Claims Processing

For claims to qualify for payment:

	The patient must be eligible for the program.
	The requested service must be authorized.
	The related claims must be received by POMCS within one year after the date of service or within 45 days after the date of authorization, whichever is later. All claims should include the patient's case number and authorization number.
	Hospital and other institutional services must be billed on a UB 92.
	Professional fee must be submitted on the HCFA 1500 for all types of services except dental services which should be billed on the current ADA form.
	Submit claims to: PURCHASE OF MEDICAL CARE SERVICES 1904 Mail Service Center Raleigh, North Carolina 27699-1904

Claims are processed within 45 days after receipt of completed claim form. Claim forms returned for additional information must be corrected and re-submitted within one year after date of service or within 45 days after return, whichever is later. Requests for payment adjustment must be received within one year after the date of service or within 45 days after a claim is paid, whichever is later.

Coordination With Other Insurers

If the patient has other third party coverage, the provider must first bill the other carrier, and wait up to 6 months after the date of service, if necessary, to receive payment or denial before billing the Cancer Control Program. Other third party coverage includes but is not limited to insurance, Medicaid, Medicare and CHAMPUS.

If the patient's other coverage is an HMO, he must go to an HMO provider for medical care. The provider may not bill the Cancer Control Program for services covered under the patient's plan. If the service is not covered under the patient's plan, a claim accompanied by an HMO denial may be submitted to Purchase of Medical Care Services (POMCS).

If the other third party pays the claim within 6 months after service, the amount paid should be indicated on the claim and the claim submitted to the Purchase of Medical Care Services. The Claims Processing Unit of POMCS will determine the maximum allowable payment rate for the service, subtract the amount already paid by other payers, and pay the difference up to the maximum reimbursement rate (Medicaid rate on all but inpatient services). If other third parties have paid more than POMCS' maximum rate, no additional payment will be made.

If the other third party payer denies payment, providers should attach a copy of the denial, including the explanation, and submit the claim to the POMCS. The maximum reimbursement rate may be paid if the third party payer denied payment because the patient had not met his deductible or because the service was not covered. POMCS will deny payment if insurance normally covers the service but did not pay because the provider failed to obtain prior approval or because the patient did not use an approved provider.

If the other third party does not respond within six months, the claim may be submitted to Purchase of Medical Care Services for processing. Providers should indicate the date insurance was billed and state that no response has yet been received.

Providers who are paid by POMCS and subsequently receive payment from another third party payer are required to reimburse POMCS within 45 days. Reimbursement should equal the lesser of the two payments received.