Transcript Document

MHS UB-04
Prior Authorization
Top Denials
October 20, 2009
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CLAIM PROCESS
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Claim Process -Top 10 Denials
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Time Limit For Filing Has Expired (EX 29)
– Claims must be received within 120 calendar days of the
date of service (Contracted Providers)
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Exceptions
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Bill
120 days from DOS for Participating Providers
Exceptions: Newborn, Third Party Liability, and Eligibility
delays (filing limit 365 days)
– 365 days from DOS for Non Participating Providers
Primary Insurer 1st (EX L6)
– Verify other insurance (TPL). Medicaid is the payer of last
resort
– MHS requires a copy of the primary EOP
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Claim Process -Top 10 Denials
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Coverage Not In Effect When Service Provided
(EX 28)
– Check eligibility at each visit prior to submitting claims to
ensure that you are billing the correct carrier
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Non Covered Service For Package B Member
(EX BP)
– Package B allows for pregnancy related services only
– Pregnancy related diagnosis must be on claim for service
to be coverage
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Claim Process -Top 10 Denials
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Not a MCO Covered Benefit (EX 50)
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Service must be covered by Indiana Medicaid
Carve Out Services not paid by MHS
Please Resubmit to Cenpatico For
Consideration (EX 54)
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Cenpatico (CBH) handles all behavioral health claims
for MHS members
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Claim Process -Top 10 Denials
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Authorization Not On File (EX A1)
– Prior Authorization should occur at least two (2) business
days prior to the date of service. All non elective
inpatient/outpatient services must be prior authorized with
MHS at least two (2) business days prior to the date of
service
– All urgent and emergent services must be called to MHS
within two (2) business days after service/admit
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Claim Process -Top 10 Denials
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Claim and Auth Service Provider Not matching
(EX HP)
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Claim and Auth Provider Specialty Not Matching
(EX HS)
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Authorization on file does not match date of service billed
Authorization on file does not match provider billing
service
Denied By Medical Services (EX EB)
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Authorization related denial
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Claim Process - Billing With Ease
NEWBORNS
• No prior authorization or referral is required for
normal newborn nursery.
• Newborn’s RID number is required for payment.
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Claim Process - Billing With Ease
HOSPITAL STAYS
• Hospital stays under 24 hours are not billable as
inpatient and must be submitted as outpatient
services.
Medical Management will not approve
inpatient less than 24 hours.
• 72-hour observation may be available for stays that
may not meet medically necessary inpatient
admissions.
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Claim Process – Claim Filing
• EDI SUBMISSION
Preferred method of claims submission
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Immediate Confirmation of receipt
Faster payment processing
Less expensive than paper submission
MHS Payor ID 39186
• It is the responsibility of the provider to review the
error reports received from the Clearinghouse
– ERF / ERA available
– Contact [email protected] with questions
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Claim Process – Claim Filing
• Paper Submission
Managed Health Services
PO Box 3002
Farmington, MO 63640-3802
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Claim Process – Resubmission
• Clearly mark RESUBMISSION or CORRECTED
CLAIM at the top of the claim.
• Must attach EOP, documentation, and explanation
of the resubmission reason.
• May use the Provider Claims Adjustment Request
Form.
• Providers have 67 calendar days from the date
they receive their EOP to file a resubmission.
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Claim Process – Claim Adjustment
• If you need to make an adjustment to a paid claim,
you can do so by submitting the adjustment request
on paper with the adjustment request form.
• Attach a MHS Provider Adjustment Form along with
documentation, including EOP (if available)
explaining reason for resubmission
• Claim adjustments requests must be submitted within
67 days of the date of the MHS EOP
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Claim Process – Dispute Resolution
PROVIDERS HAVE 67 CALENDAR DAYS FROM THE
DATE OF RECEIPT OF THE EOP TO FILE AN
OFFICIAL DISPUTE OR APPEAL WITH MHS
• Verbal inquiries can be made by calling the MHS Provider
Inquiry Line at 1-877-MHS-4U4U (647-4848).
• A verbal inquiry is not considered a dispute or appeal and does
not top the 67 calendar days from the date of receipt of the EOP
to file dispute or appeal
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Claim Process – Dispute Resolution
INFORMAL CLAIM DISPUTE/OBJECTION
Level One Appeal
• 1ST step in the appeals process
• Should be made in writing by using the Dispute/Objection form
• Submit all documentation supporting your objection
• Send to MHS within 67 calendar days of receipt of the MHS
EOP
• A call to Provider Inquiry does not reserve appeal rights
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Claim Process – Dispute Resolution
FORMAL CLAIM DISPUTE/OBJECTION
Level Two Appeal
(Administrative)
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Submit the Formal Claims Dispute (Administrative Appeal) with all
supporting documentation to the MHS appeals address:
Managed Health Services
Attn: Appeals
P.O. Box 3000
Farmington, MO 63640-3800
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MHS will acknowledge your appeal within 5 business days
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Provider will receive notice of determination within 45 calendar days of
the receipt of the Appeal
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Provider Inquiry Services
Call us at 1-877-647-4848. We are ready to
help you!
• Knowledgeable, friendly staff available 8:00-6:00 EST
• Focused commitment to professional service
• Claims address P.O. Box 3002 Farmington, MO
63640
• Dispute & appeal processes (67 days from receipt of
EOP)
• Appeal address P.O. Box 3000 Farmington, MO
63640
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Utilization Management
(Prior Authorization)
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Utilization Management
REFERRAL
A referral is a
request (verbal,
written, or telephonic
communication) by a
PMP for specialty
care services.
PRIOR
AUTHORIZATION
Prior Authorization is
an approval from
MHS to provide
services designated
as needing approval
prior to treatment
and/or payment.
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Utilization Management
• Prior Authorization (PA) should be initiated through
the MHS referral line at 1-877-MHS-4U4U (647-4848)
• The PA process begins at MHS by speaking with the
MHS non-clinical referral staff.
• Prior Authorizations can also be submitted online via
our website at www.managedhealthservices.com.
Additional documentation may be required to be sent
via fax for approval of authorization.
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Utilization Management
Self Referrals
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Podiatrist
Chiropractic
Family Planning
Immunizations
Routine Vision Care
Routine Dental Care
Mental Health by Type and Specialty
HIV/AIDS Case Management
Diabetes Self Management
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Utilization Management
Services that require a prior authorization
regardless of contract status:
– All elective hospital admissions two business days prior
All urgent and emergent hospital admissions (including
NICU) require notice to MHS by the 2nd business day
after admission
– Transition to hospice
– Newborn deliveries by 2nd business day
– Rehabilitation facility admissions
– Skilled nursing facility admissions
– Transition of care
– Transplants, including evaluations
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Utilization Management
Services that require a prior authorization
regardless of contract status:
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Cardiac rehabilitation
Hearing aides and devices
Home care services, including home hospice
In-home infusion therapy
Orthopedic footwear
Orthotics and prosthetics >$250
Respiratory therapy services
Pulmonary rehabilitation
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Utilization Management
Services that require a prior authorization
regardless of contract status:
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Abortions (spontaneous only)
Assistant Surgeon
Blepharoplasty
Cholecystectomies
Circumcision (any patient over 30 days old)
Hysteroscopy and Hysterectomy
Therapies, excluding evaluations
Dental Surgery for members >5 y/o &or general
anesthesia is requested
– Dialysis
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Utilization Management
Services that require a prior authorization
regardless of contract status:
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Experimental or investigational treatment/services
Genetic testing or counseling
Home care services
Implantable devices including cochlear implants
Infertility services
Injectable Drugs (greater than $100 per dose
Mammoplasty
Nutritional counseling (non-diabetics only)
Pain Management Programs including epidural, facet
and trigger point injections
– PET, MRI, MRA and Nuclear Cardiology/SPECT scans
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Utilization Management
Services that require a prior authorization
regardless of contract status:
– Scar revision/cosmetic or plastic surgery /Septoplasty
/Rhinoplasty
– Spider/Varicose veins
– Specific DME services (listing on Quick Reference
Guide)
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Utilization Management
Hospital Services
• All elective inpatient/outpatient services must be
prior authorized with MHS at least 2 business
days prior to the date of service.
• All urgent and emergent services must be called
to MHS within 2 business days after the admit.
*Failure to prior authorize services will result in
claim denials.
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Utilization Management
TRANSFERS
• MHS requires notification and approval for all nonemergent transfers, at a minimum 3 (three) business
days advance notice.
• MHS requires notification within three (3) business
days following all emergent transfers. Transfers are
inclusive of, but not limited to the following:
– Facility to facility
– Level of care changes
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Utilization Management
To initiate the authorization, referral staff will require the
following information:
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place of service: outpatient, observation or inpatient
service type: elective, emergent or transfer
service date
name of admitting physician
CPT code for proposed services
primary and any secondary diagnosis
• contact name and number to obtain clinical information
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Utilization Management
The MHS CM will review all available clinical
documentation; apply Milliman Care Guidelines, and
seek Medical Director input as needed.
• PA for Observation Level of Care (up to 72 hours) is
not required for contracted facilities
• If the provider requests an inpatient level of care for a
covered/eligible condition/procedure and
documentation supports an outpatient/observation
level of care, the case will be sent for a Medical
Director review
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Utilization Management
Denial of Request and Appeal Process
If MHS denies the requested service:
• MHS CM will notify the provider verbally within one business
day of the denial, provide the clinical rationale, and explain
appeal rights
• A formal letter of denial explaining denial rationale and appeals
rights will be mailed within the next business day
• If denial is based on Milliman Care Guidelines, provider has
right to obtain a copy of the guidelines in which denial is based
• If member is still receiving services the provider has the right to
an expedited appeal which must be requested by the attending
physician
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Utilization Management
Denial of Request and Appeal Process
If MHS denies the requested service:
• If the member has already discharged- an appeal must be
submitted in writing from the attending physician within 60 days
of the denial
• The attending physician has the right to a Peer to Peer
discussion
• Peer to Peer discussions and Expedited Appeals are initiated by
calling MHS at 1-877-MHS-4U4U (647-4848) and asking for the
Appeal Coordinator
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Utilization Management
• MEDICAL NECESSITY GRIEVANCE AND
APPEALS
Managed Health Services
Attn: Appeals Coordinator
1099 North Meridian Street, Suite 400
Indianapolis, IN 46204
• Determination will be communicated to the provider
within 20 business days of receipt
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MHS - Need To Know
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MHS – Need to Know
www.managedhealthservices.com
&
1-877-MHS-4U4U (647-4848)
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Need to Know - MHS Website
• www.managedhealthservices.com
• Enhanced website – Access for both contracted/non-contracted
groups
• On-line Registration – Multiple Users
• Provider Directory Search Functionality
• Enhanced Claim Detail
• Direct Claim Submission (Professional Claims only)
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Printable EOP
On-line prior authorization guide and submission
Claim Auditing Software Tool
Downloadable Eligibility Listing
Printable, Current Forms and Manual
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Need to Know - MHS Website
Upcoming Enhancements
• Direct claim submission UB04 – 2010
• Claim resubmission – 2010
• Claims Xtend – 2010
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Need to Know – Provider Education
MHS generates a Provider Watch Bulletin of helpful
tips and Plan updates to billing office locations for all
participating providers on a quarterly basis. All
providers can review this bulletin on the MHS website
at www.managedhealthservices.com.
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Questions and Answers
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