CLAIMS MANUAL FOR FISCAL YEAR

Transcription

1 CLAIMS MANUAL FOR FISCAL YEAR Rev. 7/1/2017 1

2 TABLE OF CONTENTS INTRODUCTION 3 ELECTRONIC CLAIM SUBMISSION (ECS) AGREEMENT 3 TRADING PARTNER AGREEMENT (TPA) 3 CLAIM SUBMISSION GUIDELINES 4 ALPHAMCS CLAIMS PROCESSING 4 SUBMISSION VIA CMS SUBMITTING COB INFORMATION ON CMS COPYING A CLAIM 9 SUBMISSION VIA UB04 9 SUBMISSION VIA AN RETRIEVAL OF TRANSACTIONAL UPLOAD AND DOWNLOAD QUEUE 14 REMITTANCE ADVICE (RA) REPORTS 16 UTILIZING PATIENT SEARCH 22 VERIFYING AGENCY DETAILS 22 BASE PROVIDER TAB 22 SITE TAB 23 SITE MAPPING TAB 24 CONTRACT TAB 24 IMPORTANT CONTACTS 25 IMPORTANT RESOURCES 26 Rev. 7/1/2017 2

3 Introduction Welcome to fiscal year Similar to past claims manuals from previous years, this document will provide you with basic information regarding the claims process at Alliance Behavioral Healthcare. It will be posted on our website under: Provider>Finance and Claims Resources. Providers are encouraged to follow the Alliance Provider Newsletter on a weekly basis for notification of claims processing changes throughout the year. We hope that this manual allows you to clearly understand the billing requirements for Alliance Behavioral Healthcare as well as give you insight to the entire billing process and available reports. AlphaMCS will be used for State and Medicaid service claims. Health choice claims should be billed through NC TRACKS. In addition to this manual, the Alpha Provider Portal Manual and the Alliance Provider Operations Manual, the website is also a source of reference for providers. Claims questions and needs can also be reviewed and discussed directly with a provider s assigned Claims Specialist by phone, by , or inperson (by appointment). Please remember that when communicating via , providers should adhere to HIPAA/Confidentiality best practices. Please note that the prompt pay guidelines state that the LME-MCO has 18 days to approve a claim and 30 days to pay after approval-- allowing a total of 48 days for processing. Providers are encouraged to consider this in their revenue cycle design and to plan accordingly. Providers may contact their assigned Claims Specialist or Analyst at any time with questions, concerns, requests for training or technical assistance. Providers may also contact a Claims Supervisor for assistance (Tina Everett or Wendy Mans). Should these contacts not meet the provider s needs, the provider may also contact the Claims Director (Lisa Sullivan) or our CFO (Kelly Goodfellow). Contact information is included at the end of this document. Electronic Claim Submission (ECS) Agreement Alliance Behavioral Healthcare requires an attestation for claims submitted through the provider portal. We have created an Electronic Claims Submission (ECS) agreement for this purpose. All providers must sign this agreement. The original agreement will be maintained at Alliance Behavioral Healthcare. The agreement needs to be signed only once for the fiscal year. It will be in effect for the entire fiscal year or until the provider makes changes to addresses, contacts, etc. The Alliance Notice of Change form must be completed and submitted to the Contracts Department when any change occurs. Please note that this agreement will be sent with your contract. Please sign and return it with your contract. If you do not receive an agreement or misplace it, please obtain it from our website We cannot release a check to your agency unless we have this agreement on file. Trading Partner Agreement (TPA) The Trading Partner Agreement (TPA) will be used for submission of 837s. Providers will receive a TPA with their contract. The TPA can be used for both State and Medicaid claims. The agreement needs to be signed only once for the fiscal year. It will be in effect for the entire fiscal year or until the provider makes changes to addresses, contacts, etc. The Alliance Notice of Change form must be completed and submitted to the Contracts Department when any change occurs. Rev. 7/1/2017 3

4 Please note that this agreement will be sent with your contract. Please sign and return it with your contract. If you do not receive an agreement or misplace it, please obtain it from our website We cannot release a check to your agency unless we have this agreement on file. Claim Submission Guidelines for FY18 The claim submission deadlines for Medicaid and State contracts are different. Both timelines are stated in the respective contracts and are also listed below: State or Local Funded Services - Original claim must be submitted within sixty (60) days of the date of service. - Replacement claims may be submitted within twenty (20) business days of submission of original claim. The original claim will be recouped and reprocessed. If the claim denies when reprocessed, the original claim payment will not be reissued. - If a claim cannot be submitted by the above deadlines due to an authorization delay or system correction, the claim must be submitted within ten (10) business days of receipt of authorization or correction. - Rate changes will be communicated in the provider newsletter and will be posted on our website unless it is provider-specific, which will be communicated via . ********Please remember that it is imperative to our State funding that claims be submitted on time. Your submission of claims has a direct impact on how soon we draw down our funds. If we do not draw down our State funds, the state will reduce our funding which could impact your agency************ Medicaid Services - Original claims must be submitted within ninety (90) days from the date of service. - Replacement claims can be submitted within ninety (90) days of the original submission date. The original claim will be recouped and reprocessed. If the replacement claim denies, the original payment will be reissued. - If a claim cannot be submitted by the above deadlines due to an authorization delay or system correction, the claim must be submitted within ten (10) business days of receipt of authorization or correction. - Coordination of Benefits Secondary claims must be submitted within ninety (90) days upon receipt of payment and or denial from primary insurance. Effective 01/01/16, the Provider must also submit a secondary claim within 180 days of the date of service to be within the timely filing deadline. - Retro Medicaid/Authorization Should Medicaid be activated after services are provided, the provider must submit a claim within ninety (90) days of the retroactive Medicaid being activated for unmanaged services. For managed services (requiring an authorization), the provider must submit the claim within ninety (90) days from the authorization for managed services. Taxonomy - Beginning 8/1/17, claims must include valid Billing Taxonomy and valid Rendering Taxonomy numbers. The NPI/Taxonomy on the claim must match the information in the provider s AlphaMCS setup as well as the information in the provider s NCTracks profile. Claims Specialists/Analysts can assist providers with identifying which NPI/Taxonomy combinations are active for use with claims. The below example could be used for a service that is a facility based service. The taxonomy can be used as both the billing and the rendering: Rev. 7/1/2017 4

5 Alpha NCTracks AlphaMCS Claims Processing AlphaMCS is a web-based provider portal that allows providers to submit claims to the LME/MCO. Claims can be submitted via a CMS 1500/UB04 or via an 837P/I. The daily cutoff is 5pm. The claims are adjudicated nightly. For claims submitted via CMS1500/UB04, the claims status is updated in the provider portal (download queue) the next business day. The Remittance Advice is available the following week (see Checkwrite Schedule). Claims submitted via 837s will have adjudication information on the 835s which will be available according to the standardized checkwrite schedule. The Claim Specialists and Claim Analysts review the claims processed on a daily basis to ensure claims are approving correctly, to review denials for possible system errors, and to review any claims that pended. The reviews are performed to ensure that claims are processed efficiently so that payment can be made timely. Alliance requires all Network providers to either submit claims through the AlphaMCS Portal or to file claims electronically through an 837. All paper claims submitted to Alliance by Network providers will be returned unprocessed to the provider. The instructions below will cover how to submit a claim via the CMS 1500 or UB04 as well as the process for 837 testing and submission. Submission via CMS 1500 Providers will submit a professional claim through the provider portal using the following instructions. 1. Using the menu, choose Claims>CMS Rev. 7/1/2017 5

6 2. To enter a new claim, choose Create: Note: That below the base tile, the service details and status of the claim will appear in other tiles as you click on a claim number in the base tile. Rev. 7/1/2017 6

7 3. A CMS 1500 will appear on the screen. 4. The first item the provider will choose is the site. The provider can choose the correct site for the service from the drop down box. If the site is not listed, the provider may contact provider network at providernetwork@alliancebhc.org or call and choose option The rest of the CMS 1500 fields are as follows: 1. Insurance 2. Patient name by clicking on Search, the provider can find the applicable client. Change drop down box from all to active to ensure you are pulling the correct consumer. Upon selection of the client, all the patient information will be populated. 3. Patient s date of birth this is populated when the patient is chosen. 4. Insured name - this is populated when the patient is chosen. 5. Patient address - this is populated when the patient is chosen. 6. Patient relationship to insured - this is populated when the patient is chosen. 7. Insured address - this is populated when the patient is chosen. 8. Patient status - this is populated when the patient is chosen. 9. Other insured s information this field is applicable if another name needs to be submitted or if the patient has other insurance 10. Patient s condition either yes, no, or unknown needs to be filled out for all conditions 11. Insured s policy group - this is populated when the patient is chosen. a) Insured s DOB this is populated when the patient is chosen. b) Employer s Name of School Name fill in if applicable c) Insurance Plan Name or Program Name fill in if applicable d) Other Health Benefit Plan- If yes, select yes and complete boxes under #9. If none, select no. 12. Date must be dated with the date of signature 13. Signature - Sign if applicable Rev. 7/1/2017 7

8 14. Date - Date if applicable 15. Illness date - Date if applicable 16. Unable to work date - Date if applicable 17. Name of referring physician - Fill out if applicable 18. Hospitalization dates - Date if applicable 19. Not required 20. Outside lab - Fill out if applicable 21. Diagnosis enter the applicable diagnoses for the client. Up to four can be submitted. As of 10/1/2015, ICD10 codes must be used, so check the 10 box. 22. Resubmission code if submitting a replacement or a reversal, enter the applicable code and the original claim number. 23. Prior Authorization number - Not required 24. Enter the services being billed. a) From and Thru dates of service b) Place of service c) Service code, enter and tab to the next field d) Rendering NPI 10 digits e) Diagnosis code drop down based on numbers previously entered f) Modifiers if applicable g) Charges and days/units h) Taxonomy, drop down box i) Coordination of benefits (COB) amount 25. Federal tax ID number - This is filled out when the provider is selected 26. Patient s account number - This is filled out when the patient is selected. 27. Accept assignment - This is filled out when the patient is selected. 28. Total Charge - This is filled out when the service is entered. 29. Amount paid- This is filled out when the service is entered. 30. Not a field 31. Signed box and date Check the box and fill in the date 32. Name and address of facility where services are rendered - This is filled out when the provider is selected. You need to manually complete your phone number. 33. Physicians/Supplier s billing address - This is filled out when the provider is selected. Box 33a is for Billing NPI and Box 33b is for Billing Taxonomy 6. The claim can be saved or submitted at this point. If saved, it can be updated at a later time. Claims will only be saved for up to 30 days in the provider portal. 7. Claims can be copied from previously submitted claims. Be sure to change services, dates, etc. prior to submission. Rev. 7/1/2017 8

9 Hints: In the event that a daily service is being billed, i.e. YP770, H0020, H2022, 50.00/per day, complete the bottom half as below: For services that are paid per hour or per minute it is required you enter these on a daily basis. Rev. 7/1/2017 9

10 Claims can either be submitted or saved. If claims are saved, they will be saved for 30 days before they are purged from the system. Once the claims are submitted, they will be adjudicated daily after 5pm. You will be able to view status the very next morning. Submitting COB information for secondary claims When keying secondary claims you must enter the information needed from the primary EOB as highlighted below. COB amount means how much the primary paid and COB Allowable Amount is what the primary insurance allowed for the service billed COB PAYMENT AMOUNT For approved Secondary claims, Alliance will either: 1. Pay the difference up to the Medicaid amount, or 2. Not pay any additional amount if primary pays more than Medicaid allowed amount. Copying a Claim Claims can be copied so that another claim can be created, which may be helpful and save time. Make sure you verify the site and if it is different than the claim copied you will have to use the drop down box to pick the correct site. NOTE: Be careful copying claims. If you do not change all the pertinent information from the copied claim your new claim will deny. If you are unsure about copying a claim please create a new claim instead of copying. Submission via UB04 Institutional claims can be submitted through the provider portal using the following instructions. 1. Using the menu, choose Claims>UB04 Rev. 7/1/

11 2. To enter a new claim, choose Create. 3. Below are the detailed instructions in filling out a UB04 claim: Box 1. Site # Choose the site with the drop down box next to the RED*. This will populate all information connected to the site chosen. Address, Federal Tax ID etc. NPI; Boxes 3a and 3b Patient Control and Med. Record #: Automatically populates when the consumer is chosen; Box 4. Bill Type: This Type of Bill code is comprised of three parts; a leading 0, the Facility Type code and the Bill Frequency Type code. You will have a four digit code when completed: 0111 Hospital Inpatient Admit through Discharge 0112 Hospital Inpatient First Claim 0113 Hospital Inpatient Continuing claim 0114 Hospital Inpatient Last claim 0117 Hospital Inpatient Replacement Claim 0118 Hospital Inpatient Void Claim 0131 Hospital Outpatient Admit through Discharge 0137 Hospital Outpatient Replacement Claim 0138 Hospital Outpatient Void Claim 0651 Intermediate Care Admit through Discharge 0652 Intermediate Care First Claim 0653 Intermediate Care Continuing Claim 0654 Intermediate Care Last Claim 0657 Intermediate Care Replacement Claim 0658 Intermediate Care Void Claim 0891 Residential Admit through Discharge 0892 Residential First Claim 0893 Residential Continuing Claim 0894 Residential Last Claim 0897 Residential Replacement Claim 0898 Residential Void Claim Box 5. Federal Tax ID: This is automatically populated; Box 6. Statement from Covers Period through: Enter the 6 8 digit beginning date in the From Box and the 6 8 digit ending service date in the Through box. The calendar is a drop down, Choose from the drop down calendar; 8a. Patient Search: You will need two pieces of information to search for a patient. Ex. Date of birth and last name; last name and SS #; Select; Rev. 7/1/

12 9a Through 9d. Patient Address and Name: This information will automatically populate from the patient search; Box 10. Birth Date: Automatically Populates; Box 11. Sex: Automatically Populates; Box 12. Admission Date: Calendar drop down box. Add Admission Date 6 8 digits; Box 13. Admission Hour: This field is a drop down box and must have 2 digits (Military time). Choose the hour from the drop down box. This is a required field; Box 14. Admission Type: this field requires the one digit type code indicating the urgency/priority of the admission. **Inpatient hospitalization only; Box 15. Source of Referral: Indicate the source using the one digit code for the source. **Inpatient hospitalization only; Box 16. Discharge Hour: Drop down box to choose the discharge hour. It must be 2 digits; Required for Hospital Claims. Box 17. Discharge Status: This field indicates the discharge status of the patient when service ended. This field is a two digit code; Box 38. Insured Name and Address: This information automatically populates; Boxes 39 41; a d Value Codes and Amounts: Use these form locators to indicate codes and amounts essential to the proper adjudication for the submitted claim; Box 39a must have either a 23 or a 31 as the patient liability. Put in Amount next to field. The claim will not submit properly without box 39a filled out; Box Revenue Code, Description, HCPCS Codes, Service date and Units, Total Charges and Non Covered Charges: To the right of the totals box you will see an Add, Modify or Remove button. Depending on what you are doing with this claim you would choose the box accordingly. You will type in the full revenue code and then tab. When you tab the description will populate automatically to the code typed in. You will need to add the units, charges, HCPCS Code and the Service date as applicable. The Service date does have a calendar drop down. You must choose from the drop down calendar. Click ok and if needed proceed with another service following the same example; Box 50 Primary Payor: Type in the health plan that has the primary responsibility for the costs incurred during service dates. Add additional lines as necessary; this does include if client is Alliance Medicaid; Box 51 Health Plan ID: Enter the number that identifies the insured health plan. Add additional lines if more than one payor is listed in box 50; Box 52 Release of Information: You must check this box; Box 53 Assignment of Benefits: You must check this box; Box 54 Prior Payments Secondary Payer: Enter any prior payment amounts that your facility has received toward the bill from the payor in box 50; Rev. 7/1/

13 Box 55 Estimated Amount Due: Enter the estimated amount due from each payor from box 50; Box 56 NPI: This field should populate from the site chosen in field 1; Box 58 Insured Name: Enter the name of the policyholder for the health plan indicated as primary payer in box 50; Medicaid Client name Last name then first name; Box 59 Patient Relationship: Identify the relationship of the client to the primary insurance policyholder using the following two digit codes. This is the relationship of the client to the policy holder: Code Title 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 53 Life Partner G8 Other Relationship Box 60 Insured ID Number: Enter the number assigned to identify the specific policy of the insured. Ex: Clients Medicaid Number; Box 63 Treatment Authorization Codes: Enter the appropriate Authorization number for services; (Optional) Box 64 Document Control Number: If you are voiding or replacing a claim this is where you would enter your Control Number from your Remittance Advice that you originally received from the MCO; Box 66 Principal Diagnosis: This is where you would start adding the diagnosis that pertains to this claim. There is a drop down box for the diagnosis that you may choose from and then tab, type slowly and choose the diagnosis; you must choose from the drop down box or your claim will deny; Box 69 Admitting Diagnosis: Enter the diagnosis code that describes the client at the time of admission, again type slowly and choose from the drop down box; Box 76 Attending NPI: Key attending NPI and Last and First name of attending physician; Name not required by recommended; Box 81CCa Taxonomy Code: Type in taxonomy. The taxonomy codes are pre populated. There is a drop down, choose from the drop down. Choose the correct taxonomy for your site/service. At the bottom under Saved By put in the initials of who is submitting the claim and the claim date submittal. Once you have completed all fields you may save or submit the claim. If you submit the claim you will not be able to make any changes to the claim. If you save the claim you may make any changes or add any needed information for up to 30 days. To save a claim you must have all the Red * boxes completed. Once you submit a claim, you can find it filtering submitted claims. You can copy the claim or view it. When you go to submit a claim and you have any errors, a box will populate in the center of the screen identifying the fields that are in error. You can fix the claim and/or add what information may still be needed. Then submit the claim again. If the claim is clean it will submit. Remember, saved claims will only hold on your portal for up to 30 days. Submitted claims will always remain. Rev. 7/1/

14 Submission via an 837 Providers, including hospital facilities, have the option of submitting claims through a HIPAA compliant 837. To learn more about 837s, please go to our website to access our 837 Companion Guides. Providers may also call option 2 for more information on the 837 process. Once an agency is EDI Certified, a secure FTP login and password will be assigned. 837s may be submitted using this method or by uploading the file through the provider portal using the instructions below. 1. Using the menu, choose Transactional Upload Q 2. Click on Upload file. 3. Choose the file to upload. 4. Click Save. Please note that EDI Certified must be checked under you provider information in order for the 837s to be uploaded to Alliance. If you have submitted your claims and are not seeing them in your system please claims@alliancebhc.org with a contact phone number so assistance can be given. Retrieval of 835 Agencies submitting 837s will be able to retrieve 835s on checkwrite dates. The 835s can be retrieved using the agency assigned secure FTP or via the provider portal using the instructions below. 1. Using the menu, choose Download Q. 2. Files will be listed. The user may select the applicable file and click on download. Rev. 7/1/

15 TRANSACTIONAL UPLOAD & DOWNLOAD Q Transactional Upload: The instructions below will assist you with uploading an 837 file. If your agency does not upload files via 837, proceed to the Download Que instructions. The Transactional Upload Q module allows you to upload files, such as 837 files which contain the claims you want the MCO to process, into their system. Click the Upload File button, choose the file from your local computer and click the Save button. The Download Q module allows you to download files your MCO has waiting for you. Files that will be available are: - Response files 999 s, 824 s and 277 s s - Current Client Dumps (Current_Client_) runs daily. This shows all clients for which the provider has submitted claims, has an authorization, has an enrollment, has an appointment, has a SAR, has a client update request, or is marked as the clinical home. - Current Auth Dumps (Current_Auths_) runs daily. This shows info for authorizations that have not ended within the last 90 days. - Current Claims Dumps (Current_Claims_) runs daily. This shows all claims inserted within the last year. If 835 s aren t showing on your Download Q, check your Provider Details module. On the Base tab, if your company doesn t have Certified for EDI checked OR if it is checked but there s a clearing house chosen, you will not receive 835 s from the system. Exporting from the Download Queue To export from the Download Q, click on the checkbox to the left of the document you want to download, then click the Download button. *To see the claims that you have billed, select the option that says: current_claims (not current_client). Rev. 7/1/

16 Note: The MCO that the file is from is listed in the file name right before the.txt. If you are contracted with multiple MCO s you will receive the same file (in this case, the client dump) daily from each MCO. When you click the Download button, it will may ask you if you want to leave the page or not. Click Leave this Page. After the file has been downloaded, it will either show at the bottom of your screen or a pop-up will display asking if you want to open or save it. Click Open. If it asks what you want to open it in, choose Excel. If you re not given the option, you can open the file in it s.txt version. When it s open, go to File on the menu bar and choose Save As. You ll want to resave the file name by taking out the.txt and putting in.xls instead. When you re done, click Save. Don t worry about the Save as type dropdown. Make sure to save the file somewhere you ll remember, like My Documents Go to where you saved the file and open it. Click on the A column, then go to your Menu Bar and click Data. Rev. 7/1/

17 Next, click the Text to Columns button. There will now be a series of pop-ups. Select Delimited from the screen and click Next. In the following screen, uncheck Tab and check Other. Then enter a solid vertical line in the text box. This line can be found on your keyboard just above the Enter key. Click Shift and this key to enter the line into this text box, then click Next. On the next screen, select General, then click Finish. You will now see the report in a more easy to read format. Remittance Advice (RA) Reports RAs will be available on every checkwrite date. Providers can select RAs by date range according to check date or claim processing date. 1. Using the menu, choose RA reports. 2. The user can search by a specific check number, check date or claim processing date. The RA will appear in the box below for the user to retrieve. Rev. 7/1/

18 How to read you RA. The RA is grouped by four adjudication decisions: Approved claims, Denied claims, Sub- Capitated claims and Recoupments (Credit Memos). From within each adjudication group, there are sub-groups broken down by funding source (State or Medicaid). From within the funding source grouping, it is then sub-grouped by consumer. Lastly, within the consumer grouping, claims are in order by date of service-- with subtotals under each grouping. RA Outlined: Grouping is visualized as below 1) Paid Claims a) State Claims i) Consumer (1) Date of Service b) Medicaid Claims i) Consumer (1) Date of Service 2) Denied Claims a) State Claims i) Consumer (1) Date of Service b) Medicaid Claims i) Consumer (1) Date of Service 3) Sub-Capitated Claims a) State Claims i) Consumer (1) Date of Service b) Medicaid Claims i) Consumer (1) Date of Service 4) Recoupments (Credit Memos) a) State Claims i) Consumer (1) Date of Service b) Medicaid Claims i) Consumer (1) Date of Service RA Break Down (TOP) Header Information: The RA header displays core MCO and payment information such as contact information, check number, check amount claims type and processing dates. Rev. 7/1/

19 Claim Field Labels: at the top of every page, there is a frozen pane that identifies what each data element on the claim represents. It will look as below: Paid Claims (TOP): Below is an example of a paid claim. Notice how all three claims came in on the same claim header, but broken down per claim line. Since adjudication is at the claim line level, then this claim is viewed as 3 separate claims on the RA. In the above example, you ll notice that 6 units were billed per day. Although each claim line was approved, you ll notice that the paid amount was adjusted due to claimed amount is higher than the contract amount. Billed Amount ($417.00) - (6 units * contract rate of $31.41) = Adjusted amount $ to pay $ Under the reason codes, 2 meaning the claim was approved after adjusting paid amount to equal the contract rate (indicated using the number one). Rev. 7/1/

20 Since the funding sources are grouped, you ll have a subtotal for State Claims and a sub total for Medicaid claims. Denied Claims (TOP): Denied claims are also grouped together as well as broken out by funding source with it s own sub total. On the claim line that denied, the denial code is also listed. Reason codes are defined at the end of the RA to assist in working denials. In this example the denial reason is 25 which is for Invalid POS & Service Combo. Shown below is the sub total of denied claims for State services which is listed earlier in this sample RA. This will show you the numbers to get the total amount above in gray: Sub Capitated Claims (TOP): sub capitated claims are listed in the next section of the RA. This will look very much like Fee for Service claims except a dollar amount will be indicated in the subcap field as listed below: Rev. 7/1/

21 **Note: Do not let the denied amount confuse you. This is basically stating that the FFS paid amount is denied because the provider is already being paid for the service and the encounter claim submitted was approved at the contracted rate. Claim was adjusted to the contracted rate. (Contract rate * 4 = $ ) Recoupments (Credit Memos) (TOP): the last grouping of claims are where recoupments and credit memos are identified. Each line will display the claim where a recoupment or CM was applied as well as identify the source claim from where the CM came from: The highlighted verbage explains exactly what happened: The payment for Clm_adj_ID A was used to reconcile a CM created for the recoupment of Clm_adj_ID B which was originally paid by a previous CM. This transaction satisfied of the CM. Rev. 7/1/

22 Reason Code Key (TOP): towards the end of the RA immediately under the grand totals for the RA, is a reason code key that assists in identifying why a claim denied. The listed denial reasons are not all of the MCS denial reasons, but a list of denial reasons on the RA you are looking at. So the below list of denial reason are currently on this sample RA: Field Descriptions (TOP): at the very end of the RA, field descriptions are listed to assist in navigating and reconciling the RA. How to verify EDI Certification Under the main menu, choose Provider Details. Click on the number 3 to expand the view. Please see the Certified for EDI box. If it is checked, your agency is EDI certified and we can process any 837 files that are sent from your agency. Rev. 7/1/

23 If you have completed testing for 837s and you do not see that your EDI Certified box is checked, please call and choose option 2 IT/837 support. Any claims submitted via an 837 will not be processed if the EDI Certified box is not checked. Please limit your first 837 file to no more than 5 to 10 claims. Verifying Your Agency Details It is critical to verify the details of your agency prior to submission of claims to ensure correct processing. The following instructions review tabs and tiles that are critical in your claims processing. Other tabs/tiles not show but in the Provider Portal are for reference only. Base Provider Tab From the main menu, choose Provider Details. Click on the number 3 to expand the view. Verify the tax ID, the Medicaid Provider Number (MPN) and the NPI number. The MPN and NPI number listed are what will be considered the main numbers for your agency. If you would like us to consider another number as the main number, please us at providernetwork@alliancebhc.org or you may call and choose option 4 Provider Network. Rev. 7/1/

24 Site Tab On the second tab, the multiple sites for the agency are listed. For this provider, there is a site called Billing and a site called Durham Service. Your agency may have sites that contain the license name or the street name. Click on the number 3 to expand the view. Verify the address and NPI number for each site. A site can have multiple NPI numbers. This can be considered the main NPI number for this site. Note: That when you click on the different sites, the header information will change according to the site name. Here are two views. Site Mapping Tab It is important for the agency to verify the MPN and NPI number associated with each site. As you click on the site, that site information will carry over to the Site Mapping tab. The example below shows we are on the Billing site, as verified by the header information, and the MPN is and the NPI is Rev. 7/1/

25 Contract Tab This is a critical tab in that it will show what services are in your contract, down to the exact procedure code, and at what location they can be provided. The first tile will let the provider know what contracts are in place. In this case, the provider has a state funded contract and a Medicaid contract that both started 7/1/2012. As the user clicks on the different contracts, note how the information in the other tiles change. To verify the procedure codes, click on a contract and drag the Contract Details tile into the main screen. Note: That this provider can bill for only 5 different procedure codes. What is even more important to note is that they can ONLY be provided at the Billing site. There are no services linked to the Durham Service site. It is important that your agency verify each procedure code to each site. Your billing will not process if you bill a service that is not linked to the right site on this tile. Rev. 7/1/

26 Important Contacts Alliance Help Desk (919) Option 1 Claims (Business Operations) for assistance with completion of CMS1500 or UB04, Download Q, viewing Remittance Advices, or assistance with denied claims. Option 2 - IT/Log in Issues for assistance with new Alpha portal logins or password resets. Also responsible for the 837 testing and EDI certifications. Option 3 Clinical Operations for assistance with SARS, Client Updates or Client Enrollments. Option 4 Provider Network for assistance with NPI mapping, sites and contract issues. Claims Specialists: Claims Analysts: Chelsea Reid (919) Avery Piercy (919) Tammy Hutcherson (919) Ina Shippy (919) Amy Sherrod (919) Charisse Koonce (919) Theresa Sherman (919) Barbara Morrison (919) Shayla Laird (919) Annette Sanders (919) Belinda Davis (919) Claims Supervisors: Tina Everett (919) Wendy Mans (919) EDI Specialist Hugh Greene (919) Claims Director: Lisa Sullivan (919) CFO/Executive VP: Kelly Goodfellow (919) Rev. 7/1/

27 Important Resources A variety of resources have been added to the Alliance website to assist providers with claims processing. The resources can be found under Providers>Finance and Claims Resources. Questions and Answers 1) Who do I contact if I need a log in for the Alpha Portal or if I need my password reset? Please call and choose option 2 IT/log in issues. 2) I can t see my Alpha screens very well. The best resolution is 1360x765 screen resolution. If that is not an option try holding down the Ctrl button on the left bottom part of your keyboard and rolling the ball on your mouse if using Internet Explorer. If that doesn t work, please contact your IT department for additional help. 3) My agency would like to submit 837s. How do I do that? There is a companion guide located on our website at It will provide detailed information on how to proceed with the test process. 4) Who do I contact if any of my NPI numbers are not correct? providernetwork@alliancebhc.org or you can contact the help desk at option 4 5) Who do I need to contact if I need to update a site address for my agency? Complete a Notice of Change form and send via to: providernetwork@alliancebhc.org 6) How do I add a practitioner? Complete a Notice of Change form and send via to: providernetwork@alliancebhc.org 7) Should I use the UB04 or the CMS 1500? For all IPRS services billed you will only use the CMS For Medicaid claims, professional services must be billed on a CMS Services such as ICF, inpatient, and ED claims are billed on a UB04. 8) How do I see if an authorization is in the system? Navigate in Alpha: Rev. 7/1/

28 Menu>Authorizations>Filter>Patient Search>Enter the consumers last name, first name and date of birth>highlight the consumer s name>click on the Auth Service Tile>Expand the tile by clicking the 3 in the right had corner>the start date (effective date) and the end date are displayed 9) How do I update a diagnosis for a consumer and who do I contact if I am having trouble with this? Your clinical staff will need to do a client update in ALPHA. If you are unsure about how to enter it, please contact Tasha Jennings at tjennings@alliancebhc.org. 10) What place of service should I select? Should I leave it as Pharmacy? Each service should be billed where the intervention was performed. Mostly commonly used is the office or home. For more information about place of service exceptions, see the Alliance POS Mapping located on our website under Finance and Claims Resources. 11) Where can I find Alliance rates, checkwrite schedule, ECS agreement, Trading partner agreement and Vendor profile form? Under 12) What time is the daily cutoff? Cutoff for claims to be processed is every Tuesday at 5:00 pm. Claims will adjudicate every evening and the status of most claims will be available to view the next day. *Please note: processing time can be impacted by AlphaMCS updates. If the system is updating, claims may not process until the update is complete (sometimes not until the next day). Rev. 7/1/