Claims FAQ

When did you start to pay the outpatient claims with the new APC system?
We started paying on the new outpatient APC system as of 12/01/2005.

What fee schedule does Capstone use to compensate providers?
Capstone reimburses providers on a fee for service basis at a multiple of the AHCCCS Fee Schedule.

If I have a question on how to bill the claim, whom can I call to help me?
Paget, Deborah and Sherrylee have extensive experience in how a claim should be billed; please feel free to contact any one of them to help you with the questions you have. We are unable to tell you what to bill or the diagnosis codes to use, but we are happy to give you the fundamentals of how you will need to bill the claims to Capstone Health Plan to ensure more prompt payments of your claims.

How soon can I expect payment on a claim sent to Capstone Health Plan?
We process all claims and payments within a 30-day time frame; in some cases claims can be paid within a 2-week time frame. We usually have a claims check run on a bi-weekly basis.

What does it mean when a claim is denied for Invalid from or thru DOS?
When monthly supplies are furnished to a Member or a monthly rental of DME equipment is billed into Capstone Health Plan the provider will need to span date the purchase or rental for the time frame that it is encompassed. Example: Line 24A on HCFA 1500 09/11/06 (beginning DOS), 10/10/06 (ending DOS), 24B place of service 12 (home), line 24C Type of Service R (rental), line 24D B9002 RR (Procedures services or supplies CPT/HCPCS and Modifier[s]{infusion pump rental}), line 24E diagnosis code (the number that is associated in line 21 (1,2,3,4), line 24F charges for item line 24G days or units (should be 1 for 1 month). In some cases an itemized statement will need to be attached to the submitted claim (generic codes {B9998}).

Why must you recoup on a claim? It messes up my system. Can I just send you a refund back?
Capstone must recoup on a claim if there was an error on the claim or if the claim was paid in error so that our system will show the correct payment to the correct entity. If a refund is sent, the claim will be incorrectly paid in our system, which could also affect the provider's end-of-year 1099 totals. Since all of our claims are sent to the state, the claims must be accurately keyed and paid.

Capstone Health Plan