Top Denials for Hospice Providers. Conduent MS Medicaid Project Government Healthcare Solutions

Transcription

1 Top Denials for Hospice Providers Conduent MS Medicaid Project Government Healthcare Solutions

2 Edit 0104 Exact Duplicate Claim Due to the system reprocessing on 02/28/05, providers encountered an increase in this denial. Claims that denied for this edit on or before 02/28/05 have been reprocessed. Any current denials are appropriate. Verify through RA s, the Envision web portal or Conduent Provider Beneficiary Support Call Center when the claim was previously paid. 2

3 Edit 0105 Suspect Duplicate Claim Edit 0129 Beneficiary ID Is Missing/Invalid Due to the system reprocessing on 02/28/05, providers encountered an increase in this denial. The Medicaid number on the claim is either missing or the number is invalid. Claims that denied for this edit on or before 02/28/05 have been reprocessed. Any current denials are appropriate. Verify through Conduent Provider Beneficiary Support Call Center any other claims that may have paid for the same beneficiary, same DOS. The paid claim could have been for another provider. Verify beneficiary s ID number, correct the claim, and resubmit. 3

4 Edit 0142 Beneficiary Not Eligible - Recycle Edit 0143 Beneficiary Not Eligible/Not Found Edit 0163 Line item DOS Outside Through Date The beneficiary under the number on the claim is not eligible or not found, meaning the number is not in the Medicaid system. The beneficiary under the number on the claim is not eligible or not found, meaning the number is not in the Medicaid system. The claim was submitted with a line item date of service that is after the through date on the claim. (Ex. Line item DOS is 01/01/06-01/31/06 while the From and Through date on the claim is 01/01/06-01/20/06. It is not necessary for the provider to take action on this edit, as the claim will recycle for 21 days looking for eligibility. If eligibility is not found, the claim will deny after the 21 day cycle with edit Verify the Medicaid number on the claim and resubmit the claim using the correct number. If the beneficiary is not eligible, submit the claim to the appropriate payor source. Correct the claim and resubmit. 4

5 Edit 0221 Beneficiary Name Mismatch Edit 0264 Medicare Part A Eligible W/O Attachment Edit 0302 Attending Provider Is Not On File The Medicaid number on the claim is a valid number but the name on the claim does not match the name associated with the Medicaid number on the beneficiary file. The claim was submitted as a hardcopy crossover without a Medicare Explanation of Benefits (EOMB) attached. The claim was submitted with an incorrect attending provider number or without an attending provider number. Verify the name and number on the claim, correct and resubmit the claim. Remember the name must be spelled EXACTLY the way the name is spelled on the beneficiary file. Re-file the claim with the appropriate EOMB attached. This edit is for tracking purposes only. No action is required by the provider. 5

6 Edit 0336 Billing Provider Not Authorized By Lock-in Span Edit 0357 No Hospice Lock-in Available The billing provider is not on the beneficiary s Hospice lock-in segment. There is a lock-in just not one for the billing provider. There is no Hospice lock-in on the beneficiary file. Contact Conduent Provider and Beneficiary Support Call Center to check the beneficiary s lock-in segment. Send the appropriate enrollment forms to Conduent and resubmit the claim. Contact Conduent Provider and Beneficiary Support Call Center to check the beneficiary s lock-in segment. Send the appropriate enrollment forms to Conduent and resubmit the claim. 6

7 Edit 0381 Rate Record Not Found A claim was submitted with Revenue Code 659 (LTC Room and Board) and there is not a LTC provider number on the lock in segment. Contact Conduent Provider and Beneficiary Support Call Center to verify the LTC provider number is on the beneficiary lock in segment. If necessary mail corrected enrollment forms to Conduent. Once the beneficiary file is updated, resubmit the Edit 0547 Revenue Code Requires Price A claim was submitted with Revenue Code 659 (LTC Room and Board) and there is not a LTC provider number on the lock in segment. claim. Contact Conduent Provider and Beneficiary Support Call Center to verify the LTC provider number is on the beneficiary lock in segment. If necessary mail corrected enrollment forms to Conduent. Once the beneficiary file is updated, resubmit the claim. 7

8 Edit 1253 Claim DOS/DOD Conflict The claim was submitted with a through date that is AFTER the date of death on the beneficiary file. and resubmit. Edit 1255 Beneficiary Over 65 Bill Medicare Edit 3272 DOS Greater Than 1 Year No Timely Filing TCN The claim was submitted for a beneficiary who is a dual eligible. (Medicare will cover Revenue Code 651 but not Revenue Code 659). The claim is more than 12 months from the DOS and there is not a TF TCN documented on the claim. Verify the date of death and the date of service billed, correct the claim, Submit the claim to Medicare. If the claim is for a beneficiary in a LTC facility once Medicare pays, submit the claim for Revenue Code 659 to Medicaid with a copy of the EOMB. Identify the 17 digit timely filing TCN (The TCN from the FIRST time the claim adjudicated). Enter that number in the ICN/DCN field and resubmit the claim. 8

9 Edit 3273 Date Of Service Greater Than 2 Years From Current TCN Date Edit 3453 Units Billed > Covered Days The date of service is more than 2 years from the day the claim was received. The claim was submitted with units greater than the total number of covered days. (Ex: Total number of units for ALL Revenue Codes is 30 while the total covered days is only 20). Covered services will be paid only when received within 12 months of the through date of service (DOS). Claims filed within 12 months from the DOS, but denied can be resubmitted with the 17 digit transaction control number (TCN) from the original denied claim recorded in field 37A of the UB 92. Correct the claim and resubmit. 9

10 Edit 3683 Invalid TF TCN (Timely Filing Transaction Control Number) The claim was submitted with a TF TCN that is not valid. Verify the TF TCN via the web portal, RA s or PBS. Correct the claim and resubmit. 10

11 What is the actual approval/application process for MS Medicaid? At one time there was actually a hospice category of eligibility. That is no longer the case. Medicaid beneficiaries are just eligible for hospice services. The Medicaid Regional Offices process the applications for MS Medicaid. 11

12 Frequently Asked Questions How do Hospice Lock-ins work, and how are they corrected? Lock-ins are initiated by the enrollment application. The hospice provider number must be entered in field 12 and if applicable the LTC provider number must be entered in field 14. The lock in can be verified by calling Conduent Provider and Beneficiary Support Call Center at If there is an error on the enrollment form, the form should be corrected and mailed to Conduent. What is the time frame for lock-ins? Providers should submit the enrollment form immediately as claims will deny until the lock-in segment is updated. The goal of Conduent is to update the lock-in segments within 5 business days of receipt. 12

13 Frequently Asked Questions At what point can a beneficiary be billed for hospice services? Section 3.09 and 3.10 of the Medicaid Policy addresses when a beneficiary can be billed. Policy can be accessed on the Division of Medicaid website: How to identify the amount of the Medicaid Income? The DOM-317 form documents the most recent date of Medicaid eligibility and the amount of Medicaid income due from the beneficiary each month. Hospice providers can request a copy of each 317 from the LTC facility or contact PBS and be given the amount verbally. The 317 s are mailed only to the LTC facilities. 13

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