We recently conducted an audit of claim submission errors. Here's an at-a-glance view of the most common claim submission errors with notation about how e-filing can reduce these in your practice.
|Error||Paper Submission||Provider Express||EDI|
|NPI not entered in all required places||High error rate with no built- in mechanism for identifying and correcting problems||System corrects or prevents||Vendor will likely prevent prior to any actual filing with payor(s) allowing you to complete a one-time correction to your system to address all claims filed|
|Member demographic errors
||High error rate with no built- in mechanism for identifying and correcting problems||System auto-populates member demographic information||Vendor will likely prevent prior to any actual filing with payor(s) allowing you to complete a single correction in your system to address multiple|
|Unclear rendering provider||High error rate with no built- in mechanism for identifying and correcting problems||Legibility assured; system auto-populates provider data from our database||Legibility assured
|Incomplete Diagnosis Code||High error rate with no built- in mechanism for identifying and correcting problems||System will prevent submission of an incomplete code||Vendor may prompt for valid diagnosis code|
|Date of Service (DOS) - not legible or inaccurate||High error rate with no built- in mechanism for identifying and correcting problems||Legibility assured
File claims electronically:
- Provider Express
- EDI clearinghouse
Who should use Provider Express? Our FREE direct data entry system for submitting professional claims from network clinicians and group practices is available to network clinicians. It is ideal for submitting EAP and behavioral health claims for small to medium size offices, including professional claim billing services. By submitting through Provider Express you are assured that the information filed is valid for claim submission. In addition, Provider Express supports real-time claims status inquiry.
What is EDI? Electronic Data Interchange (EDI) is the exchange of information for routine business transactions in a standardized format with your payors. For more information, visit our EDI page.
Who should use EDI? EDI is ideal for submitting batches of claims electronically right out of your practice management system software and for tracking responses back from the payors. EDI may be preferable for high volume providers.
I already file electronically, is there any way to further speed up claims payment? Yes. Receiving your claims payments and remittances from Optum is now even easier. We are pleased to offer you Electronic Payments and Statements (EPS) at no cost to you! Registered users of Provider Express can enroll with our EPS and technology partner, OptumHealth Financial Services, through the secure transactions feature on this site. For more information visit our Optum Pay™ webpage.
Filing claims electronically is by far the fastest and most efficient method to submit claims and initiate payment processing. However, if you are not using an electronic filing method, we recommend you implement the following guidelines.
If filing on paper:
- Use the CMS-1500 form
- Type information into the forms
- Complete all fields, see list below of key elements on the form that are often omitted
- Use original forms as supplied by CMS recognized vendor, do not photocopy the form
If you are filing paper claims, you must ensure that all necessary data is entered on the CMS-1500 form. Notations about item numbers below correlate to the CMS-1500 form. Failure to comply with completion of the required data fields listed below will result in delay in or denial of payment.
- Claims requirements are detailed in the Optum Network Manual and include but are not limited to:
- Member and policy holder name, Member and policy holder address, ID number, date of birth, sex, and relationship of the patient to the policy holder
- Assignment of Benefits - often entered as signature on file when applicable (item number 13)
- Complete Diagnosis out to the furthest digit allowed as designated in the ICD-9 (item number 21)
- Date of service (DOS) for each procedure code (item number 24a)
- Place of service code (item number 24b)
- Valid procedure code (CPT or HCPCS codes for professional services) for each DOS (item number 24d)
- Include the diagnosis pointer (item number 24e, this is generally "1")
- Billing and rendering provider's name, licensure, Name registered to the Tax ID number, NPI Number and Taxpayer Identification Number (TIN)
- Rendering provider NPI (item number 24j)
- Rendering provider name and license (item number 31)
- Billing provider name (item number 33)
- Billing provider NPI (item number 33a)
Note: both billing and rendering provider information must be included as noted above, even when the billing and rendering provider information are the same.
Failure to use the CMS-1500, may result in delays due to illegibility, time required for manual data entry and increased risk of incomplete data. Claims not submitted on a CMS-1500 should be type-written and include all of the required information as noted above.
Online claim services include:
- Provider Express secure transactions (claim entry & claim inquiry)
- Provider Express live chat - a real-time resource for troubleshooting when needed
- information about EDI including FAQs
- links to our EPS technology partner OptumHealth Financial Services
In addition, we have made recent corrections to our automated telephonic routing system to ensure that you get to the right claim customer service representative the first time you call. Your satisfaction with our services is very important to us.
Please visit our Contact Us page for links related to Claims contacts and information.