Requirements for Claim Submissions

Date: 08/05/24

Superior HealthPlan aims to make the provider experience seamless. To help ensure provider claims do not deny and are processed quickly and efficiently, below are important claim submission tips and reminders.

INVALID OR UNCLEAN DATA

Claims submitted with invalid or unclean data will result in denial or rejection of an entire claim. All claims submitted to Superior require valid data elements on each line of a claim.

Examples of required data elements include, but are not limited to, the following:

• Taxonomy - If billing or rendering National Provider Identifier (NPI) is submitted, the claim must also include the taxonomy or the entire claim will be rejected. It must also be the taxonomy that the provider attested to on the Master Medicaid File, which matches what was submitted during enrollment with Texas Medicaid and Healthcare Partnership (TMHP).
• Facility Address - The submitted facility address on the claim must match the physical address of the location that has been issued a neonatal level of care designation. If the facility address is not included on the claim, the submitted billing address must match the physical address of the location that was issued (ex. neonatal level of care designation).
  • Important: The hospital address on the health facilities license must match the address billed on the claim. Claims will be denied if the address submitted on the claim does not match the address on file. Providers should refer to the Department of Health and Human Services (DSHS) approval letter to verify the correct address. For more information on address updates, please refer to the DSHS website.
• National Drug Code (NDC) -  If required NDC data elements are missing or invalid for a procedure code on a claim line, the entire claim will no longer be denied, only the service line missing the NDC data will be denied.
  • Superior will deny service lines if the NDC submitted with the drug procedure code is not on the Texas NDC-to-HCPCS Crosswalk that was effective on the date of service.
  • Anytime a provider submits a national drug code on a claim, regardless if the HCPCS (Healthcare Common Procedure Coding System) is on the Vendor Drug Program NDC to HCPCS crosswalk, the following guidelines must be followed:
    • Length of NDC must be 11 digits.
    • Data in NDC must be numeric.
    • First 5 characters of NDC can’t be 00000 or 99999.
• CPT or HCPCS - If a Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure code is submitted on any line of the claim, it must be a valid code for the date of service billed or the entire claim will be denied.
• Service Facility Location - If services are rendered in a facility location, a Service Facility Location (box 32) must be included on a professional claim. Superior will reject the entire claim if the Service Facility Location is not billed on a professional claim when the location is listed below: 

PLACE OF SERVICE	2-DIGIT CODES
Inpatient hospital	21, 51, 52, 55, 56, 61
Outpatient hospital	19, 22, 23, 24, 62
Skilled nursing facility or intermediate care facility for IDD or related conditions	13, 31, 32, 54
Extended care facility	14, 33

• PO Boxes - Claims will deny if a billing provider’s address is not a street address or physical location claims. A Post Office (PO) Box is not an acceptable submission for the billing provider address. Providers that are including a PO Box as the billing provider address in their claim submission, must transition their PO Box address to a physical address.
  
  All claims submitted to Superior must include the required, valid clean claim data elements. The billing provider address is a required data element needed in a claim.
  
  Providers can enter the billing provider address in the following location for:
  
  
  • Paper claims
    • CMS 1500 Claim Form - Box 33
    • UB-04 Claim Form - Box 1
  • Electronic claims
    • Loop 2010AA N301
• Admission Date - The admission date on an institutional claim must not be after the statement begin date. The exception to this rule is allowed if the type of bill is listed in the table below:

ADMISSION DATE BILL TYPES
110	111	112	113
114	115	117	118
120	121	122	123
124	125	127	128

• Admission Source – Claims billed with an invalid admission source will be denied. Please reference the Uniform Billing Editor to determine if an admission source is valid.
• Other Billing Considerations – Institutional claims will be denied for the following instances:
  • When the billing provider is the same as the attending provider.
  • When the billing provider is the same as the rendering provider.

For any questions, please contact your Account Manager. To access their contact information visit Find My Account Manager. You may also call Provider Services at 1-877-391-5921.