Medical Billing Forum

Billing => Billing => Topic started by: pecbilling on November 20, 2013, 11:29:26 AM

Title: Claim Rejected Claim Filing Indicator
Post by: pecbilling on November 20, 2013, 11:29:26 AM
I have tried sending a patient's claim electronically and it keeps getting rejected for entity's claim filing indicator, after some searching online I figured out what the claim filing indicator should be but where/how do I change the claim filing indicator? I have even tried sending this patient's claim paper also thinking that might work but Medicare keeps sending it back to me. Any help would be really appreciated!! :)
Title: Re: Claim Rejected Claim Filing Indicator
Post by: RichardP on November 20, 2013, 06:11:08 PM
You seem to be asking the folks here to tell you how your software works.  That is what you would use to change the Claim Filing Indicator, regardless of whether you are filing electronically or paper.

You need to find out from your software vendor how to do what you are trying to do.

Our software checks the "Medicare" box in Box 1 of the CMS 1500 Form automatically - based on the fact that we have selected Medicare as the insurance for that patient.  If we select any other regular insurance (Blue Cross; HealthNet; Cigna; Aetna, etc.), the "Other" box is checked in Box 1.  But I have no clue how to make that happen.  The software does it, based on the insurance choice we make.  However, if we filled out the CMS 1500 Form by hand, we would check off whichever box is relevant in Box 1 at the top of the CMS 1500 Form.

Here are some instructions for:

Kareo
http://www.kareo.com/help/knowledge-base/50180000000UZZvAAO/claim-rejection-other-payer-claim-filing-indi

Medicare: pg. 10 of document (bottom of page), or; pg 13 of 65 pdf calculation
http://www.rmcok.com/help/medicare/CMSClaimForm.pdf
Title: Re: Claim Rejected Claim Filing Indicator
Post by: shanbull on November 21, 2013, 02:25:39 PM
What software are you using?

Definition of claim filing indicator from eClinicalWorks: A code used to indicate whether the information in this payer record should be fully validated and the claim forwarded to the indicated payer OR whether the information in this payer record is for informational purposes only.

We have only 3 options to choose from: P = payment is being requested of this payer only (we almost always use this); M = payment is being requested of more than one payer at the same time (have never used this, do not use it even if there are multiple insurance policies or you will confuse the insurers); I = payment is not being requested of this payer. The claim is being submitted for informational purposes only (very rarely used).

As for where to enter the info, that depends on what your software is. Usually it's somewhere on the insurance section of the claim.
Title: Re: Claim Rejected Claim Filing Indicator
Post by: pecbilling on November 22, 2013, 08:11:54 AM
When I first posted this, I didn't realize the claim filing indicator would be through the software program, sorry about that. We use Emdeon to transmit our electronic claims and they accept the patient's claim but Medicare rejects it when they get it, which makes me think it's something with Medicare and not our system. I have looked at this patient's account with a fine tooth comb and I see nothing different about this patient's Medicare input and every other Medicare patient we have input in our system. That's why this is so mind boggling. I called Medicare yesterday and explained everything that was going on and the woman I spoke to said she's never heard of that rejection code, she told me to send the claim electronically with STAND ALONE on it.  I tried that yesterday so I guess I will find out soon enough if Medicare accepts it. I think the big problem that might be holding all this up is the patient has Workers Comp insurance for anything related to his back (our claims are not) but that is what Medicare has as the patient's primary insurance, I had the patient call Medicare about this and they told him his workers comp would not cause any problems with us filing his claim. At first the woman at Medicare was telling me to submit the claim to the patient's workers comp plan get the denial then send it to Medicare but she backtracked on that, don't feel real positive that she knew exactly what she was talking about! I also called over to the surgery center where the patient had surgery and they had no problems getting their claims to go. Hopefully what I tried yesterday will work but I'm not feeling very positive about it.
Title: Re: Claim Rejected Claim Filing Indicator
Post by: shanbull on November 22, 2013, 09:36:22 AM
Not sure what jurisdiction you're in, but our new Medicare administration company has a terrible call center, with people who have no idea what Medicare's policies are. Very seldom do I find it worth calling, and most of the time I find the answer I need on Google while I'm still on hold anyway. They actually do more harm than good a lot of the time. If you do call, make sure you insist on talking to the next tier level or the person's supervisor if what they're saying sounds like nonsense (because it probably is nonsense - seriously, the fact that the call center person has never heard of a claim filing indicator rejection says a lot, clearly she has not been on the job very long).

We did recently have a claim with a similar issue, it kept getting rejected for the claim filing indicator even though it was set up correctly. I ended up having to delete the patient's insurance out of the claim completely and re-added it. That did work. Another option is to delete the claim (only do this if your software will manually re-spawn the claim). Sometimes for whatever reason the claim's file is corrupt and Medicare cannot interpret it correctly. If you can't do this, call Emdeon and ask them to advise. Their tech support team actually has their stuff together, and they follow up until the problem is solved. It's always worth checking with the intermediary anyway to make sure there isn't a bug.

I also do have a lot of experience with worker's comp and auto insurance confusing things. But I'm suspicious about this being the reason, because I've never heard of Medicare refusing to accept a claim for processing because of COB issues with the claim filing indicator as the denial reason. Usually they will process it and reject for "liability of no-fault carrier," and then you appeal with evidence to the contrary, and Medicare pays. If this claim has nothing to do with the worker's comp case, the woman at Medicare is absolutely wrong in saying that you should submit the claim to the worker's comp insurance. If anything this will just mess things up even more and flag all your future claims as being related to the worker's comp case so that you have to appeal every single claim (I've been through this, it is best avoided). Also I've never heard of writing "STAND ALONE" on a claim. Electronic claims aren't even read by humans during the first pass at Medicare, so writing notes on them is generally pointless. This is definitely sounding less and less like a coding error to me, and more like an issue of the data being scrambled either between you and Emdeon, or between Emdeon and Medicare. In any case, Emdeon is the common denominator here, and they can look at the raw coding for you and tell you if they're seeing anything weird happening with the claim data, or if something with their system is causing the issue. And you can even ask them to talk to Medicare for you so you don't have to go through the frustration.

If you are able to get the correct rejection from Medicare ("liability of the no-fault/worker's compensation carrier") and would like assistance with appealing, feel free to post again and I'll give you some tips on that.

And as a general rule to keep your sanity intact, do everything you possibly can to avoid ever speaking with people at the Medicare call center  ;)
Title: Re: Claim Rejected Claim Filing Indicator
Post by: RichardP on November 22, 2013, 11:06:33 AM
... the patient has Workers Comp insurance for anything related to his back (our claims are not) but that is what Medicare has as the patient's primary insurance ...

Workers Comp is insurance for a very specific purpose.  If that purpose doesn't exist (workplace injury), Workers Comp is irrelevant to a patient's health care needs.  Our experience is that Medicare does not ever pay as secondary on a Workers Comp case (I realize that maybe this is different in other MAC jurisdictions?).  We don't ever bill Medicare as secondary on a Workers Comp case. 

Workers Comp is not a primary insurance, and should not be listed as such with Medicare.  The patient's primary insurance when Workers Comp is not involved is what should be listed as primary with Medicare.  If Medicare is the patient's only insurance outside of Workers Comp, that is what should be on file with Medicare as primary.

To repeat:  the problem is that Workers Comp is listed as primary insurance with Medicare.  It shouldn't be listed with them at all.  The patient should contact Medicare and have them list as primary whatever other insurance they have outside of Workers Comp.  The patient has to do this.  Medicare will not respond to a request from any other party.
Title: Re: Claim Rejected Claim Filing Indicator
Post by: shanbull on November 22, 2013, 11:55:16 AM
Quote
To repeat:  the problem is that Workers Comp is listed as primary insurance with Medicare.  It shouldn't be listed with them at all.  The patient should contact Medicare and have them list as primary whatever other insurance they have outside of Workers Comp.  The patient has to do this.  Medicare will not respond to a request from any other party.

I'm bewildered here too. The patient did call Medicare to discuss this, and apparently the treatment in question has nothing to do with the diagnoses in the Worker's Comp case. So Medicare should have already updated their system with this info, as they did hear it from the patient, and told the patient that this treatment wouldn't be confused with the Worker's Comp injuries. Once this has happened I generally do not run into these problems. pecbilling, the only reason I can think of as to why this claim may have gotten flagged is one of the diagnoses is an "accident/injury" code to Medicare which automatically places the claim in the wrong category. Would you mind sharing the exact CPT's and ICD's on the claim? If those check out, then I definitely do not think coding is the problem, period.

Quote
Our experience is that Medicare does not ever pay as secondary on a Workers Comp case (I realize that maybe this is different in other MAC jurisdictions?).  We don't ever bill Medicare as secondary on a Workers Comp case. 

I'm not sure how to explain this without getting really complicated, but I will try. We do not bill Medicare secondary to worker's comp or auto, but in some cases Medicare is listed in the claim as the secondary insurance because we are required to still bill the liability carrier in order to collect interest once the case goes into arbitration or suit. We do need that denial and then we turn around and bill Medicare. So technically speaking, I guess we are billing Medicare as secondary, but not with the expectation that both the liability carrier and Medicare will pay. It's one or the other, with the plan that the money will eventually be reimbursed through settlement. Medical insurance payment is a stopgap measure to keep money coming in for the time being so the clinic doesn't go broke, without forcing the patient to pay thousands of dollars upfront and wait for years until the case gets settled. So it gets kind of tricky to identify Medicare as "secondary" because it's in that spot, yes, but the setup is not the same as just a regular claim with both primary and secondary insurance. What happens sometimes is Medicare messes up on a claim unrelated to worker's comp, and assigns it to the worker's comp case and this is what results. They consider themselves "secondary" for purposes of the worker's comp liability, and they are expecting an appeal with a denial from worker's comp for that claim attached. The problem is, they should have a different insurance setup for medical claims unrelated to the case (basically, two separate accounts within the patient's Medicare plan) so they get processed normally, because those claims are not supposed to go to worker's comp at all (so a denial would not exist, obviously), and it sounds like somehow that did not happen despite the patient calling and asking them to do this. So I believe it's either because Medicare did nothing, or the claim itself has an indicator that is causing it to be sent to the wrong category (worker's comp claims instead of purely medical claims).
Title: Re: Claim Rejected Claim Filing Indicator
Post by: pecbilling on November 22, 2013, 02:09:34 PM
Thank you so much for your help. I just received notice again that Medicare rejected the claim even with the STAND ALONE on it (which I knew from the moment she told me to do that it wasn't going to work. It's just like you said the claims go electronically no one is going to see that!) Right before I checked this site I thought to myself I wonder if taking the patient's insurance information completely out and starting all over will work and then saw you suggested it as well so I'm going to try that also. My next step will be calling Emdeon and hoping they can help me because I've never experienced anything like this usually if Medicare has some other ins as primary (car, workers comp etc) they still accept the claim and then send a denial stating pt has other insurance as primary. This patient's claim has become the biggest thorn in my side!

The exact CPT codes and ICD's are: 1st claim: CPT 92004  ICD: 366.53 and 224.6  CPT: 92250 ICD: 224.6 and the second claim CPT is 66821 ICD 366.53

Any other suggestions would be greatly appreciated because I am NOT calling Medicare again about this...the person I spoke to yesterday was completely useless!! I will also let you know if taking the insurance information all the way out and entering again works.

Again thank you so much for your help  :)
Title: Re: Claim Rejected Claim Filing Indicator
Post by: shanbull on November 25, 2013, 03:43:46 PM
I checked those codes and there's nothing about them that should be flagging the claims, so we can definitely cross that possibility off the list. Let us know how things go with resubmitting :)
Title: Re: Claim Rejected Claim Filing Indicator
Post by: pecbilling on November 27, 2013, 08:45:10 AM
I took the patient's insurance out and re entered it and then resubmitted the claim and it was accepted by Medicare!! I think I might be on the road to finally getting this claim paid, thank you so much for your help   ;D
Title: Re: Claim Rejected Claim Filing Indicator
Post by: shanbull on December 05, 2013, 09:52:53 AM
Glad to hear it, it's always nice when the easy solution is the answer!