Kentucky Medicaid Webinar. Fall 2017

Transcription

1 Kentucky Medicaid Webinar Fall 2017

2 Agenda How Medicaid Works Kentucky Medicaid Websites Accessing KYHealth Net KYHealth Net o o o o o Member Eligibility Verification Patient Liability Claim Inquiry Prior Authorization Remittance Advice ORP Contacts Questions and Answers 2

3 How Medicaid Works CMS Department for Medicaid Services Medicaid Policy/Enrollment Local DCBS office DXC Technology (formerly Hewlett Packard Enterprise) Carewise 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. DXC Technology (formerly known as Hewlett Packard Enterprise) the KYMMIS contractor, can only process claims according to the rules and regulations that Medicaid has designed. DXC Technology (formerly known as Hewlett Packard Enterprise) holds the prior authorization contract. Carewise, the subcontractor for DXC Technology, can only issue prior authorizations according to the rules and regulations that Medicaid has designed. 3

4 Medicaid Websites Department of Medicaid Services Regulations Provider Enrollment Provider updates/letters KYMMIS Kentucky Health Net Member Eligibility Patient Liability Claims Inquiry Claims Submission Prior Authorization Letters Prior Authorization Inquiry Remittance Advice Forms Provider Workshop Information Billing Instructions KYHealth Net User Manual Electronic Claims Companion Guides 4

5 DMS Website Regulations Legal and Policy Information Program Manuals 5

6 KYMMIS Website Provider Relations Site Updates 6

7 KYMMIS Website Provider Relations Forms Workshop Info. Billing Instructions KYHealth Net User Manual Electronic Claims Companion Guides 7

8 KYHealth Net Access PIN Release From To create a KYHealth Net account you must access the system with a PIN number received from the EDI Helpdesk. PIN Release form can be found at: Electronic Claims EDI Forms Complete the PIN Release form, attach a copy of your driver s license and fax to An will be sent containing a PIN number and a link to set up your account. Username can never be changed once created. Password must be changed every 30 days. 8

9 KYHealth Net Sign-In page 9

10 KYHealth Net Home Screen Account Management Password expiring message KYHealth Net Messages Do not share username and passwords. Each office personnel should have their own. 10

11 KYHealth Net Provider Main Page Subjects Working Provider NPI & Taxonomy Quick Reference Provider Status 11

12 KYHealth Net Member Eligibility Verification When placing your cursor over a subject, a drop down box appears with additional topics within that subject 12

13 KYHealth Net Member Eligibility Verification Service Type is automatically selected as Health Plan Coverage Look up type by Member ID or SS# Enter Member ID# Enter the From Date of Service and To Date of Service Click Search 13

14 KYHealth Net Member Eligibility 5-Year History Benefit Plan 14

15 KYHealth Net Patient Liability Member Patient Liability 15

16 KYHealth Net Patient Liability Search Enter Member ID and click search View Map 552 Patient Liability information 16

17 KYHealth Net Patient Liability Viewing MAP 552 Only the requesting provider can view the MAP 552 Select to view by effective date 17

18 KYHealth Net Claim Inquiry Claims Claim Inquiry 18

19 KYHealth Net Claim Inquiry Search Search by Member ID and From and Thru Date OR ICN ONLY (remove dates) 19

20 KYHealth Net Claim Inquiry Search Results Click on the ICN to view claim details, adjust and void 20

21 KYHealth Net Prior Authorization To view PA letter select: MMIS Prior Authorization Letter To view LOC select: CareWise Prior Authorization Letter 21

22 KYHealth Net Prior Authorization Letter and LOC letter To search for a PA Letter, enter the Member ID AND Date Sent click Search PA Letters. Click on the blue link for the letter you wish to view 22

23 KYHealth Net Prior Authorization Inquiry Search by: Member ID OR Transaction ID (PA Number) A Start Date must be entered. Click the blue link under Transaction ID to view the appropriate PA. 23

24 KYHealth Net Prior Authorization Inquiry Screens to view within PA Inquiry Servicing Provider Number 24

25 KYHealth Net Prior Authorization Inquiry Diagnosis Code To view additional Diagnosis codes Click on the arrows 25

26 KYHealth Net Prior Authorization Inquiry Procedure Code Status Requested Effective Date Authorized Effective Date Used: Units and Dollars Frequency and Frequency Units 26

27 KYHealth Net Prior Authorization Inquiry Requested Details Approved Details 27

28 Prior Authorization Modifications Provider Reps cannot make changes to prior authorizations. If CareWise advises the provider to contact HPE or their Provider Rep, the provider will need to contact Utilization Management via and include the following information: Provider ID #, Member ID #, service code, and dates along with a detailed explanation of the issue. Waiver Providers: Please contact the UM department at the provided above if Carewise states your Plan of Care is on file but you continue to have issues billing due to the Plan of Care. 28

29 KYHealth Net Remittance Advices 29

30 KYHealth Net Remittance Advices Click the blue link in the Run Date column to view details of RA 30

31 KYHealth Net Remittance Advices Download and save Remits are available for 6 months on KYHealth Net 31

32 KYHealth Net Remittance Advices 32

33 KYHealth Net Remittance Advices 33

34 ORP What is ORP? Traditionally, most providers have enrolled in the Kentucky Medicaid program to furnish covered services to Medicaid recipients and to submit claims for such services. However, as part of the Affordable Care Act (ACA), the Center for Medicare and Medicaid Services (CMS) now requires physicians or other eligible practitioners to enroll in the Medicaid program to order, refer, or prescribe items or services for Medicaid recipients ( Enrollment and Screening of Providers). As part of this initiative new claim editing has been created to ensure all Ordering, Referring, and Attending Providers submitted on Kentucky Medicaid claims are enrolled in Kentucky Medicaid, eligible for the claim date(s) of service, and are an approved ORP provider type. This editing applies to all provider types and all claim types, including crossovers. ORP claim editing was implemented March 2017 and editing is applied to dates of service 4/1/17 and after. 34

35 ORP Only individual providers can be ordering, referring, or attending providers. ORP editing is applied to all providers, regardless of where the provider is located. Attending Provider is required on all UB-04 claims, including crossovers. For PAPER UB-04 billers, the Attending Provider Taxonomy (if required) should be entered in Form Locator 80 Remarks. The 837I layout and KYHealthNet both include specific fields for Attending Provider Taxonomy so the Remarks field should be used for paper claims only. For PAPER Dental claim billers, the Referring Provider NPI and Taxonomy (if required) should be entered in Field 35 Remarks. The 837D layout and KYHealthNet both include specific fields for Referring Provider so the Remarks field should be used for paper claims only. 35

36 ORP Which types of providers are eligible to be Ordering, Referring, or Attending providers? Dentist (provider type 60) Physician (provider type 64) Nurse Anesthetist (provider type 74) Optometrist (provider type 77) Certified Nurse Practitioner (provider type 78) Podiatrist (provider type 80) Chiropractor (provider type 85) Physician Assistant (provider type 95) 36

37 ORP In what scenarios will Ordering/Referring Provider be required on Professional claims? From a claim editing standpoint, ordering or referring provider must be entered on claims submitted by the following provider types: All services billed by a DME provider (provider type 90) All crossover services billed by a Pharmacy (provider type 54) All services billed by an Independent Lab (provider type 37) All services billed by an X-Ray/Miscellaneous Supplier (provider type 86) All services billed by a Private Duty Nurse (provider type 18) All services billed by a Physical Therapist (provider type 87) All services billed by an Occupational Therapist (provider type 88) All services billed by a Speech Language Pathologist (provider type 79) All services billed by an Optician (provider type 52) All services billed by a Hearing Aid Dealer (provider type 50) All services billed by an Ambulatory Surgery Center (provider type 36) All services billed by a Multi-therapy Agency (provider type 76) All services billed by an Audiologist (provider type 70) * **Reminder even though the above scenarios are the only ones that will fail claim editing if a Referring or Ordering Provider NPI is NOT entered, the entry of Ordering or Referring Provider is still expected if a service provided by a provider type other than those above is ordered or referred. 37

38 Recent Change Community Mental Health Providers, provider type 30, are now able to use Employee ID s that range from 4 to 6 digits in length. This change is reflected in the Community Mental Health Billing Instructions. 38

39 Departments and Phone Number s DEPARTMENT PHONE NUMBER OR WEB ADDRESS ROLES DXC Technology Provider Billing Ky_provider_inquiry@hpe.com Billing questions, claims processing Inquiry questions (Providers ONLY) EDI Helpdesk Ky_edi_helpdesk@hpe.com Electronic billing, Electronic RA s, PIN request and password resets Carewise Prior Authorizations, Waiver Eligibility Department for Medicaid Services (DMS) Member Services Department for Medicaid Services (DMS) Provider Enrollment Department for Community Based Services (DCBS) Contact Center DXC Technology Provider Field Representatives Department for Medicaid Services (DMS) Provider Services Ms.services@ky.gov Questions or updates to a members file or benefit coverage. (Members ONLY) Program.integrity@ky.gov Provider file updates for ADO, contract, revalidation,, address or enrolling as a new provider. Any other Questions or updates pertaining to provider files Member eligibility, patient liability (MAP 552), Hospice election and termination Varies by County Varies by County Provider training, virtual provider visits, conference calls, association meetings and any escalated issue. (Providers Only) Questions pertaining to policy and questions or updates to a members file. (Providers ONLY) 39

40 Provider Representative Contact Details Kelly Gregory Extension Vicky Hicks Extension Assigned Counties Assigned Counties 001 ADAIR 044 GREEN 074 MCCREARY 003 ANDERSON 040 GARRARD 083 MENIFEE 002 ALLEN 050 HART 075 MCLEAN 006 BATH 041 GRANT 084 MERCER 004 BALLARD 048 HARLAN 085 METCALFE 008 BOONE 043 GRAYSON 087 MONTGOMERY 005 BARREN 051 HENDERSON 086 MONROE 009 BOURBON 045 GREENUP 088 MORGAN 007 BELL 053 HICKMAN 089 MUHLENBERG 010 BOYD 046 HANCOCK 090 NELSON 011 BOYLE 054 HOPKINS 095 OWSLEY 012 BRACKEN 047 HARDIN 091 NICHOLAS 013 BREATHITT 055 JACKSON 097 PERRY 014 BRECKINRIDGE 049 HARRISON 092 OHIO 017 CALDWELL 061 KNOX 098 PIKE 015 BULLITT 052 HENRY 093 OLDHAM 018 CALLOWAY 060 KNOTT 100 PULASKI 016 BUTLER 056 JEFFERSON 094 OWEN 020 CARLISLE 062 LARUE 102 ROCKCASTLE 019 CAMPBELL 057 JESSAMINE 096 PENDLETON 023 CASEY 063 LAUREL 104 RUSSELL 021 CARROLL 058 JOHNSON 099 POWELL 024 CHRISTIAN 066 LESLIE 107 SIMPSON 022 CARTER 059 KENTON 101 ROBERTSON 026 CLAY 068 LETCHER 109 TAYLOR 025 CLARK 064 LAWRENCE 103 ROWAN 027 CLINTON 069 LINCOLN 110 TODD 030 DAVIESS 065 LEE 105 SCOTT 028 CRITTENDEN 070 LIVINGSTON 111 TRIGG 032 ELLIOTT 067 LEWIS 106 SHELBY 029 CUMBERLAND 071 LOGAN 113 UNION 033 ESTILL 076 MADISON 108 SPENCER 031 EDMONSON 072 LYON 114 WARREN 034 FAYETTE 077 MAGOFFIN 112 TRIMBLE 036 FLOYD 078 MARION 116 WAYNE 035 FLEMING 080 MARTIN 115 WASHINGTON 038 FULTON 079 MARSHALL 117 WEBSTER 037 FRANKLIN 081 MASON 119 WOLFE 042 GRAVES 073 MCCRACKEN 118 WHITLEY 039 GALLATIN 082 MEADE 120 WOODFORD Don t be alarmed if your from your representative shows On April 3, 2017 Hewlett Packard Enterprise and CSC performed a spin-merge that created a new company DXC Technology. Our great Customer Service for Kentucky Medicaid remains the same, just with a new company name. 40

41 Questions 41