Billing

CBHA Claims Procedures

CBHA network providers are required to submit claims for services rendered on the HCFA - 1500 Claim Form. Standard HCFA - 1500 guidelines should be followed; providers are responsible to complete all applicable sections of the form.

• Claims for behavioral health services will not be processed without a DSM (most recently-published edition) diagnosis.
• Clean claims with correct information must be received within 180 days of the date of service to be eligible for reimbursement. Claims filed beyond the time limit are denied and the patient may be billed for any deductible, co pay and/or coinsurance amount only.

Remittance Advice: Network providers will receive a written statement explaining how benefits were applied that includes a Remittance Summary) and payment, if payment is due. Network providers having questions regarding their Remittance Advice should contact the CBHA Claims Department at 1-800-475-7900.

Anyone having questions regarding claims procedures or the status of a claim should contact the CBHA Claims Department at 1-800-475-7900.

Coordination of Benefits

CBHA will coordinate benefits in instances where an enrollee is covered under another plan in addition to the CBHA Plan (the Plan). When the Plan is considered primary, the Plan will reimburse the full extent of covered behavioral health services, which is the network provider's billed charges or the CBHA allowed amount (less any co-payment, co-insurance or deductible and with-hold), whichever is less. When the Plan is secondary, it will reimburse the provider for covered services in conjunction with the primary plan so that the two plans do not exceed the lowest amount, which the provider would be entitled to receive as a participant in either plan. If the enrollee does not have a legal obligation to pay all or part of the provider's billed charges, the Plan, as secondary payer, will also have no obligation to pay that portion of the provider's billed charges.

The claims should first be filed to the primary carrier as determined by the rules above. If the Plan is determined to be secondary, claims should be submitted within sixty (60) days of receipt of payment from the primary carrier along with a copy of the Explanation of Benefit (EOB). If the Plan receives a claim and has information that the enrollee has other coverage, the claim will be pended for further investigation. Release of payment for that claim will not be made until CBHA receives proof of primary payment or denial. If the enrollee does not have other coverage, it is his/her responsibility to contact the Plan directly to update his/her records; information relative to other coverage will not be accepted from a provider's office.

Note: If the Plan is secondary, the rules for the primary carrier should apply; therefore, the Plan's co-payment is not to be collected for the office visit. However, providers must still procure pre-authorization in order for the Plan to pay as secondary.

Determination of Primary Payor:

• No Coordination of Benefits Provision: When there are two plans and the other plan does not contain a written coordination of benefits provision, the plan without the provision will be the primary.
• Employee Versus Dependent Status: When a patient is covered as an employee under one plan and a dependent under the other, the plan under which the person is covered as an employee is the primary.
• Dependent Children (Birth Date Rule): When a dependent child is covered under both parents' plans, the plan of the parent whose birthday falls earlier in the year will be primary. If the parents are divorced or separated, the following guidelines apply:
  • When a parent has financial responsibility for the child's health care expenses by court decree, his/her plan is primary.
  • When financial responsibility has not been established, the health plan of the parent with legal custody of the child of is primary.
  • When financial responsibility laws have not been established and the parent with legal custody remarries and the child's step-parent's plan also covers the child as a dependent, the order of primacy is as follows:
    • The health plan of the parent with legal custody;
    • The health plan of the step-parent;
    • The health plan of the parent without legal custody.
• Active and Retirement Plans: If one health plan is a retirement plan and the other is the Plan where a person is actively employed (the active plan); the active plan is primary and the retirement plan is secondary.
• Workers Compensation, Medicare and Other Employer Liability Laws: If benefits are available as primary benefits to an enrollee or his/her covered spouse or covered dependents under Medicare or any Workers Compensation Laws, Occupational Disease Laws or Employer Liability Laws, those benefits will be primary.
• If none of the rules for order of payment apply, then the plan under which the enrollee has been enrolled the longest is the primary plan.

Any questions concerning primary insurance may be referred to the CBHA Claims Department.

Refunds and Recovery of Overpayments

In the event a claim is mistakenly underpaid, CBHA will promptly make an adjustment and issue the corrected amount on the next claims payment to the provider. If for any reason the Plan has mistakenly paid or overpaid a claim, CBHA will deduct the overpayment from the provider's next claims payment. This adjustment will be noted on the Remittance Advice as a negative amount and shall include a "Remark Code" indicating the reason the adjustment was made. All recoupments are clearly identified on the remittance summary and no single overpayment is recouped partially and carried over to the next claims payment.

Appeal/Grievance of Claims Denial

Most administrative issues such as delay in claims reimbursement can be resolved quickly and informally through verbal discussions between the provider and the CBHA Claims Department staff. Providers having an issue regarding claims payment should contact a claims staff member for further discussion. Written requests for reconsideration of denied claims must be submitted no later than one hundred eighty (180) days after the date of the denial. The request should state the reasons for the request, including supporting documentation and any new or additional information that will help CBHA make a decision. An acknowledgment letter will be sent within three (3) business days of receipt of the appeal. The letter will include the name, address and phone number of the appeals coordinator and will provide instruction for submitting written material. CBHA has thirty (30) days to review an appeal and prepare a written decision. Providers have a right to review pertinent documents and submit issues and comments to CBHA within the one hundred eighty (180) day period after receipt of the written notice of denial. (See the Complaints and Grievances and Appeals Section of this manual.)