UPDATE: Tips to Avoid Claim Denials

Date: 11/24/20

This article has been updated from the article previously posted on December 12, 2019: Tips to Avoid Claim Denials

Superior HealthPlan aims to make the provider experience seamless. To help ensure provider claims do not deny and are processed quickly and efficiently, below are important claim submission tips and reminders.

INVALID OR UNCLEAN DATA

Claims submitted with invalid or unclean data will result in denial or rejection of an entire claim. All claims submitted to Superior require valid data elements on each line of a claim.

Examples of required data elements include, but are not limited to, the following:

• TAXONOMY - If billing or rendering National Provider Identifier (NPI) is submitted, the claim must also include the taxonomy or the entire claim will be rejected. It must also be the taxonomy that the provider attested to on the Master Medicaid File, which matches what was submitted during enrollment with Texas Medicaid and Healthcare Partnership (TMHP).
• National Drug Code (NDC) - Effective December 16, 2019, for dates of service September 1, 2019 and after, if required NDC data elements are missing or invalid for a procedure code on a claim line, the entire claim will no longer be denied, only the service line missing the NDC data will be denied. For claims submitted before this date that have missing data elements or invalid for a procedures code on a claim line, the entire claim  will be denied, not just the service line missing the NDC data.
  • Superior will deny service lines if the NDC submitted with the drug procedure code is not on the Texas NDC-to-HCPCS Crosswalk that was effective on the date of service.
  • Anytime a provider submits a national drug code on a claim, regardless if the HCPCS (Healthcare Common Procedure Coding System) is on the Vendor Drug Program NDC to HCPCS crosswalk, the following guidelines must be followed:
    • Length of National Drug Code must be 11
    • Data in National Drug Code must be numeric
    • First 5 characters of National Drug Code can’t be 00000 or 99999
      
      
      
• CPT or HCPCS - If a Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure code is submitted on any line of the claim, it must be a valid code for the date of service billed or the entire claim will be denied.
• LOCATION - If services are rendered in a facility location, a Service Facility Location (box 32) must be included on a professional claim. Superior will reject the entire claim if the Service Provider Location is not billed on a professional claim when the location is listed below: 

• PO BOXES - On July 1, 2019, Superior began denying claims if a billing provider’s address is not a street address or physical location. A Post Office (PO) Box is not an acceptable submission for the billing provider address. Providers that are including a PO Box as the billing provider address in their claim submission, must transition their PO Box address to a physical address.
  • All claims submitted to Superior must include all the required, valid clean claim data elements. The billing provider address is a required data element needed in a claim.
  • Providers can enter the billing provider address in the following location for:
  • Paper claims
    • CMS 1500 Claim Form - Box 33
    • UB-04 Claim Form - Box 1
  • Electronic claims
    • Loop 2010AA N301

• ADMISSION DATE - The admission date on an institutional claim must not be after the statement begin date. The exception to this rule is allowed if the type of bill is listed in the table below:

For any questions or additional information, please contact your local Account Manager or call Provider Services at 1-877-391-5921.