Managed Health Services

Transcription

1 Managed Health Services

2 Managed Health Services DME Policy Before an item can be considered to be durable medical equipment It must be able to withstand repeated use It must be primarily and customarily used to serve a medical purpose It is generally not useful to a person in the absence of an illness or injury It is appropriate for use in the home

3 DME Policy Items including, but not limited to, the following are examples of DME: Hospital beds Wheelchairs Canes Walkers Raised toilet seat Oxygen systems Ventilators Nebulizers Neuromuscular Stimulators Bone growth Stimulators Infusion Pump CPAP/BIPAP Phototherapy (Bilirubin) light with photometer Wound Vacs

4 DME Policy DME items with a purchase price below $ do not require an MHS authorization. Orthotics and prosthetics items with a purchase price below $ do not require an MHS authorization.

5 DME Policy All DME items, regardless of purchase price, must be medically necessary as defined by: 405 IAC Medically reasonable and necessary service : Authority: IC ; IC ; IC ; IC

6 DME Policy For all DME requiring authorization, that authorization process must be completed prior to dispensing the items, with the following exceptions: DME item necessary as part of discharge planning from the hospital DME item necessary as part of the treatment plan for an urgent / emergent medical condition DME item previously authorized by another MCO as a component of continuity of care during the 1 st 30 days of transition

7 DME Policy DME authorization decisions by MHS are based on medical necessity. The MHS Prior-Authorization form should accompany all clinical information submitted as part of the prior-authorization request. Authorization duration is based on medical necessity, anticipated outcomes, compliance with utilization, benefit limitations, and alternative treatment options available to meet the medical need of the member. Authorization requests to extend an existing authorization are required to be submitted prior to the expiration date of the current authorization. Authorization numbers and units are provided for approved DME items.

8 DME Policy Prior-authorization for DME items may be initiated by contacting MHS: Via facsimile: Via US mail: Managed Health Services Attn: Medical Management 1099 N. Meridian St., Suite 400 Indianapolis, IN 46204

9 Managed Health Services CLAIMS

10 Provider Inquiry Services Call us at We are ready to help you! Knowledgeable, friendly staff available 8:00-6:00 EST Focused commitment to professional service Claims address P.O. Box 3002 Farmington, MO Dispute & appeal processes (60 days from receipt of EOP) Appeal address P.O. Box 3000 Farmington, MO Filing limits dependant upon contract status Follow IHCP requirements

11 Claims Submission Submit electronically (preferred) for fastest response. Providers should check electronic submission report daily to ensure claims were received by MHS. Filing timelines 120 days from DOS for Participating Providers Exceptions: Newborn, Third Party Liability, and Eligibility delays (filing limit 365 days) 365 days from DOS for Non Participating Providers

12 Billing MHS with Ease Helpful suggestions to prevent delay in payment are provided so that MHS can provide speedy payment. Beginning November 1 st, MHS will no longer be accepting old claim forms. Verify other insurance (TPL). Medicaid is the payer of last resort. MHS does require a copy of the primary EOP. Check eligibility at each visit prior to submitting claims to ensure that you are billing the correct carrier, as members may change MCOs often.

13 Billing MHS with Ease Please allow at least 30 to 45 days for claim adjustments to be made. PA requirements changed April 1, Please ensure that your staff is familiar, as retroactive authorizations are not provided. Utilization of our Web site will allow for the quickest service available. MHS will generate a Provider Watch Bulletin of helpful tips and Plan updates to billing office locations for all par providers on a quarterly basis. All providers can review this bulletin on the MHS Web site at

14 Resubmitted Claims If you need to resubmit a denied claim, the claim must be submitted on paper and should be clearly marked at the top with the word RESUBMISSION. Attach a MHS Claim Adjustment Form stating the reason for resubmission and include the EOP (if applicable) Resubmitted claims should be mailed to the address listed on the claim adjustment form and must be received within 60 days of the EOP date.

15 Adjusted Claims If you need to make an adjustment to a paid claim, you can do so by calling Provider Inquiry or you may submit on paper with the adjustment request form. Attach a Provider Adjustment Form along with documentation, including EOP (if available) explaining reason for resubmission Claim adjustments must be submitted within 60 days of the date of the MHS EOP.

16 Claim Dispute Resolution PROVIDERS HAVE 60 CALENDAR DAYS FROM THE DATE OF RECEIPT OF THE EOP TO FILE AN OFFICIAL DISPUTE OR APPEAL WITH MHS. Verbal Inquiries can be made by calling MHS Provider Inquiries at , option 3. *Note: A verbal inquiry is not considered a dispute or appeal and does not stop the 60 calendar days from the date of receipt of the EOP to file a dispute or appeal.

17 Third Party Liability If a member has TPL on file but no longer has other coverage or the member has other coverage but the information is not on file take the following steps: Contact Provider Inquiries with the TPL information so that changes can be made to the TPL file Send an update notification to EDS via the WebInterchange

18 Third Party Liability Claims will deny L6 if TPL is on file with MHS. What if I don t agree with MHS TPL indication: Call provider inquiries Resubmit paper claim with EOB attached Reminder: TPL claims must be submitted within 60 days of the date of the primary insurer s EOB.

19 Third Party Liability MHS updates member TPL information through: A monthly file from EDS Phone call from providers Receipt of an EOB with claim MHS always verifies new TPL.

20 National Provider Identifier MHS needs to obtain NPI numbers prior to January Please submit directly to MHS for entry into our claims payment system. Submit NPI via MHS Web site at This must be submitted even if you have already submitted to the State of Indiana or EDS.

21 National Provider Identifier MHS will process with NPI only, effective January 1, 2008, unless OMPP requires a later date. CURRENTLY: If you have reported your NPI to MHS and it is on file, you may bill with NPI only on both the CMS-1500 (field 24J top half) and the UB-04 (field 56), claims will process with NPI only. If your NPI is not on file and claims are submitted with NPI only, the claims will reject. You may continue to use you Indiana Medicaid Number until January In informational edit will be sent requesting you to report your NPI.

22 MHS Web site Enhanced Web site On-line Registration On-line Prior Authorizations Provider Directory Search Functionality Enhanced Claim Detail Code Auditing Software Tool Printable, Current Forms and Manual

23 MHS Web site Upcoming Enhancements Direct claim submission 4 th Quarter 2007 Claim resubmission 1 st Quarter 2008 Claims Xtend 4 th Quarter Transactions 4 th Quarter 2007

24 New Software Claims Xtend software replacing code edit MHS will begin utilizing a new code editing software. The software will continue to ensure that MHS is processing claims in compliance with accepted industry coding standards. It will replace our current Code Edit system. The current Web-based code audit reference tool will remain the same and is located at This tool helps explain how MHS evaluates different code combinations.

25 Questions and Answers