LTC/MMA Monthly Claims Training Claims & Prior Authorization ACS & AFCH

Transcription

1 LTC/MMA Monthly Claims Training Claims & Prior Authorization ACS & AFCH

2 Submitting Claims Providers may submit claims to Molina in the following ways: On paper, using a current version CMS-1500 form, to: Molina Healthcare PO Box Long Beach, CA Electronically, via a clearinghouse, Payer ID #51062 Visit for additional information about EDI submission Electronically, via the Molina Web Portal

3 Timely Filing F.S requires that providers submit all claims within six (6) months of the date of service. Network providers must make every effort to submit claims for payment in a timely manner, and within the statutory requirement. If Molina Healthcare of Florida is not the primary payer under coordination of benefits (COB), providers must submit claims for payment to Molina Healthcare of Florida within ninety (90) days after the final determination by the primary payer. Except as otherwise provided by law or provided by government sponsored program requirements, any claims that are not submitted to Molina Healthcare of Florida within these timelines will not be eligible for payment, and provider thereby waives any right to payment.

4 Direct Deposit of Funds Providers are encouraged to enroll in Electronic Funds Transfer (EFT) in order to receive payments quicker. Molina Healthcare s EFT provider is ProviderNet. To enroll, visit Step-by step registration instructions are included in your training materials.

5 MMA Continuity of Care No disruption of care for MMA members Providers should continue to provide care during the transition period 60 days after the implementation date Providers should bill claims to the health plan to which the MMA member is assigned Molina (and other MMA plans) will cover the continued course of treatment without authorization and without regard to participation status during the transition period For non-participating providers, Molina will pay claims at the rate previously paid by the enrollee s prior health plan for the first 30 days Care may continue after the transition period with prior authorization Region Implementation Date Transition Period End Date 7 8/1/2014 9/30/ /1/2014 9/30/ /1/2014 8/31/2014 *Timeframes not applicable to LTC members

6 Expanded Benefits Unlimited PCP Visits (non-pregnant adults) Home Health Care (non-pregnant adults) 1 visit per day Physician Home Visits 4 per month, per specialty Prenatal/Perinatal Visits 12 visits for low risk/ 16 visits for high risk pregnancy Outpatient Services Mammograms & OB ultrasounds are excluded from accruing toward the Medicaid Outpatient Services Limitations OTC - $25 per household per month Adult Dental Services Waived Copayments Vision Services Hearing Services - $500 every 3 years for an inner-ear hearing aid Newborn Circumcision - upon request during initial hospitalization Adult Pneumonia Vaccine 1 per lifetime Adult Influenza 1 per year Adult Shingles Vaccine 1 per lifetime Post Discharge Meals 3 per day for 7 days Pet Therapy & Art Therapy Medically Related Lodging and Food

7 What is Prior Authorization? Prior Authorization is the act of authorizing specific services before they are rendered. Generally, prior authorization requirements are designed to assure the medical necessity of service, prevent unanticipated denials of coverage, ensure participating Providers are utilized and all services are provided at the appropriate level of care for the Member s needs. *Prior Authorization is not a guarantee of payment.*

8 Requests for Authorization Authorization for elective services should be requested with supporting clinical documentation at least 14 days prior to the date of the requested service. Authorization for emergent services should be requested within one business day. Information generally required to support decision making includes: Current (up to 6 months), adequate patient history related to the requested services Physical examination that addresses the problem Lab or radiology results to support the request (Including previous MRI, CT, Lab or X-ray report/results) PCP or Specialist progress notes or consultations Any other information or data specific to the request Molina Healthcare of Florida will process all non-urgent requests in no more than 14 calendar days of the initial request. Urgent requests will be processed within 72 hours of the initial request. Providers who request prior authorization approval for patient services and/or procedures can request to review the criteria used to make the final decision. Providers may request to speak to the Medical Director who made the determination to approve or deny the service request. 8

9 Web Portal Authorization Tools Submit Requests for Authorization Verify Authorization Status Create Authorization Templates View Recent Authorizations Access Prior Authorization Guide 9

10 Authorization Request Situational Grid MEMBER S LINE OF BUSINESS PROVIDER TYPE SERVICE CODE REQUESTED WHO REQUESTS AUTH? MMA Only ALF T1020 Facility MMA Only AFCH T1020 Facility MMA/LTC (Comprehensive) MMA/LTC (Comprehensive) ALF T2030 Case Manager AFCH T1020 Case Manager LTC Only ALF T2030 Case Manager LTC Only AFCH T1020 Case Manager

11 Submitting Prior Authorization via Web-Portal Select Create Service Request/Authorization from the Service Request/Authorization drop-down menu.

12 Submitting Prior Authorization via Web- Portal Member Search: Enter Member ID or Member First and Last Name and Date of Birth Patient Information: NOTICE: This section will automatically populate when you enter valid information for Member Search

13 Submitting Prior Authorization via Web- Portal Service Information - Select Type of Service from drop-down. Home Health Place Of Service - Home Proposed Start Date Enter appropriate Diagnosis Code (780.99)and Procedure Codes(s) (T1020 or T2030) as applicable. (Note: Click on the Add More links to add more of the appropriate codes and/or dates needed) (Note: Use the magnifying glass next to the field to search when an item is not known)

14 Submitting Prior Authorization via Web- Portal Member Search/Patient Information Provider Information - Requestor and Contact Information fields will automatically populate based on User ID. Manually enter any other necessary information to complete the section. Accident Related Information: (If applicable) Pregnancy Related Information: (If applicable) Other Condition Related Information: (Chiropractic, DME, Oxygen Therapy, Function Limitation, Permitted Activities, Mental Status) select as applicable.

15 Submitting Prior Authorization via Web- Portal Referring Provider Information - Referring Provider Information will automatically populate based on User ID. Referred To Provider Information: (If referring to a specific provider) Enter provider NPI.

16 Submitting Prior Authorization via Web- Portal Additional Provider Access/Refer-To Facility Information Additional Provider Access (If applicable) Referred-To Facility Information: (If referring to a specific facility) This section will automatically populate when you enter valid Facility NPI.

17 Submitting Prior Authorization via Web- Portal Supporting Information Supporting Information To attach additional documentation

18 Submitting Prior Authorization via Web- Portal Supporting Information Supporting Information - When attaching additional documentation, select Type of Attachment dropdown. Select appropriate type of attachment. (i.e.: Drugs Administered, Plan of Treatment, etc.)

19 Submitting Prior Authorization via Web- Portal Supporting Information After selecting the type of attachment, select Browse. Select the appropriate document from the file upload window.

20 Submitting Prior Authorization via Web- Portal Supporting Information After adding the document, select Upload.

21 Submitting Prior Authorization via Web- Portal Supporting Information After uploading the document, it will show in the Attachments section. Clinical Notes/Comments - Additional notes or comments as needed. (Up to 8000 Characters) Review all the Prior Authorization information, and choose Submit.

22 Submitting Authorizations via the Web Portal View recent authorizations on the Home Page Receive messages when authorization status changes Prompter turnaround time 22

23 Manual Service Request Form Please ensure that all fields are filled out completely and accurately. Member Name Member ID Service Type (Elective or Routine/Expedited or Urgent) DOB Phone Referral/Service Type Requested Other Assistive Care Services Diagnosis Code CPT/HCPC T1020 or T2030 (as applicable) Number of Visits requested 6mos. Dates of Service 6 mo. Date span (ex.: 01/01/15 06/30/15) Provider Information Requesting Provider: Facility Name Facility Providing Service: Facility Name Contact Information at Facility Please provide any supporting documentation as needed. 23

24 Requests for Authorization Providers may submit requests for prior authorization to the Utilization Management Department in the following ways: Web Portal : Medicaid Fax: (866) If submitting via fax, please use the Service Request Form included in your Welcome Kit and available online, at: 24

25 Billing HCPC Situational Grid MEMBER S LINE OF BUSINESS PROVIDER TYPE HCPC TO BILL BILLING FREQUENCY WHO PAYS MMA Only Assisted Living Facility T1020 Daily, Weekly, Monthly but not in advance MMA Plan MMA Only Adult Family Care Home T1020 Daily, Weekly, Monthly but not in advance MMA Plan MMA/LTC (Comprehensive) Assisted Living Facility T2030 Beginning OR End of Month LTC Plan MMA/LTC (Comprehensive) Adult Family Care Home T1020 Daily, Weekly, Monthly but not in advance LTC Plan

26 Billing Using the Molina Web Portal Select Create Professional Claim from the Claims dropdown menu.

27 Billing Using the Molina Web Portal - MEMBER Eligibility Check Enter the following: Member ID # Last Name First Name DOB Date of Service The portal will fill in the Patient Information section

28 Billing Using the Molina Web Portal - MEMBER Other Insurance & Patient Conditions Other Insurance Yes or No (If Applicable) Patient Conditions - This section is not required. Leave this section BLANK

29 Billing Using the Molina Web Portal - MEMBER Verify Required Information Enter the following: Patient Account Number = (your internal acct number for the member) Member Authorized Assignment of Benefit = Yes Provider Assignment Code = Assigned Release of Information = Yes Choose NEXT (bottom left corner)

30 Billing Using the Molina Web Portal - PROVIDER Billing Provider Information Enter the following: Billing Provider Information is completed automatically Rendering Provider is completed automatically Facility Information = Service Location. Select Facility Name from SELECT A SERVICE LOCATION drop-down.

31 Billing Using the Molina Web Portal - PROVIDER Diagnosis Code & Claim Line Details Enter the following: Dx No. 1 = Service From Date = 1 st day of the date span Service to Date = Last day of the date span (*Refer to Situational Grid for further information on Date Entries*) Place of Service = ALF 13 or AFCH - 99 Procedure Code = T1020 or T2030 Diagnosis Code Ref = 1 Charges = Billed charges for all units Unit of Measurement = UN-Unit Quantity = Days in Month or Days in Facility Leave all other sections blank Choose NEXT (bottom left corner)

32 Billing Using the Molina Web Portal - SUMMARY Submit Claim Review all of your entries and: Choose SUBMIT (bottom right corner

33 Billing Using a CMS 1500 Form Resident Information is entered in Fields 1-11 Only Fields 1 6 are required All other fields are optional

34 Billing Using a CMS 1500 Form Resident s authorization for ALF or AFCH to bill and release information is entered in Fields Both fields are required Enter Signature on File and the date in Field 12 Enter Signature on File in Field 13 SIGNATURE ON FILE 12/15/2013 SIGNATURE ON FILE

35 Billing Using a CMS 1500 Form Diagnosis Code is entered in Field 21 This is a required field Enter number 9 in the ICD Ind. for ICD 9. Enter in position A (new CMS1500 Form version 02/12 effective for submission dates starting on 4/1/2014) Enter letter A in 24E to point the charges to the diagnosis is an unspecified code which will enable your claim to process T1020 A

36 Billing Using a CMS 1500 Form Dates of Service Assisted Living Charge details are entered in Fields 24A 24J The dates of service are entered in Field 24A. For LTC Members, Molina allows beginning of the month billing for Assisted Living Services. If billing at the beginning of the month, for the entire month, the Dates of Service FROM and TO must be the same. ASSISTED LIVING SERVICES: T2030 A

37 Billing Using a CMS 1500 Form Dates Of Service Assistive Care Assistive Care Services cannot be billed in advance. The Dates of Service FROM and TO cannot be future dates or overlap. Assistive Care Services can be billed Daily, Weekly, or Monthly. Daily: T1020 A hlhlhl *Weekly: T1020 A T1020 A Monthly: T1020 A *Please Note Dates in Weekly Example DO NOT overlap*

38 Billing Using a CMS 1500 Form The billing code is entered in Field 24D Assistive Care Services T1020 Assisted Living Services T2030

39 Provider Handbook Molina Healthcare of Florida s Provider Handbook is written specifically to address the requirements of delivering healthcare services to Molina Healthcare members, including your responsibilities as a participating provider. Providers may request printed copies of the Provider Handbook, at no cost, by contacting Provider Services at (866) , or view the handbook on our website, at: Medicaid Provider Manual medical.aspx

40 Balance Billing Participating providers shall accept Molina Healthcare s payments as payment in full for covered services. Providers may not balance bill the Member for any covered benefit, except for applicable copayments and deductibles, if any. As a Molina Healthcare of Florida participating provider, your office is responsible for verifying eligibility and obtaining approval for those services that require authorization. In the event of a denial of payment, providers shall look solely to Molina Healthcare for compensation for services rendered..

41 Questions For a copy of this presentation please Shaun.marshall@molinahealthcare.com