Effective 02/26/2019, we will introduce new Coding Integrity Reimbursement Guidelines based on industry standards, coding rules published within the Medicare Claims Processing Manual, Current Procedural Terminology (CPT®) by the American Medical Association (AMA) and ICD-10-CM guidelines governed by Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). These are the same rules used by most healthcare claims payers and enforced by the Centers for Medicare and Medicaid Services.
Additionally, to ensure claims process and pay accurately, ‘Ohana Health Plans may deny a claim and request pertinent medical documentation from the provider or supplier who submitted the claim. The medical record request is coordinated with a third-party vendor. Providers should submit adequate medical record documentation that supports the claim (services) billed. Once medical records are received, medical review professionals will examine the documentation to determine if the claim is supported (or not supported) as submitted and pay (or deny) accordingly. Please note that the submission of medical records is not a guarantee of payment.
Determinations as to whether services are reasonable and necessary for an individual patient should be made on the same basis as all other such determinations: with reference to accepted standards of medical practice and the medical circumstances of the individual case.