General SRC #16, Attachment 4: Claims Appeal Operations Desktop Procedure

Transcription

1 General SRC #16, Attachment 4: Claims Appeal Operations Desktop Procedure

2 Desktop Procedure: Claim Appeal Operations Related P&Ps: Provider Complaint System NE.MCD.7.03.(B)-(P).FL.MCC.FL CMC Last Updated: 4/3/2017 RELATED PROCESS FLOWS: BUSINESS OWNER: VENDOR INTERACTION: Customer Service/Enrollee Services- Operations NA Steps Actions Responsible Party 1. Incoming Claim A) Claim Form or Inquiry/Dispute/ appeal is received via fax or mail Customer Form or Claim 1. Mail is received Service Dispute/ Appeal a. Designated CCA sorts the mail b. Incoming mail is logged on the Mail Tracking Log c. CCA will deliver mail and have the receiving department sign the log 2. Claim dispute/appeal is received by Fax or mail a. Designated CCA scans disputes/appeals and places them in K:\Customer Service\Claim Appeals\Claims Dispute Requests- Pending by date received. b. Designated CCA s will enter the data into Resolve. K:\MCC\Customer Service\DTP, Step Guides and Workflows\Step Guides\Complaints Grievances Appeals\Resolve c. CCA s working on resolutions will be assigned cases based on the Resolve report (This report should be run by the team Supervisor) 2. Processing Claim Appeal A. Before working on any dispute, timely filing should be verified. Par - 90 days from EOP date Non par 365 from EOP date Customer Service RETRIEVE STEP GUIDE.docx Looking Up NDC and J Code Combinations. Looking Up IP and SRA Step Guide.docx OP Hospital Rates - In 3. Outcome A) Naming convention for the resolution letters should be: CDRL Name of Facility Claim# - CCA initials B) CCA will save all letters in: K:\MCC\Customer Service\Claim Appeals\Claims Dispute Appeal Response Letters -Completed\Pending to be Mailed C) Designated CCA will check folder throughout the day and will print, fold, and seal letters and placed them in the appropriate mail bin to be mailed out. Customer Service/ Team Lead 4. Claim s/ Escalations A) If an SRA or claim issue needs to be escalated an should be sent to the MCCFLResolution@magellanhealth.com (This should be reviewed with a Lead or Supervisor before sending) Customer Service/ Team Lead 1

3 SCRIPTS Correct Payment Provider was paid at the contracted inpatient/outpatient physical/behavioral health per diem/percentage rate of $. The rendering provider is a non-participating provider. Non-participating providers are reimbursed at 100% of the Medicaid Fee Schedule. According to the Medicaid Fee Schedule, the claim was reimbursed at 100% of the Medicaid rate. The rendering provider has not completed the credentialing process and would require authorization for services. Please submit complete medical records for services rendered from to so that a retrospective review can be completed. Anesthesia reimbursement for nurses The rendering provider was paid correctly according to their level of degree. Any provider other than a physician is to receive 80% of the Physician Anesthesia allowable. Provider submits claim appeal but the member is not eligible with MCC We have received your request for review of [claim #] in the amount of [$$$$] for services rendered to [patient name] on [dates of service]. However, we are unable to process your request as [patient name] was not eligible with Magellan Complete Care on the date(s) that services were rendered. If the patient was never our member, then add: Please be advised that the records received from your office have been destroyed. If the patient was our member but then coverage changed to another plan, then add: The patient s eligibility terminated on [date of termination]. Magellan Complete Care only reimburses through the date of termination. Therefore, Magellan Complete Care will not reimburse for services rendered beyond [date of termination]. Adjusted Claim Claim has been adjusted. You will receive an updated Explanation of Benefits/Explanation of Payments to the financial address on file. Adjusted Claim for Overpayment After reviewing the claim, we have determined that claim has been overpaid. Claim has been adjusted and sent to the Cost Containment Department. You will receive an updated Explanation of Benefits with an Explanation of Deductions to the financial address on file. Member eligibility terminated during an admission Member eligibility terminated on (date of termination). Magellan Complete Care only reimburses through the date of termination. Therefore, Magellan Complete Care will not reimburse for services rendered beyond (date of termination). NDC Number Denials The NDC number is missing for CPT (enter procedure code). NDC number (enter NDC number) is invalid when billed with procedure code (enter procedure code). 2

4 V Code Denials for POS 23 (Emergency) Primary diagnosis (enter diagnosis code with description) is not reimbursable by Medicaid for the place of service 23 (Emergency Room.) Non-Covered Diagnosis for the Type of Service Primary diagnosis (enter diagnosis code with description) is not reimbursable by Medicaid for the type of service rendered. NPI Attestation/Medicaid ID Denials NPI number (enter NPI number) is not registered with the State Medicaid Record. Attached is the Florida Medicaid National Provider Identifier Registration Form. Please fill out the form and send it to Medicaid Provider Enrollment. Once the NPI number has been registered with the State, contact the Customer Service Line for assistance with re-processing your claim. NPI number (enter NPI number) was not active with the State Medicaid Record on the billed date of service. Please contact Medicaid Provider Enrollment if your active dates need to be corrected. Once the NPI number s active dates have been corrected with the State, contact the Customer Service Line for assistance with reprocessing your claim. IGT Reduction Rates Par Provider According to the contract, the claim was processed at the contracted rate of (enter rate information). Per AHCA, changes for fiscal year 2014/2015, self-funded Inter-Governmental Transfers (IGT) are no longer distributed through claim payments, effective with inpatient admissions on or after 7/1/14. For Magellan Complete Care, this requires a reduction for certain facilities in the inpatient per diem amount by the provider-specific IGT component for inpatient admissions that begin on or after 7/1/14. IGT Reduction Rates Non-Par Provider Non-participating providers are reimbursed at 100% of the Medicaid Fee Schedule. According to the Medicaid Fee Schedule, the claim was reimbursed at 100% of the Medicaid rate. Per AHCA, changes for fiscal year 2014/2015, self-funded Inter-Governmental Transfers (IGT) are no longer distributed through claim payments, effective with inpatient admissions on or after 7/1/14. For Magellan Complete Care, this requires a reduction for certain facilities in the inpatient per diem amount by the provider-specific IGT component for inpatient admissions that begin on or after 7/1/14. Primary Care Physician Rate Increase Thank you for your inquiry. Your claim was originally processed in the (enter the quarter) of (enter the year). It is Magellan s policy that these rates be paid retroactively and will be part of a separate payment several months after the initial payment for the service. These claims were paid correctly based on the service provided. Please expect payment within 60 days. If you do not receive a notice within this timeframe, please contact us immediately. Lesser of Logic Clause for Contracted Providers According to the contract, the lesser of logic clause applies. If you have any questions regarding the provider contract, contact your Network Representative or contact the Provider Service Line at Lesser of Logic Clause for Non-Contracted Providers The lesser of logic clause applies to non-participating providers. The provider is not contracted with Magellan Complete Care. If you have any questions, contact the Provider Service Line at

5 Newborn Claims If the mother is Medicaid eligible, the newborn services and the mother s room and board charges must be billed on the same claim under the mother s name and Medicaid ID. The per diem rate is payment in full for both. If the mother is not Medicaid eligible but the newborn is, then the claim must be billed with the newborn s name and Medicaid ID. Nursery services only are reimbursed at the per diem rate, which is payment in full for the newborn. Emergency Room Facility ER Billed Within 2 Days Prior to Start of Inpatient Admission: Facility inpatient per diem rates are inclusive of all services rendered by the hospital to the member during the 48 hours prior to the start of the inpatient admission. Therefore, a facility ER claim is not eligible for additional reimbursement when billed within 2 days of an inpatient admission to the same facility. Multiple 0450 Revenue Codes on Same Claim According to the Agency for Health Care Administration, Provider Reimbursement Handbook, UB-04, each revenue code other than , may be reimbursed only once on an outpatient claim. Claim Doesn t Match Auth on File A review of our records indicates that your claim was not billed as authorized. Please check the authorization and submit a corrected claim to our claims department for reconsideration. Service Billed Requires Auth We are unable to process your request at this time. This service requires prior authorization. Please obtain the authorization form from our website, and fax the completed form to Service Billed by OON Provider Requires Auth We are unable to process your request at this time. The service billed was rendered by a non-participating provider. Therefore, this service requires prior authorization. Please obtain the authorization form from our website, and fax the completed form to Request for Payment Above Yearly Maximum The yearly maximum for (enter type of service) for this plan is $. According to our records, the yearly maximum has already been paid and no further action is required. Your claim (enter claim number) was processed correctly and the maximum of $ was paid on xx/xx/xxxx with check (enter check number). Claims Processing Timeframe Claims are processed in the order that they are received. Your claim was received on xx/xx/xxxx. Please allow 30 days for your claim to be processed Timely Filing We have received your documentation as proof of timely filing however, the documentation provided is not sufficient in order to prove the documentation was submitted within the timeframe. If you have any other documentation that would assist as proof of timely filing please submit to the appeals mailing address for further review. Please note: Submitting any of the following information with your appeal is considered evidence that your claim was submitted in a timely manner: o Copy of a Magellan EOP with a date within the filing standard. o Copy of a letter/correspondence from Magellan with a date within the filing standard. o Certified or overnight mail receipts dated within the filing standard. 4

6 o o o o Facsimile confirmation showing the provider faxed the claim to the correct claims address with imprinted dates within the filing standard. Copies of the microfilmed claim with Magellan s date stamped within the filing standard. Copy of 2 nd level EDI acceptance reports. Copy of EOP from the medical/health plan vendor substantiating their denial date. Use the medical/health plan EOP denial date to calculate the timely filing requirement. Timely Filing due to wrong insurance info The Managed Care Plan shall reimburse providers for the delivery of authorized services as described in s , F.S., including, but not limited to: The provider must mail or electronically submit the claim to the Managed Care Plan within six months after the date of service or discharge from an inpatient setting or the date that the provider was furnished with the correct name and address of the Managed Care Plan. Please provide any proof that the provider/facility had obtained incorrect insurance information during the time of admission such as a hospital admission face sheet as well as any documentation showing the date the provider/facility was made aware of the correct insurance. Duplicate Claim Appeal Request Request for claim appeal was received. However, case has previously been appealed and processed on XX/XX/XXXX. Visit Reimbursement Limitations Office, home, and hospital visits are limited to one visit, per recipient, per day, per specialty. Bill Type 117 for Corrected Claim with no Prior Claim on File We have received your corrected claim with type of bill 117 on xx/xx/xxxx. However, our records indicate that Magellan Complete Care has not received a prior claim for the requested date of service. Please submit the claim with the correct type of bill to P.O Maryland Heights, MO Decision for Surgery, Modifier 57- E/M code on the same date of Surgery Evaluation and management services on the day of surgery are included in the payment for a global surgery and are not reimbursable in addition to the surgical procedure codes , unless the visit includes the initial decision for surgery and is billed with a modifier indicating a significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service. Confinement Date Prior to Effective Date When a member is admitted inpatient prior to their Magellan Complete Care effective date, Magellan Complete Care is not responsible for charges until the time of discharge. This rule is applied due to DRG pricing, therefore if information is supplied indicating that the prior carrier did not reimburse according to DRG pricing, then Magellan Complete Care may be responsible for services rendered as of the effective date with Magellan Complete Care. Service not Covered by Provider Degree Level The benefit plan does not cover <ENTER THE PROCEDURE CODE, WITH DESCRIPTION> rendered by this level of provider. If there is information that supports and/or documents that this service is covered under the plan for 5

7 this provider degree level, please submit that information to Magellan Complete Care ATTN: Claim Disputes Department PO BOX Miami FL Doppler and Echo Claims (Did not bill with Stress Echo or Echocardiography) Doppler claims are only eligible for payment if billed on the same day of service as a covered Stress Echo or Echocardiography code. The Doppler code was billed, but there is no Stress Echo or Echocardiography code billed on the same date of service. Doppler and Echo Claims (Did not bill with Allow Diagnosis Code) The Doppler code and Stress Echo code were billed on the same date without an Echocardiography, but an allowed diagnosis code was not billed on either the Doppler or Stress Echo. Corrected Claim Received Past Timely Filing Par Providers We have received your corrected claim and it has been processed. However, the corrected claim was received past timely filing for participating providers (180 days from the date of the claim denial). If you have any documentation that would assist as proof of timely filing please submit to the appeals mailing address for further review. Please note: Submitting any of the following information with your appeal is considered evidence that your claim was submitted in a timely manner: o Copy of a Magellan EOP with a date within the filing standard. o Copy of a letter/correspondence from Magellan with a date within the filing standard. o Certified or overnight mail receipts dated within the filing standard. o Facsimile confirmation showing the provider faxed the claim to the correct claims address with imprinted dates within the filing standard. o Copies of the microfilmed claim with Magellan s date stamped within the filing standard. o Copy of 2 nd level EDI acceptance reports. o Copy of EOP from the medical/health plan vendor substantiating their denial date. Use the medical/health plan EOP denial date to calculate the timely filing requirement. Corrected Claim Received Past Timely Filing Non Par Providers We have received your corrected claim and it has been processed. However, the corrected claim was received past timely filing for non-participating providers (365 days from the date of the claim denial). If you have any documentation that would assist as proof of timely filing please submit to the appeals mailing address for further review. Please note: Submitting any of the following information with your appeal is considered evidence that your claim was submitted in a timely manner: o Copy of a Magellan EOP with a date within the filing standard. o Copy of a letter/correspondence from Magellan with a date within the filing standard. o Certified or overnight mail receipts dated within the filing standard. o Facsimile confirmation showing the provider faxed the claim to the correct claims address with imprinted dates within the filing standard. o Copies of the microfilmed claim with Magellan s date stamped within the filing standard. o Copy of 2 nd level EDI acceptance reports. o Copy of EOP from the medical/health plan vendor substantiating their denial date. Use the medical/health plan EOP denial date to calculate the timely filing requirement. 6

8 MD Consult Project We have received your request; however, we are missing the consultation report/ medical records. Please submit the consultation report/medical records for services rendered from to to Magellan Complete Care ATTN: Claim Disputes Department PO BOX Miami FL We have received your request; however, we are missing the consultation report/medical records provided by the rendering provider listed on the claim. Please submit the consultation report/medical records for services rendered by [NAME OF PROVIDER] to Magellan Complete Care ATTN: Claim Disputes Department PO BOX Miami FL Magellan is Secondary Payor We have received your request for review of [claim #] in the amount of [$$$$] for services rendered to [patient name] on [dates of service]. Magellan Complete Care is not the primary payor for this member. As the secondary payor, Magellan Complete Care can only reimburse the difference between the allowed amount and the amount paid by the primary payor, if any. REV Code 0450 We have received your request for review of [claim #] in the amount of [$$$$] for services rendered to [patient name] on [dates of service]. However, we are unable to process your request at this time. The service billed is not reimbursable without the appropriate CPT code. 45 Day Limit We have received your request, however we are missing the information that supports and/or documents that this claim is for emergency inpatient care, please submit that information as outlined in the appeals section. Please submit the records within 30 days of this notice to Magellan Complete Care Florida, Appeal Department C/O Emergent Care Review, P.O. BOX Miami, FL Non-covered Procedure/Rev Code We are unable to process your request at this time. The procedure/ revenue code, [enter procedure/ revenue code] is not a covered benefit under the Medicaid plan and is excluded from coverage under the plan. You may refer to the Medicaid website for more information on coverage Modifier UD/UC for Cesarean Delivery We are unable to process your request at this time. The obstetric procedure code requires the appropriate modifier indicating a medically necessary delivery prior to 39 weeks of gestation (modifier UB) or a delivery at 39 weeks of gestation or later (modifier UC). Submit a corrected claim to our claims department at PO 2097 Maryland Heights MO for reconsideration. Laboratory/ Modifier 91 We are unable to process your request at this time. The laboratory procedure code is missing the appropriate modifier indicating a repeat clinical diagnostic laboratory test. Submit a corrected claim to our claims department at PO 2097 Maryland Heights MO for reconsideration. 7

9 Radiology/ Modifier 76 - Repeat Procedure by Same Physician We are unable to process your request at this time. The radiology procedure code is missing the appropriate modifier indicating that a procedure or service was repeated subsequent to the original procedure or service by the same physician. Submit a corrected claim to our claims department with medical records at PO 2097 Maryland Heights MO for reconsideration. Radiology/ Modifier 77 - Repeat Procedure by Another Physician: We are unable to process your request at this time. The radiology procedure code is missing the appropriate modifier indicating that a basic procedure or service performed by another physician had to be repeated. Submit a corrected claim to our claims department with medical records at PO 2097 Maryland Heights MO for reconsideration. Modifier 25 We are unable to process your request at this time. The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient s condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. Submit a corrected claim to our claims department with medical records at PO 2097 Maryland Heights MO for reconsideration. Appeal for Duplicate Denial but Claim Previous Paid Our records show the claim was paid on [Insert date] with check # [Insert Check #] on previously received claim # [Insert Claim #]. Please check your records for receipt of payment. DRG Severity Level We have received your request to review the DRG pricing on [claim #]. According to the AHCA Florida Medicaid DRG Calculator, the severity level is determined by the average length of stay. The average length of stay on [claim #] is [enter # of days in claim], hence the severity level is [enter severity level]. After review of the claim, we have determined that the claim was correctly processed according to our claims processing rules. Charges excluded with approved auth on file According to Medicaid guidelines if there is no established Medicaid rate, provider must sign a SCA as well as have an authorization on file in order to be reimbursed by Magellan Complete Care. If you have any questions, contact the Customer Service Line for assistance. Provider submits refund in error Your request regarding refund submitted to Magellan in error has been processed. If there are no other outstanding balances on your account, Magellan will issue a refund within 6-8 weeks. Invisible Provider SRA Script: 8

10 DOS: XX/XX/XXX provided by NAME OF PROVIDER is to be paid. Appeals Unit verified that service was provided due to service note received by provider. As per Executive Management, no authorization line is required in TruCare and SRA to be sent for payment of same for MD/Ancillary services. RESOLVE TASKS Issue Authorization - INN Provider with No Authorization Authorization - OON Provider with No Authorization Benefit - Coordination of Benefits Issues Benefit - Not a covered benefit Billing/Claims - Billing errors Billing/Claims - Duplicate Claim Billing/Claims - Excluded Diagnosis Billing/Claims - Excluded Location Billing/Claims - Excluded Provider Billing/Claims - Incorrect Code Billing/Claims - Other Billing/Claims - Partial Denial Billing/Claims - Services cannot be performed same day Billing/Claims - Services provided were over the limit Billing/Claims- Underpayment Financial - Incorrect Claim Payment Amount Billing/Claims - Past Timely Filing Description Auth Related Denials Auth Related Denials COB/EOB Denials Service not covered Related Denial, charges excluded Provider billed incorrectly Duplicate Relate Denials Diagnosis no covered Related Denials POS not covered Denials Services not covered for provider degree, Medicaid Attest. Denials Code not covered by Medicaid Use for NCCI and ClaimChecks Denials and payment applied to deduction. Claim partially paid/denied. When the claim paid and partially denied for something there is no issue for. When more than one provider bills on the same date of the same specialty Maxed on benefits For underpayment For Overpayment Past Timely Filing Denials 9