Can providers still bill with a
26-modifier for vaccine administration?
No. The correct modifier to bill for vaccine
administration is the SE-modifier.
If a PP member has COB, do we
require a referral in order to pay our portion of the claim?
No, not for outpatient services. Providers can
submit a copy of the OIC ECB with the claim. For inpatient services,
the facility needs to place a pre-certification on file.
Can members be billed for
non-covered services? Services denied by code review? Missed
appointments? Copying of medical records for transfer to another
physician?
No. Per Medicaid
guidelines, providers cannot bill members for these services. For
non-covered services the member must have previously signed a
release form with the provider, and completely understand that they
may be responsible for the non-covered service if PP denies, yet
they still elect to have that service performed.
Will PPMCO pay for both a sick
visit and a preventive visit on the same day when the sick visit is
billed with a 25-modifier?
Yes. PPMCO will bill the sick visit with a 25-modifier, and must
bill with both a well and sick diagnosis.
If a patient is non-compliant with
regards to keeping appointments or following direction of their
provider who do I contact?
You may contact our Outreach Department directly at 1-888-500-8786
to assist in contacting the member directly to discuss.
Where do I send claims that I feel
were either paid or denied in error and/or who do I call?
You can call Customer Support at 1-800-654-9728
to discuss the claims. Or, you can resubmit the claims and attach
the Claims Adjustment/Appeal Form and mark the appropriate box
indicating what the error is.
Does Priority Partners have
certain referral form that needs to be used when referring patients
to specialist or testing?
The
referral form used by Priority Partners is the Maryland Uniform
Consultation Referral Form. This form is used by other insurance
companies as well. It is not strictly for Priority Partners.
How do I open or close my panel
to new patients?
You will
need to fax or mail your request in writing on letterhead. Once the
request is received your panel will be open/closed. You may
follow-up to ensure your request was received and processed by
calling Customer Support at 1-800-654-9728.
How do I go about requesting a
copy of my current fee schedule?
You will need to fax the list of codes you would
like fees on directly to the Provider Relations Department or your
Network Manager, please include the provider name and tax id on the
request. Once the codes are received they will find the fees for
those codes and fax them back to you.
How do providers resolve disputes with JHHC?
According to the JHHC Provider Agreement: The
parties hereto encourage the prompt and equitable settlement of all
disputes, controversies, or claims (“Disputes” ) between or among
them, including those arising out of this Agreement of the Payor
addenda. At any time, any party may give the other written notice
that it desires to settle a Dispute. Within ten (10) days of
delivery of such notice, the parties agree to meet in good faith to
resolve such Dispute. If such Dispute cannot be resolved within a
reasonable amount of time, the parties agree to resolve such Dispute
in accordance with JHHC’s written dispute resolution policies and
procedures, as set forth in the Provider Manual. Such dispute
resolution policies and procedures shall include, but not be limited
to, policies and procedures to resolve disputes relating to
Provider’s status as Participating Provider or Provider’s
professional competency or conduct.
