Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 482 - NEBRASKA MEDICAID MANAGED CARE
Chapter 4 - THE HERITAGE HEALTH MANAGED CARE CORE BENEFITS PACKAGE
Section 482-4-004 - PROVIDER PAYMENTS

004.01(A) ELECTRONIC CLAIMS SYSTEM. The health plan must maintain a health information system that includes the capability to electronically accept claims for adjudication and make payments in accordance with the standards set forth in the Health Insurance Portability and Accountability Act of 1996. Such electronic system must have the ability to transmit data to a central data repository that complies with the requirements for confidentiality of information under the Medicare program.

004.01(B) MINIMUM TIMEFRAMES. The health plan must comply with the following minimum timeframes for the submission and processing of clean claims. Timeframes are calculated from the day the clean claim is received by the health plan until the date of the postmark that returns the claim either to the provider or until posted on an electronic system;

004.01(C) PROMPT INVESTIGATION AND SETTLEMENT OF CLAIMS. The health plan must comply with the requirements related to claim forms as set forth in Title 471 NAC. For providers of outpatient services, this must include the use of CMS-1500 form, the Health Insurance Claim form, and the standard electronic Health Care Claim: Professional Transaction form (ASC X12N 837). For hospitals providing inpatient or outpatient services, this must include the CMS-1450 form (UB-92) and the standard electronic Health Care Claim: Institutional Transaction form (ASC X12N 837).

004.01(D) SYSTEM REQUIREMENT. The health plan must maintain an editable system for recording all claims, clearly indicating the date on which a claim is received and the date(s) any action(s) on the claim occur.

004.01(E) PAYMENT STANDARD. The health plan must pay clean claims promptly as provided above after the date of receipt of or electronic notice of the claim. If, for whatever reason, the claim is submitted electronically and in written form, the date of the earlier submission of the claim will be the date of notice from which the health plan must calculate the maximum thirty day period.

004.01(F) NOTICE OF CONTESTED CLAIM. The health plan must provide written or electronic notice to the provider of a determination by the health plan that the claim is a contested claim with the returned claim. The written or electronic notice must comply with the provisions in Title 482 NAC 4-004.

004.01(G) NOTICE REQUIREMENT FOR PARTIALLY CONTESTED CLAIM. If the health plan determines that part of a claim is a contested claim and returns the claim, the health plan must provide written or electronic notice of that determination to the entity submitting the claim and must proceed to pay the portion of the claim determined by the health plan to be a clean claim timely.

004.01(H) PROHIBITED ACTION. In no instance will the health plan contest or return a claim or a portion of a claim because the claim fails to provide certain information if the missing information does not prevent the plan from adjudicating the claim.

004.01(I) NOTICE OF INSUFFICIENT INFORMATION. If the health plan determines a claim provides insufficient information for the payment of the claim, the health plan must provide written or electronic notice of this determination to the entity submitting the claim timely including the following information:

004.01(J) EFFECTIVE NOTICES AND PAYMENTS. Written notice of a claim will be effective upon the date that the claim is received. Electronic transmission of the claim will be the date the claim is posted to the electronic transfer system. Payment and notices from the health plan will be effective as of the date that:

004.01(K) CONTENTS OF A NOTICE OF A CONTESTED CLAIM. The health plan must specify in its notice of a returned claim at least the following information:

004.01(L) USE OF INTERMEDIARIES. A health plan's use of subcontractors to perform one or more of the health plan's claims handling functions must not mitigate, in any way, the health plan's responsibility to comply with all of the terms of Title 482 NAC.

004.01(M) ELECTRONIC REMITTANCE ADVICE. Electronic remittance advice must be provided in accordance with the standards set forth in the Health Insurance Portability and Accountability Act of 1996.

004.01(N) CLAIM STATUS INQUIRY AND RESPONSE. Electronic claim status inquiry and response must be provided in accordance with the standards set forth in the Health Insurance Portability and Accountability Act of 1996.

004.01(O) ENCOUNTER DATA. The health plan must maintain an information system that includes the capability to collect data on member and provider characteristics, and claims information through an encounter data system. The health plan must submit encounter data to the Medicaid Management Information System monthly per Departmental specifications.