Insert photo here. Common Denials. Presented by EDS Provider Field Consultants

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1 Insert photo here Common Denials Presented by EDS Provider Field Consultants October 2007

2 Common Denials Agenda Session Objectives Edits and Audits Defined Edit Grouping Denial Overview Questions 2 October 2007

3 Session Objectives Understand the different edit groupings Understand the purposes of edits and audits Understand how to correct the claim once the claim has denied Understand how to submit correct claims to avoid edit denials 3 October 2007

Edit and Audit Groups 0001-0499 Validation Edits 0500-0999 Relational Edits 1000-1999 Provider Edits

4 Edit and Audit Groups Validation Edits Relational Edits Provider Edits Recipient Edits Prior Authorization (PA) Edits Reference Edits 4 October 2007

5 Edit and Audit Groups (cont) History Audits Medical Policy Surveillance and Utilization Review (SUR) Edits Pharmacy Miscellaneous (informational) Edits 5 October 2007

6 Edits and Audits Edits - are designed to verify data submitted on the claim form and ensure claims are submitted with the necessary data to process the claim Audits - are designed to compare the claim being processed to the claims that have already been paid (paid history) Edits and Audits are designed to ensure claims are paid within policies set forth by Office of Medicaid Policy and Planning (OMPP) and Centers for Medicare and Medicaid Services (CMS) 6 October 2007

7 Common Denials October 2007

8 Edit 0388 This service is not payable. The recipient has not satisfied spend-down for the month. Spend-down is credited on claims based on the order they are processed ARC 178 appears on the remittance advice when spend-down is credited on claims Providers should bill the member for the amount listed beside ARC 178 Member is responsible to pay upon receipt of the Spend-down Summary Notice 8 October 2007

9 Edit 0499 CCF not returned within 45 days Examples of claims that will generate a CCF: Claims over one year old (0512) Certification code missing (Medicaid Select) Claims that require attachments Sterilization consent form Periodontal Chart CCF will not print for: Electronic claims with attachments (Region 21) Note: Electronic claims will remain in a CCF status for 45 days, or until the attachment is received 9 October 2007

10 Edit 0509 Net charge out of balance Net charge is not equal to the total charge less the Third Party Liability (TPL) amount and the patient deductible amount If the member has a primary insurance that has paid for a service: Subtract the TPL paid amount from the billed amount Indicate the difference in the appropriate field Ensure the calculation is correct CMS-1500 claim form example: CMS-1500 field 28 should reflect total amount billed Field 29 should show the TPL amount paid by primary carrier Field 30 should contain the balance of field 28 minus field October 2007

11 Edit 0512 Claim Past Timely Filing Limit Timely filing guidelines Claims must be received within 365 days from the date of service Timely filing documentation includes: Previously billed claim forms (date in field 31) Remittance Advice Web interchange Claim Inquiry page Documentation of retroactive eligibility Third Party Liability (TPL) Explanation of Benefits Dated responses from EDS Written Correspondence Dated documentation from the Division of Family Resources 11 October 2007

12 Edit 0520 Invalid Revenue Code/Procedure Code Combination Procedure code entered in any of the detail lines does not match the revenue code entered on the same line Verify revenue code is valid for procedure code as per the UB-92 Editor 12 October 2007

Edit 0558 Coinsurance and deductible amount missing UB-04 -Field Locator 39 A1 = Medicare Deductible A2 = Medicare co-insurance 06 = Medicare Blood

13 Edit 0558 Coinsurance and deductible amount missing UB-04 -Field Locator 39 A1 = Medicare Deductible A2 = Medicare co-insurance 06 = Medicare Blood deductible CMS Field 22 Left = The sum amount for Medicare Coinsurance, Deductible and Psych Reduction Right = Medicare Paid Amount 13 October 2007

14 Edit 0593 Medicare Denied Detail Denied detail lines must be re-billed separately on a new claim form Occurs when Medicare denies a detail line Are not crossover claims Do not include the paid detail lines on the new claim Processed as TPL claims Include the Medicare Remittance Notice (MRN) with the claim 14 October 2007

15 Edit 0594 Type of Bill not covered by IHCP The type of bill submitted is not covered by the IHCP The IHCP does not accept all bill types accepted by other payors Verify accepted bill types at under the HIPAA section Correct the bill type and resubmit claim 15 October 2007

16 Edit 1003 Billing provider not enrolled at service location for date of service Billing provider number is not enrolled in the program on the date of service Verify the correct Legacy Provider Identifier (LPI) was reported on the claim To initiate a new enrollment Download the Provider Enrollment Application via Complete the form and submit to Provider Enrollment 16 October 2007

17 Edit 1004 Rendering provider not eligible to render service on this program for the date of service Rendering provider number is not enrolled in the specific program (for example, 590 Program) on the date of service Verify the rendering provider s enrollment via Web interchange If necessary, complete the Provider Update Form to enroll the provider in the program 17 October 2007

18 Edit 1043 Medicaid Select member s Primary Medical Provider (PMP) certification code is missing UB-04 Field 37 CMS-1500 Field 19 (RESERVED FOR LOCAL USE) 18 October 2007

19 Edit 1044 Medicaid Select member s PMP is missing UB-04 Field 78 (other) Primary medical provider NPI and/or license number is missing/invalid on the claim form CMS-1500 Field Locator 17b (NPI) Primary medical provider NPI and/or LPI is missing/invalid on the claim form 19 October 2007

20 Edit 1127 Rendering Legacy Provider Identifier (LPI) Obtained in National Provider Identifier (NPI) crosswalk conflicts with the LPI submitted Applicable to medical claim forms Post and Pay edit through transition period Field 24J Rendering NPI submitted on the claim does not crosswalk to the rendering LPI submitted on the claim Verification needed that NPI billed correctly Verification needed for provider file information 20 October 2007

21 Edit 1128 Rendering NPI has no matching LPI Applicable to medical claim forms Post and Pay edit through transition period Field Locator 24J Rendering NPI submitted on the claim does not crosswalk to an LPI in the provider database Verification needed that NPI billed correctly Verification needed of provider file information 21 October 2007

22 Edit 1129 Rendering NPI information submitted reported to multiple LPIs Applicable to medical claim forms Post and Pay edit through transition period Field 24J Rendering NPI submitted on the claim crosswalks to multiple rendering LPIs in the provider database Verification needed that NPI billed correctly Verification needed of provider file information Field 24I Use Taxonomy with a ZZ qualifier to obtain a oneto-one match 22 October 2007

23 Edit 2010 Alien Eligible for Medical Emergency Only Pharmacy Drug Claim Form Field 3 Emergency = Yes Pharmacy Compound Prescription Form Field 4 Emergency = Y ADA 2006 Dental Claim Form Field 2 Indicate emergency CMS-1500 Field 21 Report emergency diagnosis code Field 24C EMG = Y UB-04 Field 14 Admission Type = 1 Field 67 Report emergency diagnosis code Refer to Chapter 8 of the IHCP Provider Manual for a list of emergency diagnosis codes 23 October 2007

Edit 2013 Recipient Ineligible for Level of Care Applicable to HCBS waiver and long-term care providers Services billed for a member who does not have the appropriate level of care during the dates

24 Edit 2013 Recipient Ineligible for Level of Care Applicable to HCBS waiver and long-term care providers Services billed for a member who does not have the appropriate level of care during the dates of service All claims will automatically deny if the member is not listed as eligible for the appropriate level of care for that specific date of service For waiver providers, the procedure being billed must be an approved service on the Notice of Action for the member's waiver LOC 24 October 2007

25 Edit 2504 Recipient covered by private insurance (without attachment) Enter primary insurance payment UB-04 Field 54 (Prior Payment) CMS-1500 Field 29 (Amount Paid) ADA 2006 Field 35 (Remarks) Pharmacy Claim Form Field 16 (TPL Amount Paid) Compound Drug Claim Form Field 18 (TPL Amount Paid) Applied to Deductible or Denied Explanation of benefits from primary insurance Letter stating termination date Letter from insurance stating non-coverage TPL listed is no longer valid Contact EDS TPL unit at or Request TPL update via Web interchange 25 October 2007

26 Edit 2505 Recipient covered by private insurance (with attachment) Applies when the EOB does not meet TPL requirements Enter zero as the primary insurance payment UB-04 Field 54 (Prior Payment) CMS-1500 Field 29 (Amount Paid) ADA 2006 Field 35 (Remarks) Pharmacy Claim Form Field 16 (TPL Amount Paid) Compound Drug Claim Form Field 18 (TPL Amount Paid) Attach copy of EOB showing reason for denial from primary insurance carrier 26 October 2007

27 Edit 2505 Recipient covered by private insurance (with attachment) Include member identification on the claim attachment Clearly state the reason for non-coverage on the TPL attachment Ensure that the primary insurance company name on the attachment matches the information in the member s file Hand write Medicare replacement policy on the EOB, if applicable TPL listed is no longer valid 27 October 2007

Edit 2510 Member Eligible for Medicare B/D Pharmacy and Compound claims- If a recipient is on the Medicare D eligibility table and the NDC submitted is not listed as covered on the MCARD covered

28 Edit 2510 Member Eligible for Medicare B/D Pharmacy and Compound claims- If a recipient is on the Medicare D eligibility table and the NDC submitted is not listed as covered on the MCARD covered benefits table, this edit will deny the claim The MCARD covered benefits table identifies drugs covered under Medicare Part D This edit can not be overridden Claims must be filed to Medicare 28 October 2007

29 Edit 3001 Date(s) of service not on PA database Applies when the code billed requires Prior Authorization (PA) for that program, and the date(s) of service indicated on the claim do not fall within the start/stop dates prior authorized for that code. Verify PA was approved via Web interchange or via Automated Voice Response (AVR) at (317) in the Indianapolis local area or toll-free. Contact HCE Prior Authorization Department at or toll-free at October 2007

30 Edit 4021 Procedure Code vs. Program Indicator Procedure code billed is restricted to a specific program Package B Package C 590 Verify eligibility prior to rendering service Submit claim with appropriate procedure code 30 October 2007

31 Edit 4095 Non-surgical services are not reimbursed individually if preformed in conjunction with an outpatient surgery Applies when a non-surgical revenue code is submitted with a valid surgical revenue code on an outpatient claim Reimbursement for surgical services is an allinclusive flat fee that includes all related procedures for outpatient surgeries provided in either a hospital or an ambulatory surgical center (ASC) Reimbursement is limited to a maximum of two units of service regardless of the number of incisions (all other procedures are denied) Providers may combine all charges and services associated with the surgical procedure(s) as an all-inclusive charge 31 October 2007

32 Edit 4107 Revenue code is not appropriate/covered for service. Revenue group invalid Revenue code is not covered for the type of service being provided Verify correct revenue code as per the UB editor and re-submit 32 October 2007

33 Edit 4209 No pricing segment for procedure/modifier combination Applicable to medical claims reporting processing and pricing modifiers Verify procedure/modifier combination is reported correctly IHCP Fee Schedule IHCP Provider Manual 33 October 2007

34 Edit 5001 Exact Duplicate Claim being processed is an exact duplicate of a claim on the history file or another claim being processed in the same cycle Research prior claims billed for paid status 34 October 2007

35 Edit 6000 Manual Pricing Required Invoice Requirements Claim listing the NDC, drug name, and quantity used (drugs only) Average Wholesale price listing X quantity (drugs) Date Billed amount per unit (for example, box, case, and so forth) Calories (enteral feeding) Procedure code Member name Member ID number Itemization of repairs Bulk Invoices illustrate calculations specific to the member 35 October 2007

36 Helpful Tools Avenues of Resolution IHCP Web site at IHCP Provider Manual (Web, CD- ROM, or paper) HCBS Waiver Provider Manual (Web) Customer Assistance , or (317) in the Indianapolis local area Written Correspondence P.O. Box 7263 Indianapolis, IN Provider Relations Field Consultant 36 October 2007

37 October 2007 Questions

Remittance Advice and Financial Updates

Insert photo here Remittance Advice and Financial Updates Presented by EDS Provider Field Consultants August 2007 Agenda Session Objectives Remittance Advice (RA) General Information The 835 Electronic