IHCP 3 rd Quarter Workshop Hoosier Healthwise/HIP. MDwise Claims HHW HIPP0264 (6/13) Exclusively serving Indiana families since 1994.

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1 IHCP 3 rd Quarter Workshop Hoosier Healthwise/HIP MDwise Claims HHW HIPP0264 (6/13) Exclusively serving Indiana families since 1994.

2 Agenda 1. Provider Enrollment 2. Claim submission for MDwise Hoosier Healthwise and HIP 3. Top claims denials and rejected submissions 4. How to file a claim dispute and appeal 5. Quick tips for claims adjudication (including prior authorization)

3 Provider Enrollment Prior to submitting a claim In order to receive reimbursement from MDwise. The provider must: Be enrolled and be actively eligible with the Indiana Health Coverage Program (IHCP). See Chapter 4 IHCP Provider Manual Obtain a prior authorization if the provider is out of network. Complete all required elements on the CMS 1500 form. Submit claim to appropriate MDwise delivery system claims payor. See Quick Contact Guide for Delivery System contact info.

4 General Hoosier Healthwise claims processing overview for MDwise In the MDwise plan, claims processing is delegated to the MDwise delivery systems MDwise has three payers. Hoosier Alliance pays Hoosier Healthwise claims for their members. DST Health Solutions pays Hoosier Healthwise claims for the Wishard, Methodist, and Total Health Delivery systems. CMCS pays Hoosier Healthwise claims for St. Margaret Mercy, St Anthony, and St. Vincent. t1 If uncertain of the members delivery system, the provider may access this information on the MDwise Provider Portal at

5 Slide 4 t1 what goes in here? tchadd, 9/13/2012

6 MDwise Delivery Systems Hoosier Alliance Methodist Select Health St. Catherine /St. Mary, Community Hospital Munster Saint Margaret Mercy /St. Anthony St. Vincent Total Health Wishard

7 Eligibility information for MDwise When a member s RID number is entered in Web interchange, you will see: The IHCP program the member is enrolled in. The plan (MCE) For MDwise our Provider Portal will show the following: Assigned PMP and history Delivery System If they are on Right Choices

8 Eligibility Screen

9 General claims processing overview for MDwise Contractually, all in network providers are required to submit claims within 90 days of date of service Providers are encouraged to submit claims electronically for faster claim adjudication Note: MDwise behavioral health providers are required to submit claims to the proper Delivery System within 90 days of date of service

10 Third Party Liability MDwise is always the payer of last resort (Medicaid) MDwise contracts with Health Management Systems for TPL information (HMS) to work with coordination of benefit information MDwise does have a 90 day rule, providers should work with delivery systems on a case by case basis See enclosed TPL tip sheet for more information Hoosier Healthwise 9

11 90 day Rule When the member has other insurance, a MDwise provider must submit claims to the other insurance carrier before submitting to the MDwise Delivery System. When a third party insurance carrier fails to respond within 90 days of the providers billing date, the claim must be submitted to the MDwise Delivery System for payment consideration. However, one of the following must accompany a claim to substantiate attempts to bill the third party or the claim will be denied: Copies of unpaid bills or statements sent to the third party, whether an individual or an insurance company. Provider must note the date of the billing attempt and the words no response after 90 days on an attachment. This information must be clearly indicated. Written notification from the provider indicating the billing dates and explaining that the third party failed to respond within 90 days from the billing date. The provider is required to boldly make a note of the following on the attachment: Date of the filing attempt The words no response after 90 days Member identification number (RID) & Provider s National Provider Identifier (NPI) Name of primary insurance carrier billed For claims filed electronically, the following must be documented in the claim note segment of the 837P transaction: Date of the filing attempt The phrase, no response after 90 days The member s identification (RID) number & IHCP provider number Name of primary insurance carrier billed

12 Out of network providers Out of network providers Send paper or electronic claims to the appropriate MDwise delivery system Submit claims within 365 days of date of service Providers submitting a claim for the first time to a Delivery System must include a W-9

13 Top 5 claims denials Member not effective on date of service Duplicate claim Not covered by plan ER report needed No Prior Authorization on file

14 Electronic rejections Rejected claims are returned to the provider or electronic data interchange (EDI) source without registering in the claim processing system Since rejected claims are not registered in the claims processing system, the provider must resubmit the corrected claim within the claims timely filing limit

15 Top rejected claims Rejected claims are different than denied claims. If a claim rejects MDwise will have no information on it. Example of rejected claims: DX code not present Missing Patient Account Number Current ICD-9* If there is a 4 th or 5 th digit, the more general digit code may not be used Date of Illness or last menstrual period Federal Tax ID Provider NPI RID number All claims must be legible

16 Pre Claims Submission/Check List It is necessary to confirm all of the items on the check list prior to rendering services and submitting a claim. Is the member eligible for services today? Which IHCP Plan is the member enrolled in? ( Hoosier Healthwise [Anthem, MDwise, MHS], Care Select, Traditional, Presumptive Eligibility) * Is the member enrolled in the Healthy Indiana Plan? Who is their Primary Medical Provider (PMP)? Does the member have primary health insurance other than Medicaid or HIP? * Presumptive Eligible members are not eligible for any INPATIENT SERVICES. PE members ID numbers begin with 550. Hoosier Healthwise 15

17 Patient Account Number The Office of Medicaid Policy and Planning (OMPP) is requiring MDwise to require providers to submit the provider s patient account number on all claims Claims submitted without the patient account number will be rejected Patient Account numbers can be up to 20 characters in length UB-04-form field 3a CMS-1500 form field 26

18 So your claim has denied now what?

19 Claim Denials Claims Inquiry In and out of network providers need to contact MDwise to inquire about a claims denial MDwise Delivery Systems are required to respond within 30 calendar days of inquiry to the provider with the decision of the inquiry Appeals/Dispute Must be in writing & include the following * Providers have 60 calendar days to file an appeal and must include the following documentation: Appeal form, remittance advice and the claim If a delivery system fails to make a determination or the Provider disagrees with the determination, the provider should forward their appeal to: MDwise Corporate at P. O. Box Indianapolis, IN Attention: Grievance Coordinator

20 Provider Claims Dispute Form

21 Provider Inquiry Form Providers are encouraged to use this form who would like to check claims status or claims dispute status for the following Family Planning Hoosier Healthwise Wishard Hoosier Healthwise Methodist Hoosier Healthwise Total Health Healthy Indiana Plan (HIP) Please fax form to:

22 Provider Inquiry Form

23 Prior Authorization Universal Prior Authorization Form is required Form is to be used by all providers for all PA requests except Dental, Pharmacy, and Behavioral Health Please refer to IHCP Bulletin BT for more information For MDwise please submit to Delivery System Medical Management See quick contact guide at MDwise.org

24 Role of Medical Management MDwise delegates medical management functions to the MDwise delivery systems (MDwise.org) Medical Management focuses on the outcome of treatment with an emphasis on: Appropriate screening activities Demonstrate Medical Necessity of all services Quality of care reflected by the choice of services provided, type of provider involved, and the setting in which the care was delivered Prospective and concurrent care management Evaluation of standards of care/guidelines for provision of care Best practice monitors

25 Medical Management Medical Management service authorization activities conducted by the Medical Management staff include: Enhance the overall performance of practitioners and providers in achieving optimal outcomes in the delivery of quality, safe, efficient health care services to members through prospective, concurrent and retrospective data analysis and education. Contact member s Medical Management Department for services that require authorization

26 Out of Network Authorizations MDwisemembers that require covered services not available within the network must have prior authorization from the Delivery Systems Medical Management Department (before services are rendered)

27 Prior Authorization for DME Contact the member s Delivery System Medical Management Department for approved providers and DME (Durable Medical Equipment) prior authorization requirements. Universal prior authorization form available online at MDwise.org/providers.

28 Behavioral Health Prior Authorization Standardized forms for Behavioral Health: BH/Primary Medical Provider Coordination Form Behavioral Health does NOT utilize Universal PA form for Hoosier Healthwise and HIP Please use OTR form Outpatient Treatment Form (OTR) Form Psychological Testing Form Neuropsychological Testing Form These forms can be found on our website: MDwise.org/providers/forms/behavioralhealth

29 Helpful Hints to Get Started for all PA: Always verify eligibility on PA submission date Submit PA to the member s health plan and for MDwise the appropriate Delivery System Medical Management Suspended PA requests must be completed within 30 days by the provider Fax the PA form along with supporting documents together Mail Submit PA request form along with supporting documents

30 Universal Prior Authorization Form

31 Quick Tips to avoid claims denial or rejections Submit claims and corrected claims timely Inquire or dispute claims within contractual time line Check with medical management or online for services that require PA. HHW/HIP requirements differ Follow correct coding guidelines for claims submission Check member eligibility at the time of service through MDwise provider portal Verify payer id information before claims are submitted electronically Providers must report NPI to IHCP (make sure it is listed under both individual and group) Corrected claims are not claims disputes

32 HIP Claims MDwise Healthy Indiana Plan Claims

33 HIP Claims In and out of network- Use Provider Inquiry form at MDwise must respond within 30 calendar days of inquiry. Claims dispute form is available on line: Appeals Must be in writing Provider has 60 calendar days: From receiving remittance advice denial or After MDwise claims payor system fails to make determination In-network appeals should be forward to MDwise for resolution Out-of-network appeals should be forward to MDwise Corporate at Attn: MDwise Grievance Coordinator/HIP PO Box Indianapolis, IN 46225

34 HIP and Pregnant Women Pregnant women are not eligible for HIP services Pregnancy related services are non covered Physicians are encouraged to assist members to submit a statement of pregnancy to the Division of Family Resources (DFR) The member s HIP plan can also assist in the members reassignment HIP members who become pregnant are encouraged to contact the DFR to request re assignment to Hoosier Healthwise (members are not automatically termed from HIP) There will be no break in coverage Pregnant women may re enroll in HIP following the pregnancy

35 HIP Claims Claims Address: For all HIP delivery systems, effective January 1, 2013, paper claims should be submitted to: MDwise Claims DST P.O. Box Birmingham, AL All electronic EDI numbers below remain unchanged: Emdeon, TK Software and WebMD/Emdeon Institutional Payer ID 12K81 Payer ID for all EDI clearinghouses MDWIS Professional Payer ID SX172 McKesson/Relay Health Institutional Payer ID 4976 Professional Payer ID 4481

36 HIP Electronic Claim information: Emdeon, TK Software and ACS Gateway WebMD/Emdeon Institutional Payer ID 12K81 Payer ID for all EDI clearinghouses: MDWIS Professional Payer ID SX172 McKesson/Relay Health Institutional Payer ID 4976 Professional Payer ID 4481

37 What is the Enhanced Services Plan (ESP)? The HIP Enhanced Services Plan (ESP) is a plan designated for certain individuals with health care conditions that require additional support; these conditions include internal cancers, HIV/AIDS, hemophilia, aplastic anemia and organ transplants. How does a HIP member get into the ESP Plan? The application for the HIP program includes a brief medical questionnaire, which asks applicants if they have had any of the above conditions. If the applicant answers yes to any of the medical questions, they are placed in the HIP ESP plan so that they may begin receiving medical services immediately.

38 Enhanced Services Plan (ESP) ESP Contact info HIP ESP is administered by Affiliated Computer Services (ACS) P.O Indianapolis, IN Mail HIP ESP Premium Payments to P.O Cincinnati, OH If you need assistance understanding this website, please contact ACS TOLL FREE at or LOCAL at https://www.onlinehealthplan.com/hipesp

39 Provider Tools Well Child measures Best practices sheets Quick contact guide Right Choices Brochure Program information Tip sheets for DME, Vision, and TPL

40 Thank you from the staff at MDwise and our Delivery Systems

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