Overview on Claims Submission Requirements, Electronic Billing Options, and Provider Website Features

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1 Overview on Claims Submission Requirements, Electronic Billing Options, and Provider Website Features Magellan Direct Submit Electronic and Contracted Claim Submission Clearinghouses Webinar Session for and Nebraska Tracking Providers July 2013

2 Today s Agenda Welcome! (Christine Cole, NE Network Provider Relations Liaison) Claims Submission Requirements (Christine Cole and Tracey Alfaro, Sr. Network Manager for Implementations) Electronic Claim Submission Options and Tracking Magellan Direct Submit, Contracted Clearinghouses, and Claims Courier (Aimee Thatcher, Sr. Systems Analyst and Teresa O Connor, Lead Systems Analyst) Magellan Provider Website Claims Features and more (Melissa Siesener, Reference Systems Analyst) Wrap-up Contact Information and Q & A (Christine Cole) 2

3 Claims Submission Requirements Beginning on September 1, 2013

4 Claims Submission Procedures All claims relating to mental health and/or substance use disorder services provided on behalf of Managed Care members are processed and paid by Magellan beginning on September 1, We strongly encourage all providers to submit claims to Magellan electronically via Claims Courier on our provider website, EDI Direct Submit, or a Clearinghouse. For more information, visit the Getting Paid/Electronic Transactions section on the Magellan provider website at Submit all claims (paper and electronic) to: Magellan Behavioral Health P.O. Box 2008 Maryland Heights, MO

5 Claim Tips Claims with CPT or HCPCS procedure codes should be submitted electronically on a 837P (Professional) file or paper claim form CMS-1500 Claims with Revenue codes should be submitted electronically on a 837I (Institutional) file or paper claim form UB-04 Hints for claim completion: Give complete information on the member (name, address, DOB) Give complete provider information (TIN, Individual provider name and degree, rendering provider name and address, billing pay to provider name and address, National Provider Identifier [NPI] number for both the rendering and billing provider) Attach primary carrier s Explanation of Benefits Include all HIPAA-compliant diagnosis codes (ICD-9 required) Include the appropriate billing modifier (where applicable) Submit claims prior to the timely filing deadline 5

6 Claim Tips (continued) Top reasons for claim rejection/denials: Missing or invalid CPT/HCPCS/Revenue code Missing or invalid diagnosis code Missing or inaccurate place of service code Missing name and/or degree level of provider Missing or invalid NPI (for rendering provider and pay to provider) Claims submitted past the timely filing deadline 6

7 Timely Filing All claims for covered services provided to Managed Care members must be received by Magellan in accordance with the following timelines, within 180 days from date of service for most levels of care, except as provided below: Within 180 days from date of discharge for 24-hour levels of care Within 180 days of the last day of the month or the discharge date, whichever is earlier, when billing monthly for longer-treatment episodes of care at a 24-hour level facility Within 180 days of the claim settlement for third party claims. This date is based on the date of the other carrier s EOB, which must be attached to the claim you submit to Magellan. If Magellan does not receive a claim within these timeframes, the claim will be denied for payment. 7

8 Resubmission of Claims Claims with provider billing errors are called Resubmissions Resubmitted claims must be received by Magellan within 180 days of the date on Magellan s explanation of benefits Resubmitted claims can be sent electronically via an 837 file. There is a specific indicator for an adjusted claim (please consult Magellan s EDI companion guide or the EDI hotline for assistance). When re-submitting on paper, the claim must be stamped resubmission (or otherwise noted on box 22 of Form CMS-1500), and include: The date of the original submission The original claim number (if applicable) 8

9 Third Party Liability Medicaid is always the last payer; therefore providers must exhaust all other insurance benefits first, before pursuing payment through Magellan for Managed Care members. Claims for services provided to members who have another primary insurance carrier must be submitted to the primary insurer first in order to obtain an explanation of benefits (EOB). Magellan will not make payments if the full obligations of the primary insurer are not met. As a Magellan provider, you are required to hold members harmless and cannot bill them for the difference between your contracted rate with Magellan and your standard rate. This practice is called balance billing and is not permitted. 9

10 Proper Claims Forms and Codes For the proper procedure code and/or modifier(s) to use for claims, consult your Magellan agreement and reimbursement schedules. Claim form CMS-1500 or UB-04 should be used if submitting claims on paper. For more information, please see Paper Claim Forms and Elements of a Clean Claim in the Getting Paid section which is available on Magellan s provider website at 10

11 Claims Review Upon receipt of a claim, Magellan reviews the documentation and makes a payment determination. As a result of this determination, a remittance advice, known as an Explanation of Payment (EOP) or Explanation of Benefit (EOB) is sent to you. The EOP/EOB includes details of payment or the denial. It is important that you review all EOP/EOBs promptly. If you have questions about EOP/EOBs or claims submitted for Managed Care members, contact Magellan at and select prompt for claims inquiry. 11

12 Eligibility Verification Authorization for service is based on eligibility at the time of the treatment request and does not guarantee payment. Providers are responsible for verifying a member s eligibility for Managed Care coverage: Prior to the first appointment, Throughout the course of treatment, and Prior to submitting claims. Providers may check member eligibility by: Call Nebraska Medicaid Eligibility System (NMES) at Online using the Medicaid Client Eligibility Verification (RFS6) system or Magellan Provider Website after secure login Check Member Eligibility Call Magellan at

13 Provider Medicaid Enrollment All providers must be credentialed and contracted with Magellan (excluding organizational roster staff as the organization locations are credentialed). All providers must be enrolled in the Nebraska Medicaid Program and obtain a provider Medicaid ID in order to provide behavioral health services to Managed Care members. This includes any group members and organizational roster staff that will be providing services to Managed Care members. All providers must maintain their Medicaid provider enrollment and submit updates to the Nebraska Medicaid Program in order to have your claims submissions processed and paid. Moving/Address Change Expanding to a New Location New Member Joining or Leaving Your Group Practice or Organization New Federal Tax ID Number (FTIN) For provider enrollment information, please go to the state website at 13

14 National Provider Identifier (NPI) Numbers The National Provider Identifier (NPI) is a 10-digit identifier required on all HIPAA standard electronic transactions (also required for billing on paper claim forms) There are specific fields on the paper claim forms and electronic file that you should indicate the rendering provider NPI and pay to provider NPI An NPI does not replace a provider s TIN; TINs continue to be required on all claims paper and electronic The NPI is for identification purposes, while the TIN is for tax purposes Important: claims that do not include a TIN will be rejected You can find more information on NPI on the Magellan Provider Website at and go to the Getting Paid section under Electronic Transactions. 14

15 Claims Submission Procedures Specific to the NPI For claims submitted via the ASC X12N 837 professional health care claim transaction, place the Type 2 NPI in the provider billing segment, loop 2010AA; and the Type 1 NPI in loop 2310B. On the CMS-1500 paper form (version 08/05), insert the main or billing Type 2 NPI number in Box 33a. Insert the service facility Type 2 NPI (if different from main or billing NPI) in Box 32a. Group providers only must also insert Type 1 NPIs for rendering providers in Box 24J. On the UB-04 form, insert the main Type 2 NPI number in Box 56. For claims submitted to Magellan s website via Claims Courier: Organizations/ Facilities should complete the Billing/Pay-To Provider Information section using the NPI number associated with the rendering service location. Individual providers should complete the Billing/Pay-To Provider Information section with their own type 1 NPI number. The individual s NPI number should be entered in that section only. Group providers should complete the Billing/Pay-To Provider Information section with the Group s type 2 NPI number. The Rendering Provider Information section should be completed using the rendering provider s type 1 NPI. 15

16 The CMS-1500 Claim Form DX Code (field 21/Diagnosis) Place of Service Code (field 24B/Place of Service) CPT/HCPCS Code (field 24D/CPT/HCPCS) NPI (field 24Jb/Rendering Provider ID, 32a /Service Facility Location & 33a /Billing Provider Info) Name & Degree Level of Provider (field 31/Signature of Physician or Supplier) 16

17 The UB-04 Claim Form DX Code (field 67/Primary Diagnosis) NPI (field 56/Facility & 76/Attending) Name & Degree Level of Provider (field 76/Attending) 17

18 Electronic Claim Submission And Tracking

19 What s in it for Providers? Improved Efficiency No paper claims. No envelopes. No stamps. Prompt confirmation of receipt or incomplete claim Faster Reimbursement cut out the mailman Improved Quality Up-front electronic review ensure higher percentage of clean claims Magellan staff do not re-key information from paper claim, eliminating human error Secure process with encryption keys, passwords, etc. 19

20 Electronic Claim Submission Options Magellan Direct Submit and Contracted Clearinghouses for medium to high-volume submitters

21 1. Claims Clearinghouses Act as a middleman between the provider and Magellan, and can transform non-hipaa compliant to X12N compliant 837 Magellan accepts 837 Professional and 837 Institutional transactions from the following Clearinghouses: PayerPath (Allscripts) Capario Availity Emdeon Business Services RelayHealth Gateway EDI Office Ally IGI Healthcare It is critical that the proper Payer ID is used so claims are sent to Magellan: The following payer unique Payer IDs are required for all Clearinghouses; except Emdeon: 837P and 837I: The following unique Payer IDs are for Emdeon only: 837P: I: 12X27 Note that there may be charges from the clearinghouses 21

22 2. Direct Submit Primarily for high-volume claim submitters, but there is no minimum number necessary for submission Tests X12N 5010 HIPAA-compliant 837 files to be sent directly to Magellan Magellan offers providers the EDI Direct Submit testing application, which is an electronic claims tool available on an EDI-dedicated Web site at EDI Assistance Hot Line ext and Direct Submit streamlines the process by eliminating the middleman No charge to the provider 22

23 Magellan Transactions ASC X12N/005010X223A2 Health Care Claim Institutional 837 ASC X12N/005010X222A1 Health Care Claim Professional 837 ASC X12N/005010X279A1 Health Care Eligibility Benefit Inquiry and Response 270/271 ASC X12N/005010X217E2 Health Care Services Review Request for Review and Response 278 ASC X12N/005010X212E1 Health Care Claim Status Request and Response 276/277 ASC X12C/005010X231A1 Implementation Acknowledgement for Health Care Insurance 999 ASCX12N/005010X214 Health Care Claim Acknowledgment 277CA ASC X12N/005010X221A1 Health Care Claim Payment/Advice

24 EDITS Magellan uses EDIFECS Xengine for editing; there are four levels of edits 1. The TA1 Response Shows the envelope information and format of the file was accepted or rejected 2. The 999 Response Verifies the HIPAA edits 3. Companion Guide Edits The Magellan specific required edits. Only rejected claims will be reported back on a The Host Claims Edits These are claim edits for Eligibility and provider information. All claims sent to the host system will receive a status of accepted or rejected on a

25 CAPACITIES AND LIMITS Unlimited amount of files with unique control numbers Magellan requests submitters to limit files to 5000 claims per file HIPAA X standard limits the maximum number of claim lines per claim to 99 for the 837I transaction and 50 claim lines per claim for the 837P transaction. EDI SUPPORT CONTACT EDI Assistance Hot Line ext

26 Testing Center Capabilities The Submit EDI Claims application on the Web is available to Magellan providers and trading partners. It allows providers to send ANSI X12N 5010 HIPAA transaction files directly to Magellan and receive ANSI X12N 5010 responses from Magellan without the use of a clearinghouse. The software from EDIFECS, Inc. of Bellevue, WA, allows providers to self-enroll by creating a unique user ID and password, download EDI guideline documentation, upload ANSI X12N 5010 test files, and obtain immediate feedback regarding the results of the validation test. This tool allows providers the opportunity to independently validate their EDI test files (837 X12N 5010 Professional and 837 X12N 5010 Institutional) for HIPAA compliance rules and codes. Files sent to Magellan will be validated, and when production certification is granted, the user will be permitted to submit production claims files and receive responses. 26

27 Testing Center Capabilities (continued) This Web-based testing application is easy to follow and consists of a six step process. You will be assigned an IT analyst to guide you through the process and address any questions. Our providers typically take about 3 to 4 weeks to complete the process, so allow ample time to complete your independent testing so that you can enjoy the benefits of claims direct submission. The following slides walk through the screenshots you will see as you move through the process. Go to to start the process. 27

28 28 Magellan EDI Testing Center Welcome Page

29 29 Task 1 - Download Companion Guide & FAQ s

30 30 Task 2 - Complete the EDI Survey

31 31 Task 3 Magellan Internal Review of Survey

32 32 Task 4 - Upload and Validate 1st EDI Test File

33 33 Task 5 - Upload and Validate 2nd EDI Test File

34 34 Task 6 - Are You Ready for Production Status?

35 CONGRATULATIONS!! Once you have completed the six step process, you ll be ready to exchange production-ready EDI files with Magellan. If you have any questions about the process, please contact and ext

36 3. Claims Courier Claims Courier (Submit a Claim Online) is a Web-based data entry application for providers submitting professional claims on a claim-at-a-time basis Accessible after sign-in on Magellan s provider Web site. Claims Courier streamlines the claims process by eliminating the middleman No charge to the provider 36

37 Electronic Remittance Advice (ERA) Electronic Remittance Advice means receiving remittance data in an electronic form, such as the HIPAA X You have 2 options to sign up for ERA or 835: Work with an EDI analyst during Direct Submit set-up/testing phase to request Completing the ERA Registration Form and sending it to the Clearinghouse you selected to contract with Please fax the completed form to one of the clearinghouses. (Note, for Availity, you must register online at In order to receive electronic claims remittance, you must have a W-9 and a National Provider Identifier on file with Magellan, and be the owner of the Taxpayer Identification Number (TIN) under which claims are paid. 37

38 Electronic Funds Transfer (EFT) Providers can take advantage of Magellan s online feature -- Electronic Funds Transfer (EFT) -- for claims payments. You can request to have certain claims payments directly deposited to your business bank account. EFT is quicker than the standard process of mailing and cashing or depositing a check, leaving you more time to devote to your practice. EFT is available to organizations, group practices and individual providers who own the Taxpayer Identification Number (TIN) linked to the submitted claim. Individual providers within an organization or group practice are not able to receive EFT claims payment. 38

39 Registering for EFT To register for EFT, simply complete and submit the registration form. To access the EFT registration form: Enter your username and password in the Sign-in box on the Magellan provider webpage From your MyPractice page, click Display/Edit Practice Information Click Electronic Funds Transfer Click Add to enter your information Click Save to submit your EFT registration. Upon clicking you will see a confirmation page that you can print for your records. After registering for EFT, Magellan will conduct a transmission test with your bank to make sure payments are transferred properly. During this time, you will continue to receive paper checks via U.S. mail. 39

40 Using EFT Once you begin to receive EFT payments, you will no longer receive an Explanation of Payment (EOP) or Explanation of Benefits (EOB) by U.S. mail for those benefit plans that allow EFT. EOP or EOB information can be accessed and printed through the Check Claim Status application on your MyPractice page of the Magellan website. You must Check Claim Status on the Magellan provider website or review your Electronic Remittance Advice (ERA) online through your clearinghouse in order to obtain the processing result for EFT paid claims. Should a claim be denied, no payment will be due and there will be no EFT transaction. You will need to check you EOP or EOB online via Magellan provider website at 40

41 Magellan Provider Website Claims Features and more

42 42 Magellan Provider Sign-In

43 Checking Claims Status On MagellanProvider.com Sign in on Magellan provider Web site; Select Check Claims Status from menu Capabilities to search for claims by member or subscriber name, date of service, etc. Can view claim details such as check number, date and payment method If claim is denied, reason code and description provided Contact instructions available if provider has questions View EOB online through the Check Claims Status EOB search tab 43

44 44 My Claims Check Claims Status

45 45 My Claims View EOB through Check Claims Status

46 46 View EOB (continued)

47 47 View EOB (continued)

48 48 View EOB (continued)

49 49 My Claims View Claims Submitted Online

50 50 My Claims - View Claim Details

51 Magellan Provider Website Online Training On Magellan s Provider Website Go to the Education section at top-menu and select Online Training Website User Guides Authorizations/Eligibility Claims Electronic Transactions Demos of Online Tools Authorizations/Eligibility Claims Electronic Transactions 51

52 Magellan Provider Website Getting Paid Go to the Getting Paid section at top-menu In this section, you will find information and resources on: Preparing Claims CPT Code Changes DSM-5/ICD-10 HIPAA Electronic Transactions Paper Claim Forms 52

53 Magellan Provider Website News & Publications Go to the News & Publications section at top-menu and select Stateand Plan-Specific Information Then select the Nebraska Plan under Plan-Specific Information This will take you to the Nebraska Provider Handbook Supplement and Appendices Recent updates have been made to the supplement and appendices and will be posted soon *Please check back soon at to review the updated NE Provider Handbook Supplement especially Section 5 on Provider Reimbursement. 53

54 Website Support Website Support: To request a username, reset a password or ask questions about this website, or if you experience any technical issues with the site, contact our Provider Services Line at Monday - Friday from 8:00 a.m. to 5:30 p.m. Central Time. 54

55 Wrap-up Closing Information

56 Contact Information General Provider Contract and Billing Inquiries Nebraska Network Department at and ask to speak to Network representative Teresa Danforth, Field Network Director, Direct # or Christine Cole, Provider Relations Liaison, Direct # or Bryon Belding, Field Network Coordinator, Direct # or Area Contract Manager (facilities/organizations) soon to be hired Claims Inquiries Claims Customer Service Line at and select prompt for Claims Inquiry EDI Support and Inquiries EDI Support Line at and ext

57 Q & A We are here to help you! Questions Comments Feedback Concerns Please visit the Magellan of Nebraska website at and go to the For Providers section to find the latest Implementation Updates We will have a Frequently Asked Question (FAQ) document posted soon and continually updated with answers to all questions we receive from providers regarding the implementation. Recordings of the webinar sessions and the PowerPoint presentation will be posted here as well. 57

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