Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 4 - THE HERITAGE HEALTH MANAGED CARE CORE BENEFITS PACKAGE › Section 482-4-004 - PROVIDER PAYMENTS

Current through June 17, 2024
The following provisions apply regarding payments to providers by the
	 health plans.
004.01
TIMELINESS OF PROVIDER PAYMENTS.
The health plan must
  provide payment to a provider of services on a timely basis, consistent with
  Medicaid claims payment procedures and the minimum standards provided below,
  unless the health care provider and health plan agree to a capitated payment
  schedule or other arrangement.
004.01(A)
ELECTRONIC CLAIMS SYSTEM.
The health plan must
  maintain a health information system that includes the capability to
  electronically accept claims for adjudication and make payments in accordance
  with the standards set forth in the Health Insurance Portability and
  Accountability Act of 1996. Such electronic system must have the ability to
  transmit data to a central data repository that complies with the requirements
  for confidentiality of information under the Medicare program.
004.01(B)
MINIMUM
  TIMEFRAMES.
The health plan must comply with the following minimum
  timeframes for the submission and processing of clean claims. Timeframes are
  calculated from the day the clean claim is received by the health plan until
  the date of the postmark that returns the claim either to the provider or until
  posted on an electronic system;
(i) The
  health plan must pay ninety (90%) percent of all clean claims from
  practitioners, who are in individual or group practice or who practice in
  shared health facilities, within fifteen (15) business days of the date of
  receipt. The date of receipt is the date the health plan receives the claim;
  and
(ii) The health plan must also
  pay ninety-nine (99%) percent of all clean claims from practitioners, who are
  in individual or group practice or who practice in shared health facilities,
  within sixty (60) days of the date of receipt. The health plan must fully
  adjudicate (pay or deny) all other claims within six (6) months of the date of
  receipt.
004.01(C)
PROMPT INVESTIGATION AND SETTLEMENT OF CLAIMS.
The
  health plan must comply with the requirements related to claim forms as set
  forth in Title 471 NAC. For providers of outpatient services, this must include
  the use of CMS-1500 form, the Health Insurance Claim form, and the standard
  electronic Health Care Claim: Professional Transaction form (ASC X12N 837). For
  hospitals providing inpatient or outpatient services, this must include the
  CMS-1450 form (UB-92) and the standard electronic Health Care Claim:
  Institutional Transaction form (ASC X12N 837).
004.01(D)
SYSTEM
  REQUIREMENT.
The health plan must maintain an editable system for
  recording all claims, clearly indicating the date on which a claim is received
  and the date(s) any action(s) on the claim occur.
004.01(E)
PAYMENT
  STANDARD.
The health plan must pay clean claims promptly as
  provided above after the date of receipt of or electronic notice of the claim.
  If, for whatever reason, the claim is submitted electronically and in written
  form, the date of the earlier submission of the claim will be the date of
  notice from which the health plan must calculate the maximum thirty day
  period.
004.01(F)
NOTICE OF CONTESTED CLAIM.
The health plan must
  provide written or electronic notice to the provider of a determination by the
  health plan that the claim is a contested claim with the returned claim. The
  written or electronic notice must comply with the provisions in Title 482 NAC
  4-004.
004.01(G)
NOTICE REQUIREMENT FOR
  PARTIALLY CONTESTED CLAIM.
If the health plan determines that part
  of a claim is a contested claim and returns the claim, the health plan must
  provide written or electronic notice of that determination to the entity
  submitting the claim and must proceed to pay the portion of the claim
  determined by the health plan to be a clean claim timely.
004.01(H)
PROHIBITED
  ACTION.
In no instance will the health plan contest or return a
  claim or a portion of a claim because the claim fails to provide certain
  information if the missing information does not prevent the plan from
  adjudicating the claim.
004.01(I)
NOTICE OF INSUFFICIENT INFORMATION.
If the health plan
  determines a claim provides insufficient information for the payment of the
  claim, the health plan must provide written or electronic notice of this
  determination to the entity submitting the claim timely including the following
  information:
(i) All of the reasons for the
  denial of the claim;
(ii) The date
  the service was rendered, the type of service rendered, the name of the
  provider who rendered the service and the name of the person to whom the
  service was rendered; and
(iii) The
  address of the office responsible for handling the claim, and means by which
  the office may be contacted without toll charges exceeding the charges that
  otherwise apply for the provider or member to place a call in their area code.
004.01(J)
EFFECTIVE NOTICES AND PAYMENTS.
Written notice of a
  claim will be effective upon the date that the claim is received. Electronic
  transmission of the claim will be the date the claim is posted to the
  electronic transfer system. Payment and notices from the health plan will be
  effective as of the date that:
(i) A draft or
  other valid instrument equivalent to payment is placed in the United States
  mail in a properly addressed, postage-paid envelope;
(ii) The date of posting of the item to an
  electronic transfer system; or
(iii) The date of delivery of the draft or
  other valid instrument equivalent to payment if (i) or (ii) do not otherwise
  apply.
004.01(K)
CONTENTS OF A NOTICE OF A CONTESTED CLAIM.
The health
  plan must specify in its notice of a returned claim at least the following
  information:
(i) The name, address, telephone
  number and facsimile number of the office handling the claim or other
  designated claims representative knowledgeable about the claim with which the
  person submitted the claim, or provider should communicate to resolve problems
  with the claim;
(ii) The date of
  the service, the type of service, the provider of the service, and the name of
  the person to whom the service was rendered to the extent that this information
  is known to the health plan;
(iii)
  The specific information needed by the health plan to make a determination that
  the claim is a clean claim;
(iv)
  The date the claim was received; and
(v) In addition, the health plan must include
  in a notice regarding a claim determination in part a contested claim, a
  statement specifying those portions of the claim that are considered to be
  clean claim, and the amounts payable with respect to the clean claim portion.
  Requests for information made by the health plan on a contested claim must be
  reasonable and relevant to the determination of whether the claim is a clean
  claim or claim that must be denied.
004.01(L)
USE OF
  INTERMEDIARIES.
A health plan's use of subcontractors to perform
  one or more of the health plan's claims handling functions must not mitigate,
  in any way, the health plan's responsibility to comply with all of the terms of
  Title 482 NAC.
004.01(M)
ELECTRONIC REMITTANCE ADVICE.
Electronic remittance
  advice must be provided in accordance with the standards set forth in the
  Health Insurance Portability and Accountability Act of 1996.
004.01(N)
CLAIM STATUS INQUIRY
  AND RESPONSE.
Electronic claim status inquiry and response must be
  provided in accordance with the standards set forth in the Health Insurance
  Portability and Accountability Act of 1996.
004.01(O)
ENCOUNTER
  DATA.
The health plan must maintain an information system that
  includes the capability to collect data on member and provider characteristics,
  and claims information through an encounter data system. The health plan must
  submit encounter data to the Medicaid Management Information System monthly per
  Departmental specifications.