Third Quarter Updates Q3 2014

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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 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.

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