New Provider Workshop 2015 HP - Fiscal Agent for the Arkansas Division of Medical Services

Transcription

1 New Provider Workshop 2015 HP - Fiscal Agent for the Arkansas Division of Medical Services

2 Agenda Arkansas Medicaid Overview HP Enterprise Services Contacts Report your NPI Primary Care Physician (PCP) Provider Manuals Verify Eligibility Plan Descriptions / Aid Categories / Benefit Limits Submitting Claims WebRA Claim Status Passwords Billing Tips Timely Filing Questions 2

3 Arkansas Medicaid Overview

4 Arkansas Medicaid Who Does What? County Offices (DCO) Arkansas Foundation for Medical Care (AFMC) ConnectCare QSource ValueOptions Health Management Systems (HMS) Division of Medical Services (DMS) Office of the Medicaid Inspector General (OMIG) HP Enterprise Services 4

5 DHS County Offices County Case Workers Work directly with beneficiaries Determine eligibility, plan description and eligibility timeframe Assist with Primary Care Physician (PCP) selection 5

6 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 6

7 ConnectCare Helpline Enrolls beneficiaries with a PCP Assists beneficiaries in finding a dentist Educates beneficiaries, county caseworkers and providers about Medicaid

8 QSource of Arkansas Review and Authorizations Conducts therapy retrospective reviews Provides prior authorization for personal care Coordinates eprescribing Initiative

9 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:

10 HMS Third Party Recovery Health Management Systems (HMS) provides services that identify third-party payment sources (such as commercial insurance and health plans, Medicare and TRICARE) and recovers public health plan expenditures when third-party liability exists HMS

11 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. Medical Assistance manages program communications plus dental and visual programs. Pharmacy makes coverage determination and manages all drug-related issues. 11

12 Office of the Medicaid Inspector General Formerly Program Integrity The Office of the Medicaid Inspector General (OMIG) investigates fraud, waste and abuse. Report Medicaid fraud by calling the Arkansas Medicaid Inspector General s hotline: AR-OMIG ( ) Report fraud at the website: 12

13 HP Enterprise Services Fiscal Agent Provider enrollment Claims processing Remittance Advice Provider relations Medicaid Management Information System (MMIS) 13

14 HP Enterprise Services Contacts 14

15 HP Enterprise Services Provider Enrollment Monday through Friday (8 a.m. 5 p.m.) Toll-free in Arkansas Local or out-of-state Dedicated fax HP Enterprise Services PO Box 8105 Little Rock, AR

16 HP Enterprise Services Provider Assistance Center (PAC) Your first point of contact for billing, claim status, and other general questions is the Provider Assistance Center: Monday through Friday (8 a.m. 5 p.m.) Toll-free in Arkansas Local or out-of-state Please Note: Provider Assistance no longer verifies eligibility. 16

17 HP Enterprise Services Electronic Data Interchange (EDI) The HP Enterprise Services EDI Support Center assists providers with electronic claim submission issues, 997 batch responses, PES software delivery and setup support, software training and data transmission failures. Monday through Friday (8 a.m. 5 p.m.) Toll-free in Arkansas Local or out-of-state Address ARKEDI@HP.COM 17

18 HP Enterprise Services Research Analyst The HP Enterprise Services Research Analyst answers s sent to region mailboxes, researches claims issues from providers and submits eligible claims with appropriate override. Providers need to attach a cover letter explaining the reason for their inquiry and attach an original red and white claim form with their cover letter to the address below. HP Enterprise Services Attn: Research Analyst PO Box 8036 Little Rock, AR

19 HP Enterprise Services Provider Representatives Provider representatives handle billing and policy issues that have been escalated from the Provider Assistance Center. They are also available to visit your office by appointment. You can find your provider representative under Meet Your HP Enterprise Representative on the Medicaid website. You may contact your representative by calling and entering their extension. 19

20 20

21 Report Your NPI 21

22 Arkansas Medicaid Website 22

23 Report your NPI 23

24 Report your NPI John Doe (000)

25 Report your NPI John Doe (000) Healthy People Clinic 123 Street Little Rock, AR

26 Report your NPI John Doe (000)

27 NPI Registry Disclose via the Freedom of Information Act (FOIA) Search for providers' NPI numbers Visit the NNPES website: Query-only database (NPI Registry) Downloadable file 27

28 Primary Care Physician (PCP) 28

29 Primary Care Physician (PCP) Arkansas Medicaid operates as a Primary Care Case Management Program. Most beneficiaries are required to have a PCP, and most services require PCP referral. Beneficiaries that are not required to enroll with a PCP include: Beneficiaries with Medicare coverage Residents of an Intermediate Care Facility for the Mentally Retarded Residents of Long Term Care facilities Beneficiaries on spend down aid categories Retroactive eligible beneficiaries 29

30 Primary Care Physician (PCP) Main Responsibilities Provide health education Assess medical conditions, initiating and recommending treatment or therapy Refer to specialty physicians, hospital care and other medically necessary services Locate needed medical services Coordinate prescribed medical and rehabilitation services with other professionals Monitor the enrollees prescribed medical and rehabilitation services 30

31 Beneficiaries Main Responsibilities Select a PCP (most beneficiaries) Report changes in income or circumstances Report Third Party Liability (TPL) 31

32 Provider Manuals 32

33 Provider Manuals Sections Section I General Policy General information, sources, beneficiary eligibility and responsibilities, provider participation, administrative (and non-compliance) remedies and sanctions, and PCP case management program and required services and activities Section II Provider Manual (varies by provider type) Program or provider specific information, program coverage, prior authorization, reimbursement and billing procedures 33

34 Provider Manuals Sections Section III Billing Information General information, Remittance Advice (RA) and status report, adjustment request, additional or other payment sources, pseudo claims and reference books Section IV Glossary AR Medicaid acronyms and terms Section V Claim Forms Claim forms, AR Medicaid forms, contacts and links 34

35 Provider Manuals Sections Appendix A Update Log Number and release dates for updates Transmittal Letters, Official Notices, RA Messages 35

36 Verify Eligibility 36

37 Verify Eligibility Using the Portal (DDE) 37

38 Eligibility Verification Inquiry Enter NPI. Provider NPI: Taxonomy: Medicaid Provider ID: Address: City: State: Zip Code: Arkansas 38

39 Eligibility Verification Inquiry Recipient Complete one of the following search options: Beneficiary ID and Date of Birth Beneficiary ID, First Name and Date of Birth Beneficiary ID, First Name and Last Name Beneficiary ID, First Name, Last Name and Date of Birth Last Name, First Name, and Date of Birth Search Fields Beneficiary ID: Birth Date: Last Name: First Name: MI: 39

40 Eligibility Verification Inquiry Dates of Service Complete a range of dates on when you expect the service to be rendered. This will determine if the subscriber is covered by Medicaid during this date period. From (required): To (required): 10/01/ /01/2012 Submit Note: Eligibility is date-specific and can only be honored if it was checked on the date of service. 40

41 Eligibility Verification Response Subscriber Eligibility/Service Information Eligibility or Benefit Information 1 (Active Coverage) Coverage Level Code IND (Individual) Service Type Code 30 (Health Benefit Plan Coverage) Insurance Type Code MC (Medicaid) Plan Coverage Description 61 (PW-PL ) Date Time Period Service Type Code 01 (Medical Care) Service Coverage Indicator Y Service Copay $0.00 Service Coinsurance 000 Service Type Code 30 (Health Benefit Health Care Coverage) Service Coverage Indicator Y Service Copay $0.00 Service Coinsurance

42 Eligibility Verification Response Eligibility Verification will give a generic response that will include 13 service types. 1 Medical Care 30 Health Benefit Plan Coverage 33 Chiropractic 35 Dental 47 Hospital 48 Hospital-Inpatient 50 Hospital-Outpatient 86 Emergency Services 88 Pharmacy 98 Professional (Physician) Visit-Office AL Vision (Optometry) MH Mental Health UC Urgent Care 42

43 Eligibility Verification Response Extended Eligibility or Benefit Information includes: Primary Care Physician (PCP) information Third Party Liability (TPL) Benefit Information Waiver Service Eligibility Information 43

44 Verifying Eligibility Provider's Responsibility Although you may search eligibility for past dates, AR Medicaid will only accept proof of verifying eligibility if it was checked on the date of service. Scenario The beneficiary arrives at the office at 8:00 a.m. Your office verifies eligibility at the time of the visit, and the eligibility shows active. At 3:00 p.m., DHS terminates the coverage. If you file your claim after 3:00 p.m., it will deny for no coverage. AR Medicaid will process your claim only if you can provide proof of checking eligibility on the date of service. If you checked eligibility the day before or after, it will not be accepted as proof of verifying eligibility. 44

45 Voice Response Providers can verify a beneficiary s eligibility by calling the automated Voice Response System (VRS). By dialing the Provider Assistance Center line and selecting option 3, the VRS will retrieve beneficiary Medicaid eligibility, PCP and other information. Toll-free in Arkansas Local or out-of-state

46 Plan Descriptions / Aid Categories/ Benefit Limits 46

47 Plan Descriptions Overview All Medicaid beneficiaries are assigned to a plan description with corresponding levels of coverage. These are listed in Section I of the Arkansas Medicaid provider manuals. 47

48 Plan Descriptions General Classifications FR Full benefits MNLB Medically needy, limited benefits AC Additional cost sharing LB Limited benefits 48

49 Plan Description 01 ARKids First-B Beneficiaries must be age 18 and under. Beneficiaries may have limited services. Beneficiaries may have co-payment requirements. ARKids First-B beneficiaries have a co-pay cap. Co-pay cap is 5%, based on the family s total gross income. 49

50 Plan Description 03 Children s Medical Services (CMS) Services must be prior-authorized. This is a non-medicaid category. 50

51 Plan Description 04 Developmental Disability Services (DDS) This is a non-medicaid category. DDS non-medicaid beneficiary ID numbers begin with DDS non-medicaid provider ID numbers end with 86. Only DDS non-medicaid providers may bill for DDS non-medicaid beneficiaries. 51

52 Plan Description *6 Medically Needy Exceptional These beneficiaries are eligible for the full range of Medicaid services except: Nursing Facility Personal Care 52

53 Plan Description *8 Qualified Medicare Beneficiary For QMB beneficiaries, Medicaid pays Medicare premiums, coinsurance, and deductible. If the service provided is not a Medicare-covered service, then Medicaid will not pay for the service under the QMB policy. 18S ARSeniors has full benefits. 53

54 Plan Description 10 Working Disabled Beneficiaries in aid category 10 are part of an employment initiative designed to enable people with disabilities to gain employment without losing medical benefits. Beneficiaries must be ages 16 through 64 and disabled as defined by Supplemental Security Income (SSI). There are two levels of cost sharing in this aid category, depending on the individual s income: 54

55 Plan Description 10 Working Disabled 10 R WD RegCo (Regular Medicaid Cost Sharing) Beneficiaries with gross income below 100% of the Federal Poverty Level (FPL) are responsible for the regular Medicaid cost sharing (pharmacy, inpatient hospital and prescription services for eyeglasses). 10 N WD NewCo (New Cost Sharing) Beneficiaries with gross income equal to or greater than 100% FPL have cost sharing for more services. The cost sharing amounts for the WD NewCo eligibles are listed in a chart that can be found in Section I of the provider manuals. 55

56 Plan Description 58, 78, 88 Specified Low Income Medicare Beneficiary (SLIMB, SMB) Beneficiaries are not eligible for the full range of Medicaid services. Beneficiaries are eligible only for Medicaid payment of their Medicare Part B premium. 56

57 Plan Description 06 Arkansas Health Care Independence Program 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 (eligibility expansion) and are referred to as the newly eligible population. You determine if 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% of the newly eligible population those predicted to have the most medical need and risk the highest costs will be enrolled in the traditional Medicaid Program. Approximately 90% of the newly eligible population will be enrolled in a Qualified Health Plan (QHP). 57

58 Plan Description 06 Arkansas Health Care Independence Program Determining if a Beneficiary is an Arkansas Health Care Independence Program Enrollee The 10% of the newly eligible population placed on traditional Medicaid will receive Medicaid cards and regular Medicaid benefits. The 90% of the newly eligible population that receive coverage through 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. They have Medicaid benefits until their QHP coverage starts. They are limited to the same benefits as a traditional Medicaid beneficiary during the transition period. They still receive non-emergency medical transportation and EPSDT screenings if under 21 (to the extent the service is not otherwise included in the QHP benefit). 58

59 Plan Description 06 Arkansas Health Care Independence Program Determining if a Beneficiary is an Arkansas Health Care Independence Program Enrollee Newly Eligible Enrolled in Traditional Medicaid 59

60 Plan Description 06 Arkansas Health Care Independence Program Determining if a Beneficiary is an Arkansas Health Care Independence Program Enrollee QHP enrollee In Transition BCBS Ambetter QualChoice 60

61 Plan Description 06 Arkansas Health Care Independence Program Determining if a Beneficiary is an Arkansas Health Care Independence Program Enrollee QHP enrollee with active QHP Coverage BCBS Ambetter QualChoice 61

62 Plan Description 06 Arkansas Health Care Independence Program How the Arkansas Health Care Independence Program Affects Medicaid Billing All services will be provided through 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 under age 21 (to the extent the service is not otherwise included in the QHP benefit). Beneficiaries age 19 and 20 receive benefits for Vision and Dental. 62

63 Plan Description 06 Arkansas Health Care Independence Program How the Arkansas Health Care Independence Program Affects Medicaid Billing Newly Eligible Population Enrolled in Traditional Medicaid Will receive Medicaid cards. All claims will be billed to Arkansas Medicaid. Beneficiaries Enrolled in a QHP All claims will be 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 benefits. No is PCP required for beneficiaries in aid category 06 (eligibility expansion) yet. PCPs will be required for 2015 but the start date has not been determined. 63

64 Benefits Overview Arkansas Medicaid administers over 50 programs. Here are just a few of the many benefits available to eligible beneficiaries. Physician services Inpatient hospital Outpatient hospital Lab/X-Ray Prescription Therapy (OT/PT/Speech) Mental health Emergency room Long Term Care Hospice Dentistry (under age 21 and for qualifying aid categories for ages 21 +) Medical equipment 64

65 Benefit Limits Physician Visits Beneficiary age 21 and over 12 visits per state fiscal year (SFY) Under age 21 not subject to benefit limit Consults beneficiary can receive two consults per SFY regardless of age (Note: Beneficiaries under age 21 in the Child Health Services (EPSDT) Program are eligible for extensions of the physician consultation benefit if the extension is medically necessary.) See Section II of the Physician manual. 65

66 Benefit Limits Physician Visits The following are included: Physician services in the office, patient s home or nursing facility Rural Health Clinic (RHC) encounters Medical services provided by a dentist Medical services furnished by an optometrist Certified nurse-midwife services Advanced nurse practitioner services 66

67 Benefit Limits Prescription Coverage Beneficiary age 21 and over three per month (without extension of benefits) Under age 21 are not subject to prescription drug limit See Section II of the Physician manual. 67

68 Benefit Limits Lab and X-Ray Services Outpatient laboratory and radiology services and machine tests: Beneficiary age 21 and over $500 per SFY Under age 21 no benefit limit See Section II of the Physician manual. 68

69 Benefit Limits Lab and X-Ray Services The following are not included: Family planning Emergency services MRIs Cardiac catheterization 69

70 Benefit Limits Inpatient Hospital Beneficiary age 21 and over 24 days per SFY Under age 21 no benefit limit Rehabilitative hospital inpatient services See Section II of the Hospital manual. 70

71 Benefit Limits Outpatient Hospital Beneficiary age 21 and over 12 non-emergency outpatient hospital visits per SFY Under age 21 no benefit limit Outpatient hospital and rehabilitative hospital services therapy / treatments services are included in the non-emergency outpatient hospital services Excludes ER services See Section II of the Hospital manual. 71

72 Benefit Limits Pregnancy Two ultrasounds per pregnancy Two fetal non-stress tests per pregnancy See Section II of the Physician manual. 72

73 Benefit Limits Vision Beneficiary age 21 and over one exam and one pair of glasses every 12 months excluding replacement or repairs Beneficiary under age 21 one exam and one pair of glasses every 12 months (not including replacement or repairs) One visual prosthetic device every 24 months from the last date of service See Section II of the Visual Care manual. 73

74 Submitting Claims 74

75 Ways to Submit Claims Paper Direct Data Entry (DDE) Provider Electronic Solutions (PES) Vendor Software 75

76 WebRA 76

77 Arkansas WebRA Overview Remittance Advices (RAs) are in a PDF format, referred to as WebRAs. Effective July 2011, all providers should be retrieving WebRAs from the Arkansas Medicaid website. 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. 77

78 Claim Status 78

79 Claim Status Claim Adjudication Cycle 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. 79

80 Claim Status Five Ways to Check Claim Status Verify claims on the remittance advice PES software Medicaid website VRS Provider Assistance Center or

81 Passwords 81

82 AR Medicaid Passwords Use and Requirements Applications Provider Portal Submitter ID WebRA PES password Submitter ID in PES AMII 82

83 Provider Portal The Arkansas Medicaid Provider Portal is the gateway to most online tools for providers. From the Portal, providers can: Verify eligibility Submit claims View Remittance Advices Review caseload data (for PCPs) Report or change NPI information Reverse claims Provider Portal passwords do not expire. 83

84 Provider Portal Click Provider. First-time visitors will enter the provider s Medicaid ID number for the User ID and the associated Tax ID or SSN for the Password. You will be prompted to change the password. Initial password is your Tax ID or your SSN New password is a minimum of 8 alpha and numeric characters 84

85 Submitter ID Submitter IDs let you do business electronically with Arkansas Medicaid Providers must obtain a Submitter ID and password to conduct business with Arkansas Medicaid electronically outside of the Provider Portal. Whether you submit claims and verify eligibility through the Provider Electronic Solutions software or through a vendor system, you will need a Submitter ID and password. 85

86 Submitter ID Getting Your Submitter ID for New PES Users 1. Click Provider, HIPAA, and New Submitters Registration. 2. Click the New Submitter Registration Form link. 3. Complete the New Submitter Registration Information form. Click NEXT. 4. Select a question and complete the answer for Security Questions until you complete five questions and answers. Click NEXT. 5. Enter your billing provider 9-digit Medicaid ID number. 6. Click ADD. Click NEXT. 7. Enter the number of submitter IDs you want, click FINISH and PRINT THIS PAGE showing your MC number. 86

87 Submitter ID Getting Your Submitter ID 1. Click VIEW PASSWORD to view your Temporary Password (example: Abc!23De). PRINT this page. 2. Create a new secure password. Click HIPAA, then click Submitter Self Service Area. 3. Enter your submitter ID (example: MCXXXXXX) and your temporary password and click LOG IN. 4. Click Change Password tab. 5. In the New Password field, enter your new secure password. In the Confirm Password field, re-enter your new secure password. Click Submit. 87

88 Submitter ID Submitter ID 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 Passwords will be locked after 90 days if there are no changes, requiring the provider to contact EDI for assistance. Starting at 60 days, you will get an alert to change your password. 88

89 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. 89

90 WebRA Password Registering and Receiving and 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. 90

91 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. 91

92 Provider Electronic Solutions (PES) Software Setting a New PES Password Password requirements: Enter HP-pes as the initial password. Set a new password after the initial login. Passwords are not case-sensitive. Password can be any combination of alpha, numeric, and special characters. A password must have at least 5 characters but no more than 10 and can be reused. PES passwords must be updated at least every 99 days. You can use the same password. 92

93 PES and the Submitter ID TOOLS/OPTIONS/BATCH PES 2.12 and greater users must key their Submitter ID and new secure password in the Web Logon ID and Web Password fields located on the Batch tab. NOTE: The password that you enter to open the PES software is not affected by these instructions; you will continue to use your existing password to open the PES software. 93

94 Arkansas Medicaid Information Interchange (AMII) Quarterly Provider Reports for PCPs The AMII section of the Provider Portal offers PCPs special reports on their participation and clients under their care. The reports include: Caseload information Cancer screenings Diabetes screenings Beneficiary screenings 94

95 AMII Password Requirements Click Provider, log in to the Portal, and select AMII in the Available tools menu. Please read the disclaimer in the text box. Check the box I accept terms and conditions. Minimum of 8 characters up to 32 Contain at least 1 uppercase alpha character Contain at least 1 lowercase alpha character 95

96 Your passwords are your responsibility. Keep them safe. Log them in a password-protected spreadsheet for easy access!

97 Forgotten Passwords If you need assistance with any of these passwords, please contact HP s EDI helpdesk. Monday through Friday (8 a.m. 5 p.m.) Toll-free in Arkansas , Extension 300, Option 1 Local or out-of-state , Extension 300, Option 1 97

98 Billing Tips 98

99 Billing Tips Steps to locate your MC number: 1. Open the PES software. 2. Select Tools. 3. Select Options. 4. Select the Batch tab. 5. Print. 99

100 Billing Tips Claims denying/rejecting for the lack of FP modifier - When the service is a sterilization claim, the FP modifier is used for AID categories other than 69. If you are using diagnosis code V25.2, use the FP modifier. Claims denying/rejecting for the lack of a prior authorization code Enter the PA code in the Prior Authorization field. Entering a CLIA code in the PA field will also cause this error. 100

101 Billing Tips 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 101

102 Billing Tips Paper Claims When submitting CMS-1500 paper claims, verify the Arkansas Medicaid provider numbers are in Boxes 17a, 24j, and 33b. NPI is not submitted on paper claims When submitting CMS-1450 UB04 paper claims Box 57 Enter the Arkansas Medicaid provider number. Box 76 Enter 0B and the attending provider s state license number. Box 78 Enter 0B and the PCP s state license number (if a PCP referral is required). Medicare / Medicare Advantage plan pays claim Submit the Medicare/Medicaid crossover form. Medicare / Medicare Advantage plan denies claim Submit UB04 CMS-1450 or CMS-1500 with the Medicare denied EOB and an attached cover letter explaining Medicare or the Medicare Advantage plan denied the claim. 102

103 Billing Tips Denied Claims If a claim is denied because documentation is needed (for example, op report, history and physical), providers must resubmit with an original red and white claim form and attach all required documentation. If only the documentation is sent, the documentation will be returned to the provider. If a PCP referral is required for the service billed and the beneficiary is seen by a physician that is not their PCP, but the physician is in the same group as the PCP, the physician still has to file with the PCP as the referring doctor on the claim for the claim to pay. 103

104 Billing Tips Rejected Claims 1. Claim rejects for 3760 and 2290 Provider not on file or cancelled and No crosswalk from legacy number to NPI (billing provider) Make sure the NPI is reported to Arkansas Medicaid, you are using the correct taxonomy and the physical address and ZIP code are correct. 2. Z260 TPL company code/name is missing or invalid Make sure you are sending the 2- or 3-digit carrier code. Arkansas does not accept any 4-digit codes. Carrier codes are on the Medicaid website under provider/carrier codes. 3. XML NOT RETURNED IN RESPONSE OF SEND UPLOAD/HTTP Request has been opened/upload of the file failed. Make sure you are using the latest version of PES or make sure there are no (& or /) characters anywhere in the batch. 4. Network timeout on eligibility or nursing home census Not on the current version of software. Provider needs to upgrade and use batch submission for these transactions. 104

105 Billing Tips PES Software / WebRA Issues 1. Changing password for the PES web submission when expired The provider will have to call EDI to unlock the account. Once EDI unlocks the account, the provider will go to Medicaid website to change their password. Providers will need to know their MC number when calling EDI. 2. Able to log in to the Provider Portal but not WebRA Click on forgot password to set a new password. 3. Provider lock out of WebRA Provider will have to wait 30 minutes for password reset and then click on forgot password and set a new password. 4. Provider logs into WebRA but no files available Provider does not have any RAs for the 5-week period. 105

106 Billing Tips Upgrading PES Before a provider upgrades their PES software, they need to make a copy of their database file. 1. Find the location where PES files are stored. The default location is c:/arhipaa. 2. Copy the entire arhipaa folder. Copy to a disk or another folder on the hard drive. Rename the arhipaa folder (example: backup arhipaa). If the folder is not renamed, it will not be saved on the hard drive. Saving this folder is a precaution method in case the upgrade fails and all files are lost. 3. Download the upgrade from the Medicaid website and save the file in the upgrades folder located in the arhipaa folder: 4. Upgrade the software. Start / All Programs / AR EDS or HP Provider Electronic Solutions / Upgrade 106

107 Billing Tips Claims billed with a Co-Surgeon or an Asst. Surgeon need a Prior Authorization. (Section and of the Physician manual) Check eligibility, including supplemental eligibility, on the DATE OF SERVICE not before or after. Assigning or changing a PCP Connect Care The State will not allow an HP associate to tell you what code to bill with; we are not licensed coders. Providers must find their procedure and diagnosis codes in the following: ICD-9 code book, CPT code book, or the Arkansas Medicaid manuals. 107

108 Billing Tips A True ER does not need a PCP referral. However, if it is not a True ER and the PCP doesn t give a referral, Medicaid will not pay for the visit. If the patient is told it is not a payable service by Medicaid, and it would be self paid visit, you can charge the patient if the patient elects to have the service preformed. Can you bill the patient for a co-pay? This is at the State for review. Continue to follow your office policy until further notice from the State. You should be at PES You can check claim status on PES. It s easier and faster to check eligibility on the Medicaid website. Please print out the eligibility and the supplemental eligibility. Extension of benefits - Section of the Physician manual 108

109 Billing Tips Most Common Billing Errors EOB Code Error Method of Correction 254, 263 and 267 Recipient is partially or totally ineligible for the DOS. Verify the recipient is eligible for all claim dates of service. Resubmit the claim/portion of the claim for the time of eligibility. 282 and 284 Recipient has Medicare coverage. Bill Medicare first. Submit crossover claim to Medicaid after Medicare adjudication. 208 Recipient aid category 69 is limited to family planning services only. 252 Medicaid ID number submitted does not match patient s name on Medicaid ID card. Verify that the original claim has a family planning diagnosis, procedure code. Correct and resubmit the claim. Verify eligibility through Medicaid s electronic eligibility system and resubmit the claim with correct information. 109

110 Billing Tips Most Common Billing Errors EOB Code Error Method of Correction 792 or 900 Ten days post-op care is included in the payment for the surgical procedure. Pricing of this procedure includes services. A related service has been paid preventing payment of this code. 900 venipuncture Pricing of this procedure includes related services. A related service has been paid preventing payment of this code. 469 or 470 Duplicate billing. Claim is identical to another claim for DOS, performing provider, procedure, TOS, and price. Post-op care claims filed after surgery will deny correctly with EOB 792. No additional payment is made. An adjustment must be filed to bill the surgery if post-op care is paid before the procedure is billed. Venipuncture is included in lab work when performed on the same DOS by the same provider. An adjustment must be filed to bill for lab work if venipuncture has been paid. Verify that the service is not a duplicate bill. Resubmit the corrected claim. 110

111 Billing Tips Most Common Billing Errors EOB Code Error Method of Correction 103 and 009 Claim does not meet the timely filing requirements for Medicaid. 952 Service requires Primary Care Physician referral. 041 and 152 Procedure code, revenue code, modifier is invalid. Claims must be received by HP Enterprise Services within 12 months from the from DOS. Claims received beyond this deadline will not be paid. Claims for global services (i.e., claims for prenatal, delivery, and antepartum care) must be received 12 months from the date of delivery. Resubmit the claim with the corrected PCP information required for adjudication. Verify the procedure code and/or modifier in Section II of the appropriate provider manual and resubmit the claim. 111

112 Billing Tips The adjustment claim form HP-AR-004 is used to adjust or void claims that have been PAID to the provider. When Medicare denies a claim for lack of medical necessity with denial codes CO-50 or PR-50, Medicaid will not make a payment. Details are found in Provider Enrollment Contract in Section G. 112

113 Billing Tips Condition Codes *Inpatient paper claims must not use new condition codes 80, 81, or 82. Continue to use condition codes AB, AN or AX. Old/paper* Electronic 80 (EPSDT) A1 AB 80 AN 81 AX 82 Emergency (101)

114 Timely Filing Medicare/Medicaid Crossover Claims and Claims with Retroactive Eligibility (Pseudo Claims) 114

115 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: Claims for services provided to beneficiaries with joint Medicare/Medicaid eligibility. Adjustment requests and resubmissions of claims previously considered. Claims for services provided to individuals who acquire Medicaid eligibility retroactively. 115

116 Timely Filing Medicare/Medicaid Crossover Claims Federal regulations dictate that providers must file the Medicaid portion of claims for dually eligible 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 after notice of the disposition of the Medicare claim. Providers may not electronically transmit any claims for dates of service over 12 months. 116

117 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 beneficiary 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 beneficiary 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. 117

118 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

119 HP Enterprise Services Provider Assistance Center (PAC) Your first point of contact for billing, claim status, and other general questions is the Provider Assistance Center: Monday through Friday (8 a.m. 5 p.m.) Toll-free in Arkansas Local or out-of-state Please Note: Provider Assistance no longer verifies eligibility. 119

120 Questions 120

121 Thank You 121