I.    PURPOSE:

A.    To advise all employees, Health plans and providers of the claim payment policies followed by Riverside Physician Network (RPN).

II.    SCOPE:

A.    This Policy and Procedure (P&P) applies to all claims for RPN contracted providers as well as non-contracted providers.

III.    POLICY:

A.    It is the policy of RPN to pay all properly authorized claims utilizing the claims processing standards accepted by nationally recognized Medical Societies and organizations, Federal Regulatory bodies, including Medicare Guidelines (unless otherwise stated in the individual provider’s contract).

IV.    PROCEDURE:

A.    Standard RBRVS and CPT guidelines are followed by RPN in the processing of all claims (unless otherwise stated in the individual provider’s contract). The RBRVS and CPT manuals have educational sections for identifying coding fundamentals and RBRVS and CPT coding and billing issues and is revised on an annual basis.

B.    RBRVS and CPT utilizes a color-coded format for the identification of:

1.    Separate procedures

2.    Unlisted codes

3.    Non-specific codes

4.    Correct coding initiative to identify services included in primary procedures

C.    RBRVS and CPT identify codes added or deleted each year.

D.    RBRVS and CPT guidelines provide clear criteria for the Evaluation and Management codes, setting standards for providers. RPN may request additional “relevant” records to support higher levels than those services authorized.

**Under no circumstances are providers permitted to invoice or balance bill an HMO member for the difference between the provider’s billed charges and the reimbursement paid. The Provider Dispute Resolution mechanism should be utilized.

ADMINISTRATION OF IMMUNIZATIONS AND INJECTABLE MEDICATION

The administration of immunizations and injectable medications are reimbursed separately from office visits if specified in the provider’s individual contract.  Non-Contracted providers are reimbursed based on the RBRVS fee schedule in effect on the date of service.  Any “non-covered” services/medications, per RBRVS guidelines are not reimbursed by the IPA.

COORDINATION OF BENEFITS

A.    Benefits will be coordinated with other carriers when RPN is notified that the member has other insurance.

B.    RPN will not assume responsibility for claims which are for services covered under Worker’s Compensation.

C.    Services related to Third Party Injuries are handled in a pay and pursue manner.  RPN will process these claims as per the provider’s contract and a recovery specialist will determine if reimbursement is available.

OTHER BILLING AND PAYMENT CRITERIA

Services provided to any member must meet the contractual requirements, or a denial may be issued.  These requirements include, but are not limited to:

A.    Referral or prior authorization

B.    All standard elements as required to process a claim (see section on claim submission found in the downstream provider notification)

C.    All payments and co-payments are subject to the benefit information as defined by the enrollees’ employer group specific benefit plan.  Claims payment is always dependent on member eligibility status for the date of service(s).

D.    The claims filing deadline, unless otherwise specified in the individual provider’s contract is 90 days for contracted providers and no less than 180 days for non-contracted providers. All claims submitted after the timely filing periods will be reviewed for extenuating circumstances and may at the discretion of the IPA be denied for untimely submission.

E.    Submitted claims will be acknowledged in the following manner

1.    Electronic claim submitters will receive an FTP file back within 2 working days acknowledging the receipt of their file and any claims that were not accepted.

2.    Paper claim submitters may confirm receipt of their claims within 15 working days by calling the Customer Service Department at (951) 788-9800.

F.    All “clean” Commercial and Senior-contracted claims will be paid within 45 working days of receipt.  All “clean” Senior non-contracted claims will be paid within 30 working days of receipt.  RPN may contest or deny a complete or incomplete claim, or portion thereof, by written notification to the provider within 45 working days of receipt.

G.    If a claim, Commercial or Senior is not paid within the required timeframes, appropriate interest will be paid based on all regulatory requirements. If the IPA fails to include the interest on a late claim, a $10 late fee along with the interest amount will be paid.

H.    If a late payment is made for an emergency services claim a $15 late payment interest/penalty will be included.

CODING/FEE SCHEDULES

Unless otherwise stated in the provider’s individual contract, reimbursement is based on 125% of the geographical RBRVS fee schedule in effect at the time of service.  Any code not listed in the RBRVS manual is reimbursed at 60% of billed charges

Anesthesia

Anesthesia claims are processed following ASA guidelines of 1 unit for every 15 minutes up to 4 hours.  After 4 hours, 1 unit for every 10 minutes.

Assistant Surgeons

When authorized and appropriate unless otherwise specified in the provider’s individual contract, assistant surgeons are reimbursed at the RBRVS rate in effect for the date the procedure is performed.

Global periods

Services rendered within the pre and/or post global period will be included in the global procedure rate.  Procedure specific global periods are published in the RBRVS.

Modifiers

Industry standard modifiers are published by the American Medical Association and acceptable for billing.  The correct code initiative (CCI) guidelines for payments and use of modifiers are utilized when adjudicating claims.

CPT-defines the standard, acceptable modifiers to be used for professional claims.

HCPCS also includes acceptable modifiers for services not defined by CPT.

RPN accepts all modifiers published by CPT and HCPCS.

Multiple procedures

Multiple surgical procedures performed by the same physician on the same patient during the same operative session are reimbursed per RBRVS guidelines at 100% for the highest valued procedure and 50% for each additional procedure.

Unbundled procedures

RBRVS edits are followed for identification of unbundled services.

 

The above information represents the standard claims processing policies approved and used by Riverside Physician Network to administer claims for contracted and non-contracted providers.  Contracted providers may refer to your individual contract for any negotiated modifications to these policies.