QUEST Integration – Claim Processing and Returns

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

All claims submitted to HMSA’s Plan for QUEST Integration Members and accepted for processing undergo imaging as evidence of receipt and creation of a claim record to track the claim through the processing system. This allows us to respond to your inquiries on claims’ status and research how claims were processed. Electronic media claims (EMC) go directly into our processing system through your electronic submission with no manual handling by HMSA. The following information applies only to paper claims.

Claims Scanning

HMSA’s claims optical character recognition scanner allows our claims system to systematically enter the claims data from your paper claims. This scanning equipment facilitates prompt and accurate claims processing. Claims that cannot be scanned must be manually entered into the claims processing system. You can facilitate the timely, accurate processing of your claims by following these tips for cleaner print production:

• Type or computer print your claim. Use Arial or Times New Roman fonts.
• Use font sizes 10 through 12. Font sizes below 10 are not clear, and font sizes above 12 don't fit in the blocks.
• Avoid using dot-matrix printers and change your printer ribbon frequently. It is difficult for the scanner to pick up dot-matrix print clearly. Strive for print output of high quality, with characters appearing sharp and clear.
• Omit blank spaces in your provider number. Please enter your 10-position provider number using the appropriate number of leading zeros and alpha that designates the service location; for example, 00A0012345.
• Use single line text for each block. The OCR scanner is unable to read two lines squeezed into a block. Keeping font sizes at 10 or 12 will discourage this practice.
• Do not print claims information with red ink. Claim forms that are printed with the “fade away” red ink, allow scanners to pick up only claims information printed in black ink. Printing information in red ink will be treated by our scanner as a “blank” page.
• Do not highlight anything. Scanner will be unable to read and pick up the information in the area highlighted.

We will not accept:

• Faxed claims
• Paper claims submitted on copier-printed CMS 1500 forms.

Claims must have sufficient information to input and identify the claim in the processing system. At a minimum, all claims must:

• Have a patient name and QUEST Integration member number
• Have the provider’s QUEST Integration number
• Be signed by the provider or an authorized agent
• Be submitted on a valid claim form (CMS 1500, Universal Drug Claim Form or UB-92 for institutional providers)

Paper claims without the above are returned for the missing information. When refiling these claims, please leave the return slip attached for proper handling when we receive it.

Common Reasons for Delayed Claims Processing

The claims processing system contains edits to validate claim information. Claims that do not pass these edits may be denied or be paid a reduced amount. Providers may need to submit a corrected claim for processing as an adjustment. You can expedite processing of your claims by making sure complete information is provided.

The following are common reasons why a claim may be delayed.

• The birth date on the claim differs from the birth date on the QUEST Integration eligibility records.
  • An important component of patient verification is a check of the birth date. The birth date on the claim must be the same as the date on the patient’s QUEST Integration membership card. Please confirm this date with your patient and have him or her contact HMSA’s QUEST Integration Member Services or their Med-QUEST Integration worker to initiate a correction to the QUEST Integration files if the date on the card is wrong.
• The member on the claim is not covered by HMSA’s Plan for QUEST Integration Members.
  • Eligibility should be verified at each visit by:
    • asking the patient for their medical card showing coverage under HMSA’s Plan for QUEST Integration Members
    • checking your monthly PCP list if you are his/her PCP
    • confirming with the PCP if you are a specialist providing care upon the referral of the PCP
    • calling QUEST Integration Provider Service eligibility verification line at 808-948-6486 on Oahu or toll-free from the Neighbor Islands at 1-800-440-0640
    • accessing the Hawaii Healthcare Information Network (if you are part of the HHIN+ network)
    • contacting the state’s provider Hot-Line at 808-692-7360 on Oahu or 1-800-518-8887 from the Neighbor Islands
• The referring physician’s name is not arranged in last name, first name, middle initial order.
  • This is required by the state for federal reporting purposes for all consultations, lab and X-ray services, podiatry services, and rehabilitative services claims. The attending physician also must be identified on hospital claims. Inputting the referring/attending physician name in last name, first name, middle initial order enables the system to automatically identify the physician and create the necessary reports for the state. When this cannot be done electronically, it is done manually, which slows claim processing.
• An accident claim is submitted without the required accident diagnosis in the 800-999 range of ICD-9-CM diagnosis codes.
  • The state requires that claims with accident diagnosis codes in the 800-999 range of codes be reported to them for follow-up. Processing edits include a cross check of claim information to ensure that a claim with an accident indicator in block #10 of the CMS 1500 Claim Form, or with occurrence code 01-05 on the UB-92 claim form, has a diagnosis code within the 800-999 range of codes. Claims with accident indicators but no required diagnosis code, or with an 800-999 diagnosis code but no accident indicator are delayed until the accident information is confirmed and data corrected.
• The QUEST Integration membership number is invalid.
  • The number consists of leading zeros and numerals to create a ten-digit number. Do not include the “XLQ” alpha prefix printed on the card.
• The claim total in block 28 of the CMS 1500 does not match the total of the individual line charges in column 24F.
  • Carefully add the charges for each billed procedure, including tax. Enter the sum in block 28 of the CMS 1500. If claims are prepared in advance and the claim information changes, such as increased or decreased service lines, or amended charge data, be sure to adjust the claim total in block 28. We receive a number of computer-generated claims with manual revisions to the line item charges, but the total entered by the computer is left unchanged on the claim.
• A provider with multiple office locations submits claims using the incorrect provider number.
  • A unique provider number is assigned to each provider location to meet federal reporting requirements to identify where services were rendered. If you have multiple locations, you may have the same root number for each location, but the prefix and check digit for each will differ. Please use the number for the location where services were rendered. If your practice moves, a new provider number may be assigned for the new location, and the current provider number for the previous location may be terminated. Please do not use a terminated provider number.
• A diagnosis code is missing, invalid, or invalid for the patient’s age or gender, or is incorrectly entered on the claim.
  • The code for the condition being treated must be provided and it must be appropriate for the patient. Use valid codes from the ICD-10-CM coding manual coded to the highest degree of specificity. If only a narrative description is provided, the claim will suspend for manual review. On the CMS 1500 claim form, the ICD-10-CM diagnosis code must be entered in field #21. The diagnostic reference numbers 1, 2, 3, and/or 4 from field #21 must be entered in column 24E to relate the billed service(s) to the appropriate diagnosis code. Do not enter the ICD-10-CM diagnosis code in column #24E.

Revision History