Kentucky Medicaid Spring Webinar

Transcription

1 Kentucky Medicaid Spring Webinar 2016

2 Agenda References Websites Billing Instructions KYHealth Net Remittance Advice Helpful Hints Billing Updates 2

3 References Department Phone or Fax Roles HPE Provider Billing Inquiry Billing Questions, Member Eligibility verification, PA details HPE EDI Help Desk Electronic Remittance questions, PIN #, and password resets Member Services Member line for questions regarding their coverage Local DCBS Call Center Eligibility, Patient Liability, Hospice Election and Termination Provider Services Provider line for questions regarding Member Eligibility, policy questions Provider Enrollment Questions or updates to the provider file such as NPI/taxonomy, updating address, EFT s and enrollment of providers Carewise Prior Authorization, Waiver Eligibility, and Orthodontic PA Dental Prior Authorization (fax) Prior Authorizations (excluding orthodontics) 3

4 KELLY GREGORY Extension VICKY HICKS Extension Assigned Counties Assigned Counties 001 ADAIR 044 GREEN 074 MCCREARY 003 ANDERSON 040 GARRARD 083 MENIFEE 002 ALLEN 050 HART 075 MCLEAN 006 BATH 041 GRANT 084 MERCER 004 BALLARD 048 HARLAN 085 METCALFE 008 BOONE 043 GRAYSON 087 MONTGOMERY 005 BARREN 051 HENDERSON 086 MONROE 009 BOURBON 045 GREENUP 088 MORGAN 007 BELL 053 HICKMAN 089 MUHLENBERG 010 BOYD 046 HANCOCK 090 NELSON 011 BOYLE 054 HOPKINS 095 OWSLEY 012 BRACKEN 047 HARDIN 091 NICHOLAS 013 BREATHITT 055 JACKSON 097 PERRY 014 BRECKINRIDGE 049 HARRISON 092 OHIO 017 CALDWELL 061 KNOX 098 PIKE 015 BULLITT 052 HENRY 093 OLDHAM 018 CALLOWAY 060 KNOTT 100 PULASKI 016 BUTLER 056 JEFFERSON 094 OWEN 020 CARLISLE 062 LARUE 102 ROCKCASTLE 019 CAMPBELL 057 JESSAMINE 096 PENDLETON 023 CASEY 063 LAUREL 104 RUSSELL 021 CARROLL 058 JOHNSON 099 POWELL 024 CHRISTIAN 066 LESLIE 107 SIMPSON 022 CARTER 059 KENTON 101 ROBERTSON 026 CLAY 068 LETCHER 109 TAYLOR 025 CLARK 064 LAWRENCE 103 ROWAN 027 CLINTON 069 LINCOLN 110 TODD 030 DAVIESS 065 LEE 105 SCOTT 028 CRITTENDEN 070 LIVINGSTON 111 TRIGG 032 ELLIOTT 067 LEWIS 106 SHELBY 029 CUMBERLAND 071 LOGAN 113 UNION 033 ESTILL 076 MADISON 108 SPENCER 031 EDMONSON 072 LYON 114 WARREN 034 FAYETTE 077 MAGOFFIN 112 TRIMBLE 036 FLOYD 078 MARION 116 WAYNE 035 FLEMING 080 MARTIN 115 WASHINGTON 038 FULTON 079 MARSHALL 117 WEBSTER 037 FRANKLIN 081 MASON 119 WOLFE 042 GRAVES 073 MCCRACKEN 118 WHITLEY 039 GALLATIN 082 MEADE 120 WOODFORD 4

5 Websites Department for Medicaid Services Regulations Fee Schedules Provider Enrollment KYMMIS Billing Instructions KYHealth Net User Manual Workshop Materials KYHealth Net Member Eligibility Claim Status PA Inquiry Remittance Advice 5

6 Department for Medicaid Services Programs and Services Fee and Rate Schedules Legal and Policy Information 6

7 Kentucky Medicaid Management Information System (KYMMIS) KYHealth Net DMS website Provider Relations Companion Guides 7

8 Provider Billing Instructions Each Provider type has a matching Provider Billing Instructions. 8

9 KYHealth Net Account Management KYHealth Net Messages 9

10 KYHealth Net Helpful Hints The KYHealth Net User Manual can be found on the KYMMIS website under Companion Guides. This is a comprehensive page by page illustration to help you use the full potential of the website. Account usage The administrator of the provider account should create agent s accounts should additional staff need access. The EDI Helpdesk receives calls daily from users sharing accounts. Your administrator can define what access each user is granted (these instructions are available in the user manual). The importance of a valid address within KYHealthnet - The EDI Helpdesk is tasked with sending notifications to each KYHealth Net user when KY Medicaid has an outage of any type. We recently received 337 undeliverable s due to either bad addresses or the user is no longer monitoring the account (user most likely left the position). 10

11 KYHealth Net Helpful Hints Create your security question! We know everyone forgets passwords. Utilize the security question to reset your own password. Important Messages are on every home page. KY Medicaid will push immediate changes and updates to providers using these convenient message boards. 11

12 KYHealth Net Functions Member Claims PA RA Viewer 12

13 KYHealth Net Usage KYHealth Net is only compatible with Internet Explorer. We are using IE11 and your compatibility view settings may need to be adjusted to allow your use. Function Provider Responsibilities Member Eligibility Verification Bill the appropriate Medicaid entity PA (Prior Authorization) Check for PA units/usage RA Viewer Pull Remittances weekly Claims Check Claim Status using KYHealth Net or Remittance Advice (RA) 13

14 Recent Changes Effective February 1, 2016, ROUTINE claim status checks initiated by the provider to the HPE Provider Inquiry line must be at least 45 days old from the date of submission. If your claim has denied and you need assistance, there are no time limits regarding that inquiry. If you have called to inquire about claim status after 45 days from the submission of that claim and HPE finds a PAID claim status, HPE will supply the following information: The claim is in a Paid status, the date the claim paid, and how much that claim paid. All other information such as Claim ICN (a.k.a. claim number), Check number, Bulk Check amount, etc. must be obtained using the Remittance Statement (RA) that is generated weekly and made available on KYHealth Net. The RA will be available as a free download for a 6 month timeframe. 14

15 Remittance Advice (RA) Each Billing provider has a remittance statement generated weekly. These are available on Monday after each Friday night adjudication cycle. Review of these free statements should reduce the need for Claim Status calls and enhance the correct posting of your accounts. It is the Medicaid providers responsibility to review the Remittance Advice (RA) and to post the payments or denials appropriately. In addition to the RA, the KYHealth Net Claim Status page will help providers find and understand the claim status. You must log into KYHealth Net using the Pay-To provider information to obtain information regarding claim status or to access the RA. 15

16 Remittance Advice (RA) If you utilize a clearinghouse or software vendor to retrieve your Remittance Advise (RA) electronically: Please make sure the vendor has your Payee ID and Issue Date from the remittance statement. These are found at the top right of your RA. Make sure you review the paper RA available on KYHealth Net before changing a Members account to self pay. (There are very limited reasons that allow you to bill a member. These reasons can be found in your regulations on KY Medicaid s website). 16

17 Helpful Hints TPL (Third Party Liability) If the primary commercial insurance denies your claim or applies everything to deductible, bill your claim on paper with the EOB from the carrier attached. If the insurance does not respond to you within 120 days of your submission, the TPL Lead Form (found at under Provider Relations, Forms, then Provider Relations) may be utilized and attached to your paper claim. Instructions for the completion is found in each Provider Billing Instructions. 17

18 Helpful Hints Adjustment and Claim Credits Claim Credits are also known as Voids. Adjustment and Claim Credits are only to be sent to change or void a PAID claim. These forms should never accompany any other type of transaction such as a resubmission of a previously denied claim. Paid claims which cannot be ADJUSTED and must be VOIDED are the following: Taxonomy related issues Member ID Straight claim to a Medicare claim TPL related issues, paid zero claims Crossover claims from Medicare Paid claims that show a denied detail 18

19 Timely Filing Timely filing is the responsibility of the provider of service. To remain timely, a claim must be processed at least once every 12 month period and the provider must attach proof of previous processing (or other covered scenario) each time the claim is sent for processing. Providers have one year from the date of service (watch out for leap year) to process a Medicaid Member s claim, or 6 months from the adjudication date of a TPL or Medicare primary carrier EOB, whichever is later. The primary carrier s EOB must be attached to the claim to prove timely filing. Aged claims for Members whose eligibility for Medicaid is determined retroactively may be considered for payment if filed within one year from the eligibility issuance date. Claim submission must be within 12 months of the issuance date. A copy of the KYHealth-Net card issuance screen must be attached behind the paper claim. Aged claims for Providers whose eligibility for Medicaid is determined retroactively may be considered for payment if filed within one year from the letter sent 19 by KY Medicaid Enrollment. Letter must be attached to each claim.

20 Timely Filing Additional documentation that may be attached to claims for processing for possible payment is: A screen print from KYHealth-Net verifying eligibility issuance date and eligibility dates must be attached behind the claim; A screen print from KYHealth-Net verifying filing within 12 months from date of service, such as the appropriate section of the Remittance Advice or from the Claims Inquiry Summary Page (accessed via the Main Menu s Claims Inquiry selection); A copy of the Medicare Explanation of Medicare Benefits received 12 months after service date but less than six months after the Medicare adjudication date; A copy of the commercial insurance carrier s Explanation of Benefits received 12 months after service date but less than six months after the commercial insurance carrier s adjudication date. 20

21 Timely Filing Aged claims for Providers whose eligibility for Medicaid is determined retroactively may be considered for payment if filed within one year from the acceptance letter sent by KY Medicaid Enrollment. Letter copy must accompany each claim over the timely filing limits. 21

22 Claim Documentation Any supporting documentation that is requested or sent by the provider to KY Medicaid must be accompanied by a paper claim form. An attempt will be made to contact the agency sending the items without a matching claim form and that agency will be advised future mailings of this type will be destroyed. We are unable to attach documentation to an electronically submitted claim or to any previously processed claim. 22

23 Billing Updates Provider Type 01- Hospitals The future will bring changes regarding the need for KY Medicaid credentialing of the Attending, Ordering, Referring providers in the Hospital setting. Watch for information to be sent out by the Department for Medicaid Services regarding timelines. 23

24 Billing Updates Provider Type 06 Chemical Dependency Treatment Center The Chemical Dependency Treatment Center is a new provider type recently added. A Chemical Dependency Treatment Center may have the following providers enroll as a rendering provider: Licensed Professional Art Therapist Licensed Behavioral Analyst Licensed Professional Clinical Counselor Licensed Clinical Social Worker Licensed Marriage and Family Therapist Licensed Psychological Practitioner Licensed Psychologist Advanced Practice Registered Nurse Physicians Physician Assistants 24

25 Billing Updates Provider Type 10- Specialty Intermediate Care Clinic for Developmental and Intellectual Disabilities Clinic Place of service code 11 (office) is the only covered code for Provider Type 10 effective with dates of service 2/1/2016. A Specialty Intermediate Care Clinic for Developmental and Intellectual Disabilities may have the following providers enroll as a rendering provider: Licensed Professional Art Therapist Licensed Behavioral Analyst Licensed Professional Clinical Counselor Licensed Clinical Social Worker Licensed Marriage and Family Therapist Licensed Psychological Practitioner Licensed Psychologist Advanced Practice Registered Nurse Physicians Physician Assistants Dentists 25

26 Billing Updates Provider Type 26- Residential Crisis Stabilization Unit A Residential Crisis Stabilization Unit has only one covered CPT code. Procedure S9485 is to be used to report services. Place of service code 56 (Psychiatric Residential Treatment Center) is the only acceptable place of service. 26

27 Billing Updates Provider Type 17- Acquired Brain Injury (ABI) The Department for Medicaid Services filed revised regulations for the ABI Waiver, which do not include therapies as covered services since 2016 is the renewal year for the ABI/LTC Waiver. These regulations are expected to become effective in September The ABI acute waiver is also expected to transition when it is renewed in At that time, therapy services will no longer be reimbursed through the ABI Waiver program. Therefore, if the waiver is approved and you are not already enrolled as a State Plan provider, you risk not being able to bill for therapy services. State Plan provider means that the Occupational Therapist (OT), Physical Therapist (PT) or Speech/Language Therapist (ST) must be credentialed as therapists by KY Medicaid. An OT, PT, ST group number can be credentialed to tie these individual provider types to your tax ID. 27 A Multi-Therapy Agency (Provider Type 76) will be a new group provider type offered in the future.

28 Billing Updates Provider Type 33- Supports for Community Living (SCL) The Department for Medicaid Services filed revised regulations for the SCL Waiver, which do not include therapies as covered services since 2015 was the renewal year for the SCL Waiver. These regulations are expected to become effective in June At that time, therapy services will no longer be reimbursed through the SCL Waiver program. Therefore, if the waiver is approved and you are not already enrolled as a State Plan provider, you risk not being able to bill for therapy services. State Plan provider means that the Occupational Therapist (OT), Physical Therapist (PT) or Speech/Language Therapist (ST) must be credentialed as therapists by KY Medicaid. An OT, PT, ST group number can be credentialed to tie these individual provider types to your tax ID. A Multi-Therapy Agency (Provider Type 76) will be a new group provider type offered in the future. 28

29 Billing Updates Provider Types 50/70- Hearing Services Provider Types 52/77- Vision Services The Department for Medicaid Services has changed the process for the Vision and Hearing providers for claims involving children under the age of 21 that would deny for limitation exceeded. Instead of claims denying, the claims will be suspended to view the documentation attached to the claim. The documentation must show on office letterhead. For the second pair of glasses, the claim attachment must show the member has had a prescription change since the pair for that calendar year was dispensed, or that the previously dispensed pair was stolen or lost. For Hearing Services, specialty equipment may be considered based on medical necessity documentation attached. 29

30 Billing Updates Provider Type 63- Licensed Behavioral Analyst The following CPT codes have been added as covered codes with the effective date of 7/1/15. H0031 Mental Health Assessment by non-physician H2019 Therapeutic Behavioral Services, per 15 minutes 30

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