IHCP Annual Workshop October 2016

Transcription

1 IHCP Annual Workshop October 2016 MDwise UB-04 Billing and Claim Processing Exclusively serving Indiana families since APP0216 (9/15)

2 Agenda Who is MDwise? Provider Enrollment: Are you a MDwise contracted provider? General Claims Information Claim submission Top claims denials and rejected submissions You received a denial now what? How to file a claim dispute and appeal Quick Tips for claims adjudication Tools and Resources Questions -2-

3 Who is MDwise? MDwise is: A local, not-for-profit company serving Hoosier Healthwise, Hoosier Care Connect, and Healthy Indiana Plan members Exclusively serving Indiana families since 1994 Over 400,000 members 2,000 primary medical providers -3-

4 Delivery System Model What is a delivery system model? MDwise serves its Hoosier Healthwise and HIP members under a delivery system model The basis of this model is the localization of health care around a group of providers These organizations, called delivery systems are comprised of hospital, primary care, specialty care, and ancillary providers -4-

5 IHCP Overview -5-

6 MDwise Delivery System Model MDwise Franciscan St. Margaret & St. Anthony MDwise Select Health Network (SHN) MDwise Eskenazi Health MDwise Excel Network MDwise Delivery Systems MDwise Indiana University Health MDwise St. Catherine MDwise St. Vincent MDwise Total Health -6- MDwise Community Health Network CHN

7 Provider Enrollment/Prior to Submitting a Claim In order to receive reimbursement from MDwise, the provider must: Be registered and be actively eligible with the Indiana Health Coverage Program (IHCP) Be enrolled with the appropriate MDwise delivery system Obtain a prior authorization if the provider is out of network Complete all required elements on the UB-04 form Submit claim to appropriate MDwise delivery system claims payer -7-

8 General Claims Information Delivery System Claims processing for Hoosier Healthwise is delegated to the MDwise delivery systems CMCS pays Hoosier Healthwise claims for: St. Margaret Mercy St. Anthony St. Vincent St. Catherine / Select Health Claims vendor pays all other Delivery Systems All HIP claims are processed by the claims vendor If uncertain of the members delivery system, please refer to: Web Interchange MDwise Provider Portal -8-

9 General Claims Information Delivery System For Example: If a provider renders service for a MDwise Eskenazi Health member, the provider would submit their claim to the MDwise Eskenazi Health address, or using the MDwise Eskenazi payor ID. If the same provider rendered services to a MDwise IU Health member, the provider would submit claim to MDwise IU Health, following the same submission directions. -9-

10 General Claims Information Provider Portal -10-

11 General Claims Information Provider Portal -11-

12 General Claims Information Member Eligibility When a member s RID number is entered in the MDwise provider portal you will see: The IHCP program the member is enrolled in Managed Care Entity(MCE) What delivery system they are assigned to Assigned PMP PMP assignment history -12-

13 General Claims Information Member Information -13-

14 Verifying Eligibility Delivery System -14-

15 General Claims Information - Timelines Claim Submission Contracted providers must submit claims to MDwise within 90 days of the date of rendering the service When MDwise is secondary, claim must be submitted within 90 days of the date on the primary EOB Claim Inquiry One Form for all MDwise Programs Claims Inquiry Forms Claim Disputes Customer Service: Submit dispute within 60 days of the date on EOB -15-

16 General Claims Information - 90 Day Rule When the member has other insurance: Provider must submit claims to the other insurance carrier before submitting to the MDwise delivery system If there is no response within 90 days of the date of service, the claim can be submitted to MDwise for payment consideration along with one of the following required items: Copies of unpaid bills or statements sent to the third party with the date of the billing attempt Written notification from the provider indicating the billing dates Date of the filing attempt The phrase, no response after 90 days Name of primary insurance carrier billed For claims filed electronically, the following must be documented in the claim note segment of the 837P transaction: Date of the filing attempt The phrase, no response after 90 days Name of primary insurance carrier billed -16-

17 Claims Submission Information For Hoosier Healthwise: Paper claims should be submitted to: MDwise Claims DST P.O. Box Birmingham, AL CMCS pays Hoosier Healthwise claims for: - St. Margaret Mercy - St. Anthony - St. Vincent - St. Catherine / Select Health All electronic EDI: Emdeon/WebMD Institutional Payer ID: 12K81 Professional Payer ID: SX172 McKesson/Relay Health Institutional Payer ID: 4976 Professional Payer ID:

18 Claims Submission Information For Healthy Indiana Plan: Paper claims should be submitted to: MDwise Claims DST P.O. Box Birmingham, AL All electronic EDI: Emdeon/WebMD Institutional Payer ID: 12K81 Professional Payer ID: SX172 McKesson/Relay Health Institutional Payer ID: 4976 Professional Payer ID:

19 Claims Submission Information For Hoosier Care Connect: Paper claims should be submitted to: MDwise Claims DST P.O. Box Birmingham, AL All electronic EDI: Emdeon/WebMD Institutional Payer ID: 12K81 Professional Payer ID: SX172 McKesson/Relay Health Institutional Payer ID: 4976 Professional Payer ID:

20 Rejected vs. Denied Claims Rejected claims are different than denied claims Rejected claims are returned to the provider or electronic data interchange (EDI) source without registering in the claim processing system Since rejected claims are not registered in the claims processing system, the provider must resubmit the corrected claim within the claims timely filing limit Denied claims will include an EOB with a denial code Rejected claims do not extend the timely filing limit Providers have only 90 days from the date of service -20-

21 Quick Tips to Avoid Claims Denial or Rejections Confirm member eligibility at the time of service Make sure Provider Profile is accurate on Web Interchange Providers must report NPI to IHCP Follow correct coding guidelines for claims submission Verify payer information before claims are submitted Submit claims and corrected claims timely Inquire or dispute claims within contractual timeline -21-

22 Claim Denial So your claim is denied now what? -22- Hoosier Healthwise

23 So Your Claim Has Been Denied...Now What? Claims Inquiry Providers need to contact the MDwise delivery system to inquire about a claims denial MDwise delivery systems are required to respond within 30 calendar days of inquiry to the provider with the decision of the inquiry Appeals/Dispute for Hoosier Healthwise and HIP Must be in writing to the appropriate Delivery System Providers have 60 calendar days to file an appeal and must include the following documentation: Appeal form, remittance advice and a copy of the claim If a delivery system fails to make a determination or the provider disagrees with the determination, the provider should forward their appeal to: MDwise P. O. Box Indianapolis, IN Attention: Grievance Coordinator -23-

24 So Your Claim Has Been Denied...Now What? Dispute/Appeal for Hoosier Care Connect Must be in writing Providers have 60 calendar days to file an appeal and must include the following documentation: Appeal form, remittance advice and a copy of the claim If a delivery system fails to make a determination or the provider disagrees with the determination, the provider should forward their appeal to: MDwise P. O. Box Indianapolis, IN Attention: MDwise Grievance Coordinator Claims Forms Contact your Provider Relations Representative

25 Tools and Resources IHCP Claims and Billing Procedure Modules Section 2: UB-04 Claims Form information Types of services billed using UB-04 Admission and Duration Requirements Use of ICD Procedure Codes UB-04 Claim Form Instructions Submitting Electronic Claims MDwise Provider Tip Sheets Third Party Liability Vision Claims

26 Resources MDwise Provider Tip Sheets Third Party Liability Vision Claims MDwise Provider Manuals MDwise Provider Relations Territory Map MDwise Customer Service IHCP Provider Modules Indianamedicaid.com -26-

27 Questions -27-