Prevent errors on your OTP claims

First Coast wants to ensure your claims process quickly and correctly. We’re seeing Opioid Treatment Program (OTP) claims denying due to provider and patient eligibility, timely filing, and missing, incomplete, or invalid information. Review these tips to help with your claim submission.

Know your eligibility effective date

OTPs must enroll in the Medicare program. When your enrollment is approved, you will receive an approval letter with your effective date. Claims submitted for dates of service (DOS) prior to the effective will be denied. Verify the effective date for your OTP prior to submitting claims. For guidance on enrolling, please view the MLN Educational Tool: Medicare Provider Enrollment.

Check patient eligibility

To prevent denials, we recommend that you check the patient’s eligibility prior to submitting the claim. You can quickly check patient status and eligibility using the interactive voice response (IVR) system or our free internet portal, SPOT. In addition to obtaining the patient’s effective date for Part A and B, you should also obtain information for inactive periods, Medicare advantage, and Medicare secondary payer (MSP).

For more information on the IVR, please review the IVR resources webpage.

For more information on using SPOT, please review The SPOT: User guide.

File claims timely

Per Medicare guidelines, claims must be filed with the appropriate Medicare claims processing contractor no later than 12 months (one calendar year) after the DOS. Claims submitted after one calendar year from the DOS will be denied. To prevent timely filing denials, be sure to submit your claims timely and follow-up on claims that are returned as unprocessable (RUC) or returned to provider (RTP). Claims with missing, invalid, or incomplete information that prevent Medicare from processing them (RUCs and RTPs) are NOT considered submitted. RUCs and RTPs must be corrected and resubmitted for processing. For more information on timely filing, please view the Claims timely filing guidelines FAQ.

Prevent missing, incomplete, or invalid information

There are many reasons that a claim can RUC or RTP. Claims data shows the top reasons OTP claims are returned is due to invalid place of service (POS) code, MSP, or the DOS and units do not match.

POS code

Part B claims are submitted with a two-digit POS code. The POS code 58 was created for Part B OTP claims. All OTP claims must be submitted with the POS code 58.

MSP

This is related to checking patient eligibility. To prevent this return, check the patient eligibility for MSP information. If the patient has another primary insurance, submit the claim to the primary insurance first and then to Medicare including the required primary payer’s information. 

For information on submitting Part B MSP claims, please view the Electronic filing of Part B MSP claims in the 5010 format.

For information on submitting Part A MSP claims, please view the Electronic filing of Part A MSP claims in the 5010 format.

DOS and units

The HCPCS codes created for OTPs represent a weekly bundle of services and cover episodes of care lasting seven days in a row. OTPs cannot bill for the same patient more than once per seven-day period. OTPs may choose to establish a standard billing cycle with a set day of the week to begin the episodes of care. For these situations, this is the DOS you would submit on your claim. OTPs should only submit one date as the DOS along with one unit. For guidance on billing OTP claims, please review CMS Opioid Treatment Programs (OTP) - Billing & Payment.

Note: For general information about OTPs, please visit the First Coast OTP specialty page or the CMS OTP webpage.