Avoid Denials Due to Billing Errors

4 Tips for Efficient Claim Submissions

Providers can help avoid claim denials and billing errors by following a few tips for accurate billing and timely claims processing.

Tip #1: Understand Contractual Filing Limits and Key Processes

Commonwealth Care Alliance Massachusetts and CCA Health Rhode Island accept claims by either Electronic Data Interchange (EDI) or industry-standard paper claims (UB04). Claim turnaround timelines are based on the claim receipt date. The receipt date is the day that CCA receives the claim.

• File claims within the time limit: File claims no later than 90 days from date of service, unless the filing limit is defined differently in the provider contract. CCA provider contracts strictly define specific filing limits that must be followed.

• Rejected claims: If your paper or electronic claim is rejected due to missing or incomplete information, make the necessary correction(s) described in the rejection letter or the 999 response file [DSR1] and resend the claims. The claims must follow the standard billing practice for clean claims submission within the required timely filing limit.

Tip #2: Minimize Coding Errors
Be sure to double-check claims before submitting them. Pay particular attention to these common errors and validate all before submitting a claim.

• Incorrect patient information: Name, date of birth, insurance ID number, etc.
• Incorrect provider information: Address, name, contact information, etc.
• Incorrect insurance information: Policy number, address, electronic payer ID, etc.
• Incorrect modifiers: Incorrect modifier used.
• Incorrect coding: Incorrect, mismatched, or missing codes.
• Incomplete claim: Required fields, blank, incomplete or incorrect.
• Duplicate billing: Failure to verify that a service has already been reported or reimbursed.
• Poor documentation: The provider submitted incorrect, illegible, or incomplete documentation.

Tip #3: Follow Billing Best Practices
Billing best practices ensure that claims are accurate and can be processed efficiently. Be sure that all of the following are included and accurate:

• Member Demographics – include all required information:
  • Member policy number. 
  • Member demographic information (Name, DOB, address, state, zip).
• Member Eligibility – verify member eligibility:
  • Validate member is eligible on the date of service.
• Service – include all required information:
  • Diagnosis Codes – Include proper active diagnosis codes.
  • Codes – Include proper active procedure codes, HCPC and/or CPT codes.
  • Modifier – Include proper modifiers (if applicable).
  • Place of Service – include the appropriate place of service.
• Provider Information –  include all required information:
  • NPI – include   both group and rendering provider NPI.
  • Include rendering provider  service address .
  • Submit group remit (Pay to) address.
  • CMS 1500 claim forms should always include a rendering provider.
• Support Documentation:
  • Include legible and complete copies of supporting documentation.
• Submit claims with all required fields completed:
  • Resources for completing claim forms:
• CMS 1500  
• CMS UB04  

Tip #4: Sharing Provider data with CCA
CCA requires the most recent provider data.  Providers should follow these best practices to ensure claims are processed in a timely manner.

There are options for sending a monthly provider roster to CCA’s Provider Data Management team to add a new provider, terminate an existing provider, or update demographic data for your group or existing individual provider.

• Email the roster to [email protected].
  •  Send via the CCA Provider Portal.