KanCare Claims Resolution Log

Transcription

1 nderpayments: Resubmissions/adjustments will be completed on claims processed within 90 days of the system being corrected/ Affected Area Comments HP System Status System Status HP / Reprocessing 82 9/16/2013 SF # 1252 General QMB Spenddown amounts not applied correctly. AGP - 1/31/14 AGP - Refer to Issue #144 nderpayment SF - 3/1/15 - ETA moved due to AT testing still in progress. Claims will continually be manually processed until system is /18/2013 AGP144 Spenddown Members AGP detected errors in the spenddown (SD) calculation and transaction exchange for all SD members beginning in July. The errors resulted in overpayments since SD was inappropriately applied or the data to decrement a member's SD balance was not transmitted to the data warehouse. AGP is assessing the overall scope of the issue for remediation. AGP - 1/31/14 AGP - Following impact assessment, will coordinate with state on remedy. AGP has a report of claims that are ready to be reprocessed these are QMB members. 6/20/14: Claims that were processed incorrectly for QMB members will be reprocessed project is pending. Further research is necessary before reprocessing can occur /19/2014 Item # 1316 General Correct ACA payment related issues related to COB claim, Mid level practitioners, etc. This includes 2013 and 2014 dates of service 283 6/30/2014 Item # 1325 LTC LTC/SNF claims denying for OIC when OIC coverage is NOT a LTC policy. Per the state, LTC claims should only deny for an EOB if the OIC coverage is a LTC coverage. SF - 05/23/14, additional provider updates completed on 12/01/2014. SF - Manual process put in place on 9/1/2014 until configuration is complete. SF -ETA 02/28/15 ETA moved due to number of claims requiring reprocessing & additional system updates that were required. O/ ETA for system update is 03/04/ /18/2014 HC Issue # 255 Dental Our dental vendor (SCION) is not currently receiving TPL information on our members. This may result in dental claims being paid as primary when the claims should edit for other insurance. Please make sure the primary payer EOB is attached to claims when submitted. HC -ETA 5/1/15 HC - Pending O 308 8/19/2014 AMG308 CMHCs AGP is paying Q3014 (Telehealth, originating site facility fee) at $4.50, instead of the KMAP rate of $ AGP will be doing projects to pay at the correct rate starting immediately DOS 1/1/13-8/15/14, and once reconfigured with the correct rate, another project to catch claims from 8/15/14 to date of correction. AGP - 1/22/15 AGP Claims through DOS 11/30/14 have been reprocessed. 1/13/15: AGP received confirmation from KDHE that the correct rate is $20.00 for BH so this rate will be configured. Claims 12/1/14-current will be reprocessed. ECD for configuration is 30 days. 1 of 6 Revised 2/12/2015

2 nderpayments: Resubmissions/adjustments will be completed on claims processed within 90 days of the system being corrected/ 317 9/9/2014 SF # 1331 SF Ticket # INC & INC Affected Area Comments HP System Status System Status HP / Reprocessing General Sunflower identified an internal system error that caused several claims to reject in error with the reject reason "A1 19 PR (Entity acknowledges receipt of claim/encounter)". The error message SF - 8/29/14 SF - The claim information was received by SF from HP on 10/16/14. All 63 affected contained no other information to define the reason for the rejection. It was defined by Sunflower the rejection was due to a claim detail service line limitation within their core system. providers from the 261 claims have been contacted by our provider relations department. nderpayment The rejections occurred for the time period of 01/01/13 08/29/14. A second instance occurred on 12/29/2014. KMAP instructed Sunflower to reach out to the impacted providers and educate about how to correct the claims. HP -10/6/ impacted claims. Waiting on confirmation from Sunflower they are ready to receive the claims. HP has identified over 6,000 impacted claims for the time period of 1/1/13-8/29/14. HP will send to Sunflower as soon as confirmation is received they can accept the claims. Sending of these claims is on hold due to ticket #INC (Issue #380) /22/2014 SF # 1332 ISB Intermediate Swing Bed (ISB) claims are incorrectly being denie for POA indicators. SF - ETA updated to 1/15/2015 as additional configuration changes identified. Claims are being SF - ETA 02/28/ /22/2014 SF # 1333 PHD Public/Local health departments that bill vaccine and admin services are denying incorrectly with EXL6 (Resubmit with OIC EOB). SF - ETA moved to 3/1/15 - Claims are being manually reviewed until system configuration is /13/2014 SF #1337 SF Ticket # INC COBA Sunflower was rejecting claims in error with duplicate CO 45 values in the CAS segments of the electronic 837 x12 transaction files. 10/10/2014 -Sunflower s edit to reject claims when duplicate CAS segments are received has been turned off. SF - 10/02/14, additional, HP to send affected system update needed for batches as we are now ready to rejection messages, system receive. Waiting for additional updated 12/08/14, additional system update to be completed. system update required, ETA of 01/31/15. HP will be resending the claims to Sunflower that rejected for A3 521 Sunflower (Adjustment Reason Code) from 01/01/ /02/2014. Timely filing will be coordinated with Sunflower /13/2014 SF #1338 General Procedure code T1016 denies L6 (Resubmit with OIC EOB) in error. SF - 12/15/14 SF - 2/1/ /13/2014 SF #1339 DME Wheelchair claims with POS 13 and 14 denying EXLO (Invalid Location) in error. SF - 10/23/14 SF - 1/8/ /3/2014 SF# 1340 TPL COB claims denied for authorization in error when primary has processed as covered benefit /3/2014 SF# 1341 TPL COB claims denied for timely filing in error when COB timely filing has been met. SF - ETA moved to 03/01/15, additional system updates required. Claims are being SF - ETA moved to 03/01/15, additional system updates required. Claims are being /3/2014 SF# 1342 General Claims paid $0 with EX 92 (Paid in full) applied. SF - ETA moved to 02/15/15, additional system updates required. Claims are being 2 of 6 Revised 2/12/2015

3 nderpayments: Resubmissions/adjustments will be completed on claims processed within 90 days of the system being corrected/ Affected Area Comments HP System Status System Status HP / Reprocessing /5/2014 E A1 Policy HCPCS Pricing for Part B Drugs - October Effective with dates of service on and after October 1, 2014, additions, revision and deletions related to 4th Quarter HCPCS Pricing for Part B Drugs will be made according to the process outlined in Policy E AGP - 10/22/14 SF - 9/26/14 HC - 10/27/14 AGP - 1/22/15 HC - No claims impacted nderpayment O/ retroactive to dates of service on and after 10/1/ /13/2014 E Policy New DRG Grouper, Weights and Rates for October 1, 2014 retroactive to discharge dates on and after 10/1/2014. AGP 11/12/14 SF - 11/7/14 HC - 11/17/14 AGP 12/29/14 for underpayments SF - 3/15/15 HC - 1/2/15 for underpayments /21/2014 E Policy Coverage of Additional Influenza Vaccine Procedure Codes AGP 2/2/ Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use SF - 12/2/14 HC - 11/17/14 SF - 2/15/15 HC - 1/7/ Influenza virus vaccine, quadrivalent, split virus, when administered to children 6-35 months of age, for intramuscular use Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use. retroactive to dates of service on and after August 1, /18/2014 AGP354 DME Amerigroup is allowing 180 units of incontinence supplies per AGP 1/23/15 AGP 1/23/15 month when the member is eligible for this service. KDHE policy allows for 6 units per day. Amerigroup has been denying the additional 6 units when there is a 31 day month /21/2014 AGP355 CMHC Amerigroup did not configure at least one code, H0036, for the AGP 1/9/15 AGP 1/28/15 76/77 modifiers, per KDHE policy that was effective 11/1/14. Weekly sweeps for these claims will be done weekly and they will be reprocessed until the system is configured accurately to accept these modifiers. S5150 was included with this issue, and there are 99 claims currently being reprocessed for this code /9/2014 E A1 Policy HCPCS Changes October 2014 AGP - 1/8/15 AGP No claims impacted. O/ Additions, revisions and deletions related to 4th Quarter HCPCS 2014 will be made according to KMAP Program managers determinations utilizing the process established with Policy E (HCPCS Changes 2010) SF - 10/2/14 HC - 10/28/14 HC - No claims impacted retroactive to dates of service on and after 10/1/ /12/2014 AGP358 Hospitals Amerigroup is paying for drugs when billed with surgery codes, when these should be denying content of service. AGP: 3/1/15 AGP: Pending O /12/2014 HC Issue # 273 Hospital It was determined during an internal claim audit that HC is HC -1/16/15 HC - 2/6/15 denying O/P hosptial claims billed with a 761 revenue in error as being an observation related charge. This revenue code is for a treatment room not observation. Claims should process based on the CPT code billed, the revenue code should not be the only source for an O/P hospital claim to deny. 3 of 6 Revised 2/12/2015

4 nderpayments: Resubmissions/adjustments will be completed on claims processed within 90 days of the system being corrected/ Affected Area Comments HP System Status System Status HP / Reprocessing /16/2014 AGP360 Vision For the period of time 1/1/13-11/10/14, Ocular Benefits (OB) may have rejected paper claims sent through KMAP FEB for rendering provider missing or invalid in error, if the rendering provider was on the paper claim in Box 24J. A manual process was put into place on 11/10/14 to prevent this from happening, until an automated process can be implemented. AGP / OB - 11/10/14 Manual Process AGP / OB 1/30/15 nderpayment OB will identify the claims rejected in error and will reprocess these /19/2014 HC Issue #274 Institutional It was determined during a weekly internal claim review that we HC - 12/20/14 HC - 1/16/15 have claims denying for invalid type of bill (TOB) in error. Hospital and NF providers may be experiencing claim denials /19/2014 HC Issue #275 General Providers billing procedure code G0471 are experiencing front HC - 12/30/14 HC - 1/21/15 end rejections when billing this code. This is an error as this code is valid as of 10/1/14. Since claims are rejected prior to entering HC's claims processing system, no claims project can be HP - Impacted claims file sent to HC on 1/21/15 completed. HP will resend the impacted claims to HC once HC's system has been corrected /22/2014 SF #1343 Web Portal Invoices being attached to the web portal are not transferring to SF - 2/9/15 system causing claims to deny in error. In the interim, please feel free to submit adjustment requests with copy of invoice and claims will be adjusted accordingly /7/2015 E A15 Policy NCCI Procedure-to-Procedure Associated Modifiers AGP - 1/4/15 AGP No claims impacted /O KMAP GENERAL BLLETIN Four new Healthcare Common Procedure Coding System (HCPCS) modifiers will be added to the list of National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) associated modifiers for Medicaid claims: XE, XP, XS, and X. SF - 1/23/15 HC -1/1/15 HC - No claims impacted retroactive to dates of service on and after 1/1/ /9/2015 HC Issue # 277 Institutional Institutional claims billed with a patient status 30 (still a patient) HC - 1/12/15 HC - 1/26/15 are denying in error for invalid patient status /9/2015 E A17 Policy NCCI/ME pdates January 2015 AGP - 1/7/15 AGP No claims impacted /O Additions, revisions and deletions related to 4th Quarter NCCI (National Correct Coding Initiative) and MEs (Medically nlikely Edit). HC - 1/16/15 HC - No claims impacted retroactive to dates of service on and after 1/1/ /12/2015 SF #1344 General E /16/2015 AMG369 Radiology/ Imaging Services denied in error as related to global surgical period. Claims that denied in error will be reprocessed for payment. SF - 2/15/15 AGP s new radiology and imaging authorization vendor, AIM, is not receiving the full member file, nor the full participating provider file, from Amerigroup. We believe the member file has been rectified as of 1/16/15. The full participating provider file will be received by AIM on 1/23/15. In the meantime, there is a work-around in which AIM contacts the AGP call center to verify member eligibility, and participating provider status. AGP 2/1/15 AGP - There will be no claims to reprocess. pdate 2/5/15: AIM now has the full member file and full provider file. They are now able to confirm member and provider eligibility on their own, without having to contact Amerigroup. There are no claims to reprocess, because AIM does not receive claims they only do authorizations. 4 of 6 Revised 2/12/2015

5 nderpayments: Resubmissions/adjustments will be completed on claims processed within 90 days of the system being corrected/ Affected Area Comments HP System Status System Status HP / Reprocessing 369 1/15/2015 HC Issue # 278 General nitedhealthcare elected to temporarily bypass timely filing edits in an effort to assist providers with completion of their claims impacted by various claim issues. Effective 3/1/15, we will begin enforcing the timely filing requirements as defined in provider contracts for claims processed by nitedhealthcare. HC - 3/1/15 HC - No claims project needed nderpayment Provider notification posted via the HC web site /20/2015 E Policy PRTF Rates January 2015 AGP - 12/18/14 AGP - No claims impacted The PRTF rates have changed as provided within the Medicaid State Plan Amendment. Rates are adjusted each July 1 and rates are re-calculated and set each January 1. SF - 12/31/14 HC - 1/12/15 HC - No claims impacted retroactive to dates of service on and after 1/1/ /21/2015 SF #1345 Dental Dental Health and Wellness has a total of 57 pending batches /21/2015 AGP372 Hospital Amerigroup is paying some procedure codes that should be denied as content of service to ER/Observation services. O 373 1/21/2015 AGP373 Health Homes Amerigroup is applying Health Home claims to spenddown when AGP Reprocessing on a weekly a member is in the Medically Needy program. These claims should not be applied to spenddown they should be denied, until the member is in a met spenddown status. Amerigroup is reprocessing these claims as they come in, and they will show as denials since the members are not eligible for Health Homes when they have unmet spenddown. basis. The claims will show as denials /21/2015 AGP374 General Amerigroup loaded some of the QMB-only codes by mistake. These should be non-covered for members except for when the member has QMB-only coverage. AGP - 1/22/15 AGP - Recoupments have been requested O 375 1/25/2015 HC Issue # 280 General Providers billing procedure codes in the following list may are experiencing front end rejections due to these codes not being loaded as active in our front end editing system , 76642, 80300, 80301, 80302, 80321, 80345, 80346, 80349, 80356, 80361, 80365, 80373, 87624, 88341, J9267 HC corrected their claims system on 1/20/2015. HP has identified the impacted claims and will resend to HC. HC - 1/20/15 - for all codes except J9267 HC - 2/9/15 for J9267 HC - 1/26/15 for all codes except J9267 HC - 2/9/15 - for J9267 HP - 1/26/15 - Sent impacted claims to HC 376 1/25/2015 HC Issue # 279 FQHC FQHC's who provide behavioral health services are not being paid at the new rate effective for dates of service 10/1/14 and after. HC - 1/26/15 HC- 3/13/15 O/ 377 1/26/2015 E A2 Policy HCPCS Pricing for Part B Drugs January 2015 AGP 1/22/15 O/ This is the quarterly policy documented to track and implement the additions, revisions and deletions related to the 1st Quarter HCPCS Pricing for Part B Drugs. SF - 1/16/15 HC - 1/29/15 HC - No claims impacted retroactive to dates of service on and after 1/1/ of 6 Revised 2/12/2015

6 nderpayments: Resubmissions/adjustments will be completed on claims processed within 90 days of the system being corrected/ 378 1/26/2015 KMAP Bulletin Affected Area Comments HP System Status System Status HP / Reprocessing FEB HPES has identified an issue where paper claims were being 5/12/2014 rejected in FEB by KMAP for ICD-10 diagnosis code usage not yet allowed. These claims were not sent to the s. The issue occurred when implementing a change to RRI (Recognition Research Incorporated) that caused the ICD diagnosis code HC - 1/29/15 indicator from RRI to default to 0 (ICD-10) on the xml output file when creating the 837 FEB file. This occurred when the ICD indicator was blank on CMS 1500 and B04 claim forms. Because this was not required on CMS 1500 forms until July 1, 2014, the logic was corrected on May 12, 2014, to default the ICD diagnosis code indicator to 9 (ICD-9) until the requirements for this field were implemented in provider bulletin on July 1, This affected paper claims processed from 03/07/14 05/12/14. All impacted claims have been identified by HPES and will be resent to the appropriate Plan for processing. Timely filing will be coordinated with each plan for any services. AGP 2/4/15 HC - 1/30/15 HP - 1/28/15 - Impacted claims sent to Plans nderpayment 379 1/28/2015 E A1 Policy Anesthesia Conversion Factor for CY 2015 Revised O CMS has revised the original anesthesia conversion factor of $ The anesthesia conversion factor for calendar year 2015 will now be $ retroactive to dates of service on and after 1/1/2015. SF - 1/23/15 HC - 2/2/15 HC - No project will be completed due to the amount of the overpayment /28/2015 SF Ticket # INC General Sunflower identified an internal system error that caused several claims to reject in error with the reject reason "A1 19 PR (Entity acknowledges receipt of claim/encounter)". The error message contained no other information to define the reason for the rejection. This issue is still under reasearch with EDI. The rejections were isolated to 12/29/2014. SF - EDI researching, no ETA at this time. HP -12/30/ impacted claims. Waiting on confirmation from Sunflower they are ready to receive the claims. HP has identified the impacted claims for the time period of 381 2/2/2015 SF #1346 General Vaccine and Admin services are denying in error. System has been corrected and claims will be reprocessed SF - 01/30/15 SF - 03/15/ /2/2015 SF #1347 General Claims billed with diagnosis V20.1 have been rejected up front in SF - 02/28/15 error. Claims and affected providers are being identified and claims will be reprocessed /2/2015 SF #1348 General Claims paid and/or denied incorrectly as a result of POA (Present SF - 12/29/014 SF - 03/15/15 /O on Admission Indicators) submitted on the claim. System has been updated and claims will be reprocessed /3/2015 FEB HPES has identified an issue where B 04 paper claims were being rejected in FEB by KMAP with either of the following rejection messages. AGP - SF - AGP - SF - 1. (Cannot provide further status electronically.) Required segment missing: HI - Principal Diagnosis. 2. (Cannot provide further status electronically.) nrecognized segment. HC - HC - The rejection occurred when the ICD Indicator (FL 66), also known as the ICD Version Indicator, was blank on the B 04 paper claim submission. These claims were not sent to the s. This affected B 04 paper claims processed from 12/23/2014 to current. All impacted claims will need to be refiled by the provider with the appropriate ICD Indicator. Providers will need to coordinate timely filing with the appropriate Plan for any impacted services /9/2015 AGP385 General Beginning with DOS 11/1/14 through 12/31/14, Amerigroup began denying claims for echocardiograms inappropriately, for no authorization. The codes affected: 93350, 93351, , 93325, These claims will be reprocessed. As of 1/1/15, authorization is required on these codes. AGP pending 6 of 6 Revised 2/12/2015