_MHP_ProTrain_Billing

Transcription

1 _MHP_ProTrain_Billing

2 Welcome to Magnolia Health s Billing Clinic 101! We thank you for being part of or considering Magnolia s network of participating providers, hospitals, and other healthcare professionals. Our number one priority is the promotion of healthy lifestyles through preventive healthcare. Magnolia works to accomplish this goal by partnering with the providers who oversee the healthcare of Magnolia members The intent of this presentation is strictly for provider billing guidance and to assist and educate on MH policy in regards to billing. Our responsibility is to render current coding information and advise accordingly. It is always the responsibility of the provider to determine member eligibility and also determine and submit the appropriate codes, modifiers and charges for the services performed for MH members

3 Eligibility verification Claims MHP Website Prior Authorizations PaySpan Provider Services Provider Relations

4 It is highly recommended to verify member eligibility on the date services are rendered due to changes that occur throughout the month, using one of the following methods: Log on to the Medicaid Envision website at: Log on to the secure provider portal at Call our automated member eligibility interactive voice response (IVR) system at Call Magnolia Provider Services at (MEMBER ID CARDS ARE NOT A GUARANTEE OF ELIGIBILITY)

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6 Front Back

7 Claims must be filed within 90 days from the Date of Service (DOS) All requests for reconsideration or adjustment must be received within 45 days from the date of notification or denial Providers should include a copy of the Explanation of Payment (EOP) when other insurance is involved or provide information when billing electronically Filed on paper via CMS 1500 (NO HANDWRITTEN OR BLACK AND WHITE COPIES) Filed electronically through clearinghouse Filed directly through website Filed on paper claim 1 ST time paper claims, mailed to: Magnolia Health Plan Attn: CLAIMS DEPARTMENT P.O. Box 3090 Farmington, MO Claims must be completed in accordance with Division of Medicaid billing guidelines All member and provider information completed (Claims submitted directly to local office will be returned unprocessed) FILE ONLINE AT

8 If provider uses EDI software but is not setup with a clearinghouse, they must bill MHP via paper claims or through our website until the provider has established a relationship with a clearinghouse listed on our website Centene EDI Help desk: , ext or Acceptance of COB 24/7 Submission 24/7 Status

9 Claims must be filed within 90 days from the Date of Service (DOS) Filed on CMS 1500 To assist our mail center in improving the speed and accuracy to complete scanning please take the following steps: Remove all staples from pages Do not fold the forms Make sure claim information is dark and legible Please use a 12pt font or larger Please use the CMS 1500 printed in red (Approved OMB Form CMS-1500 (02-12) Red and White claim forms are required as our Optical Character Recognition ORC scanner system will put the information directly into our system. This speeds up the process and eliminates potential sources for errors and helps get your claims processed faster

10 The National Uniform Claim Committee (NUCC) has approved the conversion to the 02/12 version of the CMS 1500 form. This change is being made to accommodate the additional reporting needs related to the implementation of ICD-10. Magnolia Health Plan will follow the implementation of this form as recommended by the NUCC. Specifically: January 6, 2014 March 31, 2014: Magnolia Health Plan will accept the current version of the CMS 1500 form (version 08/05) AND will accept the new version of the CMS 1500 form (version 02/12). April 1, 2014: Magnolia Health Plan will ONLY accept the 02/12 version of the CMS 1500 form. The above is date of submission sensitive and not date of service sensitive. For example, if a claim has a date of service of March 17, 2014 and is submitted on or after April 1, 2014, the claim must be submitted on the 02/12 version.

11 Effective January 6, 2014, providers billing CLIA services to Magnolia Health Plan must include a valid and appropriate CLIA number. Invalid or missing CLIA numbers will be considered incomplete and the claim will be rejected. Box 23 CLIA # See MagnoliaHealthPlan.com for full details

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13 Box 24b Place of Service

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17 Box 24d Modifier 1,2,3 and 4

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19 EP modifier is attached to the Health Check CPT codes for periodic and interperiodic screening assessments 25 modifier is attached to a significant, separately identifiable E&M code by the same physician on the same day of a procedure or other service. (Modifier 25 uses may require medical records) 50 modifier is for bilateral operative session 51 modifier is for multiple surgeries and required per DOM administrative code TH modifier is for maternity services and required per DOM administrative code GP modifier is for Physical Therapy GO modifier is for Occupational Therapy GN modifier is for Speech Therapy

20 Rendering Provider s NPI is required in Box 24J (non-shaded) when billing Magnolia claims

21 Group or Individual Tax ID #/SSN is required in Box 25 when billing Magnolia claims

22 Paper claims require a provider signature in Box 31 when billing Magnolia claims (Electronic claim submissions are automatically signature stamped)

23 Electronic and Paper claims it is optional as of 01/03/14 for Box 32 to be completed when billing Magnolia claims

24 Billing provider address is required in Box 33 and the Group NPI is required in Box 33a when billing Magnolia Claims

25 SUBMIT: Claims Provider Complaints Demographic Updates VERIFY: Eligibility Claim Status VIEW: Provider Directory Important Notifications Provider Training Schedule Provider Resources Claim Editing Software Provider Newsletter Member Roster for PCPs

26 Provider Demographic Web Enhancement Effective: November 13, 2013 Effective 11/13/2013, providers will be able to update/change demographic information which appears on the Find A Provider (FAP) by logging on the secure web site. Simply clinking on the Update Info tab will take the user to the secure web where they log in to make their changes. The groups or practitioners may make limited updates to their service location information that displays in FAP. The new Provider demographic web change allows practitioners to sign into the Secure Web site and update: The changes flow directly into the Magnolia Health Plan system and the corrected data will appear on the web within 24 hours.

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30 Click on Claims at the top of screen. (Menu option)

31 Click on Create a New Claim

32 Click on CMS 1500 Professional Claim

33 In the Patient Info section, populate the Patient s Account Number, and other information related to the patient s condition by clicking the appropriate button. Click Next.

34 In the General Info section, populate the claim information and dates. You can Add Coordination of Benefits by selecting the button. Click Service Lines.

35 In the Service Lines section, add your service line information. You can enter up to 99 service lines. ***Note: When entering charges for the service billed, include the decimal point to ensure the data is populated accurately. For example, converts to $ To add additional service lines, click the Save/Update button and then click the New Service Line button. When you are ready to proceed, click Provider Details.

36 In the Providers section, populate the information for the Referring Provider, Rendering Provider, Billing Provider, and Service Facility Location. ***Use the blue Search button after entering a Tax ID or NPI for assistance with your search. ***Required fields are dependent on the type of claim submitted: Professional or Institutional. Click Attachments.

37 In the Attachments section you can Browse and Attach any documents to the claim as desired. If you have no attachments, none are required. Click Review and Submit.

38 In the Review section, you can review the claim once again before clicking Submit.

39 In the Success section, a confirmation ID displays for your records. Click Submit another to submit another claim.

40 Indicator for submitted applicable claims where a NDC # is required.

41 Instructions for entering where a NDC # is required.

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49 Reconsiderations - Adjustment requests for claims that do not appear to have been processed correctly the first time such as member DOB, member gender, etc. where plan may have processed in error. Typically, no documentation would be required other than the Claim Dispute Form advising of the nature of the issue. Corrected Claims - Adjustment requests for claims where a correction needs to be submitted to correct information originally submitted by a provider on a claim that was originally inaccurate. Again, could require or could not require documentation other than Claim Dispute Form. Appeals - Adjustment requests for claims that the provider has submitted a reconsideration/corrected claim or both, and still feels that the denial or payment is incorrect. These would be for nonauthorization related denials only. Denials such as HCI/CXT denials where the provider disagrees; payment disputes where the adjustments have been made, but the payments did not change and were upheld, etc. Medical Appeals - Strictly for Authorization denials where the provider must submit documentation to show medical necessity and have submitted a reconsideration and/or corrected claim to attempt to obtain claim payment and denials were upheld. Must be submitted within 45 days of adjudication

50 Reconsideration/Corrected Claims/Appeals/Medical Necessity Address: Magnolia Health Plan ATTN: (Appropriate department RECONSIDERATION, CORRECTED CLAIM, APPEALS, MEDICAL NECESSITY) P.O. Box 3090 Farmington, MO Must be submitted within 45 days of adjudication

51 Must reference original claim # on EOP Must be submitted within 45 days of adjudication Corrected/Resubmission of claims is a function of EDI as well as via the Web Portal Paper submission claims must clearly be marked RE-SUBMISSION or CORRECTION and must include the original claim number or the original EOP must be included with the resubmission These claims must be submitted to: Magnolia Health Plan Attn: CORRECTED CLAIMS PO Box 3090 Farmington, MO (Claims submitted directly to local office will be returned unprocessed)

52 Magnolia uses Code Auditing Software to detect, correct and document coding errors on claims prior to payment Analyzes CPT, HCPCS, Modifier and Place of Service Codes Claims billed in a manner that does not adhere to standard coding conventions will be denied Detects inaccuracies such as Unbundling, Fragmentation, Up Coding, Duplication, Invalid Codes and Mutually Exclusive Procedures Magnolia follows established coding rules published by the following sources to ensure claims are paid appropriately and consistently: Mississippi Medicaid Provider Manuals and/or administrative codes/regulations Centers for Medicare & Medicaid (CMS) Rules & Guidelines Inclusive of National Correct Coding Initiatives (NCCI) American Medical Association (AMA)/Current Procedural Terminology (CPT) Billing Standards Various Specialty Societies including: American College Of Obstetricians & Gynecologists American College of Surgeons

53 Patient is seen in doctors office/hospital Claim submitted via EDI or Paper Claim accepted in Payment System 6 Steps of Prepay Payment Integrity Adjudication 1. Entry Edits 2. Eligibility Verification 3. Provider Verification 4. Authorization Requirements 5. Benefit Eligibility 6. Pricing Coding Edits Applied Code/Claim Set to Pay or Deny & Claim is Repriced Claim Payment to Physician/Hospital Claim profiled by Payment Integrity Preliminary Investigation

54 Duplicate Claims Provider name, Taxpayer Identification Number (TIN), or National Practitioner Identification (NPI) number is missing Member DOB or Name not matching ID card/member record Code combinations not appropriate for demographic of patient Not filed timely No itemized bill provided when required Authorization numbers not provided Diagnosis code not to the highest degree of specificity; 4th or 5th digit when appropriate Unbundling For a complete list of common billing errors refer to the provider manual

55 Prior Authorization is a request to the Magnolia UM (Utilization Management) department for approval of services on the prior authorization list before the service is rendered All out of network services require an authorization Services that require authorizations can be found on Magnolia s website. It is highly recommended to initiate the Authorization process at least 14 calendar days in advance for non-emergent services The PCP should contact the UM department via telephone, fax, or through our website with the appropriate clinical information to request an authorization Escalated requests can be requested from the Medical Management department as needed (Emergency room and urgent care services never require prior authorization)

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58 List of services requiring authorization may also be found on

59 MRI * CT SCAN * PET SCAN AUTHORIZATION An authorization is required for MRI-CT SCAN-PET SCANS National Imaging Associates (NIA) has been selected by MHP to administer the program The servicing provider (PCP or Specialist) will be responsible for obtaining authorization for the procedures Servicing providers may request authorization and check status of an authorization by: Accessing Utilizing the toll free number Inpatient and ER procedures will not require authorization All claims should be submitted to MHP through the normal processes, electronic submission or paper claim submission Providers can contact Charmaine Gaymon, Provider Relations Manager at or via at CSGaymon@magellanhealth.com

60 Magnolia has partnered with PaySpan Health to offer expanded claim payment services Electronic Claim Payments (EFT) Online remittance advices (ERA s/eops) HIPAA 835 electronic remittance files for download directly to HIPAA-compliant Practice Management or Patient Accounting System Register at: For further information contact , or

61 Provider Services Call Center Provides Phone Support Available M-F, 8-5, CST First line of communication Eligibility Claims status Payment questions Authorizations

62 Provider Relations Provider Education Schedule in-services/training for new and existing staff Education and information on electronic solutions to authorizations, claims, etc. Web demonstration Initiate credentialing of new providers Provider will be re-credentialed every three years Obtain clarification of policies and procedures Obtain clarification of a provider contract Demographic changes

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