West Virginia Trading Partner Account Remittance Advice Reports User Guide. Date of Publication: 01/19/2016 Document Version: 1.0

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1 West Virginia Trading Partner Account Date of Publication: 01/19/2016 Document Version: 1.0

2 Privacy and Security Rules The Health Insurance Portability and Accountability Act of 1996 (HIPAA Public Law ) and the HIPAA Privacy Final Rule 1 and the American Recovery and Reinvestment Act (ARRA) of 2009 provides protection for personal health information. Protected Health Information (PHI) includes any health information and confidential information, whether verbal, written, or electronic, created, received, or maintained by Molina Healthcare. It is health care data plus identifying information that allows the data to tie the medical information to a particular person. PHI relates to the past, present, and future physical or mental health of any individual or member; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual. All member information including, but not limited to claims data, prior authorization information, and attachments such as medical records and consent forms are all PHI CFR Parts 160 and 164, Standards for Privacy of Individually Identifiable Health Information; Final Rule Proprietary and Confidential Molina Medicaid Solutions Page ii

3 Disclaimer This document and information it contains is proprietary information. Authorization is hereby provided to you to copy documents published by Molina Medicaid Solutions on the Health PAS-OnLine portal provided such copies are used for non-commercial purposes and solely for use within your organization. This authorization is specifically conditioned upon including all legends, copyright, proprietary, and other notices that appear herein on all copies you make of such documents whether they pertain to Molina Medicaid Solutions or another party. No license is granted herein expressly, impliedly, by estoppel or otherwise under any patent or to use any trademark of any party. No other rights under any copyrights are granted herein, except as expressly stated above. The documents herein may refer to products and/or services that are neither available nor planned for availability in your particular locality. In referring to such products and/or services, Molina Medicaid Solutions incurs no obligation to subsequently make them available in your locality. DOCUMENTS PUBLISHED HEREIN ARE FURNISHED TO YOU AS IS. THERE ARE NO WARRANTIES, EXPRESS, OR IMPLIED, BY OPERATION OF LAW OR OTHERWISE. MOLINA MEDICAID SOLUTIONS DISCLAIMS THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NON- INFRINGEMENT AS TO BOTH MOLINA MEDICAID SOLUTIONS AND NON-MOLINA DOCUMENTS FURNISHED HEREIN. Some states or territories do not allow the exclusion of implied warranties and the foregoing exclusions may not be applicable to you. Any communication provided by you to Molina Medicaid Solutions relating to the documents furnished herein by Molina Medicaid Solutions will be received only on a non-confidential basis. There shall be no obligation on the part of Molina Medicaid Solutions with respect to use or disclosure of any information in such communication. Molina Medicaid Solutions shall have the unrestricted right to copy, use, and distribute any information you communicate including, but not limited to any ideas, concepts, know-how, techniques, software, documentation, diagrams, schematics, or blueprints. Additionally, Molina Medicaid Solutions may use all such information in any manner or for any purpose including, but not limited to developing products or providing services. The documents furnished herein by Molina Medicaid Solutions are subject to change without notice. All brand names and product names are acknowledged to be the trademarks or registered trademarks of their respective owners. Proprietary and Confidential Molina Medicaid Solutions Page iii

4 Revision History Version Date Author Action/Summary of Changes Status /19/2016 Molina Submitted for BMS approval Approved 1.1 1/22/2016 Tisjauna Palmer Updated Hyperlinks with new portal location Approved Proprietary and Confidential Molina Medicaid Solutions Page iv

5 Table of Contents 1. Introduction Accessing Reports (Remittance Advice, Other) X Output for Claims Payment Pended Claim Report Provider Payment Status Provider Payment Search Appendix A Acronyms and Abbreviations Table of Figures Figure 2 1: Sign In Hyperlink... 1 Figure 2 2: Trading Partner Sign In... 2 Figure 2 3: Report Link... 3 Figure 2 4: Selecting Remittance Advice Options... 3 Figure 2 5: Selecting Remittance Advice Check Box... 4 Figure 2 6: Remittance Advice File Download Options... 4 Figure 2 7: Remittance Advice Cover Page... 5 Figure 2 8: Remittance Advice... 6 Figure 2 9: Disbursement of Funds Page... 7 Figure 2 10: Pended Claims Report Option... 8 Figure 2 11: Selecting Pended Claims Report Options... 8 Figure 2 12: Selecting Check Box to View Pended Claims Report... 9 Figure 2 13: Claims in Process File Download Options... 9 Figure 2 14: Claims in Process Report Figure 3 1: Accessing Provider Payment Status Figure 3 2: Accessing Provider Payment Information Figure 3 3: Payment for the Billing Provider Figure 3 4: Provider Payment Summary Figure 3 5: Claims Status: View Claim Figure 3 6: Provider Payment Search Proprietary and Confidential Molina Medicaid Solutions Page v

6 1. Introduction The purpose of this document is to guide providers on how to access their electronic remittance advices through the Health PAS-OnLine portal. 2. Accessing Reports (Remittance Advice, Other) To access and view reports on the Health PAS-OnLine portal, follow these steps: Click the Sign In hyperlink. Refer to Figure 2 1. Figure 2 1: Sign In Hyperlink Proprietary and Confidential Molina Medicaid Solutions Page 1 of 17

7 In the User Name field, type your user name. Refer to Figure 2 2. In the Password field, type your password. Click in the checkbox that is located in front of I have read and accept the HIPAA PHI privacy policy statement. Click SIGN IN. " Figure 2 2: Trading Partner Sign In Proprietary and Confidential Molina Medicaid Solutions Page 2 of 17

8 Click File Exchange. Click Reports and then click Remittance Advice Portable Document Format (PDF) to view a listing of Remittance Advices (RAs). Refer to Figure 2 3. Figure 2 3: Report Link Note: To read PDF documents, you need Adobe Reader. If the Adobe Reader is not already on your computer, go to to obtain a free download. Click the RA pdf you wish to view by clicking the check box on the left of the page, or clicking the Report Type hyperlink Electronic Remittance Advice (ERA). Refer to Figure 2 4. Figure 2 4: Selecting Remittance Advice Options Proprietary and Confidential Molina Medicaid Solutions Page 3 of 17

9 If you click the check box, you have three options to choose from. Refer to Figure 2 5. Download Selected- Allows the user to Download the selected file Mark Selected as Read- Allows the user to change status of file from Unread to Read View Zip File Requests- Allows the user to open or save the secured zip file Figure 2 5: Selecting Remittance Advice Check Box If you select the download option, you are prompted to either Open, Save, or Cancel the file. Refer to Figure 2 6. Figure 2 6: Remittance Advice File Download Options Proprietary and Confidential Molina Medicaid Solutions Page 4 of 17

10 If you click Open, the Remittance Advice downloads in a PDF file format. The RA consists of various sections of information. Refer to Figure Cover Page Pay to Provider Name/Address Pay to Provider Tax ID Pay to Provider Type/Description Banner Page Information Figure 2 7: Remittance Advice Cover Page Proprietary and Confidential Molina Medicaid Solutions Page 5 of 17

11 2. Remittance Advice. Refer to Figure 2 8. Line Number Line Status Status Reason/Remarks Service To and From Dates Revenue/Service Codes Modifiers OR Tooth number/surface Remit Units Billed Amount TPL and/or Medicare Amount Refund Amount Member Amount Copay Amount Paid Figure 2 8: Remittance Advice Proprietary and Confidential Molina Medicaid Solutions Page 6 of 17

12 3. Disbursement of Funds. Refer to Figure 2 9. Billed Claim Amount TPL/Medicare Amount Member Amount Medicaid Payment Capitated Payment Amount Less Recoupment Amount Description of Denied, Paid, and Reversed Claim Status Reason Codes Description Remark Codes Description Figure 2 9: Disbursement of Funds Page Proprietary and Confidential Molina Medicaid Solutions Page 7 of 17

13 2.1 X Output for Claims Payment For more detailed information about the 835, refer to the Molina 5010 (X12) 835 Companion Guide which is located in the Companion Guide section of the web portal. 2.2 Pended Claim Report This is a weekly report that pulls all pended or in-process claims that are not finalized. This is a companion report for the Remittance Advice (RA); it lets you know where the claims are in the adjudication process. The RA and an in-process claim report together equal all claims submitted and processed by the Medicaid Management Information System (MMIS). The Pended Claims Report is located under File Exchange/Reports. Refer to Figure Figure 2 10: Pended Claims Report Option To select the report, click the check box to the left of the File Name, or click the Claims in Process (CIP) PDF hyperlink under File Name. Refer to Figure Figure 2 11: Selecting Pended Claims Report Options Proprietary and Confidential Molina Medicaid Solutions Page 8 of 17

14 If you click the check box, you have three options to choose from: Download Selected- Allows the user to download the selected file Mark Selected as Read- Allows the user to mark the as read instead of unread View Zip File Requests- Files that are downloaded are created in a secured zipped file. Selecting view zip file request, allows the user to view the selected file. Refer to Figure Figure 2 12: Selecting Check Box to View Pended Claims Report If you click the Claims in Process PDF hyperlink, you are prompted to either Open, Save, or Cancel the file. Refer to Figure Figure 2 13: Claims in Process File Download Options Proprietary and Confidential Molina Medicaid Solutions Page 9 of 17

15 If you click Open, the Claims in Process (CIP) Report opens in a PDF file. Refer to Figure The file consists of the following information: Date/Time the CIP report was generated Submitter ID Group Provider Name Group Provider ID Service Provider Name Service Provider ID Claim Status (To Be Paid, To Be Denied, In Process) Claim status is the status of the claim after adjudication. Claim Number Patient Name/Account Number- The patient name does not appear in the headings. Dates of Service Billed Amount Paid Amount Figure 2 14: Claims in Process Report Proprietary and Confidential Molina Medicaid Solutions Page 10 of 17

16 3. Provider Payment Status Use the navigation pane to access the Provider Payment Status. Refer to Figure 3 1. Click the Form Entry link to expand the selection list. Click View Payment Detail link to go to the Payment Status screen. Figure 3 1: Accessing Provider Payment Status This screen is used to view payments that have been made to Billing Providers and to view the claims associated with these payments. From the Billing Provider drop-down list, click the name of the Billing Provider. Refer to Figure 3 2. Figure 3 2: Accessing Provider Payment Information Proprietary and Confidential Molina Medicaid Solutions Page 11 of 17

17 A list of the most recent payments for that billing provider displays in the Payments area. Refer to Figure 3 3. The Payments area displays the information in columns with the following headings: Payment ID Date: The payment date Amount Type Discount Status Note: Use the search feature to find any payments not listed. Click Print List to print, or click Export to Excel to export to a Microsoft Excel spreadsheet. Click a Payment ID in the first column to see additional information about that payment. Figure 3 3: Payment for the Billing Provider Proprietary and Confidential Molina Medicaid Solutions Page 12 of 17

18 The Payment Summary has two parts. Refer to Figure 3 4. Information about the payment itself is in the upper part of the screen: Payment ID: The equivalent of check number Payment Amount Payee Name Pay Discount Payment Date Payment Type Paid Date Clear Date In the lower portion of the screen, additional information displays about each of the claims included in the payment: Claim # Member Name Date(s) of Service Claim Amount Paid Amount Claim Copay Status To return to the list in the Payments area, click BACK TO PAYMENTS at the bottom of Payment Summary screen. Figure 3 4: Provider Payment Summary Proprietary and Confidential Molina Medicaid Solutions Page 13 of 17

19 To view the claim, click the Claim #. The Claims Status > View Claim screen is displayed. Refer to Figure 3 5. Figure 3 5: Claims Status: View Claim Proprietary and Confidential Molina Medicaid Solutions Page 14 of 17

20 3.1 Provider Payment Search To search for a particular payment click the Search icon above the Payments area on the right side. Refer to Figure 3 6. Enter the data into any of the fields for the search and then click Search. Note: You can enter a date range (format: MM/DD/YYYY) and a dollar range. To clear all the data entered, click RESET. Click CLOSE to close the search screen. Figure 3 6: Provider Payment Search Proprietary and Confidential Molina Medicaid Solutions Page 15 of 17

21 Appendix A Acronyms and Abbreviations Acronym Definition ARRA American Recovery and Reinvestment Act (2009) CFR Code of Federal Regulations CIP Claims in Process ERA Electronic Remittance Advice HIPAA Health Insurance Portability and Accountability Act of 1996 ID Identifier/Identification MMIS Medicaid Management Information System PDF Portable Document Format PHI Protected Health Information RA Remittance Advice TPL Third Party Liability Proprietary and Confidential Molina Medicaid Solutions Page 16 of 17

22 End of Documentation Proprietary and Confidential Molina Medicaid Solutions Page 17 of 17