MMBA Micki Smith 06/17/ Provider Relations

Transcription

1 MMBA Micki Smith 06/17/2014 Working to protect, preserve, and promote the health and safety of the people of Michigan by listening, communicating, and educating our providers, in order to effectively resolve issues and enable providers to find solutions within our industry. We are committed to establish customer trust and value by providing a quality experience the first time, every time. -Provider Relations

2 Agenda What s New Healthy Michigan Plan Provider Portal Spend-down Billing Beneficiaries Health Plan Benefits Website Document Management Portal Questions

3 Healthy Michigan Plan

4 Agenda Federal and State Law Healthy Michigan Plan Federal Eligibility Parameters Covered Services Service Delivery System MI Health Account Additional Resources

5 Federal Law and State Law Affordable Care Act. Public Act 107 of 2013 was signed into law by Governor Snyder September 16, Authorizes the Healthy Michigan Plan. State law requires certain cost-sharing requirements (co-pays and contributions). Required an amendment to the Adult Benefits Waiver to implement.

6 Healthy Michigan Plan Co-pays and contributions can be reduced by participating in healthy behavior activities. The Healthy Michigan Plan promotes healthy behaviors and improved health outcomes. Projected to provide health care to 300, ,000 people. As of 5/5/2014, there are 206,842 Healthy Michigan Plan beneficiaries.

7 Federal Eligibility Parameters Covers people ages Not receiving or eligible for Medicare. Not eligible for current Medicaid program. Not pregnant at the time of application. Covers up to 133% of the federal poverty level (5% disregard = 138%). No asset test. Must meet other federal requirements.

8 Covered Services Benefit coverage must be based on federal benchmark coverage and include 10 essential health care services: 1. Ambulatory patient services. 2. Emergency services. 3. Hospitalization. 4. Maternity and newborn care 5. Mental Health and substance use disorder services, including behavioral health treatment. 6. Prescription drugs. 7. Rehabilitative and rehabilitative services and devices. 8. Laboratory services. 9. Preventive and wellness services and chronic disease management; and 10. Pediatric services, including oral and vision care. 11. Other, dental, vision.

9 Service Delivery System Healthy Michigan Plan beneficiaries will enroll into one of the current Medicaid Health Plans. Current Medicaid populations that are exempt or voluntary from managed care will remain exempt or voluntary. Will use the current Prepaid Inpatient Health Plan (PIHP) system of care.

10 MI Health Account Required by Public Act 107 of Cost-sharing Average co-pays. Contribution of 2% annual income for beneficiaries with income between 100% and 133% of the FPL. Account will provide information on health care services cost and utilization. Will show cost of services and amount of contribution in account. Quarterly statements.

11 MI Health Account continued Healthy Behaviors. Health risk assessment form completed. If beneficiary engages in healthy behaviors, they may have their cost-sharing reduced. Goal is to have beneficiary more involved in health care decisions and improved health outcomes.

12 Information Sources New website New address The Healthy Michigan Plan waiver amendment and approval is posted. Will continue to post information as it becomes available.

13 Information Sources continued New toll-free numbers for Modified Adjusted Gross Income (MAGI) related activities. MI healthcare helpline is The phone application assistance helpline is

14 Questions?

15 Provider Portal

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24 Spend-Down

25 Spend-Down Some individuals are ineligible for MA because their countable income (after all applicable disregards) exceeds the applicable MA standard. However, they can become eligible for MA by "spending down" their excess income on eligible medical expenses. An individual that is over-income for MA, but who is otherwise eligible, can qualify for MA if allowable medical expenses exceed their spenddown "deductible."

26 Spend-Down Beneficiaries who exceed the income requirement must use their medical costs to get their monthly income at or below the allowable income limits for the month. The spend-down/deductible amount is usually the amount of a beneficiaries income limit that is OVER threshold. Factors or amounts may vary by county. The exact formula is determined by the DHS county where the beneficiary resides.

27 Highlights Spend-Down renews each month. Spend-Down dollar amount may change monthly. Determining factors: Income Employment Address Others in household Health insurance premiums or coverage changes

28 Sample of Expenses Care from: hospitals, doctors, nurses, clinics, dentists, podiatrists and chiropractors. Most medicines. Medical supplies and equipment. Transportation to and from medical care. Personal care services provided in an AFC home or home for the aged. Beneficiaries cannot apply costs already paid by any other insurances. Beneficiaries can report old unpaid bills and each new medical cost on their deductible report submitted to the county worker.

29 Old Bills Criteria The expense was incurred within a month prior to the month being tested. The expense is/was still unpaid, and: Liability for the expense still exists (existed). A third party resource is not expected to pay the expense. The expense was not previously used to establish MA income eligibility. (There are different programs available for PPA with NF)

30 Submitting Proof Beneficiaries can submit proof of Incurred charges to DHS worker in different formats. DHS-114A Deductible Report changes in circumstances medical costs

31 Proof cont. Unpaid Bills Paid receipts Other statements Superbills The statements must show: The date of service The amount owed or paid The name of person receiving the service

32 Specialist Process Beneficiary submits application to DHS for Medicaid coverage. DHS Specialist establishes coverage. DHS worker sends a letter titled Deductible Notice to the beneficiary. This notice is also labeled as NOTICE OF CASE ACTION (DHS-1605 ). Notice includes the deductible amount and hearing rights.

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34 Spend-Down Process MSA-Pub. 617 is the brochure sent out to beneficiaries explaining spendown/deductible guidelines and process. It is the beneficiary s responsibility to provide the required documents to the DHS caseworker. Some counties have a central location for submitting this documentation. The local DHS worker reviews the medical bills incurred and determines if the amount of beneficiary liability is met and the first date of Medicaid eligibility. Not all forms submitted will be counted. Caseworker will organize the dates of service chronologically. Bills for services rendered prior to the effective date of Medicaid eligibility are the beneficiary's responsibility. When the beneficiary turns in the bills that does not pay for the services. It is the responsibility of the beneficiary to make arrangements with the provider for payment.

35 Spend-Down Process For the first date of eligibility, the DHS worker sends letters to those providers whose services are: Entirely the beneficiary's responsibility. Partly the beneficiary's responsibility and partly Medicaid's responsibility. A letter is also sent to the beneficiary indicating which services are the beneficiary s responsibilities for that first date of Medicaid eligibility.

36 Spend-Down Process (cont.) The provider must verify MA eligibility on every visit. Utilize CHAMPS Eligibility Inquiry to verify when the beneficiary became eligible and when their eligibility was updated. Once the deductible amount is incurred, eligibility is established through the end of the month.

37 CHAMPS Eligibility Screens Transaction date reflects when eligibility was last updated. CHAMPS is updated once the application process is completed by DHS. Eligibility may be retroactive up to three months prior to the month of the application.

38 Dual Coverage Beneficiary may be in a MSP (Medicare Savings Plan) and also have a spend-down. Benefit Plan assignment will be QMB until the spend-down is met. For any Medicare non-covered service, please provide the beneficiary with proof of the incurred medical expense. The beneficiary may present these items to DHS which may be used to satisfy their spenddown. (QMB only pays Medicare Deductible/Co-insurance)

39 Billing Beneficiaries General Information for Providers Chapter Section 11

40 Non-billable Highlights When a provider accepts a patient as a Medicaid beneficiary, the beneficiary cannot be billed for: Medicaid-covered services. Providers must inform the beneficiary before the service is provided if Medicaid does not cover the service. Medicaid-covered services for which the provider has been denied payment because of: Improper billing, Failure to obtain PA, and/or Over filing limit (retro eligibility MSA-1038) Missed appointments. Copying of medical records for the purpose of supplying them to another health care provider.

41 Billable Highlights Copayment, PPA. The provider has been notified by DHS that the beneficiary has an obligation to pay for part or all of a service because services were applied to the beneficiary's Medicaid deductible amount. Medicaid does not cover the service. If the beneficiary requests a service not covered by Medicaid, the provider may charge the beneficiary for the service if the beneficiary is told prior to rendering the service that it is not covered by Medicaid. If the beneficiary is not informed of Medicaid non-coverage until after the services have been rendered, the provider cannot bill the beneficiary.

42 Billable (cont.) Patient refuses Medicare Part A or B. Provider chooses not to accept the beneficiary as a Medicaid beneficiary and the beneficiary had prior knowledge of the situation. It is recommended that providers obtain the beneficiary's written acknowledgement of payment responsibility prior to rendering any nonauthorized or non-covered service the beneficiary elects to receive.

43 Spend-Down Beneficiaries are responsible for payment of expenses that were incurred to meet the deductible amount. Payment does not have to be made before Medicaid eligibility is approved. Providers may bill a beneficiary for services rendered after a claim rejects for lack of Medicaid eligibility. Partial deductible met. Reduce amount of providers charges by the spend-down amounts in Form Locator 24F. Billing & Reimbursement for Professionals Section 6-Special Billing

44 Retro Eligibility Could be several days 3 months. DHS may apply old bills to the past three months or may prospectively apply them to the next several months, depending on the DOS and the date the bill was presented to the DHS worker. It is the provider's option to bill Medicaid if the beneficiary has paid the provider for services rendered. MDCH encourages the provider to return the amount the beneficiary paid and bill Medicaid for the service. If the provider decides to bill Medicaid, the provider must return all money the beneficiary paid over and above the amount identified as the beneficiary's responsibility on the Medicaid deductible letter.

45 Health Plan Website

46 Resources Web site developed and maintained by contractor. Displays the spend-down amount in the eligibility response on their MI Health Plan Benefits page. The information is yesterday s information because the eligibility file is sent each night via CHAMPS.

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48 Document Management Portal DMP

49 What is DMP? The Document Management Portal (DMP) provides a browser-based interface to perform various tasks pertaining to submission of documents to Michigan Medicaid. In Phase 1 of implementation, DMP will be integrated within CHAMPS. Users will be able to access DMP functionality directly through CHAMPS interface only. DMP will be authenticated via the State s Single Sign-On system (SSO).

50 What is DMP? (cont d) By directly accessing the DMP, providers will be able to submit Medicaid documents that may or may not be related to claims. Users accessing the DMP will be able to: Submit support documents. Submit documents for authorization and approval. Send and receive messages pertaining to submitted documents. View documents and associated correspondence history.

51 What is DMP? (cont d) Directly upload documents. Create cover sheets and fax documents. Search existing documents that have been uploaded. View documents notifications in CHAMPS. Have messaging capabilities. Receive notifications when documents are approved.

52 How to access DMP

53 Phase I Access Points CHAMPS Provider Portal CHAMPS Direct Data Entry CHAMPS Manage/Adjust Claim

54 CHAMPS PROVIDER PORTAL Click on UPLOAD/VIEW Documents and DMP will launch in a different window. You can work in DMP and CHAMPS simultaneously. DMP remains open until you close out.

55 DMP will open a new window when you click Upload/View Documents. There are tabs at the top of the page that are used to navigate features in DMP.

56 Search Documents in DMP

57 When DMP is launched, your NPI is prepopulated. Any documents you have loaded in the past will be shown at the bottom. Search for documents by entering different data in the search fields. If no date is entered then the last 100 documents in history based on upload date will display. *Tip: Search by beneficiary ID

58 There are 2 options for Document Type: Consents or Claims If Consents are selected you have 2 selections available for Document Title. Hysterectomy Form Voluntary Sterilization Form

59 If Document Type selected is CLAIM you have multiple options for Document Title See Drop down above

60 When searching by TCN the Header TCN must be entered (must end in 000 ). All search filters MUST match documents in history or search will not yield any results.

61 Example above searched by BENE ID. As you can see multiple NPI s were loaded for these documents. Search results will be listed at the bottom of the screen in sortable fields. Click on the Document Title hyperlink to bring up document. Click VIEW Message Icon to see messages associated with the document. Click SEND Message Icon to send a message regarding this document.

62 Searching by STATUS. Status indicator shows you what status the document is in: approved, hold, rejected, or currently in review/process.

63 You can search status of a CONSENT by searching Beneficiary ID and Document TYPE= CONSENTS.

64 Upload Documents

65 Select DOCUMENT UPLOAD from top menu bar. Guidelines for uploading documents are highlighted. Enter required information that is marked with an asterisk (*). You can share documents across different NPI s.

66 The example above shows that 5 documents are selected to upload. Options can be changed on each line. Document Type and Title entered here will be used to search documents once uploaded. Once the document is uploaded under a TCN, it will automatically be attached to the TCN and Beneficiary ID added to this screen.

67 Only TCN s that are listed in CHAMPS as IN PROCESS or SUSPENDED are eligible to attach a document to in DMP. If you do not have an IN PROCESS or SUSPENDED TCN you can still upload documents to the beneficiary ID. To connect an electronic claim with documentation submitted through the DMP, when the TCN is not known, the following notation must be included in the Claim Note Documents sent via DMP (loop 2300 NTE segment )

68 After all information is filled in CLICK BROWSE It will launch the file upload box. Select the location where your file is stored and click on file. It will populate in FILENAME box. Once file is selected click OPEN. Then CLICK SUBMIT.

69 Once document is submitted the DMP screen will flash. Upload Successful pop up will display. Upload is complete. Click OK.

70 CHAMPS New claim submission

71 After filling out all the necessary information to enter a claim in CHAMPS direct data entry (DDE) click SUBMIT CLAIM and you will receive a pop up box (as normal). The pop up box now contains a new link that says UPLOAD DOCUMENT.

72 The DMP will launch in a separate window and information from claim will be prepopulated. You have the ability to make changes at this point and to add a message. You can only update documents to a TCN that is IN PROCESS or SUSPENDED. Follow previous Document Upload instructions from this point.

73 CHAMPS Claim Adjustment

74 From CLAIMS menu Select Manage Claims Select Adjust/Void Claim Provider Enter Header TCN to be adjusted

75 Make any and all changes to the claim that are necessary. Hit SAVE. Hitting save creates a new TCN. You can see the TCN change at the top of the page. Please Note the NEW TCN. You must hit SAVE for DMP to attach to the correct TCN.

76 Click UPLOAD/VIEW documents button to add document. The DMP will launch in a separate window.

77 Information from the claim in CHAMPS will be prepopulated in DMP. Verify the information is correct, and fill in remaining areas. Follow previous Document Upload instructions from this point.

78 Submit Fax

79 Submit Fax You MUST create a new FAX cover sheet for each document submission. Re-using the same fax cover sheet will result in the documents being attached to an incorrect beneficiary and/or claim and the possibility of your claim(s) being rejected.

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81 Select FAX COVER SHEET from top of DMP page.

82 Fill in all information regarding the documentation and click SUBMIT

83 A FAX COVER sheet will launch in a new window. You must create a NEW cover sheet for each documentation submission to DMP. The BARCODE is created and used to store the PHI on the previous screen. Print out FAX cover and attach to documents. Send Fax to appropriate number listed on the cover sheet. Add note to claim: Documents sent via DMP (Loop 2300 NTE segment ) Allow 1 business day for document to be attached.

84 Messages

85 Messaging DMP has messaging capability. These messages will be attached to the document they are submitted under. You will receive an notification when you have a new Message in your DMP message box. The notification will be sent to the address that is attached to your single sign on (SSO) login. Please add our address to your address book so the doesn t delete the notification or add to SPAM or JUNK mail.

86 Select the MESSAGES tab at the to of the DMP Portal. Messages that are sent to your SSO login ID will be stored in this area. To view message click on the Message indicator If there is a new message in your box, DMP will generate a generic alerting you to the address attached to your Single Sign On (SSO). Status will show UnRead for new messages.

87 You can view the MESSAGE notations here. Once in the message you have the options to REPLY to sender and VIEW document associated with the message. Clicking OK takes you back to the Messages Screen. 250 Character limit.

88 Icons in CHAMPS

89 New ICONS display in CHAMPS if there are documents or messages attached to the TCN. The NOTE icon displays if documents are attached to the TCN. The ENVELOPE shows if there are messages related to the TCN. To see the documents /Messages attached you must click UPLOAD/View Documents.

90 If you need additional assistance please contact Provider Support Phone:

91 THANK YOU!!