Description:
Floor limits are designated payment amounts which may not be exceeded for systems generated payments without a deferral for quality control.

Policy Statement:
D9U02 occurs when the approved amount is $74,999.99 or greater.

D9U02 Claim floor limit exceeded/See your Supervisor for approval. *** For CHC: If the provider is out of network and out of state, put URSTA on header if the claim is not ITS. If this claim is over $100,000, there is a special form that must be completed and sent to Corporate Audit. If you do not have the form, see your Supervisor.

The dollar tolerance for floor limit review has been increased to $50,000 (unless otherwise instructed by each Area Management). National Alliance BDS groups are still at $75,000.  Areas may have input an "Overlay Rule" to work claims up to new amounts. Review claims as required for your particular areas high dollar amount. The processor will review the claim and override the deferral for claims payments up to $50,000 ($75,000 for NA). Floor limits are written up on all original claims with allowance over $50,000 ($75,000 for NA) and signatures from Management must be obtained before claims can be paid. Signatures will be required as follows:

1. The Area Manager/Director must approve claim payments from $75,000 to $124,999.99. If the claim payment is $125,000 to $199,999.99 the Area Director must approve.
2. The Assistant Vice President must approve all claim payments of $200,000 to $349,999.99.
3. The Vice President must approve all claim payments of $350,000 to 499,999.99.
4. The Area Senior Vice President must approve all claim payments of $500,000 and greater. (For Major Group, the area Vice President has authorization) 

1. Any hospital or SNF admission in excess of thirty days must be deferred for review by HCMS.
2. All facility provider payable claims of $30,000 or more must defer for claims area review and approval.
3. All subscriber claim payments of $2,500 or more must defer for claims area review and approval.
   

A floor limit review form must be completed on all payments over $75,000 (see exhibit).  This form contains a list of items, which must be completed to ensure quality processing of these claims and may include a review by medical staff. These claims will be processed within 45 calendar days from date of receipt.

If the approved amount on a subscriber payable claims is greater than $5,000, the second pass processor must review a copy of the claim to verify assignment.  The second pass processor will resolve the claim and have the final approval of the assignment. If the approved amount is greater than below $2,500, a floor limit review form must be completed with supervisor approval.  Each area will be responsible for ensuring that these claims are processed within the normal timeliness guidelines. Effective in 2009 for Major Group, Directors can sign off on member pay claims with an allowance below $15,000.

Adjusted claims DO NOT need to be written up unless the allowance changes enough to require an additional level of signature.

All HOST Inter-Plan Teleprocessing Service (ITS) claims processing through AMMS will not defer for floor limit review and approval.

The processor is responsible for knowing AMMS and making sure that the claim is paid correctly. The following guidelines must be followed:

Work all deferrals up to D9U02 and D7PER.
Complete ALL fields on the OTFL (over the floor limit) form to include screen print.
>Gather the package together, get signatures then have QC review, and then image and release.

For National Alliance, the OTFL (over the floor limit) form is an electronic package sent via email.  All appropriate approval levels are maintained in the high dollar database.

The purpose for attaching all screen prints for every question verified on the claim is to protect the processor as the information may change through lengthy sign off and review period by supervisor, manager, director, QC and VP’s.   The processor should include any and all screen prints that are verified or looked at to include header of claim, DRG screen with all DX codes (click on DRG and enter), TPRD screen, COB form and copy of email sent to marketing representative.  If the claim is an adjustment, payment indicated on the form should represent additional payment only.

Exception:  Some ASO accounts may elect to have floor limit amounts that differ.  Deviations from the standard requirements described in this policy should be determined by the group representatives and documented in the departmental desk procedures.

Please see area desk procedures for current form and procedures.