A cardiology claim in Kentucky gets paid or denied on three facts: which coverage the patient has on the date of service, whether the cardiologist is enrolled and in network, and where the care took place. Echoes read in the hospital get invoiced differently than a thorough diagnostic investigation done in the practice.
Cardiology Billing then develops eligibility, authorization, coding, claims and follow-up on that data. We tie Kentucky Medicaid, Medicare and commercial criteria to the documentation that supports each cardiac service so the claim reads the way the chart reads.
Verify coverage for the date of service before scheduling testing requiring approval or releasing a claim. Most Kentucky Medicaid members are in managed care, with a lesser percentage in fee-for-service, and the two have different limits.
We work in the same order every time so payer and authorization mistakes get caught early.
The Department for Medicaid Services contracts five managed care organizations/companies. Each has its own network, referral rules, authorization tools, claim routing and appeal steps.
Anthem no longer participates in Kentucky Medicaid managed care, so old Anthem Medicaid records on a patient account are a common cause of misrouted claims.
When a member is enrolled in an MCO, the plan pays the claim and sets its own authorization requirements. A Medicaid ID alone won't tell you which plan to bill.
For services that stay in fee-for-service, Gainwell Technologies processes claims and prior authorizations for the state.
KYHealthNet processes eligibility and billing transactions. MPPA (Medicaid Partner Portal Application) handles Kentucky provider enrollment, maintenance and revalidation.
Kentucky Medicaid enrollment, Medicare enrollment, and plan or commercial credentialing are three separate tasks with their own effective dates. Medicaid enrollment does not guarantee a cardiologist is in every MCO's network. We maintain an ongoing list of each approval and when it goes into effect; we manage profile updates, CAQH where applicable and contract follow-up.
We also match the record of each provider to the claims being billed: NPI, taxonomy, specialization, licensing, billing and rendering linkages, service locations, and group affiliations. Any discrepancy in any of these can hold up payment for months.
Claims need to reflect the provider's actual enrollment, credentialing, network participation, service location and billing relationship. We coordinate these records across the relevant programs and plans rather than assuming one approval applies everywhere.
Explore cardiology revenue cycle managementAuthorization review starts with the member's product, the CPT or HCPCS code being planned, the network, the benefits and the place of service. Rules vary by plan and by procedure, so a requirement that applies to one patient may not apply to the next.
Echocardiography, stress testing, nuclear imaging, catheterization, electrophysiology and interventional work are each reviewed against the patient's own plan rather than a general checklist.
We check the indication, medical policy, ordering provider, site, dates and procedure code for perfusion imaging, cardiac CT, coronary CTA, cardiac MRI and echo.
If the technique or site changes, the approval needs to be re-evaluated before anyone depends on it. Approval is not payment.
Eligibility → plan → procedure review → approval check → records → submission → tracking → claim match
The rules that apply belong to the member's product, not to the name on the insurance card.
Anthem's provider resources include separate Kentucky authorization lists for local products and for national accounts, so we identify the member's coverage before picking one.
Kentucky is part of Medicare Part A and B Jurisdiction 15, run by CGS Administrators, LLC.
Original Medicare rules do not roll over automatically. Medicare Advantage claims are usually processed according to the plan of the member, therefore we check the network status, referrals, authorization and appeal stages for each product. We verify payer order, D-SNP membership if applicable, Medicaid status, and whether the claim crossed over or needed separate secondary billing for dual-eligible patients.
Qualified Medicare Beneficiaries can't be billed for Medicare Part A or B cost sharing.
Our coders match CPT, HCPCS and ICD-10-CM options to the documented service, medical necessity, modifiers, units, and place of service. NCCI bundling edits and medically unlikely edits get a look before any claim goes out.
When a code has component billing, modifier 26 identifies the professional component and modifier TC identifies the technical component. A global claim is only valid if both pieces are submitted by the same billing entity and that entity follows the payer requirements.
We consider who owns the equipment, who analyzed the study, who rendered it, whether a facility bills too and where it took place. Not all codes have these modifiers.
Everything from the first eligibility check to old A/R, built to keep the billing record in step with the care delivered.
We organize support around procedures, diagnostics, authorization needs and documentation.
Visit documentation and diagnostic charge reconciliation.
Cath lab, PCI and bundled-service review.
Ablations, device procedures and monitoring components.
Echo, stress tests and professional and technical billing.
Perfusion studies, stress components and documented supplies.
CT and MRI authorization and interpretation records.
Procedure notes and facility and professional coordination.
Follow-up care and monitoring requirements.
The boundary between diagnostic coverage and screening.
Benefits based on age and registries of congenital diseases and their diagnosis.
Eight stages, from the front desk to reporting.
Obtain demographics and current insurance status.
Confirm Medicaid MCO or FFS, commercial or Medicare coverage.
Address network, referral and permission criteria.
Convert the recorded care into correct charges.
Review the data and confirm that the payer approved it.
Match remittances, deposit payments and balances.
Assign repairs and track each claim to resolution.
Review claim outcomes, unresolved balances and next steps.
Five things to confirm before a claim leaves the building.
Eligibility as of service date, current MCO or FFS, product and payer hierarchy.
Enrollment, credentialing, network, NPI, taxonomy, group affiliation, rendering provider and location.
Referral and authorization, procedure approved, dates and location.
CPT or HCPCS, ICD-10-CM, modifiers, units, components, site of service and documentation.
The correct payer, the filing deadline and the preserved proof of submission.
Most denials trace back to a short list: old Anthem Medicaid records, a current MCO that doesn't match the claim, MPPA affiliation or location errors, authorization mismatches, diagnostic components that the record doesn't support, coding edits and unresolved coordination of benefits. We review all of them together.
We work with practices in Louisville, Lexington, Elizabethtown, Hopkinsville, Florence, Somerset, Hazard and Murray, along with the communities around them.
No. Anthem is no longer a participant in Kentucky Medicaid managed care; nonetheless, a patient's Medicaid eligibility did not alter. Anthem commercial coverage still needs to be checked in its own right.
KYHealthNet supports eligibility and billing transactions. MPPA handles provider enrollment, maintenance and revalidation.
No. Verify benefits, network, care setting and the member's plan before scheduling anything that may need approval.
We identify the cause and accountable payer and then follow the matching corrective or appeal process. MCO and fee-for-service have separate dispute mechanisms.
CGS Administrators handles Original Medicare Parts A and B claims in Jurisdiction 15. Generally, Medicare Advantage claims are submitted to the member's plan.
Yes. The scope of the agreement can include procedure coding review, claims follow-up, payer credentialing and enrollment.
We start with evaluating your revenue stream. We then check which payer is the most prevalent issue maker to forge a priority list.