Administrative Overview

Preferred Choices PPO is a network of physicians, hospitals and other health care providers located throughout Michigan. Preferred Choices PPO is a network lease PPO product that can address employers’ desires for self-funded and insured PPOs. Preferred Choices PPO partners with several third party administrators (TPA) and/or insurance companies that utilize our Preferred Choices PPO leased network. Preferred Choices PPO provides access to a statewide network of 70 hospitals and more than 9,700 physicians.

Introduction
Overview of How Preferred Choices PPO Works
Key Contacts
Preferred Choices PPO Service Area
Provider Access Line
Filing Claims Electronically
How do I begin using Electronic Data Interchange (EDI)?
EDI Service Line
Trouble Shooting the Electronic Claims Audit Report
Filing Paper Claims
CMS-1500 Form
When to Bill the Member
Coordination of Benefits
Rebilling
OB Billing
Hospital Billing for Emergency Room or Observation Room Charges
Facility Claims
Newborn Billing
How To Submit Outlier Claims
UB-92 Form
Member ID Cards

Introduction

Preferred Choices PPO is a network of physicians, hospitals and other health care providers located throughout Michigan. Preferred Choices PPO is a network lease PPO product that can address employers’ desires for self-funded and insured PPOs. Preferred Choices PPO partners with several third party administrators (TPA) and/or insurance companies that utilize our Preferred Choices PPO leased network. Preferred Choices PPO provides access to a statewide network of 78 hospitals and more than 11,300 physicians.

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Overview of How Preferred Choices PPO Works

Employers select a TPA or insurance company to administer all aspects of their employee benefit program including, eligibility, benefits and claims processing. Preferred Choices PPO allows the employees access to the contracted physician network, but does not perform any administrative function. With Preferred Choices PPO, members can receive health care services from a participating physician or outside the network. If a member receives out-of-network services, the member may have more out-of-pocket expenses.

Pre-Pricing
When your office submits Preferred Choices PPO claims to us at Preferred Choices PPO, PO Box 9084, Farmington Hills, MI 48333-9084, our staff indicates the appropriate negotiated fee amount on the claim. This process is known as pre-pricing. Once the claims have been pre-priced they are for-warded to a TPA or insurance company for actual payment.

Precertification
Precertification assists the physician and the member in determining whether certain elective health care services are medically necessary, and/or are provided in the most appropriate setting. The employer or insurance company selects the utilization review firm and it is the physician’s responsibility to obtain precertification. Precertification may be required for inpatient admissions (any facility type); specific outpatient surgeries and services; specific diagnostic procedures; therapies and recertification.

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Key Contacts

For inquiries other than those listed below, contact the Customer Call Center.

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Provider Access Line

Preferred Choices PPO automated telephone inquiry system, called the Provider Access Line (PAL), is available 24 hours per day, seven days per week. Using a touch-tone telephone, any participating provider can access the following information rapidly with no limitation on inquiries per call.

• Pre-priced Claims Status
• Third Party Administrator (TPA) Contact Telephone Numbers

The TPA will provide information on benefits, claims status, eligibility, and precertification.

How to use the PAL

• Call (800) 387-0145
• Have your six-digit Preferred Choices PPO participating provider ID number ready
• Have the member's 9-digit member ID number ready
• Have the member's 6-digit date-of-birth ready (mmddyy)

Then follow the directions provided to access the prompts noted below.

• For Pre-Priced Claims Status (date of service is required) - Press 1
• To obtain the number for:
  • TPA eligibility Information - Press 2
  • TPA precertification Information - Press 3
  • TPA claims and benefit Information - Press 4

After you receive the requested information, you will return to the main menu. Your options are:

• Further inquiries for a member - Press 1
• Inquire about other members - Press 2
• Enter another provider number - Press 3
• Exit - Press 9

If additional information is required,

• Press 0 - To reach a Customer Call Center Coordinator (during regular business hours)

REMINDER

• Preferred Choices PPO members should present their member ID card at the time of service.
• The physician's office is responsible for confirming member eligibility.

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Filing Claims Electronically

Claims can be submitted to Preferred Choices PPO electronically using Electronic Data Interchange (EDI). EDI provides faster claim turnaround time, resulting in quicker payments, less claims preparation time and eliminates postage cost.

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How do I begin using Electronic Data Interchange (EDI)?

In order to expedite claims processing, Preferred Choices PPO is requesting that whenever possible, all claims be submitted electronically. Your office can begin filing claims electronically using the process outlined below.

To ensure your claims are processed accurately and without delay, the following information must be submitted for each claim record:

• Your unique six-digit Provider ID Number (PIN). Please contact our Customer Call Center at (800) 992-6837 if you do not have your PIN number.
  • Important: Your provider number must appear on your EDI transmission. If it is missing, your claims will be rejected.
• Provider’s current tax ID number (Note: Please make sure your tax ID number is current. Contact your Provider Relations Administrator at the telephone number located on the Key Contacts page if there is any change to your tax ID number.)
• Patient’s date of birth and sex.
• Contract Holder ID number (nine-digit number that appears on the front of the member ID card).
• Facility claims must include the claim type, indicating inpatient or outpatient.
• Ancillary, lab and radiology claims must include both the name and State License Number of the ordering physician.

Please use only Industry Standard Codes or codes specified by the State. Preferred Choices PPO does not recognize any Non-Industry Standard Codes. Note: If your claim does not include these standard codes, it will cause an error and not be processed.

Preferred Choices PPO is currently unable to accept the following types of claims electronically. We will advise you as soon as we are able to accept them.

• Anesthesia Claims
• Coordination of Benefits (COB)
• Series Claims (Outpatient services with multiple dates of service, e.g. therapy services, PT, OT, ST)
• Span dates

Claims may be submitted through the following Clearinghouse/Trading Partners:

Physicians: Clearinghouse/Trading Partners

• BCBS: (248) 486-2292
• McKesson: (800) 527-8133
• Medical Billing Services (MBS): (248) 827-0000
• MISYS: (800) 347-3473
• Perse: (440) 461-4200
• ProxyMed: (888) 894-7888
• Web-MD (NEIC): (800) 215-4730

Hospitals: Clearinghouse/Trading Partners

• NDC: (800) 852-0707

Contact one of the listed Clearinghouse/Trading Partners for an overview of the electronic claims submission process. They will address any questions or concerns you may have. Once you have established a relationship with a Clearinghouse/Trading Partner they will assist you in submitting your initial claim file and familiarize you with their particular electronic claim submission procedures.

Providers or provider groups that can create claims in a standard 837 version 4010A1 format may arrange to submit directly to Preferred Choices PPO. Direct transmission offers a way to:

• Eliminate the cost of a clearing house
• Speed up transmission
• Allow automatic feedback on the outcome of the claim pre-pricing

Contact our EDI Coordinator at (248) 489-6884 for information on submitting claims directly to Preferred Choices PPO.

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EDI Service Line

For assistance with EDI start-up, including a new set-up, please call our EDI Service Line at (248) 324-8008.

Important Notes

• Please remember to use Industry Standard Codes or codes specified by the State. Our claims payment system will not recognize Non-Industry Standard Codes.
• Almost all claim types can be submitted electronically except anesthesia, COB, series claims (such as PT/ST/OT) and span dates.
• Your clearinghouse payor number is the same for both Care Choices HMO and Preferred Choices PPO.

The Electronic Claims Audit Report
The Electronic Claims Audit Report shown below is made available and utilized by most of the Clearinghouse/Trading Partners. This report is used to inform the provider of the status of each claim submitted electronically to Preferred Choices PPO.

Claims that appear on the Electronic Claims Audit Report are deemed not to have been received by Preferred Choices and are still subject to existing filing limits. These claims must be corrected and resubmitted electronically or by hardcopy within the filing limit. As providers receive error reports for all electronic transmissions, Preferred Choices PPO will NOT accept account notes as proof of late filing limit exceptions.

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Trouble Shooting the Electronic Claims Audit Report

We frequently receive questions from providers about claims that were rejected when submitted via EDI. A claim is “rejected” when it is missing data, contains invalid data, or the member was ineligible for service. Rejected claims will only appear on your Electronic Claims Audit Report. Rejected claims are deemed not to have been received by Preferred Choices PPO and therefore are not in our system. However, they are still subject to the filing limit specified in your provider contract. These claims should be corrected and resubmitted immediately, following the guidelines in the table below. It is the provider’s responsibility to review the claim status report and determine the reason for the rejection.

Situation Impact Action Required Claims are submitted and member eligibility is not loaded into our system. If a member is not on the system for an individual PPO EDI claim, the claim will continue to error out and be sent back to the trading partner via the Electronic Claims Audit Report. If the eligibility is not maintained on our system, there is no way for the system to determine where the claim should be sent for adjudication and payment. Download the claim to paper and submit the claim to Preferred Choices PPO for investigation. In order to avoid any delays in processing, clearly identify the claim as a RESUBMISSION on the front of the Preferred Choices PPO mailing envelope, and be sure you have identified the employer in field 11 on the HCFA-1500 claim form. Claims are submitted and a provider is not loaded into our system, or there is no PPO affiliation in our database. If a provider is not loaded into our database, or if the current information in the database is incorrect, the individual PPO EDI claim will continue to error out and be sent back to the trading partner via the Electronic Claims Audit Report. Contact your Provider Relations Administrator immediately. The Provider Relations Administrator will verify if your record is in our system to ensure that we can properly pre-price your claims. Once it is verified that all PPO affiliations are correct, you can resubmit your claims electronically.

If you receive two errors on the same claim, we recommend you resubmit the claim via paper using Preferred Choices PPO claims envelopes (refer to PPO Claims Envelopes in this section). When submitting claims on paper, all filing limits will apply. It is important that you resubmit any claims returned to you for additional information within your contractual filing limit.

Reminder: For claims that have been rejected and returned for additional information necessary for pre-pricing, you must submit the corrected claim within your filing limit time period. For example, if your filing limit is 365 days, corrected claim must be submitted with 365days from the service date.

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Filing Paper Claims

Preferred Choices PPO requires all paper claims to be submitted on theCMS-1500 claim form. For efficient claims filing, please follow the steps below. If a claim is missing ANY of the information, Preferred Choices PPO will not be able to pre-price the claim and it will be returned upon receipt.

1. Complete all the required fields from the table on the following page.
2. Submit claims using the specially designed Preferred Choices PPO claims envelope (see illustration below). Contact your local Provider Relations Administrator for a supply. These specially designed claim envelopes assist with efficient sorting of claims, thereby reducing the processing turnaround time. When you use the specially designed claim envelopes, please be sure to:
   • Use separate envelopes for each category (original, resubmission,etc.)
   • Select only one box per envelope.
3. Send Preferred Choices PPO claims claims to Preferred Choices PPO for pre-pricing:

   Preferred Choices PPO
   PO Box 9084
   Farmington Hills, MI 48333-9084

The current turnaround time for pre-pricing “clean” claims is between two and four days. After the claim is pre-priced, it is submitted to the TPA for benefit administration and payment.

Note: Submitting a claim form directly to a TPA or insurance company will only cause a delay in payment as the claim will have to be returned to Preferred Choices PPO for pre-pricing.

A copy of the Preferred Choices PPO envelope is pictured below.

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CMS-1500 Form

IMPORTANT!

• If a claim is received, without any of the above critical claim elements, it will be returned.
• Claims using non-standard CPT or HCPCS codes will be returned. Providers should have a current copy of the CPT and HCPCS coding books in their office.

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When to Bill the Member

Members are expected to pay copayments, if applicable, at the time of service.

Physicians receive an Explanation of Payment (EOP) from the TPA. Once the EOP is received, physician offices may bill the member for:

• Specific services excluded from coverage
• Coinsurance and/or deductibles

Do not bill the member for any balance above the maximum allowable fee.

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Coordination of Benefits

COB claims should be sent directly to the payor and not to Preferred Choices PPO. The only exception is if the primary payor applied total charges to copays, deductibles and/or non-covered services. Please contact the TPA for instructions.

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Rebilling

Please do not continuously rebill without checking the status. You can do this by calling the PAL at (800) 387-0145. We will only confirm if we have received the claim and the date it was pre-priced. The TPA will be able to provide you with more detailed information on the claims status.

If the TPA states they do not have the claim and you have sent the claim to Preferred Choices PPO, call our Customer Call Center at (800) 992-6837 and they will verify if the claim was entered for pre-pricing and if so, when. They can also tell if the claim was scanned and if it has been, they can print the scanned image and then pre-price it. If we do not have record of receiving the claim, you can fax your claim to the Customer Call Center representative and they will coordinate pre-pricing.

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OB Billing

Bill with global codes using the delivery date if a physician (or partnering physician) provides all of a member’s prenatal care and performs the delivery. Fill in the FROM date in box 24A on the CMS-1500 Claim form with the date of the first prenatal visit. Fill in the TO date in box 24A on the CMS-1500 Claim form with the delivery date.

If one physician provides the prenatal care but another physician (from a different practice) performs the delivery (or the delivery and postpartum care), the physician providing prenatal care should itemize dates of service and use appropriate CPT visit codes.

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Hospital Billing for Emergency Room or Observation Room Charges

Care Choices will only pay one room charge for emergent conditions that become observation stays. In this case, we will default to the observation stay charge.

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Facility Claims

Preferred Choices PPO requires all paper claims for hospital expenses to be submitted on a UB-92 Form. For more efficient claims processing, please follow these steps:

• Submit claims electronically, if possible
• Use the red UB-92 revised 4-94
• Type the information from a computer
• Make sure that print is dark enough to read

IMPORTANT!

• If a claim is received without any critical claim elements, it will be returned. Please refer to the table entitled: UB-92 Form Required Fields for Preferred Choices PPO Claims.
• Claims using non-standard CPT or HCPCS codes will be returned. Providers should have a current copy of the CPT and HCPCS coding books in their office.

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Newborn Billing

• All well newborn baby charges are combined with the mom’s charges.
• All sick newborn baby charges are paid individually and the baby must be enrolled in Preferred Choices PPO. These charges are subject to a copay, if applicable.

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How to Submit Outlier Claims

This is defined by contract. Following receipt of initial payment, calculate your outlier and resubmit for further processing.

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Member ID Cards

The member ID card is designed by the TPA or Employer group, not by Preferred Choices PPO. The ID card will have the Preferred Choices PPO logon the front of the card, as well as the name of the TPA and the employer group.

The ID card may contain the following information on the front of the card:

• Contract holder name
• Member ID number
• Employer name/Plan Sponsor
• Member co-pay for office visit
• Effective date of coverage
• TPA name
• Group #
• Pharmacy Carrier

The following information should be found on the back of the ID card:

• In-Network Claims Submission address for participating Preferred Choices PPO providers:

  Preferred Choices PPO
  PO Box 9084
  Farmington Hills, MI 48333-9084

Out-of-Network Claims Submission address:

Administrator’s Name
Address
Phone

• Pre-certification instructions
• Eligibility and Benefits verification information (phone number)

Below is a sample of what an ID card may look like.

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