Life of a Claim. HP Provider Relations/August 2014

Transcription

1 Life of a Claim HP Provider Relations/August 2014

2 Agenda General requirements for reimbursement by the Indiana Health Coverage Programs (IHCP) System edits System audits Pricing methodologies Suspended claims Claim adjustments Remittance Advice Helpful tools Questions 2

3 Session Objectives Upon completion of this session, providers will be able to: Understand how claims are processed and reimbursed Identify when a prior authorization is required Distinguish between system edits and audits Understand pricing methodologies Understand the roles of the Resolutions Unit Discover how to obtain the weekly Remittance Advice 3

4 General Requirements

5 Life of a Claim Member receives services Provider submits claim to the IHCP HP receives claim Claim processed by IndianaAIM Claim adjudicated Remittance Advice generated Before rendering services, provider must verify member s eligibility and, if applicable, obtain prior authorization. If applicable, provider must first submit claim to member s private insurance or Medicare. After the claim has been adjudicated (paid or denied) by these entities, the provider can submit claim to the IHCP. IHCP claims are identified, tracked, and controlled using a unique 13-digit internal control number (ICN) assigned to each claim by IndianaAIM (IHCP computer system) Based on claim type, provider type, and member eligibility, IndianaAIM subjects the claim to system edits, NCCI editing, system audits, and appropriate pricing methodology. When adjudicated, the claim can be paid, denied, or suspended. Providers can access their weekly Remittance Advices (RAs) through Web interchange. If claim status is paid, appropriate reimbursement is sent to the provider. 5

6 Internal Control Number (ICN) IHCP claims are identified and tracked using a unique 13-digit control number Identifies when claim was received, claim submission media, and claim type Example: Region code (submission source) 14 Calendar year 183 Julian date (183 = July 1) 289 Batch range/claim type ( = Home Health) 999 Specific claim number 6

7 ICN Region Codes (First Two Digits of ICN) 10 Paper claim without attachments 11 Paper claim with attachments 20 Electronic claim without attachments 21 Electronic claim with attachments 23 Electronic crossover claim submitted on Web interchange 50 Adjustments noncheck-related 51 Adjustments check-related 56 Mass adjustments 61 Provider replacement with attachment or claim note 62 Provider replacement without attachment or claim note 63 Provider void 80 Claim reprocessed by HP 90 Special projects 7

8 Prior Authorization (PA) According to IHCP regulations, providers must request PA for certain services: To determine medical necessity When normal limits are exhausted for certain services The main purpose of the PA process is to ensure that IHCP funding is utilized only for services that are: Medically necessary Appropriate Cost-effective PA Department Appr oved Note: PA is not a guarantee of payment 8

9 Services Rendered to IHCP Members To be reimbursed by the IHCP, the service provided must be covered by the IHCP When a PA is required, the PA must be requested and approved before the service is rendered Prior authorizations can be approved retroactively in some cases (see IHCP Provider Manual, Chapter 6) A provider can verify if a service is covered by the IHCP and whether it requires PA by referring to the Fee Schedule at indianamedicaid.com. 9

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11 Fee Schedule Search by procedure code 11

12 Fee Schedule Program Coverage and PA 12

13 Fee Schedule Program Coverage and PA 13

14 Claim Is Processed by IndianaAIM PA verification IndianaAIM reviews every procedure-coded claim to determine when a procedure code requires PA Based on the PA indicator on the IHCP Fee Schedule Claims from providers located out of state also require PA For dually eligible members, services that are covered by Medicare do not require prior authorization Note: The PA belongs to the member, not to the provider 14

15 Prior Authorization Program/Services Administered By Contact Information Traditional Medicaid and Carved-out Nonpharmacy Services ADVANTAGE Health Solutions SM Fax Care Select ADVANTAGE Health Solutions SM MDwise (ADVANTAGE Health Solutions issues p.a. even if MDWise is the CMO) Fax Fax Hoosier Healthwise - Risk Based Managed Care Managed Health Services (MHS) Anthem MDwise Fax Fax (317) or Fax - see Pharmacy Services (All Programs) Catamaran Fax

16 System Edits

17 Claim Is Processed by IndianaAIM System edits As part of processing a claim, IndianaAIM performs edits to verify that the required fields are completed and that the information included in these fields is valid Claim data is validated against other IndianaAIM databases, such as the member, provider, and reference files Those claims that do not pass the edits are denied or suspended for further review, depending on the specific edit that failed 17 Edits... Ø Verify and validate claim data Ø Check the information entered (or missing) in specific fields of the claim Ø Ensure that the information submitted by the provider is valid and in the correct format Ø Are not intended to exclude services

18 Claim Is Processed by IndianaAIM Example of system edits Edit Code Provider Signature Missing 0264 The Date of Service is Missing 0340 Revenue Code is Invalid Description 0507 The From Date is After the To Date 0545 Claim Past Filing Limit 0513 Recipient Name and Number Disagree 0231 Rendering Provider Number Missing 1010 Rendering Provider Not a Member of the Billing Group 1025 Billing Provider Not Enrolled for the Date of Service 3001 Dates of Service Not on PA Master File

19 Claim Is Processed by IndianaAIM National Correct Coding Initiative (NCCI) edits CMS-1500 claims: Claims that pass header level edits are sent to McKesson to apply NCCI editing Claims that do not pass header level edits are not sent to McKesson for NCCI editing UB-04 outpatient claims: All outpatient claims are sent to McKesson to apply NCCI editing Header level edits are those applied to basic data in the heading of the claim, such as NPI, recipient name, recipient ID number, patient account number, rendering provider number, and so on 19

20 Requirements Common to All Claim Types Name of provider Services rendered (CPT or Revenue Code) Quantity/units Provider s ID (NPI/LPI) Date of service Amount billed Name of member Member s Medicaid ID (RID)

21 System Audits

22 Claim Is Processed by IndianaAIM System audits All programs under the IHCP have certain service limitations The extent of these limitations is determined by the aid categories and defined by state and federal regulations These regulations are usually referred to as the IHCP medical policy The Family and Social Services Administration (FSSA) is responsible for establishing medical policy guidelines 22

23 Claim Is Processed by IndianaAIM System audits IHCP medical policies are monitored and enforced by the auditing process Audits: Compare current claims for a specific member against all other services on the claim history file that were rendered, billed, and finalized for that member Ensure that providers do not perform excessive or unnecessary services without medical justification Ensure that state and federal regulations regarding the frequency, extent, length of stay, and cost of service are followed Audits are designed to monitor or regulate the IHCP medical policy. 23

24 Claim Is Processed by IndianaAIM System audits Similar to system edits, if the claim fails any of the system audits, the claim may be: Systematically denied Systematically cut back to reduce the number of dollars paid on the claim, or Suspended Ø Depending on the specific audit failed by the claim DEN IED SUSPEN DED CUTBACK 24

25 Claim Is Processed by IndianaAIM Example of system audits Audit Code Description 6288 PET Scan Imaging Limited to Specific Diagnosis Codes 6060 Speech Evaluation Limited to 1 Every 12 Months 6651 Additional Surgical Procedures Payable at 50% 6113 DME Limited to $2,000 Per Recipient Per Calendar Year 6235 Prophylaxis for Age 21 and Over Limited to 1 Every 12 Months 6298 Routine Vision Exam Limited to 1 per 24 Months for 21 and older 6900 Psychiatric Services in Excess of 20 per Rolling Year Require PA 25

26 Remittance Advice: EOBS, ARCS and REMARKS What do all these codes mean? 26

27 Remittance Advice: EOBS, ARCS, and REMARKS System edits and audits are EOB codes and tell why a claim or line item denied EOB 0558 Coinsurance and deductible amount missing, indicating this is not a crossover claim ARCS and REMARKS are required HIPAA-compliant codes but are general in nature and therefore, may not be beneficial when analyzing a claim or line item ARC 16 Claim lacks information needed for adjudication REMARKS MA92 Missing plan information for other insurance REMARKS N45 Payment based on authorized amount Some EOB codes are informational post-and-pay codes, but do not tell why a claim or line item denied EOB 9000 The submitted charge exceeds the allowed charge 27

28 Pricing Methodologies

29 Claim Is Processed by IndianaAIM Pricing methodology After claims have passed the system edits and audits, they are subjected to pricing review As part of this review, IndianaAIM determines whether or not the claim can be automatically priced or needs to be suspended for manual pricing This determination is based on: Claim type Procedure-specific pricing indicator Provider specialty Date of service 29

30 Claim Is Processed by IndianaAIM Pricing methodology The claim pricing process calculates the IHCPallowed amount for claims based on claim type, pricing modifiers, and defined pricing methodologies Based on the claim type, IndianaAIM directs the claim to the appropriate pricing methodology If a third-party liability (TPL) amount is present, IndianaAIM subtracts this figure, plus applicable copays and patient liability, from the IHCP-allowed amount to get the amount paid 30

31 Claim Is Processed by IndianaAIM Example of pricing methodologies 31 Pricing Methodology Diagnosis-Related Grouping (DRG) Procedure Code Max Fee or Revenue Code Flat Rate Resource-Based Relative Value Scale (RBRVS) Overhead Cost Rate/Staffing Cost Rate Max Fee Lab Fee Manual Pricing Level of Care (LOC) Applied to. Inpatient Services Outpatient Services Physician Medical Services Home Health Services Dental Lab Services Durable Medical Equipment Services LTC, IP Psychiatric, Burn, Rehab

32 Suspended Claims

33 Claim Is Adjudicated Suspended claims Role of the HP Resolutions Unit The HP Resolutions Unit examines suspended claims and makes a decision based on approved adjudication guidelines for the date of service The approved guidelines indicate the course of action that must be taken for each edit and audit These guidelines are based on the medical policies established by the FSSA 33

34 Claim Is Adjudicated Suspended claims Role of the HP Resolutions Unit Resolutions Unit team members have the following options when processing suspended claims, depending on the edit or audit failed: Add or change data (used only when the claim suspended due to data-entry errors by HP) Force the claim to process by overriding the edit or audit (some edits and audits cannot be overridden; for example,1012 Rendering provider specialty not eligible to render this procedure code) Deny the claim Put the claim on hold (used when there is a system problem or a pending policy decision) 34

35 Claim Is Adjudicated Suspended claims Medical policy Claims requiring medical policy review are placed in a suspended status by IndianaAIM, and automatically routed to ADVANTAGE SM Health Solutions or MDWise IndianaAIM enters the suspended ICNs into a scheduler for automatic routing If the member is assigned to a care management organization (CMO), the ICN is routed appropriately: ADVANTAGE Health Solutions for its Care Select members MDwise for its Care Select members 35

36 Claim Is Adjudicated Suspended claims Medical policy A designated staff member reviews the scheduler and reassigns the suspended ICNs to additional staff members for resolution Each ICN is processed according to the approved guidelines for the specific audit Based on the guidelines, the audit will be forced to a paid status, or the audit will fail (deny) Medical records are not requested from the provider during this process Medical documentation submitted with the claim, however, is reviewed by ADVANTAGE Health Solutions or MDWise Suspended ICNs should be completed within 30 days 36

37 Claim Adjustments

38 Claim Adjustments An adjustment is defined as a request to change historical data or reimbursement for a claim Adjustments are necessary when there has been an overpayment or underpayment to the provider If a net overpayment is determined, IndianaAIM establishes an accounts receivable (A/R) and recoups the overpayment If an underpayment is determined, the provider is reimbursed the net difference in the current week s payment amount Voids and replacements related to claims in any known or ongoing audit (once the provider has been made aware of the audit) are handled as directed by the FSSA Program Integrity Department 38

39 Claim Adjustments Electronic Voids and Replacements Voids Is the Health Insurance Portability and Accountability Act (HIPAA)-approved term used to describe the deletion or cancellation of an entire claim Can be completed on the same day or in the same week that the original claim was submitted, or after the original claim payment is finalized (after an RA has been created) Can be performed on paid claims only; cannot be performed on a claim in a denied status Can be performed for a previously submitted electronic claim or paper claim VOID CLAIM VOID CLAIM 39

40 Claim Adjustments Electronic Voids and Replacements Voids When a claim is voided, PA units are added back to the balance of units originally authorized Providers can view the updated balance in Web interchange using the PA Inquiry function VOID CLAIM VOID CLAIM 40

41 Claim Adjustments Electronic Voids and Replacements Replacements Is the HIPAA-approved term used to describe the correction of a claim that has already been submitted Can be completed on the same day or in the same week that the original claim was submitted, as well as after the payment is finalized Ø Do not replace claims more than one year after the date of service Can be performed on claims in paid, suspended, or denied status Can be submitted only for noncheck-related adjustments Check-related adjustments must be submitted on paper Paper adjustment form instructions are available in the IHCP Provider Manual, Chapter 11, Section 3 41

42 Paperless Remittance Advice

43 Paperless Remittance Advice (R/A) Each week, a listing of all submitted claims displays on the RA The RA sorts the claim information according to claim type and status (paid, denied, and in process) Access the Check/RA Inquiry feature of Web interchange to view and print the RA The RA is available via Web interchange for a rolling four weeks The RA for the fifth week prior to the current week will not be displayed on Web interchange The rolling four weeks include RAs for each service location 43

44 Paperless Remittance Advice 44

45 Find Help

46 Helpful Tools IHCP website at indianamedicaid.com IHCP Provider Manual Electronic Solutions Service Desk (toll-free) Customer Assistance (toll-free) Provider Relations field consultant provider.indianamedicaid.com/contactus/provider-relations-field-consultants.aspx Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN

47 Q&A