Reimbursement

E-202

When billing for services or materials, the claim submitted for payment must include a diagnosis and the coding must reflect the actual services provided or materials dispensed. Any payment received from a third-party payor or other persons applicable to the provision of services must be reflected as a credit on any claim submitted to the Department for those services or items.

E-202.1 Charges 

Charges billed to the Department must be the provider’s usual and customary charge billed to the general public for the same service or item. Providers may only bill the Department after the service has been provided. 

Covered services must be billed to the Department using the Current Procedural Technology (CPT) codes or alphanumeric HCPCS codes. An audiologist may only charge for services he or she personally provides. A certified hearing instrument dispenser may only charge for the equipment dispensed. Providers may not charge for services provided by another provider, even though one may be in the employ of the other. 

Charges for services and items provided to participants enrolled in a Managed Care Entity (MCE) must be billed to the MCE according to the contractual agreement with the MCE. Information regarding MCE’s can be found on the HFS Care Coordination web page. 

E-202.2 Electronic Claims Submittal

Any services that do not require attachments or accompanying documentation may be billed electronically

Providers billing electronically should take special note of the requirement that Form HFS 194-M-C, Billing Certification Form, must be signed and retained by the provider for a period of three years from the date of the voucher. Failure to do so may result in revocation of the provider’s right to bill electronically, recovery of monies or other adverse actions. Form HFS 194-M-C can be found on the last page of each Remittance Advice that reports the disposition of any electronic claims.

Please note that the specifications for electronic claims billing are not the same as those for paper claims. Please follow the instructions for the medium being used. If a problem occurs with electronic billing, providers should contact the Department in the same manner as would be applicable to a paper claim. It may be necessary for providers to contact their software vendor if the Department determines that the service rejections are being caused by the submission of incorrect or invalid data. 

E-202.3 Claim Preparation and Submittal

The Department will not accept paper claim forms hand-delivered to HFS office buildings by providers or their billing entities. HFS will return hand-delivered claims to the provider identified on the claim form. All services for which charges are made must be coded on the appropriate claim form.

Form HFS 3797 (pdf), Medicare Crossover Form, is to be used to submit Medicare allowable crossover charges.

 Form HFS 1443 (pdf), Provider Invoice, is to be used to submit charges for audiological services provided to a Department’s Medical Programs participant.

 Form HFS 2210 (pdf), Medical Equipment /Supplies Invoice, is to be used to submit charges to the Department for a hearing aid, hearing aid accessories, supplies, equipment, hearing aid repairs and the dispensing fee.

The Department uses a claim imaging system for scanning paper claims. The imaging system allows efficient processing of paper claims and also allows attachments to be scanned. Refer to Appendix E-1 for technical guidelines to assist in preparing paper claims for processing. The Department offers a claim scanability/imaging evaluation. Turnaround on a claim scanability/imaging evaluation is approximately seven to ten working days and providers are notified of the evaluation results in writing