Processing Requirements. The primary processes of Claims Operations Management are to maintain sufficient on-line claims information, provide on-line access to this information, and produce claims processing reports. The claims operations management function of the MIS must: 1. Maintain Claim history at the level of service line detail. 2. Maintain all adjudicated (paid and denied) claims history. Claims history must include at a minimum: All submitted diagnosis codes (including service line detail, if applicable); Line item procedure codes, including modifiers; Member ID and medical coverage group identifier; Billing, performing, referring, and attending provider Ids and corresponding provider types; All error codes associated with service line detail, if applicable; Billed, allowed, and paid amounts; TPL and Member liability amounts, if any; Prior Authorization number; Procedure, drug, or other service codes; Place of service; Date of service, date of entry, date of adjudication, date of payment, date of adjustment, if applicable. 3. Maintain non-claim-specific financial transactions as a logical component of Claims history. 4. Provide access to the adjudicated and Claims in process, showing service line detail and the edit/audits applied to the Claim. 5. Maintain accurate inventory control status on all Claims.
Appears in 4 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract, Medicaid Managed Care Contract
Processing Requirements. The primary processes of Claims Operations Management are to maintain sufficient on-line claims information, provide on-line access to this information, and produce claims processing reports. The claims operations management function of the MIS must:
1. Maintain Claim history at the level of service line detail.
2. Maintain all adjudicated (paid and denied) claims history. Claims history must include at a minimum: • All submitted diagnosis codes (including service line detail, if applicable); • Line item procedure codes, including modifiers; • Member ID and medical coverage group identifier; • Billing, performing, referring, and attending provider Ids and corresponding provider types; • All error codes associated with service line detail, if applicable; • Billed, allowed, and paid amounts; • TPL and Member liability amounts, if any; • Prior Authorization number; • Procedure, drug, or other service codes; • Place of service; • Date of service, date of entry, date of adjudication, date of payment, date of adjustment, if applicable.
3. Maintain non-claim-specific financial transactions as a logical component of Claims history.
4. Provide access to the adjudicated and Claims in process, showing service line detail and the edit/audits applied to the Claim.
5. Maintain accurate inventory control status on all Claims.
Appears in 1 contract
Samples: Managed Care Contract (Wellcare Health Plans, Inc.)
