Welcome to the ARKANSAS MEDICAID 2015 Annual Provider Workshop

Transcription

1 Welcome to the ARKANSAS MEDICAID 2015 Annual Provider Workshop 2015

2 Presentations The BreastCare Program What Are PES and DDE? Remittance Advices Policy Updates Office of the Medicaid Inspector General (OMIG) Arkansas Diamond Deferred Compensation Plan Arkansas Foundation for Medical Care (AFMC)

3 The BreastCare Program Provider Representative Karen Young 2015

4 The BreastCare Program BreastCare is a program of the Arkansas Department of Health (ADH) that offers Screening and diagnostic services to qualifying women at no cost. Public and professional education related to breast and cervical cancer. Mission: BreastCare s mission is to increase the rate of early detection of breast and cervical cancer and reduce the morbidity and mortality rates among women in Arkansas by lowering barriers to screening that result from lack of information, financial means or access to quality services

5 The BreastCare Program BreastCare Services BreastCare is for uninsured and underinsured Arkansas women ages 21 to 64 who are at or below 250% of the Federal Poverty Level (FPL). Services include Mammograms (age 40). Pelvic exams and Pap tests (age 21). Human Papilloma Virus (HPV) testing (age 30). Most biopsies some require prior authorization from program. Follow-up test as needed. Policy and decision-making

6 The BreastCare Program Medicaid Provider Portal

7 The BreastCare Program Client Eligibility Why Should You Check Eligibility? Providers are encouraged to check the eligibility status of a client before providing services because A provider rendering services without verifying eligibility for BreastCare does so at the risk of not being reimbursed for the services. An accepted eligibility verification ensures that claims will not deny due to client ineligibility. Each client has an ID card with initial dates of eligibility listed, but these may change over time

8 The BreastCare Program Submitting Claims Three Ways to Submit BreastCare Claims Provider Electronic Solutions (PES) software HPE s free eligibility and claims submission software available for download from the Arkansas Medicaid website BreastCare s Claim Form paper claims Direct Data Entry (DDE) the Provider Portal

9 The BreastCare Program ICD-10 Information Claims Submitted without ICD-10 Codes for Dates of Service on or after 10/1/15 Will Not Be Paid. All claims submitted to BreastCare for dates of service on or after 10/1/15 must bill using ICD-10 codes. Claims that do not bill ICD-10 codes will deny and you will not be paid by BreastCare. This is a federal mandate. If you currently use PES to bill claims, you MUST upgrade to version 2.23 to submit claims using ICD-10 codes. Upgrade your software in sequential order; each lower version must be upgraded before you can upgrade to the next version. Please refer to the BreastCare website for specific billing criteria. For all the latest BreastCare information, log on to and click the Just for Providers link

10 The BreastCare Program New CPT Codes Effective for Dates of Service on and after 1/1/ (Ultrasound Exam Pelvic Complete) (Transvaginal Ultrasound Non-OB)

11 The BreastCare Program Replaced CPT Codes Effective for Dates of Service on and after 5/18/ is no longer payable and has been replaced with and is no longer payable and has been replaced with G0462 is no longer payable and has been replaced with G0461 is no longer payable and has been replaced with Please refer to the BreastCare website for specific billing criteria

12 The BreastCare Program Modifier 50 Added for Bilateral Ultrasounds Effective for Dates of Service on and after 5/18/15 Modifier 50 (bilateral procedure) has been added to CPT codes and in order to accommodate billing the bilateral procedure. When billing the bilateral procedure, put modifier 50 on the claim to indicate the bilateral procedure. Use modifier 50 for the complete component. Use modifier 50 along with modifier 26 if billing the professional component. Use modifier 50 along with modifier TC if billing the technical component. If billing without the modifier 50, you will be paid for the unilateral procedure

13 The BreastCare Program Cancer Treatment Medicaid 07 ended on December 31, Contact your ADH BreastCare Regional Care Coordinator to refer a patient who is diagnosed with breast or cervical cancer, CIN II or CIN III and requires treatment. You may also contact the BreastCare Cancer Treatment Case Manager or Patient Navigator at

14 The BreastCare Program Contacts Arkansas Department of Health Policy and standards Patient enrollment questions Provider enrollment (new or renewal) HPE BreastCare Provider Services Claims and eligibility processing Provider visits for billing issues (on-site or virtual) Virtual training Provider billing assistance

15 The BreastCare Program HPE BreastCare Team Karen Young Provider Representative Terrie Withers Billing Analyst

16 Questions?

17 2015 Annual Provider Workshop 2015

18 What Are PES and DDE? HPE Fiscal Agent for the Arkansas Division of Medical Services 2015

19 Provider Electronic Solutions (PES) Software Provider Electronic Solutions software is HPE s free eligibility and claims submission software. It is available for download from the Arkansas Medicaid website. You may do submits, adjustments and voids using PES. You must have PES version 2.23 in order to bill ICD-10 codes!

20 Provider Electronic Solutions (PES) Software Problem: Vendors/Providers received errors when using any PES version lower than Solution: Upgrade to PES version PES V2.23 allows alphanumeric characters for diagnosis codes (all claim types) and surgery procedure codes (inpatient claim type only)

21 Provider Electronic Solutions (PES) Software New Edit Clarification for Electronic Claims (TANDEM) Edits Y830 and Y831 (#7 & 8) All claims go through this logic. Edit Y830 Claims containing mixed ICD-9 or ICD-10 SURG or DIAG codes will reject for this edit. Edit Y831 Claims containing ICD-9 and ICD-10 AND spanning 10/1/15 will reject for this edit. Edit Y832 (#5) Only Inpatient Claims with DOS spanning 10/1/15 AND ICD-9 present will reject for this edit. Edit Y833 (#6) Only Professional Global OB Claims with DOS spanning 10/1/15 AND ICD-9 present will reject for this edit

22 Direct Data Entry (DDE) DDE is available at the Arkansas Medicaid website - DDE claim entry is good for providers who do not submit a large volume of claims. Data entered is not retained in the DDE system as it is when using PES, so all information must be entered each time a claim is submitted. Once claim data is submitted, a response page will appear and include the ICN for the claim. Please print this page and save it with your claim documents. If the claim has errors, you will receive a response listing the errors so you can correct the claim and resubmit it

23 Direct Data Entry (DDE) Arkansas Medicaid Website Once you are logged on, your provider name will appear under Welcome back. To start a new claim, click on Professional claim. To void or adjust a previous claim, click on Professional claim reversal

24 Thank You

25 2015 Annual Provider Workshop 2015

26 Remittance Advices HPE Fiscal Agent for the Arkansas Division of Medical Services 2015

27 Agenda WebRA Payment Codes New Denial Codes for ICD-10 Recoupments Fees and Payments Adjustment Form Explanation of Refund Form

28 WebRA

29 WebRA Overview Effective July 2011, ALL Providers should be retrieving WebRAs from the Arkansas Medicaid website. Remittance Advices (RAs) are in a PDF format, referred to as WebRAs. WebRAs will only be available on the website for 35 days. A charge will apply for RAs requested after the 35-day period. For WebRA training, refer to the Provider Training link on the Medicaid website

30 WebRA Password Your WebRA We encourage all providers to register for and receive your remittance through the Provider Portal to reduce paper use and lower costs for the program. Remittances are downloaded through the Portal and you can share your remittance with business partners

31 WebRA Password Registering and Receiving Your WebRA Click Provider, log in to the Portal and select WebRA in the Available tools menu. Password requirements: Minimum of 8 characters Contain at least 1 uppercase alpha character Contain at least 1 lowercase alpha character Contain at least one number Contain at least one special character Cannot contain the same character more than twice You will be prompted to change your password for WebRAs every 90 days

32 WebRA Password Forgotten Passwords If you need assistance with any of these passwords, please contact HPE s EDI helpdesk at Ext 300, option 1 or Ext 300, option

33 WebRA Password Protect Your Passwords Your passwords are your responsibility. Keep them safe. Log them in a password protected spreadsheet for easy access!

34 Payment Codes

35 Payment Codes Paid claims EOB: 362, 363, 364, 365 and

36 Payment Codes Descriptions 362 The claim patient liability amount has been deducted from the claim payable amount. 363 Additional payment cannot be made on the claim as the recipient's private insurance paid an amount greater than or equal to the claim's Medicaid allowed amount. 364 Medicaid allowed amount reduced by other insurance payment

37 Payment Codes Descriptions 365 Fee adjusted to maximum allowable. 366 Other insurance paid an amount greater than or equal to our allowed amount. Medicaid cannot make any additional payment

38 New Denial Codes for ICD

39 New Denial Codes for ICD-10 Denial Codes on the RA Error Code Description of Error Code Who is responsible for the error

40 New Denial Codes for ICD-10 Descriptions EOB 713 Dates of service spanning 10/1/15 must be split billed Rebill (Bill ICD-9 prior to 10/1/15; Bill ICD-10 on/after 10/1/15). EOB 714 Inpatient Claim must contain only ICD-10 surgical procedure and diagnosis codes when dates of service span 10/1/15. EOB 715 Professional Global OB Claim must contain only ICD-10 diagnosis codes when dates of service span 10/1/15. EOB 717 Claim must not mix ICD-9 and ICD-10 diagnosis codes; Must bill ICD-9 prior to 10/1/15; Must bill ICD-10 on/after 10/1/15 Rebill with only ICD-9 codes/dates of service or only ICD-10 codes/dates of service

41 New Denial Codes for ICD-10 Descriptions EOB 725 Claim must not mix ICD-9 and ICD-10 surgical procedure codes; Must bill ICD-9 prior to 10/1/15; Must bill ICD-10 on/after 10/1/15 Rebill with only ICD-9 codes/dates of service or only ICD-10 codes/dates of service. A mixed claim could be any of the following: Both ICD-9 and ICD-10 coding, ICD-9 coding with DOS on/after 10/1/15, or ICD-10 coding with DOS before 10/1/

42 Recoupments

43 Recoupments Recoupments

44 Fees and Payments

45 Fees and Payments Incentive Payments

46 Fees and Payments Fees

47 Adjustment Form

48 Adjustment Form Paper Adjustments A legible signature must be on the adjustment form. This form can be found in Section V of your provider manual

49 Explanation of Refund Form

50 Explanation of Refund Form

51 Questions?

52 Thank You

53 2015 Annual Provider Workshop 2015

54 Policy Updates HPE Fiscal Agent for the Arkansas Division of Medical Services 2015

55 Agenda Medicaid Changes and Updates 2015 The Arkansas Health Care Independence Program Arkansas Medicaid Who s Who

56 Medicaid Changes and Updates

57 Medicaid Changes and Updates 2015 How Do I Know? RA Messages What s New for Arkansas Medicaid Providers Official Notices

58 Medicaid Changes and Updates 2015 Changes to ARKids-B Coverage Beginning August 1, 2015 Effective for dates of service on or after August 1, 2015, the services of orthodontia, occupational therapy, physical therapy, inpatient psychiatric hospital and psychiatric residential treatment facility services will be covered services for ARKids First-B beneficiaries

59 Medicaid Changes and Updates 2015 Changes to ARKids First-B Coverage Beginning August 1, 2015 ARKids First-B beneficiaries are no longer eligible for the Vaccines for Children (VFC) program. Providers are still able to obtain vaccines to administer to ARKids First-B beneficiaries by contacting Bill Ledford with ADH at or and indicating the need to order ARKids-B SCHIP vaccines. For dates of service on or after August 1, 2015, modifier SL will be required when billing for the administration of SCHIP* vaccines to ARKids First-B beneficiaries. *SCHIP: The State Children s Health Insurance Program (CHIP) provides health coverage to eligible children, through both Medicaid and separate CHIP programs. CHIP is administered by states, according to federal requirements. The program is funded jointly by states and the federal government

60 Medicaid Changes and Updates 2015 VFC and ARKids First-B SCHIP Vaccines Separate storage for VFC and ARKids First-B SCHIP vaccines can be accomplished through clearly labeling the VFC and ARKids First-B SCHIP vaccine vials and placing each on separate shelves of the storage unit. STORAGE in SEPARATE STORAGE UNITS is NOT REQUIRED

61 Medicaid Changes and Updates 2015 Arkansas Foundation for Medical Care (AFMC) Awarded Contract AFMC has been awarded the Medicaid contract for Retrospective Therapy Review and prior authorization (PA) for Personal Care for beneficiaries under 21, effective July 1,

62 Medicaid Changes and Updates 2015 Prior Authorization Changes to Wheelchair and Wheelchair Seating Systems Effective April 20, 2015, all DMS-679 requests for PA for wheelchairs and wheelchair seating systems will need to be submitted to AFMC for review

63 Medicaid Changes and Updates 2015 Deferred Compensation Diamond Plan Limit Changes for 2015 The State deferred compensation plan is an "eligible deferred compensation plan" established and maintained by the State of Arkansas under the provision of Internal Revenue Code Section 457(b). The maximum amount a provider can contribute to his or her 457 deferred compensation plan for the year 2015 will be raised to $18,000. The catch-up contribution limit for employees age 50 and over who participate will be raised to $6,000. The 3-year, pre-retirement, catch up will be $36,000 in For more information regarding the Plan, eligibility requirements, and investment options, contact Robert Jones of Stephens, Inc., at or

64 Medicaid Changes and Updates 2015 February 29, 2016 EHR Program Participation Deadline for Eligible Hospitals If you are a dually-eligible hospital and wish to receive an EHR incentive payment, first-time participants must attest with Medicare by February 29, Please contact the Arkansas Incentive Payment Team (AIPT) at aipt@hpe.com with questions or concerns

65 Medicaid Changes and Updates 2015 Medicare-Medicaid Crossover Invoice(s) The diagnosis code field in each form has been increased by two digits to allow space for ICD-10 codes. The method to order forms is unchanged. Continue to refer to Section V of your Arkansas Medicaid provider manual for ordering information

66 Medicaid Changes and Updates 2015 New NCCI Modifiers January 1, 2015 XE Separate encounter: a service that is distinct because it occurred during a separate encounter. XP Separate practitioner: a service that is distinct because it was performed by a different practitioner. XS Separate structure: a service that is distinct because it was performed on a separate organ/structure. XU Unusual non-overlapping service: the use of a service that is distinct because it does not overlap usual components of the main service

67 Medicaid Changes and Updates 2015 Provider Address Requested

68 The Arkansas Health Care Independence Program

69 What is the Arkansas Health Care Independence Program?

70 What is the Arkansas Health Care Independence Program? Arkansas has chosen to expand coverage using the Arkansas Health Care Independence Program. The Arkansas Health Care Independence Program covers people at or below 138% of the federal poverty level, utilizing Title XIX funding to purchase Qualified Health Plans (QHPs). The Arkansas Health Care Independence Program will expand insurance coverage to an estimated 250,000 low income Arkansas residents. The private health plans will provide coverage that meet Medicaid standards with no deductibles

71 What is the Arkansas Health Care Independence Program? Who is eligible for the Arkansas Health Care Independence Program? Adults who earn up to 138% of the Federal Poverty Level (FPL) and are not: Currently on traditional Medicaid Currently on Medicare Disabled Pregnant at the time of application Who funds the program? The program is 100% federally funded for the first three years. The Health Care Independence Program allows Arkansans to enroll in private health plans that are available on the federal Marketplace

72 Determining If a Beneficiary Is an Arkansas Health Care Independence Program Enrollee

73 Determining If a Beneficiary Is an Arkansas Health Care Independence Program Enrollee Beneficiaries who qualify for the Arkansas Health Care Independence Program are placed in aid category 06 and are referred to as the newly eligible population. Providers can determine whether the beneficiary is an Arkansas Health Care Independence Program enrollee by checking eligibility on the Arkansas Medicaid website. Any beneficiary with plan description 06 is Newly Eligible. Approximately 10% will be enrolled in traditional Medicaid. Approximately 90% will be enrolled in a Qualified Health Plan

74 Determining If a Beneficiary Is an Arkansas Health Care Independence Program Enrollee The approximate 10% enrolled in traditional Medicaid will receive Medicaid cards and have regular Medicaid benefits. The approximate 90% enrolled through one of the QHPs (BCBS, Ambetter of Arkansas and QualChoice) will not receive Medicaid cards but will receive a notice indicating their Medicaid number and describing the following supplemental benefits. Traditional Medicaid benefits provided during the transition time from eligibility determination until QHP coverage starts Non-emergency medical transportation and EPSDT for individuals between 19 and 20 (to the extent the service is not otherwise included in the QHP benefit)

75 Determining If a Beneficiary Is an Arkansas Health Care Independence Program Enrollee Newly Eligible Enrolled in Traditional Medicaid

76 Determining If a Beneficiary Is an Arkansas Health Care Independence Program Enrollee QHP enrollee In Transition BCBS Ambetter QualChoice

77 Determining If a Beneficiary Is an Arkansas Health Care Independence Program Enrollee QHP enrollee with active QHP Coverage BCBS Ambetter QualChoice

78 How the Arkansas Health Care Independence Program Affects Medicaid Billing

79 How the Arkansas Health Care Independence Program Affects Medicaid Billing All services will be provided through Qualified Health Plans (QHPs), except for two services that are not fully covered under the QHP benefit package. Specifically, the State will provide a fee-for-service supplemental benefit for: Non-emergency medical transportation Early Periodic Screening Diagnosis and Treatment for individuals 19 and 20 (to the extent the service is not otherwise included in the QHP benefit) Beneficiaries age 19 and 20 receive coverage for vision and dental services

80 How the Arkansas Health Care Independence Program Affects Medicaid Billing The newly eligible population placed on traditional Medicaid will receive Medicaid cards and all of their claims will be billed to Arkansas Medicaid. No PCP is required for beneficiaries in aid category 06 as of today. For beneficiaries enrolled in a QHP: All claims are billed to Arkansas Medicaid during the transition period. Once the QHP coverage starts, all claims should be billed to the commercial carrier with the exception of the supplemental services

81 Arkansas Health Care Independence Program Contacts

82 Arkansas Health Care Independence Program Contacts Claims and Billing Questions HPE Provider Assistance Center or Medicaid Eligibility Questions Division of County Operations Arkansas Health Care Independence Program Coverage Questions AFMC Beneficiary Relations

83 Arkansas Health Care Independence Program Contacts Ambetter of Arkansas QualChoice Arkansas Blue Cross Blue Shield Blue Cross Blue Shield Multi-State BLUE(2583)

84 Arkansas Medicaid Who s Who

85 Arkansas Medicaid Who s Who Who Does What? Division of County Offices (DCO) Arkansas Foundation for Medical Care (AFMC) ConnectCare ValueOptions Third Party Liability (TPL) Division of Medical Services (DMS) Magellan Medicaid Administration Hewlett Packard Enterprise (HPE)

86 Arkansas Medicaid Who s Who DHS County Offices County Case Workers Work directly with beneficiaries Determine eligibility, plan description and eligibility timeframe Assist with Primary Care Physician (PCP) selection For eligibility questions or concerns call the Local DHS or DCO at

87 Arkansas Medicaid Who s Who AFMC Arkansas Foundation for Medical Care Serves as a liaison for Medicaid and providers: primary care providers, specified specialty providers and acute care hospitals Manages Medicaid Quality Improvement Projects, including the Inpatient Quality Incentive Program Operates beneficiary complaint and transportation help lines Provides utilization and quality review for various Medicaid programs Authorizes extensions of benefits Therapy Review Prior Authorizations for wheelchairs and personal care

88 Arkansas Medicaid Who s Who ConnectCare Helpline Enrolls beneficiaries with a PCP Assists beneficiaries in finding a dentist Educates beneficiaries, county case workers and providers about Medicaid

89 Arkansas Medicaid Who s Who ValueOptions Mental Health Provides utilization management, continuing education and inspections of Inpatient and Outpatient mental health facilities for beneficiaries enrolled in the Medicaid Program Approves Prior Authorizations, Certifications of Need (CON) and Continuing Stay Reviews Receives general questions at

90 Arkansas Medicaid Who s Who TPL The Third Party Liability (TPL) unit identifies Medicaid beneficiaries who have other medical insurance or payment sources that must pay first. These sources include health and liability insurance, court settlements, and absent parents local and out-of-state Fax P.O. Box 1437, Slot S296 Little Rock, AR

91 Arkansas Medicaid Who s Who DHS Division of Medical Services Administers Arkansas Medicaid DMS establishes policy for all Medicaid programs. Provider Reimbursement establishes reimbursement rates. TPL validates third-party liability information. Program Development and Quality Assurance distributes Medicaid policy and monitors waiver programs. Utilization Review assists with claims and makes coverage determinations. Program Integrity investigates fraud, waste and abuse. Medical Assistance manages program communications plus dental and visual programs. Pharmacy makes coverage determinations and manages all drug-related issues

92 Arkansas Medicaid Who s Who Magellan Medicaid Administration Medicaid Pharmacy Vendor Magellan Medicaid Administration assumed administrative operation of the Medicaid Pharmacy program for the State of Arkansas and took over operations from the previous administrating company, Hewlett Packard Enterprise (HPE), on March 14, Magellan Pharmacy Call Center: Pharmacy Support Option 1 Prescriber Support Option 2 Beneficiary Support Option 3 Web Support Option 4, then Option 1 Magellan Fax Number: Call Center hours are Monday-Friday 6 AM-5 PM CST excluding state holidays. Web Support hours are Monday-Friday 7 AM-7 PM CST

93 Arkansas Medicaid Who s Who Hewlett Packard Enterprise (HPE) Fiscal Agent Provider Enrollment Claims Processing Remittance Advice Provider Relations Medicaid Management Information System (MMIS)

94 Questions?

95 Thank You

96 2015 Annual Provider Workshop 2015

97 Arkansas Medicaid Annual Workshop Bart Dickinson, Chief Counsel Office of the Medicaid Inspector General

98 ABC s of Medicaid Auditors OMIG (Office of Medicaid Inspector General) MIC - Medicaid Integrity Contractor (Health Integrity) ZPIC Zone Program Integrity Contractor RAC Medicare only SURS - Medicaid Utilization and Review audits QIO - Quality Improvement Organization

99 OMIG 2015 Annual Report Fiscal Year 2015 Total Audits/Reviews = 630 Desk Audits / Field Audits / False Claims Act Reviews Fraud Referrals = 50 Over 20 suspensions or arrests / performing providers / $1.5 million Administrative Actions 78 Suspensions / Exclusions / Terminations Recoupments and Recoveries $2.3 million Recovered or Reversed / $3 million recoupment claims

100 OMIG Overview Establishment and authority Roles of OMIG Identify Medicaid Fraud, Waste, and Abuse Medical Services to Billing Audits False Claims Act Compliance Medicaid Reform Implement changes to Medicaid policy

101 OMIG Overview Audit and Investigation process Field / Desk Audit / Self - Report Recoupment Findings of potential overpayment Observations non monetary Corrective Action Plan OR Fraud Referral Credible Allegation of Fraud requires temporary suspension Referral to Attorney General Medicaid Fraud Control Unit Possible suspension of performing provider but not billing Medicaid provider

102 OMIG Records Request Traditional authority as Program Integrity Function Arkansas Medicaid Manual Conditions Related to Record Keeping Enrollment Contract requirement Grounds for Sanctioning Providers Subpoena Power and Production of Records Ark. Code Ann

103 OMIG Data Analytics OPTUM Fraud Detection System Provider Spike Detection Peer Review Analysis Algorithms Outlier Case Studies EMFAD Enterprise Fraud Detection Pending RFP for Predictive Analytics

104 Self-Reporting & Self-Disclosure Duty of the Medicaid Inspector General is to: Develop protocols for efficient self-disclosure Consider a Medicaid Provider s good faith as a mitigating factor Self-Disclosure Protocol on OMIG website OMIG.Arkansas.gov

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107 Corrective Action Plans Website steps

108 Corrective Action Plans Read the OMIG Report / Findings Address each finding Be specific in your steps and procedure Provide a person/name/position for accountability

109 Bart Dickinson, Chief Counsel Office of the Medicaid Inspector General 323 Center Street, Ste Little Rock, AR

110 2015 Annual Provider Workshop 2015

111

112 2015 Annual Provider Workshop 2015

113 Extension of Benefits Amy Rogers, RN Manager, Clinical Review EOB/MPR 5111 Rogers Avenue, Suite 476 Fort Smith, AR 72903

114 Extension of Benefits (EOB) What is it? Benefit Limits Medicaid Provider Manuals Section II of all applicable provider manuals Considered after claim has been denied for exceeding benefits Request must be received within 90 days of the date of the benefits-exhausted denial. 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 114

115 Getting Started Provider bills for services provided Arkansas Provider Manual Section III Provider receives remittance advice with denial for exceeding benefits File for Extension of Benefits 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 115

116 Submitting the EOB request Submit to AFMC 3 options for submission Postal or carrier service iexchange Fax For US Postal Service mail: P.O. Box Fort Smith, AR For FedEx, UPS or other such carriers: (Use our physical address) AFMC Central Mall 5111 Rogers Avenue, Suite 476 Fort Smith, AR Review fax number: (479) Main phone number: (479) Website: 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 116

117 DMS-671 EOB Request Form 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 117

118 DMS-671 EOB Request Form Requesting provider or facility listed in Fields 1 and 2 Field 5 must be signed Beneficiary information completed Use specific dates of service. No range of dates. Use a valid CPT, HCPCS, or Revenue code Include any applicable modifiers Units requested All information should match what is on the RA 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 118

119 iexchange Electronic submission of requests Benefits Reduces time and expense associated with paper submissions Providers can access 24/7 to review results FREE Secure and HIPAA compliant DMS-671 EOB request form not required Records can be directly attached to the request 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 119

120 Required Documentation Detailed information on page 2 of the DMS-671 EOB request form Remittance Advice (RA) Order(s) Must be signed by a physician or NP Report(s) Must be signed by the requesting provider Must have DOS documented Place of service documented X-ray reports must include the names of the views Should be detailed and include CPT required information Medical Necessity Clinical indication for services ordered (includes but not limited to) Current and 2 previous office visits ER visits OB- need progress reports, flow chart, and all previous US and NST reports 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 120

121 EOB Review Process Received and tracked into AFMC s review system Reviewed by a Clinical Review Specialist- RN within 30 business days Approval and/or denial letter mailed to the address on file with Arkansas Medicaid IMPORTANT: Read the denial rationales on the letters. Reconsiderations Submit the requested information Must be submitted within 35 days from the date of the letter Include a copy of the denial letter Reviewed by the Clinical Review Specialist-RN Denials are determined by a Physician Advisor Appeal options Refer to Arkansas Medicaid Manual Section I 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 121

122 Common Errors DMS-671 is not signed. Fields 1 and 2 of the DMS-671 have the incorrect provider. Dates of service requested does not match records. No orders. No orders signed by a physician. No RA. Clearing house RA s are not accepted. No physician signature on documentation. Signatures must be dated and timed. 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 122

123 Contact Information Administrative Supervisors: Karla Batey: (479) Ami Winters: (479) Main Phone: (479) Review Fax: (479) /11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 123

124 2015 Annual Provider Workshop 2015

125 Wheelchair Prior Authorization Amy Carson, RN, CPHM Manager, Clinical Review 5111 Rogers Avenue, Suite 476 Fort Smith, AR 72903

126 Submitting Requests to AFMC Prior authorization requests may be submitted via hardcopy via U.S. Mail, FedEx, UPS, etc or electronically through iexchange. For U.S. Mail: AFMC P.O. Box Fort Smith, AR For FedEx, UPS or other such carriers: AFMC Central Mall 5111 Rogers Avenue, Suite 476 Fort Smith, AR /11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 126

127 iexchange Electronic submission of requests Secure and HIPAA compliant Records can be directly attached to the request Benefits Reduces time and expense associated with paper submissions Providers can access 24/7 to review results FREE 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 127

128 AFMC REVIEW PROCESS Requests are initially screened by a registered nurse. If the documentation submitted supports medical necessity, the nurse reviewer may approve the prior authorization. If the nurse reviewer is unable to approve medical necessity of the requested service, the review is referred to a physician advisor for determination. 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 128

129 Physician Review AFMC utilizes actively practicing physician s, licensed in the State of Arkansas, to review wheelchair requests. The physician advisor uses his/her medical judgment, in accordance with established Medicaid policies, to review medical necessity of the requested equipment. 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 129

130 Review Notifications Upon completion of each prior authorization request, AFMC provides written notification of the review determination to the requesting provider and the Medicaid beneficiary. 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 130

131 Approval Notifications includes each procedure code/modifiers and units approved along with the authorization number for billing. Denial Notifications - include case specific clinical rationale and detailed information about how to appeal the determination, including the time frame allowed for submission and the requirement to provide additional information to support the medical necessity of the service denied. 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 131

132 Due Process Rights Providers may request a reconsideration review through AFMC or appeal the AFMC determination through the Medicaid Provider Appeals Office at Arkansas Department of Health Medicaid beneficiaries may request an appeal of the AFMC decision through the Office of Appeals and Hearings. 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 132

133 Documentation Needed for Review by AFMC 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 133

134 Rental Wheelchairs Prior Authorization Request Form - DMS-679 or DMS-679A Prescription for the requested wheelchair Signed/dated by the beneficiary s PCP or the ordering physician Stamp signatures are not acceptable. Correct Medicaid procedure codes and associated modifiers must be utilized. Requested items will be denied if correct procedure codes are not used for items being requested. AFMC will not automatically correct the procedure code. Clinical Documentation - Medical documentation from the beneficiary s PCP or ordering physician to establish medical necessity and the length of need for the requested wheelchair. 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 134

135 Manual Wheelchairs Prior Authorization Request Form - DMS-679 or DMS-679A Prescription for the requested wheelchair Clinical Documentation - In person exam by the physician documenting mobility limitations and need for requested wheelchair Completed Wheelchair and Home Evaluation or Wheelchair and Custom Seating Evaluation A Manufacturer s Order Form documenting the suggested retail price for the brand and model of wheelchair and ALL accessories 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 135

136 Power Wheelchairs Prior Authorization Request Form - DMS-679 or DMS-679A Prescription for the requested wheelchair Clinical Documentation - In person exam by the physician documenting mobility limitations and need for requested wheelchair Completed Wheelchair and Home Evaluation or Wheelchair and Custom Seating Evaluation A Manufacturer s Order form documenting the suggested retail price for the brand and model wheelchair and ALL accessories 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 136

137 Repairs of Purchased Wheelchairs Prior Authorization Request Form - DMS-679 or DMS-679A Detailed explanation of the justification for the repair/replacement of any component or part replaced as well as the labor time to restore the item to its functionality Date of purchase and funding source of the chair, brand /model name, and the serial number of the wheelchair base A Manufacturer s Order Form/Price Quote documenting the suggested retail price for each part and accessory needed for the repair 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 137

138 Replacement Wheelchairs The purchase of a wheelchair for individuals twenty-one (21) years of age and over is limited to one wheelchair per five (5) year period if medically necessary. The purchase of a wheelchair for individual twenty (20) years of age and under is limited to one per two (2) year period if medically necessary. 12/11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 138

139 Questions? Amy Carson, RN, CPHM Manager, Clinical Review Fax: /11/2015 Copyright 2015 AFMC, Inc. All Rights Reserved. 139