How Medicaid Works Reference List Representative List Medicaid Website Forms Kentucky Health Net PA Panels Remittance Advices Timely Filing Internal

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2 How Medicaid Works Reference List Representative List Medicaid Website Forms Kentucky Health Net PA Panels Remittance Advices Timely Filing Internal Control Number Breakdown 5010 Upcoming format change for billing Test Your Knowledge Questions and Answers Evaluation SHPS Presentation 2

3 CMS Department for Medicaid Services Medicaid Policy/Enrollment Local DCBS office HP Enterprise Services SHPS Department for Medicaid Services (DMS) and Medicaid Policy enforces the rules and regulations that were designed by Legislation. The Local DCBS office enrolls members according to the rules and regulations. HP Enterprise Services, the KYMMIS contractor, can only process claims according to the rules and regulations that Medicaid has designed. HP Enterprise Services has the prior authorization contract, but SHPS who is the subcontractor for HP Enterprise Services, can only issue prior authorizations according to the rules and regulations that Medicaid has designed.

4 Department Phone Number or Fax Roles HP Provider Billing Inquiry Claim status, denials, RA s, any billing questions, member eligibility, PA s, and limitations. (Providers only) HP Provider Field Representative Varies by county Varies by county Provider training on multiple levels such as workshops, personal provider visits, teleconferences, association meetings, as well as escalated problems. (Providers only) EDI Helpdesk Electronic billing, electronic RA s, PIN #, and password reset. Member Services Questions or updates to the member files, in relation to member s program code information and member eligibility. Provider Enrollment Program.integrity@ky.gov Question or updates to the provider file which includes; NPI/taxonomy, updating address, EFT s and enrollment of providers. Local DCBS office Varies hone/index.aspx. Eligibility, Patient Liability, Hospice Election and Termination SHPS Prior Authorizations, Waiver Eligibility (LOC) and Orthodontic PA Dental/ Dental EPSDT Prior Authorizations Prior Authorizations (excluding orthodontics) 4

5 Brenda Orberson Penny Germinaro Vicky Hicks Leigh Ann Hayes Kristy Cabell Adair Allen Barren Boyle Casey Clinton Cumberland Estill Green Jackson Laurel Lincoln Madison McCreary Metcalfe Monroe Pulaski Rockcastle Russell Simpson Warren Wayne Whitley Bell Breathitt Boyd Carter Clay Elliot Greenup Floyd Harlan Johnson Knott Knox Lawrence Lee Lewis Leslie Letcher Martin Magoffin Morgan Owsley Perry Pike Rowan Bath Bourbon Clark Fleming Fayette Garrard Jessamine Menifee Mercer Montgomery Nicholas Powell Wolfe Woodford Boone Bracken Campbell Carroll Gallatin Grant Jefferson Kenton Pendleton Oldham Owen Trimble Anderson Ballard Breckinridge Bullitt Butler Caldwell Calloway Carlisle Christian Crittenden Daviess Edmonson Franklin Fulton Graves Gray Hancock Hardin Harrison Hart Henderson Henry Hickman Hopkins Larue Livingston Logan Lyon Marion Marshall Mason McCracken Mclean Meade Muhlenberg Nelson Ohio Robertson Scott Shelby Spencer Taylor Todd Trigg Union Washington Webster 5

6 Acronym Acronym ADJ Adjusted claim EPSDT Early Periodic Screening, Diagnosis and Treatment AEVS Automated Eligibility Verification FAQ Frequently Asked Questions A/R Accounts Receivable HP Hewlett Packard BCCTP Breast and Cervical Cancer Treatment Program ICN Internal Control Number BI Billing Instructions KASPER Kentucky All Schedule Prescription Electronic Reporting CHS Cabinet for Health Services KenPAC Kentucky Patient Access and Care CLIA Clinical Laboratory Improvement Amendment KYMMIS Kentucky Medicaid Management Information System CMS Centers for Medicare and Medicaid Services NDC National Drug Code DCBS Department for Community Based Services NPI National Provider Identifier DMS Department for Medicaid Services PA Prior Authorization DOB Date of Birth PA Physician Assistant DOS Date of Service PI Poverty Indicator DRG Diagnosis Related Group QMB Qualified Medicare Beneficiary EDI Electronic Data Interchange RA Remittance Advice EFT Electronic Funds Transfer TPL Third Party Liability/Commercial Insurance 6

7 Department of Medicaid Services o Regulations o Fee Schedules o Provider Enrollment KYMMIS o Billing Instructions o Forms Prior Authorization Provider Enrollment Provider Relations TPL Cash Refund Adjustment/ Claim Credit Kentucky Health Net o Sign in Page o PA Panels Prior Authorization Letters PA Inquiry 7

8 Click on tab to view current page Regulations Program Manuals 8

9 Site updates for Letters and Notices 9

10 Third Party Liability, PA, MAP Forms Information for upcoming workshops Billing Instructions Guides for KY Health Net Billing 10

11 Scroll down the page, click to view the desired Billing Instructions by provider type. 11

12 PA Forms Maintenance and Enrollment Forms TPL, Cash Refund, NDC, Coding Sheets 12

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14 MAP 380 to retrieve an 835 file and MAP 529 to update provider file 14

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16 Provider Maintenance MAP 529 Adjustment and Claim Credit Cash Refund Third Party Liability 16

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18 A MAP 529 must be used to update a provider location, phone number and/or address. When changing information on the individual doctor s file, the signature from the physician must be on the MAP form. When changing information on a corporation provider file, a delegate signature will suffice. Verify all information on the form is correct and up-to-date. A list of required documentation for each provider type is listed at 18

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20 When the other health insurance has not responded to a provider s billing within 120 days from the date the claim was filed, a provider may complete a TPL Lead Form. Mark No response in 120 days on the form. Attach the form to the back of the claim and submit to HP. This form is used for commercial insurance only. It is not used for Medicare. The Other section is obsolete. The contact name and phone number is the contact person for the commercial insurance carrier and that person s phone number. If a commercial insurance (such as Humana) applies the payment to the deductible, the claim must be billed on paper. The EOB must be attached behind the claim, omitting the TPL information from the claim form. If the primary insurance (such as Anthem Blue Cross Blue Shield) carrier denies the claim, it must come through a paper claim submission. When a payment is received by a commercial insurance carrier, the claim may be submitted electronically to Kentucky Medicaid for quicker adjudication. 20

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22 An adjustment/void is a change to be made to a PAID claim. Please keep the following points in mind when filing an adjustment request: Only a void/claim credit will reset a Prior Authorization. Attach a copy of the corrected claim and the paid remittance advice page to your adjustment form. Do not send refunds on claims for which an adjustment or void has been filed. Be specific. Explain exactly what is to be changed on the claim. Claims showing paid zero dollar amounts are considered paid claims by Medicaid. If the paid amount of zero is incorrect, the claim requires an adjustment. Do not do an adjustment/void on KyHealth Net and paper. Do one or the other. A claim credit is on paper; a void is on KyHealth Net. They are the same. 22

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24 The Cash Refund Documentation Form is to be used when refunding money to KY Medicaid. Attach the following documentation with the Cash Refund Documentation form: a check for the refund amount made payable to KY State Treasurer and a copy of the remittance advice showing the paid claim for which a refund is being issued. If an individual provider was paid instead of the group, a cash refund must be issued. If receiving a new provider number, do not bill claims. If billing takes place, money must be refunded. For a capitation refund, more than one remittance may not be combined for each check. Each RA must come with a separate check. The refund will be posted quicker if one check is sent with the RA as opposed to sending one check with multiple remittances. 24

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28 To search for a PA letter, enter the Member ID and then click Search PA Letters. Click on the blue link for the letter you wish to view. 28

29 Search by Transaction ID (the PA number) or by Member ID. A Start Date must be entered. Click on the blue link under Transaction ID to view the appropriate PA. 29

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32 Units Used 32

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34 The Commonwealth of Kentucky, in an effort to reduce costs, has eliminated the production and mailing of PAPER remittance advices (RAs), effective July 1, The RAs will be available on the Kentucky Health Net via the RA Viewer panel for six months. They must be downloaded each week by utilizing the RA Viewer. The account administrator may grant permission to retrieve the RAs. An additional way to retrieve the RAs is to become a trading partner. In order to retrieve the 835 from the Bulletin Board, MAP 380 will need to be completed. MAP 380 can be accessed on the Kentucky Health Net Provider Enrollment Forms page. 34

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37 Aged claims (those older than 12 months from date of service or six months from the Medicare or commercial insurance payment or denial date) may be considered for payment only when documentation is submitted behind the claim to support timely filing. The ONLY acceptable documentation will include a copy of one or more of the following: Remittance advices to verify timely filing within each 12 month period from date of service A screen print from KyHealth Net to verify issue date of the eligibility (the card issuance screen) A screen print from KyHealth Net Summary Page to verify timely filing within each 12 month period from date of service Medicare explanation of benefits (EOMB) Commercial insurance EOB Provider Welcome Letter Prior Authorization Letter approved after date of service. (DME only) 37

38 The KyHealth Net Claim Search Criteria screen is not acceptable for timely filing. 38

39 The KyHealth Net Header screen is not acceptable for timely filing. 39

40 The KyHealth Net Summary screen is acceptable for timely filing. 40

41 One year from issue date 41

42 ICN Internal Control Number Example: The first two digits are the region, which lets the system know how the claim was submitted to Kentucky Medicaid. 10 Paper claims with no attachments 11 Paper claims with attachments 20 Electronic claims from vendor/clearinghouse 22 Electronic claim from KyHealth Net 50 Adjustment 56 Void The second two digits are the year. The third set of digits is the Julian Date (The Julian calendar numbers the days of the year from For example, January 1, 2010 is 001). The last set of digits is the Batch sequence (used internally). Claim billed through KyHealth Net: May 19,

43 The format you use to submit 837 transactions to health insurance carriers will be upgraded in the coming months. The Centers for Medicare and Medicaid Services (CMS) are switching from the Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 and from National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version D.0. The ID qualifier of ZZ for taxonomy will be replaced with PXC (CMS 1500 claims ONLY). The billing address and servicing address on the claim can no longer be a P.O. Box. It must be a physical address (all claims). Note: These are subject to change. A companion guide will be published upon completion of the 5010 project. 43

44 Barney Fife comes into your office. He has Blue Cross Blue Shield and Kentucky Medicaid. BCBS applied the charge to the deductible. How do you file the claim? A.) Bill the claim electronically through the Kentucky Health Net and enter deductible in the TPL field on the Header page. B.) Drop the claim to paper with the EOB attached to the back of the claim form. C.) Adjust off the balance. Betty White has a Medicare replacement policy, and the insurance denied the claim. How is the claim billed to Medicaid? A.) Bill the member. B.) Bill the claim electronically. C.) Drop the claim to paper and attach the Medicare Crossover Coding sheet. D.) Drop the claim to paper and attach the Medicare replacement policy denial EOB to the claim. 44

45 Dr. Doug Ross is leaving your clinic, and moves from Corbin, KY to Louisville, KY you must submit a MAP 529 for the provider file to be updated to change his address and telephone number. True or False Bart Simpson was seen at your facility on 5/15/2008. The claim processed multiple times. The last RA was dated 10/09. A.) Attach the 10/09 remittance advice to the claim to prove timely filing. B.) Submit the claim through the Kentucky Health Net because you see that the claim was submitted 8 times in the claims inquiry screen. C.) Write it off if it is older than 2 years old. D.) Drop the claim to paper with the appropriate remittance advices attached to prove timely filing. 45

46 Aunt Bee received a service which was provided at your facility. The claim originally paid but the units of service were incorrect. A.) You adjust the claim to be paid for the correct amount of units. B.) Void the claim. C.) Drop the claim to paper. Bo Duke has Medicare primary to Medicaid. His date of service was March 2009, which is over 12 months old, however Medicare just paid June Is this billable? Yes or No Mortisha Adams is the billing clerk for Dr. Fester. She received a denial for prior authorization for services billed. Mortisha drops the claim to paper and attaches the PA approval letter. Is this the correct way to get the claim paid? Yes or No 46

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