Claims Today
Claims Tips
Inclusive Versus Exclusive Fees on Facility Claims
TIP: Contact the facility for payment if services are denied as being “included in the per diem rate”
In order to submit your claim for professional fees to the appropriate entity, it is important to know whether the Magellan agreement with the facility is inclusive or exclusive. The Magellan facility provider agreement specifically includes (inclusive) or excludes (exclusive) professional fees associated with per diem charges.
Providers who submit a claim for services rendered in a facility with an inclusive agreement with Magellan will receive the following denial:
“Reimbursement for these charges is included in the facility per diem rate.”
If you receive this denial message, please contact the facility for payment.
Use the Red-Type CMS-1500 Form for Paper Claims
TIP: Other than submitting claims electronically, using the red-type CMS-1500 form to submit claims is the best way to ensure accurate and prompt claim processing
- Magellan scans claim information submitted on red-type CMS-1500 forms directly into our claim system for benefit consideration.
- While all claim submissions are given timely and accurate consideration, the optical scanning of red-type CMS-1500 forms allows us to pull the data directly from the paper claim and immediately load it into the claim system for adjudication.
- The elimination of manual data entry further reduces the possibility of error, while allowing claim benefits to be considered promptly.
For additional information on the optical scanning process and contact information for ordering red-type CMS-1500 forms, please see the previous article on this topic.
Duplicate Claims Versus Resubmissions
Tip: Don’t resubmit original claims that have a finalized status
If you disagree with a payment decision (e.g., a denial or underpayment) and no changes to the original claim information are required, call Magellan’s customer service line before resubmitting another claim. If it is determined that the decision must be reversed, Magellan can reprocess from the original claim. This will help avoid duplicate claim denials that may result from a resubmission.
However, if changes to the original claim are required (e.g., change to CPT® code or billed amount) you should resubmit the claim with corrected information. A change to claim information cannot be taken verbally; it must be received as a corrected claim.