SDMGMA Third Party Payer Day. Anja Aplan, Payment Control Officer

Transcription

1 SDMGMA Third Party Payer Day Anja Aplan, Payment Control Officer

2 Agenda Medicaid Overview Third Party Liability Common TPL Errors NPI and Taxonomy Billing Transportation Billing Diagnosis codes Aid Category 79 Anesthesia Claims Eligibility Inquiry through Medicaid Portal Q & A

3 Medicaid Overview

4 Medicaid Overview Medicaid is one of the largest healthcare insurers in South Dakota. Federal-State partnership governed by Medicaid State Plan (agreement with federal government on who is served and what services are covered). States administer the Medicaid program Each state plan is different due to optional services provided making it difficult to compare states side-by-side Medicaid is not Medicare Medicare is specific to the over 65 population and the disabled population who meet the federal disability criteria Medicare is a federally administered and funded program

5 Claims Processing South Dakota Medicaid pays for covered health care services that are medically necessary. The program meets or exceeds Federal timely payment requirements. Processing and adjudication are completed by South Dakota Medicaid staff. In SFY 16, SD Medicaid processed more than 5.3 million claims and answered approximately 90,000 calls from providers.

6 Who We Serve Children in foster care Low income children, pregnant women, adults and families Adult coverage is limited to: The elderly or disabled Parents or caregivers of low income children at or below 52% of the Federal Poverty Level (FPL) Children 68% Aged/ Blind/ Disabled Adults 20% Pregnant Women 1% Low Income Parents 11%

7 Who Uses Medicaid Now Medicaid covered 147,671 unduplicated individuals during SFY16.

8 Health Care Services Each state is required to cover certain services, but can elect to cover additional services: Medicaid Mandatory Services South Dakota Optional Services Inpatient hospital services Outpatient hospital services Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services All medically necessary care for eligible children under the age of 21 Nursing facility services Home health services Physician services Rural health clinic services Federally qualified health center services Laboratory and X-ray services Nurse Midwife services Certified Pediatric and Family Nurse Practitioner services Transportation to medical care Tobacco cessation counseling for pregnant women Physician assistants Psychologists and independent mental health practitioners Intermediate Care Facilities for the Mentally Challenged (ICF/MR) Podiatry Prescription drugs Optometry Chiropractic services Durable medical equipment Dental services Physical, occupational, speech therapy, audiology Prosthetic devices and eyeglasses Hospice care, nursing services Personal care services and home health aides

9 Third Party Liability

10 Third Party Liability The most common sources of TPL are Medicare and private health insurance plans such as DakotaCare, Blue Cross/Blue Shield, etc. TPL can also come from worker s compensation, disability insurance, or automobile insurance. When a recipient becomes eligible for Medicaid, they assign their right to TPL payments to Medicaid. Third Party Source ARSD 67:16:26:05 The provider is eligible to receive the recipient s TPL responsibility amount, or the amount allowed under the department s payment schedule, less the TPL amount, whichever is less.

11 Reporting of Third Party Liability By Federal law, Medicaid is the payer of last resort. When a Medicaid recipient has a third party payment source, such as private health insurance, the insurance company must pay the claim before Medicaid. SD Medicaid requires all providers to submit claims to TPL before billing Medicaid. Claims not submitted to TPL first will be denied. Exception: Absent parent, Aid category 77 and 46 and auto insurance SD Medicaid requires proof of TPL denials to be submitted with all paper claims. Electronic claims are preferred when there is a TPL payment reported on the claim

12 Third Party Liability Terms Explanation of Benefits (EOB): A statement sent by a health insurance company identifying the patient and services rendered, the amount charged by the provider, the amount of charges covered and not covered by the insurance company, including any contractual write-off amounts, and the patient responsibility amount. Alternate Terms: Summary of Benefits, Remittance Advice, Coverage Determination, Beneficiary Notice Usual and Customary Charge (UCC): The amount charged by the provider for the service. This amount should not contain any deductions. Alternate Terms: Billed Charges

13 Third Party Liability Terms Patient Responsibility: The amount of the UCC the patient is responsible for paying, usually the co-payment, co-insurance, and/or deductible amount. Contractual Obligation: The amount of the UCC that neither the insurance company or the patient is responsible for paying. This amount is usually specified in a contract between the provider and the insurance company or network. Alternate Terms: Network Savings, Not-Allowed Amount, Write-Off, Adjustment, CTR True Payment: The dollar amount that the private health insurance company paid for the service.

14 TPL Information on Claim Form Block 9 Other Insured s Name Block 11 Insured s Policy Group or FECA Number Block 24 (Shaded) If commercial insurance enter the contractual obligation/network savings amount with the prefix CTR. If after Medicare do not enter CTR. Block 9 Block 11 Block 24 Shaded Block 24 F Block 28, 29, 30

15 TPL Information on Claim Form Block 24 (Shaded) If commercial insurance enter the true payment for each service in the shaded portion. If after Medicare enter payment plus contractual obligation. Block 24 F The Usual and Customary Charge will be entered in the unshaded portion. Block 9 Block 11 Block 24 Shaded Block 24 F Block 28, 29, 30

16 TPL Information on Claim Form Block 28 Enter the Total UCC amount. Block 29 Enter the dollar amount paid by TPL. This should equal the sum of the true payments in 24 Shaded. Do not include any network savings or contractual obligation amounts unless billing after Medicare. Block 30 Enter the Balance Due. Block 9 Block 11 Block 24 A Block 24 F Block 28, 29, 30

17 Explanation of Benefits Example Claim Submitted to Private Health Insurance Usual & Customary Charge: $240 Contractual Obligation: $ Insurance Payment: $72.39 Balance Due from SDMA: $ $ = $12.77

18 Third Party Liability Example UB TRICARE 999 MEDICAID

19 After Medicare Example UB TRICARE 999 MEDICAID

20 Common TPL Errors

21 Medicare Crossovers Ensure that the information sent to Medicare matches the information that is in South Dakota Medicaid s SDMEDX Provider Enrollment Record Zip+4 Servicing and Billing NPI Taxonomy Check the Medicare Box on the claim form If you do not receive a response from South Dakota Medicaid within 4 weeks of submitting a crossover claim, please contact the Telephone Service Unit

22 Adjustment and Void Errors Adjustments may only be made to paid claims. Denied claims cannot be adjusted. Corrections to a claim that has been denied should be submitted as a new claim. If you have a denied adjustment be sure to check your Remittance Advice. Payment may be recouped and a new claim will need to be submitted. Always use the correct reference number on an adjusted claim. If information on the adjusted claim does not match, the claim will be denied. Enter the numeric value of 7 in Block 22 of the claim form if you are submitting an adjustment and the numeric value of 8 if you are submitting a void.

23 Timely Filing Claims should be submitted every time an eligible service is provided for a Medicaid recipient. Please submit a claim as soon as possible following the date of service South Dakota Medicaid requires all claims to be received within 6 months following the month of the date of service Example: For a date of service of March 17, 2016, claim forms must be submitted by September 30, Claim forms must be submitted to South Dakota Medicaid within 3 months of a Medicaid denial if the denial was not for timely filing Example: If a claim is denied on March 18, 2016, a new claim must be received by South Dakota Medicaid by June 18, 2016.

24 Timely Filing After Third Party Liability When a recipient has private health insurance or Medicare, claims must be submitted to those sources for payment before Medicaid Claim forms must be submitted to Medicaid within 6 months of notice of payment or denial from private health insurance or Medicare Example: Date of service is March 17, Provider submits to insurance, insurance makes a payment on June 21, Claim must be received by Medicaid no later than December 30, 2016.

25 NPI and Taxonomy Billing

26 CMS 1500 Form Box 17b Populate with NPI of Primary Care Physician (PCP) or Health Home when the recipient or service requires a referral If the recipient is not in PCP or Health Home this is required to be a Type 1 NPI if the service requires an Ordering NPI Ordering NPI (individual/servicing) is required for Radiology services (x-rays, MRI, etc.) and Independent Laboratory Services Durable Medical Equipment, Physical, Occupational and Speech Therapy (referral required)

27 Taxonomy code CMS 1500 If the servicing provider is an entity the taxonomy needs to be only in 33b If the service is paid to the entity but an enrolled provider provides the service the entity s taxonomy must be in 33b and the servicing provider s taxonomy must be in 24J The appropriate taxonomy codes are in SDMEDX All taxonomy codes must be preceded with ZZ qualifiers on paper claims

28 UB04 NPI Attending All UB04 claims must have an individual NPI (Type 1) in locator 76. The NPI must be a practitioner type that could enroll and is authorized to order, prescribe, or refer. Do not use a pharmacist, RN, or therapist. Do use a CNP, MD, PA, and DO. The attending provider is not required to be enrolled. Exception: IHS providers are required to be enrolled. SD PAs, DOs, and MDs should ensure the SD Board of Medical and Osteopathic Examiners has their NPI on file.

29 Transportation

30 Transportation If a recipient needs to be picked up after an appointment or discharged from the hospital, a wheelchair transportation provider should only be contacted if: The recipient is wheelchair bound (para-, quadriplegic) At that point in time a wheelchair is the only means of mobility (recommend attestation note for transportation provider from the medical provider) Facility policy to escort an ambulatory recipient out of the facility in a wheelchair does not qualify for wheelchair transportation We suggest using our Medicaid Transportation Documentation Form for both Community and Wheelchair Transportation

31 Diagnosis codes

32 Diagnosis Codes Personal history and family history diagnosis codes are not acceptable as primary diagnosis codes Diagnosis code Z0289 and services covered under this diagnosis code may only be billed for services provided to a recipient with refugee status, child s voice services or special reports (99080) October 1 st, 2016 some diagnosis codes received additional digits All digits of a diagnosis code must be on the claim

33 Aid Category 79

34 Aid Category 79 Covers the unborn child of an ineligible mother based on citizenship status The claims are billed under the mother Only pregnancy related services are covered A global delivery code is covered Post-partum visits included in the global pregnancy code are allowed as they cannot be billed separately Post-partum services outside of the global pregnancy code are not allowed and will not be covered by South Dakota Medicaid Once the mother has delivered and is discharged she is no longer covered No claims for services provided to the mother after she is discharged from the hospital 6_unbornchildrenprogram.pdf

35 Anesthesia Claims

36 Anesthesia Claims SD Medicaid will pay medically necessary services Referral is not required The only date required is the date of service Medicare crossovers follow Medicare guidelines SD Medicaid does not recognize physical status modifiers 1 unit equals 15 minutes. Operating Room Modifiers Unplanned returns related to first surgery 78 Unrelated returns during post-operative period - 79

37 Online Portal

38 Medicaid Online Portal Eligibility Inquiry Live for providers Provider training: Webinars and Q&A is happening for the next week, please check the online portal site for additional information Staff Turnover - When staff leave positions their permissions should be reviewed and the account can be inactivated if necessary. Provider Admins are responsible for Provider User access. South Dakota Medicaid does not control access to the Portal at the Provider User level. Questions can be submitted to DSSonlineportal@state.sd.us Additional information and guidance can be found online at

39 PERM All claims billed between 10/01/16 and 09/30/17 may be pulled as part of a random sample CNI/A+ Government Solutions has started making phone calls and sending/faxing letters requesting medical records If you receive a letter requesting medical records, please send the documentation to the Review Contractor as soon as possible If you have questions regarding the letter or the documentation requested do not wait. Either contact the Review Contractor or the State liaison to obtain clarification.

40 Q & A

41 More Information South Dakota Medicaid Website South Dakota Medicaid Listserv Frequently Asked Questions Provider Manuals OCR Portal

42 Contact Medicaid Eligibility or Claims Questions: Provider Enrollment: Portal Questions: Chelsea King: