Claims Submission, Adjustments and Voids 2014 HP Fiscal Agent for the Arkansas Division of Medical Services

Transcription

1 Claims Submission, Adjustments and Voids 2014 HP Fiscal Agent for the Arkansas Division of Medical Services 1

2 Agenda Ways to Submit Claims How to Adjust/Void a Claim Timely Filing How to Check Claim Status 2

3 Ways to Submit Claims Paper Direct Data Entry (DDE) Provider Electronic Solutions (PES) Vendor Software 3

4 Types of Paper Claims

5 CMS

6 UB-04 6

7 Dental 7

8 Mail Paper Claims to: HP Enterprise Services Attn: Claims PO Box 8034 Little Rock, AR

9 Medicare/Advantage Plans and Medicaid (Crossover Claim Submission)

10 QUIZ!!!!!! Name one way to submit a claim. 10

11 Crossover Forms Inpatient Crossover HP-MC-001 Long Term Care Crossover HP-MC-002 Outpatient Crossover HP-MC-003 Professional Crossover HP-MC

12 Crossover Claims If the beneficiary has Medicare and Medicaid, and Medicare pays or applies money toward the deductible/co-insurance, then the claim can be billed as a crossover on PES, DDE, vendor software or the appropriate red and white crossover claim form. HP Enterprise Services Attn: Claims PO Box 8034 Little Rock, AR

13 Crossover Claims If the beneficiary has Medicare and Medicaid, and Medicare denies the claim, then the claim must be billed on a red and white claim form (CMS-1500 or UB-04) with the Medicare denial attached. Attach a cover letter of explanation. Do NOT mix in with other claims you are sending in for regular processing. HP Enterprise Services Attn: Research Analyst PO Box 8036 Little Rock, AR

14 Crossover Claims If the beneficiary has Medicare, TPL and Medicaid, and Medicare denies the claim and TPL paid, then the claim must be billed on a red and white claim form (CMS-1500 or UB-04) with the Medicare and TPL EOB attached. Attach a note stating this is for Medicare override. Do NOT mix in with other claims you are sending in for regular processing. HP Enterprise Services Attn: Research PO Box 8036 Little Rock, AR

15 Crossover Claims If the beneficiary has Medicare, TPL and Medicaid, and Medicare pays but the TPL denies the claim, then the claim can be billed as a crossover claim through PES software or be billed on the appropriate red and white crossover claim form with the TPL and Medicare EOB attached. HP Enterprise Services Attn: Claims PO Box 8034 Little Rock, AR

16 Crossover Claims If the beneficiary has Medicare, TPL and Medicaid, and both Medicare and the TPL deny the claim, then the claim must be billed on a red and white claim form (CMS-1500 or UB-04) with the Medicare and TPL denial EOBs attached. Attach a note stating this is for Medicare override. Do NOT mix in with other claims you are sending in for regular processing. HP Enterprise Services Attn: Research PO Box 8036 Little Rock, AR

17 Paper Adjustments

18 Paper Adjustments A legible signature must be on the adjustment form. This form can be found in Section V of your provider manual. 18

19 How to Order Forms from HP/Arkansas Medicaid

20 Claim Order Form 20

21 Claim Order Form Please indicate on the claim order form how many forms you are ordering. Mail request to: HP Enterprise Services Forms Request PO Box 8033 Little Rock, AR Fax:

22 Return to Provider

23 Return to Provider Paper claims with errors are returned to provides on three forms according to the type of claim submitted: CMS 1500 UB 04 Crossover The PO Box to return a corrected claim is given at the bottom of each form. On the RTP forms, the reason(s) the claim is being returned will be indicated. Please make needed corrections and resubmit claim. 23

24 Direct Data Entry (DDE)

25 Direct Data Entry (DDE) 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. 25

26 Direct Data Entry (DDE) 26

27 . Direct Data Entry (DDE) 27

28 Provider Electronic Solutions (PES) Software

29 Provider Electronic Solutions (PES) Software Provider Electronic Solutions software is HP s free eligibility and claims submission software. It is available for download from the Arkansas Medicaid website. 29

30 Submitter ID Creating Your Submitter ID for New PES Users Click Provider HIPAA New Submitters Registration. Click the New Submitter Registration Form link. Complete the New Submitter Registration Information Form and click NEXT. Select a question and complete the answer for Security Questions until you complete five questions and answers. Click NEXT. Enter your billing provider 9 digit Medicaid ID number. Click ADD. Click NEXT. Enter the number of submitter IDs you want, click FINISH and PRINT THIS PAGE showing your MC number. 30

31 Provider Electronic Solutions (PES) Software 31

32 Provider Electronic Solutions (PES) Software 32

33 Provider Electronic Solutions (PES) Software When submitting claims in PES, be sure to retrieve your response report to see rejections and claims accepted. 33

34 QUIZ TIME! How much does it cost to download the PES software? 34

35 Timely Filing Medicare/Medicaid Crossover Claims and Claims with Retroactive Eligibility (Pseudo Claims)

36 Timely Filing Federal regulations dictate that providers must file the Medicaid portion of claims for duallyeligible beneficiaries within 12 months of the beginning date of service. The Medicare claim will establish timely filing for Medicaid. If the provider files with Medicare during the 12-month Medicaid filing deadline, Medicaid may then consider payment of a Medicare deductible and/or coinsurance, even if more than a year has passed since the date of service. Federal regulations permit Medicaid to pay its portion of the claim within six (6) months from the Medicare paid/denied date. Providers may not electronically transmit any claims for dates of service over 12 months. 36

37 Timely Filing Medicaid requires providers to submit all claims no later than 12 months from the date of service. The 12-month filing deadline applies to all claims, including: Adjustment requests and resubmissions of claims previously considered Claims for services provided to individuals who acquire Medicaid eligibility retroactively 37

38 Timely Filing Claims with Retroactive Eligibility (Pseudo Claims) Retroactive eligibility does not constitute an exception to the filing deadline policy. If an appeal or other administrative action delays an eligibility determination, the provider must submit the claim within the 12-month filing deadline. If the claim is denied for recipient ineligibility, the provider may resubmit the claim when the patient becomes eligible for the retroactive date(s) of service. Medicaid may then consider the claim for payment because the provider submitted the initial claim within the 12-month filing deadline and the denial was not the result of an error by the provider. To resolve this dilemma, Arkansas Medicaid considers the pseudo recipient identification number to represent an...error originating within (the) State s claims system. Therefore, a claim containing that number is a clean claim if it contains all other information necessary for correct processing. 38

39 Timely Filing Claims with Retroactive Eligibility (Pseudo Claims) Providers have 12 months from the approval date of the patient s Medicaid eligibility to resubmit a clean claim after filing a pseudo claim. After the 12-month filing deadline (12 months from the Medicaid approval date), claims will be denied for timely filing and will not be paid. It is the responsibility of the provider to verify the eligibility approval date. Once a beneficiary receives retro eligibility, the provider must submit a paper claim, proof of the pseudo claim and a cover letter to Research for special processing. HP Enterprise Services Attn: Research Analyst PO BOX 8036 Little Rock, AR

40 Quiz Time How many days do you have to submit a clean claim to Arkansas Medicaid before it is considered timely? 40

41 Claim Status

42 Remittance and Status Report Check your remittance and status report (WebRA) each week for: Paid Claims Denied Claims Adjusted Claims Pending Claims Recoupments Claims Payment Summary HEOB Codes/Messages 42

43 Claim Status Electronic claims are typically adjudicated on the next remittance advice. Paper claims that could have been sent electronically typically adjudicate days after submission. Claims that must be sent on paper typically adjudicate 2-3 weeks after submission. 43

44 Claim Status Five Ways to Check Claim Status Verify claims on the remittance advice PES software Medicaid website VRS Provider Assistance Center (800) or (501)

45 Questions?

46 Thank you 46