General

1. Please clarify the difference between a new and established patient.
2. Where can I find fee schedule information?
3. The Interactive Voice Response system (IVR) does not understand me and I need to know the date my claim was paid, the amount that was paid, if there were any non-covered charges, and the check number. How can I obtain this information without having to call in?
4. Our patient signed an ABN because the diagnosis we initially received from the physician did not support the medical necessity of the service and the line items were denied. The physician has now provided a valid diagnosis for the services. Can we adjust the denied line items?
5. The Customer Service Representative advised me they no longer can refer my suspended claim to the claims processing department. Why?

1. Please clarify the difference between a new and established patient.

   A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

   An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

   This information can be found in the Evaluation and Management (E/M) Services Guidelines section of the Current Procedural Terminology (CPT), 2008, Professional Edition Manual.  If you need further assistance, please call the customer contact center for PA providers at 1-800-560-6170 and for MD/DC providers call 1-866-488-0545.

   Date Posted: 04/25/2008

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2. Where can I find fee schedule information?

   Fee schedule information is available on the Highmark Medicare Services website at http://www.highmarkmedicareservices.com/parta/reimbursement/index-fees.html.

   Date Posted: 04/25/2008

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3. The Interactive Voice Response system (IVR) does not understand me and I need to know the date my claim was paid, the amount that was paid, if there were any non-covered charges, and the check number. How can I obtain this information without having to call in?

   Providers can obtain this information a few ways. In addition to speaking a request, a provider can also key the request on the number pad on the telephone.

   Instructions on using the IVR are located at http://www.highmarkmedicareservices.com/parta/selfservice/pdf/md-ivr-quick-guide.pdf for MD/DC providers, and at http://www.highmarkmedicareservices.com/parta/selfservice/pdf/pa-ivr-quick-guide.pdf for PA providers.

   Claim payment information is posted on an electronic remittance advice (ERA) or standard paper remittance (SPR).

   Date Posted: 04/25/2008

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4. Our patient signed an ABN because the diagnosis we initially received from the physician did not support the medical necessity of the service and the line items were denied. The physician has now provided a valid diagnosis for the services. Can we adjust the denied line items?

   No, you should submit a Clerical Error Reopening request.  The form and instructions are located at http://www.highmarkmedicareservices.com/parta/forms/medicare-reopening-request-form.pdf.   If you need further assistance, please call the customer contact center for PA providers at 1-800-560-6170 and for MD/DC providers call 1-866-488-0545.

   Date Posted: 04/25/2008

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5. The Customer Service Representative advised me they no longer can refer my suspended claim to the claims processing department. Why?

   The claims processing department is currently working on the suspended claim inventory. Providers can access information regarding suspended claims from the Part A homepage under the Newsroom Article titled "Claims Processing Timeliness Reminder"  The direct link to the article is http://www.highmarkmedicareservices.com/bulletins/parta/newsroom/news05302007.html.

   Date Posted: 04/25/2008

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