ELIGIBILITY VERIFICATION Coordinate Care Claims FAQ Document 1. Are babies enrolled under the mom s ID? Yes, babies are assigned a dummy number using a prefix on the mother s ID. Coordinated Care can accept baby s claim with the mom s ID or the baby s temporary ID until the state has assigned the baby their own ID number. Once the state has assigned the baby s ID, claims billed using the mother s ID will be rejected. 2. What is the time frame a new mother has to add her baby to her plan? The baby is covered under mom through the end of the month in which the baby reaches 21 days of life. If the baby is not added to the mom s plan by that time, the baby s claim will be denied. 3. If a Coordinated Care patient assigned to a different PCP requests treatment from our facility, can we treat the patient? Yes, the patient can be seen that day. You can then have their PCP updated to you. 4. How is a member s PCP updated? The PCP change must come from our member. If the member is at the provider s office and requesting the change, the provider can call us to make the change and must indicate that the client is in agreement and is physically at their office. 5. Can the clinic name be added to the member enrollment card? It is not currently present on the cards. This could be added in the future. 6. When a member accesses care from an out of network provider, is he/she penalized with a higher cost share or is it the same out of pocket expense as a network provider? The member is not penalized for going to an out of network provider. The same out of pocket rules that apply to network providers would apply to out of network providers. 7. Which member identification number should be billed when submitting claims? We will accept the member ID or Medicaid ID for Healthy Options and Basic Health Plus. For Basic Health, we will accept the member ID. 8. What are the program codes that are included on the member roster (Examples: 0001, 0002, 0004)? These can be ignored. Washington does not utilize this field. Updated: June 13, 2012 Page 1
MEMBER PROGRAMS Coordinate Care Claims FAQ Document 1. Is there more information on the Start Smart Program? More information on the Start Smart Program can be found on the Coordinated Care website (http://www.coordinatedcarehealth.com/). This can be found under Health Management for members. 2. Is Nursewise English only? Yes, but interpreter services are available to the member. The following link provides a list of interpreters for each county (http://maa.dshs.wa.gov/interpreterservices/spokenlanguagevendor.htm). This website also provides member information and provider resources for the use of this service. Provider services can also be contacted to arrange this service 1 877 644 4613. 3. What can the CentAccount program be used for with Healthy Options since no copays and deductibles are required? The CentAccount card can be used at stores and pharmacies to purchase the items listed below. Additional items will be added soon and can be found on the Coordinated Care website. Contact lens solution Bandages Diabetes testing & aids Ear care Family Planning Childcare Utilities Public Transportation Telecommunications (Home and/or Cell Phones) 4. Is Member Connections for both Healthy Options and Basic Health and how does Coordinated Care find the members that need to be enrolled in the program? Yes, Member Connections is available for both Basic Health and Healthy Options. Providers should contact Member Services to refer a member to the Member Connections program. Member Connections will reach out to the member and either educate or provide the member with the tools to resolve the issues seen by the provider. Updated: June 13, 2012 Page 2
PROVIDER PORTAL Coordinate Care Claims FAQ Document 1. Does the Provider Portal require a password? The health plan web site, www.coordinatedcarehealth.com does not require a password. You can access provider reference materials, authorization requirements and other valuable information there. If you want to check eligibility, submit claims, check status of claims, request authorizations or any other HIPAA transactions you will need a user ID and password. Once your office or provider are contracted and loaded in our system you can request access for your office administrator and assign access to the rest of your staff. 2. When will the secure Provider Portal be available? Registration and eligibility are currently available. Please note that eligibility will not return results until the members are loaded in mid June. Claims and authorizations are scheduled to be available on 7/1/12. 3. Who should be contacted for Provider Portal issues? Please contact Provider Services at 1 877 644 4613. 4. A large number of our staff needs access to the portal, is it possible to have one person/administrator creating all the accounts/passwords and have staff resetting their passwords? Yes, you can have one or more administrator(s). In addition, administrators are able to register up to 10 people at one time and they would be able to reset their passwords. 5. When logged in to viewing dashboard for:, it lists a specific clinic name. Does this mean that I will only have access to those specific members? Registration and security of provider accounts are currently tied at the TIN level, not NPI. The clinic name that shows up in the provider site is populated by the IRS name. In the data, there is one IRS name for one TIN. The patient list has an optional NPI filter on it, so if the user would like to see a subset of patients for a TIN, the user can filter on individual NPI. PROVIDER RELATIONS 1. Will you provide personalized orientations? We try to meet with larger provider groups once they have been contracted. We encourage claims testing prior to go live. Please reach out to provider relations 1 877 644 4613. 2. What is the reimbursement rate for RHCs (Rural Health Clinics)? Coordinated Care will pay RHCs fee for service of the state fee schedules. The state will make wrap payments after our reimbursement has been made. Updated: June 13, 2012 Page 3
3. Can providers schedule post go-live meetings with Coordinated Care? Yes, there will be weekly Provider Summit meetings every Thursday at 1 PM. This will be a call in meeting for all providers. If you have provider specific questions, a separate meeting(s) can be scheduled with the health plan. 4. At what rate are Nurse Practitioners compensated? Nurse Practitioners are compensated at 100% of the state fee schedules. There is currently not a reduction for mid level providers. 5. Can Coordinated Care provide a provider directory? Yes, the provider directory is currently available on the Coordinated Care website (http://www.coordinatedcarehealth.com/for members/find a provider/). If you do not find the doctor you are looking for, call us at 877 644 4613. 6. How does Coordinated Care report back to the state so that the FQHC receives their enhancement payment? Coordinated Care will be sending a proprietary file annually. The state will reconcile the amount paid out through fee for service with the assigned encounter rate 7. Will the state notify Coordinated Care of rate changes? Will the state tell providers directly as well? Coordinated Care is notified of rate changes via the state emails. If you are registered on the state website, you will receive the emails. If you are not registered, you can register for the notification emails by following this link http://hrsa.dshs.wa.gov/contact/default.aspx. 8. Are physician extenders (such as Physician Assistants, Nurse Practitioners, Certified Nurse Midwives, Clinical Nurse Specialists) a contracted specialty? Yes we do contract with physician extenders. They generally are paid at 100% of the state fee schedule, unless otherwise noted in the contract. 9. How do you handle patients that are requested to be dismissed from a provider s panel? Provider may request to have a member removed from their panel for instances such as but not limited to: a member is disruptive, unruly, threatening or uncooperative to the extent that the member s behavior seriously impairs the providers ability to provide services to the member or to other members. if a member steadfastly refuses to comply with PCP services or treatment recommendations such as repeated emergency room use combined with refusal to allow the provider to treat the underlying medical condition. A provider may not request reassignment of a member due to adverse change in member health status or utilization of services which are medically necessary for the treatment of the member s condition or on the basis of race, color, national origin, sex, age, disability, political belief or religion. Updated: June 13, 2012 Page 4
10. Does Coordinated Care recognize NCQA Certification? What are the benefits? Yes, we recognize NCQA provider recognition programs (patient centered medical home). We will support providers in obtaining such recognitions through training, process review, data sharing, where applicable, and mock surveys, etc. We will highlight provider recognitions in the provider directory. 11. Is there a minimum/ maximum number of patients assigned to each physician/ nurse practitioner for each clinic? There is no minimum The maximum is defined by DHH as 2,500 per physician PCP and 1,000 per nurse practitioner or physician extender. 12. Is Coordinated Care contracted with Interpath Lab? We are in the process of contracting with Interpath Lab. Until this is finalized, they will not be listed in the Provider Directory. REFERRALS & AUTH 1. For DME and L-codes, is the $500 limit referring to cost or billed charges? Billed charges. 2. When is the guaranteed turn-around-time for authorization requests? Turn around time for a standard request is 5 to 14 days. Turn around time for an urgent request is 48 hours. 3. Do you allow retro authorizations? Yes, retro authorizations are given when documentation supports extenuating circumstances that prevented the prior authorization from being obtained. Examples of extenuative circumstances are listed in the provider manual. 4. Is it possible for an Excel spreadsheet to be sent out with an all-inclusive list of procedures that require an authorization? No, since authorization requirements are based on specialty, diagnosis, and other factors, there is not a concreted list of procedures that require an auth. While there is not an all inclusive list, the Provider Prior Authorization Quick Reference Guide, located on the Coordinated Care website under Provider Resources, will assist in determining authorization requirements. There will also be a procedure lookup tool available on the Coordinate Care website where a specific code can be entered to determine whether an authorization is required. Updated: June 13, 2012 Page 5
5. When certain procedures are approved, is there a range that can be covered? It depends on how the authorization was setup. If you receive a claim denial for a service you believed was authorized but the code was not exact, a request for reconsideration can be made to overturn the denial. 6. Are authorizations required for Paragard and Mirena? No, prior authorization is not required. 7. Do all authorizations have to be requested through fax? No, authorizations can also be submitted electronically through the secure provider portal. It is advantageous to submit electronically as you will instantly be advised if there is an issue with your request or if additional documentation is required. 8. Is the authorization number required on claim submissions? No, the authorization number is not required. In most cases, the correct authorization will automatically be selected. If you receive an authorization denial you believe to be incorrect, including the authorization number will assist in quicker resolution on the request for reconsideration. 9. Is there a limit on in-office ultrasounds? In office ultrasounds are limited to 2 per pregnancy. After 2 the service will need to be authorized for medical necessity. 10. Does Medicaid cover Chiropractic and Physical Therapy services? Chiropractic and physical therapy services are a covered benefit, but there are specific limitations on the coverage. Example: For Basic Health; Inpatient & Outpatient Chiro, OT & PT are covered only for post op treatment of reconstructive joint surgery when received within one year following surgery. A combined max of 12 visits per calendar year are covered; no more than 6 visits for Chiro care 11. How will referrals to specialists who will not see Coordinated Care members be handled? The network provider would be requested to utilize our provider directory to refer our clients to those accepting Coordinated Care. For non network providers, from July 1st for the first 90 days, we will pay the claims as long as they call for prior authorization. 12. Do providers need to get a referral from Cenpatico for in house mental health (billing with same TIN as the clinic)? Updated: June 13, 2012 Page 6
Providers do not need a referral for mental health services; but it is imperative that the facility checks the benefits before referring to services so that the member is getting the services that are in their benefits package. 13. How do you file prior authorizations for therapy for Cenpatico? The provider portal located on the CooRdinated Care website (www.coordinatedcarehealth.com) is the same portal used for therapy web authorizations. Cenpatico works on Coordinated Care s web authorization platform so the request will be automatically routed to the Specialty Therapy and Rehab Services division at Cenpatico. 14. Has a central fax line been identified for accepting daily admission and discharge census reports? Yes, the inpatient admission request fax line is 877 212 6105 and would also be used for discharges. 15. After review of an auth for an inpatient admission, the provider was instructed by the authorization department to bill as observation. How are these services to be billed? If the provider requests IP and after review it is determined that only observation is warranted, we discuss with provider. If the provider agrees to observation, an authorization is entered for observation and the provider bills observation. If the provider disagrees with the observation determination, the medical director reviews. If the medical director determines that only observation will be approved, a denial authorization is input for inpatient and an approval authorization is put in for observation. If the provider bills the claim as IP it will attach to the denial authorization and deny EXEB. The provider can then file a formal appeal. 16. Can we see if authorizations are in place as a facility? Yes, facilities can check through the Coordinated Care website to see if an authorization was obtained by the referring provider. 17. For physical therapy, occupational therapy, and speech therapy, do we need a referral for the services? No, a referral form is not required. An order or a script with the physician s signature stating that the therapy is needed is required. 18. When the emergency room doctor is ordering a CT for the next day, is an authorization required? Yes, an authorization would be required. The services would not be considered an emergency if they do not need to be performed immediately. The patient should be directed to their primary care physician. Updated: June 13, 2012 Page 7
19. Is there a grace period for submitting an authorization to NIA? No, they need to be submitted prior to the procedure. In extenuating circumstances, documentation can be submitted to overturn the denial. 20. What is the effective date used for authorizations through NIA- the date requested or the date approved? The effective date is the date the authorization was approved. When submitted electronically through the www.radmd.com website, the authorizations can be approved within minutes. BILLING & CLAIMS 1. In addition to the 59xxx code with TG modifier, the physician could also bill the office visit code with UA or TH modifier to get additional payment for High risk pregnancy. Has Coordinated Care configured their system to allow for this? Yes, procedure codes 99211 99215 are covered when billed with the TH modifier and the corresponding high risk pregnancy diagnosis. 2. Is an invoice required for 17P Hydroxyprogesterone? Yes, an invoice from the pharmacy showing the NDCs and quantities used in the compound is required for payment. This should be billed using J3490. 3. When do you want the notification of pregnancy form? As soon as possible. Members are also required to provide notification of pregnancy by calling 1 800 660 9840. Basic Health members are only covered for 30 days from the confirmed date of pregnancy and will have to apply for the Maternity Benefits Program to continue coverage. 4. Does Coordinated Care generate ERA (Electronic Remittance Advice) files? ERA and EFT (Electronic Fund Transfer) services are available through PaySpan. This service is at no cost to the provider and allows online enrollment. Providers can contact PaySpan directly by calling 877 331 7154 or visiting their website www.payspan.com. 5. Can a corrected claim be submitted online? Yes, corrected claims can be submitted through the Provider Portal and electronically via your clearinghouse. For more information on electronic billing, please visit the Coordinated Care website (www.coordinatedcarehealth.com) for Companion Guides. 6. Is it true that we only allow the red/white UB/CMS 1500 forms and deny the black and white copies for claim submission, corrected claims? No, we prefer red and white but will take the black and white. Updated: June 13, 2012 Page 8
7. Will we provide a billing manual for providers and how will it be distributed? We do have a provider billing manual. The most recent version is always available on our website (http://www.coordinatedcarehealth.com/) 8. Will non-contracted providers receive 100% of Medicaid? Non contracted providers will be paid at 100% of the state fee schedule for covered services where appropriate authorizations were obtained. 9. If the Medicaid fee schedule increases or decreases will our fee schedule do the same? What process will we have in place to notify providers of the change? Yes, we use the state fee schedules. The state notifies us of rate changes via the automated provider communication emails that are distributed through the state web site. 10. When should a provider use a group ID number vs. an individual ID number? We require the individual NPI to be billed in box 24j on the CMS 1500. The group NPI would be billed in box 33a. 11. Can claims be hand written? We prefer that claim be submitted electronically through a clearinghouse or on our provider portal at http://www.coordinatedcarehealth.com/. If you chose to submit you claim on paper they need to be submitted on the RED and WHITE CMS form. We prefer the claim to be printed electronically, but we will not reject a hand written claim that is clearly legible. These hand written claims are hand keyed into our system which lengthens time to process and increases risk for error. 12. What payment guidelines are utilized for bundling? (For example: - CCI, Claim Check, CES, etc.) We use ClaimsXten (a McKesson Product) and Health Care Insight (HCI). 13. What needs to be included for a resubmission to be processed? Submit an adjusted or corrected claim to Coordinated Care Corporation. Corrected claims must clearly indicate they are corrected in one of the following ways: o Submit corrected claim via the secure Provider Portal o Submit corrected claim electronically via Clearinghouse (preferred) with appropriate bill type or with the original claim number in the appropriate field. o Mail corrected claims to: Coordinated Care Corporation Attn: Corrected Claim P.O. Box 4030 Farmington, MO 63640 4197 Updated: June 13, 2012 Page 9
Paper claims must clearly be marked as RE SUBMISSION or CORRECTED CLAIM and must include the original claim number; or the original EOP must be included with the resubmission. Failure to mark the claim as a resubmission and include the original claim number (or include the EOP) may result in the claim being denied as a duplicate, a delay in the reprocessing, or denial for exceeding the timely filing limit 14. Do we work with claims clearinghouses? We do work currently with 3 clearinghouses; Emdeon, Gateway, and SSI. Our payer ID is 68069. A provider can continue to use their current clearinghouse who will partner with Emdeon to get claims to Coordinated Care. 15. How many check runs do we process per week and on what days? We perform check run every Wednesday. Clean claims received before end of business on Friday, should process on that Wednesday s check run. 16. What is the company average clean claims payment turnaround for providers whose claims are submitted electronically and paid through electronic funds transfer? Per the Performance Standards Report, we are running an average auto adjudication rate of about 83% but our goal is 85% so we are working toward that. The average time to pay is 7.5 days. 94% of our claims are paid in 14 days or less, with 99% being paid in 30 days or less. If the provider is set up on EFT, the payment is received within 24 and 72 hours from the check run date. This timeline depends on their bank and the time it takes to run through the banks cycle. If they share a bank with us (US Bank for medical and BOA for CBH) the payment could be received the afternoon after check run. A mailed check is mailed out the day after check run and the timeline depends on the mail. Electronic and accurate claim submission will increase a provider s auto adjudication rate and reduce the number of days to adjudicate the claim. 17. When providers do multiple procedures, do we deny until operating notes are written for each procedure, or do we look at it as a whole as process accordingly? Claims are processed at the service line level. We do utilize claim editing software the edits against bundling and unbundling of services, but it is possible for 1 service on a claim to pay and a second line to deny. If there are pended services, the ENTIRE claim is pended until a resolution is given. Operating notes are not required for most multiple procedure claims. The system is configured to automatically take the appropriate multiple procedure discounts per the state s reimbursement methodology. 18. What is the timely filing requirement for claims? Coordinated Care has changed their timely filing requirement for first time claims from 180 days to 365 days from date of service or discharge date. Updated: June 13, 2012 Page 10
19. What modifiers can be billed when billing for anesthesia? And how do they effect reimbursement? When supervising, the physician must use one of the modifiers below. Payment for these modifiers is 50% of the allowed amount. Modifier QX must be billed by the Certified Registered Nurse Anesthetist (CRNA). AD Medical supervision by a physician for more than four concurrent anesthesia services. QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. QX CRNA service with medical direction by a physician should be used when under the supervision of a physician. Payment is 50% of the allowed amount. This modifier is payable in combination with Modifiers AD or QK, which is used by the supervising anesthesiologist. Modifier QX must not be billed in combination with AA. QY CRNA and anesthesiologist are involved in a single procedure and the physician is performing the medical direction. The physician must use modifier QY and the medically directed CRNA must use modifier QX. The anesthesiologist and CRNA each receive 50% of the allowance that would have been paid had the service been provided by the anesthesiologist or CRNA alone. QZ CRNA service without medical direction by a physician. Must be used when practicing independently. Payment is 100% of the allowed amount. This modifier must not be billed in combination with any other modifier. 20. Does Coordinated Care pay for physical modifiers (P1-P6) and qualifying circumstances (99100, 99116, 99135, 99140)? Additional payment will not be made for the physical modifiers, but Coordinated Care does pay for qualifying circumstances. 21. What is the timeline/process for claims testing? We would like to begin claims testing on 6/1/2012. Please contact Casey Scheipeter in the Claim Implementation department at cscheipeter@centene.com for detailed instructions. 22. What are the guidelines for multiple surgery reductions? For multiple surgeries performed for the same client, during the same operative session, the highest allowable procedure is paid at 100% with each additional procedure being paid at 50% of the allowable fee. To ensure proper payment, submit all surgery procedures on the same claim. 23. Are Medicare Crossover claims accepted? Coordinated Care will accept secondary claims via paper or electronically but will not be accepting Medicare Crossover claims directly from Medicare. The provider billing manual lists the ways to effectively ensure a secondary claim in received and processed timely. Updated: June 13, 2012 Page 11
24. How are unlisted (generic) CPT/HCPCS codes (such as 29999, 37799, 44899, and 64999) reimbursed? The majority of generic codes on the fee schedule are listed as By Report. Most of these codes will be reimbursed by percentages provided by the state based on the service billed. In some cases, records may be requested to validate the actual services performed. Surgery = 45% Lab = 40% Medicine = 50% Radiology = 45% 25. If a provider receives a monthly capitation payment, do they need to submit claims for all visits? PCPs and all participating providers must submit claims or encounter data for every patient visit, even though they may receive a monthly capitation payment. 26. Will there be claims editing that will prohibit us from submitting claims more than once in a 30 day period? Yes, we are programming our system for 30 day supplies, but there are some instances where members might need their supplies several days prior to the next date of service. 27. Do providers need to submit claims billing with the Coordinated Care (AMISYS) ID # along with the TIN and NPI? No, the provider is only required to bill with the TIN and NPI. 28. Does Coordinated Care reimburse for PCP s located in a school setting and providing primary care services? Yes, this is reimbursable and should be billed using a place of service 3. SERVICE COVERAGE 1. Can a patient have Medicaid and Commercial coverage? There are rare instances when a member could have both Medicaid and commercial insurance. Once the state determines the member has OIC, they will most likely be termed from the MCO. 2. How many office visits will the patients be allowed to have per year? Regular office visits with a PCP are not limited. 3. Can patients self-refer? Updated: June 13, 2012 Page 12
We do not require a referral from a members PCP to be treated by a specialist. Any existing authorization requirements do still apply. 6. How are you going to ensure that claims are paid quickly and accurately? We have very strict guidelines around timeliness of payments. We do a 100% check run review of all claims during a new health plans implementation to ensure payment and denial accuracy. 9. What is our percentage rate of denials and what are the top procedures that are denied? Historically, in a new health plan, the most common denials are for duplicate submissions and authorization. In most instances, our authorization requirements are less restrictive than the state, but non par providers are required to obtain authorization for all services. 10. Are EPSDT services covered and can they be done in the provider s office? Yes, EPSDT services are covered and they can be done in the provider s office. 11. Are there any benefits covered that are not currently covered by the state? If so, what are they? The only add on benefit at this time is routine circumcisions for Basic Health and Healthy Options members under the age of 6 weeks. 12. How will we order vaccines? Detailed instructions on how to bill for vaccines can be found in the billing manual, but the process will not change from how the state currently administers it. 13. Do we reimburse for flu vaccines? Our coverage of vaccines mirrors what the state is currently administering. At this time there are several flu vaccines that are on the state fee schedule as covered services. 14. Is Depo Provera J1055 covered? Yes, Depo Provera is covered once every 67 days when billed with the corresponding family planning diagnosis. 15. Is acupuncture a covered service under Coordinated Care? No, acupuncture is not a covered service. Exclusions and non covered services for Healthy Options and Basic Health can be found in the Provider Manual on the Coordinated Care website. 16. Are sports physicals and immigration physical exams covered under Coordinated Care? No, these are considered non covered services under Coordinated Care. Updated: June 13, 2012 Page 13
17. Will audiology services be covered if performed in PCP office? Yes, audiology services will be covered if performed by a physician for both Basic Health and Healthy Options. 18. What are the limitations for PCPs in regards to lab services? Laboratory claims must include an appropriate medical diagnosis, modifier, and prior authorization, if applicable. Services billed with the ICD 9 CM diagnosis codes V72.6, V72.62, V72.63, and V72.69 as primary will not be paid. Updated: June 13, 2012 Page 14