CLAIMS
FEATURES
The Claims and Encounter Data Department adjudicates, reviews, pays and analyzes claims, compiles claims timeliness reporting, participates in claims audits by health plans, and processes encounter data and report to health plans.
Encounter Data Submission: Encounter data is used to report medical services for patients under capitated contracts. The encounter data is very similar to the information submitted on a fee‑for‑service form, but no service‑related reimbursement occurs. Encounter data must be submitted weekly via the Provider Portal or on a CMS 1500, when applicable or where applicable, UB92. Health Plans imposes significant financial penalties for lack, or inadequate submission, of Encounter data.
Claims Submission: Industry standards require that all claims be submitted within 60 calendar days following the end of the month, and no later than 90 days, from when care was rendered. Claims will be processed and payments made in accordance with the Timeliness Guidelines as promulgated by the CMS Medicare Program. Claims should be submitted to IPA for those services that are performed by the physician that are not covered under capitation and/or according to the contract. The IPA will only accept claims submitted on an industry standard CMS 1500 or UB92 Claim Form.
In order for the IPA to accurately adjudicate claims and ensure timely processing and payment for services rendered to IPA members, it is imperative that all the required information on the CMS 1500 is provided.
For all billable services/claims, they must be submitted on the respective CMS 1500 or UB-92 form for services rendered.
Superbills are not acceptable as claims for reimbursable services (i.e., non‑capitated services, etc.) Send ALL claims to the following address:
CLAIMS DEPARTMENT
17622 Armstrong Ave
Irvine, CA 92614
Via Physical Delivery: Not currently accepting
Via e-mail: Not currently accepting
Via Fax: (626) 552-3760
Via Clearinghouse: Please specify and make arrangements with the Provider Network Operations (PNO) department.
Please refer to the Compensation Fee Schedule of your Provider Agreement to determine the payment amount the provider may be expected to receive for his/her service(s)s rendered. All payable claims shall be processed in accordance to the fee schedule and guidelines promulgated by each government program. Medicare Advantage HMO claims shall adhere to the prevailing Medicare Fee Schedule and Claims Processing and Payment Guidelines as established by CMS.
For ENCOUNTER DATA submissions, they must be submitted on either LEGIBLE superbills with complete information, or on a CMS (HCFA) 1500 Form. Send ALL encounter date to the following address:
ENCOUNTER DATA DEPARTMENT
17622 Armstrong Ave
Irvine, CA 92614
The MSO and IPAs prefer that providers submit encounter data electronically. The management company will provide training on electronic authorization and encounter data entry upon orientation.
Special services that cannot be identified with the appropriate CPT or HCPCS codes shall undergo IPA medical review and, if allowable, will be processed at industry standard norms.
Claims Settlement & Grievance Practices: Provisions under AB1455 provide for fast, fair, and cost effective dispute resolution mechanisms for claim disputes. A claim dispute/grievance will be processed under the IPA’s Provider (Claim) Dispute Resolution Policy & Procedure guidelines. Disputes must be submitted in a written format to same claims submission address and clearly document and identify the issue at dispute. (Refer to the following “Downstream Provider Notice” for full disclosure and instructions.)
Claims grievances for Medicare Advantage Program are processed under CMS regulatory guidelines and shall adhere to the timelines for receipt and response as promulgated.
Calling IPA Regarding Claims: For claim filing requirements or status inquiries, you may contact MSO or IPA by calling: (626) 656-2370 OPTION 1