Welcome Third Quarter EDS Workshop Presented by MDwise, Inc., CompCare and MDwise Delivery Systems Provider Relation Reps.

Transcription

1 Welcome Third Quarter EDS Workshop Presented by MDwise, Inc., CompCare and MDwise Delivery Systems Provider Relation Reps. The Best Care. Because We Care. -1-

2 1. Claims Submission 2. Members Eligibility Topics for Today 3. Explanation of Claims Denial- Presented by MDwise 4. Top Ten denials - Presented by MDwise and CompCare 5. Reading your Remittance Advice - Presented by MDwise and CompCare 6. NDC and Billing 7. Medicaid Managed Care Update The Best Care. Because We Care. -2-

3 How to verify Member Eligibility Information on the front of the card should include the member s: Name, Gender and Date of Birth Member identification number (RID#) The Best Care. Because We Care. -3-

4 How to verify Member Eligibility To verify eligibility, the provider has several options from which to choose: Using the Interchange (Best Option) Calling AVR ( ) or Using the SSN or the OMMI Swipe, or Punching the member s Hoosier Healthwise number in by hand on the OMNI swipe card device *** CompCare Behavioral Health Providers: When checking eligibility, please make sure the member is enrolled with MDwise ** The Best Care. Because We Care. -4-

5 MDwise Delivery Systems Click to see Quick Contact Sheet The Best Care. Because We Care. -5-

6 Claims Submission Before providing services, it is necessary to confirm: Is the member eligible for services today? In what IHCP Plan are they enrolled? (Hoosier Healthwise, Medicaid Select, Traditional Medicaid) If the member is in Hoosier Healthwise, what MCO are they assigned? (MDwise, Anthem, MHS) If the member is enrolled in Hoosier Healthwise, what services are they eligible to receive? (Package A, B, or C) Who is their Primary Medical Provider (PMP)? Does the member have primary health insurance other than Medicaid (frequently seen with package B moms)? The Best Care. Because We Care. -6-

7 Claims submission and Inquiries Providers are encouraged to submit their claims electronically In-MDwise Network Providers must submit their claims to the delivery system claims department where the member is assigned. Providers should contact the applicable delivery system for specific instruction on electronic claims submission Please note that all electronic claims must be submitted using the HIPPA compliant transaction and codes sets Providers may submit paper claims to the applicable delivery system address ( see quick contact sheet) The Best Care. Because We Care. -7-

8 Claims submission and Inquiries Out of MDwise Network Providers Out of MDwise network providers should submit their paper claims directly to MDwise Claims should be submitted to: MDwise: Out of Network Claims P. O. Box Indianapolis, IN Out of network must submit their claims electroincally. However,electronic claims must be forward to the member's delivery system claims department General question regarding out of network claims should contact the MDwise Customer Service Department ( 317) or The Best Care. Because We Care. -8-

9 Claims Resolution Informal Claims Resolution Call Delivery System to inquire about claim Delivery System must respond within 30 calendar days of inquiry Formal Claims Resolution Must be in writing Provider has 60 calendar days From receiving written denial After delivery system fails to make determination From delivery system s response to the informal inquiry *** For a complete guideline on Claims Dispute and Appeal Process, s, please refer to the MDwise Provider mdwise.org *** The Best Care. Because We Care. -9-

10 TOP TEN CLAIMS DENIAL UB s UB92 Form Payment Denied/reduced/for absence of, or exceeded, percertification/authorization. Claim/Service lacks information which is needed for adjudication. Duplicate claim/service. Payment denied because this procedure code and/or modifier were invalid on the date of service. Non-covered charges. Payment denied because the benefit for this service in included in the payment/allowance to another service/procedure that has already been adjudicated. The time limit for filing has expired. Coverage not in effect at the time the service was provided. Payment adjusted because this care may be covered by another payer per coordination of benefits Charges do not meet qualifications for emergent/urgent care. The Best Care. Because We Care. -10-

11 Top Ten Claims Denial HCFA HCFA-UB02 Duplicate claim/service. Claim/Service lacks information which is needed for adjudication. Coverage not in effect at the time the service was provided. Payment Denied/reduced/for absence of, or exceeded, percertification/authorization. Non-covered charges. The referring/prescribing/rendering provider is not eligible to refer/prescriber/order/perform the service. The time limit for filing has expired. Payment adjusted beause this care may be covered by another payer per coordination of benefits Charges exceed our fee schedule or maximum allowable amount. This diagnosis is not covered, missing, or are invalid. The Best Care. Because We Care. -11-

12 Reading Your remittance Advice A Remittance Advice is an automated paper notice received from MDwise Delivery System or CompCare payors informing you about payment or other claims actions. The Best Care. Because We Care. -12-

13 Claims Filing limit In-Network Providers have a filing limit that ranges from 90 to 180 days, depending on their contract with the Delivery System. Out-of-Network Providers have 365 days from the date of service to file a claim. The Best Care. Because We Care. -13-

14 Click for sample remittance advice The Best Care. Because We Care. -14-

15 MDwise Delivery System Provider Relation Reps. Presents The Best Care. Because We Care. -15-

16 CompCare Presents The Best Care. Because We Care. -16-

17 National Drug Code The Best Care. Because We Care. -17-

18 About National Drug Codes-NDC Reminder HIPPA requirements effective August 1, 2007 *** For a complete guideline of how to bill for NDC, please refer to bulletin BT *** The Best Care. Because We Care. -18-

19 Medicaid Managed Care Updates Indiana Care Select Replaces the Indiana Medicaid Select Program Begins 10/1/07 with enrollment of members into Indiana Care Select in the Central Region; other regions to follow The purpose of the Indiana Care Select Program is to: Provide care that is holistic and less fragmented. Obtain member s participation in treatment. Involves the member s family, medical providers, other care givers, and behavioral health providers. The Best Care. Because We Care. -19-

20 Medicaid Managed Care Updates Indiana Care Select (continued) The Care Management Organization (CMO) will have two primary focuses: Care Management for all members: - Initial evaluation - Stratify member based on medical needs Prior Authorization except pharmacy: - CMO enters PA information into IndianaAIM The Best Care. Because We Care. -20-

21 Questions/Answers The Best Care. Because We Care. -21-

22 Thank You! The Best Care. Because We Care. -22-