Claims Filing Procedures
MHC is committed to reimbursing our providers promptly and accurately in accordance with our contractual agreements. We strive to inform providers of claims processing requirements to avoid administrative denials that delay payment and require resubmission of claims.
MHC reimburses mental health and substance abuse treatment providers using fee schedules for professional services. MHC’s professional reimbursement schedules include the most frequently utilized HIPAA-compliant procedure codes for professional services. MHC provider contracts require claims to be submitted within one year of the provision of covered services. MHC will deny claims not received within applicable state mandated or contractually required timely filing limits. A claim must contain no defect or impropriety, including a lack of any required substantiating documentation, HIPAA-compliant coding or other circumstance requiring special treatment that prevents timely payments from being made. If the claim does not contain all required information, it will be denied.
Note: If applicable state law defines “clean claim,” MHC applies the state-mandated definition.
- Contact MHC prior to rendering care if the member’s benefit plan requires authorization for the service.
- Complete all required fields on the CMS-1500 or UB-04 form accurately.
- Collect applicable copayments or coinsurance from members.
- Submit a clean claim for services rendered, including your usual charge amount. Do not automatically bill your contracted rate as the charge amount.
- Submit claims for services delivered in conjunction with the terms of your agreement with MHC.
- Use only standard code sets as established by the Centers for Medicare & Medicaid Services (CMS) or the state of your licensure for the specific claim form (UB-04 or CMS-1500) you are using.
- Submit claims within one year of the provision of covered services.
- Not bill the patient for any difference between your MHC contracted reimbursement rate and your standard rate. This practice is called “balance billing” and is not permitted by MHC.
- Contact the MHC provider relations department for assistance.
- You may bill a member directly who misses a scheduled appointment, but only if you have provided written advice notifying the member of your missed appointment policy and the member has acknowledged that policy in writing. Members may not be billed in excess of the applicable network fee schedule for such services.
- File any claims appeal within 90 days of payment for consideration, or in accordance with state and federal regulatory requirements and/or customer requirements.
- Provide verbal notice when we authorize services.
- Process your claim promptly and complete all transactions within regulatory and contractual standards.
- Apply pre-payment claim edits to claim submissions in order to identify common industry standard billing errors or other identified issues. MHC periodically updates its claims payment system to correctly apply coding edits, in addition to being aligned with national industry standards that include, but are not limited to:
- Centers for Medicare & Medicaid Services (CMS) guidelines
- American Medical Association (AMA) Current Procedural Terminology (CPT®)
- Health Care Common Procedure Coding System (HCPCS)
- International Classification of Diseases, 10th Edition (ICD- 10)
- Inform you of any reasons for administrative denials and action steps required to resolve the administrative denial.
- Provide appropriate notice regarding corrective action or information required if a claim is denied and reconsider the claim upon receipt of requested information.
- Adjudicate claims based on information available.
- Review our reimbursement schedules periodically in consideration of industry standard reimbursement rates and revise them when indicated.
- Communicate changes to claims filing requirements and reimbursement rates in writing prior to the effective date.