Transcript Claims-Annual Wrkshp2014

Claims Submission,
Adjustments and Voids
2014
HP – Fiscal Agent for the
Arkansas Division of Medical Services
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Agenda
• Ways to Submit Claims
• How to Adjust/Void a Claim
• Timely Filing
• How to Check Claim Status
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© Copyright 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Ways to Submit Claims
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Paper
Direct Data Entry (DDE)
Provider Electronic Solutions (PES)
Vendor Software
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Types of Paper Claims
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CMS-1500
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UB-04
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Dental
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Mail Paper Claims to:
HP Enterprise Services
Attn: Claims
PO Box 8034
Little Rock, AR 72203
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Medicare/Advantage Plans
and Medicaid
(Crossover Claim Submission)
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QUIZ!!!!!!
Name one way to submit a claim.
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Crossover Forms
Inpatient Crossover – HP-MC-001
Long Term Care Crossover – HP-MC-002
Outpatient Crossover – HP-MC-003
Professional Crossover – HP-MC-004
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Crossover Claims
If the beneficiary has Medicare and Medicaid, and Medicare pays or applies money
toward the deductible/co-insurance, then the claim can be billed as a crossover on PES,
DDE, vendor software or the appropriate red and white crossover claim form.
HP Enterprise Services
Attn: Claims
PO Box 8034
Little Rock, AR 72203
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© Copyright 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Crossover Claims
If the beneficiary has Medicare and Medicaid, and Medicare denies the claim, then the
claim must be billed on a red and white claim form (CMS-1500 or UB-04) with the
Medicare denial attached.
Attach a cover letter of explanation. Do NOT mix in with other claims you are sending in for
regular processing.
HP Enterprise Services
Attn: Research Analyst
PO Box 8036
Little Rock, AR 72203
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© Copyright 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Crossover Claims
If the beneficiary has Medicare, TPL and Medicaid, and Medicare denies the claim and
TPL paid, then the claim must be billed on a red and white claim form (CMS-1500 or UB04) with the Medicare and TPL EOB attached.
Attach a note stating this is for Medicare override. Do NOT mix in with other claims you are
sending in for regular processing.
HP Enterprise Services
Attn: Research
PO Box 8036
Little Rock, AR 72203
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© Copyright 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Crossover Claims
If the beneficiary has Medicare, TPL and Medicaid, and Medicare pays but the TPL
denies the claim, then the claim can be billed as a crossover claim through PES software
or be billed on the appropriate red and white crossover claim form with the TPL and
Medicare EOB attached.
HP Enterprise Services
Attn: Claims
PO Box 8034
Little Rock, AR 72203
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© Copyright 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Crossover Claims
If the beneficiary has Medicare, TPL and Medicaid, and both Medicare and the TPL deny
the claim, then the claim must be billed on a red and white claim form (CMS-1500 or UB04) with the Medicare and TPL denial EOBs attached.
Attach a note stating this is for Medicare override. Do NOT mix in with other claims you are
sending in for regular processing.
HP Enterprise Services
Attn: Research
PO Box 8036
Little Rock, AR 72203
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Paper Adjustments
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Paper Adjustments
A legible signature must be on the adjustment form. This form can be found in
Section V of your provider manual.
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How to Order Forms from
HP/Arkansas Medicaid
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Claim Order Form
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Claim Order Form
Please indicate on the claim order form how many forms you are ordering.
Mail request to:
HP Enterprise Services
Forms Request
PO Box 8033
Little Rock, AR 72203
Fax: 501-374-0549
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Return to Provider
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Return to Provider
Paper claims with errors are returned to provides on three forms according to the type of
claim submitted:
• CMS 1500
• UB 04
• Crossover
The PO Box to return a corrected claim is given at the bottom of each form.
On the RTP forms, the reason(s) the claim is being returned will be indicated. Please make
needed corrections and resubmit claim.
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Direct Data Entry (DDE)
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Direct Data Entry (DDE)
• Once you are logged on,
your provider name will
appear under “Welcome
back.”
• To start a new claim, click
on “Professional claim.” To
void or adjust a previous
claim, click on
“Professional claim
reversal.”
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Direct Data Entry (DDE)
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Direct Data Entry (DDE)
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Provider Electronic Solutions
(PES) Software
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Provider Electronic Solutions (PES) Software
Provider Electronic Solutions software is HP’s free
eligibility and claims submission software. It is available
for download from the Arkansas Medicaid website.
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Submitter ID
Creating Your Submitter ID for New PES Users
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Click Provider
HIPAA
New Submitters Registration.
Click the New Submitter Registration Form link.
Complete the New Submitter Registration Information Form and click NEXT.
Select a question and complete the answer for Security Questions until you complete
five questions and answers.
Click NEXT.
Enter your billing provider 9 digit Medicaid ID number.
Click ADD. Click NEXT.
Enter the number of submitter IDs you want, click FINISH and PRINT THIS PAGE
showing your MC number.
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Provider Electronic Solutions (PES) Software
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Provider Electronic Solutions (PES) Software
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Provider Electronic Solutions (PES) Software
When submitting claims in PES, be sure to retrieve your response report to see rejections
and claims accepted.
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QUIZ TIME!
How much does it cost to download the PES software?
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Timely Filing
Medicare/Medicaid Crossover Claims and
Claims with Retroactive Eligibility
(Pseudo Claims)
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Timely Filing
Federal regulations dictate that providers must file the Medicaid portion of claims for
dually-eligible beneficiaries within 12 months of the beginning date of service.
The Medicare claim will establish timely filing for Medicaid.
• If the provider files with Medicare during the 12-month Medicaid filing deadline, Medicaid may then
consider payment of a Medicare deductible and/or coinsurance, even if more than a year has passed
since the date of service.
• Federal regulations permit Medicaid to pay its portion of the claim within six (6) months from the
Medicare paid/denied date.
Providers may not electronically transmit any claims for dates of service over 12 months.
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Timely Filing
Medicaid requires providers to submit all claims no later than 12 months from the date of
service. The 12-month filing deadline applies to all claims, including:
• Adjustment requests and resubmissions of claims previously considered
• Claims for services provided to individuals who acquire Medicaid eligibility retroactively
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Timely Filing
Claims with Retroactive Eligibility (Pseudo Claims)
• Retroactive eligibility does not constitute an exception to the filing deadline policy. If an
appeal or other administrative action delays an eligibility determination, the provider must
submit the claim within the 12-month filing deadline.
• If the claim is denied for recipient ineligibility, the provider may resubmit the claim when
the patient becomes eligible for the retroactive date(s) of service. Medicaid may then
consider the claim for payment because the provider submitted the initial claim within the
12-month filing deadline and the denial was not the result of an error by the provider.
• To resolve this dilemma, Arkansas Medicaid considers the pseudo recipient identification
number 9999999999 to represent an “...error originating within (the) State’s claims
system.” Therefore, a claim containing that number is a clean claim if it contains all other
information necessary for correct processing.
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Timely Filing
Claims with Retroactive Eligibility (Pseudo Claims)
• Providers have 12 months from the approval date of the patient’s Medicaid eligibility to
resubmit a clean claim after filing a pseudo claim. After the 12-month filing deadline (12
months from the Medicaid approval date), claims will be denied for timely filing and will
not be paid. It is the responsibility of the provider to verify the eligibility approval date.
• Once a beneficiary receives retro eligibility, the provider must submit a paper claim, proof
of the pseudo claim and a cover letter to Research for special processing.
HP Enterprise Services
Attn: Research Analyst
PO BOX 8036
Little Rock, AR 72203
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© Copyright 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Quiz Time
• How many days do you have to submit a clean claim to Arkansas Medicaid before it is
considered timely?
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Claim Status
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Remittance and Status Report
Check your remittance and status report (WebRA) each week for:
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Paid Claims
Denied Claims
Adjusted Claims
Pending Claims
Recoupments
Claims Payment Summary
HEOB Codes/Messages
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Claim Status
• Electronic claims are typically adjudicated on the next remittance advice.
• Paper claims that could have been sent electronically typically adjudicate 30-45 days
after submission.
• Claims that must be sent on paper typically adjudicate 2-3 weeks after submission.
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Claim Status
Five Ways to Check Claim Status
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Verify claims on the remittance advice
PES software
Medicaid website
VRS
Provider Assistance Center (800) 457-4454 or (501) 376-2211
© Copyright 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.
Questions?
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Thank you
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