Qtr. 3, 2009 Volume 1

Transcription

1 West Virginia Medicaid Provider Update Bulletin. DME Claims Processing Updates Redesign Plans with Annual Limits of $1000 Medicaid Contact Unisys to verify limits on individual members Contact WVMI for PA when $1000 limit has been met Encourage members to enroll in Enhanced Plan Member responsible for services received outside limits of plan -- See MHC Policy Manual Mountain Health Choice Plans Cost Invoice Submission Requirements Refer to Chapter 506 DME/Medical Supplies of the provider manuals located at for the cost invoice requirement of each HCPCS code. Submit Cost Invoice to WVMI for services requiring PA Submit Cost Invoice with claim to Unisys for services that do not require PA Cost Quotes will not be accepted Provider Enrollment Requirements and Updates Every DME location must have it s own Legacy/NPI Number Send in updated licensure (Business/Vendor) to avoid delayed payments Enrollment applications will not be backdated A4221-A4222 Documentation Requirements For those claims where Medicaid is the primary payer require the WV Bureau for Medical Services Home Infusion Therapy Prior Authorization Request Form completed by Rational Drug Therapy Program (RDT) Medicare primary claims require documentation of a physician order Both must be submitted on paper Qtr. 3, 2009 Volume 1 Inside This Issue: DME Claims Processing Updates... 1 General Claims Processing Updates... 1 BMS Web Page Changes... 2 MR/DD Waiver Updates... 2 BMS Web Page Updates... 2 Medicaid Redesign... 2 Web Portal Updates... 3 Common Errors Resulting in Returned Claims or Processing Delays...4 How to Monitor Claims Submission and Determine Future Payments...4 Provider Appeals... 4 Legacy IDs Required for PAAS Approval... 5 What We Can Do Together...5 What We are Doing in Provider Services to Better Serve the Provider Community...5 Dental Corner... 6 What the Provider Community Can Do for Provider Relations...7 Timely Filing Policy...8 A Tip When Billing Secondary Claims...9 Non-Emergency Transport Providers: Reimbursement Rate Change...9 Inappropriate CPT Code Denials...9 Facilitating Payment for Sterilization and Hysterectomy Procedures...9 Acute Care and Critical Access Hospitals...9 Unisys Provider Relations Territory Map New Provider Relations Manager...11 Unisys AVRS Prompt Tree...11 General Claims Processing Updates Finance Contact Provider Enrollment to change Tax ID s, Addresses, etc. Do not send checks to correct overpayments or monies paid to provider in error - Contact Provider Relations for specific instructions: (option #3) Claims that have been submitted with NPI complications causing errors will be voided - Contact the EDI Help Desk for specific instructions: (option #6) Web Portal Effective 7/1/08 Rejection Reports (824) are no longer accepted as proof of timely filing Assistance with registration and training available Functions include claims submission, claim and eligibility status, resources, and reports for management of Accounts Receivables 1

2 MR/DD Waiver Updates Timeline In order to receive a weekly payment, claims are required to be submitted by 5:00 pm on Tuesday Billing Requirements of April 1, 2008 Prior authorization number is required to be billed on claims for all MR/DD Waiver Services. - Failure to do so, could result in a delay in processing For electronic submission, prior authorization number must be submitted at the Header level (loop 2300 ref 02) Each service has to be billed separately (claim) along with the corresponding prior authorization number - For example: T1015 with U1, U2, U3 - This is considered 3 separate services which would require 3 separate claims along with 3 corresponding authorization numbers If billing for more than one service per claim, entire claim will be denied. To avoid delay in processing, please make sure the authorization number being billed matches the service code that was authorized. WV Medicaid (BMS) Web Page Changes Chapters 500 Each provider type will now have a chapter number Hospital is now 510; Practitioner is now 519, etc. Chapter 700 was renamed to Chapter 800 The Appendices no longer exist. Exception: Billing Instructions are now located at the Unisys web page Mountain Health Choices - Medicaid Redesign The medical cards for members in the Redesign Program are designated with BA or BC for Basic Adult or Basic Child and EA or EC for Enhanced Adult or Enhanced Child respectively. Members not placed in Redesign are in the Traditional program and are designated with TR on the medical card. This indicator is on the same line as the MA ID #, name, birth date, etc. Members in these plans are considered children through the age of 17 and are adults at age 18. Information may be obtained from the BMS website, under Mountain Health Choices. Mountain Health Choices webpage is Medicaid_Redesign/MedRedesign_main.asp. The Mountain Health Choices Manual, Chapter 527, may be found under Manuals on the home page, 2

3 Web Portal Updates Enchancement to the Patient Default Manager (PDM) As of February 2, 2009, the PDM has been configured to allow a provider to save and submit claims using their NPI information. To update your Roster, use the Edit function on the Manage PDM Roster page. When editing, make sure you do not have both your WV Medicaid Provider ID and NPI fields populated. Please note: When using Taxonomy code(s), be advised that the PDM will allow you to save a Taxonomy code to both the Billing and the Group Provider, however when both are populated Unisys will only capture the Group Provider Taxonomy code in the claims processing system. If you have questions about billing your electronic claims using your NPI numbers please contact the Unisys EDI Help Desk. When entering the PAAS, Referring and Attending provider numbers you will continue to use the West Virginia Medicaid Provider Number. If you have questions about making sure your NPI is on file with Unisys you may contact the Enrollment Department, both can be reached at *This does not apply to atypical providers, i.e. non emergency transportation is not required to use NPI. Note to Nursing Home Providers: Please make sure to bill with NPI numbers when submittng your claims. 276/277 Claim Status Request/Response Update Effective February 7, 2009, the Claim Status option has been updated to accommodate NPI submissions to the web portal. Please note: If your NPI is a One To Many (NPI is linked to more than one Medicaid Legacy ID), the Organization name field(s) will need to match exactly as we have it on file in order for your response to come back correctly. For assistance, contact the EDI Helpdesk at , option 6. Attention Upload & VAN Submitters: Partial 977 Acknowledgements On February 28, 2009, Unisys implemented a correction to the 997 transaction. In the past when the value of E was reported in the AK501, the value of R was incorrectly reported in the AK901. After 02/28/09, when a value of E is reported in the AK501, the AK901 will now report a value of A. All other values reported in the AK5 and AK9 will remain unchanged. Please contact the Unisys EDI Help Desk if you have any questions at , option 6. Absent Diagnosis Codes Results In Rejection All transactions submitted without valid diagnosis codes will result in 824 rejection reports. Decimal Points Within Unit Submissions Effective March 2, 2009, electronic and paper claims received with a decimal point within the unit field will be returned/ rejected to the provider. Only whole numbers are accepted. Please see specific manuals for information on rounding. Note: This does not apply to NDC billing. Decimals may still be used in the shaded area of field 24D of the CMS-1500 and field 43 of the UB-04 per the current billing instructions. Please contact Provider Relations if you have questions. When Issuing a Check to Medicaid for Overpayments, Reversals, etc. Beginning in March 2009 when a check is provided as payment, this will constitute authorization to use the information from the check to be used as a one-time electronic fund transfer from your account or to process the payment as an image transaction. For inquiries, please call WV State Treasurer s Office at When information is used from your check to make an electronic funds transfer, funds may be withdrawn from your account as soon as the same day payment is made, and you may not receive your check back from your financial institution. 3

4 Common Errors Resulting in Returned Claims or Processing Delays Omission of diagnosis codes Omission of diagnosis indicator on CMS 1500 claim forms or referencing incorrectly Omission of Place of Service Printer Issues--Information must be aligned with claim fields Indication of prior payments on claim service lines - Negative amounts indicated - Do NOT bill negative amounts on claims. - Claim total and billed charges mismatch Illegible handwritten claims How to Monitor Claims Submission and Determine Future Payments Even if you are submitting claims through a Vendor or Clearing House, you can register to use the web portal for resources and reports not otherwise available. You can register for the Web Portal without changing how you submit your claims. Those registered to use our Web Portal have access to reports which will allow you to confirm claims received and determine future payments. This information is available on the Claims in Process Report which categorizes received claims by To Be Paid, To Be Denied, and In Process. This information will reduce the number of resubmitted claims because you are not sure if the claim was received. You will have early notification of a denial so that these can be corrected and resubmitted. The claims listed as In Process are claims received but not yet processed or pended for manual review so that the status is not determined at the time the report is generated. Those claims will move to the category To Be Paid or To Be Denied on the following reports. Some of these may remain in a PEND status until manually reviewed. In addition to the Claims in Process Report, you would also receive a Check Report which confirms deposits to your bank accounts. If you are not registered for a Web Portal account and are receiving your remittance by mail, you do not have access to the Claims in Process Report or Check Reports. You may want to consider receiving electronic remittances. Benefits of the electronic remittance includes earlier receipt, has option to save and retrieve at a later date for proof of filing, and you may print paper copy which the same as you are receiving now. The change will be effective immediately and you will not miss receipt of any reports. The Web Portal also allows you to submit secondary billing electronically, to process Reversals and Replacements, to submit Claims Status and Eligibility inquiries. You can submit up to twenty (20) inquiries at a time. The Claim Status inquiry option is an excellent way to work your Aging Report. If you have internet access, we encourage you to take advantage of these resources and offer free assistance with registration and on-site training. For those interested in registering, please contact the EDI Helpdesk at Unisys at , following options to #6. Provider Appeals All appeals must be submitted within 30 days of the adverse reaction (denied claim). Appeals may be submitted if you have a dispute regarding your participation as a Medicaid provider or a denied request for authorization. Most denied payments are due to billing errors and not considered appeals. Please contact Provider Relations for billing information or to explain reasons for denials. True appeals must be submitted directly to the Commissioner for the Bureau for Medical Services at 350 Capitol Street, Room 251 Charleston, WV Please follow directions outlined in Chapter General Administration at 4

5 Legacy Numbers Required for PAAS Approval NOTE: NPI will work for PAAS approval when it is linked to more than one Medicaid legacy number. The Legacy Provider number (WV Medicaid provider ID) is preferred when billing a PAAS (approval)#. The PAAS approval # is to be billed as follows: CMS1500: PAAS # in Field 19 UB-04: PAAS # in Field 78 The provider must also bill the appropriate qualifiers when entering PAAS # s: Legacy numbers: 1D Qualifier NPI numbers: XX Qualifier What We Can Do Together Commit to the expertise of one another. We know that you are very dedicated in your work and strive to maintain education and training of your staff. We know that you truly are the experts. Towards that end we have confidence in you and are committed to listening to you. We invite your comments and recommendations. These may be submitted through We want to foster an environment where there is mutual trust. We are dedicated to the training and education of our staff so that they can meet your needs. We take approximately 1100 calls per day and strive to always give you accurate information. We encourage you to always write down the name of the person that you speak with and the date of the conversation. Our system does catalog all phone contacts and we can reference that data. If you feel you are getting inconsistent answers, please bring that to the attention of the Provider Services Manager rather than increase call volume by calling different representatives with the same question. Our promise to you..we will work with you to develop mutual trust, by maximizing resources and exchange of ideas, thereby improving communication on all levels. What We Are Doing in Provider Services to Better Serve the Provider Community We continuously analyze telephone metrics for the call center to assure agent availability at peak call times and throughout the day to better service our providers and members. We are intensifying our efforts to cross train all staff to cover for lunch, breaks, unexpected absences, vacations, etc. We are in joint collaboration with BMS and our Quality Assurance Department to conduct quality audit reviews for all manuals, policies, provider and member calls, and other forms of communication as appropriate. We conduct weekly and monthly meetings for training/education, updates, etc. to increase effective communication. We are implementing a new process of documenting and notifying all teams of changes in departmental processes, policies, etc., as recommended by BMS, members, and the provider community.and we re just getting started! 5

6 Dental Corner Unisys Invites You to Join the Web Portal! Unisys would like to invite all Dental Providers to join the thousands of other West Virginia Medicaid Providers that currently utilize the Web Portal to submit, monitor and track claims. Other than having a better understanding of how your claims are processed, you can improve cash flow by tracking denied claims and getting them corrected and resubmitted without the delay of waiting for paper Remittance Advices to be mailed. By the way, are you aware you can receive your Remittance Advices electronically every Monday without waiting on a mailed copy simply by logging into our website? Also, if you elect to receive your Remittance Advice electronically you will receive additional reports that are not included with your paper remit, such as: Electronic Fund Transfer (EFT) Reports that confirm the dollar amount and date of transfer. EFT s are available the day the funds are transferred to your account. The Claims in Process Report (CIP) posts to the Web Portal every Friday giving you a complete list of claims that have not yet finalized. This keeps you updated on projected payments, gives you advance notice on claims that will deny or pend for review, and decreases the need for claim resubmissions. The following assistance is available for Web Portal to help maximize your use of all functionality: On Site Training by a Provider Field Representative Technical Assistance from 8:00 a.m.- 5:00 p.m. (M-F) Web Portal registration Coordination with soft ware vendors and clearing houses The following resources are available on the Web Portal to assist you in managing claim submissions and payments: Provider Alerts Resources, Billing Instructions Claims Status and Eligibility Reports Rejected Claim Report If you are interested in utilizing the Web Portal, please call our Provider Services Department at , enter NPI # and select option 6 or visit The Top 10 Denial Reasons for Dental Claims are: Dental Billing Tips Duplicate Mem/DOS/Service code/rendering Phys/Modifier CDT already billed on this date CDT already billed on this date by the same provider No Active Provider Contract No enrollment Segment HMO Guidelines Apply Benefit has age Age Restriction No Benefit for Service Benefit Visit Limit Exceeded Claim Total Mismatch When primary payments are made, do not indicate payment made by the primary as a negative amount in block number 30 Description and then reduce total of claim by amount of prior payment. This can result in a denial or incorrect payment. When claims with negative amounts are noticed by the mail room they are pulled out to be manually priced. This causes your claims processing to be delayed. What we need is the correct total of charges on the claim with the EOB attached. Unisys claims processors will code the primary payment information for you. If you are seeing a high volume of these denials in your office we advise you to call Unisys Provider Relations at for assistance. You may also contact your respective Provider Representative for an on site visit to resolve these issues. 6

7 What the Provider Community Can Do For Provider Relations Use Resources! Many of your questions can be answered by referring to your Provider Manuals located on the BMS web site at At this location you can find policy, procedure, payment information, RBRVS, reimbursement methodology, as well as links to resources necessary in your day-to-day activities. Other resources and short cuts to your day-to-day activities may be located on Unisys web site at com. At this location you can find forms necessary for completing address changes, enrollment changes, and banking changes. You will also find forms for completing Reversal and Replacement claims along with the instructions. The site also provides a listing of providers enrolled in the State Medicaid program which will assist you in locating specialty providers for your members. When registering for access to the Web Portal, you will be able to submit electronic claims transactions to include reversal/replacements, primary and secondary claims. Additionally, you will have access to Claims Status, Eligibility, Remittance Advice, EFT Reports, and the Claims in Process Reports. If you do not have a Web Portal account, you are not receiving all of the reports that are available to you! Free on site training and assistance is offered by our two Provider Field/Training Representatives. This training includes web portal utilization, report generation, and claims submission / resolution; just to name a few. We encourage you to take advantage of the different forms of communication. We send out updates on the Remittance Banner Pages. We place announcements on both the Unisys and BMS websites. Newsletters and bulletins are mailed out to the provider community, sending this information to the address that we have in your provider enrollment file. If you are not receiving this type of information, please contact Unisys, Provider Enrollment for update on your mailing information. Familiarize Your Office with Processing Guidelines and Maximize those Times -Claims should be submitted on a regular basis. -Claims should be submitted by Wednesday by 5:00 p.m. to be processed in weekly payment cycle. -MR/DD Waiver claims should be submitted by Tuesday by 5:00 to be processed in weekly payment cycle. -MR/DD Waiver Reversal/Replacements should be submitted by Monday by 5:00 p.m. to be processed in a weekly payment cycle. Know Who to Call Provider Enrollment for licensure issues, address, phone updates, and specialty enrollment criteria. Provider Representatives for claim status, explanation of edits, and other general questions of concern. EDI Helpdesk for all Technical issues. They can address problems with the Web Portal, training on the Web Portal, and explanation of functions. Also, if you are having claims to deny, reject, or fail relating to NPI billing, the helpdesk can clarify changes needed to resolve the problem. Provider Field Representatives should be contacted if you have not resolved your issues by utilizing resources listed above. If you have a large number of outstanding claims and need assistance with claims resolution, they can help with training and education. 7

8 Timely Filing Policy To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service. The year is counted from the date of receipt to the from date on acms 1500, Dental or UB04. Claims that are over one year old must have been billed and received within the one year filing limit. (See exceptions below for Medicare primary claims and backdated medical cards.) The original claim must have had the following valid information: Valid provider number Valid member number Valid date of service Valid type of bill Claims that are over one year old must be submitted to Provider Relations at PO Box 2002 with a copy a remittance advice showing where the claim was received prior to turning a year old Claims with dates of service over two years old are NOT eligible for reimbursement This policy is applicable to reversal/replacement claims If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice to PO Box 2002 You are NOT allowed to add additional services to the replacement claim If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing Medicare Primary Claims Timely filing requirement for Medicare primary claims is one year from the EOMB date TPL Primary Claims Timely filing requirement for TPL, insurance primary claims is one year from the date of service Backdated Medicaid Cards If a member receives a backdated medical card and the provider wishes to accept it and bill Medicaid for services that occurred over a year ago, the claims must be billed within one year of the issuance of the card. Claims must be billed on paper with a copy of the medical card or letter of eligibility and mailed to Provider Relations address at PO Box 2002, Charleston, WV in order to verify the card is a backdated card. Special Exceptions for HMO Unisys will accept HMO Medicaid remits as proof of timely filing. The HMO must be one of the HMOs acting on behalf of Medicaid, not an HMO that has a private insurance policy for the member. The claim could be denied for timely filing from the HMO as they sometimes have a 3 month billing period, but if the date of denial is not over a year from the date of service it can be used as proof of timely filing. *Please note: 824 reports are no longer accepted as proof of timely filing. 8

9 A TIP WHEN BILLING SECONDARY CLAIMS When mailing paper secondary claims to Unisys you need to have an EOB/EOMB with each claim. Unisys mailroom is getting claims where the EOBs are separated from the claims. We are also receiving multiple claims for one member with only one EOB/EOMB attached. Please attach the EOB/EOMB with each claim. In the future, when large volumes of claims are submitted in this manner the claims will be returned unprocessed to the provider for correction. Attention Non-Emergency Transport Providers: Reimbursement Rate Change As a result of the most recent bi-annual review of the state s mileage reimbursement rate, the Bureau for Medical services will reduce its reimbursement for procedure code A0160 (Nonemergency transportation: per mile - member transportation by caseworker or social worker) to 45 cents per mile effective for services rendered on or after Tuesday, January 20, In order to receive correct payment, Providers must bill for these services with appropriate rates and/or date spans and Denied in Error CPT code was denying as mutually exclusive to CPT code As of Saturday, March 7, 2009 the claims system was enhanced to correct this issue. We will be adjusting claims for and back to date of service 08/01/2008 when was opened as a covered service. CPT code SL has occasionally denied due to an invalid procedure code/modifier combination. The system has been corrected so this will no longer occur. We will be adjusting claims for back to 10/01/2008 when the code became a VFC vaccine. Claim denials related to both of these issues will be reprocessed by March 31, 2009 as long as they are finalized and do not need to age. Facilitate Payment for Sterilization and Hysterectomy Procedures In order to facilitate payment for the these procedures, please attach the Transmittal Letter to all Consent to Sterilization Forms, Hysterectomy Acknowledgement Forms, and Hysterectomy Certification Forms. Acute Care and Critical Access Hospitals Acute Care and Critical Access Hospital providers are advised that claims for inpatient maternity related services will process more quickly and accurately if the appropriate accommodation revenue codes for Nursery (017X) and Obstetrics (0112, 0122, 0132, 0142, and 0152) are used. Claims using other accommodation revenue codes require manual intervention which delays payment. Newborn claims may not be billed using the mother s ID number. 9

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11 New Provider Relations Manager Unisys welcomed Katrina R. Layman, RN, BSN as the new Provider Relations Manager for WV HIM Medicaid in August Katrina joined our team bringing with her 12 years of health care insurance experience. She has experience administering various benefit plans for Commercial insurance groups and Medicare and Medicaid programs in WV, DE and MD. For the past several years, Katrina has served as the Director of Health Services for Carelink Health Plans, Inc. and most recently, Coventry Health Care of Delaware, Inc. She provided direct oversight of the daily operations of Utilization Management that included a prior-authorizations call center, inpatient review, case/disease management and Appeals and Grievances. If you have any issues or concerns related to Provider Services, please feel free to contact Katrina at or Katrina.Layman@Unisys.com. Unisys AVRS Prompt Tree ( ) Please make sure that you are utilizing the appropriate prompts when making your selection(s) on the AVRS system to ensure that you will be connected to the appropriate department for your inquiry. Once you have entered in your provider number, the following prompts will be announced; 1. Accounts Payable Information 2. Eligibility Information 3. Claim Status Information 4. Provider Enrollment Department 5. Hysterectomy Sterilization Review 6. EDI Help Desk/Electronic Submission Inquiries 7. LTC Department Contact Information. Unisys Provider Relations wvmmis@.com ( ) EDI Helpdesk , prompt Provider Enrollment , prompt Unisys PR Pharmacy Help Desk Member Services Monday-Friday, 8:00 am until 5:00 pm Provider Services Fax BMS Main Number medclaimdoc@wvdhhr.org ( ) HMO Contacts Carelink Advocate-Dennis May The Health Plan Advocate-Jennifer Johnson same Unicare Advocate-Mitch Collins Claim Form Mailing Addresses. Please mail your claims to the appropriate Post Office Box as indicated below. Unisys PO Box 3765 NCPDP UCF Pharmacy PO Box 3766 UB-92 PO Box 3767 CMS-1500 PO Box 3768 ADA-2002 Charleston WV PO Box 2254 Hysterectomy, Sterilization and Pregnancy Termination Forms Charleston WV Unisys Mailing Addresses. Provider Relations & Member Services. PO Box 2002 Charleston WV Fax # Provider Enrollment & EDI Help Desk. PO Box 625 Charleston WV Fax #

12 West Virginia Medicaid WEST VIRGINIA Department of Health & Human Resources Provider Update Bulletin Q UNISYS Imagine It. Done. UNISYS PO Box 625 Charleston WV