Transcript Document

MHS CMS-1500
Prior Authorization
Top Denials
October 22, 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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Code Was Denied By Code Auditing Software
(EX 57)
– McKessen code audit analysis all claim line items and
code combinations by date of service during the
auditing/processing of claims
– Unbundling
– Global
– Assistant Surgeon
– Claim auditing software tool on web @
www.managedhealthservices.com assists in
explanation on how MHS evaluates different code
combinations
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Claim Process -Top 10 Denials
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Member Name/Number/Date Of Birth Do Not
Match (EX MQ)
– Member information on claim must match what is on file
with Indiana Medicaid
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This Service is Not Covered (EX 46)
– Service must be coverable through Indiana Medicaid to be
eligible for reimbursement
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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. Non All 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)
– Authorization on file does not match date of service billed
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Claim and Auth Provider Specialty Not Matching
(EX HS)
– Authorization on file does not match provider billing
service
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Claim Process - Billing With Ease
• Newborns
– Newborn’s RID number is required for payment.
• Consent Forms
– Need to be attached to the claim form when submitted for
claim processing.
• NPI, Taxonomy, Tax ID Not on File with MHS
Rejections
– The system cannot make a one to one match based off of
the information provided on the claim.
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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
On-line through the Managed Health Services
website:
www.managedhealthservices.com
– Provides immediate confirmation of received claims and
acceptance
• Paper Claims
– 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
stop the 67 calendar days from the date of receipt of the EOP to file
a 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)
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
MHS will acknowledge your appeal within 5 business days
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
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
• 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
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:
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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
To initiate the authorization, referral staff will
require the following information:
• place of service: outpatient, observation or
inpatient
• service type: elective, emergent or transfer
• service date
• name of physician performing service
• CPT code for proposed services
• primary and any secondary diagnosis
• contact name and number to obtain clinical
information
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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
• Member Services
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Transportation
NurseWise
Healthy Reimbursement Account
Connections
Panel Change Requests
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MHS – Need to Know
• Adding a new provider
– Provider must have Indiana Medicaid Linked to group before
MHS credentialing and set up process can begin.
– Contact Provider Relations @ 877-647-4848 to obtain
Provider Enrollment Form for proper set up and Participation
Provider Attestation to link provider to existing contract.
– Welcome letter will be issued once set up complete.
– Obtain Prior Authorization for all services rendered to MHS
prior to confirmation of contracted status. Provider Inquires
877-647-4848
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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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