TPA-Trading Partner Account User Guide. for. State of Idaho MMIS

Transcription

1 TPA-Trading Partner Account User Guide for State of Idaho MMIS Date of Publication: 4/8/2016 Document Number: RF019 Version: 11.0

2 This document and information contains proprietary information and copyrighted works of third parties. Authorization is hereby provided to you to copy documents published by Molina Medicaid Solutions on the Health PAS-OnLine portal provided such copies are used for noncommercial purposes and solely for use within your organization. This authorization is specifically conditioned upon including all legends, copyright, proprietary, and other notices that appear herein on all copies you make of such documents whether they pertain to Molina Medicaid Solutions or another party. No license is granted herein expressly, impliedly, by estoppel or otherwise under any patent or to use any trademark of any party. No other rights under any copyrights are granted herein, except as expressly stated above. The documents herein may refer to products and/or services that are neither available nor planned for availability in your particular locality. In referring to such products and/or services, Molina Medicaid Solutions incurs no obligation to subsequently make them available in your locality. DOCUMENTS PUBLISHED HEREIN ARE FURNISHED TO YOU "AS IS." THERE ARE NO WARRANTIES, EXPRESS, OR IMPLIED, BY OPERATION OF LAW OR OTHERWISE. MOLINA MEDICAID SOLUTIONS DISCLAIMS THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NON-INFRINGEMENT AS TO BOTH MOLINA MEDICAID SOLUTIONS AND NON-MOLINA DOCUMENTS FURNISHED HEREIN. Some states do not allow the exclusion of implied warranties and the foregoing exclusions may not be applicable to you. Any communication provided by you to Molina Medicaid Solutions relating to the documents furnished herein by Molina Medicaid Solutions will be received only on a non-confidential basis. There shall be no obligation on the part of Molina Medicaid Solutions with respect to use or disclosure of any information in such communication. Molina Medicaid Solutions shall have the unrestricted right to copy, use and distribute any information you communicate including but not limited to any ideas, concepts, know-how, techniques, software, documentation, diagrams, schematics or blueprints. Additionally, Molina Medicaid Solutions may use all such information in any manner or for any purpose including but not limited to developing products or providing services. The documents furnished herein by Molina Medicaid Solutions are subject to change without notice. All brand names and product names are acknowledged to be the trademarks or registered trademarks of their respective owners. HIPAA Notice This Health PAS-OnLine portal is for the use of authorized users only. Users of this Health PAS-OnLine portal may have access to protected, personally identifiable health data. As such, this Health PAS- OnLine portal and its data are subject to the Privacy and Security Regulations within the Health Insurance Portability and Accountability Act of 1996, Public Law (HIPAA). By accessing this Health PAS-OnLine portal, all users agree to protect the privacy and security of the data contained within as required by law. Access to information on this site is only allowed for necessary business reasons and is restricted to those persons with a valid user name and password. Last Updated: 4/8/2016 Page i

3 TABLE OF CONTENTS 1. Trading Partner Account Introduction Introduction Registering a New User User Types Detailed Registration Steps Account Activation Error Note Log In as a Trading Partner Administration and Account Maintenance Account Maintenance Trading Partner Status Managing Alerts Adding Alerts Editing Alerts Deleting Alerts Eligibility Verification Claim Submission Diagnosis Codes ICD Code Version Diagnosis Code Search Professional Claim Claim Information for Professional Claim Diagnoses for Professional Claim Services for the Professional Claim Additional Information for the Professional Claim Submit the Professional Claim Institutional Claim Claim Information for the Institutional Claim Admission Data for the Institutional Claim Diagnosis, Visit, and Injury Codes for the Institutional Claim Procedures for the Institutional Claim Condition, Occurrence, and Value Codes for the Institutional Claim Service Codes for the Institutional Claim Coordination of Benefits Submit the Institutional Claim Copy Last Claim Search for Last Claim Submitted Copy Claim Detail Feature Submit and Process a Claim Adding Attachments Claim Status Edit Claim Adjudicate Claim Reverse or Adjust a Claim Last Updated: 4/8/2016 Page ii

4 5. Check the Status of an Authorization Patient Roster Add or Delete a Member Copy Last Claim Feature Primary Care Roster Referrals Utilization Management Access Online Website Entry Option One Using the Primary Care Roster Link Option Two Referral Submission Link Referral Details Member Information Referral Information Referred To Provider Complex Care or Providers with Multiple Pay To NPIs Referred To Examples Notes Submitting the Referral Referral Status Retrieving a Referral View/Search Provider Referrals Viewing an Attachment File Exchange X12 Upload Routing and Version Selection Retrieving Your 835 File Archive Search Responses Reports Remittance Advice (RAs) Paper Remittance Advice Report Other Reports & PCP Incentive Payment Pended Claims Report Healthy Connections Rosters Provider Payment Status Last Updated: 4/8/2016 Page iii

5 TABLE OF FIGURES Figure 1-1: Account Maintenance Links... 1 Figure 1-2: File Exchange Links... 1 Figure 1-3: Form Entry Links... 2 Figure 1-4: Provider Tab and Register Link... 3 Figure 1-5: Trading Partner Registration: Demographic Information... 4 Figure 1-6: Trading Partner Registration: Security Information... 5 Figure 1-7: Trading Partner Registration: Electronic Remittance Advice Information... 6 Figure 1-8: Trading Partner Registration: Confirm Information... 7 Figure 1-9: Trading Partner Registration: Agreement... 7 Figure 1-10: Account Activation Page... 8 Figure 1-11: Trading Partner Tab... 8 Figure 1-12: Manage Users... 9 Figure 1-13: Add User... 9 Figure 1-14: Access Availability Figure 1-15: Terminate User Figure 1-16: Provider Associations Figure 1-17: Add Provider to Provider Associations Figure 1-18: Reset Password Screen Figure 1-19: Forgot Password Box Figure 1-20: Security Question Figure 1-21: Password Recovery Screen Figure 1-22: Lock-out Message Figure 1-23: Security Answer Figure 1-24: Unlock Account and Reset Password sent Figure 1-25: Unlock Account and Reset Password Figure 1-26: Enter New Password and Security Question Figure 1-27: Password Reset pop-up Figure 1-28: Enter New Password Figure 1-29: Valid Password Format Figure 1-30: Incorrect Password Format Figure 1-31: Lock-out Message Figure 1-32: Invalid Activation PIN Figure 1-33: Newly Generated and PIN Figure 1-34: Retrieve User Name Figure 1-35: Multiple Accounts Found Figure 1-36: Security Question Figure 1-37: Trading Partner Status Figure 1-38: Update Demographic Information Figure 1-39: Sample of Alert Types Figure 1-40: Alert Settings Figure 1-41: List of Alerts Figure 2-1: Inquire Eligibility of Participant Figure 2-2: Eligibility Verification Screen Figure 2-3: Participant Information Last Updated: 4/8/2016 Page iv

6 Figure 2-4: Eligibility Verification Figure 2-5: Important Information Figure 2-6: Eligibility Verification Response Figure 3-1: Select Billing Provider and Claim Type Figure 3-2: ICD Code Version Figure 3-3: Diagnosis Code Search Figure 3-4: Diagnosis Code Search Results Figure 3-5: Selecting Code from Search Results Figure 3-6: Claim Information for the Professional Claim Figure 3-7: Services for Professional Claim Figure 3-8: Enter NDC Codes Figure 3-9: Hyperlinks for Oxygen Therapy and COB Information Figure 3-10: Oxygen Therapy Entry Figure 3-11: Oxygen Services Summary Figure 3-12: COB Information Figure 3-13: Additional Claim Information Figure 3-14: Claim Information for the Institutional Claim Figure 3-15: Admission Data for the Institutional Claim Figure 3-16: Diagnoses, Visit, and Injury Codes for the Institutional Claim Figure 3-17: Procedure Codes for the Institutional Claim Figure 3-18: Condition, Occurrence and Value Codes Figure 3-19: Service Codes for the Institutional Claim Figure 3-20: Copy Last Claim Identifying Claim Type Figure 3-21: Claim Confirmation Figure 3-22: Add Attachments Figure 4-1: Claim Search Figure 4-2: Print and Export Options Figure 4-3: View Claim Screen Figure 4-4: Buttons to Assess a Claim Figure 4-5: Outstanding Edits Figure 4-6: Add/Delete Claims Lines, Diagnoses Figure 4-7: Add/Delete Claim Lines, Services Figure 4-8: Adjudication Results Figure 4-9: Reverse a Claim Figure 4-10: Claim Reversal Options Figure 4-11: Replacement Claim Figure 5-1: View Authorizations Figure 5-2: Authorization Details Figure 5-3: Authorization Search Figure 6-1: Patient Roster Figure 6-2: Find Member Figure 7-1: Primary Care Roster Figure 7-2: Diagnosis History Figure 7-3: View Diagnosis Details Figure 8-1: Manage Users Figure 8-2: Edit User Last Updated: 4/8/2016 Page v

7 Figure 8-3: Find Member Figure 8-4: Referral Details Figure 8-5: Referral Information Figure 8-6: Referral Reasons Figure 8-7: Referred To Provider Figure 8-8: Provider Selection Figure 8-9: Scenario One Figure 8-10: Scenario Two Figure 8-11: Scenario Three Figure 8-12: Submit Referral Confirmation Figure 8-13: Referral Status Figure 8-14: View Attachment Button Figure 8-15: File Attachment Figure 9-1: Edit Billing Providers Figure 9-2: 835 Routing Selection Options Figure 9-3: Available 835s Figure 9-4: 835 Search Criteria Fields Figure 9-5: Archive Search Figure 9-6: Claims (837) Responses Figure 10-1: Download Multiple Reports Figure 10-2: File Request Description Figure 10-3: Download Request Link Figure 10-4: Download Area Figure 10-5: Opting to Receive Paper Remittance Advice Figure 11-1: Payments for the Billing Provider Figure 11-2: Payment Summary Figure 11-3: Claims Status > View Claim Last Updated: 4/8/2016 Page vi

8 1. TRADING PARTNER ACCOUNT INTRODUCTION 1.1. Introduction This user guide is intended for providers using the Idaho Molina Medicaid website. The Healthcare Payer Administration Solution (Health PAS) OnLine portal is a web-based Medicaid administration system that permits real-time completion of healthcare transactions over the Internet. This website includes a secured provider site for registered trading partners, allowing them access to the following functions. Account Maintenance (Figure 1-1) Use these links to Manage Users, view and edit Provider Associations, Reset Password, and view your Trading Partner Status and User Status. These functions are discussed in detail below. Figure 1-1: Account Maintenance Links File Exchange (Figure 1-2) These links allow for X12 Upload, Archive Search, and viewing of Responses, Reports, and Alerts & Notifications. These functions are discussed in detail in sections 9 File Exchange and 10 Reports. Figure 1-2: File Exchange Links Last Updated: 4/8/2016 Page 1 of 72

9 Form Entry (Figure 1-3) The form entry links allow you to verify eligibility, submit and edit claims, maintain patient rosters, submit referrals, submit LTC cases, and view the status of authorizations, referrals, claims, and LTC cases. These functions are discussed in detail in this user guide. Note: The LTC Case Submission and LTC Status functions are described in the Trading Partner Account LTC Admission-Discharge Guide. Figure 1-3: Form Entry Links For more information on basic navigation of the Idaho Molina Medicaid website, see the IDMedicaid.com Welcome Guide Registering a New User To register for a Trading Partner Account, a provider must first be enrolled and in an approved status with Medicaid. Only one Trading Partner Account (TPA) should be registered; if you have one tax ID and multiple NPIs, you only need to register for one TPA account and all NPIs can be affiliated to that account. You may add additional users to the TPA after registration has been approved and activated. The registrant must supply three data elements for account validation/activation: Provider ID/NPI Tax ID (FEIN/SSN) PIN (Enrollment Case Number) Registration credentials are validated in real time and are automatically approved or denied. You will register as a new user by clicking on the Provider tab on Health PAS-OnLine. Under the Trading Partner Sign In, click on the Register link (Figure 1-4). Figure 1-4 also shows where you can find the Trading Partner Sign In to log in to your account, as well as the Reset Password link and the Retrieve User Name link (discussed in Sections and ). Last Updated: 4/8/2016 Page 2 of 72

10 Figure 1-4: Provider Tab and Register Link User Types There are six user types: Provider, Billing Agent, Clearing House, Internal User, Health Plan, and Business Associate. Each user type will require different information for Step 1 on the first page. Steps 2 through 5 will be the same for all user types. On Step 4, each of the user types will have different Trading Partner Agreements specific to its user type to e-sign. Provider - Providers are defined as entities that are contracted with IDHW to perform healthcare-related services. Billing Agent - Billing agencies are entities contracted by providers to create and manage the submission of the claims and related transactions for the providers. These entities are often hired by provider organizations to perform medical claim coding services. Clearinghouse - Clearinghouses are organizations that typically aggregate EDI transactions from multiple providers, billing agencies, and other health plans for routing and submission to the appropriate entity for processing. Clearinghouses then receive responses, split combined responses, and route the EDI responses to the appropriate originating entity. Internal User - Internal users that do not fall into one of the other defined user groups and have requested secured access to Health PAS-OnLine for access to secured documentation. Health Plan - Health plans are other carrier organizations with which Molina Healthcare will exchange EPHI (Electronic Protected Health Information) such as 834 Benefit Enrollment and Maintenance Transactions and 837 Healthcare Claims. Business Associate - Business associates are entities that perform on behalf of the covered entity any legal, actuarial, accounting, consulting, management, administrative accreditation, data aggregation, and financial services, and is not a member of the covered entity's workforce Account Administrator The first person to register will be made the administrator of the account. However, once an account is created, the administrator can assign additional administrators. Only an administrator of the account can assign another administrator or assign access rights to other individuals under the same account. In other words, the first user will administer user security for the rest of the employees of the Provider, Billing Agent, Clearinghouse, Health Plan, or Business Associate who will be accessing the same account. Other users may have access to different parts of the secure Health PAS website (such as claims or member eligibility) or may be given rights to all areas. Refer to Manage Users. Last Updated: 4/8/2016 Page 3 of 72

11 If there is only one administrator on the account and a change to the administrator rights is needed, send an on company letterhead, from a company address, to [email protected]. Include the following information: An explanation of the reason for the administrator change (e.g., no longer employed, change in ownership, new manager, etc.) TPA username on file if known, or first and last name of previous administrator Verification of the current address on file Trading partner ID or provider NPI First and last name of the new administrator New username and address of the new administrator You will receive a response to your inquiry on the same or next business day. Note: If the provider s TPA was set up by a billing agency and administrator rights need to be changed, contact Provider Services for support toll-free at 1 (866) , or locally at 1 (208) Please note that the administrator s password is needed to manage users on the account. If the individual acting as administrator changes, the new administrator will need this password in order to manage the account Detailed Registration Steps A red asterisk (*) indicates required information be entered in that field. Other fields are optional. The available and mandatory fields will change based on the user type selected. Figure 1-5: Trading Partner Registration: Demographic Information Last Updated: 4/8/2016 Page 4 of 72

12 Step 1 - Demographic Information 1) After Register As, select the appropriate user type from the drop-down list. 2) Enter First Name, Middle Initial, Last Name, and select a Title. 3) Enter the Company Name, if required. 4) Enter Address 1 with street address and/or Address 2 with P.O. Box or additional address information. 5) Enter City. 6) Select the State from the drop-down list. 7) Enter Zip Code in the five-digit or zip plus four format for USA (numeric values only). Use AXA XAX format for Canada where A is any uppercase letter and X is numeric from ) Select Country from the drop-down list. 9) Enter Telephone number in a 10-digit format (numeric values only). 10) Enter Website Address (optional). 11) Enter nine-digit Tax ID (numeric values only), if required. 12) Enter nine-digit FEIN or SSN (numeric values only), if required. 13) Enter either NPI (Typical Medicaid Healthcare Provider) or Medicaid Provider ID (Atypical Medicaid Provider). If these fields are shown on the screen, one of these is required. 14) Enter Enrollment Case Number as PIN, if required. 15) At the bottom of the screen, click the Next button or click the Cancel button to ignore the information on this screen. Figure 1-6: Trading Partner Registration: Security Information Step 2 Security Information 1) Enter User Name that will be used for the Trading Partner online access. 2) Enter Password using password guidelines stated on the screen. 3) Re-enter the same Password entered above. 4) Enter Address. 5) Re-enter the same Address entered above. 6) Enter a Security Question. 7) Enter the Security Answer. 8) At the bottom of the screen, either click the Next button to move to the next screen, click the Back button to move to the previous screen, or click the Cancel button to ignore the information on this screen. Last Updated: 4/8/2016 Page 5 of 72

13 Figure 1-7: Trading Partner Registration: Electronic Remittance Advice Information Step 3 Idaho Medicaid: Electronic Remittance Advice Information 1) Review Provider Information and Provider Identifiers and determine if any corrections need to be made at this point. 2) Under Electronic Remittance Advice Information, choose either the Provider Tax Identification Number (TIN) or the National Provider Identifier (NPI) from the dropdown. 3) If you wish to receive your remittance advice electronically, select the Download PDF checkbox. 4) Choose the appropriate radio button to determine who will receive the electronic remittance advice (ERA). a. Download 835: Sends the 835 to your Trading Partner Account. b. No 835: You will not receive an electronic 835; if selected, you can still receive a paper RA. c. Third Party: A drop-down of third parties will appear. Select the billing agency or clearinghouse who will need to receive the 835. If you choose a billing agency or clearinghouse, please verify that the entity is prepared to process your 835 transactions. Last Updated: 4/8/2016 Page 6 of 72

14 5) The Reason for Submission should be New Enrollment. 6) Fill in the Electronic Signature of Person Submitting Enrollment field. 7) Choose your Requested ERA Effective Date by clicking on the calendar icon. 8) At the bottom of the screen, either click the Next button located at the bottom of page to move to the next screen, click the Back button to move to the previous screen to make correction, or click the Cancel button to ignore the information on this screen. Figure 1-8: Trading Partner Registration: Confirm Information Step 4 Confirm Information 1) View confirmation page and determine if any corrections need to be made at this point. 2) At the bottom of the screen, either click the Next button located at the bottom of page to move to the next screen, click the Back button to move to the previous screen to make correction, or click the Cancel button to ignore the information on this screen. Figure 1-9: Trading Partner Registration: Agreement Step 5 Agreement This screen contains the Trading Partner Agreement. These may vary by user type. The side scroll bar may be used to read the entire Trading Partner Agreement or a copy may be printed by clicking on the Print link just below the scroll bar. 1) Select the Check Box located below the Trading Partner Agreement to complete the registration and accept the terms and conditions. Last Updated: 4/8/2016 Page 7 of 72

15 2) Enter Signature name. A signature is mandatory. Entering your name as an electronic signature signifies that the terms and conditions in the Trading Partner Agreement have been read and are accepted. 3) At the bottom of the screen, click the Register button to complete the registration process, click the Back button to move to the previous screen, or click the Cancel button to ignore the information on this screen. Once the registration agreement has been completed, the trading partner registration will be processed. A confirmation message will appear, explaining that an will arrive shortly with further instructions to finish the activation of the trading partner account. The will include your trading partner ID, PIN, and an activation link Account Activation An will be sent to the used during registration. Please be sure to look in your SPAM folder if you feel you did not receive the activation . 1) Click on the link in the to go to the Activation page. 2) On the Account Activation Page, enter the password chosen during registration in the Password box (Figure 1-10). Figure 1-10: Account Activation Page 1) Click the Activate Account button. The Account Activation page will display. 2) Select the OK button to proceed to the login page Error Note If you recevie an error message during account activation, call Molina EDI support at 1 (866) or [email protected] and request a manual activation for your account Log In as a Trading Partner 1) Click on the Provider tab (Figure 1-4). 2) Enter your User Name and Password. 3) Click on the Sign In button to login. Once you have logged in, a Trading Partner tab will appear above the navigation pane. Figure 1-11: Trading Partner Tab Last Updated: 4/8/2016 Page 8 of 72

16 1.6. Administration and Account Maintenance Account Maintenance The first person to register as a trading partner for an account is considered the administrator for that account. (See Account Administrator.) In Account Maintenance, the administrator can do the following. Manage users Access provider associations Reset password Access trading partner status (also known as trading partner demographic edits) The selection of options may be different based on the user types Manage Users Add User The administrator may add users as needed. The administrator may be given access to the check boxes which can be selected for each user. Figure 1-12: Manage Users 1) Click the Add User button in the top right corner of the screen. 2) Fill in the First Name, Last Name, and Address fields for the new user. 3) Select the appropriate check boxes for the user. 4) Click the Submit button to add the user or the Cancel button to exit the transaction. Note: Access is limited to the type of user that is added as seen in Figure 1-14: Access Availability Figure 1-13: Add User Last Updated: 4/8/2016 Page 9 of 72

17 Figure 1-14: Access Availability Terminate User The account administrator may also terminate user accounts as needed. To terminate a user account, follow the steps below. 1) Click on the name of the user you wish to terminate. The Edit User box will display (Figure 1-15). 2) From the Status dropdown, choose Terminated. 3) Click the Update button. Important note: If the account administrator is the only user account on the TPA, terminating this user will terminate the entire TPA account. If changes to the administrator account are needed, refer to Account Administrator. Last Updated: 4/8/2016 Page 10 of 72

18 Figure 1-15: Terminate User Change or Correct an Address The account administrator may change or correct an address for any user. To update an address, follow the steps below. 1) Click on the name of the user whose address needs a change or correction. 2) In the Address field, enter the updated address. 3) Click the Update button Provider Associations Clicking on the Provider Associations link will display the billing providers associated with a trading partner account. This information may be edited or added to by the administrator (the first person to register the account). Billing provider associations must be established to use the direct data entry forms on Health PAS-OnLine. Click the Add New Provider button to add additional billing/pay-to provider records. Figure 1-16: Provider Associations A form will display with the FEIN/SSN, NPI, Provider ID, and PIN/Check fields. Last Updated: 4/8/2016 Page 11 of 72

19 Figure 1-17: Add Provider to Provider Associations 1) Enter the FEIN/SSN. 2) Enter either the NPI or Provider ID numbers. 3) Enter the PIN/Check Number. (PIN is the provider enrollment case number assigned during Provider Record Update or new enrollment.) 4) Click the Add Provider button or the Cancel button. 5) Click the Edit button to make any changes that may be necessary Resetting Password If the current password for the trading partner user name is lost or forgotten, the administrator can reset it from the provider Welcome page. For additional security, the password for the trading partner is required to be changed every 60 days. (The user name is retained, but the password must be changed.) If the password has not been changed after 60 days, a prompt will display to reset the password at the next attempt to log in. To reset the password use one of the two methods: If the current password is known, use the Reset Password link in the Account Maintenance menu. If the current password is unknown, Reset Password from the portal Welcome page. If you are unable to successfully reset the password, contact the Help Desk for assistance. Resetting When the Current Password Is Known If the current password for the trading partner user name is known, use the Reset Password link in the Account Maintenance menu and follow the steps described below to reset the password. 1) Enter the Current Password. 2) Enter the New Password that follows these password guidelines. a. Must be at least six characters long and contain at least one each of: a) an upper case letter, b) a lower case letter, c) a special character (such as an asterisk *), and d) a number. b. May not contain spaces. 3) Enter the same new password in the Confirm New Password field. 4) Click the Change Password button. Last Updated: 4/8/2016 Page 12 of 72

20 Figure 1-18: Reset Password Screen A confirmation message will display. Click the OK button to continue. The Welcome screen will display. Resetting When the Current Password Is Unknown If the current password for the trading partner user name is lost or forgotten, reset it from the Home Page. Select the Reset Password link under the Trading Partner Sign In on the Provider tab. A pop-up box will appear. Figure 1-19: Forgot Password Box Specify the trading partner User Name in the box and click on the Continue button. The dialog box displays the address and the security question associated with the user name. Figure 1-20: Security Question Enter the answer to the security question in the Security Answer field and click on the Continue button. If the answer to the question is successful, the system sends an to the address associated with the user name and displays the confirmation message. The contains a confirmation link and activation PIN. After the is received, click the link or copy and paste it into the browser. A pop-up box displays for the Password Recovery screen with the user name and activation PIN pre-populated. Last Updated: 4/8/2016 Page 13 of 72

21 Figure 1-21: Password Recovery Screen To complete the process, follow these steps. 1) Enter a New Password that follows the password guidelines. a. Must be at least six characters long and contain at least one each of: a) an upper case letter, b) a lower case letter, c) a special character, and d) a number. b. May not contain spaces. 2) Confirm New Password by retyping the password exactly as typed in the New Password box. 3) Click the Change Password button. A confirmation message will display. Resetting When Portal Account Is Locked Out If while attempting to sign into your trading partner account, the user has five failed attempts, the portal will display a message that the users account has been locked. Once a security question is answered an is generated to the users address allowing them to unlock their account and reset their password. It does not matter which browser is being used, Google Chrome, Firefox, or Internet Explorer the functionality is the same. When the user experiences the lock-out message, they should be able to answer a preset security question and receive an that allows them to unlock their account without Call Center support. After five attempts at signing into the trading partner account the user will receive a message stating that multiple failed sign in attempts have locked the account for security reasons. In order to unlock the account the user must use the Click Here link to reset their password. Figure 1-22: Lock-out Message 1) Click the unlock link, Click here Last Updated: 4/8/2016 Page 14 of 72

22 2) When the Account Self Unlock box appears, enter in the Security Answer Figure 1-23: Security Answer 3) Click Unlock Account A notification pop-up will inform the user that their account unlock and password reset link has been ed to them. Figure 1-24: Unlock Account and Reset Password sent 4) Click OK An will be sent to the current existing address that was filled in by the provider when setting up their account. When the is received, there will be a message letting the provider know their account can be unlocked by selecting the link provided (may need to copy and paste into their browser). Figure 1-25: Unlock Account and Reset Password 5) Either click the link or copy and paste into your existing browser Once the page loads, a new password and security question can be entered. Last Updated: 4/8/2016 Page 15 of 72

23 Figure 1-26: Enter New Password and Security Question 6) Enter in a new Password, then re-enter the Password again 7) Enter in a new Security Question, then re-enter the Security Answer again 8) Click Change Password The Password Reset pop-up box will appear letting you know that the account has been unlocked successfully with the new password. The provider should now be able to use the new password to login into their Trading Partner Account. Figure 1-27: Password Reset pop-up Figure 1-28: Enter New Password The Password must contain at least 6 characters consisting of an upper and lower case letters, a special character such as # or * or ^ (except a,) and a number. The Security Question and Security Answer should be confidential. If there are issues with either one, a message will appear in Red under the section with the incorrect information. Figure 1-29: Valid Password Format Last Updated: 4/8/2016 Page 16 of 72

24 Figure 1-30: Incorrect Password Format If the Cancel button is selected without entering in a new password and the provider attempts to go back in and to reset their password, the same error message will appear. Figure 1-31: Lock-out Message If the provider cancels out of the password reset screen, they must use the pin already provided. If the provider attempts to login again and resends the account unlock they must use the new pin provided. If the provider clicks on the link for the old pin number or security question, an Invalid Activation PIN screen will pop up and no fields can be selected and the Change Password button is grayed out. They will need to go back and select the newly generated and pin. Make sure to pay attention to which pin is being used for account unlock. Figure 1-32: Invalid Activation PIN Last Updated: 4/8/2016 Page 17 of 72

25 Figure 1-33: Newly Generated and PIN New Address If the provider needs to create a new address, they will have to contact the Call Center. The Call Center representative will be able to update the address User Name Retrieval If the user name for the trading partner account is lost or forgotten, use the Retrieve User Name link under the Trading Partner Sign In on the Provider tab. After clicking the link, the Retrieve User Name pop-up screen will display (Figure 1-22). Type the address that is associated to the User Name and click on the Continue button. Figure 1-34: Retrieve User Name If the address entered is associated with multiple trading partner accounts, the confirmation message will display an error (Figure 1-23). If the address is associated to only one trading partner account, the security question screen will display (Figure 1-24). Figure 1-35: Multiple Accounts Found Last Updated: 4/8/2016 Page 18 of 72

26 If the error message is received, enter the trading partner ID in the field provided and click Continue. (This number was ed when the trading partner account was created. It is the same number that is used as the sender ID for X12 submissions.) Note: If the trading partner ID is unknown, call the number listed in the error message for additional assistance. Figure 1-36: Security Question Type the answer to the security question in the Security Answer field and click on the Continue button. If the answer to the question is successful, the system sends an to the address associated with the user name and displays a confirmation message Change User Name To change a user name, send an on company letterhead, from a company address, to [email protected]. Include the following information: Current user name on file that will be changed New user name (Note: a user name may only be used once on a TPA) First and last name of the user Verification of the current address on file Trading partner ID or provider NPI Indication of whether or not password reset is also needed You will receive a response to your inquiry on the same or next business day Trading Partner Status This selection allows the trading partner to update the trading partner demographic information that was provided during initial registration. The following fields are locked and cannot be edited. Provider or Business Name Authorized Registrant First Name Authorized Registrant Last Name The remainder of the demographic information can be updated. First, click on the Edit button (Figure 1-25). Update the information necessary and click on the Save button. Last Updated: 4/8/2016 Page 19 of 72

27 Figure 1-37: Trading Partner Status Figure 1-38: Update Demographic Information 1.7. Managing Alerts With a TPA, you can opt to receive alerts whenever certain content on the Idaho Medicaid website such as MedicAide newsletters, announcements, Information Releases, etc. is added, removed, or changed. In order to set up alerts, you must have the permissions granted to you by the administrator or be the administrator of the TPA Adding Alerts To set up alerts on your TPA, follow the steps below. Note: Alerts must be added one at a time. 1) Sign into your TPA. 2) Click on File Exchange. 3) Click on Alerts & Notifications. 4) Click on Document Library Alerts. 5) Click on Add Alert. The New Alert screen will display (Figure 1-27). Last Updated: 4/8/2016 Page 20 of 72

28 6) Select the radio button for the alert you would like to receive. Figure 1-39: Sample of Alert Types 7) Click the Next button at the bottom of the screen. 8) Verify the address the alerts will be sent to. 9) Select the changes for which you want to receive alerts. (For example, all changes, new items added, existing items modified, items are deleted.) 10) Select when you want the alerts sent to you. (For example, by immediately, daily summary, or weekly summary.) Figure 1-40: Alert Settings 11) Click OK. A list of your alerts will display (Figure 1-28). Last Updated: 4/8/2016 Page 21 of 72

29 Figure 1-41: List of Alerts Editing Alerts To edit the setup of an alert, follow the steps below. 1) Click on File Exchange. 2) Click on Alerts & Notifications. 3) Click on Document Library Alerts. 4) Click on the name of the alert you wish to edit. The Edit Alert screen will display. 5) Make any desired changes, and then click the OK button Deleting Alerts To delete an alert, follow the steps below. 1) Click on File Exchange. 2) Click on Alerts & Notifications. 3) Click on Document Library Alerts. 4) Select the checkbox next to the alerts you would like to delete. 5) Click on Delete Selected Alerts. 6) Click OK when asked to confirm if you wish to delete the selected alerts. 2. ELIGIBILITY VERIFICATION It is a best practice to verify eligibility for all Medicaid participants on the day the services are to be rendered by a provider. This ensures the provider that the participant is eligible on that date for the services. First, you will need to find the member. For eligibility verification, you will need two of the following criteria. Member ID Name (Last and First) Date of Birth Social Security Number For example, you might choose to enter the Name (Last and First) and the Date of Birth. Once you have completed the member search, the Eligibility Verification window opens to allow an inquiry for a participant (Figure 2-1). Last Updated: 4/8/2016 Page 22 of 72

30 Figure 2-1: Inquire Eligibility of Participant After the search criteria have been submitted, the Eligibility Verification screen will display (Figure 2-2) and the Name, Date of Birth, Medicaid ID, and Gender will automatically fill the Member area. This information cannot be edited. Figure 2-2: Eligibility Verification Screen To see additional information about the participant, including demographics, click on the participant name. A window showing the participant information will open. Last Updated: 4/8/2016 Page 23 of 72

31 Figure 2-3: Participant Information To go back to the Eligibility Inquiry screen, click on the Back to Eligibility Verification link. The Tracking Number (Figure 2-4) is a verification number assigned to the transaction by the Health PAS system. It is used to provide proof (when requested) that the eligibility for the participant was verified. It is good practice to print and add this verification to the member s medical record. The Dates of Service, both From and To, are required fields for this form. The dates can be entered manually using the format MM/DD/YYYY, or you can use the calendar at the end of each field. From Date o Automatically fills with current date o Date can be changed, but not for more than one year in the past To Date o Automatically fills with current date o Cannot enter a future date Figure 2-4: Eligibility Verification Last Updated: 4/8/2016 Page 24 of 72

32 If a HIPAA Category Code shows eligible, that does not mean every service is eligible. The information does not guarantee payment for services rendered. Please pay close attention to the details of the coverage code listed (Figure 2-5). If further clarification is needed, call Provider Services between 7 A.M. and 7 P.M. MT at 1 (866) Figure 2-5: Important Information Clicking on the Reset button at any time resets all the values. Before submitting, it is a good idea to review your entries for accuracy. Then click on the Submit button to enter the request. After the request is submitted, the response will display (Figure 2-6). These sections will always appear in the response. Enrollments Other Insurance PCP Assignment Figure 2-6: Eligibility Verification Response The participant s plans are listed under the Enrollments tab. Each plan heading will display the Coverage Code Descriptions for that particular plan. This section displays the types of coverage for which the participant is eligible. Last Updated: 4/8/2016 Page 25 of 72

33 The column called Coverage Status populates as either Active or Partial. In addition, effective/termination dates are populated only when coverage is partial. See the following example. When the enrollment is active for the entire inquiry period, the coverage status is displayed as Active. Otherwise, the coverage status is displayed as Partial and either effective date, or termination date, or both are populated. The table below shows the enrollment information that would display for a member with enrollment active from 1/1/2013 to 12/31/2013. Coverage Status for Enrollment of 1/1/2013 to 12/31/2013 Inquiry Period Coverage Effective Date Termination Date Status 3/1/ /31/2013 Active Blank Blank 10/1/ /31/2013 Partial 1/1/2013 Blank 3/1/2013 2/1/2014 Partial Blank 12/31/2013 You can print the request from the Eligibility Verification Response screen in order to have a paper record of your request. Click on the Print Receipt button found at the bottom of the screen below the eligibility response information. A new window displays the entire Eligibility Response with a Print button at the bottom. After printing the response, you can click on the New Verification button (above the Eligibility Verification Response) to search for a different participant s eligibility. 3. CLAIM SUBMISSION To access online claim entry, click on Claim Submission under Form Entry in the navigation pane. On the first screen (Figure 3-1), identify the billing provider. The field may have filled automatically if this is the only provider on this TPA. If not, click on the down arrow to open the drop-down menu. Choose the appropriate billing provider. On the next line, click on the radio button next to the type of claim to be entered: Professional, CMS-1500 Institutional, UB-04 (also called CMS 1450) The Dental claim option should not be used. Dental claims are processed through DentaQuest. Dentists enrolled with Molina may only bill for interpretation services. Note: Copy Last Claim is not a claim type please see Section 3.4 below to learn more about this feature. Figure 3-1: Select Billing Provider and Claim Type Identify the participant who received the services associated with this claim by entering at least two search criteria using the fields in the Find Member screen. See Section 2 Eligibility Verification, for additional detail. Last Updated: 4/8/2016 Page 26 of 72

34 3.1. Diagnosis Codes Diagnosis codes are required on all claim types. When entering diagnosis codes on your claim, be sure to use the correct ICD code sets for the date of service. For dates of service before October 1, 2015, use the appropriate ICD-9 code. For dates of service on or after October 1, 2015, use the appropriate ICD-10 code. Only one ICD version may be used per claim. If you attempt to submit a claim containing both ICD-9 and ICD-10 codes, you will receive an error message and must correct before the claim can be submitted ICD Code Version Before entering any diagnosis codes, you must indicate whether you are using ICD-9 or ICD-10 codes on the claim. The diagnosis codes entered must match the ICD version selected; if they do not match, the code description will read Code Not Found. Figure 3-2: ICD Code Version Diagnosis Code Search To search for a diagnosis code, click in the Code field on the claim and then click on the Search icon near the Line # and a search window will open. In the search window, enter a diagnosis description in the Description field. Click on the Search button to display a list of results at the bottom of the window. Search results will ONLY yield codes for the ICD version selected on the claim form (see ICD Code Version). Figure 3-3: Diagnosis Code Search Figure 3-4: Diagnosis Code Search Results In the list of search results, click once on the Code ID. The Code ID will appear in the Code field of your form (Figure 3-5). Press the Tab key or click in the Description field and the Description and Type (professional and institutional claims only) fields will be loaded into your form. Last Updated: 4/8/2016 Page 27 of 72

35 Figure 3-5: Selecting Code from Search Results 3.2. Professional Claim The professional claim, comparable to the paper CMS-1500, is used for non-institutional providers (generally group or individual provider practices) or suppliers. There are four sections to the claim screen: Claim Information Diagnosis Services Additional Information Reminder: Any fields with a red asterisk (*) are required. An error message will be displayed if these values are left blank at time of submission Claim Information for Professional Claim The participant information (Figure 3-6) will auto-fill based for the participant identified. The Patient Account #, the number assigned to the patient in your billing system, is a required field. The Medical Record # (as used by your office) may be entered if your office chooses to do so. The Referring Provider can be entered manually (exactly as it appears in the Medicaid records) or by searching for a provider by clicking the Search icon. Rendering Provider, a required field, can be selected from the drop-down menu. Click on the name of the rendering provider and the field will fill. Enter the Service Location by choosing the correct service location for the rendering provider and this particular service from the drop-down menu. The Condition Codes, Ordering Provider, and Supervising Provider fields will be used in the future, but are not required at this time and do not affect claims processing. If you choose to enter data into these fields, you may select a maximum of six condition codes. Ordering and supervising providers are entered the same as the referring provider. Figure 3-6: Claim Information for the Professional Claim Last Updated: 4/8/2016 Page 28 of 72

36 Diagnoses for Professional Claim This screen is used to enter all the diagnoses for the participant for this claim. As many diagnoses as needed may be entered. To add a new line, press the Tab key at the end of the last line and a new line will appear. There are five fields in the diagnosis section: Line # Code Description Type: Whether the diagnosis is primary or secondary ICD Version (Effective 10/1/15): Will indicate a 9 or 10 based on the ICD version selected The only field you can edit is Code. The Line # will increase automatically as each line is added. The Description and Type will appear once the code is entered. If the code cannot currently be used for billing, an error message will appear in the description field. The first line entered will be the primary diagnosis. The primary diagnosis must be closely related to the procedure. All lines entered after that will be considered secondary diagnoses. To delete a line from the list, click the Recycle Bin icon next to the Line # field. A diagnosis line cannot be deleted if it will be listed in one of the Related Diagnosis fields on a Service Code line on the claim Services for the Professional Claim The fields for entering Services are as follows. Line # Dates of Service (From and To): Format: MM/DD/YYYY Place of Service Code Modifier(s) Related Diagnosis Charge Units Minutes (This field is grayed out as it is not required at this time) EPSDT (Early Periodic Screening, Diagnosis and Treatment) Emergency Authorization # Rendering Provider Figure 3-7: Services for Professional Claim Note: Total charges and total units will need to be entered. You must enter the prior authorization (PA) number in the Auth # field if a service requires a PA. In the Auth # field, enter the entire PA number including the AUTH. (Qualis PAs do not contain the AUTH text, and do not need this text to be entered before the number.) You can search for the PA number under Authorization Status in the navigation menu. For more information, refer to Section 5 Check the Status of an Authorization. Last Updated: 4/8/2016 Page 29 of 72

37 When you press the Tab key through all these fields without entering anything, some of the fields will fill automatically. The following information will display: Dates of Service (From and To): Current date Place of Service: 11 Charge: $0.00 Units: 1 EPSDT: N Rendering Provider: Same rendering provider listed above in the Claim Information section at the top of the screen When a service code is entered, the description will appear below in the Service Code Description box. If the code cannot currently be used for billing, an error message will appear in the description field. As in the diagnosis area, to add more lines, press the Tab key at the end of the last line and a new line will appear. Up to 99 service lines are available for entry. If any required field has not been entered, the cursor will jump back to that field before displaying a new line. The Total $ and Total Units will appear in the grey area next to the Service Code Description box. If the service is for a drug product, click on the NDC check box (Enter NDC Codes) directly under the Services tab (Figure 3-7). The applicable fields will be available for entry at the right end of the array. The fields are: National Drug Code (NDC)* Unit of Measure* Quantity/Units* Rx Number Note: If any of the fields marked with a (*) are entered, the other two are required. The Rx Number field is used when a provider administers a compound drug and is billing multiple service lines with the individual NDCs that make up the compound. The Rx Number is needed to link the individual service lines together. The value should be the same for each service line containing the components of a single compound. Figure 3-8: Enter NDC Codes To search for a drug code, click first on the Code field, then click on the Search icon near the Line # and a new search window will open. More data for Oxygen Therapy and Coordination of Benefits (COB) information may be added to the claim by clicking the links at the bottom of the claim form entry screen. Figure 3-9: Hyperlinks for Oxygen Therapy and COB Information Last Updated: 4/8/2016 Page 30 of 72

38 Oxygen Service Information To enter Oxygen Services information, click on the Enter Oxygen Therapy link (Figure 3-9) to open the Oxygen Services window. Enter the information in the fields provided (Figure 3-10). Click on the Add button to add the information to the screen. Figure 3-10: Oxygen Therapy Entry After clicking on the Add button, the Oxygen Services Summary will display. To edit a value, select the Edit icon, modify a line, and select the Save button. Click the Submit button on this window to keep the information. Figure 3-11: Oxygen Services Summary Coordination of Benefits (COB) Information Click on the Enter COB Information link (Figure 3-9) to access the appropriate screen. On the COB Information screen (Figure 3-12), click on the applicable radio button to have the COB information entered by Claim or Service Line. The data should represent the amount already paid to the provider either by Medicare/Medicare Advantage or by Commercial/Medicare supplement. Medicare/Medicare Advantage and Commercial/Medicare supplement information can be entered either by the claim line or claim header for each COB type. If COB is entered at the line, totals are displayed at the top of the data-entry grid. The Medicare line contains the following fields. Note that the first three fields do not display if the By Claim radio button was chosen. Line #/Total Service Code DOS (Date(s) of Service): Format: MM/DD/YYYY Allowed Amount Last Updated: 4/8/2016 Page 31 of 72

39 Paid Amount Deductible Amount Coinsurance Amount Act (Action) Code: Up to four may be entered Paid Date: Format: MM/DD/YYYY Commercial contains the same fields with the exception of the Action Code. Figure 3-12: COB Information All dollar amounts can be entered without the dollar sign. Whole dollars can be entered without the decimal and the additional zeros. For example, the following entry conventions apply: For $100 even, enter 100, the field will display For $54.35, enter 54.35, the field will display For $45.10, enter 45.1, the field will display Note that it is not necessary to enter the last 0 Enter/update information on this page, click Submit at the bottom of the page, and then either Save or Adjudicate the claim in order to store the information. For more information on entering third party benefit information, see the General Billing Instructions section of the provider handbook or the FAQs on the Molina Medicaid website Additional Information for the Professional Claim The Additional Information section contains information about whether these services are related to any kind of accident. The choices are: Employment Auto Accident Other Accident Enter the Date of Accident in MM/DD/YYYY format. If the claim relates to an Auto Accident, enter the State in which the accident occurred in the field just below Auto Accident (Figure 3-13). Last Updated: 4/8/2016 Page 32 of 72

40 Figure 3-13: Additional Claim Information Submit the Professional Claim When all the information has been entered, review your entries for accuracy, and click on the Submit button to submit the claim. Any error messages will appear in red at the top of the page and must be corrected before the claim will actually be submitted Institutional Claim This claim, comparable to the paper UB-04, is used for all providers billing institutional claims and providers who bill Medicare fiscal intermediaries. There are six parts to this claim: Claim Information (Section 3.3.1) Admission Data (Section 3.3.2) Diagnosis, Visit, and Injury (Section 3.3.3) Procedures (Section 3.3.4) Condition, Occurrence, and Value Codes (Section 3.3.5) Service Codes (Section 3.3.6) The institutional claim contains several code fields; for more information on entering and searching for codes, refer to 3.1 Diagnosis Codes. Once a code is entered, press the Tab key and the code description will auto-populate. The system will check the codes entered; if a code cannot be used, an error message will display in the code field. All dollar amounts on the institutional claim can be entered without the dollar sign. Whole dollars can be entered without the decimal and the additional zeros. For example, the following entry conventions apply: For $100 even, enter 100, the field will display For $54.35, enter 54.35, the field will display For $45.10, enter 45.1, the field will display Note that it is not necessary to enter the last 0 When entering lines of information on the claim, you can add additional lines by pressing the Tab key at the end of each line. You can also delete lines by clicking the recycle bin icon in front of the line you wish to delete. Reminder: Any input fields with a red asterisk (*) are required. An error message will display if these values are left blank Claim Information for the Institutional Claim For Claim Information for the institutional claim, see Figure 3-14 below. The participant information will be auto-fill based on the participant identified. Last Updated: 4/8/2016 Page 33 of 72

41 For information pertaining to the following fields, please refer to Claim Information for Professional Claim. Patient Account # Medical Record # Referring Provider Service Location Bill Type is a required value. The Attending and Operating provider fields may be required depending on the bill type or the service codes entered. Enter Covered Days, Non-Covered Days, Life-time Reserve, and Co-insured Days as needed. Figure 3-14: Claim Information for the Institutional Claim Bill Type on the Institutional Claim Bill types on institutional claims require four digits, with 0 as the first digit. When entering a bill type on the institutional claim, the third digit determines whether the claim is considered inpatient or outpatient. If the third digit of the bill type is a 1 or a 2, the claim is considered inpatient and an admitting diagnosis will be required on the claim. If an admitting diagnosis is not entered, an error message will display. If the third digit of the bill type is a 3, the claim is considered outpatient and an admitting diagnosis cannot be entered on the claim. If an admitting diagnosis is entered, an error message will display Admission Data for the Institutional Claim This section of the claim form has six data fields (Figure 3-15): Admission Date: Format MM/DD/YYYY Admission Source Code Admission Time: Format: HH* Discharge Time: Format: HH* Admission Type Code Patient Status Code *Enter the closest hour to the admission/discharge time. Enter times using a 24-hour format. For example: 8:00 am would be entered as 08 7:00 pm would be entered as 19 (note that = 19) Last Updated: 4/8/2016 Page 34 of 72

42 Enter as much information as possible in the applicable fields. Figure 3-15: Admission Data for the Institutional Claim Diagnosis, Visit, and Injury Codes for the Institutional Claim This section of entry for the institutional claim has four sets of fields (Figure 3-16). Diagnosis Admitting Diagnosis Reason for Visit External Cause of Injury An Admitting Diagnosis is required if the third digit of the bill type entered on the claim is a 1 or a 2. For more information, see Bill Type on the Institutional Claim. Except for Reason for Visit, each has four fields: Code: editable Description: information will fill automatically once the code is entered Type: primary or secondary, filled in automatically once the code is entered POA (Present on Admission): use one of the following codes. Note: Although not marked with an asterisk (*), this field is required. o Y for Yes o N for No o U for Unknown/Undetermined Enter the diagnosis codes (if known) or click the Search icon to search for a code. The first line entered will be the primary type. This primary diagnosis must be closely related to the procedure(s) associated with the claim. All subsequent lines entered will be secondary. Figure 3-16: Diagnoses, Visit, and Injury Codes for the Institutional Claim Procedures for the Institutional Claim The fields for entering the Principle Procedure and Other Procedures codes include: Code Description Date: Format MM/DD/YYYY Type Last Updated: 4/8/2016 Page 35 of 72

43 For all procedure codes, the Code and the Date of Service can be entered or edited. The Description and the Type will fill automatically. The first line entered will be the primary type. All following lines entered will be secondary. Figure 3-17: Procedure Codes for the Institutional Claim Condition, Occurrence, and Value Codes for the Institutional Claim Condition, Occurrence, and Value Codes (Figure 3-18) provide additional information used in adjudicating an institutional claim. Condition Codes have two fields: Code Description Occurrence Codes have either three or four fields: Code Description Date: Format: MM/DD/YYYY o For an Occurrence Code there is one date o For an Occurrence Span there are From and Thru dates Value Codes have the three fields: Code Description Amount Figure 3-18: Condition, Occurrence and Value Codes Service Codes for the Institutional Claim Service Code fields (Figure 3-19) include: Line# Code HCPCS (Healthcare Common Procedure Coding System) Modifier(s) Dates of Service (From and To) - Format: MM/DD/YYYY Units Charge Non-Covered Charges Last Updated: 4/8/2016 Page 36 of 72

44 Auth # NDC (National Drug Code)* Unit of Measure for NDC* Quantity/Units for NDC* Rx Number for NDC* Service Code Description *NDC, Units of Measure, Quantity/Units, and Price will open and be available only when the box to the left of Enter NDC Codes contains a check mark; click on the box, a check mark will appear, and the four fields will open. For more information on entering NDC information, see Services for the Professional Claim. Up to 99 lines of service codes may be entered. After each code has been entered, the total price and total units will be displayed next to the CPT Code Description box. Pressing the Tab key to move through the fields will automatically fill the fields below: DOS From and DOS To: The current date Units: 1 Charge: $0.00 Non-Covered Charges: $0.00 You must enter the prior authorization (PA) number in the Auth # field if a service requires a PA. In the Auth # field, enter the entire PA number including the AUTH. (Qualis PAs do not contain the AUTH text and do not require this text to be entered before the number.) You can search for the PA number under Authorization Status in the navigation menu. For more information, refer to Section 5 Check the Status of an Authorization. Figure 3-19: Service Codes for the Institutional Claim Coordination of Benefits More information for the Coordination of Benefits (COB) for the claim may be added by clicking the link in the lower left of the Service Codes area (Figure 3-9). The COB Information can be entered for the whole claim or for each individual service line for any amounts previously paid to the provider. For more information on entering COB information, see Coordination of Benefits (COB) Information Submit the Institutional Claim When all the information has been entered, review your entries for accuracy and click on the Submit button to submit the claim. Any errors will appear at the top of the page in red and must be corrected before the claim will actually be submitted. Once submitted, a confirmation message will display. Here, you will have the option to edit the claim or to upload any attachments that need to be submitted with the claim. For more information on adding attachments, see Adding Attachments. Last Updated: 4/8/2016 Page 37 of 72

45 3.4. Copy Last Claim This feature allows the provider to select the most recent claim by date of service for the Member ID entered. If there is more than one claim with the same date of service, the system will select the most recent claim submitted based on time stamp. If the system does not find a claim for the member entered, the provider will get message that No Claim Found. In this case, the provider will resubmit the claim without using the Copy Last Claim feature Search for Last Claim Submitted Identify the Billing Provider and choose Copy Last Claim as the claim type. Identify the participant who received the services associated with the claim you want to copy, using the fields in the Find Member screen Copy Claim Detail Feature The system will return the most recent claim detail based on date of service. The Patient Account # and Claim DOS fields will not be copied over to the new screen. This is done to ensure these fields are entered/reviewed by the provider. The claim type is identified at the top of the screen (Figure 3-20). Figure 3-20: Copy Last Claim Identifying Claim Type All fields on the Claim Detail screen must be reviewed and completed before resubmitting the claim for payment. The claim fields/sections of the claim detail form that are required are outlined below. Reminder: All fields with a red asterisk (*) are required fields Review Claim Information The claim detail displays on the screen, where the provider can modify as needed before resubmitting the claim. For more information on the Claim Information fields, refer to the instructions for submitting that particular type of claim Diagnosis At least one diagnosis code is required to resubmit the claim. The original diagnosis code is displayed on the screen. The provider can update or modify the diagnosis code if needed Service Codes The DOS From and DOS To fields must be entered to resubmit the claim. Use the MM/DD/YYYY format for the dates Submit the Claim When all the information has been entered, review your entries for accuracy and click on the Submit button to submit the claim. Any errors will appear at the top of the page in red and must be corrected before the claim will actually be submitted. Last Updated: 4/8/2016 Page 38 of 72

46 Once submitted, a confirmation message will display. Here, you will have the option to edit the claim or to upload any attachments that need to be submitted with the claim. For more information on adding attachments, see Adding Attachments Submit and Process a Claim Once you have submitted a claim, the Claim Confirmation will be displayed (Figure 3-21). The Claim ID is in the upper left corner. The confirmation message displays the following options. Adjudicate Claim (see 4.2 Adjudicate Claim) Edit Claim (see 4.1 Edit Claim) Upload Attachments (see Adding Attachments) Print Attachment Cover Sheet New Claim: Opens a new claim form for entry Figure 3-21: Claim Confirmation Adding Attachments When your claim submission confirmation displays, you will have the option to upload any attachments that are needed to process the claim. The Add Attachments screen will display. Select the Type of Attachment from the dropdown; the type will default to X-ray. Click the Browse button to search for the file(s) that need attached. Figure 3-22: Add Attachments Note: Files must be in.pdf,.gif,.tiff,.jpeg, MS Word, or MS Excel formats. Once you have selected the appropriate file(s), click the Attach button. 4. CLAIM STATUS To check the status of a claim, click on Claim Status under Form Entry in the navigation pane. Last Updated: 4/8/2016 Page 39 of 72

47 Select the appropriate billing provider from the drop-down menu. The 40 most recent claims will display; claims are listed by date of service with the most recent claims first. To narrow your search, click the Search icon above the right side of the list of claims. Enter as much information as possible in the search fields and click the Search button. The claims matching your search criteria will display. Figure 4-1: Claim Search There are two options next to the Claims Status tab: Print List and Export to Excel (Figure 4-2). Click on Print List to print a list of all claims. Click on Export to Excel to send all claims to an Excel spreadsheet. Figure 4-2: Print and Export Options The headers include: Claim #: Assigned by the system Claim Type: Professional, dental, or institutional Patient Name Primary Diagnosis Code Dates of Service Status Click on any header to sort the rows using the selected header as the key value. At the bottom of the page, Prev/Next links are for the provider to page backward or forward. To view a claim in more detail (Figure 4-3); click on the claim number from the claims status screen. Last Updated: 4/8/2016 Page 40 of 72

48 Figure 4-3: View Claim Screen To change or process a claim, click on the radio button to the left of the claim number on the claim status screen. One or more of the following options become available, depending on the status of the claim (Figure 4-4): Edit: For claims in a Pay, Deny, Open, Adjudicated, or Pend status Adjudicate Add Attachments (see Adding Attachments) Print: Opens a dialog box to print the claim detail Reverse: For claims in a Paid or Denied status Print Attachment Cover Sheet Figure 4-4: Buttons to Assess a Claim Claims in a Wait status cannot be adjusted or edited. No action should be taken on these claims until they are in a finalized (Paid or Denied) status. For more information on how to edit, adjudicate, and add attachments, refer to section 3 Claim Submission Edit Claim Clicking the Edit Claim button displays the list of edits needed and allows for additions or deletions to parts of the claims (Figure 4-5). Click the radio button in front of the edit to select it for correction. A check box displays in front of each edit so that you can check them off and track the changes as you make them to the claim. Claim Type, Billing Provider, and Member are the only fields that cannot be changed when editing a claim. Last Updated: 4/8/2016 Page 41 of 72

49 Figure 4-5: Outstanding Edits Diagnosis lines can be added and deleted. On the Claim Edit screen, a blank diagnosis line automatically populates; additional lines can be added by pressing the Tab key at the end of the last line. Clicking the recycle bin icon next to a line will delete that particular line. Note: The code version selected on the original claim cannot be edited. Figure 4-6: Add/Delete Claims Lines, Diagnoses Services lines can also be added or deleted. The Service Code Description automatically populates when the numerical code is entered. Figure 4-7: Add/Delete Claim Lines, Services After entering all the corrections and revisions, there are three options. Back: Click on the Back button to return to the previous screen. Note: By clicking this button, any data you have entered or changed will not be saved. Save: Click on the Save button to save the changes made so far. Adjudicate: Click on the Adjudicate button to adjudicate the edited claim Adjudicate Claim Adjudication processes the claim for payment and identifies the amount that will be paid to the provider. If the claim cannot be adjudicated, the screen will show the error message, Warning: There are Outstanding Edits. Click on the Edit Claim button at the bottom of the section to fix these errors in order to attempt to adjudicate the claim again (Figure 4-8). Last Updated: 4/8/2016 Page 42 of 72

50 Figure 4-8: Adjudication Results Note: You can adjudicate up to nine times and correct any errors after adjudication. However, if you need to re-adjudicate a tenth time, then you must let the claim be processed Reverse or Adjust a Claim The adjustment process consists of a Reverse and Replace with the claim data able to be pre-populated, changed, and resubmitted during the Replace portion of the process. Any finalized claim that has been processed through a payment cycle and has a denied or paid status may be reversed and replaced by clicking on the Reverse button on the claim status screen. Figure 4-9: Reverse a Claim You can reverse the claim only, or adjust the claim by reversing it and create a new claim to replace the original. On the reverse claim screen, choose the appropriate action (Figure 4-10). If you choose Reverse this claim only, you will receive a reversal confirmation that will display the Reversal ClaimId. If you choose Reverse this claim and create a new claim, the claim detail screen for the new claim will appear. To preserve existing data, click on the check box to the left of Use the data from this claim as the basis for the new claim. The new claim will have the applicable data copied over to new claim. The new claim can be edited and submitted using updated data (Figure 4-11). Last Updated: 4/8/2016 Page 43 of 72

51 Figure 4-10: Claim Reversal Options Note: If you update any data on the claim, you must tab to the next field from the field(s) you changed. Without tabbing to the next field, the altered information will not be retained when you submit the replacement claim. When you are finished updating the information on the replacement claim, click Save. Figure 4-11: Replacement Claim Last Updated: 4/8/2016 Page 44 of 72

52 5. CHECK THE STATUS OF AN AUTHORIZATION Access the Authorization Status screen under Form Entry in the navigation pane. The View Authorizations screen will open. From the drop-down menu, choose the billing provider who requested the authorizations. A list of authorizations with the billing provider as requesting provider will display (Figure 5-1). Only the 40 most recent records will be displayed. Use the search feature to find other authorizations. Figure 5-1: View Authorizations To change the order of the items displayed, click on the heading of any of the columns; the list will re-sort using that parameter. If the list of authorizations is more than one screen long, use the Prev/Next buttons located in the bottom right corner of the screen. To view an authorization in greater detail, click on the Auth #. The complete authorization will be displayed in a new window (Figure 5-2). Figure 5-2: Authorization Details From the Authorization Details screen it is also possible to: Last Updated: 4/8/2016 Page 45 of 72

53 Add Attachments Print Attachment Cover Sheet Print Detail View Attachments To search for a specific authorization, click the Search icon above the Status column on the View Authorizations screen. Searches may be performed using any of the fields below; however, it is better to enter as much information as possible. Figure 5-3: Authorization Search 6. PATIENT ROSTER You can create a custom roster or a list of participants (members) associated with a particular billing provider. One advantage of creating a patient roster is that you can verify eligibility and submit a claim, referral, or authorization directly from the Patient Roster screen. To access the patient roster, click on the Patient Roster link in the Form Entry section of the navigation pane. The Patient Roster screen appears (Figure 6-1). Select the appropriate billing provider. The patient roster will display with participants sorted alphabetically by last name. Figure 6-1: Patient Roster The results lists the following information: Last Name First Name Date of Birth Member (Participant) ID Last Updated: 4/8/2016 Page 46 of 72

54 To view the information about the participant, click the Last Name hyperlink. To search for a specific participant, click on the Search link or select one of the highlighted letters below it. Note the Print List and Export to Excel buttons. Click on Print List to print the roster of all members. Click on Export to Excel to send the roster to an excel spreadsheet Add or Delete a Member To add a participant (member) to the patient roster, click on the Add New Member link. The Find Member fields display to allow you to search for the participant. Fill in at least two search fields and click the Submit button, and the participant s information displays. Click on the check box in front of the participant's name and then click the Add to Roster button. The name of the participant will be added to your patient roster. Figure 6-2: Find Member If you want to delete a participant from your roster, click on the recycle bin icon next to the last name of the participant on the Patient Roster screen. To create one of the forms for submission, first click the radio button in front of the name of the participant. Then click on one of the buttons at the bottom of the screen to initiate the form. Verify Eligibility See 2 Eligibility Verification Submit Claim - See 3 Claim Submission Submit Referral - See 8 Referrals 6.2. Copy Last Claim Feature This feature allows the provider to select the most recent claim by date of service for the participant selected from the patient roster. To copy the last claim submitted for a participant, click the radio button next to the participant s last name on the Patient Roster screen and then click the Submit Claim button. The Claim Type screen will display. Select the radio button next to Copy Last Claim and proceed as detailed in 3.4 Copy Last Claim. Last Updated: 4/8/2016 Page 47 of 72

55 7. PRIMARY CARE ROSTER The Primary Care Roster is the list of participants that are associated with a certain service location. Click on the Primary Care Roster link under Form Entry in the navigation pane to access the Primary Care Roster. The Primary Care Roster screen will display (Figure 7-1). Select the appropriate billing provider from the first drop-down menu. Then select the appropriate primary care provider (PCP) from the second drop-down menu. The PCP roster will display the current participants assigned to that PCP with the newest effective date at the top of the list. You can also print this list or export the list to Excel. Figure 7-1: Primary Care Roster To view the information about the participant, click on the Last Name. To search for a specific participant, click on the Search link or select one of the highlighted letters below it. For additional information on completing the various forms, see the following guides. Verify Eligibility - See 2 Eligibility Verification Submit Claim - See 3 Claim Submission Submit Referral - See 8 Referrals At the bottom of the screen is also a button to access the Diagnosis History. Click on this button to display the Medical Conditions and Diagnosis History for the selected participant (Figure 7-2). Note that the diagnoses are listed in chronological order with the oldest diagnosis first. You can sort this list by diagnosis code, description, by initial diagnosis date, and by provider. Figure 7-2: Diagnosis History Last Updated: 4/8/2016 Page 48 of 72

56 Click on Next-> or <-Prev in the lower right to see other pages in the list of the Diagnosis History. Click on a number in the Code column to see a list in date order of the medical visits associated with that diagnosis (Figure 7-3). Figure 7-3: View Diagnosis Details To leave the Diagnosis History, click on any item in the member portion of the navigation pane on the left of the screen. 8. REFERRALS To begin the referral process you must log into your Trading Partner Account (TPA). Referrals may only be entered online by a member s current primary care provider organization. Paper referrals should not be faxed to Molina and will not be entered in the system. For instructions to retrieve a referral, see Referral Status Retrieving a Referral. To make sure the referred-to providers can successfully retrieve referrals online, it is important that they provide the PCP with their correct organization pay-to NPI. Make sure that all of the information is correct before submitting the referral. If the referral is found to be incorrect, a new referral will need to be entered. Referral submissions cannot be changed once they are submitted. All claims will process regardless of referral status; it is the responsibility of the billing provider to ensure the referral is in place prior to rendering care Utilization Management Access To submit or retrieve a referral, the user must have Utilization Management access via the Manage Users link under Account Maintenance (for more information on managing users, see Manage Users). 1) Click on the Change button located at the bottom of the screen (Figure 8-1). Figure 8-1: Manage Users 2) Select the R8 Utilization Management checkbox. 3) Click the Update button to capture access (Figure 8-2). Last Updated: 4/8/2016 Page 49 of 72

57 Figure 8-2: Edit User 8.2. Online Website Entry There are two options to create and/or search for a referral. Option One Using the Primary Care Roster Link Option Two Referral Submission Link Option One Using the Primary Care Roster Link The Trading Partner Account (TPA) home page appears after signing in. Use the following information to enter a referral from the Primary Care Roster link. 1) Click on the Primary Care Roster link under Form Entry in the navigation pane. The Primary Care Roster appears (Figure 7-1). 2) If it is not auto populated, select the Billing Provider from the drop-down list. 3) From the Primary Care Provider drop-down list, select a service location. Note: The Primary Care Provider drop-down is a list of service locations with Healthy Connections affiliations to the billing/pay-to provider. To view a list of all members affiliated to the pay-to, choose All Providers from the drop down list. 1) To search for a member: a. Select the first letter of the last name of the member from the alphabetical list and click on the radio button next to the last name, or b. Use the smart search option by clicking on Search and enter all or part of the member s first or last name and click on the radio button next to the name. 2) Click on the Submit Referral button located at bottom of page to continue. This is not the final submit referral action. The next screen is where the referral reason is chosen and for whom the referral is given Option Two Referral Submission Link The second option to submit a referral is from the Referral Submission link. 1) Click on the Referral Submission link under Form Entry in the navigation pane. 2) The Select Billing Provider is auto-filled with the (TPA) information that was entered when signing in. Note: If your TPA has more than one pay-to record, make sure to select the correct billing provider record. 3) The Find Member section requires a minimum of two search criteria. For example, enter the Name (last and/or first) and the Date of Birth (Figure 8-3). 4) Click Submit. Last Updated: 4/8/2016 Page 50 of 72

58 Figure 8-3: Find Member 5) Verify the correct member is displayed. 6) Click Continue to proceed Referral Details After you follow the steps for one of the two options above, the Referral Details screen appears (Figure 8-4). There are four sections to the Referral Detail screen, each requiring specific information explained in the subsections below. Member Information Referral Information Referred to Provider Required Diagnosis/Condition. Notes referral contact name, phone number and referral details Figure 8-4: Referral Details Member Information Confirm that the correct member was selected. If not, select the Cancel button and start the search again. The information included in this section is: Last Updated: 4/8/2016 Page 51 of 72

59 Name Date of Birth Member ID Referral Information The Pay To/Billing Provider information will auto-populate from the previous screen. Required fields (Figure 8-5) are noted with a red asterisk (*). Figure 8-5: Referral Information Referral Information Fields The referral information fields are described as follows: Referral Type *: The referral type auto-populates with PCP Referral. Referral Reasons *: Select an applicable reason from the drop down list of options (Figure 8-6). Figure 8-6: Referral Reasons Diagnosis/Condition required to be documented in Notes section. Note: ALL referral reasons require information about the diagnosis/condition to be documented in the Notes section at the bottom of the Referral Submission screen. For additional instructions on notes, see Notes. Referred From Provider *: Displays a list of ALL service locations. Note: If there is only one primary care affiliation, the field will auto-populate. Start Date*: Enter the start date that the referral is effective. (This defaults to the current date.) End Date*: Enter the date that the referral should terminate. o If the End Date is not entered, it defaults to 365 days from the Start Date. It is important that the appropriate end date be modified if referral intent is less than 365 days. Visits/Units: Enter the number of visits/units. This field is optional. Visits must be greater than 0 and less than Note: If the Referral Reason selected is One-time visit until seen by PCP, the Visits/Units field defaults to 1. If the provider selects One-time visit until seen by PCP and enters a visit/units value of more than 1, the error message Maximum Number of Visits/Units for this Referral Reason is 1 will display at the top of the screen. Last Updated: 4/8/2016 Page 52 of 72

60 Referred To Provider The Referred To Provider search screen provides the ability to search and select a Referred To provider. 1) Click the search icon to find a Referred To Provider or Group (Figure 8-7). Figure 8-7: Referred To Provider 2) Provider Search displays multiple fields that are used to locate specific providers. The information that can be used includes the following: Provider/Clinic Name: Enter a partial or full name of a provider or clinic (service location). Specialty: Choose from the alphabetical drop-down list. Provider Type: Choose from the alphabetical drop-down list. Provider ID, enter the NPI number, if known. Note: Searching by NPI brings back any affiliated provider record. City: Enter a partial or full name of the city. State: Defaults to the state of Idaho; however this can be changed by making a selection from the drop-down list. Zip: Enter the provider s service location zip code. Region: Select from the drop-down list. In Figure 8-8, the search results display providers that met the entered search criteria. Figure 8-8: Provider Selection Note: The search results can display up to 300 providers. If more than 300 providers are found with the criteria entered, you will be prompted to refine your search. 3) Click the radio button next to the identified provider/group. Be cautious to review all information for each provider to confirm the correct refer to individual provider or group is chosen at the correct service location. Last Updated: 4/8/2016 Page 53 of 72

61 Note: In determining the correct Referred To Provider, the PCP can choose to issue a referral to a medical group or to a specific rendering provider within a medical group. 4) Scroll to the bottom of the Search Results screen and click on the Continue button. The Referred To Provider tab populates the Referred To Provider or Group field with the provider or group that was selected in the search screen. The Pay To/Billing Provider displays a drop-down list of Pay To providers affiliated with the referred to provider/group selected. Note: If there is only one Pay To/Billing Provider associated with the selected provider/group, the system will default to the Pay To/Billing Provider. If multiple results are available in the drop-down, select the NPI that is applicable. The Service Location displays a drop-down list based on the selection of the Pay To/Billing Provider. If multiple service locations exist, select the location from the available options in the drop-down. The Service Location is not a required field, however it is recommended for the service location information to display on the referral summary Complex Care or Providers with Multiple Pay To NPIs Primary Care Providers may grant one referral per member, to organizations that may bill with multiple NPIs when services or treatment are clearly indicated on the referral. This referral will be sufficient for the referred to Billing Provider when billing with multiple NPIs. Referrals granted with the approval reason to Diagnose, Treat, and Forward to Specialty Provider may be entered online by the PCP to only the referred to provider. The referred to provider is responsible for forwarding the referral to additional providers for treatment of conditions as identified on the original referral. Only the referred to provider has access to retrieve the referral online Referred To Examples The following examples are various scenarios based on the types of Referred To providers selected and their affiliations. Figure 8-9: Scenario One Scenario Referred To Provider or Group PayTo/Billing Service Location Referred To (Rendering) and Pay To are the same. Displays the selected Provider/Group from the Provider Search screen. No selection is displayed or available. Drop-down list of available service locations is displayed, if more than one exists. Last Updated: 4/8/2016 Page 54 of 72

62 Figure 8-10: Scenario Two Scenario Referred To Provider or Group PayTo/Billing Service Location Referred To (Rendering) not the same as the PayTo and multiple PayTos are affiliated with the rendering provider. Displays the selected Provider/Group from the Provider Search screen. Provides a drop-down list selection of PayTos to select. Note: Selection of the PayTo should be based on the NPI to be sure that the proper PayTo is selected and the associated Service Locations are returned. Drop-down list of available service locations is displayed, if more than one exists based on the selected PayTo. Note: If the PayTo is changed it will require that the service location be selected again based on the new drop down list. Last Updated: 4/8/2016 Page 55 of 72

63 Figure 8-11: Scenario Three Scenario Referred To Provider or Group PayTo/Billing Service Location Referred To (Rendering) not the same as the PayTo and only one PayTo affiliated with the rendering provider. Displays the selected Provider/Group from the Provider Search screen. Displays the static PayTo no options and no selection is necessary. Drop-down list of available service locations is displayed, if more than one exists based on the selected PayTo. Note: If the PayTo is changed it will require that the service location be selected again based on the new drop down list. Last Updated: 4/8/2016 Page 56 of 72

64 Although the list of service locations shown in the drop-down list may contain a variety of locations affiliated with the pay-to, it is important that you select ONLY the service location in where the member needs to be seen Notes The Notes tab is required for all referral reasons. Information about the diagnosis/condition should be entered into this field, including additional referral details/limitations. Notes entered on the referral can be read by the referring provider and the referred-to provider Submitting the Referral 1) Click the Submit button. The message Do you want to submit the referral? Once you click Submit, you cannot change the referral displays. 2) Select OK, if NO changes need to be made. 3) Select Cancel, if changes need to be made. Once a referral is submitted, changes CANNOT be made. Referrals cannot be modified; a new referral must be entered. After submitting the referral, the system generates a confirmation with the referral information and a confirmation number. This confirmation referral number should not be entered on any claim. All claims will process regardless of referral status; it is the responsibility of the billing provider to ensure the referral is in place prior to rendering care. The system provides the options to Print Detail or Add Attachments. For more information on adding attachments, see Adding Attachments. Last Updated: 4/8/2016 Page 57 of 72

65 Figure 8-12: Submit Referral Confirmation 8.5. Referral Status Retrieving a Referral From your TPA, use the navigation pane to access the Referral Status link under Form Entry to retrieve referrals as either the refer-from or refer-to provider. Note: To ensure referred-to providers can successfully retrieve referrals online, it is important they provide the PCP with their correct organization pay to NPI View/Search Provider Referrals The View Provider Referrals window is organized by provider and displays the top 40 active referrals and the status. 1) The Billing Provider field should auto-fill with the billing provider information associated to the TPA used to sign in. 2) Click the Primary Care Provider drop-down menu to display a list of service locations associated to that billing provider. 3) After selecting the PCP, the list displays up to 40 of the most recent referrals for the service location selected. The following fields are displayed (Figure 8-13). a. Referral # b. Date of Service c. Patient Name d. Referred From Provider e. Refer To Provider or Group f. Referral Type g. Status Figure 8-13: Referral Status 4) Sort the columns by clicking on any heading. Last Updated: 4/8/2016 Page 58 of 72

66 5) To search for additional active referrals not displayed in the initial 40, click the Search icon and enter data into the applicable fields. Then click the Search button. a. If a referral is not viewable and the organization has multiple NPIs, try choosing a different billing provider s NPI to search for the referral. 6) After clicking a referral link, the selected referral detail displays (Figure 8-14). 7) Click the Print List button to print, or click the Export to Excel button to export to an Excel spreadsheet. To view attachments, refer to Viewing an Attachment Viewing an Attachment To view attachments that have been sent with the referral, use the following steps. 1) Click on the Referral Status link under Form Entry. 2) The Billing Provider field should auto-populate with the billing provider information used to sign into the trading partner account. 3) Click the Primary Care Provider drop-down menu to display a list of service locations associated to that billing provider. 4) Click on the specific Referral # link (Figure 8-13). The Referral Details window displays. Figure 8-14: View Attachment Button 5) Click the View Attachments button (Figure 8-14). The View Attachment window opens. 6) Click in the Attachments field to show the name of the attachment (Figure 8-15). Last Updated: 4/8/2016 Page 59 of 72

67 Figure 8-15: File Attachment 7) The File Download box appears. a) Click Open to open the document for viewing. b) Click Save to save the document. 9. FILE EXCHANGE Information in this section of the portal concerns the electronic exchange of information. Click on the next to File Exchange in the navigation pane. The list will expand. Click on the next to Responses and next to Reports and those lists will also expand. Information regarding Reports can be found in 10 Reports X12 Upload All trading partners must be individually authorized to submit production EDI transactions. Please refer to the respective Companion Guide link under Reference in the lower navigation pane Routing and Version Selection You have the option of receiving the X12 HIPAA 835 Electronic Remittance Advice file by navigating to the Provider Associations link under Account Maintenance. From there you choose edit and select your desired destination for the 835 (any certified billing agency or clearinghouse, or select My Account to have the 835 delivered to your trading partner account). It is always recommended to ensure arrangements are made with the third party vendor prior to selecting a billing agency or clearinghouse. 1) Click on the Provider Associations link under Account Maintenance in the navigation pane. 2) Click on the Edit button on the list of billing providers associated to the trading partner account (Figure 9-1). The Electronic Remittance Advice (ERA) Authorization Agreement will display. Figure 9-1: Edit Billing Providers 3) Scroll down to the Electronic Remittance Advice Information heading. Select the radio button next to the desired location for the file to be sent. Last Updated: 4/8/2016 Page 60 of 72

68 Download 835 When selected, the 835 will be sent to your Trading Partner Account. No 835 When selected, you will have opted out of retrieving your 835. You can still receive a paper RA if you choose not to receive an electronic 835. Third Party When selected, a drop-down of third parties will appear. Select the billing agency or clearinghouse who will need to receive the 835. The information for the third party will display on the screen. 4) Complete the Reason for Submission, Electronic Signature, and Requested ERA Effective Date under the Submission Information heading, and then click the Update button. Figure 9-2: 835 Routing Selection Options Retrieving Your 835 File 1) Click on the Responses link under File Exchange. 2) Click on the Finance (835, 820) link. All available 835s will display (Figure 9-3). Note: The 820 transaction is not currently supported across the Idaho Medicaid community. 3) Click the 835 link under the Transaction column header to download and save the file to your computer. Figure 9-3: Available 835s 4) The Search button allows a search by Provider, Pay Date, Payment, Check EFT, and Transaction. Figure 9-4: 835 Search Criteria Fields 9.2. Archive Search The Archive Search allows you to search for, display, and retrieve responses to inbound X12 transactions, reports, and outbound only X12 files (such as 835s) directly from the EDI Last Updated: 4/8/2016 Page 61 of 72

69 Transaction Archive. Transactions are maintained online for two years and then transferred to tape. To make a request, click on Archive Search in the navigation pane. The Archive Search screen will display (Figure 9-5). Enter as much information as possible to facilitate the search. The search is limited to a three-month window to reduce the impact on various systems. Figure 9-5: Archive Search The search page contains the following fields: Submission Type (Inbound Transaction Type): o 837 o 270 o 276 o 278 o 834 Outbound Transaction Type: o TA1 o 997 o 999 o 824 o BRR o 271 o 277 o 278 o 820 o 834 o 835/Remittance Advice Sender ID o Molina Usage Indicator o Production o Test Date Range (Limited to three months, format: MM/DD/YYYY) o From o To Submission (Inbound) ICN (nine-digits numeric) Payment ID (Check number or EFT Authorization Code for 835s and 820s) Molina File ID (Numeric; Molina assigns a unique ID to all inbound and outbound transactions, including X12 and reports. This ID will be used by the Help Desk to locate the file.) Last Updated: 4/8/2016 Page 62 of 72

70 The results of the Archive Search are displayed in spreadsheet view. Download either a single file or multiple files by clicking on check boxes in the search response display. Clicking on the Download button initiates the transfer of a single ZIP file containing the file(s) selected. Transactions will be archived in offline storage for ten years. Requests for offline storage items may be made through the Technical Services Help Desk. Offline storage items will be supplied by posting the requested items to a secured document library Responses To access the response EDI transactions, first click on the particular type of response you need. Click on the icon in the navigation pane under File Exchange and then on the icon next to Responses to see the list of available EDI response transactions. The Responses menu includes: Claim (837) Claim Status (276) Eligibility (270) Enrollment (834) Finance (835,820) Services Review (278) Click on any of these items and a list of files (50 per page) of that type will be displayed. Figure 9-6 shows a portion of the list for Claim (837) responses. Figure 9-6: Claims (837) Responses Clicking on the header of a column will sort the records by that particular value. The first time the header is clicked, the list will sort by smallest to greatest. If the header is clicked again, the list will sort by the greatest to smallest. Click on the Download All button to download all the files in that row. Click on the individual file hyperlink to download the single file. 10. REPORTS To access Reports, click on the next to File Exchange in the navigation pane and then click the button next to Reports Remittance Advice (RAs) The Remittance Advice report is a legible copy of the file in PDF format. 1) To view a list of RAs, select Remittance Advice (pdf) to view a list of RAs. Last Updated: 4/8/2016 Page 63 of 72

71 2) Click the Remittance Advice you would like to view. A list of reports displays. Choose all of the reports to download by checking the box at the top of the Select All column. Select individual reports by checking the box on the line of the report that you want to download (Figure 10-1). Click the Download Selected button to download the files. (At least two must be selected.) Figure 10-1: Download Multiple Reports A dialog box will open asking for a description for the file request (Figure 10-2). Enter a descriptive name in order to recognize the file when it is retrieved from the document request download area. Then click the Next button. Figure 10-2: File Request Description A new window will open with a link to the download request area. Figure 10-3: Download Request Link Click on the download request link. The download area will display. Figure 10-4: Download Area Last Updated: 4/8/2016 Page 64 of 72

72 When the Create Date is populated, the zipped file is ready to download to your computer. The file should be ready in 30 minutes. Click on the file description to download the zipped file to your computer Paper Remittance Advice Report You may choose to receive a paper copy of your remittance advice by mail, instead of a PDF. To do so, navigate to Provider Associations under Account Maintenance in the navigation pane. On the line for the appropriate billing provider, uncheck the box in the PDF RA column. Figure 10-5: Opting to Receive Paper Remittance Advice Other Reports & PCP Incentive Payment This link includes Claims Level Advice detailing PCP Incentive Payment for eligible pay-to providers. Additional reports will be added in the future. Note: PCP Incentive Payment reports are viewable only by pay-to providers. Billing providers and clearinghouses will not have access to view these reports. To view PCP Incentive Payment reports, click on Other Reports & PCP Incentive Payment under File Exchange Reports. A list of viewable reports will populate. Select which reports you would like to view. At least two of the reports listed must be selected. For more information on how to complete the report generation process, refer to the instructions in 10.1 Remittance Advice (RAs). Once downloaded, the PCP Incentive Payment report will display the rendering provider name, rendering NPI, member name, Medicaid ID, claim ID, and the dates, codes, and amounts associated with the incentive. PCP Incentive Payment reports can be viewed for the past 365 days Pended Claims Report This is a weekly report that pulls all pended or in-process claims that have not been finalized. This is a companion report for the Remittance Advice (RA); it indicates where claims are in the adjudication process. The RA and an in-process claim report together equal all claims submitted and processed by the system Healthy Connections Rosters This is a monthly report which lists the following for Medicaid. All Idaho Medicaid members currently assigned to the PCCM provider, ordered by tiers/networks (continuing from the previous month) Members newly assigned to the provider Members who are no longer enrolled as members for that provider Members who are no longer eligible for Idaho Medicaid Last Updated: 4/8/2016 Page 65 of 72

73 See 7 Primary Care Roster, which provides similar information and has direct access to eligibility verification, claims submission, referral submission, authorization submission, and diagnosis history for those members on the roster. 11. PROVIDER PAYMENT STATUS Access Provider Payment Status by clicking Provider Payment Status under Form Entry in the navigation pane. Payments made to billing providers, and the claims associated with these payments, can be viewed in this window. Select the appropriate billing provider from the drop-down menu. A list of the most recent payments for that billing provider will display in the Payments area. You may use the search feature to find any payments not listed. Click on Print List to print, or click on Export to Excel to export to an Excel spreadsheet. The Payments area displays the information in columns with the following headings: Payment ID Date: The payment date Amount Type Discount Status Figure 11-1: Payments for the Billing Provider Click a Payment ID in the first column to see additional information about that payment. The Payment Summary will display (Figure 11-2). Last Updated: 4/8/2016 Page 66 of 72

74 Figure 11-2: Payment Summary The Payment Summary has two parts. Information about the payment itself is in the upper part of the screen. Payment ID: The equivalent of check number Payment Amount Payee Name Pay Discount Payment Date Payment Type Paid Date Clear Date In the lower part of the screen is additional information about each claim included in this payment. Claim # Member Name Date(s) of Service Claim Amount Paid Amount To return to the list in the Payments area, click the Back to Payments button at the bottom of Payment Summary screen. To view a claim included in a payment, click the Claim #. The View Claim screen displays (Figure 11-3). Last Updated: 4/8/2016 Page 67 of 72

75 Figure 11-3: Claims Status > View Claim Last Updated: 4/8/2016 Page 68 of 72

76 REVISION HISTORY Version Date Author Action/Summary of Changes /8/2016 TQD DHW validated changes 4/4/ /30/2016 B Oliverez Formatting and QA of new section Password Unlock feature /30/2016 N Carlson C Bell Added new section for the unlock feature under Resetting Password /29/2016 TQD DHW validated changes 1/29/ /29/2016 J Bews Minor corrections made to section /19/2016 K Added referral details for CCF 10790B1. Subramanian 9.2 1/12/2016 H McCain Updated screenshots and content in Section 8 and subsections for referral changes due to CCF 10790B /8/2016 H McCain Updated Figures 1-2, 2-6, and 7-1 for CCF 10768B1. Updated 10.4 Healthy Connections and Health Home Rosters for CCF 10768B1. Updated Figures 3-4, 3-5, 4-6, 4-11, 7-2, and 7-3 to show an ICD-10 code rather than ICD /18/2015 TQD DHW validated 9/17/ /13/2015 H McCain Updates for MHP 53 and MHP /9/2015 TQD DHW validated 6/8/ /4/2015 H McCain Changed Patient Identifier to Patient Account # in Copy Claim Detail 7.2 6/4/2015 H McCain Added new section 1.7 Managing Alerts /4/2015 H McCain Removed EFT/Check Number from items for account validation in 1.2 Registering a New User /16/2015 TQD DHW validated 3/12/15. Promoted to next whole version /16/2015 H McCain Updated Figures 3-5, 4-3, 4-11, and 11-3, and updated Claim Information for the Professional Claim for MHP 51. Updated Account Administrator, and Manage Users, to reflect current process. Added Change User Name and Change or Correct and Address /9/2015 TQD DHW validated 2/9/15. Promoted to next whole version /30/2015 H McCain Added clarification in Coordination of Benefits (COB) Information for Medicare and Commercial entry. Removed reference to Dental handbook in section 3. Claim Submission. Removed information about ICD-10 codes from Diagnosis Code Search. Updated miscellaneous screen shots throughout due to blurriness and to make consistent. Moved the Viewing an Attachment section to be under the Referral Status section /10/14 TQD DHW validated 7/9/ /18/14 H McCain Updated section 4.3 for clarity /23/2014 TQD DHW validated 5/20/ /9/2014 H McCain Updated per DHW comments. Updated Figure 1-13 and Figure 8-2 per changes from TR /25/2014 H McCain Updated service codes sections for CCF to reflect PA number requirement. Changed ICD-10 cutoff date in 3.1 and Diagnosis Codes. Updated screenshots throughout to eliminate blurred information /31/2014 TQD DHW validated 3/28/ /27/2014 H McCain Updated Claim Submission info for ICD-10. Included information about error message for claims containing ICD-9 and ICD-10 codes, per TR /16/2014 H McCain Promoted to next whole version after approval /11/2013 H McCain Updated per Robin Sosin s comments 1.0 9/10/2013 H McCain Compiled individual TPA guides into one document. Revised to make current and consistent and to eliminate repeat information. Authorization Status Guide 1.0 4/30/2010 Molina Original Draft Document 2.0 5/10/2010 TQD Promoted to next whole version after approval /24/2011 S Lyman Removed material not currently used in production and updated Last Updated: 4/8/2016 Page 69 of 72

77 Version Date Author Action/Summary of Changes text and screen shots for information that is available in production /31/2011 TQD Promoted to next whole version after updates are submitted /18/2012 J Dercevel Added new screenshot to show only 40 most recent authorizations will be displayed (MHP update) /22/2012 TQD Promoted to next whole version after updates are submitted Claim Status Guide 1.0 4/30/2010 Molina Original Draft Document 2.0 5/10/2010 TQD Promoted to next whole version after approval 2.1 2/10/2011 J Decreval Updates made based on (MHP-28) CM #213 for Claim Status Page Enhancements 3.0 2/14/2011 TQD Promoted to next whole version based on CM-213 (MHP-28) /22/2011 S Graham Added information on Print List and Export to Excel in section 1, for (MHP 29.3) CM # /8/2011 S Lyman Added information (MHP 30) CM #226: Section 1,0 Claim View, Section 1.1, Search for a Claim, to show that edits are being presented /8/2011 TQD Promoted to next whole version based on CM-202 (MHP-29.3) and CM-226 (MHP-30). Claim Submission Guide 1.0 4/30/2010 Molina Original Draft Document 2.0 5/10/2010 TQD Promoted to next whole version after approval /11/2010 N Walker Updated Copy Claim feature based on CCF /13/2010 TQD Promoted to next whole version after updates for CCF /8/2011 S Graham Notes in section 1.1.3, 1.2.2, and were updated for MHP /22/2011 S Lyman COB information and Figure 1-8 update for TR /30/2011 TQD Promoted to next whole version after updates for MHP 29.3 and TR /5/2011 K Updated section to state Action Code, instead of Account Stoudenmire Code /5/2011 TQD Promoted to next whole version after updates /25/2011 A Nicolls Updated to disable encounter entry for CM /26/2011 TQD Promoted to next whole version after updates /25/2012 A Nicolls Updated Oxygen Entry Form to conform with EDI X12 standard 7.0 6/5/2012 TQD Promoted to next whole version after updates /30/12 W Chin Updated information in section Services for the Professional Claim /30/12 TQD Promoted to next whole version after updates. Getting Started Guide 1.0 4/30/2010 Molina Initial draft 2.0 5/10/2010 TQD Promoted to next whole version after approval /13/2010 TQD Changed Unisys to Molina 2.2 6/13/2011 S Lyman Reviewed and updated the document to make updates for semiannual review /7/2011 TQD Promoted to next whole version /25/2011 A Nicolls Updated to add information for TR /26/2011 A Nicolls Added paragraph about file naming conventions for trading partner account /26/2011 TQD Promoted to next whole version after updates /19/2012 C Stickney Reviewed, condensed, and brought up to date Patient Roster Guide 1.0 4/30/2010 Molina Initial Document 2.0 5/10/2010 TQD Promoted to next whole version after approval /31/2011 TQD Updated with Molina logo 2.2 5/31/2011 K Nixon Updated to reflect enhancements from MHP:31.2, CM /31/2011 TQD Updated proprietary/copyright/hipaa Notice 3.0 6/1/2011 TQD Promoted to next whole version 3.1 7/15/2011 A Nicolls Updated Screen Shots to reflect TR133 Last Updated: 4/8/2016 Page 70 of 72

78 Version Date Author Action/Summary of Changes 4.0 7/20/2011 TQD Promoted to next whole version 4.1 9/19/2011 S Tarr Updated Print and Export to Excel screenshots in Figure 1-4, based on MHP /20/2011 TQD Promoted to next whole version after update for MHP Primary Care Roster Guide 1.0 4/30/2010 Molina Initial Document 2.0 5/10/2010 TQD Promoted to next whole version after approval 2.1 7/1/2011 TQD Updated to make the document more current 2.2 7/27/2011 A Nicolls Added current screen shots from our system and PCP roster enhancements from CM /27/2011 TQD Promoted to next full version after updated /20/2011 S Lyman Updated screen shots and added text on exporting to Excel and printing based on MHP /20/2011 TQD Promoted to next whole version based on update for MHP /19/2012 C Stickney Updated figures 1-2 and 1-3. Referral Guide 1.0 4/30/2010 Molina Original Draft Document 2.0 5/10/2010 TQD Promoted to next whole version after approval 2.1 3/24/2011 S Lyman Removed material not currently used in production and updated text and screen shots for information that is available in production /31/2011 TQD Promoted to next whole version after updates were submitted /18/2012 TQD Updated document to include referral submission process Online 4.1 9/5/2012 J Armstrong Screen shots 4.2 9/28/12 C Stegall Updates/Comments /04/2012 J Armstrong Updated screen shots /18/2012 N Carlson Review of the whole document and screen shots for content and understanding /25/2012 C Stegall Modified verbiage and included additional components necessary R Sosin to provide detailed scenarios and functions /30/2012 N Carlson Review of document after State meeting. Updated screenshots /05/2012 N Carlson Updated from Robin s review with additional comments and updated screen shots /12/2012 N Carlson Updated one screen shot and the verbiage and additional input sent after Robin s and Meg s review /16/2012 N Carlson Updated verbiage given by Meg Hall after the review meeting on 11/14/ /30/12 C Stickney Approved after updates from comments from DHW 11/26/ /19/2012 C Stickney Updated screen for patient roster /7/2013 N Carlson Updated referral status section /11/2013 H McCain Changed Section 6 title to eliminate duplicate headings; added information about search results to section 5.3 for MHP 42. Registration Guide 1.0 8/24/2010 Molina Initial Document 2.0 5/10/2010 TQD Promoted to next full version after approval /25/2011 S Lyman Updated screen shots and text throughout the document based on semi-annual review /18/2013 H McCain Updated registration steps 1-5 and Provider Associations information for CCF (DHW approved 1/16/14) /18/2013 H McCain Updated screen shots for password reset for TR (DHW approved 1/16/14) Remittance Advice Reports Guide 1.0 4/30/2010 Molina Original Draft Document 2.0 5/10/2010 TQD Promoted to next whole version after approval 2.1 3/24/2011 S Lyman Added information to use the Print List or Export to Excel buttons in section 2, for (MHP 29.3) CM # /30/2011 TQD Promoted to next whole version after updates for CM # /29/2012 ANicolls Updates to show new 5010 options /3/2013 TQD Promoted to next whole version after updates for /10/2013 M Hall Updated section 1.4 HC Roster Last Updated: 4/8/2016 Page 71 of 72

79 Version Date Author Action/Summary of Changes 5.0 4/12/2013 R Sosin Validated changes 5.1 5/24/2013 TQD Updated screen shots throughout document and clarified information. Added new information about Provider Associations, PDF RAs by mail, downloading multiple reports, and removed information about /16/2013 H McCain Updated Figure 1-2, updated Section 1.3 to reflect changes for CCF 10646B3 PCP Incentive Payment and to include new screen shots and information about downloading incentive reports /19/2013 TQD DHW validated changes 07/19/ /17/2013 H McCain Updated Section Routing and Version Selection with new screen shots and information for CCF Updated screen shot of PCP Incentive Payment report in new Excel format. (DHW approved 1/16/14) EDI File Exchange Guide /30/2010 Molina Original Draft Document /10/2010 TQD Promoted to next whole version after approval /23/2011 A Nicolls Updated screen shots, updated archive search contents, /26/2011 TQD Promoted to next whole version after semi-annual review /18/2012 A Nicolls Added information about option /18/2012 TQD Promoted to next whole version after updates submitted /17/2013 H McCain Updated screen shots throughout. Updated Provider Associations information for CCF (DHW approved 1/16/14) Eligibility Verification Guide 1.0 4/30/2010 Molina Original Draft Document 2.0 5/10/2010 TQD Promoted to next whole version after approval /18/2010 Molina Updates made due to TR-3397, TR-3528, TR-3753, and CCF /10/2011 J Decreval Updates made based on (MHP-28) CM #204 for Eligibility Verification 3.0 2/14/2011 TQD Promoted to next whole version based on updates for TR-3397, TR-3528, TR-3753, CCF 10376, and MHP /13/2011 S Lyman Added screen shots, added text, and responded to the UB00584B comment sheet /10/11 A Nicolis Updated information about Procedure Code/Service Code/HIPAA Category Codes 3.3 8/10/11 TQD Updated proprietary and HIPAA notices 4.0 8/12/11 TQD Approved by TKinzler, promoted to next whole version 4.1 6/18/13 C Stickney Updated multiple screen shots and add information about the New Verification button /9/13 V. Gatfield Validated changes. IDMedicaid.com Welcome Guide 1.0 8/24/2010 Molina Initial Document 1.1 7/08/2011 TQD Updated screen shots and text throughout the document based on semi-annual review 2.0 7/10/2011 TQD Promoted to next whole version Last Updated: 4/8/2016 Page 72 of 72