Billing Tips & Guidelines

Rejected Claims

  • If a claim was previously rejected by our clearinghouse, a record of the claim remains in our system. The rejection was for a front-end edit on the claim.  When you resubmit the corrected claim, do not resubmit as a Void and Replace claim.  This will cause the claim to drop from loading into our system.  Void and Replace is used for those claims that were already accepted as “clean”.  When a claim was rejected, it was not a “clean claim”.  Therefore, when resubmitting, it must be as a new, original claim to be accepted into the system.

Quality Limits

  • Never bill a service with the quantity of “0”, even when the code is for reporting purposes only. This causes the claim to pend rather than auto-adjudicate.  To ensure prompt processing, always include a unit > 0 for quantity.

Prescription Co-pay Assistance:

  • THC works with a vendor to assist members with copayments related to certain high-cost drugs. Therefore, when providers who render services of these high cost drugs receive their Explanation of Payments, it is appearing that their reimbursement is not adequate because the member responsibility is not showing up on the EOP.  The vendor is supposed to send the member’s responsibility portion directly to the provider of services.  We have had some issues with this process and are currently working to make this information more clear on the EOP.  Stay tuned.