Healthcare Claiming. Help Desk Q&A, Reports and Claiming Tips. Presenter: Stacey Alsdurf. SSIS Fiscal Mentor Meeting Healthcare Claiming 02/11/15

Transcription

1 Healthcare Claiming Help Desk Q&A, Reports and Claiming Tips Presenter: Stacey Alsdurf 1

2 Presentation Overview Healthcare Claim Proofing Reprocessing Healthcare Claims Using Reports in SSIS Claiming Tips New to Healthcare Claiming in

3 Healthcare Claim Proofing Check Healthcare Claim Proofing to determine if missing or incorrect information is preventing Healthcare Claim generation 3

4 Healthcare Claim Proofing Evaluate or develop internal agency processes to: Minimize proofing messages Correct proofing messages Create Exclusions or Do Not Claim Determination Records when messages cannot be corrected Determine how to distribute proofing reports to workers and case aides 4

5 Healthcare Claim Proofing Creating revenue from Healthcare Claiming does not stop at Healthcare Claim Batch generation 5

6 Healthcare Claim Proofing Additional Healthcare Claiming revenue might be available if proofing messages can be resolved 6

7 Healthcare Claim Proofing Helpdesk reports related to Time Records or Payments not claimed are often due to proofing messages preventing claims generation. 7

8 Healthcare Claim Proofing My MH-TCM Time Record did not claim. Why not? A Billable Mental Health diagnosis is required for MH-TCM claims If no Billable Mental Health Diagnosis code entered in SSIS, a proofing message displays 8

9 Healthcare Claim Proofing A Help Description displays in Error help with more detail regarding the proofing message when clicking on the Proofing Message in Data Clean-up 9

10 Healthcare Claim Proofing If possible, the application brings you to the most likely place to resolve the issue In this case, SSIS displays the client s Diagnosis information from the Disability/Diagnosis/Substance folder No diagnosis codes have been entered for the client 10

11 Healthcare Claim Proofing Frequent proofing messages include: No Supplemental Eligibility exists for the service dates. (#2015) Entered in SSIS No Eligibility Span exists for the service dates.(#2010) Entered in MAXIS, MMIS No MMIS Service Agreement Line Item exists for the HCPCS/Modifiers for the service dates. (#2304) Entered in MMIS 11

12 Healthcare Claim Proofing If a Time Record or Payment is not claimable, create Exclusions or Do Not Claim Determination records Exclusions work well for an individual Time Record or Payment not claimable. For example, if an Attempted Contact is not claimable, enter an Exclusion Do Not Claim Determination records work well for periods of time that are not eligible for claiming. For example, if a client is not MA eligible, enter a Do Not Claim Determination 12

13 Reprocessing Claims Multiple actions are available to reprocess claims including: Resubmit Void and Resubmit Void and Finalize 13

14 Reprocessing Claims My claims were paid at the wrong rate, how to I fix this? I fixed the problem that caused my claim denial, now what? More units were added to the MMIS Service Agreement, how do we get the additional reimbursement that we are now due? The client went into a nursing facility and we should not have been paid, what do we do now? 14

15 Reprocessing Claims: Resubmit I fixed the problem that caused my claim denials, now what? Denied claims can be sent to MMIS again after errors have been corrected Run proofing again to verify Denied Healthcare Claims that can be resubmitted must be marked for submission individually 15

16 Reprocessing Claims: Resubmit Healthcare Claims can be resubmitted from: Healthcare Claims batch Healthcare Claim Searches Fiscal Details folder 16

17 Reprocessing Claims: Resubmit Only Healthcare Claims with Denied or To be Denied Claim status can be resubmitted The multi-select function is not available for claims resubmission 17

18 Reprocessing Claims: Resubmit To Resubmit from the Claim batch: Select claim in the Claims grid Access Action menu and select Resubmit Claim The Disposition updates to Resubmitted 18

19 Reprocessing Claims: Resubmit To Resubmit from the Healthcare Claim Searches: Select claim in the Healthcare Claim Search grid Access Action menu and select Resubmit Claim 19

20 Reprocessing Claims: Resubmit To Resubmit from the client s Fiscal Details folder: Select Healthcare Claims folder Select claim in the Healthcare Claim grid Access Action menu and select Resubmit Claim 20

21 Reprocessing Claims: Void and Resubmit Void and Resubmit is used to take back a payment and resend a claim to MMIS because the information that was originally sent was incorrect Often done because payment amount was incorrect 21

22 Reprocessing Claims: Void and Resubmit My claims were paid at the wrong rate, how do I fix this? More units were added to the MMIS Service Agreement, how do we get the additional reimbursement that we are now due? Paid or Partially Paid Claims that need to be reprocessed must be voided and resubmitted. 22

23 Reprocessing Claims: Void and Resubmit Void and Resubmit in six easy steps: Create Void batch Add claims to the Void batch Access the Action Menu and select Void and Resubmit Submit the Void batch Void claims process in MMIS and claim Disposition set to Resubmit Claims set to Resubmit are pulled into a Claim batch with matching Claim Category and Service Dates 23

24 Reprocessing Claims: Void and Resubmit Create Void Batch from Claim Batch Search Select Claim category of Void 24

25 Reprocessing Claims: Void and Resubmit Add claims to be voided to the Void batch by accessing the Action Menu and selecting Void and Resubmit Adding claims to void batch from Claims tab of a Healthcare Claim Batch: 25

26 Reprocessing Claims: Void and Resubmit Adding claims to Void batch from Healthcare Claims tab of a Healthcare Claim Search: 26

27 Reprocessing Claims: Void and Resubmit Adding claims to Void batch from Healthcare Claims tab of the client s Fiscal Details folder 27

28 Reprocessing Claims: Void and Resubmit Submit Void batch 28

29 Reprocessing Claims: Void and Resubmit When a Void processes in MMIS, the claim Disposition changes to Resubmit Pull the claims with a Disposition of Resubmit into a claim batch with matching Claim Category and batch dates 29

30 Void and Finalize Void and Finalize is used to take back the payment of a claim and not seek further reimbursement 30

31 Reprocessing Claims: Void and Finalize The client went into a nursing facility and we should not have been paid, what do we do now? Use the Void and Finalize process to take back the payment of a claim The process is similar to the Void and Resubmit Process 31

32 Reprocessing Claims: Void and Finalize Void and Finalize in five easy steps: Create Void batch Add claims to the Void batch Access Action Menu and Select Void and Finalize Submit the Void batch Void claims process in MMIS and Claim Disposition is set to Finalize 32

33 Reprocessing Claims: Void Batches Void batches are saved, not generated Once a Void batch has claims in it, it cannot be deleted 33

34 Reports and More Reports. Time Not Automated Potentially Billable Claims Exception Client Time Detail 34

35 Time Not Automated Potentially Billable Report What can the Time Not Automated Potentially Billable Report be used for? This report is used to bill for Time Records linked to HCPCS that are in the Not Automated Claim Category Not Automated HCPCS cannot be claimed through SSIS 35

36 Time Not Automated Potentially Billable Report Report accessed from Healthcare Claim Reporting Use report to identify services such as H0001 that were provided and must be billed outside of SSIS 36

37 Time Not Automated Potentially Billable Report Examples of Not Automated HCPCS H0001 Alcohol and/or drug assessment Used to bill Managed Care Organizations (MCOs) for MH-TCM Rule 25 Assessments H0040 Assertive Community Treatment (ACT) T2025 Consumer Support Grant 37

38 Time Not Automated Potentially Billable Report H0001 information in Programs and Services: 38

39 Time Not Automated Potentially Billable Report Enter Service Date Range and HCPCS/modifiers as report criteria on Setup screen 39

40 Time Not Automated Potentially Billable Report Use information from report results to bill payers outside of SSIS Healthcare Claiming process Remove default columns and add optional columns needed for billing 40

41 Claims Exception Report The Claims Exception Report has been primarily used for Targeted Case Management to ensure that monthly contacts have been made and claimed 41

42 Claims Exception Report Lists clients that have an active CW-TCM, MH-TCM, and/or VA/DD- TCM Supplemental Healthcare Eligibility record Lists month and year for which no eligible contact(s) have been claimed or Displays message indicating a claim or Do Not Claim Determination record exists for the client 42

43 Claims Exception Report Research why months have not been claimed for a client Determine whether the Do Not Claim Determination record should still be in effect Determine whether client is no longer eligible for services and Supplemental Healthcare Eligibility should be ended 43

44 Claims Exception Report 44

45 Client Time Detail Report This report displays Time Record information for workers and their clients for a selected date range SSIS Fiscal Mentor Meeting 45

46 Client Time Detail Report Lists Time Records for a client for a selected Date Range Option to select specific Program and Service Option to select specific client 46

47 Client Time Detail Report Use this report to determine total time claimed and not claimed for each worker Group by Claimed and Worker Use group footers and footers to sum the total Regarding duration 47

48 Client Time Detail Report 48

49 Claiming Tips From Helpdesk Reports Fiscal Mentor Meeting Surveys Items that we cover over and over and over again. 49

50 Claiming Tips: Not Claimable Through SSIS Rule 5 Healthcare Claims for Woodland Hills must be claimed through MN-ITS Direct Data Entry (DDE) because a taxonomy code must be sent on the claim Rule 5 Healthcare Claims for clients on MinnesotaCare with a Living Arrangement of 80 Community 50

51 Claiming Tips: Not Claimable Through SSIS If the client has Third Party Liability (TPL) insurance and the service could be billed to and covered by the insurance company HCPCS codes that require a description on the claim such as: E1399 Specialized Supplies and Equipment T2029 Specialized Supplies and Equipment Waiver 51

52 Claiming Tips: Not Claimable Through SSIS HCPCS in the Not Automated Claim Category When appropriate, continue to resubmit claims through MN-ITS with 59 modifier when receiving Exception code denial 758 NCCI procedure code conflict 52

53 Claim Tips: Why are Healthcare Claims not Generating? A potential claim would be identified in proofing A Time Record has been changed and the record is no longer claimable A Time Record has been changed and was originally claimed under a different Claim Category 53

54 Claim Tips: Why are Healthcare Claims not Generating? The standard criteria for claiming have not been met Standard criteria are found in section of the Healthcare Claiming Design specs Includes conditions such as: Service and Activity are valid for the selected Claim Category Contact Status and Method are valid for the Claim Category 54

55 Claim Tips: Best Practices Monitor age of draft healthcare claim batches Healthcare claims can be reimbursed within one year of the claim service dates Always regenerate Healthcare Claim batches prior to submission to pull in newly entered records as well as new claims created after proofing messages corrected 55

56 Claim Tips: Best Practices Timely entry of Time Records can prevent face-to-face and phone contacts processing out of order For example, if a Time Record for a Faceto-Face contact is not entered until after a Time Record for a Phone contact has been submitted, the Phone contact might deny if there hasn t been a Face-to-Face contact within the previous three months Submit claim batches in chronological order, especially when back claiming 56

57 Claim Tips: Best Practices Review Claiming Interface log to verify that claiming interfaces have successfully processed 57

58 Claim Tips: Always Remember Claims processing looks at the clients selected in the Regarding section of the Time Record Client selected in Regarding = claim for client Claim are only generated for Time Records with a Status of Completed Attempted contacts are not claimable 58

59 Claim Tips: Did you know? Healthcare Claims submitted through MN-ITS DDE do not display in SSIS Submit and Resubmit Healthcare Claims through SSIS instead of MN-ITS to record claim information in SSIS Healthcare Claims that are mass adjusted in MMIS do not display in SSIS These claims are identified on your remittance advice by Transaction Control Numbers (TCN) that begin with a 4 59

60 Claim Tips: Did you know? To get a copy of a 837 electronic claim batch submission generated from SSIS: 1. Login to MN-ITS. 2. Click on Transaction History under MN- ITS/Submit Transaction History. 3. Enter Date Range that claim batch was submitted in Start and End Dates. 4. Click on X12 or Pharmacy 1.2 File Type and Search. 5. Select your claim batch from the list of files and download to your PC. 60

61 Claim Tips: Did you know? Screenshot from MN-ITS: 61

62 Claim Tips: Did you know? Draft Healthcare Claim batches can be deleted If no claims in batch: delete is enabled; go ahead and delete batch If claims are in batch: Change the batch dates to future Batch Start and End Dates Regenerate claim batch Claims are no longer in the batch so the Delete Action is enabled Note: draft Void batches with claims cannot be deleted 62

63 What s planned for Healthcare Claiming in 2015? ICD-10 Diagnosis Codes Implementation still mandated for Service Dates on and after 10/01/2015 SSIS ICD-10 claiming changes scheduled for Version 15.3 Reminder: ICD-10 diagnosis codes can be entered in SSIS now with current or previous dates. Future dates cannot be entered. See SSIS Update #409 for more information in ICD-10 Diagnosis code entry 63

64 What s planned for Healthcare Claiming in 2015? Essential Community Supports (ECS) Provides transition support to individuals affected by changes to nursing facility level of care (NF LOC) and is also available to support people age 65 and older who do not meet NF LOC and are not eligible for Medical Assistance, but who have emerging needs for community support 64

65 What s planned for Healthcare Claiming in 2015? ECS is not a waiver but will be processed like a waiver in SSIS and MMIS ECS services are available to clients as of 01/01/2015 SSIS plans to implement the ECS program in Version

66 What s planned for Healthcare Claiming in 2015? Uniform Claiming Interface Schedule for all counties Implement around 15.2; not release dependent Will increase performance of claiming interfaces should be less connection errors and time outs when connecting to MN-ITS 66

67 What s planned for Healthcare Claiming in 2015? New interface schedule: 835 Remittance Advice run once a day at 6:30 AM. 837 Claim Submission run every 60 minutes from 7:00 AM to 6:00 PM Claim Status run once a day at 6:00 AM 999 Claim Acknowledgement run every 60 minutes from 7:15 AM to 6:15 PM Counties can continue to run Claiming Interfaces manually if they need to run them more often 67

68 Questions? 68