Annual provider training: IAPEC September 2017

Transcription

1 Annual provider training: 2017 IAPEC September 2017

2 Topics Plan updates Common billing questions (with answers) Top denial reasons Utilization Management Tools and resources 2

3 Updates 3

4 Ambulance claims: Recent and upcoming changes Both emergent and nonemergent transportation should be submitted to Amerigroup Iowa, Inc. Prescheduled transportation will remain with LogistiCare. Manually priced items and services: Pricing and methodology is determined. Medicare crossovers: Reprocessing of crossover methodology is determined. 4

5 Iowa Medicaid Enterprise (IME) provider enrollment renewal Reminder: All providers must be enrolled and active with the IME to participate with Amerigroup. To remain an active Medicaid provider, complete your re-enrollment electronically using the Iowa Medicaid Portal Access system at: Legally accept the new agreement. Complete the Ownership and Control Disclosure. Submit (if applicable) any required documentation to the IME. 5

6 Common billing questions 6

7 Common billing questions How should I bill claims for physician assistant assisting in surgery? The claim may be billed under the supervising physician s NPI but must contain the physician assistant NPI and license number in box 19 of the claim form. The claim may be billed directly under the physician assistant s NPI if they are credentialed and participating. 7

8 Common billing questions (cont.) When should I submit claims with a date span? Dates of service must reflect individual authorization certification periods. Each individual authorization ID or time frame requires a separate claims submission. Failure to do so will result in a denied or underpaid claim. 8

9 Common billing questions (cont.) How do I submit a corrected claim? Facility claims/ub-04: For Amerigroup to identify the submission as a correction, the submission should be billed using the XX7 type of bill for a correction or XX8 for a replacement. Professional claims/cms-1500: Corrections should be billed using the claim number you are correcting and the following proper resubmission codes: 5 for late charges 7 for replacement of a prior claim 8 for voided or canceled claim 9

10 Common billing questions (cont.) How do I submit a claim for an injectable J-code with the rebate National Drug Code (NDC)? Proper billing of claims submitted for outpatient-administered HCPCS drug codes requires 11-digit all-numeric NDCs Billing includes units for both the HCPCS code and the NDC. NDC units are based on the numeric quantities administered to the patient and the unit of measure (UOM). The UOM codes are as follows: F2: international unit GR: gram ML: milliliter UN: unit (each) 10

11 Common billing questions (cont.) My claim line denied with reason i15 National Correct Coding Initiative (NCCI) incidental. Should I rebill with a modifier? Amerigroup follows the NCCI rules established by CMS. Please review the CMS policies to determine if the code pair is allowed before resubmitting with an NCCI modifier. 11

12 Common billing questions (cont.) I would like to dispute the claim denial. How can I do that? You may submit a payment dispute through our website. Written instructions are available at the following site: nlineclaimsappealtutorial.pdf. 12

13 Timely filing defined Topic First time claim submission (Medicaid primary) Corrected claim submission (all) Time frame 180 days from the date of service 365 days from the date of service First time claim submission (Medicaid 365 days from the date of service is not primary.) First time claim submission 365 days from the date of service (nonparticipating providers) Submitting a payment dispute 120 days from the date of service (first time) Submitting a rejected/mail back claim 90 days from the date of mail back 13

14 Top denial reasons 14

15 Top denial reasons Denial Duplicate claim (CDD/i56/c14/W1N/Y38) Timely filing (TF0/TF1) Date of service is before/after coverage benefit period (S23). Precertification/authorization is missing (W4G/Y40/Y3Z/Y41). Charge exceeds fee schedule/maximum allowable or contracted (PS). Resolution To adjust a claim for correcting a submission error, please indicate as such. Timely filing is 180 days from the date of service. Confirm eligibility status prior to rendering services. Certain services require prior authorization (PA). All services by nonparticipating providers require a PA. Consult our contractual agreement for restrictions/billing/payment information related to these charges. 15

16 Top denial reasons (cont.) Denial Missing Explanation of Benefits (EOB) (YC7/YC6) Service not payable per contract (G04) Claim/service lacks information or has submission/billing error(s) needed for adjudication (W1M). Resolution Please resubmit the claim with primary carrier EOB for either commercial primary insurance (other health insurance) and/or Medicare. If you are a contracted provider, review the fee schedule for your provider type at: MedicaidFeeSched. If the billed code is allowed, please contact your Provider Relations consultant. Claim contains incomplete and/or invalid information The claim is unprocessable. Please submit a new claim with the complete/correct information. 16

17 Top denial reasons (cont.) Denial The benefit for this service is included in the payment/allowance for another service/procedure that was adjudicated (W2G/i09/i00). Units of service exceed medically unlikely edit (N72). Resolution The code billed is incidental to another code (or service) that is considered primary. The claims are considered paid in full. Claim may need to be date-spanned versus billed with all units under one date of service. 17

18 Utilization Management 18

19 Utilization Management (UM) Providers may request authorization for services via phone, fax or online. UM uses evidence-based medical necessity criteria (InterQual) as well as medical policy and board-certified physician consultants to ensure our members receive the highest quality of care. 19

20 Precertification Request Form For accurate and timely response, please use the Precertification Request Form available on our website: ProviderDocuments/IAIA_Universal PreCertUpdate.pdf. 20

21 Information needed for medical necessity determination Member name and IA Health Link ID number Diagnosis with the ICD-10 code Procedure with the CPT code Date of injury or hospital admission Third-party liability information (if applicable) Facility name (if applicable) Facility ID number (if applicable) Requesting physician/provider (if applicable) PCP (if applicable and different from the requesting physician/provider) Level of care requested (if applicable) with supporting documentation 21

22 Information needed for medical necessity determination (cont.) Clinical justification for the request including but not limited to the following: Lab, radiology and pathology test results Medications Treatment plan including time frames Treatment(s)/intervention(s) and the member s response including treatments and interventions provided in the ER Diagnoses of differentiation (if applicable) Current history and physical Prognosis Psychosocial status Exceptional or special needs issues Ability to perform activities of daily living Discharge plans Any known barriers to discharge For acute admissions with a length of stay of three days or less, the entire medical record for the current hospitalization should be provided. 22

23 Inpatient notifications National Customer Care Precertification is required for: Acute inpatient (emergency and planned admissions). Skilled nursing facilities (SNFs). Long-term acute care (LTAC). Acute rehabilitation: Intake calls will be routed to the health plan for SNF, LTAC and acute rehabilitation admissions. Clinical information for emergency acute admissions, SNF, LTAC and acute rehabilitation should be faxed to the corresponding fax number (see slide for UM clinical fax numbers). 23

24 Inpatient notifications (cont.) Notification is only required for the following: Observation Obstetric deliveries Completed Newborn Notification of Delivery Form should be faxed to

25 Helpful UM tips Write clearly and legibly on the request form. Verify CPT and HCPCS codes requested require PA: Authorization status can be verified using the Availity Portal: Include name, phone number and fax number on the authorization request for the person to contact if additional information is needed or when a decision was rendered. Clinical submitted should tell the story of the care that is required identifies need, intervention and treatment progress. 25

26 UM inpatient notification contact numbers Planned or emergency acute admission, observation, and obstetric delivery notifications: Phone: Fax: Acute rehabilitation, SNF and LTAC admissions: Phone: Intake calls will be routed to appropriate department at the health plan: Physical health fax (acute inpatient): Long-term services and supports (LTSS) fax (acute inpatient):

27 Physical health acute inpatient: Fax: Physical health outpatient: Fax: LTSS acute inpatient: Fax: LTSS outpatient: Fax: UM clinical fax numbers LTSS includes members whose permanent residence is a nursing facility; skilled nursing facility; or who are enrolled in the AIDS/HIV, Brain Injury, Elderly, Health and Disability, Intellectual Disability, or Physical Disability Waivers. 27

28 Provider tools and resources 28

29 Amerigroup website: 29

30 Newsletters Current and archived newsletters are also available under the Provider Resources & Documents tab of the website. 30

31 Reimbursement policies Iowa-specific guidance 31

32 Thank you! 32