State of Maryland VALUEOPTIONS. Department of Health and Mental Hygiene & Claims & EFT Training. August 2009

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1 State of Maryland Department of Health and Mental Hygiene & VALUEOPTIONS Claims & EFT Training August 2009

2 2 Welcome to ValueOptions

3 Presenters Lisa LaPlante ValueOptions Director of Claims Mike Wagner - ValueOptions Manager of Claims Jessica Barry ValueOptions Manager of EDI Help Desk Ray Coleman ValueOptions National Director, Provider Relations, PSD Jackie Hanasik - ValueOptions Director of Claims Disbursements Payformance Representatives 3

4 Agenda Claims Processing Rules EDI Claims Submission ProviderConnect Overview and Demo EFT Questions 4

5 Claims Processing Rules 5

6 Transition and ACS ValueOptions has contracted with ACS to process claims with dates of service prior to 9/1/09. ACS will also be available to address claims payment questions on claims with these dates. Continue to call option 3, number used today (After September 1, 2009, there will be telephone prompt option specifically for ACS) 6

7 Paper Claims Submission Dates of service 9/1/09 and after must be submitted on a standard CMS-1500 or UB-04 forms to: ValueOptions, Maryland MHA Claims PO Box 1950 Latham, NY We recommend you look at our Direct Claims Submission online application which is easier than creating a paper claim. Until further notice, dates of service before 9/1/09 are to be submitted to: ACS PO Box 7061 Silver Spring, MD

8 EDI Claims Submission Until further notice, claims for dates of service prior to 9/1/09 must be separately batched and submitted to ACS. Claims for dates of service on or after 9/1/09 must be separately batched and submitted to ValueOptions. While we do not contract with clearing houses, ValueOptions does accept their files 8

9 NPI Requirements The National Provider Identifier (NPI) is required on all claims, both submitted electronically or on paper. The Provider NPI should be entered into the NPI field If the NPI is not on the claim, the file will be rejected If the NPI submitted does not match the NPI we have on file from Medicaid for your agency, the claim will be denied. You need to work with Medicaid to resolve this discrepancy. 9

10 Claims Coding UB-04 and 837I claims must contain HIPAA compliant 4 digit Revenue Codes and the corresponding HCPCS (lead zero is required) CMS-1500 or 837P claims must contain HIPAA compliant CPT-4 or HCPCS service codes Follow the billing rules and Procedure Codes in place today 10

11 Multiple Services On A Single Claim Each date of service must be submitted on a separate claim line Multiple units of the same service code/modifier on the same day must be submitted on one claim line The Dates Of Services on a claim cannot span a month end/next month start dates 11

12 Diagnosis Codes Must be ICD-9 codes and include the 4 th and 5 th digit as specified in the ICD-9 guidelines DSM- IV Codes will not be accepted 12

13 Timely Filing of Claims ValueOptions may not reimburse claims received for payment more than 12 months after the earliest date of service on the claim Claims involving commercial third party liability (TPL) must be received by ValueOptions within 12 months of the earliest date of service on the claim When Medicare is primary, claims for services not covered by Medicare are required to be received by ValueOptions within 12 months of the date of service or 120 days from the Medicare remittance date, whichever is later 13

14 Replacement Claims & Timely Filing Replacement/corrected claims: A corrected claim must be received by ValueOptions within 12 months of the date of service, or within 60 days of the original rejection as shown on the provider voucher, whichever is later Retro-active Eligibility: Claims must be received by ValueOptions within 12 months of the date eligibility was determined 14

15 Corrected/Replacement Claims on Paper Indicate CORRECTED CLAIM across top of claim form Indicate ValueOptions original claim number on top of claim form 15

16 Corrected/Replacement EDI Claims LOOP 2300 CLAIM INFORMATION When an original claim was denied or incorrectly billed, send a corrected or replacement claim by indicating the Claim Frequency Type Code 6=Corrected 7=Replacement Enter ValueOptions original Claim Number prefixed with RC in the Reference Identification 16

17 Reasons for Claim Denial Consumer Information: Consumer ID doesn t match the ID assigned by MMIS Service code on the claim is not on the list of covered services Service code billed is not one the provider is contracted to render Consumer is not eligible on the date of service. Codes/Modifiers Service code is not a covered code Place of service code on the claim is not a valid for the service rendered Modifier code billed on the claim is not valid with the CPT or HCPCS code Diagnosis code is not current ICD-9 standard Diagnosis code does not contain a required 4th or 5th digit Authorization There is no authorization for the date of service billed or for the billing provider There is an authorization but the dates of service on the claim are either before the effective date or after the expiration date of the authorization 17

18 18 EDI Claims Submission

19 Provider ID s Providers have various ID s related to ValueOptions Provider ID: Six-digit ValueOptions assigned identifier ProviderConnect ID: (also known as USER ID or Submitter ID) This is the ID used to log-in to the ProviderConnect site There may be multiple ProviderConnect IDs assigned to each provider ID, depending on how you choose to set up the accounts ProviderConnect ID s may or may not be identical to your Provider ID Medicaid ID: 7 digit ID assigned by Maryland State NPI: 10 digit National Provider ID 19

20 ProviderConnect ID (User ID) Set-up Depending on provider need, you can: Obtain a log-in for each group of users OR Obtain a log-in for each individual user When Grouping Users: Multiple people can log on to ProviderConnect at the same time, using the same ProviderConnect ID & password If you are submitting claims or authorizations for multiple providers, we can create a ProviderConnect ID for you that links to multiple provider accounts You log in under one ID and can access all the providers you bill for 20

21 HIPAA Standards on EDI Claims HIPAA standards govern both the file format and the codes used within electronic claims files The following provider information is required for each claim: 10 digit NPI number that matches a NPI we have on file Tax ID number Service location Taxonomy Code (Facilities) 21

22 EDI Claims Set-up ValueOptions will accept any HIPAA compliant 837p or 837i file Claims are submitted through Filing guidelines are the same, regardless of the software used to submit a claim A completed Account Request Form must be submitted and processed before any claims can be submitted Third party billing agents must also submit an Intermediary Form for each provider they are billing on behalf of ValueOptions has Experience working with multiple clearing houses 22

23 EDI Claims Set-up (continued) Account Setup Online Registration Online registration can only be used for the first ProviderConnect User ID. To register online, click the provider tab on then click on the Register link in the upper right. The ValueOptions unique provider ID and EXACT spelling of the last name is required. 23

24 EDI Claims Set-up (continued) Account Options Every account automatically receives access to : View Eligibility View Claims Status View Authorizations Obtaining Additional ProviderConnect ID s Contact the EDI Helpdesk at e- support.services@valueoptions.com or to request the Maryland Additional User Account form. Complete the form and fax back to

25 EDI Claims Set-up (continued) To obtain claims submission access: During online registration, click on the Claims Submission check box and the forms will be e- mailed to you Download form at s.htm Contact the EDI Helpdesk at e- or to attain the appropriate forms. Complete Account Request Form* and fax back to *Billing Agents also have to complete an Intermediary Authorization Form which needs to be signed by both the billing agent & provider. 25

26 EDI Claims Set-up (continued) Account Forms To obtain claims submission access: Completed Account Request Forms and Intermediary forms should be faxed to Allow 2-3 business days for the account to be setup. Once account set-up is complete, an will be sent containing the USERID and password. Passwords will be generic & should be changed during the first log-in by clicking on My Online Profile. Passwords must be 8 10 alpha numeric characters and are case sensitive. Special characters and spaces are not allowed. 26

27 What if I use a Clearinghouse? ValueOptions does not contract directly with any clearinghouses BUT we can accept claims files from any clearinghouse that creates HIPAA compliant 837 files Contact your clearinghouse directly and advise them that dates of service 9/1/09 and after need to be sent to ValueOptions The clearinghouse, in turn, can contact the EDI helpdesk directly and we will set them up with a unique Maryland specific ProviderConnect ID 27

28 28 ValueOptions ProviderConnect Overview

29 ValueOptions ProviderConnect ProviderConnect is an online tool that increases convenience & decreases administrative burden. Free, secure, online application Easy access 24 hours a day, 7 days a week Complete multiple transactions in a single sitting 29

30 ValueOptions ProviderConnect Features With ProviderConnect providers can: Verify Consumer eligibility Register Uninsured Consumers Request Authorizations View Authorizations Submit Claims (Batch and Direct/On-line claim) View Claim Status View and Print Provider Summary Voucher Submit inquiries to Customer Service Access and print forms 30

31 Accessing ProviderConnect Each provider has a secure login and online registration, including a provider ID number via the ProviderConnect Web site. Additional logins for other providers in the same practice are available through ProviderConnect. Contact: ValueOptions EDI Helpdesk (888) , Option 3 Monday through Friday 8 a.m. 6 p.m. EST Turn around time for additional logins is 48 hours. 31

32 ProviderConnect Registration Phase I (August 3) If already in ValueOptions system and know your provider ID, you may register for ProviderConnect immediately at If you do not know your provider ID, contact ValueOptions EDI helpdesk at from 8:00am to 6:00pm EST, Monday thru Friday Phase I providers will receive communication from ValueOptions with your specific provider ID required for registration Phase II (August 15) Phase II providers can begin to register on ProviderConnect on August 15 at Remember: Online registration can only be used for the first ProviderConnect User ID 32

33 ProviderConnect Uninsured Registration On-line functionality which allows providers to request Uninsured benefits for consumers The system collects responses to the required eligibility questions as well as the consumer s demographic information and will provide you with the Eligibility Number for authorizations and claims processes for approved requests 33

34 ProviderConnect Uninsured Registration Results The consumer demographic data entered is automatically processed using best match logic to determine if the consumer is already on file by comparing Social Security Number, Last Name, First Name and Date of Birth If consumer data entered is new and the requirements for benefits are met, the consumer is added for Uninsured benefits and the ID number assigned to the individual for authorization and claims processing is provided If consumer is already covered, you will be provided with the consumer s Medicaid or Uninsured ID number If possible match to a consumer is already on file, your request will suspend for further review If consumer does not meet the criteria for Uninsured eligibility, the registration will suspend for further review by CSA and you will be notified via ProviderConnect of the final review 34

35 35 Uninsured Eligibility Request

36 36 Uninsured Eligibility Request

37 37 Respond to Qualifying Questions

38 ProviderConnect Demonstration Step 1: Step 2: Click on Providers Step 3: Click on Try the Demo 38

39 39 ProviderConnect Login Screen

40 40 User Agreement

41 41 Search/View Member Eligibility

42 42 Member Eligibility Results

43 43 Uninsured Eligibility Request

44 44 Enter Demographic Information

45 45 Respond to Qualifying Questions

46 46 Review an Authorization

47 47 Search Authorizations

48 48 Authorization Search Results

49 49 Authorization Summary

50 50 Authorization Detail

51 51 My Online Registration Profile

52 52 Updating My Online Profile

53 53 ProviderConnect Message Center (Personalized!)

54 54 Inquiry Details

55 55 View Provider Summary Voucher

56 56 Provider Summary Voucher Search

57 57 Provider Summary Voucher Results

58 58 PaySpan Health and Electronic Funds Transfer (EFT)

59 59

60 What is PaySpan Health? PaySpan Health is a tool that will enable you to do the following: Receive payments automatically in the bank account of your choice. Receive notifications immediately upon payment. View your remittance advice online. Download an 835 file to use for auto-posting purposes. 60

61 61 Visit our website at

62 What is EFT/ERA? Electronic Funds Transfer (EFT) Secure system of transferring funds from one bank account directly to another. Also referred to as direct deposit or ACH (Automated Clearing House) Assures faster payment deposits of provider payments. Electronic Remittance Advice (ERA) Electronic version of a payment explanation which provides details about providers claims payment. ERA s are provided by plans to providers. The industry standard for sending ERA data is the HIPAA compliant A1. 62

63 Why should we register? PaySpan Health is a secure, self-service website. Improved cash flow through automated deposits. Access remittance data 24 hours a day. Access up to 18 months of historical remittance data. Ability to import payment data directly into the practice management systems. Mailbox functionality to automate the delivery of remittance data. Multi-payer solution. It s FREE! 63

64 Registering for PaySpan Health is easy! Register for PaySpan Health online using your registration code, which we can provide to you today. The person who registers will become the Administrator of the account. The address entered during registration will be the Administrators User Name. Add additional users and set levels of access by user. Create additional receiving accounts. 64

65 What do I need to register? Internet connection. Valid address. Your bank routing and account numbers. Registration Code. Your Pay-To Vendor Number (PIN). Tax ID Number. 65

66 Registration Process Enter your registration code in the box provided on our website: 66

67 Registration Process Enter your Vendor Pay-To Number and Tax ID Numbers in the spaces provided. 67

68 Registration Step One of Three The person who registers should enter their personal contact information on this screen. 68

69 Registration Step Two of Three Enter your bank routing and account number from an actual check. 69

70 Registration Step Three of Three Verify the information is correct and agree to the terms and conditions. 70

71 Registration Success! Upon successful registration, you will see this screen: 71

72 How do I activate my account? Payformance will make a deposit of less than one dollar into the account entered during registration. To activate your account, contact your financial institution for the dollar amount deposited. Log in to your PaySpan Health account and enter the amount deposited on your Home Screen. You do not need to return the deposit, it is a gift for registering! 72

73 How do I login to my account? Select the Secure Login button on our website and enter your address as your user name. 73

74 Home Screen Once you have activated your account, your Home Screen will look like this. Click on the New Payments link to view your payment information. 74

75 New Payments Use the View links to view your remittance advice, or use the checkboxes to confirm payments or download an 835 file. 75

76 Document Archive Search You can search for payment information by: Check/EFT Number Payment Amount Payment Date Payment Type Payer Name 76

77 77 Search by Payment Screen

78 78 Search by Payment Results Screen

79 Document Archive Search You can search for claim information by: Date or date range Patient First/Last Name Member First/Last Name Patient Account Number Claim Number Member ID Charge Amount Payment Amount 79

80 80 Search by Claim Screen

81 81 Search by Claim Results Screen

82 Provider Support We are available to assist you! Provider Support contact information: Provider Support is available from 7am to 9pm Eastern time, Monday through Friday. 82

83 Next Steps Continued Provider trainings, multiple modalities Maryland Website development continues This presentation/updates will be posted on the DHMH Website ValueOptions contract will be effective September 1,

84 Questions 84

85 85 Thank You!