Presentation title here

Transcription

1 Presentation Provider toolbox title here Sylvia Strickland, MBA, Provider Reimbursement Presentation title here Bridgette Ampey, CPC, Code Review Jorri Smith, Network Innovation & Education priorityhealth.com 0 Agenda Today, we re going to review the tools we offer that can help us work together as efficiently as possible. Feel free to ask questions throughout. We ll also make time at the end to address questions. Provider reimbursement Sylvia Strickland, MBA, Provider Reimbursement Analyst I 1

2 Provider Helpline: General Website: priorityhealth.com/provider Viewing prior authorizations You must have a web account and auth inquiry as a tool in your profile. If you re the requesting provider as well as the servicing (ie. orthopedic surgeon for a knee arthroscopy), an authorization will be entered into our system under both the facility where this will take place and the surgeon performing. If you re a referring provider only and the service will be performed by someone else, you will not be able to view the authorization on our provider portal. You must call our provider helpline for a status. Mid-level provider billing Surgical assist or facility rounding Mid-levels employed by a physician group may contract and bill Priority Health directly for surgical assist or facility rounding. All office-based services need to be billed under the supervising participating physician. Reimbursement and coding Most services reimbursed at 85% of the professional fee schedule Some services paid at 100% of the physician fee schedule Primary care designation Mid-level providers who are credentialed and contracted by Priority Health as primary care providers should bill us directly. These services are paid at 100% of the physician fee schedule. 2

3 Past filing limit Correction timelines Follow-up is required within one year of the date of service, including resolving all claim discrepancies. Corrected or augmented information received after that date will automatically deny. Negligence by the provider's staff does not justify an exception to the policy. Medicaid claims must be processed within 45 days of when we receive them to comply with the Timelines of Claims Payment Public Act 187. We ll notify you in writing of any problems or defects with your claim within 30 days; you ll have 30 days to correct and resubmit the claim. When another payer makes or recovers payment near or after our filing limit, you have 90 days from the date on the EOB to submit the claim to us. Corrected claim submission Corrected claim submission changes for Oct. 1, 2014 To comply with contract language regarding claim submission, effective Oct. 01, 2014, we will no longer accept requests for reprocessing claims by , reports or Excel files. If a claim was denied or paid incorrectly as the result of the way the claim was originally billed (i.e. billing error, improper billing), the provider must submit a corrected or voided claim. Find complete information on how to submit a corrected claim in the Provider Manual at priorityhealth.com. Denial reasons Billing error Claim resubmitted with a frequency 5 or 7, original claim adjusted and new claim paid Disenrollment retroactive Coverage terminated, member did not elect COBRA coverage Priority Health is secondary Claim submitted without primary carrier explanation of benefits Claim reprocessed: Work related injury Information provided confirming workers comp coverage Claim reprocessed: Auto insurance primary Information provided confirming auto coverage Claim reconsidered following Code Review Notes do not support charge billed 3

4 Coding and clinical edits Bridgette Ampey, Medical Coding Coordinator Clinical edits Priority Health clinical edits decisions are based on multiple criterion that may include: Medicare edits such as Medically Unlikely Edits (MUE) or National Correct Coding Initiative (NCCI edits) CMS guidelines CPT or ICD-9 guidelines Standard clinical practices and recommendations from medical societies Clinical edits are applied to all claims submitted by facilities or professionals, in and out of network, for all Priority Health medical plans, including Medicaid and Medicare, self-funded and fully funded. Providers often assume that if there s no NCCI edit for the code combination they submitted, then Priority Health should pay both codes. However, the claim may generate a clinical edit from any of the other sources of our clinical edit database. Changes for Modifier 59 Modifier 59: Used to describe a circumstance when services commonly bundled should be considered separate and distinct Different encounters Different anatomical sites Different practitioner Distinct services Commonly abused or misused Frequently requires medical records to validate accurate use 4

5 Modifier 59 continued New modifiers effective Jan. 1, 2015: XE Separate encounter XS Separate anatomical structure (separate organ/structure) XP Separate practitioner XU Unusual non-overlapping service CPT guidelines require use of most descriptive modifier MLN Matters Number MM8863 outlines changes for these modifiers Additional resource: ers/modifier-59.shtml Modifier 25 Modifier 25 is used to identify a significant, separately identifiable service Documentation must meet all requirements for reporting an E/M service In many cases, E/M services are inherent to procedures or services performed on the same date Problem oriented E/M services and preventive medicine When should these be coded together? Do these need to be documented separately? Do chronic conditions or health problems support separate E/M? Additional resource: modifier-25.shtml Medicare LCD & NCD edits Provide benefit, limit and frequency criteria for both medically necessary and non-covered services Commonly driven by CPT/HCPCS, modifiers and/or diagnosis codes GA modifier GY modifier Medical documentation must support services rendered and coded Priority Health supplemental services CMS website contains listing of all policies For more information on NCDs and LCDs, visit priorityhealth.com/provider/ manual/billing-andpayment/edits/medicare-lcds 5

6 Edit Checker Enter data pre-claim submission for edit scrubbing or verify edit criteria between code pair(s) Edit Checker can mirror how a claims submitted will process for criteria outlined below: Age Gender Unbundling and bundling Frequency Medicare LCD & NCD Criteria Inappropriate modifier use Remember to input all criteria to obtain accurate data missing or incorrect data can impact claim processing Gender Claim type (Medicare, HMO, Medicaid, etc.) This information does not guarantee coverage or payment by the patient's plan. Edit Checker Coding and clinical edit appeals To dispute a coding or clinical edit denial, please include the following: Priority Health Provider Appeal form Supporting medical documentation Any supporting coding documentation Clear and concise explanation as to why an appeal is submitted 6

7 Coding and clinical edit appeals Common reasons appeals are upheld: No supporting documentation submitted Insufficient documentation Unsigned medical records or medical records not authenticated Submitting wrong documentation Appeals should not be submitted simply because a code combination allows for a modifier or to verify editing is correct priorityhealth.com/provider/manual/billing-andpayment/reviews-appeals/standard-process Network innovation and education Jorri Smith, Senior Administrator ICD-9 to ICD-10 Support Free ICD-10 webinar series starting March 2015 Resources and webinar registration available at priorityhealth.com/provider/ news-and-education/icd-10 icd-10@priorityhealth.com 7

8 Billable codes outlined on our Provider Center priorityhealth.com/ provider/manual/ billing-and-payment/services/ phone-and-e-visits 8

9 Thank you! Who has the first question? 9