Indiana Health Coverage Program Seminar Presented by MDwise UB-04 October 22-24, 2007

Transcription

1 Indiana Health Coverage Program Seminar Presented by MDwise UB-04 October 22-24, 2007

2 Topics for today Who is MDwise MDwise Delivery Systems UB-04 Claims submission and Inquiries Referrals and Prior Authorization

3 Who is MDwise? MDwise is a local, not-for-profit company serving Hoosier Healthwise members. We have been giving the best possible health care to our neighbors since 1994.

4 Who is MDwise continued MDwise has a variety of programs and capabilities to meet the special medical and social needs of the Medicaid population. Our services are provided to more than 280,000 members in partnership with over 1,400 primary medical providers. Supplementing these delivery systems are networks for pharmacy services and member transportation. Current capabilities include all management and administrative services necessary to operate a stateof-the-art managed care organization.

5 MDwise Programs

6 Additional Service Provided MDwise Member advocates Website: 24/7 Customer Service On-line Provider Manual

7 Additional Service Provided MDwise Quick Contact Sheet

8 What is the UB-04? Formerly known as the UB-92. Hard copy form used by hospitals, skilled nursing facilities, home health agencies, etc. Hard copy form to mirror electronic format put into action as a result of HIPAA

9 SAMPLE UB-04

10 Eliminated or changed locators on UB- 92 UB-04 Major Changes The following form locators (FL) on the UB-92 are either not used Or their definition changed on the UB-04: FL 7 Covered Days (converted to Value Code) FL 8 Noncovered Days (converted to Value Code) FL 9 Coinsurance Days (converted to Value Code) FL 10 Lifetime Reserve Days (converted to Value Code) FL 16 Patient Marital Status FL 64 Employment Status Code FL 66 Employer Location FL 79 Procedure Coding Method Used FL 85 Provider Representative Signature FL 86 Provider Representative Signature Date

11 New Form locators on UB-04 New form locators (FL) on the UB-04 are: FL 2 Pay-to Location FL 8 Patient Name ID FL 29 Accident State (to denote state where accident occurred) Line 23 Page of Line 23 Creation Date FL 56 National Provider Identifier (NPI) FL 57 Other Payer Identification FL 66 International Classification of Diseases (ICD) Version Qualifier (i.e., ICD-9) FL 71 Prospective Payment System (PPS) Code FL 76 NPI for the Attending Physician FL 77 NPI for the Operating Physician FL 78, 79 NPI for the Other Physicians FL 81 Code - Code (overflow field for additional codes that do not fit into other fields)

12 MDwise vs. Fee-for-Service Generally, follow the same rules as fee-for-service MDwise requires Federal Tax ID in Form Field 5 Form Field 63a-63c- Treatment Authorization Codes - Required by MDwise

13 Claims Submission and Resolution

14 Claims submission Before providing services, it is necessary to confirm: Is the member eligible for services today? In what IHCP Plan are they enrolled? (Hoosier Healthwise, Medicaid Select, Traditional Medicaid) If the member is in Hoosier Healthwise, what MCO are they assigned? (MDwise, Anthem, MHS) If the member is enrolled in Hoosier Healthwise, what services are they eligible to receive? (Package A, B, or C) Who is their Primary Medical Provider (PMP)? Does the member have primary health insurance other than Medicaid (frequently seen with package B moms)?

15 Claims Submission and Inquiries Providers are encouraged to submit their claims electronically In-MDwise Network Providers must submit their claims to the delivery system claims department where the member is assigned. Providers should contact the applicable delivery system for specific instruction on electronic claims submission Please note that all electronic claims must be submitted using the HIPPA compliant transaction and codes sets Providers may submit paper claims to the applicable delivery system address ( see quick contact sheet)

16 Claims Resolutions Informal Claims Resolution Call Delivery System to inquire about claim Delivery System must respond within 30 calendar days of inquiry Formal Claims Resolution Must be in writing Provider has 60 calendar days From receiving written denial After delivery system fails to make determination From delivery system s response to the informal inquiry

17 Claims Filing Limit In-Network Providers have a filing limit that ranges from 90 to 180 days, depending on their contract with the Delivery System. Out-of-Network Providers have 365 days from the date of service to file a claim.

18 REMINDER! It is the responsibility of ALL providers to check eligibility at the time of each visit.

19 Referrals and Authorization

20 Referrals & Prior Authorization Referrals must come from PMP. (Sometimes not needed if in network.) Referrals to out-of-network specialists providers may be approved for continuity of care ( including auto assignment pregnant members in their third trimester) and for specialist not available within the network. Prior Authorization Call MDwise and ask for Medical Management. Out-of-delivery system PA is typically only given if services not available in network. If the request is for an out-of-delivery system provider, PA is always needed from the appropriate Medical Management Department. Call MDwise and ask for Medical Management staff:

21 Have Questions or Problems? Contracted Providers - Each delivery system has: 1. Provider Relations Representative 2. Medical Director 3. Medical Management department 4. Claims department Non-Contracted Providers MDwise Customer Service Live voice 7 days a week, 24 hours a day Provider Relations Department at corporate office Member Services and Outreach Member Advocates MDwise website:

22 Questions

23 Thank You From the MDwise Staff!