Maine Chapter of the Healthcare Financial Management Association. MaineCare Provider Relations

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Howard Austin
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1 Maine Chapter of the Healthcare Financial Management Association MaineCare Provider Relations

2 Agenda New Drug Testing Laboratory Codes Improve your Search for Prior Authorization (PA) Completing Pathways Prior Authorizations Urgent CT/PET Prior Authorizations Managing Users in MyHealthPAS Trading Partner Accounts Modifying user permissions Terminating a user MaineCare Updates/Reminders

3 New Drug Testing Laboratory Codes CR and CR Claims submitted with G0477 through G0483 and processed after 1/22/16 will be denied. The Remittance Advice will reflect CARC 204. These codes were entered in the system on 02/10/16, and should no longer deny. Claims that denied in error prior to 02/10/16 will be adjusted (Affected 1500 claims only) Claims submitted prior to 1/22/16 were rejected through the EDI gateway This means the claims did not make it into the MIHMS System. These claims will require resubmission (Affected both 1500 and UB claims)

4 Improve your Search for Prior Authorization (PA) When searching for a PA on the Health PAS Online Portal, please include specific search criteria. Including specific criteria will speed up your search and give you better results. Some examples of specific search criteria are: Date range Member s MaineCare ID Member s first and last name Member s Social Security Number Member s date of birth Not only will including specific search criteria improve your search speed and results, but it will also mitigate portal slowness and technical issues. Please contact the EDI Helpdesk with questions at: , option 3

5 Completing Pathways Prior Authorizations Submitting a Prior Authorization to MaineCare Paper form HealthPAS Portal Submit supporting documentation When sending in supporting documentation, be sure to use the Pathways Radiology PA form and note the assigned PA number The disposition will be PEND for up to 2 business days If no further information is received, the disposition will be changed to CLOSED It is the goal of MaineCare to process all non-urgent Pathway Radiology requests within 2 business days of receipt of all supporting documentation

6 Urgent CT&PET Scans MaineCare has 1 business day to review Be sure to upload or fax all supporting medical documentation within 24 hours Some Urgent PA s can be completed for immediate approval via the HealthPAS Portal will be asked two questions regarding the medical urgency attest that member needs immediate attention by answering yes to both questions answering no to either question will result in PEND for medical review

7 Managing Users in MyHealthPAS Trading Partner Accounts Managing the security roles of users and deactivation of individuals is essential when access requirements have changed or when access is no longer needed. Managing users can be done by going to the Health PAS Online Portal and logging into your trading partner account. Existing users may be edited, deactivated, or reactivated by clicking on the row of the user you would like to manage The Administrator of the account and users with a security role of R7-User Management are allowed to use these features. Please contact the EDI Helpdesk with questions at: , option 3.

8 Managing Users in MyHealthPAS Trading Partner Accounts Sign in to the secure Trading Partner area on the online portal Provider page. On the Welcome to Trading Partner window, expand the Account Maintenance option in the far left column. Click on Account Maintenance and then select Manage Users.

9 Managing Users in MyHealthPAS Trading Partner Accounts Each user on a trading partner account must have at least one permission, any combination of the permissions are available to assign Requires TPA Code Trading Partner User Access Area User Powers* Y R1 Provider Enrollment Maintenance Provider account maintenance Y R2 Trading Partner Maintenance Account maintenance including provider associations and demographics updates Y R3 X12 EDI Transactions File Exchange (X12), and report access Y R4 Claim Submission, Claim Status Access Remittance Advice (PDF) and reports, claim submission, claim status, patient roster and primary care roster Y R5 Eligibility Verification Eligibility verification, patient roster and primary care roster Y R6 Payment Status Provider payment status Y R7 User Management Manage account users Y R8 Referral Submission & Status, Authorization Submission & Status Authorization submission, authorization status, patient roster, primary care roster, referral submission and referral status Y R9 Alerts and Subscriptions EDI Gateway alerts and subscriptions these advise trading partners when they have a X.12 (825, 271, RA, etc.,) response awaiting collection. * All codes grant personal password reset powers.

10 Requires TPA Menu Item Health PAS Online User Access* Billing Provider Account Maintenance Access Rights Y Manage Users R7 X Y Provider Associations R2 X Y Rest Password All X Y Update Demographics R2 X Y File Exchange (X12) R3 X Y Remittance Advice (PDF) R4 X Y Other Reports All X Y Alerts and Subscriptions R9 X Form Entry Access Rights Y Authorization Submission R8 X Y Authorization Status R8 X Y Claim Submission R4 X Y Claim Status R4 X Y Eligibility Information R5 X Y Patient Roster R4, R5, R8 X Y Primary Care Roster R4, R5, R8 X Y Provider Payment Status R6 X Y Referral Submission R8 X Y Referral Status R8 X Provider Enrollment Access Rights Y Provider Maintenance R1 X

11 Modifying User Permissions Click anywhere on the row of the user whose permissions need to be modified. The Manage Users window expands to show identification, status, and permissions fields for the user selected

12 Terminating a User Click the drop down arrow for Status and select Terminated, as shown below. Click the Update button. The online portal saves the changes and refreshes the window. The Status field now shows Terminated

13 MaineCare Updates & Reminders Timely Filing is 1 Year from the Date of Service Providers have 120 days from the remit date to adjust a paid claim If a member receives retro-active eligibility, timely filing is 1 year from the update date

14 MaineCare Updates & Reminders Molina will no longer be sending out notifications to providers letting them know that their license is due to expire. Previously, letters were sent at 30/60/90 days prior to license expiration Per policy section Enrolled providers must maintain licenses as applicable, and must submit a copy of the license renewals to the provider Enrollment Unit to ensure continuity of services through license expiration dates

15 MaineCare Information Subscribe to our new E-Message System:

Contact info: Bobbi-Jo Bernier - Provider Relations Specialist 207-624-6950, or Bobbi-Jo.Bernier@maine.

16 Contact info: Bobbi-Jo Bernier - Provider Relations Specialist , or Bobbi-Jo.Bernier@maine.gov Policy Sections 4-Ambulatory Surgical Center Services 14-APRN (Advanced Practice Registered Nursing Services) 45-Hospital Services (including facility owned FQHC/RHC) 90-Physician Services 101-Medical Imaging Services Department of Health and Human Services 16

WV Bureau for Medical Services, KEPRO, & Molina Medicaid Solutions

WV Bureau for Medical Services, KEPRO, & Molina Medicaid Solutions 1 The West Virginia Medicaid and West Virginia Children s Health Insurance Program web portal for Members and Providers provides significant