UCare’s December 2018 Healthlines Bulletin included a notice to all providers indicating entire claims will be denied effective January 1, 2019 when any line on the claim is an unlisted HCPCS or CPT code if submitted without supporting documentation. Outlined in the bulletin were guidelines to expedite the claims review process with sets of instructions on how UCare expects to receive the information.
Per the bulletin, the brief description of the unlisted service or procedure code for electronic submissions should be in the following loops:
Professional – CMS1500 - Loop 2300 NTE01 and NTE02
Facility – UB04 - Loop 2300 NTE01 and NTE02
Upon receipt of the said bulletin, XIFIN immediately reached out to UCare’s Provider Assistance Center and advocated for the use of an existing standard segment meant for the purpose of sending unlisted procedure code descriptions as per 5010 837 TR3 specs included in the WPC (Washington Publishing Company) Guidelines.
XIFIN’s petition prompted UCare’s review of the use case and the corresponding section of the standards document referenced. On January 2019, UCare agreed to modify their bulletin to include guidelines that is in accordance with published EDI standards.
The bulletin was modified to include the following:
“Submit a detailed description of the unlisted service or item that was provided. This can be done by submitting a separate document or by providing a brief description electronically in one of the following loops: Professional - CMS1500 - Loop 2400 SV101-07, Facility - UB04 - Loop 2400 SV202-07. Information submitted should be limited to the description of the unlisted service and its medical necessity. Submit only the information directly related to the unlisted service.”
This is one of many examples of how XIFIN continues to uphold standards that benefit our customer base and the rest of the healthcare EDI ecosystem. By being vigilant for potential deviation to standards along with our willingness to partner with payors and stakeholders in the healthcare industry, XIFIN continues to influence adherence to standards.
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