Third Quarter Updates Q3 2014

Size: px
Start display at page:

Download "Third Quarter Updates Q3 2014"

Transcription

1 Third Quarter Updates Q PR.P.PP. 2014

2 Agenda Claim Process Reminders and Updates Top Rejections Top Denials IHCP Updates Resources

3 Claim Process Electronic submission MHS accepts TPL information via EDI It is the responsibility of the provider to review the error reports received from the Clearinghouse. Online submission through the MHS Secure Provider Portal at: mhsindiana.com/login Provides immediate confirmation of received claims and acceptance. Professional and Facility claims accepted. Paper Claims Claim Inquiries Check status online with the MHS Secure Provider Portal: mhsindiana.com/login. Call Provider Services at: IVR 3

4 Claim Process CONTRACTED PROVIDERS Claims must be received within 90 calendar days of the date of service. Exceptions Newborns (30 days of life or less) Claims must be received within 365 days from the date of service. Claim must be filed with the newborn s RID number. TPL - Claims with primary insurance must be received within 365 days of the date of service with a copy of the primary EOB. If primary EOB is received after the 365 days, providers have 60 days from date of primary EOB to file claim to MHS. 4

5 Claims Process Revised CMS 1500 Revised CMS 1500 Claim Form required by Medicaid effective 4/1/14. MHS will accept both versions of the CMS-1500 from 1/6/ /1/2014. For additional information regarding the revised CMS-1500 please refer to IHCP Bulletin BT

6 Claims Process CLIA Effective January 1, 2014, providers billing CLIA services to MHS must include a valid and appropriate CLIA number. For paper claims, a valid and appropriate CLIA number must be included in Box 23 of the CMS-1500 form. For EDI claims, if a single claim is submitted for those laboratory services for which CLIA certification or waiver is required, report the CLIA certification or waiver number in: X12N 837 (HIPAA version) loop 2300, REF02. REF01 = X4. If a claim is submitted with both laboratory services for which CLIA certification or waiver is required and non-clia covered laboratory test, in the 2400 loop for the appropriate line report the CLIA certification or waiver number in: X12N 837. (HIPAA version) loop 2400, REF02. REF01 = X4. Valid and appropriate CLIA numbers must be provided. 6

7 Claims Process CLIA continued Claims for CLIA certified or waived tests that do not contain a valid CLIA number will be rejected. This applies to all MHS products (Medicaid, HIP, and Ambetter). For a list of CLIA Waived services, Provider Performed Microscopy Procedures, tests subject to CLIA edits and tests excluded from CLIA edits, please visit: cms.gov/regulations-and- Guidance/Legislation/CLIA/Categorization_of_Tests.h tml 7

8 Claims Process HIP Updates Effective August 1, 2014; Outpatient hospital claims submitted under the HIP program will be required to comply with the changes as outlined by CMS in the aforementioned paragraphs. As such, hospitals submitting outpatient claims under the HIP program can report as follows: Report Laboratory Only services using Bill Type 141 Report Laboratory only services using Bill Type 131; and append modifier L1 to each of the laboratory service CPT code(s) that are submitted as required by CMS. There is no change to the reporting of comprehensive outpatient services under Bill Type 131 that extends beyond laboratory services. Failure to report HIP Outpatient Hospital services in compliance with the CMS directive will result in a denial of the claim. 8

9 Claim Rejection Claim Process A rejection is an unclean claim that contains invalid or missing data elements required for acceptance of the claim in the claim process system. The provider will receive a letter or a rejection report from their EDI vendor if the claim was submitted electronically. Claim Denial A denial is a claim that has passed edits and is entered into the system but has been billed with invalid or inappropriate information causing the claim to deny. An EOP will be sent that includes the denial reason PR.P.PP.1 9

10 Claim Process - Rejections Member invalid on date of service (09) Member eligibility should be verified via Web interchange, Omni Swipe, or AVR at the point of service (maintained by Indiana Medicaid). If you believe that the member information on the claim is correct, please call to speak with an MHS Provider Services Representative so that the member s eligibility can be updated in our system PR.P.PP.1 10

11 Claim Rejections Invalid member date of birth (08) Member s information needs to match what is on file with Indiana Medicaid. Did not bill with CLIA certificate number for Lab services billed (B5) The CLIA number must be reported on claims involving CLIA waived or CLIA certified tests. Rendering provider is not set up with MHS for the TIN and NPI billed, or line of business billed (B2) Providers must separately contract or enroll as a non-contracted provider with MHS. Provider s claim information must match the information in their HP provider profile PR.P.PP.1 11

12 Claim Denials Time Limit For Filing Has Expired (EX 29) Claims must be received within 90 calendar days of the date of service (contracted providers). Exceptions Exceptions: Newborn, Third Party Liability, and Non Participating Providers Bill Primary Insurer 1 st (EX L6) Verify other insurance (TPL). Medicaid is the payer of last resort. Electronic submission preferred. Guide.pdf 0913.PR.P.PP.1 12

13 Claim Denials Authorization Not On File (EX A1) Prior Authorization should occur at least two (2) business days prior to the date of service. All urgent and emergent services must be called to MHS within two (2) business days after service/admit. Authorization screening tool available at Claim and Auth Locations do not match (EX HL) Authorization on file does not match the place of service billed PR.P.PP.1 13

14 Claim Denials Claim and Auth Service Provider Not Matching (EX HP) Authorization on file does not match the billing provider Member Name/Number/Date Of Birth Do Not Match (EX MQ) Member information on claim must match what is on file with Indiana Medicaid PR.P.PP.1 14

15 Claim Adjustments If you need to make an adjustment to a paid claim, you can do so by submitting the adjustment request via the MHS Secure Provider Portal. For assistance, there is a tutorial available at mhsindiana.com/provider-guides How to Use the Adjust Claims Feature on the MHS Provider Portal. Adjustments can also be processed via paper submissions. The MHS claim adjustment form is available at mhsindiana.com/provider-forms. Attach an MHS claim adjustment form along with documentation, including EOP (if available) explaining reason for resubmission. Please indicate original claim number. Example: (K123INE00987 K123INE00987). Claim adjustments requests must be submitted within 67 days of the date of the MHS EOP. Please note, claims will not be reconsidered after day

16 Dispute Resolution Should be made in writing by using the MHS informal claim dispute or objection form, available at mhsindiana.com/provider-forms. Submit all documentation supporting your objection. Send to MHS within 67 calendar days of receipt of the MHS EOP. Please reference the original claim number. Requests received after day 67 will not be considered. Managed Health Services Attn: Appeals P.O. Box 3000 Farmington, MO MHS will acknowledge your appeal within 5 business days. Provider will receive notice of determination within 45 calendar days of the receipt of the appeal. A call to MHS Provider Services does not reserve appeal rights. 16

17 Dispute Resolution 1 ST step in the appeals process. Level One Appeal Should be made in writing by using the MHS informal claim dispute or objection form. Submit all documentation supporting your objection. Send to MHS within 67 calendar days of receipt of the MHS EOP. A call to MHS Provider Services does not reserve appeal rights. 17

18 Dispute Resolution Level Two Appeal (Administrative) Submit the Informal Claims Dispute/Objection Form with all supporting documentation to the MHS appeals address: Managed Health Services Attn: Appeals P.O. Box 3000 Farmington, MO MHS will acknowledge your appeal within 5 business days. Provider will receive notice of determination within 45 calendar days of the receipt of the appeal. 18

19 IHCP Updates

20 Early Elective Deliveries Effective July 1, 2014 deliveries that are not medically indicated prior to 39 weeks and 0 days will be non-covered. Effective for dates of admission on or after July 1, 2014 CMS 1500 claim forms must contain 1 of the following modifiers for CPT codes 59409, 59514, 59612, and UB Medically necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UA Non-medically necessary delivery prior to 39 weeks of gestation Effective for dates of admission on or after July , UB-04 claim forms must be billed with one of the following correct condition codes in fields for obstetrical delivery services. 81 C-sections or inductions performed at less than 39 weeks gestation for medical necessity 82 C-sections or inductions performed at less than 39 weeks gestation electively 83 C-sections or inductions performed at 39 weeks gestation or greater For Further information regarding medically necessary conditions please see IHCP Bulletin BT

21 Notification of Pregnancy Form Effective June 25, 2014 the Notification of Pregnancy Form (NOP) has been simplified. Providers are no longer required to complete an extensive risk assessment Prenatal Care providers can receive a $60 incentive payment for completing the NOP and submitting it via Web interchange. Pregnant woman must be enrolled with an MCE. The woman s pregnancy must be less than 30 weeks gestation. NOP must be submitted via Web interchange within 5 calendar days. Claim must be billed with CPT code with modifier TH Only 1 NOP be completed per pregnancy. NOP s can be submitted for women enrolled in the presumptive eligibility program as well as the Hoosier HealthWise Program. For additional information please refer to IHCP Bulletin BT

22 Smoking Cessation The Indiana Tobacco Quitline QUIT-NOW/ Free phone-based counseling service that helps Indiana smokers quit. One on one coaching for tobacco users trying to quit. Resources available for both providers and patients. Counseling can be billed to MHS using CPT code U6 with a primary diagnosis of Counseling must be at least 10 minutes.

23 HIP 2.0 Family and Social Services Administration (FSSA) has submitted a request to the Centers for Medicare and Medicaid Services (CMS) to expand Medicaid using HIP as a conceptual framework. Intended for those 19 to 64 with incomes up to 138% of FPL. Expansion covers approximately 350,000 Hoosiers. Maternity benefit and non-emergency transportation services added for pregnant women. Removes existing annual and lifetime HIP limits. Eliminates existing enrollment limitations in the current program. Maintains provider reimbursement at 100% of Medicare rates. Creates 3 tiers of HIP coverage HIP Basic HIP Plus HIP Employer Benefit Link (2016) 23

24 HIP 2.0 HIP Basic Members are placed into the basic plan if no POWER Account contributions are made. State funded POWER Account covers the $2,500 annual deductible. Includes all essential health benefits. Reduced benefit package (no dental or vision, limited prescription drug benefit). Copays on most services 24

25 HIP 2.0 HIP Plus Members make a standardized contribution payment ($3, $8, $15, $20, or $25). Members and FSSA jointly fund the $2,500 POWER Account. No other cost sharing Comprehensive coverage (includes dental and vision) 25

26 HIP 2.0 HIP Employer Benefit Link (2016) Financial support to members to access employersponsored insurance. Allows HIP-eligibles to choose to either enroll in HIP Plus or receive a defined contribution POWER account. POWER Account can be used for premium, co-pays, or deductibles. Enrollment is optional. 26

27 Resources

28 Resources EFT s and ERA s PaySpan Health Web based solution for Electronic Funds Transfers (EFTs) and Electronic Remittance Advices (ERAs). One year retrieval of remittance advice Provided at no cost to providers and allows online enrollment. Register at payspanhealth.com. For questions call or providersupport@payspanhealth.com 28

29 Resources - MHS Website mhsindiana.com Provider directory search. Provider manuals, guides, and tutorials. Provider and member forms. Member brochures. Health Library with over 4,000 free, printable health information sheets available in English, Spanish, and other languages. MHS Secure Provider Portal Access for both contracted/non-contracted groups. Account manager access allows facilities to set up multiple users. Enhanced claim detail. Submit claims / adjust submitted claims. Printable explanation of payments. Submit prior authorization. Claim auditing tool. Eligibility verification/listings including TPL information. View patient care gaps (patients needing services). 29

30 MHS Secure Portal Features Access for both contracted/non-contracted groups Online registration multiple users per office Enhanced claim detail Direct claim submission Batch claim submission COB processing with or without attachments Claim adjustment Claim auditing tool Direct claim submission Prior authorization Eligibility and COB verification Care gaps alert Online Health Record Vault for your patients (includes specialty care) Secure messaging send a secure message if you need to reference PHI in an to MHS.

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

IHCP 3 rd Quarter Workshop Hoosier Healthwise/HIP. MDwise Claims HHW HIPP0264 (6/13) Exclusively serving Indiana families since 1994. IHCP 3 rd Quarter Workshop Hoosier Healthwise/HIP MDwise Claims HHW HIPP0264 (6/13) Exclusively serving Indiana families since 1994. Agenda 1. Provider Enrollment 2. Claim submission for MDwise Hoosier

More information

October 2013 IHCP Annual Workshop Hoosier Healthwise/HIP

October 2013 IHCP Annual Workshop Hoosier Healthwise/HIP HHW-HIPP0311 (9/13) October 2013 IHCP Annual Workshop Hoosier Healthwise/HIP MDwise UB-04 for Hoosier Healthwise and HIP: A guide for claim adjudication Exclusively serving Indiana families since 1994.

More information

Superior HealthPlan Hospital Training. SHP_2013158 Hospital Orientation Presentation

Superior HealthPlan Hospital Training. SHP_2013158 Hospital Orientation Presentation Superior HealthPlan Hospital Training SHP_2013158 Hospital Orientation Presentation Introductions & Agenda Presenter Introductions About Superior HealthPlan Eligibility Medical Management CHIP Perinate

More information

Get Even More HIP with HIP 2.0. HP Provider Relations/October 2014

Get Even More HIP with HIP 2.0. HP Provider Relations/October 2014 Get Even More HIP with HIP 2.0 HP Provider Relations/October 2014 Agenda Introduction Healthy Indiana Plan (HIP) Expansion Compare HIP 1.0 and HIP 2.0 Benefit Plans Reimbursement and Copayments Other Information

More information

Third Party Liability. HP Provider Relations October 2012

Third Party Liability. HP Provider Relations October 2012 Third Party Liability HP Provider Relations October 2012 Agenda Objectives Third Party Liability (TPL) TPL Program Responsibilities TPL Resources Cost Avoidance Claims Processing Guidelines TPL Update

More information

Third Party Liability. HP Provider Relations/October 2014

Third Party Liability. HP Provider Relations/October 2014 Third Party Liability HP Provider Relations/October 2014 Agenda Objectives Define Third Party Liability (TPL) TPL Program Responsibilities TPL Resources Cost Avoidance Medicare Buy-in Program Claims Processing

More information

Billing Medicaid as a Secondary Payer. Provider Relations / Second quarter 2015

Billing Medicaid as a Secondary Payer. Provider Relations / Second quarter 2015 Billing Medicaid as a Secondary Payer Provider Relations / Second quarter 2015 Agenda Other Coverage How to Identify Other Coverage and Request Coverage Updates Medicare Crossover Claims Third-Party Liability

More information

Chapter 5: Third Party Liability

Chapter 5: Third Party Liability I N D I A N A H E A L T H C O V E R A G E P R O G R A M S P R O V I D E R M A N U A L Chapter 5: Third Party Liability Library Reference Number: PRPR10004 5-1 Document Version Number Version 1.0 September,

More information

IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT201503 JANUARY 27, 2015

IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT201503 JANUARY 27, 2015 IHCP bulletin INDIANA HEALTH COVERAGE PROGRAMS BT201503 JANUARY 27, 2015 FSSA announces the NEW Healthy Indiana Plan! Coverage for qualifying Hoosiers will start effective Feb. 1, 2015 The Indiana Family

More information

CLAIMS Section 5. Overview. Clean Claim. Prompt Payment. Timely Claims Submission. Claim Submission Format

CLAIMS Section 5. Overview. Clean Claim. Prompt Payment. Timely Claims Submission. Claim Submission Format Overview The Claims department partners with the Provider Relations, Health Services and Customer Service departments to assist providers with any claims-related questions. The focus of the Claims department

More information

MyCare Ohio Assisted Living Provider Orientation & Training

MyCare Ohio Assisted Living Provider Orientation & Training MyCare Ohio Assisted Living Provider Orientation & Training Opt IN Enrollees - Full duals with Buckeye Medicare and Medicaid benefits through Buckeye Medicare option to change plans monthly If member selects

More information

MyCare Ohio Skilled Nursing Facility Orientation

MyCare Ohio Skilled Nursing Facility Orientation MyCare Ohio Skilled Nursing Facility Orientation Demonstration/Pilot Area Demonstration/Pilot Area 2 Health Plan Options Northwest Southwest West Central Central East Central Northeast Central Northeast

More information

Qtr 2. 2011 Provider Update Bulletin

Qtr 2. 2011 Provider Update Bulletin West Virginia Medicaid WEST VIRGINIA Department of Health & Human Resources Qtr 2. 2011 Provider Update Bulletin West Virginia Medicaid Provider Update Bulletin Qtr. 2, 2011 Volume 1 Inside This Issue:

More information

Provider Manual. mhsindiana.com 1-877-647-4848 TTY/TDD: 1-800-743-3333 VOLUME 20

Provider Manual. mhsindiana.com 1-877-647-4848 TTY/TDD: 1-800-743-3333 VOLUME 20 2015 Provider Manual mhsindiana.com 1-877-647-4848 TTY/TDD: 1-800-743-3333 VOLUME 20 Table of Contents Chapter 1: Managed Health Services (MHS)... 6 Chapter 2: Guidelines for Providers... 7 The Medical

More information

SECTION 4. A. Balance Billing Policies. B. Claim Form

SECTION 4. A. Balance Billing Policies. B. Claim Form SECTION 4 Participating Physicians, hospitals and ancillary providers shall be entitled to payment for covered services that are provided to a DMC Care member. Payment is made at the established and prevailing

More information

! Claims and Billing Guidelines

! Claims and Billing Guidelines ! Claims and Billing Guidelines Electronic Claims Clearinghouses and Vendors 16.1 Electronic Billing 16.2 Institutional Claims and Billing Guidelines 16.3 Professional Claims and Billing Guidelines 16.4

More information

Basics of the Healthcare Professional s Revenue Cycle

Basics of the Healthcare Professional s Revenue Cycle Basics of the Healthcare Professional s Revenue Cycle Payer View of the Claim and Payment Workflow Brenda Fielder, Cigna May 1, 2012 Objective Explain the claim workflow from the initial interaction through

More information

Third Party Liability

Third Party Liability INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Third Party Liability L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 1 7 P U B L I S H E D : F E B R U A R Y 2 5, 2 0 1 6 P

More information

Home Health, Hospice and Long-Term Care. HP Provider Relations/October 2015

Home Health, Hospice and Long-Term Care. HP Provider Relations/October 2015 Home Health, Hospice and Long-Term Care HP Provider Relations/October 2015 Agenda Claim inquiry on Web interchange By member number and date of service Understand claim status information, disposition,

More information

Compensation and Claims Processing

Compensation and Claims Processing Compensation and Claims Processing Compensation The network rate for eligible outpatient visits is reimbursed to you at the lesser of (1) your customary charge, less any applicable co-payments, coinsurance

More information

Compensation and Claims Processing

Compensation and Claims Processing Compensation and Claims Processing Compensation The network rate for eligible outpatient visits is reimbursed to you at the lesser of (1) your customary charge, less any applicable co-payments, coinsurance

More information

Molina Healthcare of Puerto Rico (MHPR) Non-Participating Provider Information

Molina Healthcare of Puerto Rico (MHPR) Non-Participating Provider Information Molina Healthcare of Puerto Rico (MHPR) Non-Participating Provider Information Please refer to Carta Normativa 15-0326 Re Transicion for details regarding the ASES-established Transition of Care and Reimbursement

More information

01172014_MHP_ProTrain_Billing

01172014_MHP_ProTrain_Billing 01172014_MHP_ProTrain_Billing Welcome to Magnolia Health s Billing Clinic 101! We thank you for being part of or considering Magnolia s network of participating providers, hospitals, and other healthcare

More information

Instructions for submitting Claim Reconsideration Requests

Instructions for submitting Claim Reconsideration Requests Instructions for submitting Claim Reconsideration Requests A Claim Reconsideration Request is typically the quickest way to address any concern you have with how we processed your claim. With a Claim Reconsideration

More information

Claims Procedures. H.2 At a Glance. H.4 Submission Guidelines. H.9 Claims Documentation. H.17 Codes and Modifiers. H.

Claims Procedures. H.2 At a Glance. H.4 Submission Guidelines. H.9 Claims Documentation. H.17 Codes and Modifiers. H. H.2 At a Glance H.4 Submission Guidelines H.9 Claims Documentation H.17 Codes and Modifiers H.22 Reimbursement H.25 Denials and Appeals At a Glance pledges to provide accurate and efficient claims processing.

More information

ebilling Support ebilling Support webinar: ebilling terms Lifecycle of a claim

ebilling Support ebilling Support webinar: ebilling terms Lifecycle of a claim ebilling Support ebilling Support webinar: ebilling terms ebilling enrollment Lifecycle of a claim 2 Terms EDI Electronic Data Interchange Flow of electronic information, specifically claims information

More information

Section 9. Claims Claim Submission Molina Healthcare PO Box 22815 Long Beach, CA 90801

Section 9. Claims Claim Submission Molina Healthcare PO Box 22815 Long Beach, CA 90801 Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your

More information

HP Managed Care Unit. Hoosier Healthwise and Healthy Indiana Plan MCE Policies and Procedures Manual

HP Managed Care Unit. Hoosier Healthwise and Healthy Indiana Plan MCE Policies and Procedures Manual HP Managed Care Unit I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Hoosier Healthwise and Healthy Indiana Plan MCE Policies and Procedures Manual L I B R A R Y R E F E R E N C E N U M B E R

More information

2014 IHCP Annual Provider Seminar Prior Authorization 101 For Traditional Medicaid and Care Select

2014 IHCP Annual Provider Seminar Prior Authorization 101 For Traditional Medicaid and Care Select 2014 IHCP Annual Provider Seminar Prior Authorization 101 For Traditional Medicaid and Care Select This presentation can be downloaded at: www.advantageplan.com/advcareselect DOC-1212-14 Agenda Prior Authorization

More information

Billing Clinic (STAR, STAR Health, CHIP and STAR+PLUS (non-nf residents)

Billing Clinic (STAR, STAR Health, CHIP and STAR+PLUS (non-nf residents) Billing Clinic (STAR, STAR Health, CHIP and STAR+PLUS (non-nf residents) Provider Training SHP_2014624 Introductions & Agenda Verifying Eligibility Authorization Process Establishing Medical Necessity

More information

LTC Monthly Claims Training How to Bill UB04 on Web Portal

LTC Monthly Claims Training How to Bill UB04 on Web Portal LTC Monthly Claims Training How to Bill UB04 on Web Portal Statewide Medicaid Managed Care: Key Components STATEWIDE MEDICAID MANAGED CARE PROGRAM MANAGED MEDICAL ASSISTANCE PROGRAM LONG-TERM CARE PROGRAM

More information

PROSPECT MEDICAL GROUP DOWNSTREAM PROVIDER NOTICE CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION MECHANISM

PROSPECT MEDICAL GROUP DOWNSTREAM PROVIDER NOTICE CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION MECHANISM PROSPECT MEDICAL GROUP DOWNSTREAM PROVIDER NOTICE CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION MECHANISM As required by Assembly Bill 1455, the California Department of Managed Health Care has set

More information

2010 BCBSNC Provider Conference Top 20 Questions Answers

2010 BCBSNC Provider Conference Top 20 Questions Answers Questions Answers There is currently no centralized listing of all out-of-state Blue Plan alpha prefixes. There is a listing available for BCBSNC alpha prefixes only; please contact your Provider Relations

More information

Glossary of Insurance and Medical Billing Terms

Glossary of Insurance and Medical Billing Terms A Accept Assignment Provider has agreed to accept the insurance company allowed amount as full payment for the covered services. Adjudication The final determination of the issues involving settlement

More information

SECTION 7: APPEALS TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1

SECTION 7: APPEALS TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 SECTION 7: APPEALS 7.1 Appeal Methods................................................................. 7-2 7.1.1 Electronic Appeal Submission.......................................................

More information

MEDICAID BASICS BOOK Third Party Liability

MEDICAID BASICS BOOK Third Party Liability Healthy Connections Visual MEDICAID BASICS BOOK Third Party Liability An illustrated companion to the interactive courses at: MedicaideLearning.com. This topic includes content from the exclusive Third

More information

Durable Medical Equipment (DME), Home Health and Home Infusion Services (UNIVITA TRANSITION)

Durable Medical Equipment (DME), Home Health and Home Infusion Services (UNIVITA TRANSITION) Durable Medical Equipment (DME), Home Health and Home Infusion Services (UNIVITA TRANSITION) Fall 2014 Welcome to Magnolia Health! We thank you for being part of or considering Magnolia s network of participating

More information

2013 IHCP Annual Provider Seminar Prior Authorization 101 For Traditional Medicaid and Care Select

2013 IHCP Annual Provider Seminar Prior Authorization 101 For Traditional Medicaid and Care Select 2013 IHCP Annual Provider Seminar Prior Authorization 101 For Traditional Medicaid and Care Select This presentation can be downloaded at: www.advantageplan.com/advcareselect http://www.mdwise.org/providers-workshops.html

More information

Mental Health. HP Provider Relations

Mental Health. HP Provider Relations Mental Health Guidelines and Billing Practices HP Provider Relations July 2011 Agenda Session Objectives Outpatient Mental Health Medicaid Rehabilitation Option (MRO) Risk-Based Managed Care (RBMC) Eligibility

More information

POWER Account Funds Calculator Point of Service Payments 0515.OS.P.PP 05/15

POWER Account Funds Calculator Point of Service Payments 0515.OS.P.PP 05/15 POWER Account Funds Calculator Point of Service Payments 0515.OS.P.PP 05/15 POWER Account Overview In the Healthy Indiana Plan (HIP), the first $2,500 of medical expenses for covered benefits are paid

More information

Florida Medicaid Provider Resource Guide

Florida Medicaid Provider Resource Guide Florida Medicaid Provider Resource Guide Staywell Health Plan of Florida, Inc., (WellCare) understands that having access to the right tools can help you and your staff streamline day-to-day administrative

More information

How To Participate In The Well Sense Health Plan

How To Participate In The Well Sense Health Plan Well Sense Health Plan How We Do Business with Providers New Hampshire Health Protection Program August 2014 Agenda Working with Well Sense and our members Our partners Provider responsibilities Resources

More information

Chapter 82-60 WAC All Payer Claims Database

Chapter 82-60 WAC All Payer Claims Database Chapter 82-60 WAC All Payer Claims Database WAC 82-60-010 Purpose (1) Chapter 43.371 RCW establishes the framework for the creation and administration of a statewide all-payer health care claims database.

More information

Provider Claims Billing

Provider Claims Billing Provider Claims Billing Objective At the end of this session, you should be able to recognize the importance of using Harvard Pilgrim s online tools and resources to manage the revenue cycle: Multiple

More information

Dental Orientation. Molina Healthcare

Dental Orientation. Molina Healthcare Dental Orientation Molina Healthcare Scion Provider Web Portal The Scion Electronic Outreach Team is calling all providers offices to provide information and help with registration. Some offices may receive

More information

Medical Nutrition Therapy Dietitians Caring for Our Members Health

Medical Nutrition Therapy Dietitians Caring for Our Members Health Medical Nutrition Therapy Dietitians Caring for Our Members Health BCBSNC Dietitian Network 1 2014, Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield

More information

Health Partners Plans Provider Manual Provider Billing & Reimbursement

Health Partners Plans Provider Manual Provider Billing & Reimbursement 12 Health Partners Plans Provider Manual Provider Billing & Reimbursement Purpose: Topics This chapter provides an overview of provider billing requirements and reimbursement considerations. Provider Reimbursement

More information

HIP 2.0. 1 st Quarter 2015 IHCP Workshop. A wise choice for you and your family. HIP 200001

HIP 2.0. 1 st Quarter 2015 IHCP Workshop. A wise choice for you and your family. HIP 200001 HIP 2.0 1 st Quarter 2015 IHCP Workshop A wise choice for you and your family. HIP 200001 Agenda What is HIP? Applying for HIP Whole Family Solution Plans Eligibility Changing Plans POWER Account Invoices/Billing

More information

How To Contact Americigroup

How To Contact Americigroup Mental Health Rehabilitative Services and Mental Health Targeted Case Management TXPEC-0870-14 1 Agenda Key contacts Eligibility Mental Health Rehabilitative services (MHR) and Mental Health Targeted (TCM)

More information

Connecticut Medical Assistance Program Refresher for Home Health Providers. Presented by The Department of Social Services & HP for Billing Providers

Connecticut Medical Assistance Program Refresher for Home Health Providers. Presented by The Department of Social Services & HP for Billing Providers Connecticut Medical Assistance Program Refresher for Home Health Providers Presented by The Department of Social Services & HP for Billing Providers 1 Training Topics Home Health Agenda Fee Schedule Update

More information

Claims Filing Instructions

Claims Filing Instructions Claims Filing Instructions Table of Contents Procedures for Claim Submission... 3 Claims Filing Deadlines...4 Claim Requests for Reconsideration, Claim Disputes and Corrected Claims...5 Procedures for

More information

Claims and Billing Process. AHCCCS Provider Identification Number and NPI Number

Claims and Billing Process. AHCCCS Provider Identification Number and NPI Number Claims and Billing Process AHCCCS Provider Identification Number and NPI Number All United Healthcare Community Plan providers requesting reimbursement for services must be properly registered with AHCCCS

More information

Behavioral Health Provider Training: Substance Abuse Treatment Updates

Behavioral Health Provider Training: Substance Abuse Treatment Updates Behavioral Health Provider Training: Substance Abuse Treatment Updates Agenda Laboratory Services Behavioral Health Claims Submission Process Targeted Case Management Utilization Management eservices Claims

More information

Provider Billing Manual

Provider Billing Manual Fidelis SecureLife Medicare-Medicaid Plan (MMP) Provider Billing Manual www.fidelissc.com/mmp 1 P a g e BILLING MANUAL TABLE OF CONTENTS INTRODUCTORY BILLING INFORMATION 5 BILLING INSTRUCTIONS 5 GENERAL

More information

Medical Practitioner Reimbursement

Medical Practitioner Reimbursement INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Medical Practitioner Reimbursement L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 1 6 P U B L I S H E D : F E B R U A R Y 25,

More information

CHAPTER 7 (E) DENTAL PROGRAM CLAIMS FILING CHAPTER CONTENTS

CHAPTER 7 (E) DENTAL PROGRAM CLAIMS FILING CHAPTER CONTENTS CHAPTER 7 (E) DENTAL PROGRAM CHAPTER CONTENTS 7.0 CLAIMS SUBMISSION AND PROCESSING...1 7.1 ELECTRONIC MEDIA CLAIMS (EMC) FILING...1 7.2 CLAIMS DOCUMENTATION...2 7.3 THIRD PARTY LIABILITY (TPL)...2 7.4

More information

Chapter 10: Claims Processing Procedures

Chapter 10: Claims Processing Procedures I N D I A N A H E A L T H C O V E R A G E P R O G R A M S P R O V I D E R M A N U A L Chapter 10: Claims Processing Procedures Library Reference Number: PRPR10004 10-1 Chapter 10: Revision History Version

More information

KanCare Billing and Payment

KanCare Billing and Payment JANUARY 2013 KMAP HCBS & NF BULLETIN 13021 KanCare Billing and Payment Kansas Department of Health and Environment, Division of Health Care Finance (KDHE-DHCF) and Kansas Department for Aging and Disability

More information

Billing Manual. Claims Filing Instructions. IlliniCare.com

Billing Manual. Claims Filing Instructions. IlliniCare.com Billing Manual Claims Filing Instructions IlliniCare.com 1 2 Table of Contents Procedures for Claim Submission...4 Claims Filing Deadlines...4 Claim Requests for Reconsideration, Claim Disputes and Corrected

More information

Molina Healthcare of Ohio, Inc. PO Box 22712 Long Beach, CA 90801

Molina Healthcare of Ohio, Inc. PO Box 22712 Long Beach, CA 90801 Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your

More information

CLAIM FORM REQUIREMENTS

CLAIM FORM REQUIREMENTS CLAIM FORM REQUIREMENTS When billing for services, please pay attention to the following points: Submit claims on a current CMS 1500 or UB04 form. Please include the following information: 1. Patient s

More information

Duplicate Claims Verify claims receipt with BCBSNM prior to resubmitting to prevent denials.

Duplicate Claims Verify claims receipt with BCBSNM prior to resubmitting to prevent denials. Claims Submission Electronically : Use Payer ID 00790 For information on electronic filing of claims, contact Availity at 1-800-282-4548. Paper claims must be submitted on the Standard CMS-1500 (Physician/Professional

More information

Children s Long Term Support (CLTS) Waiver Third Party Administration (TPA) Claims Processing

Children s Long Term Support (CLTS) Waiver Third Party Administration (TPA) Claims Processing Children s Long Term Support (CLTS) Waiver Third Party Administration (TPA) Claims Processing Wisconsin Department of Health Services Division of Long Term Care Bureau of Long-Term Support 1 Third Party

More information

Directory Of Resources Downloads/Bulletins Downloads/Forms

Directory Of Resources Downloads/Bulletins Downloads/Forms Directory Of Resources Information is listed by webpage name; a link has been included to automatically open each page of the Medicaid Portal. If the page location of an item or topic is not known, type

More information

Medicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) FQHC/RHC Claims and Billing Training

Medicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) FQHC/RHC Claims and Billing Training Medicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) FQHC/RHC Claims and Billing Training 2012 Provider Training Rev 030512 A Division of Health Care Service Corporation,

More information

Top 50 Billing Error Reason Codes With Common Resolutions (09-12)

Top 50 Billing Error Reason Codes With Common Resolutions (09-12) Top 50 Billing Error Reason Codes With Common Resolutions (09-12) On the following table you will find the top 50 Error Reason Codes with Common Resolutions for denied claims at Virginia Medicaid. This

More information

CLAIMS AND BILLING INSTRUCTIONAL MANUAL

CLAIMS AND BILLING INSTRUCTIONAL MANUAL CLAIMS AND BILLING INSTRUCTIONAL MANUAL 2007 TABLE OF ONTENTS Paper Claims and Block Grant Submission Requirements... 3 State Requirements for Claims Turnaround Time... 12 Claims Appeal Process... 13 Third

More information

May 13, 2015 Third Party Liability Recovery

May 13, 2015 Third Party Liability Recovery May 13, 2015 Third Party Liability Recovery On May 13, 2015, the Department of Public Welfare's (Department) Division of Third Party Liability (TPL) issued a Medicare Part B TPL/Coordination of Benefits

More information

Glossary of Terms. Account Number/Client Code. Adjudication ANSI. Assignment of Benefits

Glossary of Terms. Account Number/Client Code. Adjudication ANSI. Assignment of Benefits Account Number/Client Code Adjudication ANSI Assignment of Benefits Billing Provider/Pay-to-Provider Billing Service Business Associate Agreement Clean Claim Clearinghouse CLIA Number (Clinical Laboratory

More information

CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030

CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030 CODE DESCRIPTION 011 Claim denial (claim level) due to SF message 012 Line denial (line level) due to SF message 017 Incorrect Alpha Prefix 030 Missing service provider zip code (box 32) 031 Missing pickup

More information

GEORGIA MEDICAL BILLING AND REIMBURSEMENT FOR WORKERS COMPENSATION

GEORGIA MEDICAL BILLING AND REIMBURSEMENT FOR WORKERS COMPENSATION Approved GEORGIA MEDICAL BILLING AND REIMBURSEMENT FOR WORKERS COMPENSATION Table of Contents Section 1: Section 2: Section 3: Section 4: Section 5: Section 6: Section 7: Section 8: Section 9: Section

More information

Billing Guidelines for Obstetrical Services and PCO Responsibilities

Billing Guidelines for Obstetrical Services and PCO Responsibilities Billing Guidelines for Obstetrical Services and PCO Responsibilities Providing obstetrical services to UnitedHealthcare Community Plan members and your patients is a collaborative effort. Complying with

More information

Beginning Billing Workshop Audiology

Beginning Billing Workshop Audiology Beginning Billing Workshop Audiology Colorado Medicaid 2015 1 Centers for Medicare & Medicaid Services Department of Health Care Policy and Financing Medicaid Medicaid/CHP+ Medical Providers Xerox State

More information

Billing Guidelines Manual for Contracted Professional HMO Claims Submission

Billing Guidelines Manual for Contracted Professional HMO Claims Submission Billing Guidelines Manual for Contracted Professional HMO Claims Submission The Centers for Medicare and Medicaid Services (CMS) 1500 claim form is the acceptable standard for paper billing of professional

More information

Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company

Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for American Medical Security Life Insurance Company Insureds 2009 Contents How to contact us... 2 Our claims process...

More information

Claims Filling Instructions

Claims Filling Instructions Claims Filling Instructions Table of Contents Procedures for Claim Submission... 2 Claims Filing Deadlines....4 Claim Requests for Reconsideration, Claim Disputes and Corrected Claims...5 Claim Payment.....7

More information

Providers must attach a copy of the payer s EOB with the UnitedHealthcare Community Plan dental claim (2012 ADA form).

Providers must attach a copy of the payer s EOB with the UnitedHealthcare Community Plan dental claim (2012 ADA form). UnitedHealthcare Community Plan (formerly APIPA) Medicaid Dental Claims and Billing Process Effective Dates of Service October 01, 2015 or after AHCCCS Provider Identification Number and NPI Number All

More information

Mental Health. HP Provider Relations/October 2014

Mental Health. HP Provider Relations/October 2014 Mental Health HP Provider Relations/October 2014 Agenda Objectives Outpatient Mental Health Inpatient Mental Health Eligibility and Aid Categories Prior Authorization Medicaid Rehabilitation Option (MRO)

More information

Claims Filing Instructions

Claims Filing Instructions Claims Filing Instructions Table of Contents PROCEDURES FOR CLAIM FORM SUBMISSION... 3 Claims Filing Deadlines... 4 Claim Requests for Reconsideration, Claim Disputes and Corrected Claims... 5 Claim Payment...

More information

Date Posted: Nov. 27, 2012. Overview:

Date Posted: Nov. 27, 2012. Overview: Landon State Office Building Phone: 785-296-3981 900 SW Jackson Street, Room 900-N Fax: 785-296-4813 Topeka, KS 66612 www.kdheks.gov/hcf/ Robert Moser, MD, Secretary Kari Bruffett, Director Sam Brownback,

More information

LTSS Billing Clinic. Provider Training. February 2015 SHP_2015891

LTSS Billing Clinic. Provider Training. February 2015 SHP_2015891 LTSS Billing Clinic Provider Training February 2015 SHP_2015891 Agenda Introduction to Superior HealthPlan STAR+PLUS STAR+PLUS Medicare-Medicaid Plan Long Term Services & Support Community First Choice

More information

Early Intervention Central Billing Office. Provider Insurance Billing Procedures

Early Intervention Central Billing Office. Provider Insurance Billing Procedures Early Intervention Central Billing Office Provider Insurance Billing Procedures May 2013 Provider Insurance Billing Procedures Provider Registration Each provider choosing to opt out of billing for one,

More information

Molina Healthcare of Washington, Inc. CLAIMS

Molina Healthcare of Washington, Inc. CLAIMS CLAIMS As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your reference:

More information

Practice management system criteria checklist

Practice management system criteria checklist Practice management system criteria checklist The American Medical Association (AMA) and Medical Group Management Association (MGMA) have created the following checklist as a starting point for assessing

More information

Questions & Answers on ACA Section 4106 Improving Access to Preventive Services for Eligible Adults in Medicaid

Questions & Answers on ACA Section 4106 Improving Access to Preventive Services for Eligible Adults in Medicaid Questions & Answers on ACA Section 4106 Improving Access to Preventive Services for Eligible Adults in Medicaid STATE PLAN AMENDMENT (SPA) Q1. Can a state submit a SPA to implement section 4106 at any

More information

Patient Account Services. Patient Reference & Frequently Asked Questions. Admissions

Patient Account Services. Patient Reference & Frequently Asked Questions. Admissions Patient Account Services Patient Reference & Frequently Asked Questions Admissions Each time you present for a new medical service, a new account number will be assigned. You will be asked to pay any patient

More information

The benefits of electronic claims submission improve practice efficiencies

The benefits of electronic claims submission improve practice efficiencies The benefits of electronic claims submission improve practice efficiencies Electronic claims submission vs. manual claims submission An electronic claim is a paperless patient claim form generated by computer

More information

Health Resources Division Rule Changes (Effective 7/1/14)

Health Resources Division Rule Changes (Effective 7/1/14) Health Resources Division Rule Changes (Effective 7/1/14) Health Resources Division Mega Rule: ARM 37.85.105 The department is amending ARM 37.85.105 to reflect a 2% increase in Medicaid fees to providers.

More information

State of Nevada Department of Health and Human Services (DHHS) Division of Health Care Financing and Policy (DHCFP)

State of Nevada Department of Health and Human Services (DHHS) Division of Health Care Financing and Policy (DHCFP) Hewlett Packard Enterprise for HIPAA Compliant Electronic Transactions Nevada Medicaid Management Information System (NV MMIS) State of Nevada Department of Health and Human Services (DHHS) Division of

More information

Diabetes Self-Management Training Services

Diabetes Self-Management Training Services INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Diabetes Self-Management Training Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 2 3 P U B L I S H E D : F E B R U

More information

Claims Filing Instructions

Claims Filing Instructions Billing Manual 1 2 Claims Filing Instructions Table of Contents PROCEDURES FOR CLAIM SUBMISSION...4 CLAIMS FILING DEADLINES...4 CLAIM REQUESTS FOR RECONSIDERATION, CLAIM DISPUTES AND CORRECTED CLAIMS..5

More information

HEALTHY INDIANA PLAN FREQUENTLY ASKED QUESTIONS (FAQs)

HEALTHY INDIANA PLAN FREQUENTLY ASKED QUESTIONS (FAQs) HEALTHY INDIANA PLAN FREQUENTLY ASKED QUESTIONS (FAQs) Eligibility Plan Benefits The Healthy Indiana Plan Requirements POWER Accounts Administration Employers Enrollment Additional Information Eligibility

More information

Anthem Hoosier Healthwise / Healthy Indiana Plan. Behavioral Health Provider Training

Anthem Hoosier Healthwise / Healthy Indiana Plan. Behavioral Health Provider Training Anthem Hoosier Healthwise / Healthy Indiana Plan Behavioral Health Provider Training An Innovative Solution for Hoosier Healthwise and Healthy Indiana Plan Members Connecting everyone involved to help

More information

Chapter 4. Provider Billing

Chapter 4. Provider Billing Chapter 4 Provider Billing Overview This chapter details general billing and reimbursement procedures. Refer to the specific service chapter for more detailed information. This chapter includes: Billing

More information

Frequently Asked Questions About Your Hospital Bills

Frequently Asked Questions About Your Hospital Bills Frequently Asked Questions About Your Hospital Bills The Registration Process Why do I have to verify my address each time? Though address and telephone numbers remain constant for approximately 70% of

More information

NEW JERSEY MEDICARE FAQs FREQUENTLY ASKED QUESTIONS FROM PROVIDERS

NEW JERSEY MEDICARE FAQs FREQUENTLY ASKED QUESTIONS FROM PROVIDERS NEW JERSEY MEDICARE FAQs To help answer some of the most frequently asked questions we receive from providers and members, please see below. If you have a question that isn't listed here, or if you need

More information

Title 40. Labor and Employment. Part 1. Workers' Compensation Administration

Title 40. Labor and Employment. Part 1. Workers' Compensation Administration Title 40 Labor and Employment Part 1. Workers' Compensation Administration Chapter 3. Electronic Billing 301. Purpose The purpose of this Rule is to provide a legal framework for electronic billing, processing,

More information

National Provider Identifier (NPI) Frequently Asked Questions

National Provider Identifier (NPI) Frequently Asked Questions National Provider Identifier (NPI) Frequently Asked Questions I. GETTING, SHARING, AND USING NPI GENERAL QUESTIONS II. TYPE 1 (INDIVIDUAL) VS TYPE 2 (ORGANIZATIONAL) III. ELECTRONIC CLAIM SUBMISSION IV.

More information

OBGYN Orientation & Billing Guide 9/22/2014

OBGYN Orientation & Billing Guide 9/22/2014 OBGYN Orientation & Billing Guide 2014 Welcome to Magnolia Health! We thank you for being part of or considering Magnolia s network of participating providers, hospitals, and other healthcare professionals.

More information

Provider Frequently Asked Questions

Provider Frequently Asked Questions Provider Frequently Asked Questions CATEGORIES CLAIMS ELIGIBILITY APPEALS/GRIEVANCES Out-of-MDwise Network Provider Claims Dispute In-MDwise Network Provider Claims Disputes Informal Claims Resolution

More information