Magellan: Virginia s Behavioral Health Services Administrator

Transcription

1 Magellan: Virginia s Behavioral Health Services Administrator Electronic Claim Submission and Tracking Overview of Claims Submission Requirements, Electronic Billing Options and Provider Website Features November 5, 2013

2 Today s Agenda Welcome! (Ajah Mills, Field Network Director, VA BHSA) Claims Submission Requirements (Tracey Alfaro, Sr. Network Manager, Implementations) Electronic Claim Submission Options and Tracking (Aimee Thatcher, Sr. Systems Analyst and Teresa O Connor, Lead Systems Analyst) Magellan Provider Website Demo on Claims Courier, Provider Website Features and more (Melissa Siesener, Reference Systems Analyst) Wrap-up Contact Information and Q & A (Tracey Alfaro) 2

3 Claims Submission Requirements Beginning with dates of service on or after December 1, 2013

4 Claims Submission Procedures Beginning with dates of service on or after December 1, 2013, you will need to submit your claims for rendered DMAS behavioral health fee-for-service and Medicaid/FAMIS Managed Care plan services to Magellan. For dates of service prior to December 1, submit claims to DMAS per your usual process. We strongly encourage all providers to submit claims to Magellan electronically using one of our three EDI Options: Direct Submit, Clearinghouse, or Claims Courier on our provider website. For more information, visit the Getting Paid/Electronic Transactions section on the Magellan provider website at Submit all paper claims to: Magellan Behavioral Health P.O. Box 1099 Maryland Heights, MO For electronic claims, please indicate P.O. Box

5 Claims Tips Claims with CPT or HCPCS procedure codes should be submitted electronically on a 837P (Professional) file or paper claim form CMS 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/SSN, servicing provider name and address, billing provider name and address, National Provider Identifier [NPI] number for both the servicing and billing provider). Atypical providers use your Atypical Provider Identifier (API). Attach the primary carrier s Explanation of Benefits (EOB), if applicable. Include all HIPAA-compliant diagnosis codes. Include the appropriate billing modifier (where applicable). Submit claims prior to the timely filing deadline. 5

6 Claims 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 or invalid NPI (for servicing provider and billing provider) or API Claims submitted past the timely filing deadline 6

7 Timely Filing The initial submission of all claims for covered services provided to members must be received by Magellan within 365 days of the date of service. If Magellan does not receive a claim within these timeframes, the claim will be denied for payment. Please refer to the DMAS Provider Manual, Chapter 5 Billing instructions regarding Timely Filing and Denied Claims The Medical Assistance Program regulations require the prompt submission of all claims. Virginia Medicaid is mandated by federal regulations [42 CFR (d)] to require the initial submission of all claims within 12 months from the date of service. Providers are encouraged to submit billings within 30 days from the last date of service or discharge. Denied claims must be submitted and processed on or before thirteen months from date of the initial denied claim where the initial claim was filed within the 12 months limit to be considered for payment by Magellan. 7

8 Claim Denials and Corrected Claims Claim denials will either be sent on the provider paper remittance or the Electronic Remittance Advice (ERA), whichever the provider receives. Providers who sign up for Electronic Funds Transfer (EFT) will be able to view paper remittances on the Magellan Provider Website after secure login Check Claim Status/EOB Search. Electronic submissions are the preferred method for claims submission, payment and remittance advice. If there is a need for a corrective change to a paid claim, the corrective claim should be sent as an adjusted claim and the original claim will be adjusted, not voided. Please note: Only claims that were originally paid and have changes should be sent as corrected. An originally denied claim should just be submitted as a new claim, even if there are changes. Corrected claims can be submitted electronically by selecting the appropriate corrected claim field (please consult Magellan s EDI companion guide). For paper submissions, please write corrected claim on the top of the claim form and note the Medicaid Resubmission code and original reference # in box 22 on CMS Highlighting the changes will ensure Magellan understands the changes being made. 8

9 Dual-Eligible Members and Coordination of Benefits Claims for dual-eligibles should be submitted to Medicare for reimbursement, for services covered by Medicare. The claims will crossover to DMAS for processing for the Medicaid portion as currently being done. Magellan will not receive the dual-eligible claims. 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. There are some service codes that will be TPL exempt (further clarification will be provided). 9

10 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 Benefits (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. You can review your EOB online after sign-in with your secure log-in to Select Check Claims Status and select the EOB Search tab. 10

11 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 coverage: Prior to the first appointment, Throughout the course of treatment, and Prior to submitting claims. Providers may check member eligibility beginning on 12/1/13 by: Using the Magellan provider website; after secure login, go to Check Member Eligibility. Call Magellan at and speak to customer service representative. 11

12 National Provider Identifier (NPI) Numbers The National Provider Identifier (NPI) is a 10-digit identifier required on all HIPAA standard electronic transactions. 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. For Atypical providers, you would use your Atypical Provider Identifier (API). An NPI does not replace a provider s TIN; the TIN/SSN continues to be required on all claims paper and electronic. Note: this is a change from the current billing process with DMAS The NPI is for identification purposes, while the TIN/SSN is for tax purposes. Important: claims that do not include a TIN/SSN will be rejected. You can find more information on NPI on the Magellan provider website at go to the Getting Paid section under Electronic Transactions. 12

13 National Provider Identifier (NPI) Numbers (continued) For organizations, please bill the organization as the rendering and pay to NPI (this excludes inpatient facilities who bill on UB-04 and requires attending physician). For groups, please bill the individual as the rendering NPI and the group as the pay to NPI. For Atypical providers, you would use your Atypical Provider Identifier (API). 13

14 Frequently Asked Questions Please review the Claims section in the Frequently Asked Questions (FAQ) document posted on the Magellan of Virginia website and go to the For Providers section. We are continually updating this FAQ document with answers to all questions we receive from providers regarding the implementation. 14

15 Electronic Claim Submission Options And Tracking

16 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 ensures 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. 16

17 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 contracted Clearinghouses: PayerPath (Allscripts) Capario Availity Emdeon Business Services RelayHealth Gateway EDI Office Ally IGI Healthcare If you are currently working with a different Clearinghouse, you may continue to use your Clearinghouse. You will need to have your Clearinghouse work with 1 of the 8 Magellan contracted Clearinghouses to submit your EDI transactions. Note that there may be charges from the clearinghouses (check directly with the clearinghouse). 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: 837P and 837I: The following unique Payer IDs are for Emdeon only: 837I: 12X27 17

18 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 website at EDI Assistance Hot Line: ext , and Direct Submit streamlines the process by eliminating the middleman. No charge to the provider from Magellan to use Direct Submit. 18

19 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

20 Edits Magellan uses EDIFECS Xengine for editing. There are four levels of Magellan 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 Magellan s host system will receive a status of accepted or rejected on a 277. A provider will receive 277 transaction report to inform them which claims were accepted or rejected. 20

21 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

22 Testing Center Capabilities The Submit EDI Claims application on the provider website 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. 22

23 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. We strongly encourage all providers who would like to use Direct Submit to begin the process now to be ready to submit EDI files directly to Magellan beginning on December 1. The following slides walk through the screenshots you will see as you move through the process. Go to to start the process. 23

24 24 Magellan EDI Testing Center Welcome Page

25 25 Task 1 - Download Companion Guide & FAQs

26 26 Task 2 - Complete the EDI Survey

27 27 Task 3 Magellan Internal Review of Survey

28 28 Task 4 - Upload and Validate 1st EDI Test File

29 29 Task 5 - Upload and Validate 2nd EDI Test File

30 30 Task 6 - Are You Ready for Production Status?

31 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 or ext

32 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. This application is not for institutional claim submissions. Accessible after sign-in on Magellan s provider website: Claims Courier streamlines the claims process by eliminating the middleman. No charge to the provider from Magellan to use this application. 32

33 Electronic Remittance Advice (ERA) Electronic Remittance Advice means receiving remittance data in an electronic form, such as the HIPAA X You have two 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 with which you chose to contract. 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 (or Atypical Provider Identifier) on file with Magellan, and be the owner of the Taxpayer Identification Number (TIN) under which claims are paid. 33

34 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. 34

35 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 at 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. If you do not have a provider website login yet, please request via at VAProviderQuestions@magellanhealth.com an EFT registration form to complete and fax to Magellan 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. 35

36 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 provider website. You must use 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 the Magellan provider website at 36

37 Claims Courier and Provider Website Features Demonstration

38 Magellan Provider Website Claims Features and more

39 39 Magellan Provider Sign-In

40 Checking Claims Status on MagellanHealth.com/provider 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 are provided. Contact instructions available if provider has questions. View EOB online through the Check Claims Status EOB search tab. 40

41 41 My Claims Check Claims Status

42 42 My Claims View EOB through Check Claims Status

43 43 View EOB (continued)

44 44 View EOB (continued)

45 45 View EOB (continued)

46 46 My Claims View Claims Submitted Online

47 47 My Claims - View Claim Details

48 48 View Authorizations

49 49 Check Member Eligibility

50 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 50

51 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 51

52 Magellan Provider Website News & Publications Go to the News & Publications section at top-menu and select Stateand Plan-Specific Information. Then select the Virginia BHSA under Plan-Specific Information. This will take you to the Virginia BHSA Provider Handbook Supplement and Appendices. The supplement and appendices are currently in review and will be posted soon. 52

53 Wrap-up Closing Information

54 Magellan Provider Website Provider Sign In (Secure Provider Information) Provider Website Login Set-Up Process How to Login the Provider Website Once you receive your executed contract, the cover letter will give you instructions on how to sign in on the Magellan provider website for the first time. For new providers who are still in the credentialing/contracting process with Magellan and do not have an executed contract, Magellan is in process of setting up website logins for providers. A Magellan Network representative will be contacting you to provide you with your Username and temporary password. If you do not hear from us in the next couple weeks, please send an to VAProviderQuestions@magellanhealth.com to inquire about your website login. For existing providers, please use your same website login information. We may have to link additional service locations to your existing login. Log on to Enter your User Name and Temporary Password in the Sign In Box User Name = Magellan MIS # Password =???? Once you sign in, follow the online instructions to create a new password You will need to assign someone as the administrator (it can be yourself if you are a solo practitioner) Administrative rights allow you to create a login, set an initial password and specify system rights tailored for each member of your practice You may wish to grant access to these online tools to other staff members as you deem appropriate an office manager, billing clerk, clinical staff, etc. 54

55 Contact Information General Provider Credentialing, Contract and General Billing Inquiries Virginia BHSA Network Department at or Ajah Mills, Field Network Director, Danyelle Dutton, Area Contract Manager Renee Chichester, Field Network Coordinator, Timothy Louk, Field Network Coordinator, Kelly Norton, Field Network Coordinator, Blair Swanson, Field Network Coordinator, Niquetra Temple, Field Network Coordinator, Shakara Wilkins, Field Network Coordinator, Claims Denial Inquiries Magellan of Virginia Call Center at and select the prompt for Claims Inquiry to speak to the Claims Customer Service department (prompt will not be activated until 12/1). This claims customer service line only assists with inquiries regarding claims that have been submitted and denied. 55

56 Contact Information (continued) EDI Support and Inquiries EDI Support Line at and ext Magellan Provider Website Support If you have trouble logging in to your secure account or you need technical assistance, go to the FAQs page at the top of and select the option that best meets your needs. 56

57 Q & A We are here to help you! Questions Comments Feedback Concerns Please visit the Magellan of Virginia website at and go to the For Providers section. We have a Frequently Asked Questions (FAQ) document posted 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

58 Confidential Information This presentation may include material non-public information about Magellan Health Services, Inc. ( Magellan or the Company ). By receipt of this presentation each recipient acknowledges that it is aware that the United States securities laws prohibit any person or entity in possession of material non-public information about a company or its affiliates from purchasing or selling securities of such company or from the communication of such information to any other person under circumstance in which it is reasonably foreseeable that such person may purchase or sell such securities with the benefit of such information. The information presented in this presentation is confidential and expected to be used for the sole purpose of considering the purchase of Magellan s services. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential. The attached material shall not be photocopied, reproduced, distributed to or disclosed to others at any time without the prior written consent of the Company.