Claims Management. February 2016

Transcription

1 Claims Management February 2016

2 Overview Claim Submission Remittance Advice (RA) Exception Codes Exception Resolution Claim Status Inquiry Additional Information 2

3 Claim Submission 3

4 4 Life of a Claim

5 Claims Intake Claims are submitted using various methods. Electronic Claims Health Enterprise Practice Management Software Payerpath Crossover Claims via Medicare Paper Claims CMS-1500, Professional Health Insurance Claim Form UB-04 (CMS-1450), Institutional Claim Form AK-04, Transportation Authorization and Invoice J430, American Dental Association Dental Claim Form AK-05, Adjustment/Void Request Form 5

6 Transaction Control Number (TCN) Once received, all claims are entered into the system, either electronically or by data entry, and assigned a TCN. TCNs are unique to each claim and determined by multiple submission factors The format of this number is YYJJJMBBBBDDDDDDT YYJJJ - Year and the current Julian calendar date M - Media source code BBBB - Conduent internal use DDDDDD - Conduent internal use T - Transaction code 6

7 Julian Date Calendar 7

8 Transaction Control Number Media Source Codes Transaction Type Codes 1 - Web submitted claims 2 - Electronic crossover claims 3 - EMC claims 4 - System generated claims 8 - Paper Claims 9 - Pharmacy 0 Original claim 1 Void 2 Credit of adjustment 3 Debit of adjustment 8

9 Claims Processing After being assigned a TCN, all claims enter the automated adjudication process. Automated Adjudication Claims that are automatically processed Manual Adjudication If the claim has certain attachments, requires specific or specialized justification to process or is for a diagnosis or procedure that requires review, it will be suspended from the automated process for manual processing by a claims representative 9

10 Suspended Claims Common reasons for suspended claims: Review third-party liability and any attached Explanation of Benefits (EOB) Review medical justification Manual pricing If all necessary documentation was properly submitted, no action is required by the provider while a claim is in suspended status unless contacted by DHSS or Conduent for further documentation 10

11 Claim Resolution All claims will adjudicate to a final status of paid or denied. Paid All paid claims will be reflected on your RA There may or may not be EOB exceptions Denied All denied claims will have EOB exceptions listed on your RA Look through all of the EOB codes, not just the first few, to decide whether or not to correct and resubmit Also use to determine if other actions, such as an appeal may be appropriate 11

12 Remittance Advice 12

13 Remittance Advice A Remittance Advice is a notice of payments and adjustments sent to providers. Once a claim has been received and accepted, it is processed and the appropriate payment is determined Informs provider of submitted claims status Adjudicated claims (paid and denied): Claims adjudication in health insurance refers to the determination of an insurer's payment or financial responsibility, after the member's insurance benefits are applied to a medical claim In-process claims Adjusted and voided claims RA Claims Status Codes to look for: P Paid D Denied S Suspended O To Be Paid C To Be Denied 13

14 Remittance Advice RAs, especially the EOB exception codes, can help providers correct denied claims and prevent future ones Your RA can tell you how to proceed with denied claims: Some denied claims may require additional documentation, such as an EOB or medical justification, for resubmission Some denied claims may be corrected and resubmitted, such as correcting your NPI/taxonomy information or including a service authorization number Some denied claims may require providers to take other actions, such as billing TPL or getting a service authorization, before resubmission 14

15 Electronic RA 835 If you are using approved practice management software, you may receive your RA a little differently If you are submitting HIPAA compliant 837 transactions, you may receive an 835 transaction as a response The 835 is the electronic version of the RA You might notice some differences: Remark codes returned on an 835 will be HIPAA compliant v5010 X12 remark codes rather than the 4- character Enterprise codes These codes can be found in your Technical Report Type 3 (TR3) guides Only one transmission is available - providers must indicate if they want to receive the 835 or if it should be sent to their billing agent The appearance of the 835 will vary depending on the provider s software Provider Notice: If using practice management software, it is your (or the billing agent s) responsibility to be able to interpret 835 remark codes. The Provider Inquiry department does not have that capability. - TR3 guides are available for purchase from 15

16 RA Sections RAs are separated into several different sections, each containing very important information regarding claims processing. RAs contain: Cover Page RA Messages Adjudicated Claims Adjustments Voids In-Process Claims Explanation of Benefits Financial Transactions Summary Helpful Tip: Review all areas of your Remittance Advice. It will help you identify any errors, ways to correct denied claims, and prevent future issues. It also contains helpful notes, reminders, and training opportunities, as well as useful accounting information throughout. 16

17 Cover Page The cover page identifies the provider to which the RA applies. Provider ID Provider Name Provider Address 17

18 RA Messages Every RA will start off with a message section. Providers and billing agencies should read these messages each week. It contains: New information Changes in billing procedures or program coverage Messages from Department of Health and Social Services (DHSS) and Conduent Billing procedures/reminders Training schedules 18

19 Example RA message page 19

20 Adjudicated Claims Adjudicated claims are those that have reached final disposition since the last payment cycle. Paid Denied Explains how claims were adjudicated If claim contains errors or is denied, EOB, or exception, codes will be listed next to the line item or beneath the individual claim Any exception code listed in the RA will be in the EOB Description section at the end of the RA for quick reference If there are multiple exception codes, be sure to look at all of them, not just the first 1 or 2 Shows payment date of previously paid claims 20

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23 Adjustment Claims Adjustments are used to make minor corrections to paid claims. Processed adjustments appear in two parts on the RA: Credit: Alaska Medical Assistance credits our account by taking back the money that was paid incorrectly Credit TCNs will end in a 2 Debit: Alaska Medical Assistance takes money out of our account to pay the claim correctly Debit TCNs will end in a 3 23

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27 Voided Claims A processed void request will result in: Reversal of the original transaction Removal of service and payment information from the provider and member history files Refund back to Alaska Medical Assistance for the full claim amount Reduction in claims paid year-to-date dollar amount on RA summary Any claim with a status of P, D, O, or C may be voided. Suspended claims cannot be voided. Common Voids on Paid Claims Wrong member ID number Wrong provider ID number Services not rendered Voids related to Medicare crossover claims: If paid by Medicaid and also received payment from Medicare, provider must void the claim submitted to Medicaid and re-bill using the crossover format. 27

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29 In-Process Claims In-process claims are those claims that have not fully adjudicated. They may require additional processing steps (status S) or are complete but missed the billing cycle deadline (status O or C). Common reasons for claims to suspend: To review third-party liability To review medical justification No action is required by the provider while a claim is in suspended status, unless contacted by DHSS or Conduent 29

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31 Explanation of Benefits (EOB) The EOB Description is a complete list of exception codes found on the remittance advice, including a brief description of each code. For further explanation or assistance you may: Look up more in-depth descriptions using Health Enterprise Documentation>Documents & Forms>Exception Code Lookup Call Provider Inquiry Claim status and other inquiries , option 1,1 or (toll-free), option 1,1,1 31

32 The Through Service Date on Claim Header is Missing or Invalid.

33 Financial Transactions Financial transactions are payment or recoupment transactions: for example, provider reimbursements or processing a voided claim that was already paid out. This section only populates on the RA if there are applicable financial transactions for the pay cycle Financial transactions may appear on consecutive RAs as each part of the payment or recoupment process takes place Provider Tip: If you notice this section but the full transaction doesn t appear on that particular RA, look at the RA from the previous week or wait for the next pay cycle for the rest of the specific transaction. 33

34 The 1 st part shows how the particular transaction(s) will affect the current pay cycle. Negative amount = provider overpayment The 2 nd part contains details of each transaction affecting the current pay cycle. The RA Summary accounts for financial transactions as a separate line item that is applied to cycle totals and applicable balances. Any negative balance will be deducted from the total cycle payment. If overall cycle total is negative, the negative balance will be carried forward to the next cycle for recoupment. The financial transaction(s) would show here for accounts receivable purposes. This is an example of what a Financial Transaction section would look like if a provider were overpaid as a result of paid claims that are then voided. 34

35 The 1 st part again shows how the particular transaction(s) will affect the current pay cycle. Postive amount = provider payment reduction The 2 nd part contains details of each transaction affecting the current pay cycle. For example, recoupment of previous week s negative balance. The RA Summary shows how the financial transactions were applied to cycle totals and applicable balances. In this case, a reduction of payment to account for prior overpayment due to void. The recoupment shows here as a prior balance that is deducted from the current cycle in the full amount. This is the next week s RA for the previous example showing the overpaid balance from the voided claims being applied to the next cycle. 35

36 Summary Page Each RA includes a summary of all provider claims data. Shows the current cycle and year-to-date total dollars paid to and collected from the provider After each calendar year, Conduent sends each provider a 1099 tax statement showing total calendar year Alaska Medicaid reimbursements Information will match year-to-date total paid on last RA issued for calendar year Contact Conduent regarding discrepancies 36

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38 Exception Codes 38

39 What is an Exception? Some claims have what is called an exception attached to it. Exceptions are codes signifying an issue on a submitted claim Listed as Explanation of Benefits (EOB) codes Generated manually (claims personnel) or automatically (MMIS) Composed of four numeric digits Appears on your RA in multiple areas Used as information to help correct errors or help rebill denied claims 39

40 Hierarchy of Exception Codes Claims data is reviewed in a hierarchy, from most important details to least important to determine if the claim needs to be suspended, reduced, or denied. For example, member and provider eligibility are reviewed before the rest of the claim; if either is determined ineligible, the claim is denied before a full review of the submitted claim is complete Review and correct entire claim before trying to resubmit A complete list of exception codes identified throughout the RA can be found in the EOB Description section of the RA (just before Summary) Line Level EOB Header Level EOB 40

41 Exception Code Online Inquiry Exception codes can be looked up online using Under Documentation, select Documents & Forms When the documents and forms page comes up, select Exception Code Lookup Enter the code you want a description for and click Submit A complete exception listing can be downloaded by clicking on the Exception Listing for Providers link. If you need more information about an exception code, contact Provider Inquiry at , option 1,1 or (toll-free), option 1,1,1. 41

42 Reading Exception Codes It is important to review all exception codes associated with each claim, being careful to look at details, to determine a course of action. For example, this claim has five exception codes attached to it: The code attached tells you that this claim is in a suspended status for further review Based off all attached codes, there is an issue with the Medicare Crossover and the NDC listed on the claim These errors could be as simple as making a NDC typographical error and mislabeling timely filing justification attachments; a complete review of the claim would help you determine what is actually happening 42

43 Suspended Claim Codes A suspended claim is one being held for manual review by: Conduent State of Alaska No action is required by the provider unless directly contacted. These are all examples of exception codes that indicate a claim has been suspended for further review: 1922 Explanation of Medicare Benefits (EOMB) requires review 4076 Review for Medical Justification - Professional Claim Types 4427 The Procedure Code and Modifier submitted on the claim require manual review 6430 Cost Avoid for no TPL dollars but EOB exists 43

44 Denied Claim Codes A denial code indicates a denial and reason for the denial. Providers should review all denial codes Some denied claims can be resubmitted after correcting errors: may require resubmission with additional documentation may need corrected information before resubmission may require providers to take other actions, such as billing TPL, before resubmission 44

45 Denied Claim Codes These are examples of common denial exception codes: 1030 Billing provider number missing or invalid 1320 Member number missing or invalid 1882 Claim exceed timely filing and no proof of timely filing attached 2006 The Dates of Service on the claim are after the Member's eligibility end date 2020 Claim DOS after Member DOD 3005 Billing provider not actively enrolled on DOS 6512 Code pairs found to be unbundled in accordance with National Correct Coding Initiative (NCCI) for Practitioner or ASC 6600 Exact duplicate 8040 The Number of Units on the Claim have exceeded the Service Authorization Approved Number of Units 45

46 Exception Resolution 46

47 Exception Resolution - TPL Exceptions related to Third-Party Liability (TPL) If member has other health benefits that may be responsible for partial or total payment of a claim, those benefits are primary and must be billed first Exceptions: Indian Health Services (IHS) Services for which a federal TPL waiver has been granted Providers will also receive a denial exception code if the explanation of benefits of the TPL is not attached to the claim 47

48 Exception Resolution - TPL How can I tell if a member has other coverage? Alaska Medical Assistance eligibility coupons and cards Resource code / carrier code Automatic Voice Recognition System (AVR) Look up the member s eligibility information in Health Enterprise Provider Inquiry , option 1,2 or (toll-free) option 1,1,2 You can review the specific carrier codes on under Documentation>Documents & Forms>TPL Carrier Lookup 48

49 Exception Resolution TPL Verification TPL Carrier Lists can be found on Documentation > Documents & Forms Select TPL Carrier Lookup 49

50 Exception Resolution TPL Verification If the member is covered under another government program, they will have one of the following resource codes listed: Government Agency Resource Codes G/H/J Medicare M Tricare N Veterans Administration (VA) N2 Veterans Greater than 50% Disabled P Alaska Area Native Health Services Y No Other Insurance 50

51 Exception Resolution Member Eligibility If a denial is received because of member eligibility: Verify member eligibility dates Member may be eligible for retroactive eligibility to cover date of service Member should provide updated information to provider Refile claim to Alaska Medicaid after eligibility has been updated These are examples of possible member eligibility exception codes: 2005 DOS is prior to Member s eligibility begin date 2006 DOS is after Member s eligibility end date 2008 Member s eligibility does not cover entire period between From and Through DOS 2011 DOS is after Member s eligibility end date with attachment 51

52 Exception Resolution Procedure Code If a denial is received because procedure code/item not covered for Medicaid: Check procedure codes on the claim Was the most appropriate code reported on the claim? Are you qualified to provide that service per your specialty? Review billing manual or fee schedule for a list of covered services Is procedure code covered? If procedure code is not valid: Determine correct billing code Verify validity of new code Send in new claim with corrected information Provider Tip: Make sure you are using the appropriate fee schedule for the DOS time period. Billing manuals and fee schedules can be found on in the Documents & Forms section 52

53 Exception Resolution SA Some denials result from service authorization requirements. If proper SA was obtained, was SA number and associated information correct and recorded on the claim? If not, rebill claim with correct SA information Does procedure code match service that was authorized? If not, rebill with correct code or have service authorization amended to correct code If SA was not obtained but required, contact appropriate authorizing entity to obtain SA Provider Tip: Refer to fee schedules and billing manuals to determine which services require a service authorization. 53

54 Exception Resolution Timely Filing Some claims deny because they exceed the 12-month timely filing limit. All claims must be filed within 12 months of the date services are provided to a member 12-month timely filing limit applies to all claims, including those that must first be filed for TPL or Medicare crossover Claims denied with this type of exception code cannot be corrected and resubmitted; you may only appeal the decision A claim denied for timely filing may be appealed within 180 days from the initial denial date Member Retroactive or Backdated Eligibility There are times when a member is granted retroactive or backdated eligibility. If this occurs, the member should forward all appropriate documentation to their provider. Providers have the ability to file claims for the retroactive timeframe if this documentation is attached to the claim. Even with this documentation, there is still a time limit to file, so don t delay. 54

55 Exception Resolution Other Other common exception codes include incidental procedures and medical justification requirements. A procedure is considered incidental when carried out at the same time as a primary procedure and is clinically integral to the performance of the primary procedure; these procedures should not be billed separately Provider will receive a denial but it is possible to appeal with proper justification A procedure code billed might require medical justification/records for service rendered; fee schedules and billing manuals denote supporting documentation requirements for procedure codes Rebill with supporting documentation attached Medical records Chart notes Doctor s orders 55

56 Exception Resolution Duplicate Billing A duplicate billing error occurs when two claims are submitted with some or all of the same information. This can include, but is not limited to: Dates of service Charges Member s ID Provider s billing ID Procedure codes This can happen if: Two different providers bill for the same/overlapped DOS or same procedure for the same member Same provider sends the same claim more than once Entire bill resubmitted to add/change charges on a previously paid claim 56

57 Exception Resolution Duplicate Billing These are examples of possible multi-provider duplicate exception codes: 6610 Inpatient or Nursing home claim vs. Personal Care Services - duplicate 6604 Possible Conflict/Different Provider To resolve this type of error: Check your records rebill with corrected information if necessary Contact other provider to address the issue If the paid provider billed incorrectly, they must void their claim Second provider can bill once the incorrectly paid claim is voided Provider Tip: If both providers did actually provide the same service on the same date to the same member, the provider submitting their claim first is paid. The other provider will need to appeal the denial documenting the duplicated service. 57

58 Exception Resolution Duplicate Billing These are examples of multiple submission duplicate exception codes: 6600 Exact Duplicate 6602 Possible Duplicate To resolve this type of error: Keep up-to-date records of all claims If duplicate services medically necessary, appeal with proper justification If you filed electronically and think the duplicate submission might be the result of a glitch, contact your vendor When charges need to be added, deleted or changed, file an adjustment Do not rebill the whole claim as an original If the change involves TPL, be sure to include EOB with your adjustment 58

59 Prevent Duplicate Billing Many duplicate denials can be prevented. Routinely check claim status, especially before trying to re-bill When adding charges to a DOS, adjust the already paid claim instead of rebilling Be careful of duplicate revenue codes and HCPCS when billing both inpatient and outpatient claims for the same member and DOS If duplicate services are medically necessary, be aware appeal may be necessary 59

60 NCCI Exceptions National Correct Coding Initiative (NCCI) exceptions were developed by CMS to promote appropriate coding methods and reduce improper coding that could lead to payment errors. Part of the Patient Protection and Affordable Care Act of 2010 In effect October 1, 2010 Any NCCI exception on a claim will cause a denial and requires an appeal for reimbursement; first level NCCI exception denials go to Conduent Members cannot be billed for services denied for NCCI exceptions For appeals questions and information, contact the Appeals Department at option 8 or (toll-free), option 1,5 60

61 NCCI Exceptions Two types of NCCI exceptions: Procedure-to-Procedure (P-P) Defines pairs of HCPCS/CPT codes that should not be reported together Medically Unlikely Edits (MUE) Defines the maximum number of units of service for each HCPCS/CPT code a provider would report under normal circumstances for a single member on a single date of service Applied to practitioners, ambulatory surgical centers, outpatient services, and durable medical equipment claims Each NCCI exception has a Correspondence Language Example Identification Number (CLEID) that gives a rationale and is used for all related correspondence 61

62 Claim Status 62

63 Claim Status Inquiry There are many methods for checking a claim s status. Login to your Health Enterprise account Under the Claims tab, select Claim Status Inquiry Enter the search criteria for the claim(s) you are looking for Fax a Check Amount and Claim Status Inquiry form to Provider Inquiry at Be sure that all included information is legible if handwritten Call Provider Inquiry at , option 1,1 or (toll-free), option 1,1,1 63

64 Claim Status Form This form can be found on Documentation > Documents & Forms > Forms Select Check Amount and Claim Status Inquiry Form 64

65 Electronic Claim Status Inquiry If you are certified to submit a HIPAA compliant 276 inquiry transaction and receive a 277 response transaction, you may check your claim status electronically. You must successfully test these transactions Contact the Conduent Electronic Data Interchange (EDI) Coordinator , option 3 or (toll-free), option 1, 4 You must have some form of practice management software that supports these transactions Refer to companion guides for electronic transaction information: Refer to the applicable TR3 for further information: 65

66 Additional Information 66

67 Alaska Medicaid Compliance & Ethics Training Compliance & Ethics: Alaska Medicaid 101 is a computer-based training which includes an interactive video presentation and a supplemental handbook This training serves to: Familiarize providers with the responsibilities and requirements associated with being a Medicaid provider Guide providers through the laws and regulations Medicaid providers must follow The training is available at Select Provider>Compliance & Ethics Alaska Medicaid provides a certificate for completing this training Please direct any questions to the Provider Training department at or

68 Additional Resources Alaska Medicaid Health Enterprise website at Information necessary for successful billing Includes provider-specific Medicaid billing manuals and fee schedules You may also call: Provider Inquiry Eligibility only , option 1,2 or (toll-free), option 1,1,2 Claim status and other inquiries , option 1,1 or (tollfree), option 1,1,1 EDI Coordinator Electronic transaction inquiries , option 3 or (toll-free), option 1, 4 68

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