Claims Submission & Payment
NMHC has implemented claims program requirements to ensure timely and accurate processing of claims for our participating providers.
Members are also required to follow the applicable requirements of their plan to receive benefits.
Member Eligibility and Benefits
Providers must verify that a patient is an eligible member of the Plan and should verify benefits prior to rendering services.
NMHC encourages providers to verify a member’s eligibility status throughout the period of continued and/or extended services as eligibility may change at any time. It is not uncommon for retroactive terminations to occur, which may affect the status of a member’s eligibility. For this reason, verification of eligibility is not a guarantee of payment.
Provider offices should consider the following as a guide to help obtain verification of eligibility and benefits:
- All NMHC members must present their ID card at the time of service. Providers should further verify eligibility and benefits. Providers can use the link to the Provider Portal from our website at http://www.mynmhc.org/my-account-login.aspx.
- Providers should review the Prior Authorization Requirements prior to rendering services to determine whether or not prior authorization is required.
- Collect the member’s cost-sharing requirement at the time of service.
Billing Members for Services
Providers should not bill members for any covered services, except for applicable copays, deductibles, and/or coinsurance amounts. Members may not be billed for services due to a provider’s failure to obtain required authorizations. Any deductibles and/or coinsurance and charges for non-covered services should be billed to the member following the receipt of the Explanation of Payment (EOP) from NMHC.
Providers should not require payment from a Member for any non-covered service that the Member receives unless the Member is informed that the services are non-covered and has agreed in writing, in advance of receiving the services, to pay for such services. A Member informed by the Provider that care is potentially non-covered, and proceeds with receiving the potentially non-covered service, may, not be billed for the non-covered service unless the Member has previously agreed in writing to pay for the service.
Any waivers signed by the Member must be specific as to the details of the excluded or non-covered service and its cost. General agreements to pay, such as those signed by the Member at the time of service, are not evidence that the Member knew specific services were excluded or excludable or that the Member agreed to pay.
Providers are required to submit clean claims for any services rendered to NMHC members. NMHC is required to process clean claims within thirty (30) days of receipt for electronic submissions, and forty-five (45) days for paper submissions. Providers will receive an Explanation of Payment (EOP) for all claims received.
A clean claim is a manually or electronically submitted claim that:
- Contains substantially all the required data elements necessary for accurate adjudication in accordance with the terms and conditions of the applicable plan and without the need for additional information;
- Is not materially deficient or improper, including lacking substantiating documentation currently required by the payor;
- Presents no mitigating or unusual circumstances (including the need for current coordination of benefits information) that prevent payment from being made in accordance with required time-frames; and
- Is submitted within NMHC’s timely filing requirements.
Accurate and timely submission of claims for billing is a critical component to a provider’s compensation.
Additional tips for submitting claims are:
- Submit clean claims on a CMS-1500 form or UB04 form that is compliant with the National Provider Identifier (NPI) and Health Insurance Portability and Accountability Act (HIPAA) regulations. Valid CPT, Revenue, HCPCS, ASA, and ICD-10 codes must be used and include appropriate modifiers, if applicable.
- Clean claim example includes the information listed on the attached link below. We may require additional information for particular types of services, or based on particular circumstances or state requirements.
- While some claims may require supporting information for initial review. NMHC will request additional information when needed.
For questions about claims, filing, or contracted reimbursement, please contact NMHC’s customer care center at 1-855-769-6642.
Timeframe for Filing Claims
- Claims must be submitted no later than ninety (90) days after the provision of covered services.
- In cases in which NMHC is the secondary payor, claims must be filed ninety (90) days from the date of service or ninety (90) days from the date that the Provider receives notice of payment decision from the primary payor, whichever is later.
Only those charges for Covered Services billed in accordance with NMHC’s standard claim coding and bundling methodology will be considered for payment. The Plan reserves the right to “re-bundle” billed charges that have been unbundled and to review claims for medical necessity determination prior to payment. Only services that are medically necessary and covered by the plan will be considered for payment.
Providers must submit a claim for your services, regardless of whether you have collected the copayment, deductible, or coinsurance from the member at the time of service.
Electronic Claim Submission
NMHC understands how important it is for claim submissions to be processed timely and accurately. The quickest and most efficient way to file claims is electronically. If your office is not currently submitting claims electronically, we encourage you to do so. Electronic claim submission offers a number of benefits for a provider’s office, including:
- Streamlined billing, which helps reduce paperwork;
- Faster claim delivery to NMHC instead of traditional mail delivery time;
- Improved feedback/correction capability for claims with missing or invalid data;
- One address for all NMHC claim submissions;
- Receipt acknowledging proof of acceptance by NMHC; and
- Quicker response/payment time for claims.
NMHC uses Change Healthcare as its clearinghouse. Providers should work with their clearinghouses to ensure they can file to Change Healthcare.
NMHC Payer ID: 45129
Paper Claims Submission
Although NMHC highly recommends filing claims electronically, provider offices can help timeliness and accuracy of paper claims filing by adhering to the following guidelines when completing and submitting paper claims:
- Use the current CMS-1500 or the current UB04 claim form as appropriate when submitting paper claims that are compliant with the National Provider Identifier (NPI) and HIPAA regulations. Generally, the CMS-1500 form is used for professional services and the UB04 is used for facility services. Please use original claim forms as opposed to copies of the forms.
- Make sure that all the fields are completed accurately. This will help avoid returned claims due to missing information.
- Refer to the member’s current identification (ID) card to help ensure you have the appropriate member ID number as well as the correct address for submitting claims.
- Use machine/computer generated printed forms. NMHC will not accept hand written claims.
- Claims with altered information or markings will not be accepted for consideration.
- When submitting attachments or documents that are to be considered as part of the claim processing, please include the member’s ID number.
All paper claims must be submitted to:
New Mexico Health Connections
P.O. Box 3828
Corpus Christi, TX 78463
Industry standard will be applied to claims based on:
- CPT definitions or guidance
- CMS guidance (including, but not limited to Correct Coding Initiatives [CCI])
- Specialty society guidance
- Clinical consultant network – industry/specialty-specific subject matter experts
- Health Plan Policy (HPP) – Health Plans concur that these edits are consistent with current health plan policies.
It is not uncommon for CPT-4, Revenue, HCPCS and/or ICD-10-CM codes to be added, deleted, or modified. Providers are encouraged to keep track of such changes and ensure that claims are submitted with valid codes. Any claims submitted with invalid CPT-4, HCPCS, or ICD-10-CM codes may be rejected for payment. ICD-10-CM codes requiring fourth and fifth digits must be indicated on claims. Additionally, appropriate modifiers should be included on claim submissions when applicable.
When a miscellaneous code must be used to identify a procedure, providers must include an explanation and/or the surgical procedure or operative notes supporting the use of the code. For miscellaneous or temporary pharmaceutical codes, providers must include the NDC number, drug name, and dosage and/or a copy of the invoice in order for the claim to be considered for payment.
Checking Claims Status
NMHC is required to process clean claims upon receipt within thirty (30) days for electronic submissions and forty-five (45) days for paper submissions. Providers will receive an Explanation of Payment (EOP) for all claims received. Claims may be rejected or be returned to the provider prior to acceptance into our claims system. Various reasons may cause this to occur; the most common being incomplete claims, invalid codes, electronic clearinghouse problems, or claims sent to the wrong address.
NMHC recognizes that there are a variety of reasons that may prevent a claim from entering the claims system to be processed. Therefore, if a provider submits a claim to NMHC and NMHC has not provided an EOP within the timeframes stated above, it is important for the provider to follow up with NMHC to check status of the claim(s) in question. Claims that are not followed up by provider within required time periods will not be processed for payment.
Providers should follow up at least every 30 days when checking status of any outstanding claims to ensure that both NMHC and providers identify and communicate issues preventing processing are resolved timely, so claims may be processed.
Any claims submitted outside the timely filing requirements as noted above will not be considered for payment unless the provider has documented proof of timely follow-up at least monthly from the date claim was submitted to NMHC.
Providers can verify claim status with NMHC in the following ways:
The most common claim submission errors are as follows:
- Missing, expired or misused, CPT, ICD-10, HCPCS, or Revenue codes;
- No Explanation of Benefits (EOB) submitted when the member has other insurance coverage or Medicare primary coverage;
- Missing anesthesia time;
- Itemized statement is not attached;
- Missing place of service, type of service, or bill type;
- Incorrect or missing member ID number;
- Missing NPI number (Rendering and/or Billing); and
- Incorrect date of birth for the patient.
It is the responsibility of the provider offices to immediately post/track all claim payments and/or denials based on the Explanation of Payment (EOP) provided. It is not uncommon for a provider to request reassessment or adjustment following the processing of a claim(s). There are a variety of reasons that providers may request a reassessment or adjustment.
Some examples included are:
- Corrected claims
- Proof of timely filing
- Calculation of units billed
- Claim was submitted and paid twice
- Claim was paid at the wrong rate (contractual)
- Claim was paid for the wrong date(s) of service(s)
- Claim was paid at a wrong level of care
- Services were span billed with overlapping days on more than one claim
- A compliance audit was conducted
- Post payment recoveries
- Authorization was not applied accurately
However, regardless of the reason for the reassessment or adjustment request, providers must comply with the following timeframes and processes when submitting these requests:
- The request must be made within twelve (12) months after the date the claims were originally paid or the date NMHC discovered the overpayment.
- Requests for reassessment and adjustments can be made to Customer Care, 8:00 a.m. to 5:00 MST, at 1-855-769-6642.
- Providers are strongly encouraged to utilize the Claim Reassessment/Adjustment Request Form. Please refer to the Forms section for a copy of this form.
Corrected claims are handled as indicated below:
- Electronic adjustments for corrected claims – Service Loop CLM 05/03 Frequency Field “7” (I – Institutional or P – Professional) – this indicator will allow for an electronic claim adjustment.
- Paper – Providers file CMS-1450 or CMS-1500 paper forms to P.O. Box 3828, Corpus Christi, TX 78463. Providers must include any of the required/supporting documentation such as EOB, Original Paper Claim Form, and Clinical Documentation (if applicable).
Coordination of Benefits
Occasionally, claims for services rendered to members are the primary responsibility of other payors. Providers are requested to assist NMHC to maximize recoveries under coordination of benefits or subrogation and bill services to the responsible primary payor. For coordination of benefits, NMHC requires an explanation of payment (EOP) from the primary payor before considering payment of claims when we are secondary. If the EOP is not attached, the claim will be denied with the request of this additional information.
In cases in which NMHC is the secondary payor, claims must be filed ninety (90) days from the date of service or ninety (90) days from the date that the Provider receives notice of payment decision from the primary payor, whichever is later.
Please attach a copy of the primary payor’s EOP to the submitted claim. EOPs are also required for services denied by the primary payor and should be submitted to NMHC for consideration. Any claims submitted without the primary payor’s EOP will be denied with a request for the additional information.
NMHC follows the National Association of Insurance Commissioners (NAIC) Coordination of Benefits Model rules in determining which payor’s plan is primary and which is secondary.
NMHC conducts subrogation investigations for services that may indicate third party liability. When the member or provider receives money to compensate for medical or hospital care for injuries or illness caused by another party, NMHC must be reimbursed for any expenses that we may have paid in connection to the incident. If the member or provider does not seek damages, the provider must agree to allow NMHC to attempt recovery. For more information regarding subrogation policies and procedures, please contact Customer Care at 1-855-769-6642.