Condition for Clean claim
For information about the forms to use for submitting claims, see Claim Specifications section in this chapter.
To qualify for payment, clean claims must also meet the following Conditions of Payment:
** The billed services must be:
** Covered in accordance with the applicable benefit document provided to Tufts Medicare Preferred HMO members who meet eligibility criteria and are Members on the date of service
** Furnished by a provider eligible for payment under Medicare
** Provided or authorized by the member’s PCP or the PCP’s covering provider in accordance with the applicable benefit document, or as identified elsewhere in your agreement with Tufts Health Plan (if applicable)
** Provided in the member’s Evidence of Coverage document
** Medically necessary as defined in the Medicare coverage guidelines
** Tufts Health Plan received the claim within 60 days from the date of service or the date of discharge if the member was inpatient, or date of the primary insurance carrier’s explanation of benefits (EOB).
** The services were preregistered and/or prior authorized in accordance with Tufts Medicare Preferred HMO’s preregistration and precertification procedures.
** The services were billed using the appropriate CPT codes and/or HCPCS codes.
** In the case of professional services billed by the hospital, services were billed electronically according to the HIPAA standard or on CMS-1500 and/or UB-04 forms with a valid CPT code and/or HCPCS code.
All services rendered to Tufts Medicare Preferred HMO members must be reported to Tufts Health Plan as claims data. Claim forms are submitted by providers for both payment and tracking purposes.
All services rendered to Tufts Medicare Preferred HMO members must be reported to Tufts Health Plan Medicare Preferred as encounter or claims data. An encounter is a billing form submitted by capitated providers for tracking purposes. Claim forms are submitted by noncapitated providers for both payment and tracking purposes.
For information about the forms to use for submitting claims, see Claim Specifications section in this chapter.
To qualify for payment, clean claims must also meet the following Conditions of Payment:
** The billed services must be:
** Covered in accordance with the applicable benefit document provided to Tufts Medicare Preferred HMO members who meet eligibility criteria and are Members on the date of service
** Furnished by a provider eligible for payment under Medicare
** Provided or authorized by the member’s PCP or the PCP’s covering provider in accordance with the applicable benefit document, or as identified elsewhere in your agreement with Tufts Health Plan (if applicable)
** Provided in the member’s Evidence of Coverage document
** Medically necessary as defined in the Medicare coverage guidelines
** Tufts Health Plan received the claim within 60 days from the date of service or the date of discharge if the member was inpatient, or date of the primary insurance carrier’s explanation of benefits (EOB).
** The services were preregistered and/or prior authorized in accordance with Tufts Medicare Preferred HMO’s preregistration and precertification procedures.
** The services were billed using the appropriate CPT codes and/or HCPCS codes.
** In the case of professional services billed by the hospital, services were billed electronically according to the HIPAA standard or on CMS-1500 and/or UB-04 forms with a valid CPT code and/or HCPCS code.
All services rendered to Tufts Medicare Preferred HMO members must be reported to Tufts Health Plan as claims data. Claim forms are submitted by providers for both payment and tracking purposes.
All services rendered to Tufts Medicare Preferred HMO members must be reported to Tufts Health Plan Medicare Preferred as encounter or claims data. An encounter is a billing form submitted by capitated providers for tracking purposes. Claim forms are submitted by noncapitated providers for both payment and tracking purposes.