Cardialogy Billing handles a cardiology claim from the first insurance check to the last open balance. The workflows follow how Massachusetts payers actually behave.
Built for Massachusetts. This solution has been built for Massachusetts. MassHealth plan types are kept separate while commercial and Medicare claims are routed to their respective products. Medicare Part B is never combined with Medicare Advantage.
ACPP, Primary Care ACO, MCO, PCC Plan, FFS
Product-level network and authorization
CPT, HCPCS, ICD-10-CM, Modifiers, NCCI edits
Posting, denials, enrollment, A/R
One cardiology visit is sufficient for a professional claim, a technical claim and a device or imaging charge, each with its own edit rules. Massachusetts adds local conditions. MassHealth splits members across several plan types, the large commercial carriers hand cardiac authorization to outside vendors, and Original Medicare Part B claims go to National Government Services, the contractor for Jurisdiction K.
At Cardialogy Billing we begin with the member's actual coverage and the service on the schedule. Referral, network status, documentation and authorization get checked before the claim is built. That costs less than finding the gap in a denial letter weeks later.
A MassHealth ID card says little about where a claim should go. The member's plan type decides that. It dictates regarding the place where bills would be sent, controls the network and decides the referral rules.
By using ACCP, numerous practices of primary care are incorporated into a single health plan. Companies like WellSense, Fallon Health and Tufts Health Together all run plans of this kind. A cardiologist should be part of that plan's own network which sets the referral, claim and appeal rules.
Primary Care ACOs contract straight with MassHealth. Community Care Cooperative is one example. Some members choose WellSense Essential MCO instead of an ACO. Each route handles claims its own way, so we confirm the member's route before anything gets scheduled.
In Primary Care Clinician Plan (PCC) and Fee for Service coverage, MassHealth members are billed directly and MassHealth systems include eligibility, prior authorization and claim status as well as the Provider Online Service Center.
Members change plans, and plans swap ACO partners. So we check the plan on the date of service, not the file from the last visit.
Providers use the Provider Online Service Center for eligibility check, claims entry, uploading of batches and requesting prior authorization. The time period is important here. MassHealth wants an initial claim within 90 days of the service date. When another insurer pays first, those 90 days run from that insurer's explanation of benefits.
MassHealth enrollment, contracting and commercial credentialing are three different processes. While they all use the same taxonomy, license and location data, there are differences. One mismatch can set off rejections somewhere else.
Note: Plan names and ACO partnerships in Massachusetts have changed more than once. Before applying any payer rule, we verify the member's plan against current MassHealth guidance.
Two plans from the same carrier can follow different rules. The exact product gets confirmed before a test is scheduled.
Product matters here. HMO, PPO, indemnity, Medicare HMO Blue, Medicare PPO Blue and out-of-state BlueCard members do not all follow the same steps.
BCBSMA delegates review of advanced cardiac imaging to Carelon Medical Benefits Management. This covers cardiac CT, coronary CT angiography, cardiac MRI, nuclear myocardial perfusion imaging, and indemnity members are exempt.
Although both brands are united under Point32Health, Harvard Pilgrim and Tufts Health Plan operate separate businesses and portals. Prior authorization for cardiac diagnostic testing and interventional procedures, as well as high-tech cardiac and vascular imaging, is handled by Evolent for most of their commercial and public products.
Pacemaker, ICD and cardiac resynchronization codes sit on the utilization review matrices. We pull the matrix for the member's product instead of working from a saved list.
Massachusetts is covered by NGS under Medicare A/B MAC Jurisdiction K. Part B Cardiology claims are processed in accordance with NGS Local Coverage Determinations. Original Medicare allows 12 months from the date of service to process Part B claims.
Medicare Advantage Plans are processed by separate plans and issuers. The BCBSMA Medicare Advantage Plans utilize Carelon to also manage cardiac imaging.
Note: An approved prior authorization does not guarantee payment. The claim must be processed to support medical necessity.
Before a test is done, confirm what the payer requires and who owns the equipment, performs the study and reads it.
There are a variety of cardiac services that may be reviewed including echocardiography, stress testing, nuclear studies, cardiac CT/MRI, heart catheterization, pacemaker and ICD procedures, and EP studies. Code review, plan and setting may influence the review of a service. Outpatient cardiac services may be treated differently from inpatient cardiac services.
Modifier 26 marks the professional component of a split code and TC marks the technical one. A global claim fits when one entity owns the equipment and reads the study. Hospital-based reads and office-based testing follow different paths.
Services are processed differently based on payer and the volume of the procedure.
Identify member’s coverage type, MassHealth plan type, commercial product, Medicare (or Medicare Advantage) plan, secondary payer, and network status prior to the appointment.
Obtain prior authorization, when needed, and/or support the clinical justification for the request to the appropriate vendor. Follow up on the status of the prior authorization and compare approval details to the study scheduled.
Analyze the appropriateness of CPT and HCPCS codes and ICD-10-CM codes, modifiers, units and NCCI edits documented by the physician.
Address documentation errors for schedules, orders, and procedure notes and interpretations to capture all services provided.
Ensure all the requirements for a claim (i.e. NPI, taxonomy, payer, modifiers, place of service, and authorization) are correct, prior to submitting the claim.
Reconcile the payment to the contracted rate.
Categorize denials and either correct errors supported in the record or file an appeal.
Working from the oldest balances first, contact payers to determine claim status and request records. Prioritize claims that do not process.
Support enrollment in MassHealth and various ACOs/MCOs. Support Medicare enrollment and CAQH profile and credentialing as well as commercial revalidation.
A good starting point is a review of verification, authorization, coding, claim routing, denials and aging A/R.
The review is performed based on the service performed, the documentation associated with the service and the payer’s rules in that environment.
Office E/M visits, ECGs and tracking referrals with medical necessity.
Bundled Professional/Facility editing for Coronary Intervention Procedures (PCI) and CT Angiogram.
Ablation procedures, implantation of cardiac devices (Pacemaker and ICD) and check device documentation.
Bills for cardiac monitoring and stress testing with component separations.
Cardiac CT and MRI with authorized plan.
Documentation for procedures and remote monitoring. Care management and coordination, and cardiac rehabilitation.
Risk assessment and screening tests for right diagnosis code.
Rules for various age groups, diagnostic services and checks for MassHealth.
Holter and remote monitoring with claims justification and documentation.
There are twelve steps relating to registration, payer rules, documentation, and follow-up.
Accurately capture demographics and insurance details the first time.
Confirm active coverage for service date.
Route member to the correct MassHealth, commercial or Medicare plan.
Confirm plan participation and referral requirements.
Assess payer’s requirements against the approval in effect.
Document diagnoses and procedures and assign related modifiers.
Capture charges for services performed.
Identify and correct data and edit errors.
Send claim to the correct payer or plan.
Post payment remittance and reconcile each adjustment.
Identify the reason for denial, implement remedy supported by record, and/or appeal.
Evaluate aging balances, filing limit and/or payer’s response.
A short list for catching common errors before a claim goes out.
Tracking these areas shows where the same errors keep coming back.
MassHealth members move between plans, and commercial products carry different networks and claim paths.
A mismatch in NPI, taxonomy, location or group affiliation can stall acceptance and payment.
Rules differ by payer, plan, code and setting, and the approval has to match the claim.
A wrong PC/TC split, place of service or interpreting provider creates rework.
Bundling edits, modifiers, units and diagnosis links must follow the documentation.
Unpaid claims need documented follow-up and attention to filing and appeal windows.
We work with practices remotely and adapt to each group's locations, payer mix and ties to hospital and referral networks. Cardiology Billing has no office or staff based in Massachusetts.
Availability and payer rules should be confirmed for the specific practice and plan.
Our clients with front office staffing shortages can rely on our teams to hold checklists steady.
Whoever is out that week does eligibility and MassHealth plan ID, referral and authorization tracking, and other routine tasks.
Denial reasons, aging balances and repeat errors are tracked to help address causes at registration and scheduling.
There are NCCI Conflicts, component and payer errors. Reviewers with cardiology codes may catch these issues sooner.
Reporting denial reasons, aging balances and repeat errors.
Disclaimer: Outsourcing does not guarantee reimbursement or a financial result. Payer contracts, eligibility, documentation, coding and editing and workflow determine outcomes.
Short answers on MassHealth, payer rules, authorization and cardiology claims.
Prior authorization support, coding review, charge capture and editing, claim submissions, payment posting, denials management, AR follow-up, and credentialing support, across all plan types.
Depending on the MassHealth plan type, members can be in an ACPP or a Primary Care ACO, a PCC Plan or fee-for-service. Each plan type has their own network, referrals, and claims rules, so the plan type needs to be verified for each visit.
ACPPs contract with only one health plan to connect a primary care practice. A Primary Care ACO works with MassHealth to connect with various hospitals and specialists.
POSC is the MassHealth web portal for providers. It supports eligibility checks, claims, prior authorization requests and profile updates for MassHealth business. Managed-care plans keep their own portals and appeal routes.
No. Enrollment with MassHealth, contracting with an ACO or MCO, and commercial credentialing are separate processes.
MassHealth must receive an initial claim within 90 days of the service date, or within 90 days of the other insurer's EOB when another payer is primary. Waivers exist for a few specific situations.
That depends on the payer, product, code and setting. Advanced cardiac imaging, pacemaker and ICD procedures, and catheterization are common review targets. The plan's requirements are checked for each member.
BCBSMA delegates advanced cardiac imaging review to Carelon. Harvard Pilgrim and Tufts Health Plan use Evolent for cardiac diagnostic tests, interventional procedures and high-tech imaging on most products.
National Government Services, the A/B MAC for Jurisdiction K. Original Medicare allows 12 months from the date of service to file.
No. We support Massachusetts practices remotely and have no office or staff in the state.
Share how eligibility, authorization, coding, claims, denials and A/R work in the practice today, and we will show where the process loses money.
https://cardiologybillingservices.us/Payer rules, coverage, authorization requirements and filing limits may vary by product, member eligibility, service and claim circumstances. Confirm current payer guidance before relying on a specific billing rule.