Claims and Billing
(1)Only an enrolling or ancillary provider providing WW Program covered services pursuant to a fully executed medical services agreement, and who has been assigned an agency number may submit claims for payment to the Center for providing WW Program covered services.
(2)An enrolling or ancillary provider shall, as applicable:
(a)Submit claim information in the manner specified by the WW Program;
(b)Include a primary diagnosis code on all claims;
(c)Code all claims with the most current and appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis codes and the most appropriate Current Procedural Terminology (CPT) codes as noted in the WW Program Manual;
(d)Submit to the Center all claims for services within 12 months of the date of service;
(e)Submit a billing error edit correction, or refund the amount of the overpayment, on any claim where a provider identifies an overpayment made by the Center;
(f)Make all reasonable efforts to ensure that the WW Program is the payor of last resort with the exception of clinics or offices operated by the Indian Health Service (IHS) or individual American Indian tribes. For the purposes of this rule “reasonable efforts” include:
(A)Determining the existence of insurance coverage or other resource by asking the client; and
(B)Except in the case of the underinsured, billing any known insurer in compliance with that insurer’s billing and authorization requirements.
(g)Submit to the Center a billing error edit correction if it receives a third party payment and refund to the Center the amount received from the other source within 30 days of the date the payment is received.
(3)The Center may not pay a claim older than 12 months, except as provided for in section (4) of this rule. An enrolling or ancillary provider that has a claim rejected because of an error must resolve the error within 12 months of the date of service.
(4)If the Center makes an error that makes it impossible for an enrolling or ancillary provider to bill within 12 months of the date of service, the enrolling or ancillary provider shall notify the Center of the alleged error and submit the claim to the Center. The Center shall confirm that it made an error prior to payment being made.
(5)The Center may not pay a claim that includes a primary diagnosis code that is not in the WW Program Manual.
(6)An enrolling or ancillary provider with the WW Program may not seek payment from a client, or from a financially responsible relative or representative of that client for any services covered by the WW Program.
(7)An enrolling or ancillary provider may bill a client for services that are not covered by the WW Program. However, the provider must inform the client in advance of receiving the specific service that it is not covered, the estimated cost of the service, and that the client or client’s representative is financially responsible for payment for the specific service. Providers must document in writing that the client was provided this information and the client knowingly and voluntarily agreed to be responsible for payment. The client or client’s representative must sign the documentation.
(8)Except for services performed by a CLIA certified laboratory outside of the clinic, all billings by an enrolling provider must be for services provided within the provider’s licensure or certification.
(9)A provider who has been suspended or terminated from participation in a federal or state medical program, such as Medicare or Medicaid, or whose license to practice has been suspended or revoked by a state licensing board, may not submit claims for payment, either personally or through claims submitted by any billing provider or other provider, for any services or supplies provided under the WW Program, except those services provided prior to the date of suspension or termination.
Rule 333-010-0245 — Claims and Billing,