West Virginia Medicaid Provider Update Bulletin.

Transcription

1 West Virginia Medicaid Provider Update Bulletin. Welcome. The Department of Health and Human Resources and Unisys welcome you to the Medicaid Provider Newsletter! This monthly newsletter will provide information regarding healthcare policy and claims processing. You will also find timely and useful answers to your questions. DHHR and Unisys are looking to the future and selected advanced technology that will enhance Medicaid in several areas: a Web-based functionality for claims submission, eligibility verification, claims status inquiries, and reporting that allow providers to interact with Medicaid on a scale never before possible. a Advanced tools to enable the department to more closely monitor the health status of patients and to provide current, reliable information to healthcare providers. We also are committed to continuous process improvement. For example, Unisys has modified the Remittance Advice to improve timeliness and readability. New Claims in Process and Check We are committed to continuous process improvement. Number/EFT reports are available via the web portal or by contacting Provider Services. The web portal also has updated Frequently Asked Questions that are valuable for resolving issues. In our Provider Services Call Center, Unisys is committed to provide assistance with any claims transaction issues. The provider community can look forward to several updates in the immediate future. Claims processing will continue to be a focus as eligibility and enrollment information is reconciled. The X Electronic Remittance Advice is scheduled for pilot testing in December, with full deployment in January This newsletter is for you, the Medicaid healthcare provider. Please call or Provider Services at wvmmis@unisys.com with suggestions on how we can use it to keep communications open and flowing among the provider community, DHHR and Unisys. We need your input so we can continue to improve. Remittance Advice Updates. Beginning with the remittance advice dated 22 October 2004, the following changes have been made to the West Virginia Medicaid RAs: Remittance Advice: The remittance advice that is either mailed or placed on the web portal at wvmmis.com shows only finalized claims with the status of: a Paid (The claim has been finalized and submitted for payment) a Denied (The claim has failed the adjudication process and has been denied) a Reversed (The claim has been finalized. Dollars and units have been credited. There is an R in the 6 th position of the claim TCN) a Recoupments In order to produce the RAs in a timely manner, the check or EFT number and claims that are not finalized are no longer listed on the RA. These items are listed on new reports described below. New Reports: There are two additional documents available to providers who have web portal accounts. These are the Claimsin-Process report and the Check or EFT Payment report. The Claims-in-Process report shows claims with the status of: a Pended (The claim requires review to determine if it should be paid or denied) a To be Paid (The claim has passed the adjudication process and is ready to be submitted to Accounts Payable) a To be Denied (The claim has been submitted to Accounts Payable to be denied) The Check or EFT Payment report (only available on the web site) lists the date and Check or EFT payment information. If you do not have a web portal account, you may contact provider services for this information at and request that a copy be mailed to you. Please see the next section Get a Web Account to register to receive electronic remittances. Volume 1, Number 1 December 2004 Get a Web Account at To register for a web portal account, download and complete a Trading Partner Agreement (TPA) located in the Forms section of the Health PAS Online web site at Once Unisys receives this TPA, the EDI Helpdesk will return an EDI form for you to complete. The EDI form may be returned via at edihelpdesk@unisys. com or faxed to After returning the EDI form, insert www. wvmmis.com into you browser s address bar and select Health PAS Online Registration. The online registration process will allow you to choose your logon name. When your account is approved, you will be ed a link that will allow you to set your account password. If you have any problems downloading and completing these forms or with the online registration process, please contact the EDI Helpdesk at , prompt 6. You may also questions to edihelpdesk@unisys.com. Inside This Issue: Welcome... 1 Remittance Advice Updates... 1 Get a Web Account... 1 HealthPAS Online (web portal)... 2 Billing Updates... 3 Provider Training Request... 3 Tips from the Unisys Mail Room... 3 Automated Voice Response System... 4 AVRS Menu... 4 Billing FAQ Holiday Schedule... 5 Contact Information unisys

2 Health PAS Online. The Health PAS Online web portal offers the WV Medicaid provider community access to a variety of convenient services through an Internet based system, available through any computer with an Internet connection. The website address is Web Portal Features: a Access 24 hours a day, 7 days a week from any Internet enabled computer. a Claim submission via direct-dataentry and X12 file upload. a Billing module stores provider and Medicaid member information to pre-populate claim forms. a Near-instant feedback for front end claim rejections based on HIPAA regulations and WV Medicaid billing rules, allowing providers to immediately correct and rebill claims. a Claim status check. a Member eligibility check. a Remittance advices and related reports. a Forms and publications including billing instructions and manuals. a Provider directory. To be granted access to the Web Portal, see the article Get a Web Account on page one of this newsletter. Web Site Requirements: a All files downloaded from the website are in compressed format and require WinZip to decompress. WinZip is available for download at a Internet Explorer version 6, or Mozilla FireFox version 1 are recommend. Upgrade instructions are posted under Site Requirements at Transaction Submission: Claims entry, member eligibility verification, and claims status requests are accomplished via a direct data-entry process. Providers who own software capable of generating HIPAA-compliant (X12) transaction files may use the X12 file exchange feature to bypass direct data entry submission. Responses to these transactions are posted in the Download area. Rejection & Transaction Responses: A variety of responses provide feedback to transaction submissions. It is imperative to check claim responses. Claims rejected on the TA1, 997, or 824 responses will not appear on your remittance advices. Access these responses by selecting Download File under File Exchange. These responses are generally available within 5 10 minutes after submission. See the chart below for more information. TA1 Interchange Acknowledgement Response. a The TA1 acknowledges that the inbound 837 (claim file) was received. a The TA1 will indicate file acceptance or rejection. 997 Functional Acknowledgement Response. a The 997 acknowledges that the 837 is syntactically correct. The entire file or specific claims can be rejected depending upon the error. Contact your software vendor or the EDI Helpdesk for more information. a Two versions of this file are available: a PDF document and a X12 transaction. Open the X12 file with a text editor and the PDF Human Readable version with Adobe Reader. a You may immediately correct and rebill claims rejected on the Application Advice Response. a The 824 rejects claims based on business rules, i.e., invalid diagnosis codes, invalid procedure codes, invalid provider numbers, etc. Responses Generated by Claim Submission Method Response Direct Data Entry X12 File Upload TA1 (X12) Not Generated ISA 14 I13 (Acknowledgtment Requested Element ) must be set to 1 to receive response. 997 (X12) Rejected Only Rejected and Accepted 997 (PDF) Rejected Only Rejected and Accepted 824 (X12) Rejected Only Rejected Only 824 (TXT) Rejected Only Rejected Only 835 (X12) Determined by EDI Registration a Unlike the TA1 and 997, the 824 will only display claim rejections. a Two versions are available: the Human Readable report in plain text format and the X12 file format. Use a text editor such as NotePad, UltraEdit, or MS Word to open these files. a You may immediately correct and rebill claims rejected on the Claim Payment Advice Response. a Information in the 835 Remittance Determined by EDI Registration Advice transaction is generated by the WV MMIS adjudication system. This is an X12 transaction and requires a software program to be translated. The 835 is generally used to electronically post payments to your practice management or accounting software package. Contact your software vendor for more information. a 835s are anticipated to be available in January RA Remittance Advice. a Remittance Advices are posted in PDF format and require Adobe Reader to open, view, print, etc. The RA shows claims that are paid, denied, or reversed. This report is the RA normally received in the mail. RAs remain available for 60 days. a Claims-in-Process report details claims that have been received by WVMMIS, but are not yet paid, denied or reversed. This report is only available to web portal users. It is replaced every week with a new report. a Check or EFT Payment report lists the date and either the check number or EFT transaction code of your payments. This report is only available to web portal users. This report remains available for 60 days. a You may elect to receive these electronic reports by contacting the EDI Helpdesk. Eligibility Request Response. a Eligibility requests now return HMO, PAAS, and TPL enrollment information. Up to twenty requests may be entered per transaction. Two eligibility request responses are available: the 271 Eligibility Inquiry Report in PDF format and the Eligibility Inquiry Response in X12 format. Claim Status Response. a Providers may enter up to twenty claim status requests per transaction. Two claim status request responses are available: the 277 Claim Status Report in PDF format and the 277 Claim status Responses in X12 format. Assistance and Contact Information: The EDI Helpdesk is staffed Monday thru Friday from 8 am until 5 pm for assistance with the web portal and electronic billing. You may call , prompt 6 or edihelpdesk@unisys.com. 2

3 Billing Updates. Pharmacy. Fax a copy of your pharmacy permit to the Enrollment Unit at , if you have not done so. The hours of operation are Monday Friday, 8 am until 5 pm. Claims will not be processed unless a current permit is on file. If you need to verify receipt of this permit, contact the Enrollment Unit at or Home Health. Home Health providers MUST bill all claims to Unisys on a UB-92 paper form or in an 837I electronic format regardless of the date of service. An updated manual is available on the BMS website, to assist you with using the correct revenue codes to bill. Types of bill for Home Health are: a 32x Inpatient a 33x Outpatient a 34x Other Supplies for all dates of service should be billed using the appropriate revenue code with the appropriate HCPCS supply code. These codes are listed in the manual on the BMS website. Dates of service after 07/01/04 should be billed on a UB-92 using only the revenue codes. The appropriate revenue codes to bill are: a 0421 Physical Therapy-Visit Charge a 0431 Occupational Therapy-Visit Charge a 0441 Speech Therapy-Visit Charge a 0551 Skilled Nursing- Visit Charge a 0561 Medical Social Services-Visit Charge a 0571 Home Health Aid-Visit Charge Dates of services prior to 07/01/04 should be billed on a UB- 92 using the revenue codes above with the appropriate W-code. Edits 171 and 153. a This edit will post when a member is enrolled in Managed Care (PAAS or HMO). Tips from the Unisys Mail Room a Use only one staple when attaching supporting documentation. Staple only in the upper-left corner. a Use a black magic marker only to mark-out a member s name (for PHI purposes). a Do not use a highlighter. This can prevent required information from being accurately captured. a Ensure claims contain the provider number, member number, and Tax ID. a Ensure the signature box is not empty. a The EOMB must match the submitted claim; verify the date and member information. Attach one EOMB copy per claim. a We are in the process of revising these edits. a These edits will process correctly after the eligibility has been corrected and the system change has been implemented. a The system change will be made by the end of a Claims that are pended for these edits will be released upon the completion of these changes. a Claims that have been denied for these edits will be reprocessed upon the completion of these changes. a Check the Updates section on the front page of the web portal at www. wvmmis.com for future information. Reversals / Replacements. a Currently reversals and replacements cannot be billed electronically. a You must complete the Reversal / Replacement form that is located at The form mailing address is PO Box 3767, Charleston, WV a Effective December 1, there is a new Reversal / Replacement form located under the Forms section of the web portal. This form replaces the current one dated 7/30/2004. Prior Authorizations. When you submit claims with prior authorization numbers, be sure to include the leading alpha characters if they are present on the authorization that you received. The alpha character will not be present on any authorizations received from WVMI and APS. Watch future bulletins for updates. TC Modifiers. Hospitals and IDTFs (Independent Diagnostic Testing Facilities) MUST put the TC modifier on the procedure codes that are divided into technical and professional components. This applies to most radiology codes, some diagnostic tests, some pathology lab codes, and a few surgical codes. The codes that are divided are in the RBRVS manual that is posted on the BMS web site, (The ACS system added the TC modifier for you on lab, radiology and diagnostic tests but you had to add it yourself on the surgical codes.) Durable Medical Equipment. Many DME providers have called regarding some denials and cutbacks that they have received. Most of these claims were a result of the rolling month limitations. Beginning 07/01/04, many supply codes were moved to a rolling month period, rather than a calendar month period. A rolling month is defined as a thirty day period of time. The count of days begins with the date of service on the most recently processed claim for the item. Therefore, there must be 30 days between dates of service for bills that you submit to Medicaid for these supplies. Please call provider services to inquire about specific codes and the limitations on these codes. Claims to be Reprocessed. If you have denied claims for one of the following reasons, do not resubmit. Unisys will reprocess these claims. a 171 (Term applies to assigned members only) a 153 (PCP is solely responsible for service) a 612 (Prior authorization has insufficient units remaining) a 606 (Prior authorization number not found) a 610 (Prior authorization services do not match claim) a 158 (Invalid CPT code on date of service) for date of service 6/30/2004. Provider Training Request. Provider representatives are available for on-site training or assistance on issues related to the web portal, and the submission of electronic and paper claims. Providers who would like to request on-site training should contact the provider representatives listed below. Angela Richards (gray counties and Kanawha) angela.richards@unisys.com Virginia Leffingwell (red counties and Kanawha) virginia.leffingwell@unisys.com unisys 3

4 AVRS. When the West Virginia Medicaid provider dials , the caller will hear: Welcome to West Virginia s Medicaid Provider Services. Your call may be recorded for quality assurance purposes. Please enter or speak (individually) your 10-digit West Virginia Medicaid ID. Once the provider number has been accepted by the system, the caller will hear the AVRS menu listed in the chart to the right: Billing FAQ. Reversals / Replacement Process. Q. How do I reverse a claim that was processed by ACS? A. All reversals must be submitted on paper. You must complete the reversal / replacement form that is located at www. wvmmis.com. After you login to the web portal, please click on Forms. Once you download or receive the form, you must check the box at the top that reads, Original claims processed by ACS. Complete all fields on the form and attach a copy of your original remittance advice. If you do not have Internet access, call AVRS and press 0. Unisys can fax or you a copy of this form. You can also send a check if the original claim was processed by ACS. Q. How do I reverse and replace a claim that was processed by ACS? AVRS Menu. Caller Option Description Valid Entry Result 1 For payment information, press or say 1. 2 For eligibility information, press or say 2. 3 For claims status press or say 3. 4 For Provider Enrollment press or say 4. 5 For Hysterectomy / Sterilization Review, press or say 5. 6 For EDI Help Desk press or say 6. 0 Press or say zero to speak with an agent. Caller will hear last payment and current accounts payable, if available. Caller will be able to perform ten automated member eligibility inquiries. Caller will be able to perform ten automated claim status inquiries. Caller will be transferred to a provider enrollment agent. Please be advised that a Provider Enrollment agent will not be able to field Provider Service or EDI Help Desk calls. Caller will be transferred to a medical review agent. Please be advised that a Medical Review agent will not be able to field Provider Service or EDI Help Desk calls. The caller will be sent to voic if an agent is not available within the first seconds of entering the queue OR if no agents are currently logged into the queue. Caller will be transferred to a provider enrollment agent. Please be advised that a EDI Help Desk agents will not be able to field Provider Service calls. Caller will be transferred to a Provider Services agent. Please be advised that a Provider Service agent will not be able to field EDI Helpdesk calls. * Press or say * to repeat. The current menu (Provider Main Menu) will be repeated. # Press or say # to return to the previous menu. The previous menu (Welcome / Provider Entry Message) will be repeated. A. All reversals and replacements must be submitted on paper. You must complete the reversal / replacement form that is located at After you login to the web portal, please click on Forms and Agreements. Once you download or receive the form, you must check the box at the top that reads, Original claims processed in ACS. Complete all fields on the form and attach a replacement claim, completed exactly the way that you want it to pay, and a copy of the original RA. Remember you are deleting all of the information on the original claim. Also, attach a copy of your original remittance advice. If you do not have internet access, call AVRS and press 0. Unisys can fax or you a copy of this form. You can also send a check if the original claim was processed in ACS. Q. How do I reverse a claim that was processed by Unisys? A. Currently, all reversals must be submitted on paper. We are working on a process that will allow providers to bill these reversals electronically. Once this process is working, a message will be placed on the front page of the web portal to inform providers. You must complete the reversal / replacement form that is located at After you login to the web portal, please click on Forms and Agreements. If you do not have internet access, call AVRS and press 0. Unisys can fax or you a copy of this form. Once you download or receive the form, you must complete all fields. Q. How do I reverse and replace a claim that was processed by Unisys? A. Currently, all reversals and replacements must be submitted on paper. We are working on a process that will allow providers to bill these electronically. Once this process is working, a message will be placed on the front page of the web portal to inform providers. You must complete the reversal / replacement form that is located at After you login to the web portal, please click on Forms and Agreements. If you do not have internet access, call AVRS and press 0. Unisys can fax or you a copy of this form. Once you download or receive the form, you must complete all fields on the form and attach a replacement claim, completed exactly the way that you want it to pay, and a copy of the original RA. Remember you are deleting all of the information on the original claim. Q. There is not a block to check for check attached. How do I proceed? A. Please write Check Attached on your submitted form. Only send a check if the original claim was processed by ACS. TPL and Medicare Crossovers. Q. Why are my COB and Medicare primary claims not showing up in the system? A. Claims from AdminaStar (DMERC), Palmetto, and UGS-Part A have crossed and we are holding. We are also holding Medicare and Insurance primary claims that were submitted on paper. We are currently validating accurate pricing before claim adjudication. Do not submit these claims elec- 4

5 tronically until notified that this process is completed. The update will allow the claims to be processed and paid as secondary, rather than primary. Once this is placed into production, we will be able to process these claims and those received from carriers and intermediaries. Claims that have processed incorrectly will be reprocessed. Q. Who determines if a resident of West Virginia is eligible for Medicaid? A. The local county office determines Medicaid eligibility. RAPIDS sends Unisys this eligibility daily. Q. Who determines whether a Medicaid eligible individual is PAAS (PCP) or HMO? A. The type of eligibility established by the county office determines if the member needs to be enrolled in managed care. BMS has contracted with Automated Health Systems to assist members with their choice of PAAS provider or HMO. Q. Where are the HMOs in completing their eligibility reconciliations? A. Unisys now has the correct information. The HMOs are still reconciling their files. It is anticipated this will be completed by the end of the year. Carelink and The Health Plan will reprocess any claims paid or denied in error. Since Unicare returned claims, providers will have to rebill. Q. Will timely filing be waived because of the eligibility problems with PAAS and HMOs? A. Timely filing has been waived for the HMOs and they will consider authorization of medically necessary services retroactive to July. Check with each HMO for their filing requirements. Q. I am a provider treating a member with a valid ID card with no indication of HMO. I submitted the claim and it was denied for 153 or 171. What do I do now? A. Unisys has corrected the system problems and is establishing the process for readjudicating the claims with edits 153 & 171. Claims involving PAAS providers will be reprocessed as the accuracy of the provider s file is verified. At this time, if you receive a denial for edit 153 or 171, you should call the AVRS to verify eligibility. If the person has an HMO, you will need to submit the claim in question to the HMO. Q. I am a provider treating a member with a valid ID card. When I verified eligibility through the Automated Voice Response System, I was told Member is not eligible. What do I do? A. Fax a copy of the card with your name, provider number, and phone number to Unisys at Unisys will verify eligibility and call you back. Q. I am a provider treating a member with a valid ID card. I received a 201 denial on my remittance advice. I checked the Automated Voice Response System and it indicated the recipient is not eligible for dates of service. What do I do? A. Fax a copy of the card with your name, provider number, and phone number to Unisys at A representative will call you back to get the information to process the claim. Q. How do I bill DME incontinent supplies? A. Beginning 07/01/04, the incontinent supply codes were moved to a rolling month period. A rolling month is defined as a thirty day period of time. The count of days begin once the member has received the initial service and a claim has been processed. Therefore, there must be 30 days between bills that you submit to Medicaid for these supplies. Q. Do I submit my anesthesia services in units or in minutes? A. West Virginia Medicaid mandates that all anesthesia services are billed using one unit for every fifteen minutes of service. Do not add the base units. Unisys Holidays (closed). Holiday Weekday Date Christmas Eve Friday 12/24/2004 New Year s Eve Friday 12/31/2004 Contact Information. Provider Services Monday-Friday, 8:00 am until 5:00 pm wvmmis@unisys.com ( ) EDI Helpdesk , prompt Monday-Friday, 8:00 am until 5:00 pm edihelpdesk@unisys.com ( ) Member Services Monday-Friday, 8:00 am until 5:00 pm Fax AVRS. Access AVRS using the same phone numbers, 24 hours a day, 7 days a week. Holiday Schedule. a Due to the Christmas Holiday, New Year s Holiday, and fiscal quarter end, no payment will be made during the week of Christmas. a A payment will be made on Tuesday, December 28, with funds transferred 7 to 10 working days later. a Claims will need to be received no later than noon, Monday, December 27, to be included for potential payment the following day. a The payment day will return to Friday starting on January 7, Claim Form Mailing Addresses. Please mail your claims to the appropriate Post Office Box as indicated below. Unisys PO Box 3765 NCPDP UCF Pharmacy PO Box 3766 UB-92 PO Box 3767 HCFA-1500 PO Box 3768 ADA-2002 Charleston WV PO Box 2254 Hysterectomy, Sterilization and Pregnancy Termination Forms Charleston WV Provider Services Mailing Addresses. Unisys Provider Relations & Member Services. PO Box 2002 Charleston WV Unisys Provider Enrollment & EDI Help Desk. PO Box 625 Charleston WV unisys 5

6 West Virginia Medicaid Provider Update Bulletin. WEST VIRGINIA Department of Health & Human Resources UNISYS Imagine It. Done. UNISYS PO Box 625 Charleston WV PROVIDER NAME 123 STREET CITY ST