Avenues of Resolution for Indiana Health Coverage Programs

Transcription

1 Avenues of Resolution for Indiana Health Coverage Programs HP Provider Relations/October 2013

2 Agenda Resolving Claims-related Questions Provider Enrollment Prior Authorization Fee Schedule Indiana Health Coverage Programs (IHCP) Quick Reference Guide Questions 2 Avenues of Resolution for Indiana Health Coverage Programs October 2013

3 Session Objectives Upon completion of this session, providers will know: Where to go to find: How to file a claim How to check the status of payment on a claim A claim denial reason What to do if HP shows a claim has not been received or has denied for Ordering, Prescribing, Referring Physician (OPR) Where to go to find answers for Enrollment questions Who to contact for the appropriate Prior Authorization How to look up specific procedure code coverage 3 Avenues of Resolution for Indiana Health Coverage Programs October 2013

4 Resolving claims-related questions

5 Claims Where to go to file a claim? Select Help on Web interchange Proceed to the reference materials or Transaction Help sections Make the selection of instruction needed

6 Claims Go to Reference Materials section to select Quick Reference guides for billing

7 Claims

8 Why is my claim denying? To check the status of a claim or payment of a claim different avenues may be used such as: Web interchange for: Remittance Advice (RA) Claim inquiry IHCP Provider Line at Option 4 Note: If an RA is available for a specific date, you can click on the icon to view and/or save a copy of the RA. RAs are available online for four weeks. In keeping with Centers for Medicare & Medicaid Services (CMS) privacy requirements, built-in security features allow only the billing provider to view the checks that they have received. 8 Avenues of Resolution for Indiana Health Coverage Programs October 2013

9 Claim From the Check/RA Inquiry link

10 Claims From the Claim Inquiry link

11 Claims

12 Claims When you select the Show More Claim Information option, a screen displays the information for the reason for denial or status of the claim. ARC 178 indicates that the member has spend-down; refer to patient responsibility for the amount the patient owes. Note: The remark code, adjustment reason code (ARC), and explanation of benefits (EOB) codes shown here will be reflected on the RA as well

13 Claims Match the claim EOB code shown on the left with the correct EOB code from the EOB code descriptions page of your RA shown on the right Note: Remark and ARC codes are found in the same manner as the EOB codes

14 Claims Paper claim submission instructions Located in IHCP Provider Manual Chapter 8 UB-04 billing instructions Section 2 UB-04 Claim Form Locator Descriptions CMS-1500 Transaction billing instructions Section 4 CMS-1500, Claim Form Locator Descriptions Dental instructions Section 5 ADA 2006 Dental Claim Form Field Descriptions

15 Claims Why did my claim suspend? Typically a claim will suspend for need of further review The IHCP suspends claims for: Review of medical documentation Appropriate documentation supporting medical necessity Analyst review of Consent Form The use of claim notes allowing the claim to suspend for review of the claim note and be adjudicated appropriately Modifier review, which causes a claim to suspend for review What can I do if my claim suspends? Wait for notification and watch your RAs for the final adjudication Example of modifiers that will suspend for review from Chapter 8 Section 4. Procedure code linkage is not required for these modifiers as well as modifiers that are Informational or Medical Direction 99 Review Suspend for review Multiple modifiers for anesthesia 22 Review Unusual services; for use with surgery codes only; must provide documentation to substantiate 15 Avenues of Resolution for Indiana Health Coverage Programs October 2013

16 Claims When things do not add up I do not see a record of my claim. What do I do? Check the status of the claim on Web interchange Make sure popup blockers are off If no record of claim is found, the claim may need to be resubmitted I have referred a patient for DME and the DME provider is stating that their claim is denying stating I am not enrolled. I am enrolled in IHCP program why is the DME provider claim denying? If you are an enrolled provider for the IHCP and the durable medical equipment (DME) provider states that their claim is denying because you are not enrolled, verify that the DME provider is using the correct referring provider National Provider Identifier (NPI). 16 Avenues of Resolution for Indiana Health Coverage Programs October 2013

17 Provider Enrollment

18 Provider Enrollment Enrollment assistance First line of contact indianamedicaid.com Chapter 4 of the IHCP Provider Manual Provider Enrollment, under Quick Links IHCP Provider Type and Specialty Matrix Risk Category and Application Fee Matrix Second line of contact Provider Enrollment Line at or option 3 Third line of contact Provider Relations consultant Provider education 18 Avenues of Resolution for Indiana Health Coverage Programs October 2013

19 Provider Enrollment Enrollment assistance Provider Education page News Letters, bulletins, and banner pages Note: The Notification System is used to send news letters, bulletins, and banner pages to subscribers on behalf of the IHCP and can be a great way to keep up on enrollment updates. 19 Avenues of Resolution for Indiana Health Coverage Programs October 2013

20 Provider Enrollment Top of page 20 Avenues of Resolution for Indiana Health Coverage Programs October 2013

21 Provider Enrollment Bottom of page 21 Avenues of Resolution for Indiana Health Coverage Programs October 2013

22 Prior Authorization

23 Prior Authorization Delivery systems Traditional (ADVANTAGE Health Solutions) Care Select (ADVANTAGE, MDwise) RBMC (Anthem, Managed Health Services (MHS), MDwise) Pharmacy point-of-sale medication (Catamaran) Note: Administrative Review and Appeals of Prior Authorizations (PAs) are handled by the vendor that provided the PA. Please refer to the Indiana Health Coverage Programs Quick Reference Guide. 23 Avenues of Resolution for Indiana Health Coverage Programs October 2013

24 Prior Authorization Prior authorization by telephone, fax, or mail Traditional (FFS) ADVANTAGE Health Solutions P. O. Box Indianapolis, IN Fax: Care Select ADVANTAGE Care Select P.O. Box Indianapolis, IN Fax : MDwise Care Select P.O. Box Indianapolis, IN or (317) Fax: Healthy Indiana Plan (HIP) Anthem P.O. Box Louisville, KY Fax: MDwise See Quick contact sheet at mdwise.org MHS 1099 N. Meridian Street, Suite 400 Indianapolis, IN Fax: Avenues of Resolution for Indiana Health Coverage Programs October 2013

25 Prior Authorization Prior authorization by telephone, fax, or mail Hoosier Healthwise MDwise See Quick Contact Guide at mdwise.org Anthem Medical PA Inpatient Authorization Fax: Outpatient Clinical Services Fax: St. Frances Health Network (SFHN) Fax: MHS 1099 N Meridian Street, Suite # 400 Indianapolis, IN Fax: Pharmacy Catamaran Fax: Member.ServicesINM@SXC.com 24 hours a day, seven days a week Note: Always verify eligibility to determine where to send the PA request. Appropriate forms to request PA may be found on Web Interchange. 25 Avenues of Resolution for Indiana Health Coverage Programs October 2013

26 Fee Schedule

27 Procedure Code Specific Coverage To determine if a Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT ) code is covered: Access indianamedicaid.com Select Fee Schedule (under Quick Links) Read User Agreement (Accept) This is an interactive site that allows you to View the Entire Fee Schedule or Search by Procedure Code, Procedure Code Range, or Procedure Code Description. The IHCP Fee Schedule includes a variety of search capabilities such as procedure code range and keywords, i.e., tooth, surgery, etc. 27 Avenues of Resolution for Indiana Health Coverage Programs October 2013

28 Fee Schedule Click on link, Search by Procedure Input HCPCS/CPT code (submit) Scroll to bottom of page and refer to Program Coverage/Program PA Refer to Fee Schedule Instructions to understand Program Coverage and Program PA This is an interactive site that allows you to View the Entire Fee Schedule or Search by Procedure Code, Procedure Code Range, or Procedure Code Description. The IHCP Fee Schedule includes a variety of search capabilities such as procedure code range and keywords (for example, tooth and surgery).

29 Fee Schedule

30 IHCP Quick Reference Guide

31 IHCP Quick Reference Guide All contacts mentioned previously and more are listed on the IHCP Quick Reference Guide Click Contact Us located in the upper right corner of the indianamedicaid.com provider home page At the Contact Us page, click the link for the IHCP Quick Reference Guide A copy of the IHCP Quick Reference Guide has been provided with this packet for your convenience 31 Avenues of Resolution for Indiana Health Coverage Programs October 2013

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