Claims Overview and Status
Claiming Benefits for Services Rendered
The provider of service controls the submission of charges to NetCare for benefit payment. NetCare requires the usage of the Standard HCFA 1500 Claim Form for submission of outpatient medical charges or a hospital and facilities UB 92 claim form for inpatient medical charges. NetCare does not supply HCFA 1500 or UB 92 claim forms. These forms are the provider’s responsibility to obtain.
The claim should indicate your full billed charges, although payment will be based on your specific contracted rate. Make sure you indicate the member’s payment on the “amount paid” field of the HCFA 1500 claim form, or on the “prior payments” field of the UB 92 claim form. If your method of reimbursement is fee-for-service, NetCare reimburses your office the agreed upon contractual rate less any co-payments due from the member.
As a participating provider, you are required by local law to submit claims to NetCare within ninety (90) days from the date of service provided. Claims not submitted within this timeframe will be denied and you are not allowed to bill NetCare or the member pursuant to Guam law. You may submit claims daily or at least weekly to NetCare at the following mailing address or preferably via electronic transmission to NetCare’s clearinghouse vendor:
Claims Management Department
NetCare Life & Health Insurance Company
424 West O’Brien Drive, Suite 200
Hagatna, Guam 96910
NetCare will review for appropriateness all original claims delayed over one year from the month of service due to court decisions, administrative errors in determining a member’s eligibility, reversal of decisions on appealed authorizations, and/or other circumstances beyond a provider’s control. Claims submitted that are past the filing date limit must include the cause of delay or court order where applicable.
To assure prompt payment of the patient’s claim, the following information must be on the claim form submitted for payment:
These items are essential for prompt payment. Incomplete or missing information on the claim form submitted for payment may result in additional delays in payment of benefits or denial of the claim.
- Coverage Information
- Patient Information
- Physician Information
- ICD-9 and CPT codes as well as applicable modifiers
- Supplemental Information (e.g. Nature of Injury for possible Worker’s Compensation claim; Motor Vehicular Accident information for possible Third Party Liability).
Billing, Coding and Documentations of Claims
In compliance with the 1997 Evaluation and Management National Guidelines and in order to improve the validation of the intended code selection; quality of medical record documentation and claims processing and payment, NetCare requires the following policies and procedures:
PLEASE NOTE: CORRECT AND ACCURATE CODING AND ICD SEQUENTIAL IS A MUST IN ORDER TO AVOID REJECTION OF CLAIMS BEING TRANSMITTED ELECTRONICALLY.
- You will need to establish medical necessity through proper ICD-9 and CPT Codes.
- NetCare requires that all claims submitted be coded to the ultimate level of specificity and in correct sequencing of ICD-9 Codes.
- All clinical notes and medical records must be complete and legible to support proper usage of ICD-9 and CPT modifiers. Clinical notes and back-up records that are difficult to read may be denied for payment.
- NetCare requires the submission of all necessary documentation to support higher levels of acuity, including new patient or established patient and consults, such as levels III through V.
- All codes which are noted as having both professional and technical components for the procedure must be billed with appropriate modifier to note the service rendered by the provider.
- If both components are rendered by a single provider, then the global modifier must be billed.
- Employer or Group Name, patient or subscriber
- Group or Policy Number
- Subscriber’s Social Security Number
- Have the employee or spouse sign a Consent Authorization Form that authorizes NetCare to pay benefits directly to the provider. NetCare accepts the message, which is the “signature on file” on the physician statement as an assignment of benefits.
- Patient's Name
- Patient’s Date of Birth
- Patient’s Sex
- Patient’s Relationship to Subscriber
- Patient’s Place of Employment
- Name of other Insurance Company or Payer, if applicable
- Address of other Insurance Company or Payer, if applicable
- Patient’s diagnosis or symptoms, ICD-9 Coding, including a written description.
- Date the patient was first seen for diagnosis or condition treated.
- Description of service(s) to patient, using the CPT Coding.
- Date patient received service(s).
- Charge amount for each service or treatment received. Do not deduct or subtract any co-payments, the charge should reflect the actual fee for service.
- Patient Account Number (if available)
- Employer Tax Identification Number (EIN) of individual Social Security Number of attending physician.
- Name and address of the attending physician.
- Signature of attending physician.
- If the patient’s condition or injury was due to an accident, include details of the accident.
- If the patient’s condition or injury is related to the patient’s occupation, indicate this on your statement (NetCare does not cover work related injuries).
- If surgery was performed and the procedure is not listed in the CPT Code, attach a copy of the operative report.
- If surgery was performed and procedure was complicated or took more time than usual, attach a copy of the operative report.
Request for Medical Information
NetCare reserves the right to obtain and request medical information on members who have signed a Consent Authorization Form for release of such information. Providers are asked to cooperate with our Medical Management Department that request medical information and documents for the purpose of determining eligibility and for ease in processing a claim. NetCare will provide at least forty eight (48) hour written notice for such information.
An Explanation of Benefits (EOB) and a letter will be attached to a claim that has been processed and denied for payment. This will be sent to both the provider of service and the member. The member will then be financially responsible for satisfying the outstanding payment to the provider.
Electronic Submission of Claims
NetCare is now accepting medical claims submission through our clearinghouse provider, Interactive Payer Network (IPN). Please use payer I.D. number 66055 if you will be submitting claims electronically through IPN. This method can promote faster and more accurate claims processing and payment and is preferred to submitting paper claims. Contact NetCare’s Systems Department 472-3610 for more information on the required files specifications and layout for electronic submission.
Please be aware that once you are able to submit claims electronically, NetCare will not accept any manual claims from you should your claims be rejected electronically due to coding or sequencing errors etc. You will be required to make the proper adjustments and corrections on the rejected claims and re-submit electronically.
Resubmissions and Inquiries of Claims
The following procedures have been established for claims resubmissions and inquiries:
- Resubmit claims or Request Status of claims only after it is at least forty five (45) days from the date of submission to NetCare. This approach will avoid unnecessary system entry of duplicated claims as well as foregoing unwanted claim reconciliation.
Copy your Explanation of Payment (EOP) or Provider Payment Transmittal Report to resubmit a Denied claims with notation of correction or questions on the copy. Highlight on the EOP copy the following:
- The claim number
- The Member’s Name and NetCare I.D. number
- The Date Of Service (DOS)
- If additional information is required (i.e. proof of timely filing authenticated receipt of claims by NetCare bearing the member’s signature or other insurance EOP for dual coverage.)
- If you have not received payment and an Explanation of Payment for a claim, after 45 days, then you may resubmit a HFCA 1500 claim form again. Please be sure to record at the top of the claim for: “RESUBMISSION OR TRACER”. You may also contact our customer service department to check the status of a claim.
- Do not mix “new” Date of Service with previously submitted Dates of Service. New Dates of Service should be submitted as a new claim; not as a resubmittal claim.
Claims Processing Overview
All claims received are sorted, date stamped, eligibility verified and entered into the claims processing system within two (2) business days of receipt from provider.
Claims received and entered into the system will be processed for payment or denied based on the date received order. To be eligible for payment, the claim must be clean and complete in all aspects such as:
Uncontested or clean claims are processed within 30 calendar days of the date of receipt to ensure that payment or denial notice is received by the 45th day.
- Complete coding or full written description of services
- Itemization of all services
- Complete dates of services
- Billed amount diagnosis code or written description
- Amount paid by member
To follow-up on a claims status, you are encouraged to register under the Provider Portal at www.netcarelifeandhealth.com. This will allow you to view claims status and obtain an Explanation of Benefits. You may also contact NetCare’s Provider Relations Department at 472-3610, extension 216.