Managed Health Services

Transcription

1 Managed Health Services

2 UB 04 Effective November 1, 2007, MHS will not longer accept the UB 92 form

3 National Provider Identifier MHS needs to obtain NPI numbers prior to January Please submit directly to MHS for entry into our claims payment system. Submit NPI via MHS Web site at This must be submitted even if you have already submitted to the State of Indiana or EDS.

4 National Provider Identifier MHS will process with NPI only, effective January 1, 2008, unless OMPP requires a later date. CURRENTLY: If you have reported your NPI to MHS and it is on file, you may bill with NPI only on both the CMS-1500 (field 24J top half) and the UB-04 (field 56), claims will process with NPI only. If your NPI is not on file and claims are submitted with NPI only, the claims will reject. You may continue to use your Indiana Medicaid Number until January In informational edit will be sent requesting you to report your NPI.

5 MHS Web site Enhanced Web site On-line Registration On-line Prior Authorizations Provider Directory Search Functionality Enhanced Claim Detail Code Auditing Software Tool Printable, Current Forms and Manual

6 MHS Web site Upcoming Enhancements Direct claim submission 4 th Quarter 2007 Claim resubmission 1 st Quarter 2008 Claims Xtend 4 th Quarter Transactions 4 th Quarter 2007

7 New Software Claims Xtend software replacing code edit MHS will begin utilizing a new code editing software. The software will continue to ensure that MHS is processing claims in compliance with accepted industry coding standards. It will replace our current Code Edit system. The current Web-based code audit reference tool will remain the same and is located at This tool helps explain how MHS evaluates different code combinations.

8 Managed Health Services UB04 Billing CLAIMS

9 Provider Inquiry Services Call us at We are ready to help you! Knowledgeable, friendly staff available 8:00am 6:00pm EST Focused commitment to professional service Claims address P.O. Box 3002 Farmington, MO Dispute & appeal processes (60 days from receipt of EOP) Appeal address P.O. Box 3000 Farmington, MO Filing limits dependant upon contract status Follow IHCP requirements

10 Claims Submission Submit electronically (preferred) for fastest response. Providers should check electronic submission report daily to ensure claims were received by MHS. Filing timelines 120 days from DOS for Participating Providers Exceptions: Newborn, Third Party Liability, and Eligibility delays (filing limit 365 days) 365 days from DOS for Non Participating Providers

11 Billing MHS with Ease Helpful suggestions to prevent delay in payment are provided so that MHS can provide speedy payment. Beginning November 1 st, MHS will no longer be accepting old claim forms. Verify other insurance (TPL). Medicaid is the payer of last resort. MHS does require a copy of the primary EOP. Check eligibility at each visit prior to submitting claims to ensure that you are billing the correct carrier, as members may change MCOs often.

12 Billing MHS with Ease Please allow at least 30 to 45 days for claim adjustments to be made. PA requirements changed April 1, Please ensure that your staff is familiar, as retroactive authorizations are not provided. Utilization of our Web site will allow for the quickest service available. MHS will generate a Provider Watch Bulletin of helpful tips and Plan updates to billing office locations for all par providers on a quarterly basis. All providers can review this bulletin on the MHS Web site at

13 Resubmitted Claims If you need to resubmit a denied claim, the claim must be submitted on paper and should be clearly marked at the top with the word RESUBMISSION. Attach a MHS Claim Adjustment Form stating the reason for resubmission, and include the EOP (if applicable). Resubmitted claims should be mailed to the address listed on the claim adjustment form and must be received within 60 days of the EOP date.

14 Adjusted Claims If you need to make an adjustment to a paid claim, you can do so by calling Provider Inquiry, or you may submit on paper with the adjustment request form. Attach a Provider Adjustment Form along with documentation, including EOP (if available) explaining reason for resubmission Claim adjustments must be submitted within 60 days of the date of the MHS EOP

15 Claim Dispute Resolution PROVIDERS HAVE 60 CALENDAR DAYS FROM THE DATE OF RECEIPT OF THE EOP TO FILE AN OFFICIAL DISPUTE OR APPEAL WITH MHS Verbal Inquiries can be made by calling MHS Provider Inquiries at , option 3. *Note: A verbal inquiry is not considered a dispute or appeal and does not stop the 60 calendar days from the date of receipt of the EOP to file a dispute or appeal.

16 Third Party Liability If a member has TPL on file but no longer has other coverage or the member has other coverage but the information is not on file take the following steps: Contact Provider Inquiries with the TPL information so that changes can be made to the TPL file Send an update notification to EDS via the WebInterchange

17 Third Party Liability Claims will deny L6 if TPL is on file with MHS. What if I don t agree with MHS TPL indication? Call provider inquiries Resubmit paper claim with EOB attached Reminder: TPL claims must be submitted within 60 days of the date of the primary insurer s EOB.

18 Third Party Liability MHS updates member TPL information through: A monthly file from EDS Phone call from providers Receipt of an EOB with claim MHS always verifies new TPL

19 Emergency Room Payment The Emergency Department claims will be categorized by the primary ICD-9 diagnosis code. Diagnosis categorized as emergency: Contracted facilities negotiated rate Non-contracted facilities may be paid in accordance with state established rates. Diagnosis categorized as a not an obvious emergency: Contracted facilities negotiated rate Non-contracted facilities, if the code is categorized as not an obvious emergency, an EOP goes to the facility to request the ED records. These records must sent within 45 days from the EOP date.

20 Referrals and Prior Authorization Referrals and Prior Authorization

21 Prior Authorization REFERRAL A referral is a request (verbal, written, or telephonic communication) by a PMP Specialty care services. PRIOR AUTHORIZATION Prior Authorization is an approval from MHS to provide services designated as needing approval prior to treatment and/or payment.

22 Prior Authorization ALL Referrals to Contracted Specialists for Office Visits require communication between the PMP and the Specialist.

23 Prior Authorization ALL Referrals to Non-Contracted Specialists and/or for Procedures that Require Authorization Must be Obtained by Contacting MHS. Telephonic Process or Fax to Call must be placed at least two business days prior to date of service. A PA number will be given at the time of the call unless clinical information is required.

24 Prior Authorization When should the PMP get the authorization or referral from MHS? When referring to a non contracted specialist for an office visit When referring a patient directly for a procedure that requires an authorization even if the PMP is not performing

25 Prior Authorization When should the Specialist get the authorization from MHS? For any procedure or test that requires an authorization that the specialist decides in needed after the patient has been seen during an office visit.

26 Self Referral Services Podiatrist Chiropractic Family Planning Routine Vision Care Routine Dental Care Mental health by Type and Specialty HIV/AIDS Case Management Diabetes Self Management Individualized Education Plan (IEP) for Schools Immunizations

27 UB04 Billing Voluntary Sterilization/Tubal Ligation/Vasectomy/Hysterectomy Member consults with PMP Indiana State Form 46314/10-93 is signed at least 30 days but no more than 6 months prior to procedure, or acknowledgement of receipt of hysterectomy information provided to MHS either before or after the procedure, but before the claim is submitted AND Form is submitted to MHS after procedure is completed and forms are signed and dated by both parties. The form should be provided to MHS before the claim is submitted to MHS. Fax to Medical Management (317)

28 Hospital Stays Hospital stays under 24 hours are not billable as inpatient and must be submitted as outpatient services. Med Management will not approve inpatient less than 24 hours. 72 hours observations is allowed for stays that may not meet medically necessary inpatient admissions.

29 Newborns No prior authorization or referral is required for members who are less than 30 days old. Except for NICU Admissions and if baby is not discharged with mom. MHS MUST be notified by calling Medical Management at (800) The newborn s RID number is required for payment.

30 Transfers MHS requires notification and approval for all non-emergent transfers, at a minimum, within one business day prior to the transfer. MHS requires notification within two business days following all emergent transfers. Transfers are inclusive of, but not limited to, the following: Facility to facility (including newborns transferred to another hospital) Level of care changes (including newborns in special care nursery or NICU)

31 Nursery Nursery level does not include services that Would normally be considered special care nursery level of care Would not normally be rendered in a normal newborn nursery setting Would normally be rendered in a NICU level of care Special Care Nursery and NICU level of care services require MHS authorization within two business days of the start of the service. Call Medical Management at

32 Medical Necessity Appeals Medical Necessity Grievances (Level I) Medical Necessity Appeal (Level II) Expedited Medical Necessity Appeals

33 Questions and Answers