Commonwealth of Kentucky KyHealth Choices KyHealth Net Dental Companion Guide

Transcription

1 Commonwealth of Kentucky KyHealth Choices KyHealth Net Dental Companion Guide Version 5.0 February 26, 2007

2 Revision History Document Version Date Name Comments /27/2006 Patti George Created /27/2006 Ron Chandler Review and format /29/2007 Patti George Updates per DMS walkthrough /09/2007 Lize Deane Formatted according to KY standards /26/2007 Michelle Goins Updated with latest information /26/2007 Patti George Updates /06/2007 Ann Murray Updated according to comments.

3 Table of Contents NUMBER DESCRIPTION PAGE 1 Submitting a Dental Claim Claims Wizard (Dental) Header Screen Dental Claim Header Screen Field-by-Field Instructions Claims Wizard (Dental) Detail Screen Dental Claim Detail Screen Field-by-Field Instructions Claims Wizard (Dental) Summary Screen Dental Summary Screen Field-by-Field Instructions KyHealth Choices Response KyHealth Choices Response Field-by-Field Explanation Using KyHealth Net Card Issuance Verifying Eligibility Member ID Lookup Social Security Number Lookup Case Number Lookup Member Screen Pharmacy History Pharmacy Claims History Panel Accessing the Presumptive Eligibility/BCCTP Application Presumptive Eligibility Application BCCTP Application Claims Inquiry Search Criteria Panel Search Results Locating a TPL Carrier Reference Search Screen Printing a Prior Authorization Letter Looking up a Prior Authorization Number Requesting Prior Authorization Viewing a Remittance Advice Printing a Remittance Advice Adjusting/Crediting a Paid Claim Crediting a paid claim Adjustment/Claim Credit Response...Error! Bookmark not defined. Date Printed 3/12/2007 Page i

4 1 Submitting a Dental Claim Select Claims Submission (Dental) from the Claims drop down menu. Select the applicable provider number from the drop down menu. If you are a provider, only your number appears. If you are an agent, you see the providers for whom you bill. Date Printed 3/12/2007 Page 1

5 Click next. The Claims Wizard opens. The Header screen appears first. Date Printed 3/12/2007 Page 2

6 1.1 Claims Wizard (Dental) Header Screen Dental Claim Header Screen Field-by-Field Instructions No Field/Menu Selection 1 Header Identifies this screen as the Header screen. Contains the initial claim information 2 Billing Information Identifies the Billing Information section of the Header screen 3 Provider Number The KyHealth Choices Provider number. This field is auto-populated based on the previous screen selection. 4 Member ID* Enter the Member s KyHealth Choices ID number. The * indicates that this is a mandatory field. Date Printed 3/12/2007 Page 3

7 No Field/Menu Selection 5 Last Name The member s last name. This field is auto-populated after the member number is entered. 6 First Name The member s first name. This field is auto-populated after the member number is entered. 7 Date of Birth The member s date of birth. This field is auto-populated after the member number is entered. 8 Gender The member s gender. This field is auto-populated after the member number is entered. 9 Patient Account # Enter the provider-assigned patient account number. This field is optional. 10 Insurance Denied? Select Yes if the claim was filed with a commercial carrier and denied. 11 Prior Authorization If the service requires Prior Authorization, enter the 10 digit PA number here. 12 Service Information Identifies the Service Information section of the Header screen. 13 Emergency If the service is the result of an emergency, choose yes from the drop down menu. If not, leave the default selection, no. 14 Accident If the service is the result of an accident, choose the type of accident from the drop down menu. If not, leave the default selection, none. 15 Accident Date If anything other than none is selected from the Accident drop down menu, enter the date of the accident. If a date is entered indicating an accident, the claim must be filed on paper rather than electronic. The date should be in MMDDCCYY format. 16 EPSDT If the service is the result of an EPSDT screening, choose yes from the drop down menu. If not, leave the default selection, no. 17 Place of Service Select the appropriate Place of Service from the drop down menu. Date Printed 3/12/2007 Page 4

8 No Field/Menu Selection 18 Rendering Provider Enter the KyHealth Choices rendering provider s ID number. The * indicates that this is a mandatory field. A KyHealth Choices provider ID or an NPI may be entered. If the NPI is entered, a field appears to enter the appropriate taxonomy code(s) to the right of the Provider ID field. Please note that KyHealth Choices provider ID numbers may be either 8 or 10 digits, depending on date of issue. 19 Claim Charges Identifies the Claim Charges section of the Header screen. 20 Total Charges This field is auto-populated after detail charges are entered in the detail screen. 21 TPL Amount This field is auto-populated after detail TPL payments are entered in the detail screen. 22 Total Amount Paid This field is auto-populated after the claim is submitted. 23 Next Click the Next button to continue to the detail screen. Date Printed 3/12/2007 Page 5

9 1.2 Claims Wizard (Dental) Detail Screen Dental Claim Detail Screen Field-by-Field Instructions No Field/Menu Selection 1 Header Clicking on Header allows the user to return to the Header screen. 2 Details Identifies this screen as the Details screen. Contains the claim details (for example procedure codes). 3 Detail Information Identifies this as the Detail Information section of the Details screen. 4 Item Line number of the detail. This field is auto-populated. Date Printed 3/12/2007 Page 6

10 No Field/Menu Selection 5 DOS* Enter the date the service was provided. The * indicates that this field is required. The date should be entered in MMDDCCYY format. 6 Place of Service Select the place of service from the drop-down menu. 7 Procedure* Enter the ADA procedure code that identifies the service provided. The * indicates that this field is required. 8 Tooth Number Enter the tooth number on which the procedure was performed (if applicable). 9 Surface Enter the tooth surface on which the procedure was performed (if applicable). 10 Quadrant Use the drop down menu to select the quadrant, if applicable. 11 Prosthesis Use the drop down menu to select the prosthesis, if applicable. 12 Cavity Codes These fields are not used. 13 Units* Enter the number of units (1 is the default value). The * indicates that this field is required. 14 Charges* Enter the usual and customary charge for the procedure. The * indicates that this field is required. 15 Status Status of the claim (if you are accessing a previously submitted claim). 16 Allowed Amount The amount allowed by KyHealth Choices (paid claims only). This field is auto-populated after the claim is submitted. 17 Warrant Amount Total amount of the check. This field is auto-populated after the claim is paid (for paid claims only). 18 Save Click Save to save the detail entered. You must click Save before proceeding. 19 Add Click Add to add an additional detail. 20 Delete Click Delete to delete the detail entered. 21 Next Click Next to proceed to the next screen. Date Printed 3/12/2007 Page 7

11 1.3 Claims Wizard (Dental) Summary Screen Dental Summary Screen Field-by-Field Instructions No Field/Menu Selection 1 Header Clicking on Header allows the user to return to the Header screen. 2 Details Clicking on Details allows the user to return to the Details screen. 3 Summary Identifies this as the Summary screen. 4 Billing Information Identifies this section as the Billing Information section of the Summary screen. 5 Service Information Identifies this section as the Service Information section of the Summary screen. Date Printed 3/12/2007 Page 8

12 No Field/Menu Selection 6 Claim Charges Identifies this section as the Claim Charges section of the Summary screen. 7 Details Identifies this section as the Details section of the Summary screen. (Click on the Detail number to return to that detail). 8 Submit Claim Click Submit Claim to submit the claim for processing. Date Printed 3/12/2007 Page 9

13 1.4 KyHealth Choices Response After you submit your claim, you receive a response, which appears at the top of the summary screen in a section labeled Claim Information. Date Printed 3/12/2007 Page 10

14 1.4.1 KyHealth Choices Response Field-by-Field Explanation No Field/Menu Selection 1 Header Clicking on Header allows the user to return to the Header screen. 2 Details Clicking on Details allows the user to return to the Details screen. 3 Summary Identifies this as the Summary screen. 4 Claim Status Informs the user of the claim disposition (Paid, Denied or Suspended). 5 Claim ICN The 13-digit Internal Control Number assigned to the claim. This number may be used to reference the claim later. 6 Paid Date The date claim payment is made (if applicable). 7 Adjudicated Date The date the claim was set to be paid or denied. 8 Adjusted Claim ICN If the claim has been adjusted, the new claim ICN appears here. 9 Patient Liability The amount of patient liability applied to the claim (if applicable). 10 Spenddown Amount The spenddown amount applied to the claim (if applicable). 11 Copay Amount The co-payment deducted from claim payment. 12 Total Allowed Amount The total dollar amount allowed by KyHealth Choices. This is the paid amount before any deductions for TPL payment, patient liability, spenddown or co-payment. 13 Allowed Amount The amount paid after deductions for TPL payment, patient liability, spenddown or co-payment. 14 Header/Detail EOB codes and descriptions appear here. Any under a heading of header apply to the entire claim. Any under detail apply to the detail line indicated. 15 EOB The explanation of benefits code appears here. 16 The EOB code full description (reason for denial). 17 Click Here for EOB Listing. This is a link to a full list of EOB codes and descriptions. 18 Billing Information Identifies the Billing Information section of the screen, which shows information submitted. 19 Service Information Identifies the Service Information section of the screen, which shows information submitted. Date Printed 3/12/2007 Page 11

15 No Field/Menu Selection 20 Claim Charges Identifies the Claim Charges section of the screen. 21 Details Identifies the Details section of the screen. 22 Submit Claim Click Submit Claim to submit the claim for payment. In the case of a denied claim the submit button will appear. In the case of a paid claim the copy claim button, void claim button, and the adjust claim button will appear. Date Printed 3/12/2007 Page 12

16 2 Using KyHealth Net 2.1 Card Issuance Card issuance information is available to providers for use when filing aged claims. Claims may be filed for the first time up to one year from the date of service, and must be re-filed at least one time every 12 months thereafter. However, if a member is issued back-dated eligibility, the provider may file the claim for the first time up to one year after the card issue date. Select Card Issuance from the Member drop down menu. Enter the Member s Medicaid ID number in the Member ID field. Date Printed 3/12/2007 Page 13

17 Click Search. Field 1. Member ID Input Member ID 2. Search Search button 3 Issue Date Date the card was issued. 4. Retroactive Indicates if the card was issued retroactively. An R will appear in the field if the card is a retroactive card. 5. Beginning Date First date of eligibility in the segment. Date Printed 3/12/2007 Page 14

18 Field 6. End Date Last date of eligibility in the segment. 7. Type Type of card. 8. Source Agency which generated the information. 9. Currently Billable If the current date is between the start date and end date of the card, a Y will appear here. 2.2 Verifying Eligibility Eligibility information is available so providers can check eligibility PRIOR to the provision of services. Eligibility can be accessed with a Member ID, Social Security Number, Name and Date of Birth, or Case Number. Select Eligibility Verification from the Member drop down menu or the quick link on left. Date Printed 3/12/2007 Page 15

19 Select the criteria for the search (Member ID Lookup, SSN Lookup, or Case Number Lookup) Member ID Lookup Enter the Member ID at #4 and the dates of service at #5 in question. 1. Provider ID Verify Provider Id from the dropdown menu 2. Select Lookup Type Select lookup type from dropdown menu 3. Search Click Search 4. Member ID Enter the Members ID 5. From date of service Enter the from date of service 6. To date of service Enter the to date of service Date Printed 3/12/2007 Page 16

20 Click Search Social Security Number Lookup Enter the member s Social Security number at #4 and date of birth at #5, and the dates of service at #6 and 7 on the following screen. 1. Provider ID Verify Provider Id from the dropdown menu 2. Select Lookup Type Select lookup type from dropdown menu 3. Search Click Search 4. SSN Enter the Members social security number 5. Date of Birth Enter the from date of birth 6. From Date of service Enter the from date of service 7. To date of service Enter the to date of service Click Search. Date Printed 3/12/2007 Page 17

21 2.2.3 Case Number Lookup Enter the member s case number at #4 and the dates of service at #5 and #6 on the following screen. 1. Provider ID Verify Provider Id from the dropdown menu 2. Select Lookup Type Select lookup type from dropdown menu 3. Search Click Search 4. Case number Enter the Members case number 5. From date of service Enter the from date of service 6. To date of service Enter the to date of service Click Search. Date Printed 3/12/2007 Page 18

22 2.2.4 Member Screen The Member Eligibility Screen displays the Member s demographic information on the Member Panel. Additional information appears in the following panels: Eligibility (click the hyperlink for 5 year history) #25 on the screen above. TPL (click the hyperlink for 5 year history) #26 on the screen above. Managed Care (click the hyperlink for 5 year history) #27 on the screen above. Date Printed 3/12/2007 Page 19

23 Lockin (click the hyperlink for 5 year history) #28 on the screen above. Note that only current information is displayed on the main page. If the Member is not currently eligible, you may still find information for old dates of service by clicking a 5 year history link Member Screen Field#/Menu Selection 7. I.D. The member s Medicaid ID number 8. Last Name Member s last name 9. First Name Member s first name 10. Date of Birth Member s date of birth 11. SSN Member s Social Security Number. 12. County Code Member s County Code. 13. Case Number Member s Case Number. Hyper link to the members under that case number. 14. Case Name Member s Case Name. 15. Last EPSDT Member s most recent EPSDT screening (based on claims processed; if no information is present, there are no applicable claims on file) *only applicable to members under the age of Last Dental Visit Member s most recent Dental visit (based on claims processed; if no information is present, there are no applicable claims on file) 17. Hospice Election Date Date Member elected to receive Hospice care (if applicable) 18. Medicare A A Y indicates Member has Medicare Part A benefits 19. Vision Date Member s most recent Vision service(based on claims processed; if no information is present, there are no applicable claims on file) *only applicable to members under the age of Medicare B A Y indicates Member has Medicare Part B benefits 21. Hearing Date Member s most recent Hearing service(based on claims processed; if no information is present, there are no applicable claims on file) *only applicable to members under the age of Ultrasound Member s most recent Ultrasound(based on claims processed; if no information is present, there are no applicable claims on file) 23. Service Limitations Member s 5 year service limitations. Date Printed 3/12/2007 Page 20

24 Copay/Coinsurance Field# Menu Selection 24 CoPay/Coinsurance Member s Copay or Coinsurance accumulated out of pocket paid amount Eligibility Panel Field#/Menu Selection 2. Benefit Plan Benefit Plan in which Member is enrolled 3. Begin Date Start date of eligibility (for current segment) 4. End Date End date of eligibility (for current segment) Date Printed 3/12/2007 Page 21

25 Eligibility 5 Year History Field#/Menu Selection 1. Program Program in which Member is enrolled 2. Begin Date Start date of eligibility (for that segment) 3. End Date End date of eligibility (for that segment) Date Printed 3/12/2007 Page 22

26 Third Party Liability (TPL) Panel Third Party Liability refers to a member s other insurance coverage. Medicaid is the payer of last resort, so all other payers must be billed first. The information is available to providers so that they may bill other carriers first. Access the member s TPL information and use the carrier code to look up the insurance company address on the TPL Carrier link. Please note that Medicare is NOT considered TPL. Field#/Menu Selection 2. Carrier Name The name of the member s other insurance carrier. 3. Policy Number The member s policy number (with the other carrier). 4. Policy Holder The name on the policy. 5. Coverage Type Type of coverage (i.e. medical, dental). 6. Carrier Code The number assigned to this carrier by Kentucky Medicaid. 7. Effective The effective date of the policy. 8. End The termination date of the policy. Date Printed 3/12/2007 Page 23

27 TPL 5 Year History Field#/Menu Selection 1. Carrier Name The name of the member s other insurance carrier. 2. Policy Number The member s policy number (with the other carrier). 3. Policy Holder The name on the policy. 4. Coverage Type Type of coverage (i.e. medical, dental). 5. Carrier Code The number assigned to this carrier by Kentucky Medicaid. 6. Effective The effective date of the policy. 7. End The termination date of the policy. Date Printed 3/12/2007 Page 24

28 Partnership (Passport) Panel Field# Menu Selection 1. Partnership (Passport) Select 5 year history 2. Effective Date Member effective date. 3. End Date Members end date Partnership (Passport) 5 Year History Date Printed 3/12/2007 Page 25

29 Field#/Menu Selection 1. Program Member s Managed Care program (i.e. KenPAC). 2. Begin Date First date of eligibility under program (in that segment). 3. End Date Last date of eligibility under program (in that segment) KenPAC Panel Field# Menu Selection 1. KenPAC five year history. Hyper link to members five year history. 2. Provider Name KenPAC provider s name. 3. Provider phone number KenPAC provider s phone number. 4. Begin date Members begin date. 5. End date Members end date KenPAC 5 Year History Field# Menu Selection 1. Provider Name KenPAC provider s name. 2. Provider phone number KenPAC provider s phone number. 3. Begin date Members begin date. 4. End date Members end date. Date Printed 3/12/2007 Page 26

30 Lockin Panel Lockin assignment information is available so providers may request needed referrals prior to the provision of services, or refer the member to his or her Lockin provider if appropriate. Field#/Menu Selection 2. Provider Name The name of the provider to whom the member is locked in. 3. Provider Phone The Lock In provider s phone number. 4. Service Type The type of service provided by the lock in provider. 5. Effective The first date the lock in assignment was effective. 6. End The last date the lock in assignment was/is effective Lockin 5 Year History Date Printed 3/12/2007 Page 27

31 Field#/Menu Selection 1. Provider Name The name of the provider to whom the member is locked in. 2. Provider Phone The Lock In provider s phone number. 3. Service Type The type of service provided by the lock in provider. 4. Effective The first date the lock in assignment was effective. 5. End The last date the lock in assignment was/is effective. Date Printed 3/12/2007 Page 28

32 2.3 Pharmacy History KyHealth Choices providers may check the pharmacy history for KyHealth Choices patients. History information is based on claims processed by Kentucky Medicaid; no information about other prescriptions is available. Select Pharmacy History from the Member drop down menu. Enter the Member ID number. Click Search. Date Printed 3/12/2007 Page 29

33 2.3.1 Pharmacy Claims History Panel Field#/Menu Selection 3. Prescription Name Name of the drug prescribed. 4. Date Filled Date the prescription was filled. 5. Supply Days Number of days supply. 6. ICN Internal Control Number of the claim. Date Printed 3/12/2007 Page 30

34 2.4 Accessing the Presumptive Eligibility/BCCTP Application Only for PE or BCCTP providers. Choose Presumptive Eligibility from the Member drop down menu. Select the applicable provider number from the drop down menu. If you are a provider, only your number will appear. If you are an agent, you will see the providers for whom you bill. Date Printed 3/12/2007 Page 31

35 Enter the Confirmation Number and click Login. Date Printed 3/12/2007 Page 32

36 2.4.1 Presumptive Eligibility Application Date Printed 3/12/2007 Page 33

37 Field#/Menu Selection Application Information 1. Application Date The current date will appear. 2. Provider Number The provider number selected on the previous screen. 3. DMS Confirmation # The confirmation number issued to the provider by the Presumptive Eligibility unit. Patient Information 4. Patient SSN The patient s Social Security number. The * indicates that this field is required. 5. Last Name The patient s last name will appear here. 6. First Name The patient s first name will appear here. 7. Date of Birth The patient s date of birth will appear here. 8. Street Address Enter the patient s street address. The * indicates that this field is required. 9. City Enter the patient s city of residence. The * indicates that this field is required. 10. State Enter the patient s state of residence. The * indicates that this field is required. 11. Zip Code Enter the patient s Zip code. The * indicates that this field is required. 12. County Select the patient s county of residence from the drop-down menu. The * indicates that this field is required. 13. Home Phone Enter the patient s home phone number. The * indicates that this field is required. 14. Work Phone Enter the patient s work phone number. 15. Marital Status Select the patient s marital status from the drop-down menu. 16. Race Select the patient s race from the drop-down menu. Mailing Address (if different) 17. Street Address Enter the patient s mailing street address. 18. City Enter the patient s mailing city. 19. State Enter the patient s mailing state. 20. Zip Code Enter the patient s mailing Zip code. Family Income Date Printed 3/12/2007 Page 34

38 Field#/Menu Selection 21. # of Family Members Enter the number of members in the patient s family. The number should include the patient, the baby (or babies) expected, and other family members in the household. 22. Total Monthly Family Income Enter the dollar amount of the family s total monthly income. Additional Information 23. Proof of Pregnancy If there is proof of the patient s pregnancy, click the radio button to the left of Yes. 24. Due Date Enter the patient s due date. 25. Multiple Pregnancy If this is a multiple pregnancy, click the radio button to the left of Yes. 26. If so, how many? Enter the number of babies expected. 27. Referred to WIC? If you referred the patient to Women and Infant Care, click the radio button to the left of Yes. Other Insurance Information 28. Name of Plan Enter the name of the patient s primary insurance plan. 29. Name of Insurance Co. Enter the name of the patient s primary insurance company. 30. Policy Number Enter the name of the patient s primary insurance policy number. 31. Group Number Enter the name of the patient s primary insurance group number. 32. Name of Plan Enter the name of the patient s secondary insurance plan. 33. Name of Insurance Co. Enter the name of the patient s secondary insurance company. 34. Policy Number Enter the name of the patient s secondary insurance policy number. 35. Group Number Enter the name of the patient s secondary insurance group number. Date Printed 3/12/2007 Page 35

39 2.4.2 BCCTP Application Date Printed 3/12/2007 Page 36

40 Field#/Menu Selection Application Information 1. Application Date The current date will appear. 2. Provider Number The provider number selected on the previous screen. 3. DMS Confirmation # The confirmation number issued to the provider by the Presumptive Eligibility unit. Patient Information 4. Patient SSN The patient s Social Security number. The * indicates that this field is required. 5. Last Name The patient s last name will appear here. 6. First Name The patient s first name will appear here. 7. Date of Birth The patient s date of birth will appear here. 8. Street Address Enter the patient s street address. The * indicates that this field is required. 9. City Enter the patient s city of residence. The * indicates that this field is required. 10. State Enter the patient s state of residence. The * indicates that this field is required. 11. Zip Code Enter the patient s Zip code. The * indicates that this field is required. 12. County Select the patient s county of residence from the drop-down menu. The * indicates that this field is required. 13. Home Phone Enter the patient s home phone number. The * indicates that this field is required. 14. Work Phone Enter the patient s work phone number. 15. Marital Status Select the patient s marital status from the drop-down menu. 16. Race Select the patient s race from the drop-down menu. Mailing Address (if different) 17. Street Address Enter the patient s mailing street address. 18. City Enter the patient s mailing city. 19. State Enter the patient s mailing state. 20. Zip Code Enter the patient s mailing Zip code. Additional Information Date Printed 3/12/2007 Page 37

41 Field#/Menu Selection 21. Proof of CDC NBCCEDP Screening? If there is proof of an CDC NBCCEDP screening, check Yes. Patient Needs Treatment For: 22. Breast cancer (4 months) If the patient needs treatment for Breast cancer, check Yes. 23. Cervical cancer (3 months) 24. Precancerous cervical disease or breast disorder (2 months) If the patient needs treatment for Cervical cancer, check Yes. If the patient needs treatment for a precancerous cervical disease or breast disorder, check Yes. Other Insurance Information 25. Name of Plan Enter the name of the patient s primary insurance plan. 26. Name of Insurance Co. Enter the name of the patient s primary insurance company. 27. Policy Number Enter the name of the patient s primary insurance policy number. 28. Group Number Enter the name of the patient s primary insurance group number. 29. Name of Plan Enter the name of the patient s secondary insurance plan. 30. Name of Insurance Co. Enter the name of the patient s secondary insurance company. 31. Policy Number Enter the name of the patient s secondary insurance policy number. 32. Group Number Enter the name of the patient s secondary insurance group number. Complete the form and click Submit Information. Date Printed 3/12/2007 Page 38

42 This screen will appear. Print the certificate for the patient. This is the member s temporary card. Date Printed 3/12/2007 Page 39

43 Presumptive Eligibility Certificate BCCTP Certificate Date Printed 3/12/2007 Page 40

44 2.5 Claims Inquiry Select Claims Inquiry from the Claims drop down menu or the quick link on the left hand side. Enter search criteria and click Search. Date Printed 3/12/2007 Page 41

45 2.5.1 Search Criteria Panel Field#/Menu Selection 1. Provider ID Verify Provider ID 2, Refresh Unfinished Claims 3. Member ID The member s Kentucky Medicaid ID number 4. Claim Status Inquiry may be limited to claims that are Paid, Denied, Suspended, or the user may select Any Status Date Printed 3/12/2007 Page 42

46 Field#/Menu Selection 5. Patient Acct. # If the provider included this information on the claim, the patient account number may be used as search criteria 6. Date Type User may select Date of Service or Warrant Date 7. ICN Provider may use the Internal Control Number as search criteria 8. From Date First date to search 9. Thru Date Last date to search Search Results Search results are listed below the search criteria. Date Printed 3/12/2007 Page 43

47 Field#/Menu Selection 1. ICN Internal Control Number assigned to the claim 2. From DOS First Date of Service on the claim 3. To DOS Last Date of Service on the claim 4. Amount Billed Total Billed Amount on the claim 5. Claim Status Indicates the current status of the claim 6. Member No. Member s Kentucky Medicaid ID number 7. Claim Type Type of claim 2.6 Locating a TPL Carrier Click TPL Carrier from the Provider Reference drop-down menu. Date Printed 3/12/2007 Page 44

48 After viewing a member s TPL information, use the carrier code to locate the carrier on this page. The full name, billing address and phone number of the carrier are displayed Field# Menu Selection 1. Carrier name Commercial insurance carriers name 2. Search button Click search for results 3. Carrier code Commercial insurance carrier code. 4. Carrier name Commercial insurance carriers name Date Printed 3/12/2007 Page 45

49 Field# Menu Selection 5. Carrier address Commercial insurance carriers address. 6. Carrier phone number Commercial insurance carriers phone number. 7. Page numbers Additional pages. Date Printed 3/12/2007 Page 46

50 2.7 Reference Search Screen Click the Reference Search link on the Provider Home Page. Field#/Menu Selection 1. Choose Search Type Select the criteria for your search (Procedure or Diagnosis) Date Printed 3/12/2007 Page 47

51 Field#/Menu Selection 2. Procedure Code/Diagnosis Code This field label changes depending on the selection made in Choose Search Type. 3. Benefit Package Use the drop down menu to select the Benefit Package of the member who will receive the service in question. 4. Date of Service Enter the date the service will be performed. Enter the appropriate information and click Search Procedure Search Results The white box contains the information about coverage and limitations for the procedure in question, with regard to the benefit package in question. (All benefit packages do not offer the same coverage). Date Printed 3/12/2007 Page 48

52 Field#/Menu Selection 8. PA Requirement Indicates whether the procedure requires Prior Authorization No PA Required PA Required 9. Age Restriction Lists the procedure age restriction 10. Maximum Units Lists the maximum number of units that can be performed at one time. 11. Gender Lists gender requirements. 12. Attachment Notes whether claim attachments are required with this procedure. 13. CLIA Indicates if CLIA certification is required to perform the procedure. 14. Lifetime Procedure Indicates if the procedure is limited to once in a lifetime. 15. Diagnosis Indicates if the procedure may only be performed with certain diagnoses 16. Specialty Indicates if only providers with certain specialties may perform the procedure. 2.8 Printing a Prior Authorization Letter Select Prior Authorization Letter from the PA drop down menu. Date Printed 3/12/2007 Page 49

53 2.9 Looking up a Prior Authorization Number See the KyHealth Net Prior Authorization Companion Guide Requesting Prior Authorization See the KyHealth Net Prior Authorization Companion Guide Viewing a Remittance Advice Select a date range from the RA Viewer drop down menu. Select the applicable provider number from the drop down menu. Click Search. Date Printed 3/12/2007 Page 50

54 Field#/Menu Selection 1 Enter a search string and all occurrences of matching data will be displayed. Date Printed 3/12/2007 Page 51

55 2.12 Printing a Remittance Advice Field#/Menu Selection 1 Download Click download to download files. 2 Go button Click Go to go to the page selected. 3 Search Enter search string and all occurrences of matching data will be displayed. 4 First/ Next Click first/next to page through the RA. 5 Print Click print to print RA. Date Printed 3/12/2007 Page 52

56 2.13 Adjusting/Crediting a Paid Claim To adjust a claim, locate the claim record via Claims Inquiry. Select a claim and click the hyperlinked ICN. Follow the instructions for submitting a claim (via the claim wizard) to make any changes to the existing claim. Click the Adjust button at the bottom of the screen. Field#/Menu Selection 1. Next Use the Next button to move to the next page in the claims wizard. 2. Adjust Click the Adjust button after changes are made to the original paid claim. 3. Void Claim Click the Void Claim button to credit the claim completely. 4. Copy Claim Click Copy Claim to use this claim to begin entering information for a new claim Crediting a paid claim Access the claim via claims inquiry. Click the Void Claim button at the bottom of the screen. Date Printed 3/12/2007 Page 53

57 Adjustment Response Screen Field/Menu Selection 1 Header Clicking on Header allows the user to return to the Header screen. 2 Diagnosis Clicking on Diagnosis allows the user to return to the Diagnosis screen. Date Printed 3/12/2007 Page 54

58 Field/Menu Selection 3 Details Clicking on Details allows the user to return to the Details screen. 4 Summary Identifies this as the Summary screen. 5 Claim Status The current disposition of the claim Paid Denied Suspended 6 Claim ICN The unique 13-digit number assigned to the claim. 7 Paid Date The date of the Remittance Advice where the claim EOB appears. 8 Adjudicated Date Date the claim s final disposition was determined. 9 Adjusted Claim ICN If this claim has been adjusted, the new claim ICN appears here. 10 Patient Liability Amount of member s continuing income applied to the claim. 11 Spenddown Amount Amount due from member if member is Spenddown 12 Co pay Amount due from the member 13 Total Allowed Amount Total amount allowed by KyHealth Choices for services billed, prior to deductions for other insurance payment, or amounts due from member. 14 Allowed Amount Total amount allowed by KyHealth Choices for services billed, after deductions for other insurance payment, or amounts due from member. 15 Header/Detail EOB codes and descriptions appears here. Any under a heading of header apply to the entire claim. Any under detail apply to the detail line indicated. 16 EOB The explanation of benefits code appears here. 17 The EOB code full description (reason for denial). 18 Click Here for EOB Listing. This is a link to a full list of EOB codes and descriptions. 19 Billing Information Identifies this section as the Billing Information section of the Summary screen. 20 Service Information Identifies this section as the Service Information section of the Summary screen. 21 Claim Charges Identifies this section as the Claim Charges section of the Summary screen. Date Printed 3/12/2007 Page 55

59 Field/Menu Selection 22 Diagnosis Codes Identifies this section as the Diagnosis section of the Summary screen. (Click on the Diagnosis line number to return to that detail). 23 Details Identifies this section as the Details section of the Summary screen. (Click on the Detail number to return to that detail). 24 Submit Claim Click here to adjust claim. 25 Void Click here to submit a claim credit Claim Credit Response Screen After filing a claim credit using the "Void Claim" button, the following screen will appear: Date Printed 3/12/2007 Page 56