Hometown Health reimburses providers according to its standard payment policies. In developing its standard payment policies, we consider current healthcare trends and advances, as well as information from a variety of different sources, including but not limited to provider questions and comments; guidelines from the Centers for Medicare and Medicaid Services; AMA guidelines; CPT Assistant; Correct Coding Initiative; and specialty medical societies. However, Hometown Health’s standard payment policies may differ from policies adopted, endorsed, or recommended by any or all of those sources.
Hometown Health uses an automated code-auditing tool in its claims processing system. This code-auditing tool incorporates edits based on Hometown Health’s standard payment policies. If a claim submitted for payment is not in accordance with Hometown Health’s standard payment policies, we may deny or pend payment on the claim completely or partially. Access to information about the edits applied during claims processing is available through Clear Claim Connection, which is accessible through HealthConnect 24 hours a day, 7 days a week.
In the event of a conflict between Hometown Health’s standard payment policies and an automated edit, Hometown Health’s standard payment policies will control. Additionally, all payment decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to all applicable state and/or federal laws.
If your claim is denied or pended for any reason, you may appeal the decision by following the procedures as explained in your Provider Manual and on this website.