Children s Long Term Support (CLTS) Waiver Third Party Administration (TPA) Claims Processing

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1 Children s Long Term Support (CLTS) Waiver Third Party Administration (TPA) Claims Processing Wisconsin Department of Health Services Division of Long Term Care Bureau of Long-Term Support 1

2 Third Party Administration (TPA) Claims Processing for Children s Long-Term Support (CLTS) Waivers DHS pursuing key opportunities that result in: Cost Savings Operational efficiencies & consistencies Use of common information technology systems Outsourcing to allow county agency programs to focus on core Medicaid Waiver responsibilities Claims processing major business function that provides this opportunity 2

3 TPA Claims Processing for Children s Long-Term Support Waivers Centers for Medicare & Medicaid Services (CMS) claims and reporting system requirements include: Statewide Standardized Applies to all Medicaid funded programs including Medicaid Waiver programs 3

4 Third Party Administrator Vendor DHS considered variety of solutions: Contracting with TPA vendor to process CLTS Waiver claims most cost-effective solution Requirements specified in Request for Proposal (RFP) for functions similar to Family Care Managed Care Organizations Vendor demonstrating statewide and timely implementation capacity Wisconsin Physicians Service (WPS) 4

5 Third Party Administration Pilot Phase DHS selected 5 county waiver agencies (CWAs) to participate in TPA Pilot phase Dane La Crosse Milwaukee Shawano Waushara WPS began processing TPA claims in pilot CWAs effective September 2010 Statewide WPS TPA claims processing targeted to begin Spring

6 Wisconsin Physicians Service Health Insurance Herb Held Director Government Programs Katie McClellan Business Analyst Government Programs WPS is proud and privileged to be part of the Children's Long Term Support (CLTS) implementation project. We have worked closely with State of Wisconsin Department of Health Services and Five Pilot County Waiver Agencies to create a standardized statewide CWA transition plan so that WPS can start receiving and processing provider claims throughout the State of Wisconsin. The main purpose of this Web Cast is to educate all of our Children's Long Term Support (CLTS) providers on how to submit claims for the CLTS Program. We're going to go over general information about WPS Talk about our role within the CLTS waiver process And go over all the Provider Claim submission requirements 6

7 WPS Health Insurance Corporation Over 60 years as Wisconsin Health Insurer Medicare Part A and B Administrator Tricare Administrator Administrator for Milwaukee County Family Care Program since January 2004 Administrator for Community Care of Central Wisconsin Family Care program since November 2008 Administrator for Southwest Family Care Alliance program since January WPS Health Insurance is located in Madison Wisconsin - We have been providing quality health and benefit plan administration for over 60 years. During our six decades, we have become one of the state s largest health insurers, serving more than a quarter million of Wisconsin s businesses and residents. - In addition to our Wisconsin business, WPS administers Medicare Part A benefits nationally and Part B benefits for 4.6 million seniors throughout 8 states. - The WPS TRICARE division provides claims administration, customer service, and other related activities for the U.S. Department of Defense, serving more than 4.5 million people worldwide. - We have been administering the Milwaukee County Department on Aging Family Care Program since 2004, Community Care of Central Wisconsin since November 2008 and Southwest Family Care Alliance since January We have experienced success with each of the three Family Care program transitions to WPS. 7

8 RECEIVES SERVICE AUTHORIZATION NOTIFICATION FROM CWA PERFORMS AUTHORIZED SERVICE SUBMITS CLAIM TO OTHER INSURANCE OR MEDICARE (IF APPLICABLE) PARTICIPANT NEEDS APPROVED WAIVER SERVICE CWA AUTHORIZES THE APPROVED WAIVER SERVICE SUBMITS CLAIM TO WPS (ELECTRONIC, EXCEL OR PAPER) WPS RECEIVES AUTHORIZATION FILE FROM CWA WPS PROCESSES CLAIM WITH CORRESPONDING SERVICE AUTHORIZATION PAYMENT AND/OR REMITTANCE ADVICE ARE SENT TO The County Waiver Agencies, Providers and WPS all have important roles in the CLTS process. Here is a high level flow chart starting with Participant's needs for services, To providers servicing the participants, and then providers getting reimbursed for their services. 8

9 PARTICIPANT NEEDS APPROVED WAIVER SERVICE The whole process starts with the Participant who needs various approved waiver services and/or supplies 9

10 PARTICIPANT NEEDS APPROVED WAIVER SERVICE CWA AUTHORIZES THE APPROVED WAIVER SERVICE - The CWA Care Management team's role is to assess the Participant's needs and to pre-authorize all the services and supplies a Participant would require. 10

11 RECEIVES SERVICE AUTHORIZATION NOTIFICATION FROM CWA PARTICIPANT NEEDS APPROVED WAIVER SERVICE CWA AUTHORIZES THE APPROVED WAIVER SERVICE WPS RECEIVES AUTHORIZATION FILE FROM CWA - The CWA Care Management Unit will create Service Authorization (SA) notifications that will be sent to the provider. Each SA will have one unique service code or a range of codes. Other various information is contained on the SA, such as Date span, Modifiers, unit frequencies, provider billing number. Much of this information on the SA will be used by the provider to submit claims to WPS. - WPS will also receive the Service Authorization electronically from each CWA. We will load the authorization data into a authorization data base within our our processing system. 11

12 RECEIVES SERVICE AUTHORIZATION NOTIFICATION FROM CWA PERFORMS AUTHORIZED SERVICE PARTICIPANT NEEDS APPROVED WAIVER SERVICE CWA AUTHORIZES THE APPROVED WAIVER SERVICE WPS RECEIVES AUTHORIZATION FILE FROM CWA - Services/supplies are provided to the participant by the provider. 12

13 RECEIVES SERVICE AUTHORIZATION NOTIFICATION FROM CWA PERFORMS AUTHORIZED SERVICE SUBMITS CLAIM TO OTHER INSURANCE OR MEDICARE (IF APPLICABLE) PARTICIPANT NEEDS APPROVED WAIVER SERVICE CWA AUTHORIZES THE APPROVED WAIVER SERVICE WPS RECEIVES AUTHORIZATION FILE FROM CWA -If participant has other primary coverage, such as other private insurance or Medicare the claims should be sent to the primary carrier first. Providers should submit claims to WPS even if there is no remaining CLTS liability. The claims data is important for encounter reporting purpose. -If participant has no other primary coverage or the service is non medical, the claim can be submitted to WPS first. 13

14 RECEIVES SERVICE AUTHORIZATION NOTIFICATION FROM CWA PERFORMS AUTHORIZED SERVICE SUBMITS CLAIM TO OTHER INSURANCE OR MEDICARE (IF APPLICABLE) PARTICIPANT NEEDS APPROVED WAIVER SERVICE CWA AUTHORIZES THE APPROVED WAIVER SERVICE WPS RECEIVES AUTHORIZATION FILE FROM CWA SUBMITS CLAIM TO WPS (ELECTRONIC, EXCEL OR PAPER) - The provider will submit the claim to WPS with all the required claims data elements along with the primary payor's EOB/EOMB (if applicable). -Providers can submit claims in various ways to WPS (Electronically, Excel spreadsheet and paper). We will explain the submission options later in the presentation. 14

15 RECEIVES SERVICE AUTHORIZATION NOTIFICATION FROM CWA PERFORMS AUTHORIZED SERVICE SUBMITS CLAIM TO OTHER INSURANCE OR MEDICARE (IF APPLICABLE) PARTICIPANT NEEDS APPROVED WAIVER SERVICE CWA AUTHORIZES THE APPROVED WAIVER SERVICE SUBMITS CLAIM TO WPS (ELECTRONIC, EXCEL OR PAPER) WPS RECEIVES AUTHORIZATION FILE FROM CWA WPS PROCESSES CLAIM WITH CORRESPONDING SERVICE AUTHORIZATION - WPS receives and processes the provider s claim. During our processing, we will ensure we received the Authorization record from the CWA and that all required data elements match. If all the data elements match appropriately, then payment will be made to the provider. If all the proper claim data elements are submitted correctly, the claim will process quickly and payment will be made promptly. 15

16 RECEIVES SERVICE AUTHORIZATION NOTIFICATION FROM CWA PERFORMS AUTHORIZED SERVICE SUBMITS CLAIM TO OTHER INSURANCE OR MEDICARE (IF APPLICABLE) PARTICIPANT NEEDS APPROVED WAIVER SERVICE CWA AUTHORIZES THE APPROVED WAIVER SERVICE SUBMITS CLAIM TO WPS (ELECTRONIC, EXCEL OR PAPER) WPS RECEIVES AUTHORIZATION FILE FROM CWA WPS PROCESSES CLAIM WITH CORRESPONDING SERVICE AUTHORIZATION PAYMENT AND/OR REMITTANCE ADVICE ARE SENT TO WPS will send payment and the Provider remittance advice to the provider. 16

17 RECEIVES SERVICE AUTHORIZATION NOTIFICATION FROM CWA PERFORMS AUTHORIZED SERVICE SUBMITS CLAIM TO OTHER INSURANCE OR MEDICARE (IF APPLICABLE) PARTICIPANT NEEDS APPROVED WAIVER SERVICE CWA AUTHORIZES THE APPROVED WAIVER SERVICE SUBMITS CLAIM TO WPS (ELECTRONIC, EXCEL OR PAPER) WPS RECEIVES AUTHORIZATION FILE FROM CWA WPS PROCESSES CLAIM WITH CORRESPONDING SERVICE AUTHORIZATION PAYMENT AND/OR REMITTANCE ADVICE ARE SENT TO 17

18 General Claim Submission Requirements You may submit claims for authorized services using any of the following options: Electronic Filing Excel Spreadsheet Submission Paper Claims HCFA (CMS 1500) UB04 (CMS 1450) CLTS Waiver Claim Form 18

19 Electronic Filing What is EDI? EDI stands for Electronic Data Interchange Two-way electronic exchange of business data between WPS and the provider s office EDI is supported by the WPS Electronic Data Services department 19

20 Electronic Filing What does EDI mean to your office? Faster payment Immediate verification of claims received - Error Report Save on postage and mailing time Lower administrative cost More control over claims 100% data accuracy Claim submission flexibility 20

21 EDI Submission Options Submissions through Clearinghouse WPS free claim entry software PC-Ace Pro32 Includes easy-to-follow user guides (Institutional and Professional) 21

22 Where to get more EDI information? WPS dedicated EDI staff available to discuss submission options with your office To learn more about EDI claim submission options, feel free to contact us at: Toll Free: , Option 6 or Fax: Also visit our web site at: 22

23 Excel Spreadsheet Submission Paperless claim submission option Multiple participants per each submission Faster claim turnaround time 100% data accuracy Submission verification Ease of billing routine services Designed for medium to low claim volume submissions We offer a user friendly claim submission options called Excel Spreadsheet. Advantages for Excel spreadsheet: - Paperless claim submission option. Excel spreadsheet sent to WPS via secured process - Multiple participants per each submission spreadsheet - Faster claim turnaround time vs. paper - 100% data accuracy we input data elements as submitted. - Submission verification We will send a notification back to the provider validating that we received the spreadsheet - Ease of billing routine services on a set billing schedule - Designed for medium to low claim volume submissions. Large volume providers should resort to Electronic submissions. 23

24 Excel Claim Submission For more information or to get started: Please include the following information: Business Name Contact Person Phone Number If you are interested the Excel spreadsheet option, simply us at this address. Include: Business Name Contact Person Phone Number A WPS representative will get back to you to provide you with all the information you need to submit claims via the excel spreadsheet process. 24

25 Paper Claim Submission Where to submit paper claims? Bureau of Long-Term Support CLTS Waiver C/O WPS Insurance Corporation P O Box Madison, WI Paper claims should be submitted to this address: This is a Bureau of Long-Term Support CLTS Waiver dedicated address. We will isolate CLTS claims from other WPS lines of business during the claims processing process. 25

26 We developed a special CLTS Waiver claim form. Much of the required data elements are contained on the service authorization notification received from the CWA and should be billed on this claim form. 26

27 WPS CLTS Customer Service Call Center Claim Status or Payment Questions Phone Number: Hours of Operation: Monday through Friday 8:00 AM 4:30 PM Our WPS Call Center staff will serve you with any Claim Status or Payment Questions related questions that you may have. -We have a dedicated CLTS phone number and experienced staff to service providers. -Hours of operation are Monday Friday 8 am 4:30 pm 27

28 Claim Status or Payment Questions When claim is processed and paid Amount of check, check date, check number Requests for additional copy of Provider Remittance Advice How to submit corrected claims How to correct denied claims What to do if claim was overpaid Other claims related questions We will answer any type of claim related question, such as: - When claim is processed and paid - Amount of check, check date, check number - Requests for additional copy of Provider Remittance Advice - How to submit corrected claims - How to correct denied claims - What to do if claim was overpaid - Other claims related questions -Service authorization type questions should continue to be directed to the CWA 28

29 Provider Payments Paper checks sent out every Tuesday and Thursday via USPS (2-5 business days) Electronic Funds Transfer (EFT) transmitted Monday and Wednesday (1-2 business days) 29

30 CLTS Claims Submission Claims submitted with all the accurate data elements will result in timely claim payments Claims that are submitted with missing or incorrect information could result in claims being denied *Please refer to attached Denial Code worksheet* 30

31 Required Claim Data Elements Participant Information: Participant First/Last name Participant Date of Birth Participant MCI (Master Client Index) Providers should bill with the appropriate participant information: Participant First/Last name Participant Date of Birth Participant MCI (Master Client Index) The participant ID number is the Medicaid 10 digit MCI Number. This number will be on your SA you receive from the CWA. Please make sure claims are billed with this number. 31

32 Required Claim Data Elements Provider Information Billing Provider Name Billing Address Place of Business Address Billing Provider Tax-ID Number (TIN, EIN, SSN) Rendering Provider Name Billing Provider NPI Number (National Provider Indicator) (required for medical services) Provider information: - The Billing Provider name is how you want the check made out to. - The Billing address is where you want to check to be sent to. - The Place of Business address is your physical address (Not a P.O. Box) - We will set each of you up in our provider file under a TAX ID, EIN, or SSN. This information is being provided to WPS by The State DHS. It's important that you submit this number on each claim. This number will be on the SA notification. - Include the rendering provider's name. (ie... Name of person who performed the service) - Billing Provider NPI Number (National Provider Indicator) (required for medical services) If you submit an invalid NPI, the claims will reject. 32

33 Required Claim Data Elements Claim Detail Information Date of Service Date of service must be within authorized date span Bill individual dates Date spans acceptable for consecutive service dates No future dates will be accepted *See handout for date of service examples that are acceptable* 33

34 Required Claim Data Elements Claim Detail Information Service Code HCPCS/CPT/Revenue Codes (bill with the service code on your service authorization notification) Modifier(s) - modifier(s) must be billed as they appear on your service authorization notification 34

35 Required Claim Data Elements Claim Detail Information Charge Amount Number of Units provided (partial units will not be accepted) Units increments examples: Number of Days 1 unit for every 15 minutes Number of hours Number of items - Bill the total charge amount for the service/supply - Bill only the number of units you performed. - Partial units (decimals/fractions) will not be accepted Units increments examples: Number of Days 1 unit for every 15 minutes Number of hours Number of items 35

36 Billing Requirements Participant must be eligible for Medicaid and CLTS Waiver during period service was provided Claims must be received by WPS within 90 days of date of service or 90 days from other insurance carrier s processed date 36

37 Billing Requirements Medicare EOMB (Explanation of Medicare Benefits) or Primary Insurance EOB (Explanation of Benefits) information must be submitted with claim regardless if CLTS Waiver will make further payment or not Medicare or Other Insurance disclaimer codes can be included on claim instead of EOB or EOMB 37

38 Denied Claims Claim denied in full (see attachment for claim denial reasons) Resubmit as NEW claim with proper data elements Claim can be resubmitted via EDI, excel spreadsheet or paper claim If a claim is denied in full due to a wrong or missing data element (See attached denial explanations listing), providers should resubmit the claims a a NEW claim. Resubmit claim to WPS as you normally would submit new claims to WPS (Electronic, excel spreadsheet, paper). 38

39 Corrected Claims Correcting previously paid claim Resubmit PAPER claim with CORRECTED CLAIM noted on top of claim form Clearly indicate what data element is being corrected (e.g., charge amount, units, date of service, etc.) For any claim that was previously paid and requires a correction, such as units, charge amount date of service, Providers must Resubmit PAPER claim with CORRECTED CLAIM noted on top of claim form Clearly indicate what data element is being corrected (e.g., charge amount, units, date of service, etc We are required to reprocess the claims under the same claim #. 39

40 Refunds Send check and appropriate documentation to: WPS Health Insurance ATTN: WPS Refund Dept PO BOX 8190 Madison, WI

41 THANK YOU FOR VIEWING THIS PRESENTATION If you have questions about submitting claims to WPS for CLTS Waiver Services, contact the WPS CLTS Customer Call Center at

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