Claim Adjustment Process. HP Provider Relations/October 2015

Transcription

1 Claim Adjustment Process HP Provider Relations/October 2015

2 Agenda Types of adjustments System-initiated adjustments Web interchange adjustment process Void feature Paper adjustment process Timely filing limitations Adjustment mailing addresses Administrative review and appeal process Resources available Q&A 2

3 Types of Adjustments

4 Remember Only PAID claims can be adjusted If a claim adjustment is submitted for a claim that has been denied, the paper adjustment will be returned Electronic adjustments can be performed online If a claim has been denied, please review the RA error codes Additional Information for billing requirements is found in the IHCP Provider Manual, Chapter 8 Adjustment information/instruction can be found in Chapter 10 4

5 Region Adjustment Codes ICNs (Internal Control Numbers) 50 Provider-initiated noncheck-related adjustments 51 Provider-initiated check-related adjustments 54 Void transaction 55 Mass adjustment nursing facility retroactive rate 56 Mass adjustment 61 Electronic replacement with attachment or claim notes 62 Electronic replacement without attachment or claim notes 63 Electronic Void of a paid claim This information is located in Chapter 10 5

6 Noncheck-related Adjustments Refunds without a check Initiated by the provider due to an underpayment or an overpayment Providers DO NOT mail a refund check with this type of adjustment Examples of noncheck-related adjustments: Underpayment adjustment The claim not paid at the rate expected Partial payment adjustment The claim was overpaid The overpayment amount is deducted from future claim payments through an accounts receivable offset Full claim adjustment The provider was overpaid on the entire claim; the entire claim is recouped ICNs begin with 50 6

7 Check-related Adjustments Check-related adjustments must be completed with the paper Adjustment Request Form Adjustment forms are located under the Forms menu at indianamedicaid.com Provider sends a check in the amount of the excess payment with the adjustment form ICNs begin with 51 7

8 Electronic Replacement with Attachment A replacement claim is an electronic adjustment using Web interchange A previously submitted claim, whether electronic or paper, can be replaced electronically Only noncheck-related replacements are accepted electronically ICNs begin with 61 8

9 How to Find Instructions for Claim Attachments Quick Reference Guide 9

10 Attachment Process Complete all the required claim information 10

11 Web Claim Submission Attachments Create the Attachment Control Number (ACN) Unique number assigned by provider Claim- and document-specific Each ACN may only be used one time Enter the appropriate Report Type Code Report Type describes the document being sent Transmission Code defaults to BM (by mail) Electronic and ed attachments are not accepted 11

12 Report Type Codes to use for Attachments 12

13 Electronic Replacement without Attachment A claim that was submitted previously whether electronic or paper may be replaced electronically via Web InterChange ICNs begin with a 62 13

14 System-initiated Adjustments

15 Retroactive Rate Adjustments Myers & Stauffer initiates retroactive rate adjustments for long-term care facilities Retroactive rate adjustments are performed when the rates for the long term care facilities increase or decrease. Claims paid for the dates of service affected are reprocessed and can result in increased or decreased payments ICNs begin with 55 15

16 Mass Adjustments The State can initiate a mass adjustment Mass adjustment requests are applied to change a large number of paid claims at one time Mass adjustments can apply to many providers or just one provider Mass adjustments can be used when a system problem caused claims to be paid incorrectly, or when a rate for a procedure code changed retroactively ICNs begin with 56 16

17 Web interchange Adjustment Process

18 Claim Inquiry 18

19 Web interchange Replacement Claims Replacing a claim changes an original claim and can be performed at anytime. Original claim indicates the most recent ICN assigned to that claim Note: Claim must be replaced within 60 days of the original claim submission Only noncheck-related replacements are accepted electronically Check-related replacements continue to be submitted on paper 19

20 Replacement Feature Filing limits for replacements Filing limit rules apply for replacement requests Electronic claims adjusted after one year from the date of service will result in an automatic full recoupment; adjustments must be submitted using the paper adjustment form if over one year from date of service The system compares the date of service to the date of the current activity to make sure that a year has not passed Web interchange will not display a Replace This Claim button on claims older than one year from the claim s Remittance Advice (RA) date These replacements must be submitted on paper 20

21 How to Replace a Claim 21

22 Claim Submission Professional Detail information 22

23 Void Feature

24 Web interchange Void Feature 24

25 Void Feature Void is a Health Insurance Portability and Accountability Act (HIPAA) term for adjustment Void is the cancellation of an entire claim, whether the original claim was sent the same day, same week, or a claim that has been processed previously Void requests can be submitted electronically using the 837 transaction or Web interchange Void requests submitted electronically can be for a previously submitted electronic claim or paper claim Voids cannot be performed on a claim in a denied status A void can only be performed on a claim in a paid or suspended status 25

26 Void Feature If the voiding of a claim occurs the same day or week that the original claim was submitted, a new ICN is not created 26 The same ICN assigned to the claim applies to the void The original claim denies with edit 0120 Claim denied due to an electronic void request If the original claim being voided is a historical claim, a new ICN is created The new ICN starts with 63 Examples of claim voids Billed incorrect member for services not received Billed incorrect member ID (RID) Billed incorrect billing provider NPI Claim was paid as Medicaid primary when member had Medicare/Primary insurance that paid the full amount or more than Medicaid allowed. Voiding the claim will recoup the reimbursement

27 Paper Adjustment Process

28 Paper Adjustment Process Always submit claim adjustments via paper when: Submitting a check-related adjustment The date you are requesting the adjustment is more than one year from the date of service Past filing documentation must be submitted with the adjustment request Refer to BT for timely filing guidelines Providers may submit an adjustment on the overpaid detail line without causing a recoupment of the entire claim 28

29 Adjustment Forms Types of paper adjustment forms CMS-1500, Dental, Crossover Part B Paid Claim Adjustment Request, UB-04 Inpatient/ Outpatient Crossover Adjustment Request indianamedicaid.com > Providers > Quick Links > Forms > Claim Adjustment Forms (Nonpharmacy) Instructions will print with each form All relevant information on the form must be completed, or the form will be returned Attach copies of the Medicare and/or Third Party Liability (TPL) remittance notices, if applicable 29

30 CMS-1500, Dental, Crossover Part B 30

31 31

32 32

33 UB-04 and Inpatient/Outpatient Crossover Adjustment Request 33

34 34

35 35

36 Timely Filing Limitations

37 Timely Filing Limitations Documentation to waive timely filing limits Commonly accepted documentation for waiving timely filing limit: A print-screen of the Web interchange Claim Inquiry screen, showing all the previous submission attempts Dated paper RAs with bills, dated claim forms, dated letters to and from insurers or the insured Dated explanations of benefits (EOBs) from the primary insurer Written Inquiry responses, Indiana Prior Review and Authorization Request Decision Forms, dated letters and s to and from the county Division of Family Resources (DFR) offices and the member 37

38 Timely Filing Limitations Documentation to waive timely filing limits Commonly accepted documentation for waiving timely filing limit: A print-screen of the Web interchange Claim Inquiry screen, showing all the previous submission attempts Dated paper RAs with bills, dated claim forms, dated letters to and from insurers or the insured Dated explanations of benefits (EOBs) from the primary insurer Written Inquiry responses, Indiana Prior Review and Authorization Request Decision Forms, dated letters and s to and from the county Division of Family Resources (DFR) offices and the member 38

39 Timely Filing Limitations Initial claims must be filed within one year from the date services are rendered The one-year timely filing limit is extended in the following circumstances: member s eligibility is effective retroactively prior authorization (PA) for a service is approved retroactively IHCP policy change is effective retroactively third-party payer notification is delayed If claim submissions all denied for the same reason and no changes were made, refiling the claims will not extend the filing limit. Reference BT or additional information on filing limits and appeal processes. 39

40 Proof of Timely Filing Claim Inquiry Screen 40

41 Timely Filing Limitations Waiving the timely filing limit HP may waive the timely filing limit when the following can be documented: HP, State, or county error or action has delayed payment A member has been enrolled in the IHCP retroactively 41

42 Timely Filing Limitations Electronic claims To submit documentation to waive timely filing limits with electronic claims: Click the Attachments button and follow the Attachment process to mail the documentation Place supporting documentation in chronological order behind the Attachment Cover Sheet 42

43 Timely Filing Limitations Paper claims Submit legible and signed (if necessary) paper claims photocopies are acceptable Attach supporting documentation as needed (example: Consent for Sterilization Form) Place documentation to waive timely filing limits in chronological order behind the adjustment form Each claim must have its own documentation Address any gaps in timely filing limit documentation Use correct address; there is no separate address for timely filing limit adjustments 43

44 Adjustment Mailing Addresses

45 Where to Submit Adjustment Requests Forward noncheck-related and underpayment adjustment requests to: HP Adjustments PO Box 7265 Indianapolis, IN Forward check-related adjustments to: HP Refunds PO Box 2303, Dept. 130 Indianapolis, IN Return uncashed IHCP checks to: HP Finance Unit 950 N. Meridian, Suite 1150 Indianapolis, IN

46 Where to Submit Adjustment Requests This information can be located on the Quick Reference Guide located under the Contact Us Link on the IHCP website Send refunds for Community Alternatives to Psychiatric Residential Treatment Facilities (CA-PRTF) claims to: HP/CA-PRTF Refunds PO Box 7247 Indianapolis, IN Send Money Follows the Person (MFP) refunds to: HP/MFP Refunds PO Box 7194 Indianapolis, IN

47 Administrative Review and Appeal Process

48 Administrative Review An administrative review may be requested when a provider disagrees with the way a payment was determined or a claim was denied Before requesting an administrative review, providers must exhaust routine measures to obtain the desired payment, including: Correct billing and resubmit claim Claim adjustment When requesting an adjustment for a paid claim, include documentation explaining the reason the provider disagrees with the IHCP payment Administrative Review Inquiries should be submitted to the HP Written Correspondence Unit Note: These steps are not considered to be an appeal of a claim 48

49 Administrative Review A formal administrative review must be filed within 60 days of notification of claim payment or denial from HP Send the administrative review form, claim, and all pertinent supporting data to the following address: Administrative Review HP Written Correspondence PO Box 7263 Indianapolis, IN Providers receive a response within 90 days of the request Note: If the request for administrative review is for a National Correct Coding Initiative denial, an appeal must be filed within 60 days of the date on the RA 49

50 Process for NCCI edits BT National Correct Coding Initiative The Indiana Health Coverage Programs (IHCP) implemented three basic coding concepts as required by NCCI editing requirements to the IndianaAIM claims processing system: NCCI Column I and Column II edits Mutually Exclusive (ME) edits Medical Unlikely Edits (MUE) The NCCI Policy Manual, as well as other publications related to NCCI claim editing, are located on the CMS Web site. 50

51 Administrative Review Form Located on the IHCP website under Forms Provider Correspondence Forms 51

52 Appeal Process A formal appeal may be requested after the administrative review process has been exhausted Appeal requests must be made to the following address within 15 days of receipt of the final administrative review decision: Secretary c/o Office of Medicaid Policy and Planning MS07 Indiana Family and Social Services Administration 402 W. Washington Street, Room W382 Indianapolis, IN

53 Resources Available

54 Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual Customer Assistance Locate area consultant map on: indianamedicaid.com (provider home page > Contact Us > Provider Relations Field Consultants) or Web interchange > Help > Contact Us Written Correspondence HP Provider Written Correspondence PO Box 7263 Indianapolis, IN

55 Q&A