Transcript Headline Here - Magellan of Iowa

Habilitation Services – Billing and Claims Process
Presented by Dennis Petersen, COO – February 18, 2014
Magellan Transition
• Only services rendered 7/1/13 or AFTER, should be billed to Magellan.
• For all services rendered PRIOR to 7/1/13, claims should be submitted
directly to Iowa Medicaid Enterprise (IME).
• Existing service plans for HAB services active as of July 1, 2013, were
transferred to Magellan.
• Why the change in billing procedures? Magellan has processes in place to
ensure HIPAA and CMS compliance. The codes/processes previously used
were not in compliance in order for us to process a claim.
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Provider Billing Codes
IA Medicaid HAB Service Name
Day Habilitation
Time
Unit/Basis
Old W Code
New
HIPAA Code
HIPAA Modifier*
Date Span
Per 15 Min
W1206
T2021
UC
Daily
Per Day
W1204
T2020
UC
Daily, could bill date span
as long as span matches
the # of units billed.
Home-Based Habilitation
Per 15 Min
W1207
H2015
UC
Daily
Home-Based Habilitation
Per Day
W1208
H2016
UC
Daily, could bill date span
as long as span matches
the # of units billed.
Pre-Vocational Services
Per Hour
W4425
T2015
UC
Daily
Pre-Vocational Services
Per Day
W1425
T2014
UC
Daily, could bill date span
as long as span matches
the # of units billed.
Day Habilitation
*For all Iowa Medicaid Habilitation services, the UC modifier must be included on claims. Claims for this service submitted without this
modifier will be denied.
*For those members with an ETP/Ad Hoc rate, you must bill with a KX modifier in the first position, and the UC modifier in the second
position in order for the claim to process at the correct rate. (i.e. T2021 KX UC)
Note: This is a list of all HAB services. Please check your contract for the services your site can provide.
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Provider Billing Codes, cont.
IA Medicaid HAB Service Name
Time
Unit/Basis
Old W
Code
New
HIPAA Code
HIPAA Modifier*
Date Span
Supported Employment:
Maintain Employment/Job Coaching
Per 15 Min
W1431
H2025
UC
Daily
Supported Employment:
Maintain Employment/Enclave
Per 15 Min
W1433
H2023
UC
Daily
Supported Employment:
Job Development
Per Unit
W5019
T2018
UC
Daily
Supported Employment:
Employer Development
Per Unit
W5020
H2024
UC
Daily
Supported Employment:
Enhanced Job Search
Per 15 Min
W5021
H2019
UC
Daily
*For all Iowa Medicaid Habilitation services, the UC modifier must be included on claims. Claims for this service submitted without this
modifier will be denied.
*For those members with an ETP/Ad Hoc rate, you must bill with a KX modifier in the first position, and the UC modifier in the second position
in order for the claim to process at the correct rate. (i.e. T2021 KX UC)
Note: This is a list of all HAB services. Please check your contract for the services your site can provide.
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Magellan Covered Diagnosis
Code
290
291
292
293
294
295
296
297
298
299
300
301
302
306
307
308
309
311
312
314
Description
Senile and presenile organic psychotic conditions
Alcoholic psychoses
Drug psychoses
Transient organic psychotic conditions
Other organic psychotic conditions (chronic)
Schizophrenic disorders
Affective psychosis
Paranoid states
Other non-organic psychosis (i.e. emotional stress, environmental factors as major part of
etiology)
Psychoses with origin specific to childhood
Anxiety states
Personality disorders
Sexual deviations and disorders
Physiology malfunction arising from mental factors
Special symptoms or syndromes, not elsewhere classified
Acute reaction to stress
Adjustment reaction
Depressive disorder, not elsewhere classified
Disturbance of conduct, not elsewhere classified
Attention deficit disorder
Note: 310.00-310.99 – Mental Retardation is NOT covered.
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Place of Service (POS) Codes
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Code
Definition
Code
Definition
03
School
33
Custodial Care Facility
04
Homeless Shelter
49
Independent Clinic
11
Office
50
Federally Qualified Health Center
12
Home
53
Community Mental Health Center
13
Assisted Living Facility
54
Intermediate Care Facility
14
Group Home
57
Non-residential SA Treatment Facility
22
Outpatient Hospital
71
State or Local Health Clinic
23
Emergency Room
72
Rural Health Clinic
31
Skilled Nursing Facility
99
Other
32
Nursing Facility
Claims – Expediting the Process
FACT: The majority of claims are processed within 24-48 hours.
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Electronic Claim Submission
Submit “Clean” Claim
Submit Within Timely Filing Guidelines
Sign Up For Electronic Funds Transfer (EFT)
Sign Up For Electronic Remittance Advice (ERA)
Electronic Claim Submission Options
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Electronic Claim Submission – On-Line
Training Available
• Go to www.MagellanProvider.com.
• Choose “Education”, and then “Online Training”.
• The section on “Electronic Transactions” includes the following demos:
– 835 Transactions
– Clearinghouse
– Submit EDI Claims
– EDI Testing Center
– Electronic Funds Transfer
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Claims/Website Contact Information
General Billing Questions
Customer Service 1-800-638-8820
EDI/Website Technical Support
Getting Started – visit our EDI Testing Center at
www.edi.magellanprovider.com
EDI Hotline – 1-800-450-7281, ext. 75890 or email
[email protected]
General Website Technical Assistance
For all other website technical assistance, call
Provider Services at 1-800-788-4005.
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Submit “Clean” Claims – Top Claim Denial Reasons
• Member Not Found – Be sure you are using the correct spelling of the
member’s name and DOB that appears in eligibility. If this information
does not match, it will cause the claim to reject and it will not be accepted
for adjudication. If the information in eligibility is incorrect, contact IME to
make a correction.
• No Authorization – Be sure you have an active authorization on file and
units available to use.
• Not Eligible – Verify member eligibility each month of service. You can do
this on our website at www.magellanprovider.com or via ELVS at 800-3387752. Even if services are authorized, the member must still have active
eligibility.
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Top Claim Denial Reasons, cont.
• Invalid/Non-Covered Dx Codes – Be sure the primary Dx you are billing is a
covered Dx with Magellan. Be sure ALL the Dx codes you are billing are
valid.
• Invalid CPT/HCPCS Codes – Confirm the code you are billing is the same
code that was authorized for service. Refer to your authorization letter
which can be accessed at www.magellanprovider.com.
• Invalid or Missing Modifier or Place of Service Code (POS)
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Top Claim Denial Reasons, cont.
• Missing Name and Degree of Provider – CMS 1500 only
• Site not contracted/credentialed – be sure the claim’s “rendering” site is
contracted for the services you are billing for. Not all sites may be
contracted for the same services. Be sure you are using the correct TIN/NPI
number combination for that site.
• Duplicate Claim Submission – if you are submitting a CORRECTED CLAIM, be
sure you indicate as such on the claim so that it doesn’t deny as a duplicate.
When submitting a CORRECTED CLAIM, fill out the claim the way it should
have been submitted.
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Submit Within Timely Filing Guidelines
• In accordance with State requirements, Magellan requires Medicaid claims
to be resolved by the 365th calendar day from the date of service.
14
Sign Up for EFT and ERA
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Website Resources
• www.MagellanofIowa.com
• www.MagellanProvider.com
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On-Line Resources
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On-Line Resources, cont.
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Magellan Customer Service Contact Information
Customer Service – 1-800-638-8820; Fax 1-888-656-5302
Donna Booth, Customer Service Supervisor – 1-800-638-8820, x85251
Email – [email protected]
Christine Bryant, Customer Service Manager – 1-800-638-8820, x85009
Email – [email protected]
Dennis Petersen, Chief Operations Officer – 1-800-638-8820, x85044
Email – [email protected]
Customer Service Address
Magellan Health Services
PO Box 71129
Des Moines, IA 50325
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Claims Address
Magellan Health Services
PO Box 1869
Maryland Heights, MO 63043
Additional Contact Information
ELVS – Eligibility Verification System - 1-800-338-7752
Contracting/Rates questions, or to add an additional site – call Anne
Thielking, Network Provider Relations Liaison at 1-800-638-8820 ext.
85045
How to file an appeal – Request should be made in writing and include
all supporting documentation.
Email [email protected]
Fax 1-888-656-2658 or
Mail to:
Magellan Health Services
Attn: Appeals, P.O. Box 71129
Des Moines, IA 50325
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Q&A
Question(s)
Magellan Response
I was hoping for some advice regarding recent interactions with Magellan. We have
always been instructed to use full legal names for clients in our system, as per Iowa
Code. We’ve had feedback from Magellan saying that for their records, they use the
client’s name they receive from DHS each year when eligibility is reviewed. There
have been instances where the name that Magellan has does not match the legal
name in our system, therefore billing is denied. For example, our record may state
“James Smith” and Magellan’s record may state “Jimmy Smith”. Apparently this is
also an issue with maiden and married names. This has resulted in our billing
department needing to manually resubmit billing for these clients, which is a tedious
process. Any advice you can offer would be greatly appreciated.
This information is provided to us
through the eligibility feeds we get
regularly from the State. When you
submit a claim, if the member’s
name (including spelling) and DOB
do not match exactly what’s in
eligibility, the claim will reject. This
means we cannot identify the
member and the claim will not
enter our system for adjudication.
If the information contained in
eligibility is incorrect, this must be
corrected directly with IME.
Usually the member’s worker can
assist with this.
No. The reporting requirement of
this QI process remains with Iowa
Medicaid. For more information on
these requirements, contact
Provider Services at 1-800-3387909.
Regarding audits - Will Magellan be conducting their own audits of documentation
pertaining to services provided and what kinds of things will they be looking for? Is a
mental health statement necessary? ID SCL Hourly/Daily services specifically.
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Q&A, cont.
Question(s)
Will there be any electronic confirmation of when claims will be paid or have
been paid? Right now I have to search the website for an EOB, or check with
my bank for an ACH deposit.
Why is there no one to call to ask questions about claim denial or lack of
response on submitted claims that have not yet appeared on an EOB? When I
contact Magellan, I am referred back to the website that has no information
about the submitted claim(s).
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Magellan Response
If you receive paper checks from
Magellan for claims payment,
then an EOB or EOP would be
included. However, if you are
signed up for EFT, you will no
longer receive these remits as
indicated on the EFT form. In
order to get EOB or EOP
information, you would need to
either view this information on
the website, or you can sign up
to receive Electronic Remittance
Advice (ERA). This form can be
found on our website. You may
also contact customer service at
1-800-638-8820 for assistance.
Our customer service
department is here to assist you
with things such as this. Our
customer service associates can
give you denial reasons and
advise you if additional
information is needed. If you are
having difficulty getting this
information, please ask to speak
to a supervisor to further assist
you.
Q&A, cont.
Question(s)
1) How is the timeframe determined for length of service? Sometimes it’s only
approved for 3 months, and then the next time it might be 5 or 8 months. We are
used to renewing annually and it becomes a tracking nightmare!
2) Enhanced services do not seem to be consistent with number of hours/units
for each individual. My understanding from the way we previously billed; was
that individual had 26 hours (or 104 units) total. When that number had been
used it was done, whether it took 6 months or a year. (the intent was that was
meeting 1 hour per week for 6 months originally) The authorizations are not
consistent…sometimes authorizing 104 units per month and others authorizing
104 units for 3 months, which is usually not possible.
How does your refund policy function? I have a payment from Magellan that
needs to be returned but have no information on how to send it back properly.
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Magellan Response
Magellan staff members do make
individual authorization decisions
based on the needs of the
member and overall need for the
service. Some of these
authorizations for exception rates
have also been shorter as we try
to move to a standardized rate
process.
As we are making adjustments in
process and units, we will be
moving more to a range of
authorizations for high, medium
and low need members. More to
come out in the next 30 days.
If you have a payment that needs
to be returned, call customer
service at 1-800-638-8820. They
will request an adjustment be
done on the claim in question, and
will also request that an
overpayment letter be sent to you
with instructions on returning the
payment.
Q&A, cont.
Question(s)
1. We had a case manager stop in last week and ask for a copy of a client’s
Habilitation NOD from the Magellan website. Are case managers unable to pull
a client’s NOD from the website themselves or does she just need to be shown
how to do it?
2. The authorization that I pull from the Magellan website does not have the
approved rate on it. Am I doing something wrong or is this normal? Does the
rate need to be on the NOD in case of an audit?
Within Claims Courier on the Magellan Provider website, how do you “repay” a
claim that was paid but was incomplete? And furthermore, if the previous
question is possible, how do you correct that claim?
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Magellan Response
1. Due to privacy laws, access to
our website is limited to those
with granted access. Your
company’s website administrator
has the ability to grant access
such as this to individuals within
your office. If the case manager is
not an employee, then they
would not have access to this
information and you would need
to supply it as necessary.
2. Magellan authorizations
(NODs) do not list a rate, unless
an Exception to Policy or Ad Hoc
rate has been approved. If there
is no rate listed on the auth form,
then standard rates would apply.
Claims Courier, through the
Magellan Provider website, will
only allow you to “correct” all
aspects of a claim up until 3pm
on the same day the claim was
submitted. If you need to make
any corrections after that, you
may only do so to the Place of
Service, Billed Amount and the
Number of Units fields. Other
corrections must be submitted on
a hard copy corrected claim via
postal mail, noting “Corrected
Claim” at the top.
Confidential Information
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be kept confidential. The attached material shall not be photocopied, reproduced, distributed to or disclosed to others at any time
without the prior written consent of the Company.