Billing procedures Form

Billing procedures Fallon Health Provider Manual | 1 Revised April 2026

Introduction and Commitment to Quality Claims guidelines

Coordination of benefits Claims status checks

Understanding your RAS Overpayments

Negative balances Adjustments and appeals Claims Reference

Zelis

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Introduction The Fallon Health Provider Manual billing section provides you with an overview of our billing requirements. This manual refers to commonly used codes supplied by the American Medical Association’s Manual of current Procedural Terminology (CPT) and the Centers for Medicare and Medicaid Services Healthcare Common Procedure Coding System (HCPCS). Fallon Health is a customer driven organization that is dedicated to the prompt and accurate claims payment of our providers’ claim submissions in accordance with regulatory and contractual requirements.

Fallon Health’s commitment to quality: Claims Department Quality Monitoring Fallon Health is committed to giving our customers quality service. To ensure claims processing quality, our Claim Department monitors claims every month, verifying the accuracy of claims entry and adjudication. The data from this monitoring is used for additional training and for updating our procedures. Claims Payment Integrity To keep pace with ever changing medical technology and coding complexities, Fallon Health has enhanced its claim editing capabilities. Fallon Health payment integrity program exists to evaluate billing and coding accuracy on submitted claims. Fallon Health payment integrity program is guided by the coding criteria and protocols established by various sources including the Centers for Medicare and Medicaid Services (CMS), the CPT Manual published by the American Medical Association (AMA) and special society guidelines. Fallon Health continually evaluates, edits, and modifies the Payment Integrity program to accommodate Fallon Health payment methodology. Fallon Health performs routine upgrades to payment integrity software.

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Claims guidelines Submitting a claim: Claims should be submitted with the Provider’s National Provider Identifier (NPI) and Tax ID to Fallon Health in one of the following formats: • Electronic file: 837P Professional or 837I Institutional • CMS 1500 claim form (CMS 1500 claims can also be submitted through our Provider Portal by approved Portal users) • UB 04 claim form

Electronic claims have two methods offered for submission. Direct submission to Fallon Health Clearinghouse submission

Visit our website for additional information on these methods, and the Health Insurance Portability and Accountability Act (HIPAA) of 1996: https://fallonhealth.org/en/providers/provider-tools/electronic-data-submission#direct

Paper claims should be submitted by mail to: Fallon Health Claims Department PO Box 211308 Eagan, MN 55121-2908

When shipping paper claims that are not deliverable to a P.O. Box, (via FedEx etc.), please send to the following address: Fallon Health Claims - Smart Data Solutions 960 Blue Gentian Road Eagan, MN 55121

Forms and billing guidelines For the most up to date information on forms and use guidelines, visit CMS.gov: https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans, with links to the following:

o CMS 1500 Professional Paper Claim Form and Instruction manual: National Uniform Claim Committee (NUCC), nucc.org

o UB -04/CMS 1450 Institutional paper claim form and Data Specifications Manual: National Uniform Billing Committee (NUBC), nubc.org

Helpful billing tips to ensure your paper claims submissions are processed expeditiously and efficiently: • Please ensure your form meets NUCC/CMS guidelines • Use black font and avoid light print to avoid data capture errors • Do not submit handwritten claims

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• Font guidance o Use a 10-point font o Do not mix fonts or use italics, percentage signs, question marks, slashes, dashes, decimal points, dollar signs, or parentheses o Use UPPERCASE letters for alphabetical entries • UB04 specific guidance o A claim must not exceed 450 lines o Total the claims on the last page only

Claims addresses for our vendor partners: American Specialty Health (ASH) Claims Administration American Specialty Health PO Box 509001 San Diego, CA 92150-9001 Care Centrix PO Box 30722-3722 Tampa, FL 33630 For more information: https://fallonhealth.org/en/providers/criteria-policies-guidelines/sleep- studies

Carelon (formerly Beacon Health Options) Fallon Health Plan Claims Department P.O. Box 1866 Hicksville, NY 11802-1866 For more information: https://fallonhealth.org/en/providers/contact-us DentaQuest PO Box 2906 Milwaukee, WI 53201-2906 For more information: https://www.dentaquest.com/en/providers/massachusetts EyeMed Vision Care First American Administrators, Attn: Claims PO Box 8504 Mason, OH 45040-7111

Zelis (appeals only) Zelis Claims Integrity, Inc. 340 MT Kemble Ave. Morristown, NJ 07960 Attn: Appeals Department

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Balance billing: Balance billing Fallon Health members (other than deductibles, copayments or coinsurance) is not allowed for covered services. ACO and NaviCare members do not have cost share and should never be billed for covered services.

Billing Enrollees for Missed Appointments Providers cannot bill ACO and NaviCare enrollees for missed appointments. Qualified Medicare Beneficiaries (QMB) programs For Plan Members enrolled in Medicare and Medicaid, Plan Members shall not be held liable for Medicare Part A and B cost sharing when MassHealth is responsible for paying such amounts and Physician Organization (PO) shall accept Plan payment as payment in full, or bill MassHealth.

Covering providers: When submitting claims to Fallon Health as a covering provider, the provider must identify him/herself as a covering physician on the CMS 1500 form. There are two options to submit these claims:

• Append Modifier Q5 to the E&M claim line will indicate the rendering is working in a covering capacity for the PCP. This can be done on paper or with electronic claim submissions. • A paper claim can be submitted with “covering physician” indicated at the top and the name of the physician you are providing coverage for should be typed or written in box 17.

Reciprocal billing/Locum Tenens arrangements: • The reciprocal provider and locum tenens are responsible for adhering to the same Fallon Health’s policies and procedures as the absentee physician. The absentee physician may submit the claim and receive payment for part B covered arrangements services under Locum Tenens and/or reciprocal billing arrangements. • Services of a substituting physician are identified by entering modifier Q5 or Q6 in item 24d of the CMS 1500 claim form. The NPI number of the substituting physician must be reported on the claim submitted by the billing “absentee” physician in item 23 on the CMS 1500 claim form. • The billing “absentee” physician’s NPI number must be reported in item 33 on the CMS 1500 claim form for a solo practice and item 24j on the CMS 1500 claim form for group practice arrangements. Interim billing: We do not accept interim billing for Inpatient claims. Inpatient claims should be submitted for the complete length of service (admit through discharge).

Filing limits: Contracted provider claims must be received within 120 days from the date of service. Non-Contracted providers must be received within one year from the date of service.

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If… You should… You initially understood Fallon Health to be the secondary insurer, but Fallon Health is the primary insurer Submit a paper claim to Fallon Health along with the other insurer’s Explanation of Benefits (EOB). You must submit within 120 days of the date on the other insurers’ EOB. The claim is related to a motor vehicle accident Submit claims to Fallon Health after the Personal Injury Protection (PIP) is denied and submit a copy of the PIP letter. The claim is related to Workers’ Compensation Submit claims to Fallon Health with a copy of the workers’ illness/injury compensation insurers’ denial. Note: Fallon Health members cannot be billed for claims denied due to late submissions. See the Adjustments and Appeals section for more information on appealing filing limits. See Coordination of Benefits (COB) section for more information on COB.

Late charges and replacement claims: Late charges will be accepted electronically for claims billed on a UB04 form type. The claim must be submitted with a frequency code of 5 (bill type ends in a 5).

Only submit charges not included on the original institutional/facility claim. Corrected claim lines must be submitted in accordance with adjustment guidelines; see Adjustment and Appeal section.

Replacement claims are the preferred method to submit corrections, including late charges. A replacement claim will void/retract the original claim and replace those charges. All charges for the encounter should be submitted on the replacement claim, including the accurate original charges that do not require modification, corrected claim lines and additional charges. Standard filing limits apply. Replacement claims will be accepted electronically for both institutional and professional charges. Claims must be submitted with a frequency code of 7 to indicate a replacement. Claims billed on a UB04 form type may also be submitted on paper using a bill type that ends in a 7; a request for claim review form is not required. Requests for claim review due to payment, authorization, filing limit, or other claim processing issues must be submitted in accordance with the Adjustment and Appeal guidelines; see Adjustment and Appeal guidelines.

Referrals and prior authorizations: Primary care referrals: A recommendation by which a Primary Care Provider (PCP) sends a member to another provider for services that are typically outside the PCP’s scope of practice.

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PCP referral process for Fallon Medicare Plus, NaviCare and Medicaid ACO members: Referrals for specialty care are required for Fallon Medicare Plus (Central), NaviCare and MassHealth ACO members. Refer to the PCP referral and plan prior authorization process section of the provider manual.

To ensure reimbursement to specialists and facilities: • The specialist must verify the referral number through the Provider Portal or ProAuth prior to seeing the member. To sign up for Proauth https://www.fchp.org/Providertools/ProAuthRegistration/ProAuthRegContacts/Create • There is no need to bill the approved referral number on the claim as Fallon Health will have this on file

If a specialist decides that a member needs a service that he/she cannot provide, the specialist must consult with the member’s PCP, who will initiate a new referral to the appropriate specialist.

Please note that all services with non-contracted providers or facilities require a plan Prior Authorization.

Be sure to follow all referral policies and procedures for Coordination of Benefits (COB), Motor Vehicle Accident (MVA) or workers’ compensation cases. For more details, please see the Coordination of Benefits section of this manual. Members’ coverage for services is subject to their eligibility based on their benefits, contract policies and exclusions.

Retroactive referrals may be submitted as follows: Product Timeline Fallon Medicare Plus Up to 90 days after Date of Service NaviCare Up to 90 days after Date of Service Berkshire Fallon Health Collaborative Up to 30 days after Date of Service Fallon 365 Care Up to 30 days after Date of Service Fallon Health-Atrius Health Care Collaborative Up to 30 days after Date of Service

PCP referral process for Community Care: Referrals for specialty care are required for Community Care Refer to the PCP referral and plan prior authorization process section of the provider manual.

To ensure reimbursement to specialists and facilities: The specialist submits a claim to Fallon Health with evidence of a referral (the PCP’s NPI number) from the member’s PCP. For CMS 1500 paper submitters: • Box 17 – enter referring provider/PCP’s name • Box 17b – enter referring provider/PCP’s NPI number

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For Fallon Health direct claims submitters • Loop 2310A Segment NM1 –enter the referring provider/PCP’s name • Loop 2310A Segment REF with the G2 qualifier – enter referring provider/PCP’s NPI number Failure to include complete referral information (the referring provider’s name and NPI number) on the claims will result in a denial.

PCP referrals will be accepted retroactively up to 120 days from the date of the Remittance Advice Summary (RAS). Should an initial claim be rejected for lack of a referral number (i.e., the PCP NPI number), the specialist has 120 days from the date of the RAS to resubmit a corrected claim with the provider NPI number.

If a member does not have a valid referral but visits a specialist for services that require a PCP referral, the specialist should contact the member’s PCP to obtain a PCP referral. If the PCP does not approve the referral, the specialist should inform the member of his or her financial liability and ask the member to sign a waiver of liability.

If a specialist decides that a member needs a service that he/she cannot provide, the specialist must consult with the member’s PCP, who will initiate a new referral to the appropriate specialist.

Please note that all services with non-contracted providers or facilities require a plan Prior Authorization.

Provider must follow all referral policies and procedures for Coordination of Benefits (COB), Motor Vehicle Accident (MVA) or workers’ compensation cases. For more details, please see the Coordination of Benefits section of this manual. Members’ coverage for services is subject to their eligibility based on their benefits, contract policies and exclusions.

Prior authorization process for all plans: (with the exception of Summit ElderCare)

The prospective or concurrent review process used by Fallon Health to determine coverage of a particular medical service. Prior authorization involves the review of eligibility, level of benefits, servicing provider’s participating status and medical necessity. Depending on the contract, some groups for some product lines might be delegated for this process. If this is a question, contact your Provider Relations Representative.

For services that require Prior Authorization, all contracted providers are responsible for ensuring that the appropriate authorization is in place prior to services being rendered. If medically necessary services are rendered to an eligible plan member and there is no Prior Authorization, the provider will not be reimbursed for related charges, and the member cannot be billed.

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To ensure reimbursement to specialists and facilities: • The specialist must verify the prior authorization number through our Provider Portal, through ProAuth or by calling care services prior to seeing the member. • There is no need to bill the approved Prior Authorization number on the claim as Fallon will have this on file. Members’ coverage for services is subject to their eligibility based on their benefits, contract policies and exclusions.

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Coordination of benefits Coordination of benefits is required when more than one insurance plan covers a service. This occurs when a person has coverage from more than one insurance company, or when Medicare, Workers’ Compensation, or a motor vehicle accident (MVA) is involved. For services to be considered for payment as a secondary insurer, Fallon Health’s policy and procedures for referrals and authorizations must be followed. Why do the insurance plans coordinate benefits? Payments are coordinated to prevent total payments from exceeding the total charges for the patient’s health services. How do I know where to send the claims? All insurance companies use the same rules to determine the primary and secondary carriers. These rules are explained below. If another company is the primary carrier, you should first send the bills to that company. After you receive the other insurer’s Explanation of Benefits, submit a copy of that document to Fallon Health with the CMS 1500 or the UB04 claim forms. Complete information on the other insurer must be shown on boxes 11 and 24j of the CMS 1500 claims form or box 50 on the UB04 claim form. Are there limits on when a claim can be filed with Fallon Health? Claims must be filed within 120 days from the date on the other insurance carrier’s Explanation of Benefits (EOB). Remember to include the EOB from the other carrier with your claim when you submit to Fallon Health.

How is primary coverage determined?

More than one possible carrier Spouse If the subscriber’s spouse has other health insurance, that is the spouse’s primary plan. Dependent children Claims are processed using the birthday rule. The primary carrier is the insurance of the parent whose birth date occurs first in the calendar year. When both parents have the same birth date, the primary carrier for the dependent child is the plan that has been in effect the longest.

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Special situations for dependent children Joint custody If neither parent is specified as responsible for health insurance the birthday rule applies. . Court decree If the court decree specifies that one parent is responsible for health coverage, that parent’s plan is primary. Single custody The following order applies: 1. Parent with custody

2. Spouse of parent with custody.

   Medicare Rules are determined by Medicare Secondary Payer (MSP) Laws. These laws apply to age 65 or older active employees and their spouses who are enrolled in a group health plan of an employer with at least 20 employees. In these cases, the employee would have coverage through the group and through Medicare. Subscriber is 65 or older and still working Fallon Health is primary, Medicare is secondary Subscriber is 65 or older and is retired Medicare is primary, Fallon Health is secondary Actively employed subscriber’s spouse is 65 or older Fallon Health is primary, Medicare is secondary Retired subscriber’s spouse is 65 or older Medicare is primary, Fallon Health is secondary Medicare entitlement due to end stage renal disease or disability Special rules apply, call 866-275-3247 with questions

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How are motor vehicle accident (MVA) claims handled? Determining primary coverage The automobile insurance company is primary for the first $2,000 in medical expenses under the Personal Injury Protections (PIP). If the member is covered under Fallon Medicare Plus, Medicaid ACO the automobile insurance is primary for $8,000 under the PIP. Fallon Health will adjust claims accordingly if it is determined that services are a result of an MVA after the claims have been processed. Submitting claims Use the CMS 1500 claim form or UB-04 claim form. Record name of auto insurance carrier or other responsible party in Box 9 of the CMS 1500 claim form or Box 50 of the UB-04 claim form. Indicate that the services are as a result of an MVA and include the following: • Auto claim number • Date of accident • PIP insurance carrier • Address of PIP carrier • Notice from the PIP carrier stating that benefits have been exhausted • Name of patient’s attorney Fallon Health will process claims providing that the member completes an assignment of insurance payment form. If the member does not complete the form, claims will be held until the coordination of benefits with the automobile insurance or other responsible party is settled. Filing limits An MVA claim must be submitted to Fallon Health within 120 days or your contracted time frame from the date of the other insurance Explanation of Benefits. Please attach the Explanation of Benefits or PIP exhaustion letter from the other insurance carrier. Referrals and authorization guidelines In order for services to be considered for payment, Fallon Health Health’s policies and procedures for referrals and authorizations must be followed. Claims adjustments Fallon Health will adjust claims accordingly if it is determined that services are result of an MVA after the claims have been processed. Balance billing Balance billing Fallon Health members is not allowed.

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How are workers’ compensation claims handled? Referrals and authorization guidelines Claims must be submitted to Fallon Health within 120 days or your contracted time frame from the date of the denial from the workers’ compensation carrier. For services to be considered for payment, Fallon Health’s policies and procedures for referrals and authorizations must be followed.

What is subrogation? Subrogation applies when a payment for a member’s illness or injury may be the responsibility of a third party. Subrogation cases may be a result of an injury in a public place. Submitting claims Please provide: • Date of accident • File number • Name of patient’s attorney

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Claim status checks

Claim Status Inquiry Guidance for Providers There are several ways to check the status of your claims. Claim Status Request Options Providers may check claim status through the following methods: • Provider Portal; preferred method for participating/contracted providers • Mail • Fax • Telephone Contact the Provider Services Line at 866-275-3247, Prompt 2. Hours of Operation: • Monday–Friday: 8:00 AM – 5:00 PM • Wednesdays: 9:00 AM – 5:00 PM Important Notes: • Telephone inquiries are limited to three claims per call. For high-volume requests, please use the portal, mail or fax. • Status checks should be made 45 days after claim submission to allow for processing and potential resubmission before the filing limit. • Clearly mark mailed or faxed claims as “STATUS INQUIRY” to avoid duplicate entry.

Claim Status Check – electronically Fallon Health Supports EDI 276/277 Version 005010X212 for claim status requests and responses. Providers, billing services and clearinghouses are advised to use the ASC X12N 276/277 (005010X212) Implementation Guide as a basis for their submission of Claims Status inquiries. Additional information on this electronic Claim status enquiry can be found at our website: http://www.fchp.org/providers/provider-tools/electronic-data-submission.aspx

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Understanding your Remittance Advice Summary (RAS) For specific details on electronic Remittance Advice Summaries, please refer to our companion guide: Health Care Payment/Advice ANSI X12 835 (Version 005010X221A1) Implementation Guide at: http://www.fchp.org/providers/provider-tools/electronic-data-submission.aspx

Remittance Advice Summary — Field Definition A Remittance Advice Summary (RAS) is a printed explanation of the adjudication of a claim. Here is a description of each field on the RAS. See the reference section for a detailed description of Fallon Health’s adjudication codes.

FIELD DEFINITION 1 Provider The name of the provider rendering services. 2 Member name The name of the member to whom the service was provided. 3 Contract # The member’s ID number 4 Referral # The number of the referral to which the claim is linked, if applicable. 5 Claim # The number assigned by Fallon Health to the claim. 6 Post date The date on which the claim was posted to the system. 7 Account number The account number submitted by the provider. 8 Status flag (S/F) Status flag: Y or N appears in this field, indicating if the claim is approved as statistical (reporting purposes) or non- statistical (fee for service). Statistical (Y) or non-statistical (N). 9 Procedure The procedure code(s) and description(s) submitted on the claim. 10 Modifier (MOD) The primary modifier code submitted on the claim.

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11 Service dates The service from and to dates, on the claim line. 12 Billed The total amount billed on the claim line. 13 Rejected The total amount rejected on the claim line. Refer to legend for detailed explanation. 14 Deductible (Deduct) The amount the member must pay towards his or her deductible and or coinsurance. 15 Copay amount The amount the member must pay as a copayment and/or coinsurance. 16 Approved The total approved amount on the claim line. 17 Withhold/seque stration The total amount withheld based on the contractual agreement with the vendor/ sequestration, *see Sequestration Payment Policy. 18 Refund The total amount of money received back from the provider and applied to the claim. 19 Interest The total amount of money paid to the provider due to late payment by Fallon Health. 20 Net The net amount, including all non-statistical approved dollars on the claim line. 21 Claim totals Subtotal, by claim. 22 Notes An information field is provided at the end of a claim. The purpose of this field is to provide helpful information for future billing, such as “Please update member’s ID #”. 23 Provider summary Totals split out by statistical claim totals, non-statistical claim totals and negative balance amounts. 24 Provider net amount The total amount of the check issues for this Remittance Advice Summary. 25 Legend The legend indicates the claim line rejection disposition codes and their descriptions.

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A message section is provided on the last page of your RAS to notify you of important information or helpful facts.

Sample of RAS: Double click on image to open.

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Fallon Health overpayments What is an overpayment? Overpayment occurs when Fallon Health sends you more money than we should have in the payment of a claim. What should you do if this happens? You should either return the Fallon Health check or issue a refund to Fallon Health. Your refund will be credited to your account. Refund procedure:

When returning a Fallon Health check, include the following: • The Remittance Advise Summary (RAS) that was received with the check • The reason you are returning the check • Name and phone number of the contact person at the office

When sending a refund check, include the following: • Member name • Membership number • Member date of birth • Date of Service or the RAS that was received with the check, highlighting the pertinent information • The reason for the refund • Name and phone number of the contact person at the office Checks should be mailed to: Fallon Health ATTN: Medical Accounting 1 Mercantile St., Ste. 400 Worcester, MA 01608

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Negative balances Fallon Health periodically monitors claim payment activity to identify payments made to providers in error. Those payments made in error will be adjusted to the provider’s account showing the amount overpaid as a negative amount originally paid in error. In some instances, a negative balance is generated when the total amount of adjusted claim dollars is greater than a provider’s positive claim payment activity. If a provider is in a negative balance status with Fallon Health, the last page of your Remittance Advice Summary (RAS) will show the total amount due to Fallon Health. You will only receive the detailed patient claim information on the original negative balance RAS. Please be sure to keep this negative balance RAS as this will be needed to post your accounts. If you anticipate the amount due Fallon Health will be cleared by future claim submissions, you may choose not to remit a refund to Fallon Health. However, if you wish to remit payment for the amount due, you may do so by making a check payable to Fallon Health and sending it to the address below. Please include a copy of the last page of your RAS.

Fallon Health - Finance Department 1 Mercantile St., Ste. 400 Worcester, MA 01608 The Claims Department will send a report and a letter of explanation to the provider at intervals of 30/60/90 days from when the negative balance was created. Fallon Health will not issue any future payments until the negative balance is cleared. When sending your refund check, please enclose a copy of the letter and report sent to you.

Sample of RAS notification

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Adjustments and appeals If you do not agree with a claim determination made by Fallon Health, you have the right to request a claim to be reviewed. Claim Adjustments The most efficient way to submit a corrected claim to Fallon Health is to send electronically using industry standard 837 submissions within 120 days of the Remittance Advice Summary (RAS) for contracted providers and within 1 year for non-contracted providers. Electronic corrections require Frequency Code “7” indicating they are corrected/ replacement claims: Written requests for provider corrections to a claim must be submitted within 120 days of the date of the Remittance Advice Summary (RAS) for contracted providers and within one year for non-contracted providers. Submissions must include the Request for Claim Review form. Please mail or fax your adjustment request to: Fallon Health Claims Department: Adjustment Team P.O. Box 211308 Eagan, MN 55121-2908 Fax: 508-368-9890 An adjustment or correction submission may be related to one of the following: • Coordination of Benefits: The requested review is for a claim that could not be fully processed until information from another insurer has been received. An Explanation of Benefits (EOB) of the primary insurer must be included. • Corrected Claim: The previously processed claim (paid or denied) requires an attribute correction (e.g., units, procedure, diagnosis, modifiers, etc.). Please specify the correction to be made and include all the previous claim information along with any corrected or additional information. • Duplicate Claim: The original reason for denial was due to a duplicate claim submission. • Retraction of Payment: The provider is requesting a retraction of entire payment or service line (e.g., not your patient, service not performed, etc.). • Correction to a claim denied for a Zelis edit- see Zelis section. Claim Appeals Provider appeals must be submitted within 120 days of the date of the Remittance Advice Summary (RAS) or initial denial. Provider claim appeals must be submitted in writing by using a Request for Claim Review form (same form that is used for adjustments) and include all pertinent information to substantiate your request. See next page for submission requirements. Please mail or fax the form and supporting documentation to: Fallon Health Attn: Request for Claims Review/Provider Appeals P.O. Box 211308 Eagan, MN 55121-2908

Fax: 508-368-9890

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An appeal submission may be related to one of the following: • Filing Limit: The claim whose original reason for denial was untimely filing. • Payer Policy, Clinical: The provider believes the previously processed claim was incorrectly reimbursed because of the payer’s clinical policy. • Payer Policy, Payment: The provider believes the previously processed claim was incorrectly reimbursed because of the payer’s payment policy. • Pre-Certification/Notification or Prior-Authorization or Reduced Payment: The request for a claim whose original reason for denial or reimbursement level was related to a failure to notify or pre-authorize services or exceeding authorized limits. • Referral Denial: The claim whose original reason for denial was invalid or missing primary care physician (PCP) referral. • Request for additional information: The requested review is in response to a claim that was originally denied due to missing or incomplete information (NOC Codes, Home Infusion Therapy). • Any appeal related to a Zelis edit should be submitted directly to Zelis o By Mail: Zelis Claims Integrity, Inc. 340 MT Kemble Ave Morristown, NJ 07960 Attn: Appeals Department o By Fax: 1-855-787-2677 o By email: Email: appeals.integrity@zelis.com

Submission requirements All appeal requests must be received within 120 days from the date of the initial claim denial/Remittance Advice Summary (RAS). All claims must be completely processed by Fallon Health prior to the submission of a request for an appeal review. A separate Request for Claim Review form must be supplied for each adjustment/appeal and all pertinent supporting documentation must be attached. The Claim Review form must clearly specify the item, code, or service being appealed. While Fallon Health doesn’t offer second-level appeals on the same issue, we want to reinforce that providers may submit a second appeal on the same claim for a different issue. For instance, if a claim is appealed due to a member enrollment issue and is subsequently paid, the provider may then submit a second appeal (e.g., regarding payment on specific billing codes) and must include all supporting documentation. Please refer to the Request for Claim Review Reference Guide for examples of review types and required documentation for each review request. Please note: Fallon Health will ensure that no punitive action is taken against a provider who submits an expedited request or supports an enrollee’s appeal.

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Submission requirements for non-contracted Medicare providers All claims review appeal requests must be received in writing within 60 days from the date of the initial claim denial/Remittance Advice Summary (RAS) in order to be considered for review. All claims must be completely processed by Fallon Health prior to the submission of a request for appeal review. A separate Request for Claim Review form must be supplied for each appeal, and all pertinent supporting documentation must be attached. Please include a copy of the original claim, remittance showing the denial and any clinical records/documentation that would support the appeal. Please refer to the Request for Claim Review Reference Guide for examples of review types and required documentation for each review request. Please note, Fallon Health will ensure that no punitive action is taken against a provider who requests an expedited request or supports an enrollee’s appeal. In addition, non-contracted providers must include a signed Waiver of Liability form holding the enrollee harmless regardless of the outcome of the appeal. This form must be accompanied with the appeal request. Please mail or fax the forms and supporting information to: Fallon Health Attn: Request for Claims Review/Provider Appeals P.O. Box 211308 Eagan, MN 55121-2908 Fax: 508-368-9890 Filing limit appeals All appeal requests must be received in writing within 120 days from the date of the initial claim denial/Remittance Advice Summary (RAS). All claims must be completely processed by Fallon Health prior to the submission of a claim review request. Filing Limit Appeal Requirements • Submit a separate Request for Claims Review Form for each appeal. • Copy of original Fallon Health RAS • CMS-1500, ADA, or UB claim form. • Supporting Documentation Any request received after this timeframe will not be considered for review. Supporting Documentation Paper Claims If you are requesting a filing limit appeal review of a claim that was submitted on paper, the following are acceptable proofs of timely submission. • If the member or another insurer had been previously billed, include proof that the member or another carrier had been billed (Other payors EOB/RAS). • RAS from another insurer • Clinical notes, medical records, discharge summary (should the filing limit denial pertains to services such as an inpatient admission or outpatient observation)

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EDI Claims If you are requesting a filing limit appeal review of an EDI claim, submitted either through a clearinghouse, billing agency, or directly to Fallon Health, the following are the only acceptable proofs of timely submission. • 999 Report • EDI Clearinghouse or billing agency report indicating that the claim was accepted by Fallon Health within the filing limit Additional information regarding EDI Claims Fallon Health does not routinely waive the filing limit for EDI claims. It is the responsibility of a provider’s office staff or billing service to process their EDI reports as well as Remittance Advice Summaries on a regular basis and resubmit rejected/problematic claims within the filing limit. Due to the availability of these reporting and tracking tools, it is unusual for the Fallon Health Claims department to expect late claim submission. Please resubmit any claims in question immediately. If the claim cannot be resubmitted electronically, office staff should reprocess the claims on paper and send them directly to Fallon Health within your contractual time frame.

Mail or fax your filing limit claim review request to: Fallon Health Attn: Request for Claims Review/Provider Appeals P.O. Box 211308 Eagan, MN 55121-2908 Fax: 508-368-9890

Provider appeal determinations Following receipt of a completed request for an appeal review, Fallon Health will research the request and notify the provider of the determination. When the original claim denial is upheld, a letter will be sent explaining the review determination. When a review is approved, the Remittance Advice Summary or 835 file will indicate the message of Approved per Provider Appeals. All appeal review determinations will be final and binding and in keeping with the provisions of your contract with Fallon Health Please note: Fallon Health will ensure that no punitive action is taken against a provider who submits an expedited request or supports an enrollee’s appeal.

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Claims reference

Payment Policy guidelines: Fallon Health has an extensive list of service specific payment policies https://fallonhealth.org/providers/criteria-policies-guidelines/payment-policies

Place of service codes Place of Service codes please visit: https://www.cms.gov/Medicare/Coding/place-of- service-codes/PlaceofServiceCodeSet Type of Bill (TOB) TOB visit: CMS Chapter 1 General Billing Requirements: https://www.cms.gov/regulations- and-guidance/guidance/manuals/downloads/clm104c01.pdf

New, revised and deleted codes Each year, the American Medical Association, and CMS review the CPT and HCPCS codes to determine whether codes should be added, revised or deleted. Fallon Health adheres to the standard coding guidelines of the American Medical Association in conjunction with Medicare and Medicaid guidelines. To make sure that contract documents and payment mechanisms remain current with industry standards, Fallon Health will add new codes for covered benefits to our claims payment system as contract language allows. Codes for new technology must first be reviewed by Fallon Health to determine whether the procedure is a covered benefit. Codes deleted by the AMA will be deactivated from our system effective January1st of each year.

Unlisted procedure codes Unlisted procedure codes should never be used when a more descriptive procedure code is available.

Community Care Qualifying Payment Amount (QPA) for non-contracted providers Fallon Health pays out-of-network claims for the Community Care product pursuant to the federal No Surprises Act. The allowed amount for out-of-network claims covered by the No Surprises Act will be set at the Qualifying Payment Amount (QPA). • Fallon Health is working with our vendor partner ClearHealth to identify claims subject to the No Surprises Act and to determine the appropriate QPA. • For any claims paid in accordance with the No Surprises Act, the Fallon Remittance Advise (RAS) will note at a claim line level “Paid according to the qualifying payment amount (QPA), as defined by the No Surprises Act Regulations.” additional details will be included with the RAS. • If an out-of-network provider or facility wishes to initiate a 30-day open negotiation period for purposes of determining the amount of final payment to the provider or facility, they may contact ClearHealth via the secure portal https://provider.clearhs.com or by calling (866) 722- 3773.

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Claim Disposition codes reasonid remit_description DF001 Denied-above invoice cost DF002 Denied-above authorization limit DF003 Denied- valid admission source required DF004 Denied-admit type required DF005 Denied-age invalid per medical policy DF006 Denied-age/procedure conflict DF007 Denied-appeals review DF008 Denied-assistant surgeon not necessary DF009 Denied-authorization line not approved DF010 Denied-authorized services do not match billed DF011 Denied-benefit has age restriction DF012 Denied-benefits no longer administered by FCHP DF013 Denied-bill as observation DF014 Denied-claim document or information not received DF015 Denied-clinical trial DF016 Denied-co surgeon not allowed DF017 Denied-detail supply code needed DF018 Denied-diagnosis invalid per medical policy DF019 Denied-discharge status required DF020 Denied-duplicate claim line DF021 Denied-exceeds review time limit DF022 Denied-gender invalid per medical policy DF023 Denied-gender/procedure conflict DF025 Denied-hospice primary DF026 Denied- diagnosis code invalid for dos DF027 Denied-diagnosis code required DF028 Denied-ICD procedure code invalid for dos DF029 Denied-ICD diagnosis code/CPT code mismatch DF030 Denied-incidental to other procedure DF031 Denied-included in admission DF032 Denied-included in global fee DF033 Denied-incorrect bill DF034 Denied-incorrect date of service DF035 Denied-incorrect medical notes DF036 Denied-incorrect number of units billed DF037 Denied-incorrect place of service DF038 Denied-incorrect provider DF039 Denied-invalid REV code DF040 Denied-invalid condition code on dos DF041 Denied-invalid CPT/HCPCS for dos DF042 Denied-invalid diagnosis code for benefit DF043 Denied-invalid mod/CPT combo DF044 Denied-invalid modifier for dos DF045 Denied-invalid occurrence code on dos DF046 Denied-invalid occurrence span code on dos DF047 Denied-invalid or missing admission date DF048 Denied-invalid REV/CPT code combo

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DF049

Denied-missing or invalid value code DF050 Denied-invoice required DF051 Denied-itemization required DF052 Denied-late charges/corrections DF053 Denied-max benefit limit exceeded DF055 Denied-medical criteria not met DF056 Denied-medical notes required DF057 Denied-medical visit not paid separately DF058 Denied-member not enrolled on dos DF059 Denied-modifier is invalid or missing per medical policy DF060 Denied-modifier missing DF061 Denied-modifier on claim does not match contract term or modifier not billed and contract requires modifier DF062 Denied-motor vehicle accident DF063 Denied-mutually exclusive service DF064 Denied - no authorization or PCP referral DF065 Denied-no available bed days on auth DF066 Denied-no response. DF067 Denied-no supporting documentation DF068 Denied-not a covered benefit DF069 Denied-not paid separately DF070 Denied-NPI invalid format DF071 Denied-NPI missing DF072 Denied-NPI not matched DF073 Denied-OP notes required DF074 Denied-original bill in review DF075 Denied-other agency may be responsible for payment DF076 Denied-other insurance primary DF077 Denied-over submit date DF078 Denied-paid by other insurance DF079 Denied-PHCS repricing applied in error DF080 Denied-physician specialty is invalid for medical policy DF081 Denied-place of service invalid per medical policy DF082 Denied-prior authorization not approved DF083 Denied-provider specialty not appropriate for service DF084 Denied-provider type is invalid per medical policy DF085 Denied-provider type not appropriate for service DF086 Denied-readmit related DRG DF087 Denied-readmit same DRG DF088 Denied-rebill initiating hospital for transport DF089 Denied-rebill with anesthesia CPT code DF090 Denied- Tax ID Number Does Not Match Billing Provider DF091 Denied-rebill with referring physician's NPI DF092 Denied-rebill with rendering physician DF093 Denied-rebundled DF094 Denied-referring provider not PCP DF095 Denied-retro review request DF096 Denied-send ambulance trip sheet DF097 Denied-send ER record

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DF098

Denied-services not on provider contract DF099 Denied-submit on 1500 form w rendering physician DF100 Denied-submit to ASHN DF101 Denied-submit to Behavioral Health Vendor DF102 Denied- Submit to delegated Dental Vendor. DF103 Denied-submit to Lifetrac Network DF104 Denied-submit to skilled nursing facility DF105 Denied-submit to United Behavioral Health DF106 Denied-team surgeon not allowed DF107 Denied-too many units billed for service DF108 Denied-units exceeded per medical policy DF109 Denied-workers compensation DF110 Denied-excluded service provider liable DF111 Denied-E&M code not valid for established patient DF112 Denied-member penalty no precertification DF113 Denied-anesthesia time required DF114 Denied-incorrect procedure code after OP-Note Review DF115 Denied-paid in error DF116 Denied-invalid from or thru date of service DF117 Denied-incorrect bill type DF118 Part D-Submitted to Pharmacare DF119 Denied-maximum approved units of service exhausted DF120 Denied-not a preferred provider DF121 Denied- Incorrect billing according to Medicare guidelines DF122 Denied- Incorrect billing according to Medicare OPPS guidelines DF123 Denied-missing end date on claim DF124 Denied-claim submitted to Behavioral Health Vendor for review DF125 Denied-incorrect procedure code DF126 Denied-referring physician not within member's HCO DF127 Denied-referring physician NPI is invalid DF128 Denied-state supplied vaccine no reimbursement DF129 Denied -incorrect or missing modifier DF130 Denied -incomplete notes DF131 Denied -submit with code DF132 Denied-sds service requires cpt/hcpc code DF133 Denied-claim total billed does not equal claim lines DF134 Denied-place of service incorrect for billed service DF135 Denied- documentation required for mod 22 DF136 Denied-submit to Interlink DF137 Denied-CPT/HCPCS code required DF138 Denied-member lost eligibility during date span DF139 Denied-rebill on UB04 DF140 Denied-replacement claim received DF141 Services excluded for provider specialty-denied member liable DF142 Denied-resubmit to Optum DF143 Denied-resubmit to Cigna DF144 Denied-invalid diagnosis pointer on service line DF145 Denied-over the rental period

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DF146

Denied notes received past review time DF155 Denied-U modifier required for code 96110 DF156 Denied-FCHP reimbursed member directly DF157 Denied-notes not received timely DF158 Denied-Submit to Caremark DF159 Denied-Corrected claim received DF160 Part D - Submitted to Caremark DF161 Resubmit with primary carrier's paid date DF162 Denied-submit to EyeMed Vision Care DF163 Denied-referring NPI not matched DF164 Denied-serious reportable event DF165 Denied-Provider preventable condition DF166 Denied-Incorrect member id DF167 Denied-lack of medical necessity determined. Please submit medical records for redetermination. DF168 Denied-NDC code required for payment DF169 Denied-request requires appeal and medical notes to be submitted DF170 Denied-Resubmit claim with PPA DF171 Denied-submit to Sleep Management Solutions DF172 Denied- DHP commission paid in error DF173 Denied-Expiration of run out period DF174 Denied- ASO Escheatment Process DF176 Claim not processed. Op Note required. Please fax op notes to 508 368 9094. DF177 Denied-Member has met OOP max DF178 Code not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Please resubmit with this code. DF179 Denied-invalid or mismatched EOB submitted. DF180 Denied-Medical Records Not Received DF181 This drug is not covered by the plan administered by Fallon Health. To obtain this drug, please contact CVS Caremark Specialty Pharmacy at 800 237 2767 DF182 Denied-Provider is not state certified DF183 Denied-Bill as Same Day Surgery DF184 Denied-Tax ID Missing DF185 Denied - Submit to MedCost DF186 Denied-assist not paid at teaching facilities DF187 Denied-Add on code denied as primary code not billed DF188 Denied-incorrect bill corrected claim required DF189 Denied-date of service billed does not match date of service authorized DF190 Denied-not separately reimbursed per Medicare guidelines DF191 Denied-Missing billing provider information DF192 Denied- Provider Not Credentialed DF193 Denied– CPT not supported in documentation DF194 Denied Reversed in PBM DF195 Denied Reimbursed to PBM DF196 Denied - service not covered under the MLTC benefit. Bill to NY state Fee for service Medicaid DF197 Denied – Provider is Non-Participating approval was not obtained for this service DF198 Denied - Incorrect billing according to Medicaid guidelines

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DF199

Denied - Not a covered service by Fallon Health -bill Mass Health DF200 Denied - Services require valid referring PCPs NPI within Members HCO DF201 Benefits for this service are managed by American Specialty Health. Claim has been forwarded to ASH for processing. DF202 Benefits for this service are managed by Behavioral Health Vendor. Claim has been forwarded to Behavioral Health Vendor for processing. DF203 Benefits for this service are managed by Sleep Management Solutions/CareCentrix. Claim has been forwarded to SMS/CCX for processing. DF204 Benefits for this service are managed by Dental vendor. Claim has been forwarded to delegated Dental Vendor for processing. DF205 Benefits for this service are managed by EyeMed. Claim has been forwarded to EyeMed for processing. DF206 Denied - Modifier is missing invalid or not covered per medical policy DF207 Denied-modifier not supported in documentation DF208 Denied - Documentation provided does not support service billed DF209 Denied - Documentation does not support medical necessity of service billed DF210 Denied - Documentation requested and not received DF211 Denied - Documentation submitted not sufficient to determine service was provided DF212 Denied- unable to validate services performed DF213 BLS provider is responsible for payment of paramedic intercept services. Please bill BLS provider DF214 The services/drugs you received from this provider are not covered by your medical plan. Call your Express Scripts Prescription plan at 1-800-922-8279 for coverage and claims submission details DF215 Denied - Split claim in accordance with member's enrollment DF216 Denied - Benefits for this service are processed as member reimbursement only. Member is liable for charges and may request reimbursement from the plan up to the max benefit limit. DF217 Denied-provider liable-excluded provider DF218 Contact Contract Manager for single case agreement DF219 Denied - External NCCI/MCE edit applied DF220 Denied -Code does not represent a physician service DF221 Denied-Services not covered when related to SRE or OPPC DF222 Denied-Principal diagnosis invalid as discharge diagnosis DF223 Denied-Invalid DRG DF224 Denied-Not a Covered Service DF225 Denied-Invalid or missing zip code DF226 Denied - Provider requested retraction or void of this claim DF227 Denied- CMS does not provide rate for this code in the DMEPOS fee schedule DF228 Denied - Procedure Code Not Payable Per MassHealth DF229 Deny - Clinical Trial Diagnosis Code Missing DF230 Deny - NCT Identifier Missing DF231 Deny - IDE Number Missing DF232 Deny - Clinical Trial Condition Code Missing DF233 Deny - Clinical Trial Modifier Missing DF234 Denied-Resubmit active NDC code and appropriate unit of measure DF235 Denied - This service is not covered by your Benefit Bank plan benefits. Review your Evidence of Coverage for more information.

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DF236

Denied - You submitted your request past the allowed time frame. Requests must be received within 90 days from the end of the calendar year. Review your Evidence of Coverage for more information DF237 Denied - Your request is missing required information. Please resubmit your request with all required documentation in a legible format DF238 Denied - There was an issue when you swiped your card. If you are still experiencing issues, please call Customer Service. DF239 Denied - You need to activate your card. Call the number on the back of your card to activate it. DF240 Denied - You attempted to use your Benefit Bank card benefits at a merchant or provider outside the benefits covered by the card. Review your Evidence of Coverage for more information DF241 Denied - The balance on your card is less than the total charge. The charged amount cannot exceed your available balance. Check your card balance by going to the portal at fallonhealth.org/myfallon-medicare or by calling Customer Service. DF242 Denied - This is a duplicate request for reimbursement. DF243 Denied - This provider is excluded from participating with Medicare. This means we cannot pay this claim. Call Customer Service if you have any questions. DF244 Denied -Not an approved Telehealth service for Member's Program DF245 Denied - The request is for an item not covered by your fitness reimbursement benefit. Review your Evidence of Coverage for more information. DF246 Denied - The request is for a non-preventive dental service. Preventive services are cleanings, x-rays, fluoride treatments and oral exams. Review your Evidence of Coverage for more information. DF247 Denied - Your plan does not include a dental reimbursement benefit. Review your Evidence of Coverage for more information about covered benefits. DF248 Denied - Your plan does not cover eyewear from out-of-network providers. Review your Evidence of Coverage for more information about covered benefits. DF249 No payment due. Item provided without cost to provider, supplier or practitioner DF250 Denied-diagnosis is inconsistent with the patient's birth weight DF251 Denied professional service is included in hospital global rate DF252 Denied-COVID admin requires COVID vaccine on same claim DF253 Denied - Invalid HIPPS code. Resubmit a valid HIPPS code with applicable revenue code DF254 Per CMS, type of bill 320 indicates that the HHA expects full denial of services billed. No payment is made on this claim DF255 Denied - This is a RAP/NOA. RAP/NOA was submitted must not be checked DF256 Denied - This required occurrence code 50 is missing DF257 Denied - A non-RAP claim must have skilled visits unless condition code 54 is reported on the claim DF258 Denied - for non-RAP with more than 4 visits, a HIPPS is needed DF259 Denied - HCPCS code Q5001 is reported with revenue code that is not 042X,043X,044X,055X,056X or 057X DF260 Denied - Item or service is not billable under TOB 034X DF261 Denied - Dates of service span two calendar years. Calendar year overlap is not allowed for this type of bill 034X DF262 Denied - Claim spans eligible and ineligible periods of coverage. Rebill separate claims DF263 Denied - RAP/NOA received date is missing DF264 Denied - Invalid HCPCS for DOS

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DF265

Denied-invalid NDC for submitted CPT/HCPCS code DF266 Denied - No Rate per MA Medicaid Outpatient Pricing DF267 Denied - not separately reimbursed for all codes that pertain to these services. Contracted and non-contracted providers must not seek further reimbursement from the member for these services DF268 Denied - The Required FIPS code is missing or invalid DF269 Denied - Claim is being sent to the pharmacy benefit administrator for review. Contact your provider if you receive a bill. DF270 DMR dismissed. AOR not on file DF271 Denied - Missing or Invalid Admission Date DF272 Denied - Missing or Invalid Value Code DF273 Denied - Item is a packaged Service DF274 Denied - Patient Height is invalid or missing DF275 Denied - Patient Weight is invalid or missing DF276 Denied - Procedure can not be billed on AKI claim DF278 Denied - Incorrect Billing of Principle Diag Code DF279 Denied - Ambulance Service to a Physician office is not covered DF280 Denied - Inappropriate use of Q codes DF282 Denied - Diag Inconsistent with Patient Age DF283 Denied - Diag Inconsistent with Patient Sex DF284 Denied - POA indicator missing or invalid DF285 Denied - services require valid Attending Provider NPI DF286 This non-payable code is for required reporting only DF287 Denied - Statutorily excluded service (s). DF288 Denied - the date of death precedes the date of service. DF289 Denied due to settlement DF290 Denied - No HRSN referral DF291 MediQuant - Age requirement not met DF292 MediQuant - Diagnosis requirement not met DF293 MediQuant - Maximum frequency exceeded DF294 MediQuant - Statutorily excluded service DF295 DMR Dismissed-not a valid request due to missing, invalid, or illegible documentation. DF296 DMR Dismissed-enrollee is deceased, initial determination not pursued because the financial liability of another party was not established. DF297 DMR Dismissed-the request has been withdrawn. DF298 Denied – prior authorization required for service. No authorization on file. DF299 Denied – PCP referral required for service. No PCP referral on file DF300 Zelis Edit Procedure code is obsolete DF301 Zelis Edit Co-Surgeon or Team Surgery not appropriate DF302 Zelis Edit Inappropriate Use of Modifier DF303 Zelis Edit Already paid in part or full on another claim or provider DF304 Zelis Edit Add-on Code: Primary procedure not found DF305 Zelis Edit Not allowed separate payment with procedure {0} DF306 Zelis Edit Incidental or packaged proc no separate payment warranted DF307 Zelis Edit Assistant surgery not appropriate DF308 Zelis Edit In global fee period for procedure {0} DF309 Zelis Edit Too many new patient codes replace with code {0} DF310 Zelis Edit Inappropriate initial admission or discharge facility visit

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DF311

Zelis Edit Too many ICU visits on same service date DF312 Zelis Edit Other office visit ({0}) on same service date DF313 Zelis Edit Inappropriate use of HCPCS code CPT code exists DF314 Zelis Edit Not allowed payment with procedure {0} DF315 Zelis Edit Diagnosis does not qualify procedure or frequency of proc DF316 Zelis Edit Medical records do not support procedure billed DF317 Zelis Edit Denied due to lack of medical necessity DF318 Zelis Edit Ambulance charge denied due to lack of medical necessity DF319 Zelis Edit Laboratory charge denied due to lack of medical necessity DF320 Zelis Edit Exceeds clinical guidelines DF321 Zelis Edit Rebundled with other procedure(s) into procedure {0} DF322 Zelis Edit Too many procedures of this type billed DF323 Zelis Edit Duplicate procedure DF324 Zelis Edit Procedure has been processed for another provider DF325 Zelis Edit Service/procedure upcoding, audit will allow payment for {0} DF326 Zelis Edit Procedure is inconsistent with the patients age DF327 Zelis Edit Procedure is inconsistent with the patients gender DF328 Zelis Edit Diagnosis is inconsistent with the patients age DF329 Zelis Edit Diagnosis is inconsistent with the patients gender DF330 Zelis Edit Not allowed for this provider DF331 Zelis Edit Deemed ineligible when performed in an ASC setting DF332 Zelis Edit Procedure not compatible with diagnosis DF333 Zelis Edit As per NCCI, not allowed separate payment with procedure {0} DF334 Zelis Edit No corresponding surgeon charge on file - ineligible for processing DF335 Zelis Edit Incomplete Diagnosis Code DF336 Zelis Denial DME code not compatible with diagnosis DF337 Zelis Denial DME modifier missing or invalid DF338 Zelis Denial Unspecified laterality diagnosis code DF339 Zelis Edit CPT and/or HCPCS code is not effective on DOS DF340 Zelis Edit CPT and/or HCPCS code(s) submitted is invalid DF341 Zelis Edit Denied - Therapy code was received with more than one therapy modifier. DF342 Zelis Edit Denied - Assistant therapy code requires additional modifier. DF343 Zelis Edit Denied - Assistant therapy code requires additional modifier. DF344 Zelis Edit Denied - Therapy code was received with more than one therapy modifier. DF345 Zelis Edit Denied - Therapy code was received with more than one therapy modifier. DF346 Zelis Edit Denied - ST code with inappropriate modifier/REV code pairing. DF347 Zelis Edit Denied - OT code with inappropriate modifier/REV code pairing DF348 Zelis Edit Denied - PT code with inappropriate modifier/REV code pairing. DF349 Zelis Edit Denied - Therapy modifier with inappropriate REV code pairing. DF350 Zelis Edit - Inappropriate Global Service billed in a Hospital Setting DF351 Zelis Edit - Inappropriate Technical Component billed in a Hospital Setting DF352 Zelis Edit - Inappropriate Place of Service for CPT/HCPCS with PC/TC indicator DF353 Zelis Edit - Inappropriate Place of Service for Inpatient Hospital Care CPT/HCPCS DF354 Zelis Edit - Inappropriate Place of Service for Hospital Observation CPT/HCPCS

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DF355

Zelis Edit - Not Payable CPT/HCPCS for Place of Service Ambulatory Surgical Center DF356 Zelis Edit - Inappropriate Place of Service for Home Services CPT/HCPCS DF357 Zelis Edit - Inappropriate Place of Service for Nursing Facility CPT/HCPCS DF358 Zelis Edit - Inappropriate Place of Service for Office or Other Outpatient CPT/HCPCS DF359 Zelis Edit - Inpatient Only CPT/HCPCS Billed with Inappropriate POS DF360 Zelis Edit -The critical care service is not supported due to the diagnosis code(s) submitted on the claim. DF400 RX UM Vendor- deny itemization needed DF401 RX UM Vendor- deny NDC number blank or invalid DF402 RX UM Vendor- deny non par no authorization on file DF403 RX UM Vendor- deny drug cannot be billed with JW modifier DF404 RX UM Vendor- deny clinical department denial DF405 RX UM Vendor- deny multiple E modifiers billed for one service DF406 RX UM Vendor- deny health plan denied DF407 RX UM Vendor- deny incorrect unclassified drug code billed DF408 RX UM Vendor- deny NDC submitted not FDA approved DF409 RX UM Vendor- deny duplicate prev submit and processed or still in process DF410 RX UM Vendor- deny units per day exceed amount allowable DF411 RX UM Vendor- deny units exceed amount allowable for time period DF412 RX UM Vendor- deny units per day exceed amount allowable for dx combination DF413 RX UM Vendor- deny RX over amount of units authorized DF414 RX UM Vendor- deny NCCI procedure to procedure DF415 RX UM Vendor- deny OCE dx/age conflict DF416 RX UM Vendor- deny OCE dx/gender conflict DF417 RX UM Vendor- deny par provider no authorization on file DF418 RX UM Vendor- deny JW-modifier billed same line DF419 RX UM Vendor- deny DX not eligible for code DF420 RX UM Vendor- deny unclassified drug code-valid code available DF421 RX UM Vendor- deny procedure and dos does not match authorization DF422 RX UM Vendor- deny procedure code does not match authorization DF423 RX UM Vendor- deny OCE 50-statutory exclusion list DF424 RX UM Vendor- deny external causes of morbidity dx can't be primary dx DF425 RX UM Vendor- deny units exceed amount allowable for time period w/in authorization DF418 RX UM Vendor- deny JW-modifier billed same line DF419 RX UM Vendor- deny DX not eligible for code DF420 RX UM Vendor- deny unclassified drug code-valid code available DF421 RX UM Vendor- deny procedure and dos does not match authorization DF422 RX UM Vendor- deny procedure code does not match authorization DF423 RX UM Vendor- deny OCE 50-statutory exclusion list DF424 RX UM Vendor- deny external causes of morbidity dx can't be primary dx DF425 RX UM Vendor- deny units exceed amount allowable for time period w/in authorization DF426 RX UM Vendor- deny rebundling-procedure code changed DF427 RX UM Vendor- deny patient has exceeded authorized number of visits DF428 RX UM Vendor- deny date of service does not match authorized date span DF429 RX UM Vendor- deny units per day exceed amount allowable within authorization

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DF430 RX UM Vendor- deny procedure code and/or modifier invalid for patient age DF431 RX UM Vendor- deny invalid procedure code/modifier combination DF432 RX UM Vendor- deny place of service does not match authorization DF433 RX UM Vendor- deny drugs billed w/out modifier DF434 RX UM Vendor- drug billed w/incorrect modifier DF435 RX UM Vendor- not appropriate for drug billed DF436 RX UM Vendor- deny NDC submitted not valid w/procedure code DF437 RX UM Vendor- deny NDC unit of measure and/or quantity missing DF438 RX UM Vendor- deny medically unlikely edit (MUE) DF439 RX UM Vendor- deny drug is not covered or preferred drug DF440 RX UM Vendor- deny JZ modifier not allowed twice on same proc code on same date DF441 RX UM Vendor- deny JZ modifier cannot be on 2 lines DF442 RX UM Vendor- deny appropriate modifier is missing DF500 Denied- Only one payment allowed per DOS DF501 Denied - item/service is considered experimental or investigational.

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Zelis Fallon Health uses an integrated claims editing tool offered by Zelis to further evaluate claims for adherence to industry-recognized edits and guidelines, and to ensure compliance with payment policies and standard coding practices. If a claim line denies for a Zelis edit, providers will find a message on the Remittance Advice Summary (RAS) and the Electronic Remittance Advice (835 file) indicating an edit was applied by Zelis. Questions surrounding these Zelis edits should be directed to Zelis at 1-866-489-9444. Appeals related to a Zelis edit should be sent to Zelis within 120 days of the original RAS at the following address:

Zelis Claims Integrity, Inc. 340 MT Kemble Ave Morristown, NJ 07960 Attn: Appeals Department Fax: 1-855-787-2677 Email: appeals.integrity@zelis.com Zelis appeals require: • A completed Request for Claim Review form explaining the reason for the dispute, including contact information and a fax number • A copy of the original claim billed • A copy of the RAS including the denial • All pertinent medical records and/or reports necessary for reconsideration of the claim Claim Adjustments related to a Zelis edit should be sent to Fallon Health. The most efficient way to submit a corrected claim to Fallon Health is to send a full replacement claim electronically using industry standard 837 submissions within 120 days of the Remittance Advice Summary. Electronic replacements must be submitted with Frequency Code “7” indicating they are replacement claims: Written requests for provider corrections to a claim must be submitted within 120 days of the date of the Remittance Advice Summary (RAS) using a Request for Claim Review form and the corrected claim with all claim lines submitted to the following address:

Fallon Health Claims Department: Adjustment Team P.O. Box 211308 Eagan, MN 55121-2908 Fax: 508-368-9890