KENTUCKY SPRING 2010 TARGET CASE MANAGEMENT MEDICAID WORKSHOP

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1 KENTUCKY SPRING 2010 TARGET CASE MANAGEMENT MEDICAID WORKSHOP 1

2 2 Agenda How Medicaid Works Reference List Communications Aspects of Electronic Billing 5010 Websites available Going Green with Remittance Advices Member ID s Billing Scenarios Points to Remember Top Denials Questions Evaluation

3 How Medicaid Works CMS Department for Medicaid Services Medicaid Policy/Enrollment Local DCBS office HP Enterprise Services Department for Medicaid Services (DMS) and Medicaid Policy enforces the rules and regulations that were designed by Legislation. SHPS 3 The Local DCBS office enrolls members who apply according to the rules and regulations. HP Enterprise Services, the KYMMIS contractor, can only process claims according to the rules and regulations that Medicaid has designed. HP Enterprise Services has the prior authorization contract, but SHPS who is the subcontractor for HP Enterprise Services, can only issue prior authorizations according to the rules and regulations that Medicaid has designed.

4 Representative List Brenda Orberson Adair Allen Barren Boyle Casey Clinton Cumberland Estill Green Jackson Laurel Lincoln Madison McCreary Metcalfe Monroe Pulaski Rockcastle Russell Simpson Warren Wayne Whitley Penny Germinaro Bell Breathitt Boyd Carter Clay Elliot Greenup Floyd Harlan Johnson Knott Knox Lawrence Lee Lewis Leslie Letcher Martin Magoffin Morgan Owsley Perry Pike Rowan Vicky Hicks Bath Bourbon Clark Fleming Fayette Garrard Jessamine Menifee Mercer Montgomery Nicholas Powell Wolfe Woodford 4

5 Representative List Leigh Ann Hayes Boone Bracken Campbell Carroll Gallatin Grant Jefferson Kenton Pendleton Oldham Owen Trimble Kristy Cabell Anderson Ballard Breckinridge Bullitt Butler Caldwell Calloway Carlisle Christian Crittenden Daviess Edmonson Franklin Fulton Graves Grayson Hancock Hardin Harrison Hart Henderson Henry Hickman Hopkins Larue Livingston Logan Lyon Marion Marshall Mason Mccracken Mclean Meade Muhlenberg Nelson Ohio Robertson Scott Shelby Spencer Taylor Todd Trigg Union Washington Webster 5

6 Phone Numbers Reference List Departments EDI Helpdesk HP Provider Billing Inquiry Provider Enrollment Member Services Passport Fraud Medicaid Policy Web addresses Departments KY Medicaid Regulations, Provider updates, Provider Enrollment HP Website KyHealth Net Forms, Workshop updates, Billing Instructions, KyHealth Net guide, Provider Directory Immediate claim adjudication, Member Eligibility, Claim status PA, and RA s. 6

7 Communications Departments HP Provider Inquiry Claim status, denials, RA s, any billing questions, member eligibility, PA s and limitations. (for providers only) EDI Helpdesk Provider Field Representative Medicaid Policy Medicaid Provider Enrollment Local DCBS office Member Services Electronic billing, electronic RA s, PIN #, and password reset. Provider Workshops, training, one on one provider visits, mini-workshops, association meetings, teleconferences and escalated problems. (not for claim status and for providers only) Questions concerning coverage, rate and regulations Questions or updates to the provider file, such as: NPI/Taxonomy, updating address, EFT s and enrollment of providers. Eligibility updates Question on member files, such as: program code information and member eligibility. (for providers and members) 7

8 Communications Department for Medicaid Services uses the following publications and tools to communicate information to providers: RA Banner Message board KyHealth Net main page Provider Letters All Websites Provider Representatives 8

9 Aspects of Electronic Billing All claims submitted via paper or electronically appear in the claims inquiry area of the KyHealth Net. Claims submitted via 837 or KyHealth Net are processed faster because manual intervention is not required. KYMMIS Website holds DDE User Manuals and Companion Guides for requirements providers must follow for proper claim submission. Provider may view, adjust and void paid claims and resubmit denied claims. This functionality is available for all claims submitted. 9

10 5010 The format you use to submit 837 transactions to health insurance carriers will be upgraded in the coming months. The Centers for Medicare and Medicaid Services (CMS) are switching from the Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 and from National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version D.0. This will be fully implemented by January 1, Please contact your vendors and clearinghouses to be sure they are compliant before January 1, More information will be forthcoming for changes specific to Kentucky Medicaid. 10

11 Medicaid s Website Kymmis Website Regulations Provider Directory 11

12 KYMMIS Website KyHealth Net Claims Submission/Information Member Information Provider Directory Billing Instruction, Forms and Workshop Updates Letters and Notifications 12

13 KyHealth Net Website 13

14 KyHealth Net Website Home Page Discontinue Paper RA Resume Paper RA 14

15 RA Viewer View weekly RA 15

16 RA Viewer 16

17 Remittance Advice Available on the pay-to provider RA viewer of the KyHealth Net. Available prior to receipt of the hard copy version. Even if the provider has opted out of receiving paper RAs, RAs will be available on the KyHealth Net for six months. To obtain RAs older than six months, providers may contact Provider Inquiry. RAs on the KyHealth Net are image files of the paper RAs. 17

18 Format for larger print on RA Choose Image Options Enlarge to 125 Choose Preferences Click Ok, Then print 18

19 Member ID s Use Current ID 19

20 Billing Scenarios The Member s Medicaid ID is entered in field 9a of the CMS 1500 claim form. Medicaid does not review field 1a. 20

21 Billing Scenarios The Rendering NPI in field 24j, must be the same NPI billed in field 33a. 21

22 Points to Remember Fields 11, 11c and 29 are used for Commercial insurance payments only. If a TPL (Commercial insurance) denies or does not pay money, leave these fields blank. TPL claims- When a payment is received from a commercial insurance, the claim may be billed electronically. The money received must be entered on the claim, (no contractual amount). When no money is received from a commercial insurance the claim must be billed on paper with the EOB attached to the back of the claim. When TPL makes payment on all charges submitted on the CMS 1500 claim form: Medicaid will calculate the Medicaid allowed amount per line. The TPL payment is then applied to the claim per detail until the TPL payment has been applied in its entirety. When TPL pays several lines of the CMS 1500 claim form but denies other lines: Two claims are billed. The first claim must hold lines paid by the primary carrier and carrier paid amount in field 29. The second claim must hold all charges denied by the primary carrier. Bill by paper with the denial EOB attached. 22

23 Points to Remember Adjustments and Voids can only be done on Paid claims. If the claim has denied, it must be resubmitted. Adjusting Paid Claims on KyHealth Net. Select the claim to adjust. Once changes are made, select the Adjust button. Once the steps have been completed, the new claim and ICN will display. Refer to the information at the top of the page to see how your new claim processed. Voiding Paid Claims, choose the claim to void and select the Void button. To verify the status or research the history of your Void, use the claim search functionality from the Claims Inquiry tab to locate the original claim. The diagnosis cross reference must be billed on all claims. One digit field of either a 1, 2, 3, or 4. 23

24 Points to Remember For Medicare primary claims If Medicare denies a services, that service is billed on a separate claim than allowed amount from Medicare. Medicaid then becomes primary. If a Medicare crossover claim is billed paper, attach the Medicare coding sheet, which includes Medicare Replacement Policies. Medicare Replacements do not cross electronically. Member Program Codes to watch for: Z-QMB Only-Medicaid only allows after Medicare, so if Medicare denies, Medicaid will deny. ZJ, ZL, ZQ Buy-In Member-Medicaid is only paying the Medicare Premiums. No claims coverage. If a claim is suspended, do not rebill the claim. A claim must be in a paid or denied status before further action can be taken. 24

25 Top Denials EOB 0102 Timely filing All timely filing claims must be billed on paper with documentation attached behind the claims showing proof. EOB 0465 Member has other medical coverage Medicaid is payor of last resort, always bill the commercial insurance first. The commercial insurance information will be given on the RA and KyHealth Net. EOB 2003 Member not eligible on dates of service Verify the member s eligibility either from KyHealth Net or voice response. Use the member s current ID submitting claims. 25

26 Top Denials EOB 0121 This service not payable for QMB only members Program code of a Z, Medicaid will allow the charges after Medicare. If Medicare denies, Medicaid will deny. EOB 0260 Buy In - Program codes of ZJ, ZL and ZQ, the member does not have claims coverage. 26

27 True or False A claim must be billed paper when a commercial insurance pays providers. True or False Member s ID is entered in field 1a. True or False Claim denied for timely filing, resubmit electronically. True or False Claim is in suspense, wait before you bill again. True or False Void a denied claim. True or False 27

28 Questions? 28

29 29

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