Kentucky Medicaid 2016 Spring Webinar Q&A s

Transcription

1 Kentucky Medicaid 2016 Spring Webinar Q&A s Passport stated they raised their fees for dental preventive procedures to match Medicaid s 25% increase. But, we have not seen an increase anywhere but Passport. Is there going to be an increase across the board? a- Please see the DMS website for any updates. For dental visits for members 21 and older, is the limitation of 12 visits per year listed as per calendar year? a- Yes. For dental visits for members 21 and older, is the limitation of 12 visits per year listed as per calendar year and per doctor? a- Limitation is per member. Same question but is this only pertaining to KY Medicaid or to the MCO s as well? (For dental visits for members 21 and older, is the limitation of 12 visits per year listed as per calendar year and per doctor?) a- Please contact the Department for Medicaid Services for this information. Same topic, will there be a provider letter sent out about this change? (For dental visits for members 21 and older, is the limitation of 12 visits per year listed as per calendar year and per doctor?) a- The Regulation is updated and can be viewed on the DMS website. We had a patient at our office who had regular Medicaid one day for a consult and the following day her insurance changed to Passport. a- Member eligibility updates nightly, check eligibility on the date of service. Do all the Medicaid MCO's also honor the regulations and instructions you mentioned in the webinars? a- Not necessarily. Check your contract with that particular MCO. On the new sterilization consent form, does it have an expiration date of 11/30/2015 at the top? a- New Sterilization consent form can be found in your Billing Instructions. The new form shows the expiration date as 12/31/2018. What happens if the MCO paid the claim twice and recouped the overpayment, resulting in the claim being recouped from KY Medicaid when it should not have been? How do we get our payment back from KY Medicaid for the Wrap? a- Please this question to the KY_Provider_Inquiry@hpe.com with the subject line Webinar Questions. 1

2 We have received several wrap payments for services such as nurse visits only (B-12 injections only, etc.). It is our understanding that we are only supposed to receive wrap payments for face to face visits with a provider. Do we need to refund this wrap payment or will KY Medicaid recoup these payments? a- Please this question to the KY_Provider_Inquiry@hpe.com with the subject line Webinar Questions. When an MCO pays in error, recoups the payment, and we file to Medicaid we are receiving a denial from Medicaid for duplicate because the MCO has not sent over the file showing they voided the claim. Do you have any suggestions on what to do in this situation when the claim is within timely filing limits? a- The MCO MUST void their paid claim with KY Medicaid. Please work with the MCO to void the claim, then you may bill KY Medicaid. When is the definite June 2016 date for State Plan to take effective for EPSDT special services? None of the MCO's have heard about this... a- The Department for Medicaid Services has sent letters to the waiver providers regarding these changes, the pages in the packet regarding these changes were taken from those letters. The member population this is changing for should not be enrolled in MCO's. Any possibility of future Medicaid plans to pay for Pulmonary Rehabilitation which includes therapy by registered respiratory therapist a- Please this question to the KY_Provider_Inquiry@hpe.com with the subject line Webinar Questions. Why does or would eligibility go back and forth between KY Medicaid and an MCO? a- Change in member eligibility is driven by information received from the local DCBS office database. Their system sends the data to KYHealth Net and the claims processing system. Is there a recorded version we can download? a- There is no recording of this webinar. When a Patient has Medicaid, and they fail to provide the information to us in a timely manner, and then come back and want us to bill for the services rendered, but Medicaid denies for timely. Can we then bill PR because the Patient failed to provide the accurate information in a timely manner to us? a- It is the provider s responsibility to check Member Eligibility status, you can use the KY HealthNet Member Eligibility Verification search using the member SSN. Why is member eligibility being such an issue? Examples: Newborn being added to mother's case is taking months to show eligible. Also some newborns may have Medicaid ID card but are not in Medicaid system at all no eligibility can be pulled. Some members have letters stating they are eligible and it is retro d but when I verify eligibility the system does not show this. a- The local offices system was changed and it has affected timelines for updates. 2

3 Did the bill type change for a PRTF? a- If the type of bill has changed, the Billing Instructions will state it. What if we know a patient no longer has primary coverage, as the family has told us and we pull up the insurance on line and it confirms the primary insurance termed. Can we use TPL form with copy of Primary insurance termed to get Medicaid to remove the primary insurance from their system? a- For a member covered by KY Medicaid, the TPL Lead form can be sent with the screenshot of the TPL website showing the termination date of coverage for the member. Please attach this to the claim as well. A patient had been in an MCO since 2011, now he/she is showing as Traditional back to If claims are voided and paid back to the MCO and submitted to Traditional Medicaid how will home health agencies obtain prior authorization for the member so the claim will not deny for no PA? a- Any PA granted by the MCO will be honored when the member is retroactively changed to KY Medicaid coverage. Why are the RAs by NPIs and checks/efts have provider number? Can it be consistent and have one form of identification? a- Both have the Provider ID on the documents. When will KY Medicaid accept access via Google Chrome; e.g. as is allowed by WV Medicaid and BCBS now? a- No change at this time but if future changes are made we will notify everyone using the message boards. Since Kentucky Medicaid pays for afterhours services, code 99050, shouldn't all the MCO's? a- Not necessarily, check your Provider Contract with the MCO for any nuances you have agreed to during credentialing. We have a Client whose last name was legally changed by the courts. We sent in the necessary documentation over 2 months ago but her name has not been changed in KY Health Net. What do we need to do to make this change happen? a- Contact the local DCBS office. KY Health net reflects the information from Medicaid files. Sometimes Medicaid shows patient has primary insurance but the MCO does not and in fact the patient does not have primary insurance. Do we still have to show a denial from primary if we are filing to the MCO only? a- Follow the instructions given to you by the MCO regarding their claims processing directions. How does the patient go about having a TPL removed from KY Medicaid? We have several TPL's that are listed that are not active. a- The member can find the phone number in their Member Services Handbook. 3

4 How do we get incarceration date updated? a- Contact the local DCBS office or can be corrected on KYNECT. If Medicare doesn't show a member as having Medicaid and not crossing over claims, how can they get Medicare to update to show the member as having Medicaid so the claims will cross over? a- The member can contact Medicare but there are some situations where the member may be covered under a spouse that will not load. Sometimes the eligibility screen shows MCO coverage but doesn't list which plan. Can you explain why the plan is not listed? a- On the member eligibility verification screen where it tells you which benefit plan the member has, you must scroll down and look under the Manage Care information subject to view which MCO the member is in. When we submit an electronic 2ndry claim to Medicaid and a Medicare MCO is primary the claim always rejects stating to bill Medicare. We have to submit a printed paper claim with the MCO Medicare EOB before Medicaid will actually pay the claim. We don't have this issue when the primary payer is Traditional Medicare (only when the primary payer is a Medicare MCO). Can you explain why these 2ndry claims need to be submitted as paper claims? a- The Medicare Member ID sent on the 837 does not match what the Medicare system has sent as the Medicare ID. These claims can be sent electronically by using KYHealth Net or by paper. When we submit swing bed claims the claims will deny for available income information not on file. We usually contact member services and she helps us get these accounts updated but it usually takes 5 or 6 months. Is there anything we can do on our end to speed up these issues? a- Patient liability is placed on a members file via the MAP 552 which is managed by the DCBS office. If the members patient liability is not showing on file you will need to contact the DCBS call center. Their system sends the data to the claims processing system. We have patients that are admitted under Medicaid MCO's because at the time of admission their Medicaid eligibility showed MCO coverage but later the coverage is retro-actively switched to traditional Medicaid. We are not aware of this issue until the Medicaid MCO recoups their payment. Then when we bill traditional Medicaid the claim denies for duplicate (even though the MCO has recouped their payment) because the MCO did not void their claim (837). We attempt to request that the MCO void their claim but receive no response. These MCO claims will eventually cause the traditional claim to become timely. Is there another way to insist that the MCO voids their claims in a timely fashion? a- The MCO claim must be voided in KY Medicaid s system before the claim can be successfully submitted to KY Medicaid. If repeated conversations happen with the MCO about voiding the paid claim but without success, please contact the MCO Oversight Branch of the Department for Medicaid Services at

5 When is the providers out of state (rendering, ordering, and referring) on the UB going to have to be enrolled? Do we have a date? a- There is no date as of this time. Please watch for future letters and notification by the Department for Medicaid Services. Where can I get a list of the Type of Bills? I am with a NF and currently use the TOB starting with 89 but will need to change to 21; but I do not know which to use for the third digit. Example 894 is used for Final Bills. What is the third digit when using 21? Is the third digit end with 4 as in the 89 TOB? a- The new TOB are in the billing Instructions on kymmis.com What are the new extensions for the HPE Representatives? a- The phone number is Kelly Gregory s extension is , Vicky Hicks s is Who manages providers not located in the state of Kentucky? a- The rep whose counties are closest to that border. What about those of us who updated to Windows 10 that no longer supports Explorer? It comes with something called Edge. a- There is an option in EDGE that will allow you to use Internet Explorer. Contact Vicky by or the EDI Helpdesk at for assistance. Are they looking at any solutions for Medicare crossovers? Right now Medicare crosses over and then it is denied because the taxonomy is not listed. Then they have to be rebilled. a- The solution is to place the taxonomy on the Medicare claim so that it is on the crossover when we receive the claim. Why is Kentucky Medicaid the only Medicaid payer that requires the ZZ qualifier and taxonomy codes on the CMS 1500? a- KY Medicaid allows the use of one NPI to be attached to multiple provider ID's. To uniquely tell them apart, we must use taxonomy. The ZZ qualifier has to be used on a paper claim to identify the next item to be seen is the taxonomy. Will the MCO claims fall within that 1 year retroactive date and do we send the printout with a paper claim to the MCO? a- You must follow the instructions from the MCO regarding their claims processing guidelines. 5

6 What if the effective date in the body of the (Initial Provider Enrollment) letter is different from the date at the top of the letter why can you not use the effective date in the body of the letter? a- KY Medicaid will allow an override of timely filing based on the date the letter was sent to the provider if the dates of coverage are retroactive in nature. Can we use KYMMIS with Windows 10? a- Please contact EDI helpdesk for software compatibility questions. Please repeat documents for retro enrollment from MCO back to Medicaid, when MCO request recoupment, once recoupment happens how long does it take for the MCO to update the Medicaid file? a- When a member s benefit plan is MCO, the provider submits a claim to the MCO and the MCO pays the claim. The MCO send the paid claim data to the HPE to show in the claims processing system. If the state changes the members benefit plan to straight Medicaid and makes the change retroactive, the MCO will recoup, the MCO must send the void data to HPE to show the paid data is voided. Otherwise the provider claim to straight Medicaid will deny. Provider needs to attach a timely filing claim with the scenario - the claim, paid EOB from MCO, void EOB from MCO, letter stating what happened and requesting an override of timely filing. If you cannot get the MCO to send the void data, please contact the Medicaid Oversight branch at the state. Is there any update on the implementation of the HCB waiver changes that have been previously discussed? a- We do not currently have any additional information other than what is showing and discussed in this presentation. Watch the websites for additional details in the future. Is a PA still required for replacement glasses on patients under the age of 21 or do we just send the claim with the explanation on letter head. a- PA is not required. Send claim with a letter on provider letterhead stating why the 2nd pair is needed. Can we mail secondary claims or do they have to be put into the portal? a- You may submit either way if the primary carrier paid as primary. What is the best way to bill for a hospital call in an outpatient hospital setting? I bill them and all codes get paid but the D9420 for the hospital call. What am I doing wrong? a- Please ky_provider_inquiry@hpe.com with the subject line as Webinar Questions. Are we able to charge a dental Medicaid patient a missed appointment fee? a- No you cannot - you may find the regulation on chfs.ky.gov/dms. When does the 12 dental visits per year as opposed to once a month take effect? a- Currently effective. Find the Regulation on the Department for Medicaid Services website. 6

7 How do I sign up for EFT? a- Please contact Provider Enrollment at You mentioned that patients can have 12 visits yearly instead of 1 a calendar month. Does these 12 visits also include everything including emergency type appointments? Also is this just Medicaid or across the board for MCO's as well? a- This does not include emergency type appointments. As for MCO's, we are unable to answer MCO questions. Please send and we will pass on to the department for Medicaid Services. When a member is showing TPL on KYMMIS but state they do not have any other insurance, what is the best way for them to have this removed so that a claim is not rejected? I have had members contact member services without any results and am unsure what else to suggest to them? a- If the member is in a MCO - you will need to contact the MCO. If member is traditional Medicaid - the member can call TPL to have it removed. The provider may complete a TPL form and mail in advising the member no longer has the primary and that this has been verified with the TPL, Our staff will investigate and remove once the TPL verifies in writing that the policy is no longer in effect. I'm very frustrating on doing the denture PPL deviations. I have had the reps do the deviations with me on the phone and some of the PPL numbers you can view in the PPL screen and a lot of the processed ones you can t see yet. And the 552 map forms are not being able to be viewed by the homes and they can't print them. They won't pay us till they can see them. a- Question not understood. Please this to the KY_Provider_Inquiry@hpe.com with the subject line Webinar Questions. For the Billing Instructions which provider type should we use for anesthesia? a- If you are a CRNA, use the provider type 74. Physicians use the provider type 64. Is there some sort of requirement to keep the Remittance Advices for a certain amount of time? a- Providers must keep the Remittance statements for 5 years for auditing purposes. I have been told in the past to bill with EOMB form. Is this correct or wrong? a- You only bill using EOB after Medicare if Medicare denied and; for Private insurance if Private insurance denied or applied full amount to deductible.(or to prove timely filing.) If provider is not in network with primary, there is no out of network benefits, will KY Medicaid process and pay claims. a- If provider is out of network with the primary insurance, provider must bill, get denial from primary, attach primary EOB to paper claim to send to KY Medicaid. 7

8 If Medicare is primary, you can enter on KY health net for co-ins, and deductible. a- Yes, you may bill a claim electronically to KY Medicaid for coinsurance and/or deductible. When Medicare claims are in audit more than a year we can file w/ KY Medicaid w/o an EOMB form? Need clarification a- If you bill Medicare and they wait a year to respond to the provider, the provider has 6 months from the Medicare EOMB date to bill KY Medicaid, your Medicare EOMB is your proof of timely filing, attach to paper claim. In regards to the Address Disenrollment s which Medicaid is implementing; If MCD has a bad address for a patient how are they being effectively notified during the address warning period? a- Address disenrollment indication is on KYHealth Net under Member Eligibility Verification for providers. KY Medicaid is unable to locate the member. We are asking the provider to let the member know that an update is needed on their address. In multiple occasions pt. s have corrected their address via phone and or fax but have not been updated through Medicaid as requested and they remain disenrolled due to no fault of their own. How can we ensure the update occurs? a- The first call should be made to the local DCBS office to make sure update occurred. Member Services would be the next entity to contact. If all of these entities have been contacted and you still have questions, to the KY_Provider_Inquiry@hpe.com and we will escalate the issue to Member Services for you. Please remember HPE has no update capability but we do want to get you to the people that can help. Is MCD supposed to remove the Address Disenrollment status once the address has been corrected? We are finding the status is unchanged but the MCO history along with eligibility have been updated within the disenrollment period and the MCO coverage has been reinstated. Should we rely solely on the eligibility status on Kymmis? a- Contact the local DCBS office to make sure update occurred. Member Services would be the next entity to contact. If all of these entities have been contacted and you still have questions, to the KY_Provider_Inquiry@hpe.com and we will escalate the issue to Member Services for you. Please remember HPE has no update capability but we do want to get you to the people that can help. I have a patient that is homeless and has been disenrolled for address. How can I correct since I can't reach patient? a- Please contact Member Services. When a patient renews their Medicaid benefits is their demographic information re-entered manually? We are having hundreds of patients that have gender discrepancies and DOB discrepancies and the pattern we can attribute some of them to are MCO changes and renewals. Medicaid then relays the incorrect information to the MCO resulting in claims denials. a- Please contact member services. We have read only access. The DCBS office or state Medicaid will need to update. 8

9 Does a newborn truly have coverage for 60 days under their mother s MCO? Often times the MCO has attached themselves to the baby but Medicaid has not granted eligibility. a- Please contact Member Services or the local DCBS office. With all of the issues currently occurring and such conflict with the address disenrollment status does Medicaid plan to offer additional training to the providers who are trying to decipher the inconsistencies? a- Please contact Member Services or the local DCBS office with any member plan questions. What exception criteria can you provide for instances when the coverage will be back dated after an address disenrollment period if any? (i.e. update within 30 days, pregnant woman, children, etc.) a- Please contact Member Services or the local DCBS office with any member plan questions. If we are ABI, do we have to have "credentialing" with Medicaid for a counselor/therapist and how do we go about "credentialing that part of our ABI program. a- Per page 27 of the presentation: Occupational Therapist (OT), Physical Therapist (PT) or Speech/Language Therapist (ST) must be credentialed as therapists by KY Medicaid. An OT, PT, ST group number can be credentialed to tie these individual provider types to your tax ID. Please contact Provider Enrollment for additional information What is the asking deadline for Medicaid to request for a refund on a date of service? a- There is no limitation on a request for refund by the Department for Medicaid Services. I am a vision provider. Will the second pair include damaged glasses that cannot be repaired? a- Please contact the Department for Medicaid Services Policy division. Where can I find the coding sheet? a- The CMS 1500 Crossover Coding Sheet can be found at on the left click on Provider Relations, on the left click on Forms, in the center of the screen click the link that says Provider Relation forms. Can you please explain denial code 1121 on the MCD remit? a- Please the Provider inquiry mailbox ky_provider_inquiry@hpe.com with the ICN as an example. If the provider is not Medicare billable, you cannot file with Medicare to obtain an EOB. Will Kentucky pay claims for those provider types? Specifically LPCC. a- Please the Provider inquiry mailbox ky_provider_inquiry@hpe.com 9

10 You showed a letter to the Provider with an effective date of credentialing. What is the KY Medicaid expectation of how long it should take the MCO to load in their system? a- You must enroll separately with each MCO. We have been told that foster children should carry a program status that exempts them from address disenrollment s but we cannot seem to get this appropriately recognized and have foster children who suffer a loss of coverage, who should this information be relayed to? (i.e. foster parent, case worker, MCD?) a- Please contact Member Services. Are Kynect and Medicaid s systems truly interfaced? Patients were instructed to ensure their address was updated with the entity in which they filed for insurance but patients are receiving Kynect mailing despite the lack of address update with Medicaid viewable on Kymmis and resulting in a disenrollment. a- Please contact Member Services or the local DCBS office for assistance. If member services cannot help us then we should send an ? Is that correct? a- If member services cannot help, they may direct you to contact the local DCBS office. If you are still unable to get resolved, ky_provider_inquiry@hpe.com and we will escalate that question to Member Services for additional review. There was a question regarding TPL coverage and MCO's. The answer was that it was the MCO's responsibility to verify TPL. Whenever there is a question concerning coverage (eligibility, TPL or benefits) we are told by the MCO's that they get this information from you. Is this incorrect? a- The MCO s are sent our information as an FYI but it is their responsibility to update their own files. 10