Wayne Johnson, MD
Procedure: MRI of Left Wrist
Clinical History or Indication
• Reason for the MRI Exam
Technique
• Equipment used
• Listing of sequences
Findings
• Discussing all imaged areas
Impression
• Summary of abnormalities
• Diagnosis if applicable
• Comment on whether or not the injury is acute or chronic if this is able to be
determined.
Signature of Reading Radiologist
Revised 4.8.2013
Page 38
OCCM GUIDELINES FOR NEURODIAGNOSTIC MEDICAL REPORTS
Revised 4.8.2013
Page 39
OCCM GUIDELINES FOR NEURODIAGNOSTIC MEDICAL REPORTS - Continued
Revised 4.8.2013
Page 40
OCCM GUIDELINES FOR NEURODIAGNOSTIC MEDICAL REPORTS - Continued
Revised 4.8.2013
Page 41
One Call Care Management - Medical Claim Appeal for Radiology Procedures
Instructions: Complete top half of form and fax to 973-257-1363 or email to [email protected]
________________________________
Date of Appeal: _________
Patient Name:
Date of Service: ______________
Patient Social Security #: _________________________________
Date of Check: _________________ [Appeals cannot exceed contract limit of 180 days]
Submitted by:
___________________
Phone:
___________________
Fax: ______________________________
Email address: ________________________________________________________________________
OR Mailing address for results of appeal:
___________________________________________________________________________
First Appeal
Second Appeal [2nd Level Appeal requires medical justification from physician.]
Codes being appealed (CPT code and # of units):
_____________________________________________________
Amount of reimbursement being appealed: _________________________________________________
Detailed Explanation (Must include MEDICAL JUSTIFICATION and supporting documentation such things as HCFAs or bills, authorizations, prescriptions,
and any corrected medical reports.):
This section for OCM internal use only – Please do not write below this line.
Outcome:
Approved
Denied
Reason for approval:
Medical Justification submitted
Additional documentation submitted
Corrected report submitted
OCM data entry error
Not considered previously
Not billed previously
Incorrect bill review
Other:______________________________________
Partial Allowance
________________________________________________
Reason for
No medical justification submitted
No additional documentation submitted
Not authorized
Incorrect coding
CCI Edit–procedure included in primary procedure
Already considered and paid
Contrast is included per contract
Supplies/reports are included per contract
Appeal exceeds contract limit of 180 days
Other:______________________________________
_________________________________________________
_________________________________________________
Nurse Reviewer,
Clinical Services
Date:
Director,
Clinical Services
Date:
Stephen R. Baker, M.D.
Radiology Advisory Board member
Date:
For 2nd Level reviews:
Radiology Advisory Board member
Date:
Finance
Date:
Provider I.D.:
Payer Claim No.:
Documentation in Phoenix Date:
Action Request to Finance Date:
Action Request to Finance:
Revised 4.8.2013
Initials:
Initials:
Documentation in SS Date:
Notification to Provider Date:
Initials:
Initials:
Page 42
One Call Care Management -- Neurodiagnostic Medical Claim Appeal
Instructions: Complete top half of form and fax to 973-257-1363 or email to [email protected]
Date of Appeal: ________________
Patient Name: ______________________________________
Date of Service: ________________
Patient Social Security #: _____________________________
Date of Check: _________________ [Appeals cannot exceed contract limit of 180 days]
Submitted by:_____________________ Phone: ______________________ Fax: __________________
Email address:
OR Mailing address for results of appeal:
_________________________________________________________________________________________
First Appeal
Second Appeal [2nd Level Appeal requires medical justification from physician.]
CPT Codes and units being appealed: ______________________________________________________________
Amount of reimbursement being appealed: _________________________________________________
Detailed Explanation (Must include MEDICAL JUSTIFICATION and supporting documentation such things as HCFAs or bills,
authorizations, prescriptions, and any corrected medical reports.):
This section for OCM internal use only – Please do not write below this line.
Outcome:
Approved
Denied
Reason for approval:
Medical Justification submitted
Additional documentation submitted
Corrected report submitted
Amplitudes submitted
Nerve conduction numerical data submitted
Detailed list of muscles submitted
OCM data entry error
Not considered previously
Not billed previously
Incorrect bill review
2012 new EMG CPT codes
2013 new NCS CPT codes
Other:______________________________________
________________________________________________
Partial Allowance
Reason for denial:
No medical justification submitted
No additional documentation submitted
Not authorized
Incorrect coding
Excessive NCS per AANEM guidelines & OCM policies
95900 is included in reimbursement for 95903
Less than 5 muscles studied per limb is a limited study
Documentation does not support level of service
Review of Systems required but not documented
Exam is problem focused, not detailed
Physical examination required but not documented
Supplies/reports are included per contract
Appeal exceeds contract limit of 180 days
2012 new EMG CPT codes -not effective for DOS in ____
2013 new NCS CPT codes –not effective for DOS in____
Other:______________________________________
_________________________________________________
Nurse Reviewer, Clinical Services
Date:
John E. Robinton, M.D.
Medical Director
Date:
Documentation in Phoenix Date:
Action Request to Finance Date:
Action Request to Finance:
Revised 4.8.2013
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Director, Clinical Services
Date:
Medical Advisory Board
Date:
Initials:
Initials:
Documentation in SS Date:
Notification to Provider Date:
Initials:
Initials:
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Revised 4.8.2013
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Revised 4.8.2013
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