KanCare All MCO Training FQHC s & RHC s Spring 2018

Transcription

1 KanCare All MCO Training FQHC s & RHC s Spring 2018

2 Welcome Introductions Welcome, Introductions & Agenda Agenda Encounter Rates Place of Service (POS) Secondary Claims Credentialing Issues How to avoid them IUD Billing Top Denials Per MCO 2

3 Encounter Rates Visit or Encounter A covered Rural Health Center (RHC) or Federally Qualified Health Center (FQHC) visit means a face-to-face encounter between a clinic/center patient and a clinic/center health care professional or practitioner during which a covered RHC/FQHC service or dental service is rendered: Physician Physician assistant (PA) Advanced registered nurse practitioner (ARNP) Nurse midwife Clinical psychologist Clinical social worker Registered nurse (RN), for KBH nursing screen only, bill with modifier TD Visiting nurse (if the conditions listed under visiting nurse services are fulfilled) Dentist (for FQHCs only) Registered dental hygienist, extended care permit (FQHCs only) 3

4 Place of Service Criteria Services at the Clinic or Center If covered services are furnished by a clinic/center practitioner at the facility, they are payable only to the clinic/center and should not be billed under any other Medicaid provider number. RHCs and FQHCs are required to use the following POS codes 72 (RHC), 50 FQHC non-dental), and 99 (FQHC dental only). Services that are considered non-rhc and non-fqhc, such as the technical components of radiology, electrocardiogram (EKG), and clinical diagnostic lab services, must be billed as they are currently being billed (using POS code 11). Source: 4

5 Place of Service Criteria Services Away from the Clinic or Center If the service is furnished at a location other than the facility (such as the patient s place of residence, the scene of an accident), the coverage as an RHC/FQHC encounter depends on whether there is an agreement that the clinic/center would compensate the practitioner for furnishing services in a location away from the clinic/center. The following criteria apply for billing for these services: Practitioner Agreement: The service is covered as an RHC/FQHC visit and should only be billed under the RHC/FQHC provider number. It may not be billed under any other Medicaid provider number. No Practitioner Agreement: The service is not covered as an RHC/FQHC visit. It can be billed under the performing provider s individual Medicaid provider number. Dental services can be provided in an existing dental office away from the center. The FQHC must have a contractual arrangement with the dental office for space, services, supplies, etc. If the RHC or FQHC services are in a setting outside of the clinic, the appropriate POS code must be used. For example, if an RHC or FQHC service is provided in a skilled nursing facility (SNF), POS code 31 is applicable. If an RHC or FQHC service is provided in the home, POS code 12 is applicable. 5 Source:

6 Place of Service Criteria FQHC Dental Services It should be understood (held out to the public) that the services provided are being provided by the FQHC. These services provided by the FQHC are billed as an encounter. All encounters provided by the RDH ECP professionals while employed/contracted with the FQHC, whether provided to Medicaid, uninsured, or another payer type, are FQHC encounters and must be reported by the FQHC in the total FQHC encounters for the cost report. Dental professionals who provide services away from the center must have a contractual arrangement in place with the FQHC. Source: 6

7 Place of Service Criteria Services in a Hospital Services provided by a clinic/center practitioner in an outpatient, inpatient, or emergency room of a hospital or in a swing-bed do not constitute covered RHC or FQHC services under KMAP. These services may be billed under the performing provider s individual Medicaid provider number. Note: If these services are rendered during a timeframe for which the practitioner is compensated by the RHC/FQHC for providing services at the clinic/center, all expenditures associated with these services must be carved out on the RHC/FQHC cost report. Source: 7

8 Secondary Claims KanCare MCOs are required to follow the same pricing logic when pricing and paying claims as the secondary payor. FQHCs/RHCs/Indian Health Centers Paid up to the state determined encounter rate so that amount is always the allowed amount for the claim MCOs are required to deduct the primary carrier payment from the state set encounter rate and pay the remaining balance 8

9 KMAP Provider Enrollment and MCO Credentialing Recent Changes: January Effective 1/1/2018 all new provider enrollments and re-credentialed providers must enroll with KMAP in order to be enrolled/credentialed with an MCO Upcoming Changes: December 2018 All providers in one of the MCO networks must have an active KMAP Provider ID # in order to remain in the MCO network If a provider is in an MCO Network and does not have an active KMAP Provider #, it is strongly recommended that providers submit an enrollment application to KMAP as quickly as possible to ensure compliance well before the due date: Please note that providers must continue to send their credentialing information to the MCOs, even though the enrollment process is changing. The new KanCare enrollment process only applies to the Medicaid product. Providers enrolled with other insurance products, such as Medicare or the Marketplace, will still need to submit provider and practitioner demographic changes directly to the payor contracted. 9

10 Do: Forms Recredentialing Issues How to avoid them Use up to date forms ( See slide 30 for links) Complete all fields on forms (i.e. mark either Primary Care Physician (PCP) or Specialist and answer Clinical Laboratory Improvement Amendments CLIA) Verify that the Uniform Credentialing Form is completed Be Clear! Include with written correspondence a cover letter that outlines your request. Include all Tax IDs (TINs) and National Provider Identifiers (NPIs) Include all required documentation such as: If CLIA Certificate is required, include a copy of the certificate Verify that CAQH (Counsel for Affordable Quality Healthcare) Data Form is completed Include a copy of the Certificate of Insurance If practitioner is being added to a group not associated with a hospital, a Disclosure of Ownership is needed for each practitioner **This information is based off of the enrollment process for

11 Recredentialing Issues How to avoid them Con t Don t: Send an without the required forms. We must have CAQH Data Form or roster for enrollment. And, we must have Provider Change Form or Roster for changes. Assume that we know what you want please be specific. List more than one NPI on the CAQH Data Form. Separate CAQH Data Forms are needed for each practitioner and each NPI being enrolled. **This information is based off of the current enrollment process for

12 Intrauterine Device (IUD) Billing Effective with dates of service on and after 02/27/2018, long acting reversible contraceptives (LARCs), both IUDs and implants, are no longer included in the Prospective Payment Systems (PPS) rate. An RHC/FQHC will bill the Medicaid Fiscal Agent or the MCO for MCO enrolled members and be reimbursed on a fee-for-service basis. The LARC must be billed using the individual Medicaid provider number rather than the RHC/FQHC number. RHC/FQHC will be reimbursed their encounter rate for insertion of the LARC and an amount for the pharmaceutical device. Insertion should be billed using the RHC/FQHC provider number. Place of service code 11 (office) should be used when billing for the LARC. 12

13 13 TOP DENIALS

14 Amerigroup Disallow; not allowed under contract. Common language: The service being billed on this claim and/or line item is not a covered service for this specific provider, service is non-covered for the member, or service is a non-covered service per the state of Kansas for all members and providers. Denial codes: CO 256: Service not payable per managed care contract. CO 204/N130: This service/equipment/drug is not covered under the patient s current benefit plan Primary causes for this type of RHC/FQHC claim denial: This most often applies to procedure codes that are not covered in the RHC or FQHC place of service (Cat II CPT codes; some lab codes; venipuncture; etc.) 14

15 Amerigroup Primary payer information required Common Language: Member has other insurance that is primary to Medicaid, the primary explanation of benefits was not submitted Denial code(s): CO 252: An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code, or Remittance Advice Remark Code that is not an ALERT). Primary causes for this type of RHC/FQHC claim denial: If a provider does not have other insurance on file for the member, check the appropriate MCO Website for member s other insurance information If a provider feels the primary/secondary payer information on file for the member is outdated or invalid, contact the MCO Provider Services Call Center to request a COB/TPL validation If a provider believes they submitted the required primary/secondary payer information with the original claim and it was not considered, submit a claims reconsideration or formal appeal 15

16 Amerigroup Expenses incurred after coverage terminated. Common language: The member is not showing as an active member for the MCO billed on the date of service billed Denial code(s): CO 27: Expenses incurred after coverage. Primary causes for this type of RHC/FQHC claim denial: Check member eligibility for the date of service on the claim and ensure they were active. Check member MCO assignment and ensure claim was submitted to the correct MCO 16

17 Amerigroup Procedure code inconsistent with place of service. Common language: The place of service on the claim is not valid for the procedure code or provider per state or federal regulations Denial code(s): CO5/M77: The procedure code/bill type is inconsistent with the place of service. Primary causes for this type of RHC/FQHC claim denial: Claims billed with ER or inpatient codes and using POS 50 or 72 instead of the ER or hospital POS Nursing facility E&M codes, observation, hospital E&M codes cannot be billed in POS 50 or 72. Although the encounter rate for billing a NF E&M code is approved, it must be for the correct POS for NF 17

18 Amerigroup NDC, UOM, or Quantity missing or invalid Common language: A drug related procedure code was billed on the claim and the NDC or other required items were not submitted Denial code(s): CO16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. M123: Missing/incomplete/invalid name, strength, or dosage of the drug furnished. Primary causes for this type of RHC/FQHC claim denial: Missing NDC. Providers who bill for drugs related to HCPC or CPT codes are required to submit NDC codes (340B providers are excluded) 18

19 Sunflower Health Plan EX GX - DENY ENCOUNTER CODE REQUIRED AND MUST BE BILLED W/ PAYABLE DETAIL LINES Common language: The claim billed is missing a procedure code or an invalid procedure code was in use Denial code(s): A1 Claim Service Denied, see Remark Code M51 Missing/Incomplete/Invalid procedure Code Primary causes for this type of RHC/FQHC claim denial: Billing a service that is not RHC/FQHC encounter service 19

20 Sunflower Health Plan EX L6 - DENY: BILL PRIMARY INSURER 1ST RESUBMIT WITH EOB Common language: Member has other insurance that is primary to Medicaid, bill the primary insurer first and resubmit with explanation of benefits Denial code(s): Claim Adjustment Reason Code (CARC): 252 An attachment/other documentation is required to adjudicate this claim/service Remittance Advice Remark Code (CARC): N479 Missing Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer) Primary causes for this type of RHC/FQHC claim denial: Original claim was submitted without primary/secondary payer information EOB not submitted or submitted incorrectly 20

21 Sunflower Health Plan EX 29 DENY: THE TIME LIMIT FOR FILING A CLAIM HAS EXPIRED Common language: The claim was submitted more than 180 days after the date of service. Or a reconsideration was submitted outside of the timely filing guidelines. Denial code(s): Claim Adjustment Reason Code (CARC): 29 The time limit for filing has expired Remittance Advice Remark Code (CARC): N30 Missing/incomplete/invalid assessment date Primary causes for this type of RHC/FQHC claim denial: Timely filing is 180 days from the date of service unless otherwise specified in your contract. Timely filing when the member has other insurance is 180 days from the primary payer s EOB (Explanation of Benefit) 21

22 Sunflower Health Plan EX 18 - DENY: DUPLICATE CLAIM SERVICE Common language: The claim or service billed is a duplicate to a claim already on file Denial code(s): Claim Adjustment Reason Code (CARC): 18 Exact duplicate claim/service Remittance Advice Remark Code (CARC): N522 Duplicate of a claim processed, or to be processed, as a crossover claim Primary causes for this type of RHC/FQHC claim denial: Please allow 30 days for claims to process (this is the State requirement for the MCOs) 22

23 Sunflower Health Plan EX An - DENY: ADMIN CODE AND VACCINE MUST BE SUBMITTED TOGETHER Common language: A vaccination code was billed on the claim without the administration code. Denial code(s): Claim Adjustment Reason Code (CARC): A1 Claim Service Denied, see Remark Code Remittance Advice Remark Code (CARC): N349 The administration method and drug must be reported to adjudicate this service Primary causes for this type of RHC/FQHC claim denial: Vaccines must be billed with the appropriate administration code and the vaccine detail code As a reminder, if the member visits the facility only for a vaccination, that is not eligible as a valid encounter 23

24 United HealthCare Claim or claim line is denied for non-covered Common language: The service being billed on this claim and/or line item is not a covered service for this specific provider, service is non-covered for the member, or service is a non-covered service per the state of Kansas for all members and providers Denial code(s): CO 96: Non-covered charge Primary causes for this type of RHC/FQHC claim denial: Vaccine and Vaccine administration codes Use of non-covered codes 24

25 United HealthCare Claim or claim line denied or zero paid because the service being billed is considered included in the payment of another service provided on the same date of service Common language: Payment for this services was included or bundled into another service provided on this date Denial code(s): CO 97: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated Primary causes for this type of RHC/FQHC claim denial: Encounter payment made on another line item Codes being billed are bundled or inclusive per National Correct Coding Initiative NCCI) Service being billed is included in a Global OB code billed 25

26 United HealthCare Claim or claim line denied for missing required documentation Common language: Required information or documentation is missing Denial code(s): CO 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication Primary causes for this type of RHC/FQHC claim denial: Vaccine Administration code billed without a vaccine serum code Billing address submitted on the claim does not match billing address on the provider file Principal diagnosis code billed is not valid NDC code not billed, when required, for a drug related code 26

27 United HealthCare Claim or claim line denied for invalid Place of Service (POS) Common language: The place of service on the claim is not valid for the procedure code or provider per state or federal regulations Denial code(s): CO-58: Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service Primary causes for this type of RHC/FQHC claim denial: This denial occurs when the services provided are billed in a non-allowed POS for an RHC/FQHC provider or the code billed is not allowed in the billed POS 27

28 United HealthCare Claim or claim line denied because member has other insurance (Medicare or other commercial plan) responsible for payment prior to Medicaid consideration of payment Common language: Member has other insurance that is primary to Medicaid, the primary explanation of benefits was not submitted Denial code(s): PI 252: An attachment/other documentation is required to adjudicate this claim/service Primary causes for this type of RHC/FQHC claim denial: This denial will occur when our files indicate the member has other insurance primary to Medicaid and primary insurance payment or denial information was not provided 28

29 KANSAS MEDICAID OPIOID UPDATES 29

30 Kansas Medicaid Opioid Products Indicated for Pain Management PA Effective (tentatively 06/01/2018) Criteria will apply to all patients covered under Kansas Medicaid. Information on the Kansas Medicaid Opioid Products Indicated for Pain Management PA is available on the following links: PA Criteria PA Form _pa_forms.htm

31 Kansas Medicaid Opioid Products Indicated for Pain Management PA Short-Term/Acute Pain Opioid User (patients who have received opioid prescription(s) for < 90 days in a look back period of 4 months): Limit of 7 day supply of short acting opioid (e.g. immediate release formulation). Up to 14 day supply is allowed within a 60 day look back period. Must be no more than 7 day supply per prescription. Daily limit of 90 MME (morphine milligram equivalent). PA required for All long-acting opioid prescriptions (e.g. extended release formulations). Any short-acting opioid prescriptions exceeding the short-term/acute pain use day supply or 90 MME limits.

32 Kansas Medicaid Opioid Products Indicated for Pain Management PA Chronic Opioid User (patients who have received opioid prescription(s) for 90 day in a look back period of 4 months): Prior Authorization required (for any duration) Patients with cancer, sickle cell, or hospice/palliative care diagnosis in paid medical claims will be EXEMPT from the 7 day supply and MME limits and long-acting PA edit. Buprenorphine products for opioid dependence (e.g. Suboxone) are NOT affected by this policy.

33 33 QUESTIONS?

34 Helpful Links KMAP Forms: Amerigroup RealSolutions Provider Resources: Sunflower Health Plan Provider Resources: United HealthCare Provider Resources: 34