Important information on claims review policy, routine supplies, services and medical equipment reimbursement, and itemized bill submission.
Community Health Options Claims Review Policy
Claims submitted to Health Options are evaluated for compliance with CMS coding and billing rules, any applicable contractual requirements, and our own policies. For transparency about the claim edits noted on your Bill Audit Review Summary Reports we include direct links to the applicable policy rules. The full Payment Integrity Audit Reimbursement Policy is available at https://healthoptions.org/media/2127/payment-integrity-audit-policy.pdf.
Healthcare providers are responsible for accurate and timely documenting, coding and billing to enable appropriate claims review. We recommend a proactive review of the policy to ensure compliance and reduce your claim denials. Please be particularly aware that claims lacking appropriate CPT or HCPCS coding and associated modifiers will not be guaranteed appropriate reimbursement.
Routine Supplies, Services, and Medical Equipment
Community Health Options uses the CMS definition for routine supplies and services that are considered bundled into a main procedure and are not reimbursable separately. This includes medical equipment, instruments, apparatuses, implements or items that are generally used for diagnostic or therapeutic purposes, are not implanted or incorporated into a body part, and are reusable. The Routine Supplies, Services, and Medical Equipment Reimbursement Policy is available at https://www.healthoptions.org/media/2031/routine-supplies-services-and-medical-equipment-06-27-19.pdf.
Itemized Bill Submission
Claims of $20,000 or more must include an itemized bill to be considered for payment. You can avoid payment delays by emailing the itemized bill to firstname.lastname@example.org on the same day the associated claim is submitted. We may also request Itemized bills on claims identified for further review. The Itemized Bill Submission Reimbursement Policy is available at https://www.healthoptions.org/media/2033/itemized-bill-submission-07-15-19.pdf.
For additional information on these, or other guidelines and policies, contact Health Options’ Provider Relations Team at (207) 402-3347.
Every year Community Health Options provides a report to the communities we serve. The resulting document is not only a retrospective look, but also provides insight into the succeeding year's programs and services aimed at changing the landscape of health insurance, transforming the healthcare experience, and expanding access to needed care for people we serve in Maine.