SD MEDX South Dakota Medical Electronic Data Exchange SD Department of Social Services

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1 GENERAL INFORMATION Q. Is SD MEDX specifically for medical claims and prior authorizations or what will a dental provider use SD MEDX for? A. Delta Dental is still contracted with Medical Services for processing claims and the payments to dental providers. As a dental provider, continue to submit claims to them. However, Delta Dental will transfer claim information to SD MEDX, and dental providers will be able to complete claim inquiries to see the status of their claims. Dental Providers will need to complete the re-enrollment process to remain an active Medicaid Provider eligible to receive claim reimbursement. Q. If a prior authorization is required for dental, is the prior authorization submitted to Delta Dental or SD MEDX? A. The prior authorization should be submitted to Delta Dental. Delta Dental will continue to approve or deny prior authorizations for dental services. Q. From a security perspective when using the provider search functionality, what information is being returned on a provider? A. When the public or a recipient uses the Provider Search functionality on the SD MEDX website, they will receive the provider s name, clinic name, address, and telephone number. Q. How will the specialist physician know if there is a referral card? Will the SD MEDX be a tool for this? A. The process for referrals in the Managed Care program is not changing. A specialist will still need to have documentation of a referral from the recipient s primary care provider. There may be changes to the Managed Care program in the future. Q. What types of formats can be used as a referral if there is not a state supplied card? A. Examples of other acceptable referrals include documented telephone referrals; referral letters; customized referral forms; other insurance referral forms; hospital admittance letters, treatment notes, or discharge orders; and physician orders that contain all the required referral information. The required information includes, the recipient name, referred to provider s name (be specifi c as to which provider the patient will see, do not use a facilities name), services or condition, time-span (not to exceed one year) or number of visits authorized, primary care provider name, primary care provider NPI and/or taxonomy, date and authorized signature. If a provider is indicating referral information on a claim, the referral has to be documented and retained within the medical record for verifi cation. Q. When and where will the training information be available? A. Training session information will be available on the SD MEDX Website prior to provider re-enrollment go live as well as posted to the SD MEDX General and Training listservs. To insure you receive the most current information, please join one of these listservs at Q. You indicated that Mozilla Firefox is one of the acceptable browsers for accessing SD MEDX. How can we obtain this browser? A. Mozilla Firefox is a browser that you can download on your computer. A free download is available at mozilla.com/en-us/fi refox/ie.html. Q. Will there be training tools available for each enrollment type? A. Yes, there will be separate tools available for each enrollment type. These training tools include a Quick Reference Guide, Computer Based Training module and Checklists. This information is specifi c to your enrollment type and is available for both re-enrollment and new enrollments. The training tools will be available at when the website is deployed. For complete training information, please sign up for the Training listserv at the above-mentioned website.

2 Q. Can the quick reference guides be saved and printed? A. Yes, you may save and print the Quick Reference Guides as well as the Re-enrollment Checklists. Q. Is there a reason that the training is in order with a phased approach? A. Yes, SD MEDX is a relational database which allows associations between billing agents and providers as well as groups and servicing providers and so on. Considering that the system allows these types of associations, we will require that the re-enrollment process be phased so that billing agents begin the process fi rst. Once billing agents are enrolled, Groups and Facilities/Agencies/Organizations/Institutions/Pharmacies will then be able to associate to a billing agent. Groups and Facilities/Agencies/Organizations/Institutions/Pharmacies will also be able to associate their servicing providers during the re-enrollment process. RECIPIENT INFORMATION / ELIGIBILITY CHECKS Q. Currently Web MD/Emdeon is used to check eligibility, will we be able to use this in the future? A. You can still use Web MD/Emdeon. SD MEDX also has an eligibility check that providers will be able to access through the provider portal. Q. Will recipients be able to log on and find out which providers accept Medicaid? The SD MEDX website will have a Provider Locator. Q. Is the recipient identification number changing? A. No. The recipient 9-digit number will remain the same. Q. Is the recipient identification card changing? When photo copied, the card is not clear. A. The card design will remain the same. The photocopy concern will be considered for future card designs. Q. When checking dates of eligibility will it show all coverage dates? A. It will show current and two other spans if available. SECURITY Q. When will the Security letter with the user name and password be sent out? A. The letter will be sent out one week before each provider type is required to re-enroll. You will receive two letters. One letter will contain your Domain and User Name. A second letter will contain your password. This is to insure that no one but you will have access your Provider information. Q. When the provider re-enrollment letters are sent to the providers, where are they sending the information? A. We are sending the correspondence to the current Pay To address we have listed in our records. A letter will be sent to the contacts provided on the contact registration page to inform them the letter has been sent to the Pay To address. Q. If a provider s billing address is out of State, Minnesota for example, will they be the security administrator and set up their own accounts? Q. Will there be certain criteria for passwords? The specifi c information will be shared in the future, but as an example, the passwords will be case sensitive.

3 Q. Do the users have access to all the information in the SD MEDX? A. The security administrator will associate profi les to users which will determine what information can be accessed. For example, if you wish to limit only the Provider Enrollment activity in your organization to certain staff members, you are able to do that by associating a specifi c profi le or you may wish to allow the Clinic Business Manager to have access to all the records of that clinic but not another clinic. Q. Is the administrator role for security assignable by the providers? A. Yes, providers will inform the Department of Social Services who is responsible for the administrator duties. The administrator will have the ability to create additional administrators, but the State will be working with only the one provided security contact. On the SD MEDX website, we are asking providers to list their contact information by clicking the enter your information link under Provider Contact Information registration. Q. If an organization has multiple billing NPIs, will there be multiple usernames/passwords? A. If your organization has multiple billing NPIs, you will receive separate credentials for each of the billing NPIs for the reenrollment process. After the re-enrollment process, you will have the ability to associate all of these separate billing NPIs to a parent organization. This will allow you to establish your security to associate different user profi les to staff within the clinics. Department of Social Service staff will work with your organization to establish these parent organization associations and also to establish the security credentials for the staff in the clinics and associate the correct profi les. The profi les are based on the roles or job duties that you wish for an individual staff member to be able to complete or records that they might have access to. For example, if you wish to limit only the Provider Enrollment activity in your organization to certain staff members, you are able to do that by associate a specifi c profi le or you may wish to allow the Clinic Business Manager to have access to all the records of that clinic but not another clinic. Please contact the State and let us know if you will need to be set up at a parent organization after you have completed your re-enrollment. Q. Will pharmacy claim responses change with SD MEDX? A. No, the pharmacy claims response will stay the same. We will be using a new Point of Sale system. The pharmacy will not notice a difference in the new system. A benefi t for the pharmacy is that they will have the ability to view their remittance advice in SD MEDX. Q. What is the prior authorization (PA) process in SD MEDX? A. If there are PAs required for services, etc., currently, the same PA will be required in SD MEDX. Please review administrative rules for specifi c requirements. In SD MEDX, you will be able to submit your PA online, attach the required document, and check for the status of the PA. Providers will no longer need to wait for a paper copy of the PA. You will also have a computer record of all PAs for your reference. In the future, there will be additional services requiring prior authorization. Providers will be notifi ed of any program changes. Q. Does the prior authorization (PA) override the necessity of a referral card? A. No, the referral card is also a pre-requisite for treatment or service requiring a PA. Please do not confuse the PA process with the Managed Care process. The referral card is required for the Managed Care program and the PA is for the service being provided.

4 Q. Will Medical Services continue giving the South Dakota legacy number or just the NPI? A. Your SD Legacy number will be converted to SD MEDX for historical claim association only. Medical Services will not be using this number to process claims in SD MEDX. Providers should transition to use their NPI number. If you can not obtain an NPI number, a pseudo NPI will be assigned to you. SD MEDX PROVIDER ENROLLMENT AND RE-ENROLLMENT Q. If the documents such as the provider agreements, addendums, and licenses have been submitted with previous enrollment, do they have to be resubmitted? A. Yes, in order to re-enroll as a South Dakota Medicaid provider, new provider agreements and addendums are required. The agreement and/or addendums must be mailed in. Medical Services will require providers to submit all agreements and addendums with a wet signature. These forms will be made available on the SD MEDX Website prior to the start of re-enrollment. Note: If you have a current unexpired license(s) already submitted with Medicaid, you do not have to submit the documents again. Licenses may be uploaded during re-enrollment process and in the future as you maintain your fi le. Q. If we have a provider at 4 or 5 different clinics that are not actively billing, will they show up in SD MEDX for the re-enrollment process? A. Yes, if they are enrolled Medicaid Provider, their information will be able to be viewed as long as the provider has not notifi ed the Division of Medical Services that they wish to discontinue participating as a Medicaid provider and they have submitted a claim within the past two years. Q. What if our facility has a post office box for mailings? A. You will be able to select a multiple addresses in SD MEDX including your base location, servicing address, mailing address and prior authorization address. A post offi ce box may be used for any of the addresses except for your servicing address. The servicing address must be the physical location where you will see recipients. This address will be used to populate the Provider Locator function on the SD MEDX website. Q. When a school district enrolls the occupational therapist or a physical therapist, will they need to provide the licenses and certification for them? A. Yes, the proof of licensing and certifi cation will be a required step to associate this servicing provider to the school district. Q. How often will the credential updates be required, i.e., licensing information? A. SD MEDX will have expiration checks on the licenses, 45 days, 30 days, and 15 days prior to expiration. A letter will be sent out to the providers asking to submit an updated copy of the license. You are required to have an unexpired license on fi le to remain an active Medicaid Provider. You will need to provide your updated license in the future. You will be able to do this by uploading it through the Provider portal. Q. If licenses are not updated, will the providers not be paid? A. SD MEDX will have expiration checks on the licenses, 45 days, 30 days, and 15 days prior to expiration. A letter will be sent out to the providers asking to submit an updated copy of the license. If an updated license is not returned, there will be a hold on provider payments until the proper licensing credentials are mailed or uploaded to SD MEDX. Q. Will the provider s EDI information be populated from the legacy system? A. No. The providers will be required to indicate their claims submission types during the re-enrollment/enrollment process. If Billing Agent/Clearinghouse, FTP Server or Web Batch submission types are selected, providers will then need to provide additional information such as the Billing Agent submitter number, EDI contact information and/or software details.

5 Q. For the school cooperatives, do school districts need to enter their contact information on the SD MEDX website? A. We encourage both school districts and school cooperatives to enter contact information on the SD MEDX Website. Q. Do the schools need to come up with their own contact person? The schools will need to re-enroll. By having the correct contacts, it will help us get the information to the correct individuals. Q. Will the taxonomy stay with the NPI during Re-enrollment? However, providers will be asked to verify the information during the re-enrollment process. Your taxonomy association drives claims payment and the procedures that you can bill for. Claims missing taxonomies or improper taxonomies will deny. Q. We use a clearinghouse for our claims. Do we have to contact them about the SD MEDX? A. No. The Department of Social Services will be contacting all clearinghouses who currently submit claims. A list of enrolled clearinghouses and billing agents will be posted on the SD MEDX website. If your billing agent or clearinghouse is not listed, please contact the Provider Response Team at , so we may contact them to enroll in SD MEDX. Q. Do retail pharmacies need to re-enroll? Q. How are the Intermediaries notified of the enrollment process and changes to SD MEDX? A. Medicare Intermediaries are not enrolled with Medicaid as a provider. There will be no changes with this process. Q. If I need to enroll a provider in the next few weeks in the legacy system, do I have to do a re-enrollment in SD MEDX? We are requiring additional information in SD MEDX that is not currently captured in the Legacy system. To insure that we have captured the proper information on all 10,600 active Providers, we are asking even newly enrolled Providers to complete the re-enrollment process. Q. How do I find out my taxonomy number? A. When you obtained your National Provider Identifi cation Number (NPI), you selected a taxonomy number. You can obtain that taxonomy information by going to the National Plan & Provider Enumeration System website Q. Currently I have one NPI number and two legacy numbers, do I re-enroll twice? A. Re-enrollment will be based on billing NPI. If there is only one billing NPI, then you will re-enroll once. Q. Can you submit provider terminations in provider portal? Providers can terminate their business status by entering an End Date as well as a termination reason within SD MEDX. Q. Will South Dakota be like North Dakota and require providers to register on a state NPI registry? A. No. South Dakota does not have a state NPI registry. Q. If the billing agent we use is already enrolled and we associate to that billing agent, will the steps pre-populate the billing agent information? A. No. Providers will be required to contact their billing agent/clearinghouse to obtain their submitter number. This submitter number will then be used when making the association to the billing agent within SD MEDX. The rest of the billing agent information will already have been captured during the billing agent s enrollment process.

6 Q. Will the bank deposit information be pre-populated? A. No. Providers will be asked to re-enter that information due to security issues. Q. Can the provider agreement be printed out? There is a link located on the document checklist as well as on the SD MEDX website where the provider agreement can be accessed and printed. Provider agreements and associated addendums will be accessible at prior to provider re-enrollment. A listserv message will be sent to providers notifying them once these documents are available. CLAIMS Q. How do providers know the claims that are in the old system will be paid correctly by SD MEDX? A. It is the goal of the State to process as many claims as possible in the current system prior to converting to SD MEDX. However, claims that are not completed in the old system will be denied and providers will receive a remittance advice asking them to resubmit those claims. Q. Will providers be able to void a claim in SD MEDX? SD MEDX allows the functionality to adjust or void a claim on-line. Q. Can nursing homes submit the UB-04 on line? A. Professional and institutional claims can be submitted through Direct Data Entry in SD MEDX. Q. When a clearinghouse is utilized by a provider, will claims be sent directly to SD MEDX and will the provider be able to view the submitted claims? The claims will be sent to SD MEDX and the provider will be able to view the info through SD MEDX. Q. Currently I use electronic claims submission, but if I want to use the direct data entry option, should I select electronic and Direct Data Entry? A. You can select both options right away or you also will have the option to change the type of claim submission at a later date. Q. For secondary claims, do you need to indicate Direct Data Entry? A. Providers can use Direct Data Entry, scan and upload explanation of benefi ts and submit claim. Q. On a manual review of a claim that has been submitted, how will the provider know when the claim has been reviewed and approved? A. After approval, a message will be sent to the provider s My Inbox. Q. What if I am a provider that submits claims manually? A. Providers will have the ability to do direct data entry instead of completing the claim by writing or typing. If you continue to submit paper CMS 1500 or UB-04 the only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Q. For third party payer claims, we attach the explanation of benefits when we submit the claims. Do we have to continue to black out other patient s information? To continue to be HIPPA compliant, the information that is not relating to the recipient on the claim will have to be blackened out.

7 Q. Is there going to be a test period for submitting electronic claims? A. There will be a testing period for electronic claims. More information will be available at a later date. In addition a Companion Guide will be available for providers who submit electronically. This guide will be available on the SD MEDX website. A listserv posting will be sent to providers notifying them once this is available. Q. Will the limits be available to the recipients on the recipient website? A. No. Q. Since the remittance advices are going to be available on line, will the old remittance advices be converted and viewable on line? A. No. We are unable to convert the old remittance advices from the old legacy system. However, once SD MEDX goes live, the providers will be able to download new Remittance Advices within SD MEDX. There will also be 6 years of claims history on line. Q. When submitting claims for durable medical equipment and other waiver-type services for Adult Services and Aging, will they be able to submit with just one NPI? A. If the billing NPI and taxonomy are different for the services being billed, they would need to be billed on separate claim forms. Q. Is there a taxonomy code for each of those types of services? Q: If claims are submitted via paper, claims that pend for a provider to fix, will they have 96 hours to correct the error? A: Yes, providers will have 96 hours to correct. After 96 hours or 4 business days, the claim would deny and the provider would be notifi ed on their next remittance advice, regardless of when the payroll cycle is completed. Q. Currently, audiologists have to wait one month to bill for hearing aid. Will they still have to wait with SD MEDX? A. There will be no programmatic changes at this time. The State may review this policy for future possible changes. Q. Will the electronic remittance advice give more information than the electronic 835? A. The electronic version of the remittance advice will give the same information as today s paper remittance advice, and the 835 will also have the same information as it does today. Q. Will the paper remittance advice go away eventually? Q. Currently, clearinghouses send remittance advices electronically. Will SD MEDX change this process? A. If clearinghouses are sending an 835 to the provider, that process will not change with SD MEDX. In addition the provider s will be able to access their remittance advice via SD MEDX. Providers will not have to wait to receive their remittance advices from their clearinghouse.

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