Iowa Family Planning Network (IFPN) 2012

Transcription

1 Iowa Family Planning Network (IFPN) 2012

2 Discussion Topics: Iowa Family Planning Network Eligibility Coverage Top 10 Billing Errors/ Issues Updates Miscellaneous Topics Billing and Forms Resources Contact Information Q/A

3 Iowa Family Planning Network

4 Iowa Family Planning Network (IFPN) Eligibility Male or Female age Woman Cannot be pregnant Income at or below 300% Federal Poverty level Any woman who had a pregnancy end on or after 1/01/2006 and received Medicaid on that date

5 IFPN Eligibility-Continued Must be an Iowa Resident Be an U.S. Citizen Eligibility is typically for 12 months Member will receive Iowa Medicaid card

6 Coverage Covers only specifically identified family planning services Members may receive family planning services from any Iowa Medicaid provider Request any updated list of covered services and diagnosis from IME Provider Services Informational Letters 1097 & 1105 discuss program updates

7 Sterilization Must meet informed consent No Medicaid payment for those under 21; at time of consent Cannot be mentally incompetent or institutionalized Must sign informed consent Form# Must be obtained at least 30 days but no more than 180 days before sterilization ges/manual_documents/provman/famplan.pdf

8 Top 10 Billing Errors

9 Billing Error #1 Diagnosis/Procedure code not valid for IFPN Denial Code 225 Only IFPN approved services listed on Iowa Family Planning Waiver covered services sheet are payable Correction: Check with coders on the appropriate codes for the member s claim Resubmit claim if appropriate

10 Billing Error #2 Recipient ID not on file Denial Code 250 Member ID# is either not a valid # or is missing completely ID# must be A (Example- 7 digits and a letter) Correction: Check claim for error(s) Resubmit claim with correct Recipient ID #

11 Billing Error #3 Duplicate claim Denial Code 101 All or part of claim was previously billed to Iowa Medicaid Correction: Locate previous claim on EOB; that paid at least partial and submit an adjustment using that TCN# Form #

12 Billing Error #4 Procedure Code/age conflict Denial Code 434 Some procedure codes are age specific Example: J1055 Depo Provera Age years of age only Correction: Check with medical coders on appropriate procedure code for the claim Resubmit claim if appropriate

13 Billing Error #5 J codes- require NDC Denial Code 157 Correction: Resubmit claim with rebate-able National Drug Code (NDC) IL# 803

14 Billing Error #6 Treating Provider missing, invalid or not part of group Denial Code 410 Treating provider information must match our system Treating provider must be attached to billing group ( if billing group is used) Correction: Check claim for error(s) And/or Enroll and/or attach treating provider to group

15 Billing Error #7 Diagnosis/age conflict Denial Code 323 Some diagnosis codes are age specific Example: V25.11 Insertion of Intrauterine Contraceptive Device Age years old only Correction: Cross check member age with age allowed on diagnosis code Resubmit corrected claim if appropriate

16 Billing Error #8 Service not covered for recipient Denial Code 275 Member has limited or no eligibility for DOS Correction: Check eligibility Bill patient if no eligibility for DOS

17 Billing Error #9 Procedure Code/ Gender conflict Denial Code 435 Some procedure codes are gender (sex) specific Example: Vasectomy- Male Only Correction: Cross check gender of member with gender allowed in billed code Resubmit corrected claim if appropriate

18 Billing Error #10 Procedure not allowed for service date Denial Code 439 Procedure code(s) not valid in Iowa Medicaid system Reference IL#1105

19 Updates 2012

20 Provider Enrollment Renewal Providers will designate: Administrator Signatory Ownership control Background checks disclosure IMPA will be utilized for this task Refer to Informational Letter 1128 & 1166

21 ICD-10 April 17 th, 2012 Department of Health and Human Services proposed a one year Implementation delay to October 2014 Includes a proposed rule that would adopt a standard unique Health Plan Identifier (HPID) IME moving forward with transitioning process CMS ICD-10 resources and information:

22 Miscellaneous Topics

23 Updating TPL with Iowa Medicaid Members can call Member Services to update their insurance information or Complete the Insurance Questionnaire (IQ) found at Form # The IQ form can be ed to or faxed to

24 Timely Filing Guidelines Claims must be filed within 365 days of the date of service (DOS). A claim that is timely adjudicated (paid, denied, or suspended), will have an additional 365 days from the adjudication date to resubmit, not to exceed 2 years from the DOS. Last Clarified on Informational Letter 637

25 Timely Filing (continued) Claim Adjustments: Requests for claim adjustments must be made within 365 days of the payment date Claim credits are not subject to a time limit *Discussion of adjustment/recoupment forms will follow

26 Exceptions to Timely Filing Retroactive eligibility: Needs to be billed with the Notice of Decision (NOD) Submit claims within 365 days of the date on the NOD Third-party related delays Need to include reason for delay Within 365 days of TPL payment Must include EOB

27 Iowa Medicaid Billing and Forms

28 Electronic Billing Providers must enroll with EDISS through their Total OnBoarding program PC-ACE Pro32- Free software available through DHS PC-Ace Pro32 Help documents available at: APHD Iowa Medicaid specific HIPAA 5010 resources available at: Refer to Informational Letter 1115 for transition details

29 Adjustments/Recoupments

30 Adjustments Adjustment Form is located on the IME provider website (form # ) Use to request changes or corrections to claims already paid by Iowa Medicaid Adjustment requests MUST HAVE a corrected claim or Remittance Advice (RA) with changes attached Corrected claims should include all charges that need processing. (not just the line that needs correcting) Changes made on the RA must be clear

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32 Recoupments Recoupment form is located on the IME provider website (form # ) Recoupment request form is used to request that Medicaid take back the full claim payment Recoupment request MUST HAVE a Remittance Advice (RA) attached Informational letter 1111

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34 Provider Inquiry Form is located on the IME provider website (Form # ) When to use: To initiate an investigation into a claim denial To request Medical Services review When not to use: To add documentation to a claim To update/change/correct a paid claim

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36 IME Tools & Resources

37 Iowa Medicaid Website Download forms Access Provider Manuals Updated manuals available beginning Fall 2012 January 1 st or July 1, 2012 will be updated version Access Informational letters Fee Schedule Links for claim submission & eligibility verification

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39 IMPA View weekly remittance advice online 24/7 History going back 18 months Informational letters

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41 Checking Eligibility ELVS- Eligibility Verification System 24 hours a day/7 days a week (Des Moines Area) Provider Services 7:30am- 4:30pm (Des Moines Area) ELVS (EDISS) through the web portal.

42 Fraud and Abuse To report instances of possible fraud or abuse, contact one of the following telephone numbers Medicaid Fraud Control Unit Medicaid Program Integrity or (Des Moines area)

43 Address and Contact Information Claims address: IME PO Box Des Moines, IA Correspondence address: IME PO Box Des Moines, IA IME Provider Services: (Des Moines area) ELVS: (Des Moines area) 43

44 Contact Information Sally Nadolsky, Policy Specialist Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA Phone: (515) Misty Peters, Education and Outreach Coordinator Provider Services Phone: (515)

45 Questions?