Provider Manual

Preauthorization

Certain medical services including some in-patient hospital admissions and all in-patient rehabilitation admissions require preauthorization before being eligible for payment. The PEHP Prauthorization team appreciates the assistance that providers offer to our members by helping with this process. Clincials will be requested for admissions that require preauthorization and the provider will be notified within 5-7 working days.

Authorizations for in-patient treatment may be an elective or emergency admission. Preauthorizations relate to length of stay. Clinical notes and information are required from the hospital. Preauthorizations DO have an option to change the Dates of Service.

The following services require written Preauthorization:

• Any out-of-network In-patient hospitalization
• Skilled nursing/rehab stays
• In-patient hospitalization at Primary Children's Medical Center
• Out-of-state admissions for in-patient hospitalization
• Any mental health in-patient hospitalization

Clinicals and requests for preauthorization maybe faxed to 801-366-7449.

When multiple surgical procedures are done during the same operative session, the primary procedure is payable at 100% of the Fee Schedule. Each additional eligible procedure done is payable at 50% of the Fee Schedule. Certain procedures are considered incidental and are excluded.

To obtain patient eligibility, benefits, and general claim status, providers must login to the secured provider site at www.pehp.org. If your office doesn't have login credentials, enroll by downloading the trading partner agreement (ETPA), executing the last page, and returning the entire document to your provider relations specialist. Upon receipt of the agreement, you will be sent an assigned user ID and password.

You’ll need the following after you have successfully logged in:

To Obtain Eligibility and Benefits:

• Subscriber ID Number
• Patient's Name

Note: Not all benefits are listed. If you need additional benefits that aren’t provided, please call our Customer Service Department at 801-366-7555. Make sure to have the patient’s ID number, name, date of service, DX, CPT code, and type of visit and/or procedure to be done.

To Check General Claim Status:

• Subscriber ID Number
• Patient’s Name
• Date of Service
• Provider of Service

Note: Once you’ve checked on your claim online and still have lingering complex questions, please call our Customer Service Department at 801-366-7555.

Healthcare Fraud is an intentional deception or misrepresentation that the individual or entity makes, knowing that the misrepresentation could result in some unauthorized benefit to the individual, entity, or to some other party.

It is speculated that between 10% and 20% of the dollars paid by insurance companies could be attributable to Healthcare Fraud and Abuse. False claims can be divided into two categories: fraudulent and abusive.

Public Employees Health Program has established a Special Investigative Unit comprised of a Special Investigator, Provider Relations Representative, Claims Review Representative, Finance/Healthcare Analysis Representative, Claims Representative and a Case Management Representative. The SIU duties include desk and on site audits, providing internal and external fraud and abuse training, and preparation of information for criminal investigations. Investigations include providers with aberrant billing practices to determine if the practice constitutes over-utilization or fraud and includes member eligibility fraud and prescription abuse.

When the SIU staff discovers a pattern of fraudulent, abusive, or inappropriate billing practices, they will take appropriate measures to stop the activity. Claims may be denied and refunds requested for previously processed claims. Cases may be referred to the Utah Insurance Fraud Division for investigation and possible prosecution.

Please report suspected fraudulent activity to PEHP by calling 801-366-7529. You may remain anonymous.

Examples of fraudulent, abusive, or inappropriate billing for services

• Filing claims for services not provided.
• A pattern of billing that includes submitting incorrect or misleading diagnostic or procedure codes, which leads to incorrect processing services.
• Billing for more expensive service than was actually performed (upcoding).
• Advertising free or discounted services, then billing PEHP for additional services that may or may not be medically necessary.
• Billing for services or treatment performed on a family member, even those with different last names.
• Submitting claims for charges that, in the absence of the member’s insurance, there would be no obligation to pay; services provided by a family member (It is inappropriate to bill for services that, in the absence of insurance coverage, would become “professional courtesy,” i.e., for members of your staff and members of your group practice and their families.).

As of January 1, 2015, PEHP requires all contracted medical providers to submit their claims electronically. This includes COB claims. PEHP currently sends and receives healthcare transactions through the Utah Health Information Network (UHIN) or through a number of other clearinghouses and billing services that submit through UHIN.

Providers who wish to send and receive electronic healthcare transactions themselves and not through a clearinghouse will need to contact UHIN at 801-466-7705 to establish a Trading Partner Number (TPN). The TPN will be used for all payers that accept claims through UHIN. Once the TPN has been established, contact our EDI Department at 801-366-7544 or 800-753-7818, to be set up in our system and arrange testing.

Furthermore, PEHP is happy to announce that your office can send electronic claims through our website. Therefore, a clearinghouse and/or UHIN are not needed. It is through the secured portion of our website. If you do not currently have login credentials, contact your Provider Relations Specialist to get set up today!

Additionally, when a new provider is added to your practice, contact your Provider Relations Specialist to add the new provider to the correct TPN, in order to avoid claim rejections. We will need to know the provider(s), demographic information, individual NPI, TIN and TPN or clearinghouse.

Paper Submission

PEHP only accepts paper claims for the following:

• Out of network and/non-contracted out of state providers;
• Provider not contracted with any PEHP Networks;
• Claims that require medical records – Note: This does not include COB claims; or
• If PEHP is the tertiary payer.

The following is required for paper submission:

• CPT (Current Procedural Terminology)
• HCPCS (Health Care Financing Administration’s Common Procedural Coding System)
• ICD-9 (DOS prior to 10/01/2015) and ICD-10 (DOS after 10/01/2015)
• NDC# (National Drug Code) – if applicable
• Rendering provider and individual NPI
• Provider’s charges must be provided

PEHP accetps the UB-04 or HCFA-1500 claim form.

Coordination of Benefits

PEHP accepts:

• COB claims electronically. When submitted this way, we do not require the paper EOB in addition to the electronic claim. Your software should enable you to enter in the primary EOB information. If you need help, contact your software company to learn more about this feature.
• If PEHP is the tertiary payer, please send those via paper with both the primary and secondary EOB.

• Medicare Crossover (COBA) claims electronically. These claims are automatically crossed over to PEHP after Medicare has processed the claim.
  
  • If member has PEHP secondary to Medicare and the claim is sent to PEHP by provider and not by Medicare, PEHP will reject the claim with A3:771 (Claim submitted prematurely. Please resubmit after crossover/payer to payer COB allotted waiting period – 30 days after Medicare’s payment).
  • 30 days after Medicare's payment, if PHEP does not have the claim, privider will need to electronically send directly to PEHP as a corrected claim.

Processing / Turn Around Time

PEHP contracts with many different Employer Groups; therefore, there is no specific time frame. The claims turnaround time is based on the Employer Group that your member is with. Please note, paper claims turnaround time is longer than if the claim was submitted electronically, as electronic claims have first priority.

Payments

Contracted Providers - Claims are always paid directly to Contracted Providers

Non-Contracted Providers - PEHP shall pay claims directly to the member.

Claims Address

Please submit all claims to:

If a provider disagrees with how a claim was processed, provider may dispute the claim referring to the steps listed below:

• Disputed Claim– Within 180 days after PEHP’s initial determination, Provider may request a full and fair review by writing to the Appeals and Policy Management Department. Upon written request, including receipt of any pertinent additional information or comments, the Benefits Resolution Department will commence an investigation. This process occurs whether an appeal form is attached with the original request or not. Upon receipt of the Benefits Resolution Department determination, the Provider will be given instruction on how to request a review by the Executive Review Committee. Please follow the instructions exactly and make sure to note the specific time period that the request must be submitted by.
• Hearing Officer Appeal – If denied by the Executive Review Committee, Provider has 30 days from denial, to send in a written petition with the hearing officer, in accordance with the procedure set forth in Utah Code Ann. §49-11-613. Provider will file using a form provided by URS. For more information download
  How to Petition the Retirement Board.
• Court of Appeals – If you disagree with the hearing officer’s decision, Provider may petition the Board for reconsideration or appeal directly to the Utah Court of Appeals within 30 days.

Note: The board packet is sent to the person who sent the original appeal

Direct your initial written requests to:

PEHP Appeals and Policy Management Department
P.O. Box 3836
Salt Lake City, Utah 84110-3836
By fax: 801-320-0541

Note: If a provider wants to represent a member in the appeals process, the member must designate the provider as an Authorized Representative. The member must complete an “Appointment of Authorized Representative” and PEHP requires a “Member/Provider Appeal Filing Form” also be completed at the time of appeal.

The Appeals Claims Process, Appointment of Authorized Representative form (not required), Member/Provider Appeal Filing Form, and Member Record Release Consent Forms (only required if the Provider is representing the member as described above, and if the appeal determination involved medical judgment as required by federal law) are available at the secure PEHP for PROVIDERS site.

There are distinct differences in how Member and Provider appeals are processed.