Provider Healthcare Portal Secondary Claims Submissions and Updates. Indiana Health Coverage Programs DXC Technology June 2017

Transcription

1 Provider Healthcare Portal Secondary Claims Submissions and Updates Indiana Health Coverage Programs DXC Technology June 2017

2 2 Session Objectives When to include primary insurance information When is the primary EOB required for other insurance (TPL)? Completing Other Insurance (TPL) When is the primary Medicare or Medicare replacement plan EOB required? Completing Medicare or Medicare replacement plans Adding claim attachments Completing the IHCP Other Insurance (TPL)/Medicare Special Attachment Form How to submit Other Insurance (TPL) updates What is appropriate to send to Provider Written Correspondence Updates Program Integrity Helpful tools Questions

3 When is the primary EOB required for Other Insurance (TPL)? When the TPL has denied the service as noncovered Exception If the TPL primary EOB contains an acceptable denial ARC code, the secondary windows can be completed with the ARC code, and no EOB is required When TPL has applied the entire amount to the copay, co-insurance, or deductible Services that are NONCOVERED by the primary are NOT filed as a secondary claim. The secondary windows may be completed to bypass the need for the primary EOB attachment for TPL CLAIMS only 3

4 When is the primary EOB for Other Insurance information (TPL) not needed? The primary insurance COVERS the service and has PAID on the claim Actual dollars were received 4

5 How to complete Other Insurance (TPL) on the Provider Healthcare Portal

6 6 Step 1: Other Insurance (TPL) at the header

7 7 Step 2: Other Insurance (TPL) Header

8 8 Step 3: Other Insurance (TPL) header

9 9 Step 4: Other Insurance (TPL) Header

10 10 Step 1: Other Insurance (TPL) detail

11 11 Step 2: Other Insurance (TPL) detail

12 12 Step 3: Other Insurance (TPL) additional details

13 13 Step 4: Other Insurance (TPL) additional details

14 When is the primary Medicare or Medicare Replacement Plan EOB required? When Medicare or the Medicare Replacement Plan denies the service 14

15 When is the primary EOB for Medicare or Medicare replacement plans not needed? The Medicare or Medicare Replacement Plan COVERS the service. Actual dollars were received Entire or partial amount was applied to deductible, co-insurance or copay 15

16 How to complete Medicare or Medicare replacement plans on the Provider Healthcare Portal

17 17 Step 1: Medicare or Medicare replacement plans header

18 18 Step 2: Medicare or Medicare replacement plan header

19 19 Step 3: Medicare or Medicare replacement plan header

20 20 Step 4: Medicare or Medicare replacement plan header

21 21 Step 5: Medicare or Medicare replacement plan header

22 22 Step 6: Medicare or Medicare replacement plan header

23 23 Step 1: Medicare or Medicare replacement plan at detail

24 24 Step 2: Medicare or Medicare replacement plan at detail

25 25 Step 3: Medicare or Medicare replacement plan at detail

26 26 Step 4: Medicare or Medicare replacement plan at detail

27 27 Step 5: Medicare or Medicare replacement plan at detail

28 28 Step 6: Medicare or Medicare replacement plan at additional details

29 29 Step 7: Medicare or Medicare replacement plan at additional details

30 30 Step 8: Medicare or Medicare replacement plan at additional details

31 31 Step 9: Medicare or Medicare replacement plan at additional details

32 32 Step 10: Medicare or Medicare replacement plan at additional details

33 How to copy an existing claim to add other insurance Search for claim by Member ID and dates of service to see if the claim is in the system. If it is not, complete the required claim information. 33

34 How to complete Other Insurance on the Provider Healthcare Portal Look at the EOB code to make sure the claim is only denying for primary insurance 34

35 How to complete Other Insurance on the Provider Healthcare Portal Copy the ENTIRE CLAIM 35

36 How to complete Other Insurance on the Provider Healthcare Portal If the primary PAID the claim even if it was applied to a deductible check the box to Include Other Insurance If the primary DENIED as non-covered: Include Other Insurance is BLANK do not add insurance information. ATTACH THE PRIMARY EOB, or For TPL claims only, check Include Other Insurance and add the APPROPRIATE ARC code to bypass the need for the EOB 36

37 Submit the claim adding claim attachments

38 Adding claim attachments When the primary EOB is required, use the Attachments feature 38

39 39 Submit the claim

40 40 Submit the claim

41 How to complete the IHCP Other Insurance (TPL)/Medicare Special Attachment Form

42 TPL and Medicare crossover billing paper claims The IHCP encourages providers to use electronic transactions or the Portal for submitting claims that contain TPL or Medicare information. For providers that choose to submit claims on paper, the Third-Party Liability (TPL)/Medicare Special Attachment Form must be submitted to provide detail-level TPL and Medicare information. > Forms > Claim Forms (Nonpharmacy) Paper claim forms require this form be attached. Claims received without this form will deny for explanation of benefits (EOB) 655 Missing/Invalid other payer reject code. Form is NOT required for inpatient or long-term care claims. 42

43 43 IHCP Third-Party Liability (TPL)/Medicare Special Attachment Form

44 How to submit Other Insurance (TPL) updates on the Provider Healthcare Portal

45 45 How to submit Other Insurance (TPL) updates

46 46 How to submit Other Insurance (TPL) updates

47 47 How to submit Other Insurance (TPL) updates

48 48 How to submit Other Insurance (TPL) updates

49 How to submit Other Insurance (TPL) updates Add any available attachments to support the request. 49

50 What is appropriate to send to Provider Written Correspondence

51 When to use Written Correspondence Written Correspondence requests that providers submit via the Portal should be submitted for the same reasons that providers submit paper Written Correspondence inquiries or administrative review requests: Provider disagrees with claim payment or denial Provider is requesting a copy of an RA from before February 13, 2017 Provider disagrees with clam denial due to benefit limit having been reached Provider is requesting administrative review of an NCCI claim denial 51

52 When to use Written Correspondence Include all pertinent documentation supporting reconsideration with the secure correspondence, form, including the claim form and proof of timely filing, if required. Document: The unusual circumstances in which the provider believes the claim was coded correctly and would like a reconsideration of the NCCI editing. The reason for disagreement. The denial reason and the reason the payment is being disputed. File the formal administrative review request within 60 calendar days of notification of claim payment or denial from DXC Technology. The date of notification is considered the date on the RA. 52

53 When not to use Written Correspondence Providers should not use Written Correspondence to: Check claim status Claim status can be determined by checking RA statements or inquiring through the Portal or Interactive Voice Response system Submit claims unless specifically directed to do so. The provider should exhaust routine measures to obtain payment before filing an administrative review request. 53

54 Updates

55 Rendering linkage (EOB 1010) The IHCP has temporarily converted EOB 1010, ARC B7, and Remark N570 to post-and-pay status, meaning that the system will allow claims and claim details with the issue to pay. However, the EOB 1010, ARC B7, and Remark N570 messages will continue to post on the RAs. The post-and-pay status will be in place through August 31, 2017, allowing providers ample time to link rendering providers to the appropriate group locations to support proper claims adjudication. Effective September 1, 2017, the EOB 1010, ARC B7, and Remark N570 will revert to a denial status. 55

56 Ordering, Prescribing, and Referring (OPR) Ordering, prescribing, and referring providers (OPR) will begin the revalidation process in June Because revalidation is a new process for OPRs, providers are encouraged to confirm that the OPR continues to be active even those the provider works with frequently before delivering a service by using the OPR Provider Search at indianamedicaid.com. OPR providers can revalidate on the Provider Healthcare Portal and mail the supporting pages to complete revalidation. Letters are being mailed to OPRs mail-to addresses. 56

57 Red-and-white claim form Effective January 1, 2018, all claims billed on professional (CMS-1500) (02-12) and institutional UB- 04 (CMS-1450) claim forms must be submitted on a standard red and white claim form. The IHCP will no longer accept copied (black and white) claim forms. Claims not received on the red-and-white claim form on or after January 1, 2018, will be returned to the provider. ADA Form 1260 is available only in black and white. 57

58 Program Integrity

59 Indiana Medicaid Program Integrity Audit Process Why must we audit? Program Integrity (PI) conducts retrospective reviews of Indiana Medicaid providers to evaluate and document patterns of healthcare provided to recipients. Additionally, PI works to ensure compliance with all applicable federal, state, and Indiana Medicaid guidelines, as well as recover any identified overpayments. This is facilitated through our Fraud & Abuse Detection System (FADS) contractors. Overpayments identified must be recovered in order to repay the federal portion of the Medicaid funds back to CMS.

60 Who else may audit Indiana Medicaid? Reviews can be initiated by other external entities in conjunction with IN Program Integrity, including, but not limited to: CMS Payment Error Rate Measurement (PERM) audit Establish state-wide error rate from sample audit CNI Advantage and The Lewin Group (vendors) 2017 Audit cycle began in late 2016 Record request letters can be expected by mid-summer 2017 Unified Program Integrity Contractor (UPIC) Has the ability to audit Medicare & Medicaid claims for providers Indiana UPIC vendor = NCI AdvanceMed

61 Who else may audit Indiana Medicaid? (cont.) Recovery Audit Contractor (RAC) Department of Health & Human Services Office of Inspector General Indiana Medicaid Fraud Control Unit (MFCU)

62 Helpful tools

63 Helpful Tools IHCP website at indianamedicaid.com IHCP Provider Reference Modules Medical Policy Manual Customer Assistance Provider Relations Field Consultants indianamedicaid.com > Provider Home page > Contact Us Written Correspondence DXC Technology Provider Written Correspondence P.O. Box 7263 Indianapolis, In Secure correspondence via the Provider Healthcare Portal 63

64 Questions