Clean Claims
Quest Behavioral Health will pay clean claims, defined as a claim for payment for a behavioral health service which has no defect or impropriety (Act 68), within 45 days of receipt of the claim. Clean claims do not include claims which are under investigation for fraud or abuse. Claims are processed in order of the date received. Claims which do not meet the definition of a clean claim are claims that have a defect or impropriety, including lack of required substantiating documentation or a particular circumstance requiring special treatment which prevents timely payment from being made on the claim. The provider will receive notification from Quest when such instances occur. Please remember, as a utilization review entity, Quest may not be responsible for claims reimbursement services for all lines of business. If you have any questions regarding the claims process, our Business Office can assist in directing you to the appropriate place.
The following are elements that are necessary for a claim to be considered a clean claim:
- Demographic information (name, address, date of birth, social security number) of the member and subscriber.
- Member must be eligible for services under insurance plan.
- Member's benefits must not be exhausted.
- Provider and service provided must be eligible under member's benefit plan.
- Member's insurance plan
- Appropriate behavioral health diagnosis code (DSM-IV diagnosis code excluding V-codes and sleep disorders)
- Date of service(s) and procedure code (CPT) must match service approved by Quest (services not covered by the member's benefit plan will not be reimbursed)
- Service provided must be a recognized contractual procedure code.
- Provider information (name of provider must match authorization approved by Quest, address where service occurred, and tax ID number)
- Verification that the service has been certified by providing the authorization number on the claim
- Number of sessions must not have exceeded number of sessions authorized by Quest
- Authorization by Quest must be current and not expired
- One unit of service per date of service per provider cannot be exceeded
- EOB must be included when Quest is the secondary payer
- Coordination of benefits must be received or in place from member prior to claims processing
