V O L U M E 2, I S S U E

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1 Claims St. Patricks Day March 17th First Day of Spring March 20th Greetings from Eastpointe s Claims Department. We hope you will find this monthly newsletter helpful in answering claims questions. Let s stay connected! Connections M A R C H V O L U M E 2, I S S U E 3 Rate Change (Effective 04/01/2017) The February 2017 NC Medicaid Bulletin outlined some changes to the service Inside This Issue IMPORTANT NEWS 1-2 REMINDERS 3 definition and rate for Intensive In- Home. Eastpointe has reviewed this information and will be adopting the new rate of $ as the daily rate as of 4/1/17 dates of service. FAQ S 4 DENIAL 5 SPOTLIGHTS QUICK LINKS 6

2 P A G E 2 M A R C H Eastpointe Website Eastpointe launched its new website on February 1, Claims information is located in two different areas on the website. General billing information such as the claims manual, rate schedule and checkwrite schedule can be found by clicking on Provider Contracting and Payment for Services General billing documents are found at the bottom of the screen under Submitting Claims. Links to the Claims Inquiry/Timely Filing Override Form and Claims Connection Newsletters are also located at the bottom of the screen. Billing Information specific to the AlphaMCS system can be found by clicking on Provider Meeting and Trainings Under trainings, click on Alpha Claims. AlphaMCS specific documents and videos posted by the Claims Department can be found here.

3 M A R C H P A G E 3 March 12th Deadline for FY 2016 Time Limit Override Requests The deadline for submitting time limit override request for claims with dates of service 7/1/15 through 6/30/16 is March 31, Management of Accounts Receivable Providers must take full responsibility for the management of their Member accounts receivables. Eastpointe produces remittance advices based on the current checkwrite schedule and makes them available to providers for posting adjudication results. Not managing your accounts receivables could produce unfavorable results to your financial stability. Overpayments/Duplicate Payments If an overpayment/duplicate payment is received in a checkwrite it is good practice to contact Eastpointe to verify what has occurred. As explained in our December 2016 newsletter, when re-adjudication of claims occurs, if the claim was initially approved and approves again there is a credit memo and debit memo processed for that claim that may not process on the same checkwrite. This often causes an overpayment to providers in one checkwrite and a recoupment in a different checkwrite. The impact could be unfavorable if the overpayment was not handled appropriately and the recoupments are processed at a later date. Reviewing Claims Status via the Claims Dump File A claims dump file is made available to providers containing detailed information regarding claims submitted. It can be used to easily research what happened to every claim submitted. These files are generated and overwritten nightly to provide up-to-date information. The claims dump file can be located in the Download Q of the AlphaMCS Provider Portal and contains every claim submitted for the past 6 months. For step-by step instructions on how to access these files please refer to the Claims Dump guide found on the Provider Portal and by accessing this link: Guide

4 P A G E 4 M A R C H We didn t get a payment this week due to claim recoupments, why? Our payment was much less than expected this week, why? Questions to consider when this occurs 1. Were any replacement claims or voids submitted? 2. Was an overpayment received on a previous checkwrite? 3. Was there a week when posting accounts receivables, we could not balance to Eastpointe s RA? March is National Nutrition Month. Below are some interesting nutritional facts. Improved nutrition (as well as vaccinations and antibiotics) has extended the average U.S. lifespan from 30 to 40 years old in the early twentieth century to 70 to 80 years old today. Eggs contain the highest quality food protein known. Lemons are one of the healthiest foods in the world. The highest-calorie fast food item in the world is a milkshake.

5 M A R C H P A G E 5 97 Charges are Covered Under a Capitation Agreement/Managed Care Plan Description: There has been a cap placed on the provider/service/definition/age group/dx group/benefit plan that has been reached. This claim would exceed that amount. Example ABC Residential has been given a $200,000 contracted amount for YP750 for the MCO. Claims have been submitted and paid up to that amount a claim is submitted that will push the approved amount above $200,000. This claim would deny for reason 97. The member was not enrolled in the funding source on the date of service or they were never enrolled in it. Recommended Action Steps: Review your contract with Eastpointe for any maximum amounts listed. Compare that amount to total approved claims for the contract period. If a discrepancy is found, contact Eastpointe Network Operations. Description The MCO is no longer or has never reimbursed providers for performing this service. Recommended Action Steps 14 - Invalid Service or Service Discontinued Service has been lapsed/removed from the MCO benefit plan and is no longer billable. Confirm this by contacting Eastpointe Network Operations. Description: The units submitted for the claim are blank, 0, less than 0, do not meet the minimum required for the service, exceed the one date maximum for the service or the units billed are not appropriate for the date range submitted. Recommended Action Steps: 29 Invalid Units Verify that the units are correct for the service billed. If they are not, resubmit a corrected claim. If they are, contact Eastpointe Network Operations for assistance.

6 M A R C H P A G E 6 Claims Manual Service Rate Schedule Standardized MCO Check write Schedule Need Assistance? Many of your claim related questions can be answered via our website at Click Provider Contracting and Payment for Services Still Have Questions? Contact Network Operations