Claim Filing Procedures for Claim Submission

Keystone Mercy Health Plan, hereafter referred to as the Plan, is required by State and Federal regulations to capture specific data regarding services rendered to its members. All billing requirements must be adhered to by the provider in order to ensure timely processing of claims.

When required data elements are missing or are invalid, claims will be rejected by the Plan for correction and re- submission.

Claims for billable and capitated services provided to Plan members must be submitted by the provider who performed the services.

Claims filed with the Plan are subject to the following procedures:
• Verification that all required fields are completed on the CMS 1500 or UB-04 forms.
• Verification that all Diagnosis and Procedure Codes are valid for the date of service.
• Verification of the referral for Specialist or non-Primary Care Physician claims.
• Verification of member eligibility for services under the Plan during the time period in which services were provided.
• Verification that the services were provided by a participating provider or that the “out of plan” provider has received authorization to provide services to the eligible member.
• Verification that the provider participated with the Medical Assistance Program at the time of service.
• Verification that an authorization has been given for services that require prior authorization by the Plan.
• Verification of whether there is Medicare coverage or any other third party resources and, if so, verification that the Plan is the “payer of last resort” on all claims submitted to the Plan.