Wyoming Medicaid. Presented by Field Representatives Kinzie Baker & Liz Lovell-Poynor

Transcription

1 Wyoming Medicaid Presented by Field Representatives Kinzie Baker & Liz Lovell-Poynor

2 Chapter 1- General Information Chapter 2-Getting Help When You Need It Chapter 3-Provider Responsibilities Chapter 4-Utilization Review Chapter 5-Client Eligibility Chapter 6-Common Billing Information Chapter 7- Third Party Liability Chapter 8-Electronic Data Interchange (EDI) Chapter 9-Wyoming HIPPA Electronic Specifications Chapter 10-Important Information

3 RA Banner RA Payment Summary * Bulletins

4 It is important for all providers, both treating and pay-to providers, to maintain current and accurate contact information. Why it is important to update provider contact information? o To receive up-to-date policy information o Receive updates when Medicaid needs a copy of your new license o Any other communication which needs to occur between Wyoming Medicaid and providers To update your provider contact information, please do the following: o or mail a request on office letterhead and include the following: NPI/Provider number & Name Provide contact information Update needed Physical, correspondence, or financial address, provider phone or fax number, or addresses on file Date this change needs to go into effect Pay-to Providers can also update their contact information by logging into the Provider Web Portal and going to Update Provider Demographics addresses on file can also be updated by speaking to a representative at Provider Relations by calling options 1, 5, and then 0.

5 Quick Reference When to write for help Online resources Requesting a provider training visit

6 Eligibility When can a client be billed? Issues most commonly heard in call center: Clients requested to troubleshoot claims or check PA status Client billed or sent to collection Billing and coding questions Recordkeeping

7 Record Keeping Provider must have completed all required signatures, before or at the time the provider submits the claim. Documentation prepared or completed after the submission of a claim will be deemed to be insufficient to substantiate the claim and Medicaid funds shall be withheld or recovered. Requirements The Provider Agreement requires that the medical and financial records fully disclose the extent of services provided to Medicaid clients. The following elements include but are not limited to: Legible Client identified on each page Diagnosis and history All services and treatment plan Progress Treatment minutes NOTE: Specific or additional documentation requirements may be listed in the covered services sections or designated policy manuals.

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9 Service thresholds Under 21 Over 21 NDC Conversion Attachment coversheet See Web Portal Tutorial Adjustments and Voids Sterilization, Hysterectomy and Abortion Consent Form Requesting Replacement RA s Timely filing Telehealth

10 Paper-Attachment cover sheet TCN How to get the TCN ACN (Attachment Cover Sheet) Electronic Attachments How to complete Common Attachment issues: Incomplete ACN does not match Legibility issues Information on form does match claim Rendering provider listed as Payto No Attachment indicated on claim

11 Paper Complete all required information Attach corrected clean claim and indicate on form Attachments Electronic How to complete 6-Adjustment 7-Replacement Common Issues: All lines not included on electronic adjustment No changes made to the claim Too many changes being made Not all corrections made Not attaching supporting documents

12 Sterilization consent form: PDF Federal Form Ensure all providers aware of any updates The person that signed the line is the only person that can make the alteration. Common issues: Incomplete Abbreviations Not Legible White out Correct process: Single line through error with initials Date less than 30 day-no emergency

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14 Third Party Payers Unreported coverage Provider not enrolled/no Opt out option How to indicate TPL on a claim Medicare/No Opt out option

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16 Date Procedure code Modifier Units Billed 04/25/ $ /25/ SL 1 $ /25/ SL 1 $ /25/ SL 1 $ /25/ $ /25/ $85.00 Claim Paid

17 Date Procedure code Units Billed Amount 4/10/ $ /10/ $ /10/ $ Claim denied 051 THE RECIPIENT HAS EXCEED THE 20 VISIT THRESHOLD FOR PHYSICAL THERAPY. (800)

18 The taxonomies listed in the table to the left will require a referring provider on each claim in order for it to process. If a referring provider is not listed on the claim the claim will be denied.

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20 Date Procedure code Modifier Units Billed 04/05/18-04/26/18 H2019 HQ 16 $80.00 Correctly billed claim Date Procedure code Modifier Units Billed 04/05/18 H2019 HQ 4 $ /12/18 H2019 HQ 4 $ /19/18 H2019 HQ 4 $ /26/18 H2019 HQ 4 $80.00

21 Date Procedure code Units Billed Amount 4/2/ $ /11/ $ /16/ $ /23/ $62.00 Claim in Process 900 Children receiving services at a Developmental Centers are subject to the thresholds after 20 visits.

22 Date Procedure code Units Billed Amount 5/01/ $ /01/ $ Claim denied 374

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24 Date Procedure code Units Billed Amount 05/03/ * 1 $ /03/ * 1 $ /03/ $ /03/ * 1 $45.00 Claim Paid

25 Line 1 03/13/ Line 2 03/22/18 V Line 3 03/22/18 V Line 4 03/22/18 V Line 5 03/13/ Billed amount: $ Claim paid: $371.92

26 Line 1 03/24/ Line 2 04/03/18 V Line 3 04/03/18 V Line 4 04/03/18 V Line 5 03/24/ Line 1 03/24/ Line 2 03/24/18 V Line 3 03/24/18 V Line 4 03/24/18 V Line 5 03/24/ Correctly rebilled claim example

27 Line 1 3/02/ Line 2 3/14/18 V Line 3 3/14/18 V Line 5 3/14/ Claim denied

28 Welcome Page Manuals and Bulletins Fee schedule Contact us Forms Provider Training Web Tutorials

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30 Claim Submission Refer to: pdf Attachments Refer to: Registering and adding users Refer to: _18.pdf

31 The CCD is a HITSP standard patient summary document that contains the following information from the THR Gateway: Problems Family& Social History Immunizations Vital Signs Test Results Medications Procedures Up to 2 years claims history Alerts Allergies/Adverse Reactions And more To request THR CCD Viewer access, please send an containing: Clinic Name Address Phone Number Provider Names Provider Addresses Primary Contact To Andrea Bailey at: andrea.bailey@wyo.gov Visit the website at: -viewer

32 The Program Integrity (PI) unit is responsible, through a coordinated process of education, reviews, audits, and appropriate corrective action plans, for ensuring the integrity and accountability of all payments made for healthcare services on behalf of a recipient. Providers new to Medicaid should view the Wyoming Medicaid Program Integrity presentation. Learn more about PI or report suspected abuse, fraud, or waste by visiting:

33 Provider Relations (Option 1,5,0) o 9-5 MST Monday - Friday o Fax Number o EDI Services (Option 3) o 9-5 MST Monday Friday o EDI Enrollment Form o Trading Partner Agreement o WINASAP Software & Technical Support for WINASAP o Technical Support for Vendors, Billing Agents, and Clearinghouses o Provider Web Portal Registration o Technical Support for Provider Web Portal & Password Resets

34 *Medical Policy (Option 1,1,4,3) o 9-5 MST Monday Friday o Prior Authorizations (PAs) Requests for: o Surgeries requiring PAs o Hospice Services: Limited to Clients Residing in a Nursing Home o Status of a Pending PA o How to Complete a PA Request o Authorizations of Medical Necessity for services prior to 11/1/17 o Denials for: o WATRS -Ambulance claims/ regarding trip report o Invoices * Third Party Liability (TPL) (option 2) o 9-5 MST Monday Friday o Client accident covered by liability or casualty insurance or legal liability is being pursued o Estate and Trust Recovery o Medicare Buy-In status o Reporting client TPL o New insurance coverage o Policy no longer active o Problems getting insurance information needed to bill o Questions or problems regarding third party coverage or payers o WHIPP program

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