Professional Refresher Workshop. Presented by The Department of Social Services & HP

Transcription

1 Professional Refresher Workshop Presented by The Department of Social Services & HP 1

2 Training Topics Client Eligibility SAGA Becomes Medicaid for Low Income Adults Automated Voice Response System (AVRS) Updates Internet Prior Authorization Inquiry Internet Claim Status Inquiry Third Party Liability Update Procedures Chapter 11 of the Provider Manual Timely Filing System Enhancement HUSKY B Co-pays Most Frequent Claim Denials Questions 2

3 Client Eligibility Reference Guide To access the Client Eligibility Reference Guide, the following steps apply: 1. Go to the Public Web site at navigate to the Information page and select Publications on the drop down. 2. Scroll down the Information page to the Claims Processing Information Panel. 3. Select the Eligibility Response Quick Reference Guide. 3

4 Client Eligibility Reference Guide Client Eligibility Responses: Client Population Program Benefits Prior Authorization Request Claims 4

5 Client Eligibility To access Client Eligibility Verification, the following steps apply: 1. Go to the Public Web site at navigate to the Provider page and click on the hotlink for SECURE SITE 2. Enter the user name and password on the log in page. If an invalid user name or password is entered, an error message displays prompting for the correct information. When the correct user name and password is entered, the Account Home page displays 3. Select the Client Eligibility Verification link under the Quick Links section of the page 4. Once on the Client Eligibility Verification page (Attachment 1), complete the form by entering data in the appropriate fields. Providers may enter one of the two following options as the search criteria: A. Client Number, with either: Social Security Number (SSN) or Date of Birth B. SSN with Date of Birth C. Full Name, with either: Social Security Number (SSN) or Date of Birth 5. Enter a From Date of Service (From DOS) and To Date of Service (To DOS) in a MMDDCCYY format 5

6 Client Eligibility cont. Client Eligibility Responses Review: Attachment 2 Attachment 3 6

7 State Administered General Assistance Program (SAGA) Becomes Medicaid for Low Income Adults SAGA has been discontinued as of April 1, 2010 Individuals formerly covered under SAGA will be covered under Medicaid and will have access to the fee-for-service Medical health care benefits The new program is Medicaid for Low Income Adults (Medicaid L-I-A) 7

8 State Administered General Assistance Program (SAGA) Becomes Medicaid for Low Income Adults cont. As of July 1, 2010 Community Health Network of CT (CHNCT) discontinued managing the medical component of the SAGA medical program Providers will be required to return the funds paid by CHN for SAGA clients for dates of service on or after April 1, This will allow the state to receive Federal reimbursement for services provided to these clients retroactive to April 1, Beginning July 1, 2010 providers should submit claims for dates of service on or after April 1, 2010 to HP. 8

9 State Administered General Assistance Program (SAGA) Becomes Medicaid for Low Income Adults cont. Authorizations provided by CHNCT for dates of service April 1, 2010 through June 30, 2010 will be honored. Effective July 1, 2010 and forward providers should follow the Medicaid fee for service prior authorization protocol. PB10-38 provides additional information on Medicaid L-I-A. 9

10 Automated Voice Response System (AVRS) Updates Effective August 2, 2010 additional menu options will be available for providers New menu will offer: 1. Self Service Options 2. Claim and Enrollment Assistance 3. Technical Assistance Option #1 Self Service Options Providers must provide security information: AVRS ID PIN 10

11 Automated Voice Response System (AVRS) Updates cont. AVRS Self Service Main Menu Options: 1 Eligibility Verification 2 Remittance Advice 3 Claim Status 4 Diagnosis Code Lookup 5 Change PIN 6 Alphabetic Character Instructions 7 Fax Requests 8 Prior Authorization 0 Speak with Customer Service Representative (CSR) * Repeat the Menu (applies to all Options) The Eligibility Verification option will not be available for inactive providers. 11

12 Automated Voice Response System (AVRS) Updates cont. Option #2 Claim & Enrollment Assistance 1 Other Insurance/Medicare Billing Instructions 2 Provider Enrollment 3 Dental 4 Long Term Care/Home Health/Hospice 5 Pharmacy 6 Behavioral Health 7 Eyeglass Vision History 0 All other questions/speak with CSR 12

13 Automated Voice Response System (AVRS) Updates cont. Option #3 Technical Assistance 1 EDI 2 Provider Electronic Solutions (PES) 3 Web Portal Account 4 Web Password Reset 0 All other questions/speak with CSR 13

14 Internet Prior Authorization Inquiry Prior Authorization (PA) inquiry allows providers to view the status of their Prior Authorization Requests at any given time Confirm Receipt of PA Request Confirm Authorization of Services Authorization matches Request Units requested equal units authorized Procedure codes/modifiers match request Prior to receipt of authorization confirmation letter 14

15 Internet Prior Authorization Inquiry cont. Providers can perform an inquiry (Attachment 4) on the status of their Prior Authorization Requests using the following search criteria: Prior Authorization Number Client ID Note: To narrow your search, enter additional criteria such as one of the following in your search: Requested Effective/End Dates Authorized Effective/End Dates Status Procedure Code 15

16 Internet Prior Authorization Inquiry cont. Inquiry results (Attachments 5, 6): Status Requested Effective/End Dates Used Units Available Units 16

17 Internet Claim Status Inquiry Claim Status Inquiry is available for providers to view processed claims regardless of the submission method. The Provider Assistance Center no longer answers simple claim status questions. As claims are processed on a daily basis, the claim inquiry tool allows providers to determine, on a daily basis, if a claim they have submitted: Paid Denied Suspended 17

18 Internet Claim Status Inquiry cont. Providers can perform an inquiry on the status of their claims using the following search criteria: Internal Control Number (ICN) (assigned to your claim in interchange) Client ID Must also include one of the following in your search: ICN TCN (Transaction Control Number) (legacy ICN) FDOS/TDOS, (must span no greater than 93 days) FDate Paid/TDate Paid (must span no greater than 93 days) Check Pending Claims box to bring up claims that have not yet appeared on your Remittance Advice Adjusted claims can be excluded 18

19 Internet Claim Inquiry To perform a claim inquiry: Enter search criteria Entering multiple criteria narrows the search (Attachment 7) Click Search Results will populate: Multiple claims meet search criteria (Attachment 8) Search Results list will be returned» Click claim you wish to view Single claim meets search criteria (Attachments 9, 10, 11) Entire claim panel will be returned Check Pending Claims All Claims not yet posted to the Remittance Advice will be returned 19

20 Third Party Liability Medicaid is the Payer of last resort. The three digit Carrier Code of the Other Insurance (OI) is required to be submitted on the claim when OI is primary. You can find the Carrier Code: Verify eligibility via Automated Voice Response System Toll free or locally in the Farmington, CT area at (860) From the Web site click on Information Publications Carrier Listing under Chapter 5 of the Provider Manual 20

21 Third Party Liability Update Procedures To correct or update Third Party Liability (TPL) information: Obtain TPL forms - Print out form located on Web site at under Information Publications Forms Other Forms TPL Information Form - Call Health Management System, Inc. (HMS) HMS staff will mail or fax the form to the provider - request to ctinsurance@hms.com and form will be ed back to provider - Scan completed forms and submit through to ctinsurance@hms.com 21

22 Third Party Liability Update Procedures cont Submit completed forms - Mail to HMS Attn: CT Insurance Verification Unit 5615 High Point Drive, Suite 100 Irving, Texas Fax to HMS with HIPAA compliant letter to Scan completed forms and submit through to ctinsurance@hms.com 22

23 Third Party Liability Update Procedures cont. To correct or update Third Party Liability (TPL) information: HMS contacts the provider either by telephone or in writing with the results within 45 days of receipt of the TPL information If providers are having difficulties with this process or want to suggest changes to this process, they may supply this information by at or mail to: Department of Social Services Division of Fraud and Recoveries 25 Sigourney Street Hartford, CT

24 Chapter 11 of the Provider Manual Chapter 11 of the Provider Manual contains Other Insurance and Medicare Billing Guides by claim type Chapter 11 can be accessed from the Web site, Click on Information Publications under Provider Manuals scroll down to Chapter 11, select a claim type (dental, institutional, professional) 24

25 Timely Filing System Enhancement Previously claims that denied for timely filing Explanation of Benefits (EOB) codes 512 Claim exceeds timely filing limit and 555 Claim is past behavioral health timely filing guidelines needed to be submitted on paper with attachments to support a timely filing override Providers may now submit claims with dates of service over one year old (Fee for Service) or 120 days (CTBHP) electronically, using Web claim submission or on paper without attachments 25

26 Timely Filing System Enhancement cont. Fee for Service - Claims will bypass timely filing EOB 512 Claim exceeds timely filing limit Original claim with no TPL: ICN Julian date is within 366 days from the detail through date(s) of service on the claim Client eligibility file change: Client eligibility has been added or updated where the ICN Julian date is within 366 days of the change and the claim date of service is between the effective dates of the change Medicare and/or Other Insurance Payment: OI or Medicare paid amount is greater than $0.00 and the paid date is within 366 days of the ICN Julian date of the claim If multiple carriers exist and if any one does not meet the above criteria, the claim will deny with EOB

27 Timely Filing System Enhancement cont. Other Insurance denial: OI denial date is within 366 days of the from date of service on the claim and within 366 days of the ICN Julian date If multiple carriers exist and if any one does not meet the above criteria, the claim will deny with EOB 512 Medicare denial: Medicare (carrier code MPB) denial date on the claim is within 549 days of the from date of service on the claim and within 366 days of the ICN Julian date 27

28 Timely Filing System Enhancement cont. Prior claim history: When paid or denied claim in history with same client, provider, billed amount, detail from and through date of service and procedure code where ICN Julian date on the current claim is less than or equal to 366 days from the previous claims Remittance Advice (RA) date and the previous claim did not deny for timely filing Claim adjustments: When the number of days between the paid date of the claim and the adjustment s ICN Julian date is less than 366 days 28

29 Timely Filing System Enhancement cont. Connecticut Behavioral Health Partnership (CTBHP) Claims will bypass timely filing EOB 555 Claim is past behavioral health timely filing guidelines Original claim: Detail through dates of service on the claim is within 120 days prior to the ICN Julian date Claim History: Adjudicated claim for same client, provider, billed amount, detail from and through date of service, procedure code where the ICN Julian date on the current claim is less than or equal to 120 days from the previous claims Remittance Advice date and the previous claim did not deny for timely filing 29

30 HUSKY B Co-pays Covered Services Table list is available on CT Medical Assistance Program Web site or CT Behavioral Health Partnership (CT BHP) Web site CT Medical Assistance Program Web Site select provider, Select Provider Fee Schedule Download, Click Behavioral Health Partnership PDF format, Scroll to page 17 of the fee schedule; Exhibit D- Covered Services Table list the codes that will apply a co-pay 30

31 HUSKY B Co-pays cont. CT Behavioral Health Partnership (CT BHP) Web site select For Providers, Scroll down and select Covered Services/Fees, Click on HUSKY B Client Cost-Share Services link EOB 9001 Reimbursement reduced by the client s copayment amount will post to your claims to identify Co-Pay amounts for HUSKY B clients 31

32 Most Frequent Claim Denials EOB 2017 Service is included in MCO coverage Claims should be verified to determine if they should be processed by HP or the MCO (Managed Care Organization) Verify client eligibility to determine if client is enrolled in a managed care organization If yes, and it is a medical claim, submit the claim to the client s MCO If no, client eligibility could have been updated at some point. Re-submit the claim to the appropriate responsible party according to the client eligibility reference guide 32

33 Most Frequent Claim Denials cont. EOB 3003 Prior Authorization is Required for Payment of this Service Providers need to check the PA inquiry on their secure Web site to verify if there is an Authorization on file If Prior Authorization is not on your secure Web site, you will need to submit a PA request to DSS If Prior Authorization is on the provider secure Web site: Verify that the procedure code and effective and end date of the Prior Authorization match what are being billed 33

34 Most Frequent Claim Denials cont. EOB 1945 Claim/detail denied. Billing/performing provider could not be determined When a provider has one NPI associated to multiple provider AVRS IDs, additional claim data such as the billing provider s taxonomy code or 9 digit zip code must be used to determine the correct provider AVRS ID to apply to the claim This error will be present when the system cannot identify a unique provider AVRS ID with which to process the claim. This denial will occur when the 9 digit zip code and/or the billing provider s taxonomy code on the claim does not match the information submitted at the time of enrollment The provider must correct the 9 digit zip code and/or the taxonomy code on the claim and resubmit the claim 34

35 Most Frequent Claim Denials cont. EOB 2503 Bill Medicare first The provider should verify client eligibility to identify if the client has Medicare coverage through the secure Web site at If the client has Medicare, the eligibility verification will show Medicare effective for the date of service on your claim If the claim was submitted without the Medicare information, you will need to correct the claim and re-submit the claim to HP Reminder: Medicare primary with Medicaid as secondary payer can be submitted to HP through the provider secure Web site 35

36 Most Frequent Claim Denials cont. EOB 4021 The Procedure billed is not a covered service under the client s benefit plan The provider should verify client eligibility to determine if services are covered for your provider type and specialty If services are covered under client s benefit plan, client eligibility could have been updated at some point. Providers should re-submit the claim for processing This denial may by the result of multiple benefit plans. It is necessary to correct all other errors on the claim If the claim continues to deny, contact the HP Provider Assistance Center 36

37 Training Session Wrap Up Where to go for more information HP Provider Assistance Center (PAC): Monday through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays: (in-state toll free) (860) (local to Farmington, CT) 37

38 Time for Questions Questions & Answers 38