MHS UB-04 Billing and Claim Processing Tips and Billing Guidelines

Transcription

1 MHS UB-04 Billing and Claim Processing Tips and Billing Guidelines PR.P.PP 10/15

2 Agenda Who is MHS? Claim Process Filing Process Common Claim Rejections Common Claim Denials Claim Adjustments Claims Dispute Resolution HIP Billing Tips Billing Reminders MHS Website/Portal Contacts 2

3 Who is MHS? Managed Health Services (MHS) is a health insurance provider that has been proudly serving Indiana residents for two decades through Hoosier Healthwise, the Healthy Indiana Plan and Hoosier Care Connect MHS also offers a qualified health plan through the Health Insurance Marketplace called Ambetter from MHS. All of our plans include quality, comprehensive coverage, with a provider network you can trust MHS is your choice for affordable health insurance 3

4 CLAIM PROCESS 4

5 Claim Process Electronic submission through EDI vendor Payer ID MHS accepts TPL information via EDI It is the responsibility of the provider to review the error reports received from the Clearinghouse (Payer Reject Report) Online submission through the MHS Secure Provider Portal at: mhsindiana.com/login Provides immediate confirmation of received claims and acceptance Professional and Facility claims accepted Attachments accepted via MHS Secure Portal Claim Adjustments and TPL accepted Paper Claims Managed Health Services PO Box 3002 Farmington, MO Claim Inquiries Check status online with the MHS Secure Provider Portal: mhsindiana.com/login. Call Provider Services at: IVR 5

6 Claim Process Billing with Ease CONTRACTED PROVIDERS Claims must be received within 90 calendar days of the date of service. Exceptions: Newborns (30 days of life or less) Claims must be received within 365 days from the date of service. Claim must be filed with the newborn s RID number Third party Liability (TPL)- Claims with primary insurance must be received within 365 days of the date of service with a copy of the primary EOB. If primary EOB is received after the 365 days, providers have 60 days from date of primary EOB to file claim to MHS 6

7 Claim Rejection Claim Process A rejection is an unclean claim that contains invalid or missing data elements required for acceptance of the claim in the claim process system. The provider will receive a letter or a rejection report from their EDI vendor if the claim was submitted electronically Claim Denial A denial is a claim that has passed edits and is entered into the system but has been billed with invalid or inappropriate information causing the claim to deny. An EOP will be sent that includes the denial reason 7 7

8 CLAIM REJECTIONS 8

9 Claim Rejections EDI rejections require the provider to contact their clearinghouse and obtain a payer rejection report Paper to electronic mapping guide (EDI COB Mapping Guide) is available on mhsindiana.com/provider-guides 9

10 Claim Rejection Tips Member Information Newborn s RID number is required for payment TPL or Secondary Claims Accepted electronically from vendors or via the MHS Secure Provider Portal COB verification can be requested via portal message option 10

11 Claim Rejections (Paper) The provider identification and the tax identification numbers are missing or not on file with the health plan. Verify that the provider s NPI is entered on the claim in box 56 Verify that the address located in box 1 is the provider s service location address with the complete zip code Verify that the group taxonomy is in box 81CC a with the B3 qualifier 11

12 Common Claim Rejections Member s DOB is missing or invalid Member s information needs to match what is on file with Indiana Medicaid Incomplete or invalid member information Member eligibility should be verified via Web interchange, or AVR at the point of service (maintained by IHCP). If you believe that the member information on the claim is correct, please call to speak with an MHS Provider Services Representative or use the online portal messaging system to update the member s eligibility 12

13 Common Claim Rejections NDC information missing or invalid Services requiring NDC numbers must be billed with valid NDC numbers in the correct format: Enter the NDC qualifier of N4 Enter the NDC 11 digit numeric code Enter the drug description Enter the NCD unit qualifier of F2 for international unit, GR for gram, ML for Milliliter and UN units Enter the NDC quantity (administered/billed amount) in the formation of

14 CLAIM DENIALS 14

15 Common Claim Denials Time Limit For Filing Has Expired (EX 29) Claims must be received within 90 calendar days of the date of service (contracted providers) Exceptions Newborn, Third Party Liability, and Non Participating Providers Bill Primary Insurer 1 st (EX L6) Verify other insurance (TPL). Medicaid is the payer of last resort 15

16 Common Claim Denials Coverage Not In Effect When Service Provided (EX 28) Check eligibility at each visit prior to submitting claims to ensure that you are billing the correct carrier Please Resubmit To Cenpatico For Consideration (EX 54) Behavioral Health Services for MHS members are covered by Cenpatico Missing or Invalid POA (EX VV) Required for inpatient admissions unless exempt diagnosis 16

17 Common Claim Denials Authorization Not On File (EX A1) Prior authorization should occur at least two (2) business days prior to the date of service All urgent and emergent services must be called in to MHS within two (2) business days after service/admit Claim and Auth Service Provider Not Matching (EX HP) Authorization on file does not match date of service billed Denied By Medical Services (EX HL) Claim and authorization locations do not match 17

18 CLAIM ADJUSTMENTS 18

19 Claim Adjustments If you need to make an adjustment to a paid claim, you can do so by submitting the adjustment request via the MHS Secure Provider Portal. For assistance, there is a tutorial available at mhsindiana.com/provider-guides - How to Use the Adjust Claims Feature on the MHS Provider Portal Adjustments can be submitted electronically through your clearinghouse. EDI 837P, the data should be sent in the 2300 Loop, segment CLM05 (with value of 7) along with an addition loop in the 2300 loop, segment REF*F8* with the original claim number for which the corrected claim is being submitted 19

20 Claim Adjustments Adjustments can also be processed via paper submissions. The MHS claim adjustment form is available at mhsindiana.com/provider-forms. UB-04 should be submitted with the appropriate resubmission code in the 3rd digit of the bill type (for corrected claim this will be 7) and the original claim number in field 64 of the paper claim Attach an MHS claim adjustment form along with documentation, including EOP (if available) explaining reason for resubmission. Please indicate original claim number. Example: (N123INE00987) Claim adjustments requests must be submitted within 67 days of the date of the MHS EOP. Claims will not be reconsidered after day 67 20

21 DISPUTE RESOLUTION (2 STEP PROCESS) 21

22 Dispute Resolution v Level One Appeal Should be made in writing by using the MHS informal claim dispute or objection form, available at mhsindiana.com/provider-forms Submit all documentation supporting your objection Send to MHS within 67 calendar days of receipt of the MHS EOP. Please reference the original claim number. Requests received after day 67 will not be considered Managed Health Services Attn: Appeals P.O. Box 3000 Farmington, MO MHS will acknowledge your appeal within 5 business days Provider will receive notice of determination within 45 calendar days of the receipt of the appeal A call to MHS Provider Services does not reserve appeal rights 22

23 Dispute Resolution Level Two Appeal (Administrative) Submit the Informal Claims Dispute/Objection Form with all supporting documentation to the MHS appeals address: Managed Health Services Attn: Appeals P.O. Box 3000 Farmington, MO MHS will acknowledge your appeal within 5 business days Provider will receive notice of determination within 45 calendar days of the receipt of the appeal 23

24 PaySpan Health EFTs and ERAs Web based solution for Electronic Funds Transfers (EFTs) and Electronic Remittance Advices (ERAs). One year retrieval of remittance advice Provided at no cost to providers and allows online enrollment Register at payspanhealth.com For questions call or 24

25 HIP Billing Tips 25

26 Emergency Department Copay HIP requires non-emergent Emergency Department (ED) copayments unless: Member meets cost sharing maximum for the quarter Member is referred to ED by physician (physician must notify MHS) Member calls MHS Nurse-line and is told to go to ED The visit is a true emergency HIP features a graduated ED copayment model HIP Plus members cannot use their power account (debit card) for copayments $8 $25 Each 1 st non-emergent additional ED visit in the non-emergent benefit period ED visit in the benefit period 26

27 Reimbursement Rates HIP Reimbursement Rates Exceptions Medicare Rates 130% of Medicaid rate if no Medicare rate exists HAF eligible hospitals paid at Medicaid rates 27

28 HIP Billing Tips Hospital Assessment Fee MHS will include Hospital Assessment Fee (HAF) payments into claim reimbursement, no longer a separate check Ex1I will be the indicator on payment detail Applicable only to eligible hospitals As of Dates of Service 1/1/16 for Inpatient Services 3/1/16 for Outpatient Services References: BT201608, BT201622, BT

29 When billing Emergency Room (ER) claims, the revenue code 450 needs to be billed using the appropriate CPT and the appropriate modifier Physical therapy/occupational therapy/speech therapy claims, when billed with the revenue codes 042X, 043X, and/or 044X, need to be billed with appropriate CPT codes and modifiers. For example, the revenue code 0420 would need to be billed using the appropriate CPT and the appropriate modifier, such as GP There are other revenue codes that require billing of an appropriate CPT and, in some cases, with an appropriate modifier. For example, the revenue code 0510 would need to be billed using the appropriate CPT and the appropriate modifier Resource IHCP website modules HIP Billing Tips 29

30 HIP Billing Tips Skilled Nursing Facilities must bill appropriate Resource Utilization Group (RUG) codes as supported by medical chart documentation Resource; IHCP long term care billing module 30

31 Billing Reminders 31 31

32 Billing Reminders Home Health billing tips Paper Claims Box 31a-34b to claim overhead reimbursement (8 dates) May enter span dates in fields 35a-36b (up to 4 spans) May NOT claim more than 1 overhead per date of service billed Date of service billed must be represented in box 45 of the UB with correct codes Occurrence code 50 and date of the hospital discharge (30 days) Web Portal Occurrence codes billed on the portal are currently limited to 12 dates 61 occurrence code with the Date of Service in the From field If you enter the to date, it will give you an error, and not let you continue, without removing that date. 32

33 Hospice Billing HCC Non-Institutional Services All-inclusive per diem rate is paid based on level of care Effective October 1st MHS providers can bill a maximum of 5 respite days Medicaid reimbursement methodology Prior authorization is required HHW MHS is not responsible for covering Hospice for HHW members Members in the HHW program that are in need of hospice services must be disenrolled from managed care and enrolled in a direct IHCP program such as fee for service HIP MHS covers Hospice for all HIP members in both and institution and home based setting Room and Board leave days are not covered Hip hospice benefits mirror the covered services and reimbursement methodology of the Medicare hospice program Prior authorization is required 33

34 ER Claim Processing Claims will be considered for reimbursement based on appropriate levels of care Documentation supported by the Medical Record Diagnosis based review 34

35 HPE Claim Processing Member Hospital Presumptive Eligibility (PE) begins on the date that the PE application is submitted and the approval determination is made (600 series #) Services delivered prior to this date are not covered If a hospital admission date is prior to the PE eligibility start date, no portion of that stay will be considered a PE-covered service (this applicable to DRG) BT PE Coverage continues unless. The member fails to file an Indiana Application for Health Coverage by the last day of the month following the month in which the PE period began. A determination has been made on the individual's Indiana Application for Health Coverage An individual is allowed to receive PE coverage only once per rolling 12-month period PE benefits mirror Traditional Medicaid benefits 35

36 Authorization Considerations Authorizations and Benefits Limitations apply What requires Authorization? Reference QRG Pre-Auth Tool Contact MHS Customer Service to verify How to obtain Authorization Phone Fax Online Reminder: Authorizations are not a guarantee of payment 36

37 Prior Authorization Some Services that require prior authorization regardless of contract status (not inclusive) are: All elective hospital admissions All urgent and emergent hospital admissions (including NICU) require notice to MHS following the admission Transition to hospice Newborn deliveries (following delivery) Rehabilitation facility admissions Skilled nursing facility admissions Transition of care Transplants, including evaluations Reference QRG for a more detailed listing

38 MHS Website

39 39

40 Creating a claim on MHS Provider Portal 40

41 Create a New Claim Enter the Member s Last Name or Member ID along with their Date of Birth. 41

42 Click on Type of Claim 42

43 Reviewing Claims 43

44 Submitted Claims The following screen will show those claims created via the portal only

45 Individual Claims To view the details of the individual claim, click the blue Claim Number to open the claim

46 View Claim Information 46

47 Payment History To view the Explanation of Payment details, click the Check Date

48 Payment History To view the Explanation of Payment details, click the Check Date. 48

49 Submitted Claims The following screen will show those claims created via the portal only. 49

50 Contact US 50

51 MHS Customer Service Provider Services 8 am-8 pm Claims inquiries 51

52 Secure Messaging If you have any questions or experience issues, you can always use Secure Messaging. All messages are answered within one business day Click on Create Message to begin a new message. 52

53 MHS Provider Relations Team Bob McDaniel Vice President, Contracting & Network Operations ext Nancy Robinson Director, Provider Relations ext Chad Pratt Provider Relations Specialist Northeast Region ext Tawanna Danzie Provider Relations Specialist Northwest Region ext Jennifer Garner Provider Relations Specialist Southeast Region ext Taneya Wagaman Provider Relations Specialist Central Region ext Katherine Gibson Provider Relations Specialist North Central Region ext Esther Cervantes Provider Relations Specialist South West Region ext Kelvin Orr Director, Behavioral Health Network ext Richard Elliot Manager, Behavioral Health Network Development ext Mary Schermer Behavioral Health Provider Relations Specialist - West Region ext mary.schermer@evolvehealth.com LaKisha Browder Behavioral Health Provider Relations Specialist - East Region ext lakisha.browder@evolvehealth.com 53

54 Contracting Team Mark Vonderheit Director, Contracting & Network Development ext Tim Balko Contract Manager ext Tracee Swift Contract Negotiator - West Region ext tracee.l.swift@mhsindiana.com Jessica Bradley Contract Negotiator - East Region ext jbradley@mhsindiana.com 54

55 Questions Thank you for partnering with MHS! 55