Physician Fee Schedule
PHP is a Medicare Advantage health plan and follows the
Medicare physician fee schedule unless a differing reimbursement rate is contracted.
(By clicking on the link above, you will be taken to the Centers for Medicare and Medicaid Services (CMS)website which is operated by CMS and not PHP.)
Initial Claim Submission
Claims for services provided to members assigned to PHP must be submitted on the appropriate billing form (CMS1500, UB04, etc.) within ninety (90) calendar days, or as stated in the written service agreement with PHP. The provider is responsible to submit all claims to PHP within the specified timely filing limit. PHP may deny any claim billed by the provider that is not received within the specified timely filing limit.
The following information must be included on every claim:
- Provider name
- Provider address
- Patient name
- Patient date of birth
- Patient ID
- Date(s) of service
- All ICD10 diagnosis code(s) present upon visit
- Revenue, CPT, HCPCS code for service or item provided
- NDC(s) for any drugs provided
- Billed charges
- Place of service or UB04 bill type code
- Tax ID number
- NPI number
- Name and state license number of rendering provider
Claims that do not meet the criteria described above will be returned to the provider indicating the necessary information that is missing. PHP will process only legible claims received on the proper claim form that contains the essential data elements described above.
Only current standard procedural terminology is acceptable for reimbursement per the following coding manuals:
- Current Procedural Terminology (CPT) for physician procedural terminology
- International Classification of Diseases (ICD10-CM) for diagnostic coding
- Health Care Procedure Coding System (HCPC)
CMS-1500 paper claim submissions must be submitted on form OMB-0938-0999(08-05) as noted on the document’s footer. We accept the revised CMS-1500 and UB-04 forms printed in Flint OCR Red, J6983, (or exact match) ink.
To ensure timely claim processing, PHP requires that adequate and appropriate documentation be submitted with each claim filed.
Documentation required with a CMS1500 or UB04 claim form:
|
Documentation
|
Applies to
|
| Other coverage explanation of benefits |
All Providers |
| Dialysis log |
Dialysis Service |
| Doctor’s orders, nursing or therapy notes |
Home Health |
| Full medical record with discharge summary |
Hospital |
| Consult, procedures report |
Physician |
| Emergency room report |
Emergency Medicine Physician |
| Operative report |
Surgeon |
| Minimum Data Set (MDS) Assessment |
Skilled Nursing Facility |
Standard Code Sets
Standard Code Sets as required by HIPAA are the codes used to identify specific diagnosis and clinical procedures on claims and encounter forms. All providers are required to submit claims and encounters using current HIPAA compliant codes, which include the standard CMS codes for ICD10, CPT, HCPCS, NDC and CDT, as appropriate.
Information for Obtaining an NPI
To obtain a national provider identifier (NPI) you may:
- Telephone: (800) 465-3203 or TTY: (800) 692-2326
- E-mail customerservice@npienumerator.com
- Mail to NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059
- Refer to CMS’s NPI information (By clicking this link, you will be taken to the Centers for Medicare and Medicaid Services’ website.)
Claim Definitions
Clean Claim — A “clean claim” is defined as a claim for services submitted by a practitioner that is complete and includes all information reasonably required by PHP, and as to which request for payment there is no material issue regarding PHP’s obligation to pay under the terms of a managed care plan.
Timely Filing Limit — The claim’s “Timely Filing Limit” is defined as the calendar day period between the claim’s last date of service, or payment/denial by the primary payer, and the date by which PHP must first receive the claim.
Received Date — The “Received Date” is the oldest PHP date stamp on the claim. Acceptable date stamps include any of the following:
- PHP Claims department date stamp,
- Primary payer claim payment/denial date
Claims Processing
Claims will be paid to contracted providers in accordance with the timeliness provisions set forth in the provider’s contract and/or by applicable California Law. Unless the subcontracting provider and contractor have agreed in writing to an alternate payment schedule, claims will be adjudicated as follows:
- For clean claims, expect reimbursement within 45 days of PHP’s receipt of the claim if submitted on paper
- You will receive an Explanation of Benefits (EOB) that details how each service is paid
- You will receive an Explanation of Payment and Recovery Detail (EOPRD) when PHP identifies a previous claim overpayment
