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Claims Processing Policies & Guidelines

A series of projects have been completed with the goal of reducing the amount of paper providers send to health plans, thereby reducing staff time and speeding payment.


» Submitting Corrected Claims

Corrected Claims Cover Sheet   Fields on form can be typed for clarity before printing.
(.pdf | 64k | Rev 3.5| 5/2011)

Corrected Claims Guideline Document
(.pdf | 135k | Rev 4.2 | 5/2011)

» Submitting Supporting Documentation

Supporting Documentation Cover Sheet    Fields on form can be typed for clarity before printing.
(.pdf | 69K | Rev 10.08 | 10/07)

Supporting Documentation Guideline Document
(.pdf | 33K | Version 10.8 | 10/07)


» Following-Up on Processed Claims

Guideline Document
(.pdf | 29K | Rev 5.0 | 10/07)


» Using Common Modifiers
< Updated to include additional health plans and user defined reports. Supports correct billing when most common modifiers are used.

Guideline Document
(.pdf | 26K | Rev 10.08 | 10/07)


» Anesthesia Coding & Billing CRNA Services

Guideline Document
(.pdf | 23K | Rev 10.08 | 10/07)


» Getting Claim Receipt and Status Information

Guideline Document
(.pdf | 26K | Draft 10.08 | 10/07)


» Conditions for Splitting Claims

Updated to include additional health plans and user defined reports. Clarifies the eight most common conditions under which claims are split.

Guideline Document
(.pdf | 15K | Rev 8.1 | 4.15.04)


» Quicker Resolution of Payment Responsibility for Injuries

Now a dynamic report based upon diagnosis code and selected health plans.

Guideline Document
(.pdf | 49K | Rev 10.08 | 10/07)


» Incorporate Explanation of Benefits (EOB) Info on Electronic Claims

Handling EOB Info Guidelines
(.pdf | 33K | Rev 10.08 | 10/07)


» Resubmission of Claims Electronically

Policy Statement RE: No Paper Claims
(.pdf | 9K | Rev 3.2)


» Clinical Notes Do Not Need to be Submitted for Emergency Room Visits

Policy Statement RE: No Clinical Notes For ER
(.pdf | 9K | Rev 3.3)


» Patient Insurance Card Not Required

Policy Statement RE: No Insurance Card
(.pdf | 9K | Rev 3.2)


» How Health Plans Handle Under Payments & Over Payments

Common questions about how participating Health Plans handle Claims Adjustments are answered. Health Plans spell out their processes and timelines.

Guideline Document
(.pdf | 21K | Rev 5.0)


» CPT Codes that will NO LONGER Automatically Pend a Claim for an Attachment

Health Plans and Providers are reducing the number of attachments that are required to process claims. Participating health plans have agreed that the attached list of CPT codes will NO LONGER trigger an automatic pend for an attachment. (NOTE: Not all of the participating health plans were automatically pending claims billed with these codes to await an attachment, but one or more were previously doing so. Now, none of the participating health plans will automatically pend claims with CPT codes on the attached list.)

Providers who have put automated edits into place to submit attachments when billing with these CPT codes should review their edits and adjust accordingly. Provider should also encourage non-participating health plans to similarly relax their requirements for these CPT codes.

Download Codes
(.xls | 33K | 12.06)

 




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Credentialing and Privileging Data Collection - videos. To view the training videos on Provider Attestation and Browser Second Factor Provisioning click here

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Health Information Exchange Project Updated. Read the latest on the Washington State HIE: click here