Provider Reporting Responsibilities
You are required to report all adverse events identified above, whether actual or potential. To report such incidents, call 877-504-1179.
You must report incidents to the Agency for Healthcare Administration within 24 hours of it happening. You must report all serious incidents, such as those listed below, immediately. This allows us to quickly access the risk and address liability.
Examples of serious incidents include:
- Death or serious injury;
- Brain or spinal damage;
- Performance of a surgical procedure on the wrong patient;
- Performance of a wrong site surgical procedure;
- Performance of a wrong surgical procedure;
- Medically unnecessary surgical procedure;
- Surgical repair of damage from a planned surgical procedure; or
- Removal of unplanned foreign object remaining from a surgical procedure.
Our provider contracts include the obligation to participate in Quality Management inquiries upon request from the Clinical Quality Analyst.
What are the Responsibilities of Physicians and Providers?
You must report the ICD-10-CM diagnosis codes to the highest level of specificity and accurately. This requires accurate and complete medical record documentation. You are required to alert the Medicare Advantage organization of wrong information submitted. You must follow the Medicare Advantage organization’s procedures for correcting information.
Finally, you must report claims and encounter information in a timely manner, generally within 30 days of the date of service (or discharge for hospital inpatient facilities).
Links to resources for the latest ICD guidelines and MRA resources are available online at medicaplans.com.
CPT and HCPCS Codes
The American Medical Association (AMA) and the CMS update procedure codes quarterly, with the largest volume effective January 1 of each year. CPT and HCPCS codes may be added, deleted, or revised to reflect changes in healthcare and medical practices.
If you submit your claim with an invalid or deleted procedure code, we will deny or return it. A valid procedure code is required for claims processing.
We encourage you to access CPT, HCPCS and ICD-10 coding resources and materials at the American Medical Association website at ama-assn.org, or from another vendor.