Transcript BT_Icon_Dk_Blue_HP_XP_Template

Life of a Claim
Presented by HP Provider Relations
Agenda
•
General requirements for reimbursement
•
System Edits
•
Pricing Methodologies
•
System Audits
•
Suspended Claims
•
Claim Adjustments
2
October 2010
Lif e of a Claim
M ember
receives
services
Bef or e
r ender ing
ser vices,
pr ovider m ust
ver if y
m em ber ’s
eligibilit y and,
if applicable,
obt ain pr ior
aut hor izat ion.
3
October 2010
Provider
submits claim
to IHCP
If applicable,
pr ovider m ust
f ir st subm it claim
t o m em ber ’s
pr ivat e insur ance
or Medicar e.
Af t er t he claim
has been
adjudicat ed (paid
or denied) by
t hese ent it ies,
t hen t he pr ovider
can subm it claim
t o IHPC.
HP receives
the claim
IHCP claim s
ar e
ident if ied,
t r acked, and
cont r olled
using a
unique 13digit int er nal
cont r ol
num ber (ICN)
assigned t o
each claim
by
IndianaAIM.
Claim is
processed by
IndianaAIM
Based on claim
t ype, pr ovider
t ype and
m em ber
eligibilit y,
IndianaAIM w ill
subject t he
claim t o
syst em s edit s,
appr opr iat e
pr icing
m et hodology,
and syst em s
audit s.
Claim is
adjudicated
When
adjudicat ed,
t he claim
can be:
- Paid
- Denied
- Suspended
A Remittance
Advice is
generated for
the provider
Pr ovider can
access t heir
w eekly
r em it t ance
advice (RA)
t hr ough Web
int er Change.
If t he claim is
on Paid St at us,
appr opr iat e
r eim bur sem ent
w ill be sent t o
t he pr ovider .
Services Rendered to IHCP Members
•
To be reimbursed by IHCP, the service
provided must be covered by IHCP and
when a prior authorization (PA) is
required, the PA must be requested
and approved before the service is
rendered
•
How can a provider verify if a service is
covered by IHCP, and whether or not it
requires PA?
− By contacting the HP Customer
Assistance Provider Line
− Referring to the Fee Schedule, located in
the IHCP Web site
4
October 2010
Prior Authorization
•
According to the IHCP regulations,
providers must request prior
authorization (PA) for certain services …
PA
Department
•
The main purpose of the PA process is
to ensure that Indiana Medicaid
funding is utilized only for those
services that are
− Medically necessary
− Appropriate
− Cost effective
5
October 2010
ov
pr
Ap
− When normal limits are exhausted for
certain services
ed
− To determine medical necessity, or
Note: PA is not a
guarantee of
payment.
Prior Authorization
Program/Services
Administered by…
Contact Information
Traditional Medicaid
and Carved-out
Services
ADVANTAGE Health
SolutionsSM
1-800-269-5720
Care Select
ADVANTAGE Health
SolutionsSM
1-800-784-3981
MDwise
1-866-440-2449
Managed Health Services
(MHS)
1-877-647-4848
Anthem
1-866-408-7187
MDwise
(317) 630-2831 or
1-800-356-1204
ACS
1-866-879-0106
Hoosier Healthwise
Pharmacy Services
(All Programs)
6
October 2010
Claim is Processed by IndianaAIM
System Edits
7
October 2010
Edits...
Ø Verify and validate
claim data
Ø Check the
information
entered (or
missing) in
specific fields of
the claim
Ø Ensure that the
information
submitted by the
provider is valid
and in the correct
format
Ø Are not intended
to exclude
services
•
As part of processing a claim,
IndianaAIM performs systems edits
to verify that the required fields
are completed and that the
information included in these
fields is valid
•
Claim data is validated against
other IndianaAIM databases, such
as the member, provider, and
reference files
–
Those claims that do not pass the
system edit review are denied or
suspended for further review,
depending on the specific edit
triggered by the claim
Claim is Processed by IndianaAIM
Example of System Edits
Edit Code
8
Description
0228
Provider Signature Missing
0264
The Date of Service is Missing
0527
Date Billed After ICN Date
0507
The “From” Date is After the “To” Date
0545
Claim Past Filing Limit
0513
Recipient Name and Number Disagree
0644
Covered by Private Insurance- Bill Prior to Medicaid
1010
Rendering Provider Not a Member of the Billing Group
1025
Billing Provider Not Enrolled for the Date of Service
1100
Billing NPI Not Reported to a Legacy Provider Identifier
2008
Recipient Ineligible for Level of Care Billed
3003
Procedure Code Requires PA
4019
Procedure Code Requires Attachment
October 2010
National Correct Coding Initiative
What is it?
•
In the 1990's, the Centers for Medicare
& Medicaid Services (CMS) developed
the National Correct Coding Initiative
(NCCI) to promote national correct
coding methodologies and to control
improper coding leading to
inappropriate payment
•
NCCI has been in place for many years
and most providers are familiar with the
editing methodologies with Medicare
9
UB-04 – Institutional Claim
October 2010
National Correct Coding Initiative
What is it?
•
Based on input from a variety of
sources:
–
American Medical Association (AMA)
Current Procedural Terminology (CPT®)
Guidelines
–
Coding guidelines developed by national
societies
–
Analysis of standard medical and surgical
practices
–
Review of current coding practices
"CPT copyright 2009 American Medical Association. All rights reserved.
CPT is a registered trademark of the American Medical Association."
10
UB-04 – Institutional Claim
October 2010
National Correct Coding Initiative
11
–
The recent healthcare legislation passed into law (H.R. 3962),
requires that Medicaid programs incorporate compatible
methodologies of the National Correct Coding Initiative (NCCI)
into their claims processing system
–
Section 1761 –Mandatory State Use of National Correct
Coding Initiative, of this bill mandates that NCCI
methodologies must be effective for claims received on or
after October 1, 2010
–
Initial editing will encompass three basic coding concepts:
–
NCCI Column I and Column II (also known as bundling)
–
Mutually Exclusive (ME) edits
–
Medical Unlikely Edits (MUE)
UB-04 – Institutional Claim
October 2010
12
October 2010
Claim is Processed by IndianaAIM
Prior Authorization Verification
•
IndianaAIM reviews every procedure-coded claim to
determine when a procedure code requires prior
authorization (PA)
•
This determination is based on the PA Indicator on the
IHCP fee schedule
•
Claims from providers located out of state also require PA
•
Once approved, the PA belongs to the member, not to the
provider
13
October 2010
Claim is Processed by IndianaAIM
Prior Authorization Verification
•
IndianaAIM denies the service when a procedure code
requires PA and:
—There
is no approved PA on file
—The
date of service on the claim does not match the
prior authorized date(s)
•
IndianaAIM decrements the PA units when:
—The
procedure code requires PA and there is an
approved PA on file
14
October 2010
Claim is Processed by IndianaAIM
Pricing Methodology
•
After claims have passed the edits
review, they are subjected to pricing
review
–
As part of this review, the system
determines whether or not the claim can
be automatically priced or needs to be
suspended for manual pricing
o
15
This determination is based on:
October 2010
o
Claim Type
o
Procedure-Specific Pricing Indicator
o
Provider Specialty
o
Date of Service
Claim is Processed by IndianaAIM
Pricing Methodology
•
16
October 2010
The claim pricing process
calculates the Medicaid-allowed
amount for claims based on claim
type, pricing modifiers and defined
pricing methodologies
–
Based on the claim type,
IndianaAIM directs the claim to the
appropriate pricing methodology
–
If a third-party liability (TPL) amount
is present, the system subtracts
this figure from the IHCP allowed
amount to get the amount paid
Claim is Processed by IndianaAIM
Example of Pricing Methodologies
17
Pricing Methodology
Applied on ….
Diagnosis-Related Grouping (DRG)
Inpatient Services
Procedure Code Max Fee, or
Revenue Code Flat Rate
Outpatient Services
Resource-Based Relative Value
Scale (RBRVS)
Medical Services
Overhead Cost Rate/Staffing Cost
Rate
Home Health Services
Max Fee
Transportation Services and DME
Lab Fee
Lab Services
Manual Pricing
Durable Medical Equipment
Services
State Maximum Allowable Cost
(SMAC)
Pharmacy Services
October 2010
Claim is Processed by IndianaAIM
Systems Audits
•
All the programs that fall under the
umbrella of the IHCP (such as
Traditional Medicaid and Care
Select) have certain service
limitations
–
18
The extent of these limitations will be
determined by the aid categories and
are defined by state and federal
regulations
–
These regulations are usually referred
to as the IHCP Medical Policy
–
The Office of Medicaid Policy and
Planning (OMPP) is responsible for
establishing these medical policies
October 2010
IHCP Policies
All Indiana health
coverage programs
have certain limitation
of services, which are
determined by IHCP
Medical Policy (state
and federal
regulations).
Claim is Processed by IndianaAIM
System Audits
•
IHCP Medical Policies are monitored and
enforced by the auditing process
•
Audits….
19
–
Compare current claims for a specific
member against all other services on the
claim history file that were rendered, billed,
and finalized for that member
–
Ensure that providers do not perform
excessive or unnecessary services without
medical justification
–
Ensure that state and/or federal regulations
regarding the frequency, extent, length of
stay, and cost of service are followed
October 2010
Audits are
designed to
monitor or
regulate the IHCP
medical policy.
Claim is Processed by IndianaAIM
System Audits
•
Similar to what happens
early in the process when
the claim is subjected to
system edits; if the claim
fails any of the system
audits, the claim may be…
–
Systematically denied
–
Systematically cut back to
reduce the number of units or
dollars paid on the claim, or
–
Suspended,
….depending on the
specific audit triggered by
the claim
20
October 2010
DEN I ED
SUSPEN DED
CUTBACK
Claim is Processed by IndianaAIM
Example of System Audits
Audit
Code
21
Description
5000
Possible Duplicate
5001
Exact Duplicate
6056
Only One Hearing Aid Repair Per 12 Months Allowed For
Recipients 18 and Older
6113
DME Limited to $2,000 Per Recipient Per Calendar Year
6115
Physical Therapy Services Limited to 50 Visits Per Calendar
Year
6710
Diabetic Test Strips are Limited to 2 Units Per Month
6011
Professional / Technical Components For Radiology or
Pathology Not Payable When Complete Procedure Already
Paid
6701
Procedure Code 93352 Must be Billed on the Same Day as
93350 and 93351
October 2010
Claim is Adjudicated
Suspended Claims – Role of the HP Resolutions Unit
•
22
October 2010
The HP resolution claims adjudication
staff examines suspended claims and
makes a decision based on approved
adjudication guidelines for the date of
service
–
The approved guidelines indicate the
course of action that must be taken for
all the error codes (edit/audits failures)
that are reviewed and resolved by the
HP Resolutions Unit
–
These guidelines are based on the
medical policies established by OMPP
Claim is Adjudicated
Suspended Claims – Role of the HP Resolutions Unit
•
23
Resolution examiners have the option of
applying the following transactions when
processing suspended claims, depending
on the edit or audit failure:
–
Add or change data (data entry errors by
HP)
–
Force or override the edit or audit
–
Deny the claim
–
Put the claim on hold (which can be due to a
system problem or a pending policy
decision)
–
Resubmit the claim
October 2010
Claim is Processed by IndianaAIM
Suspended Claims – Medical Policy
24
•
Claims requiring medical policy review are placed in a
suspended status by IndianaAIM
•
IndianaAIM enters the suspended ICNs onto a scheduler and
automatically routes the suspended ICNs to the Care
Management Organization (CMO) to which the member is
assigned
•
ADVANTAGE Health Solutions for Traditional Medicaid and
for their Care Select members
•
MDwise for their Care Select members
October 2010
Claim is Processed by IndianaAIM
Suspended Claim Resolution – Medical Policy
25
•
A designated staff member reviews the scheduler and reassigns the suspended ICNs to additional staff members for
resolution
•
Each ICN is processed according to the approved guidelines
for the specific audit
•
Based on the guidelines, the audit will be forced to a paid
status, or the audit will fail (deny)
•
Medical records are not requested from the provider during
this process
•
Medical documentation submitted with the claim, however,
is reviewed
•
Suspended ICNs should be completed within 30 days
October 2010
Claims Adjustment
Claims Adjustments
•
An adjustment is defined as a request to
change historical data or reimbursement
for a claim
–
27
Adjustments are necessary when there has
been an overpayment or underpayment to
the provider
o
If a net overpayment is determined,
IndianaAIM will establish an accounts
receivable and recoup the overpayment
o
If an underpayment is determined, the
provider will be reimbursed the net
difference in the current week’s payment
amount
October 2010
Claims Adjustment
Adjustments cannot be performed for the following
scenarios:
•
Change member name
•
Change member ID (RID)
•
Change billing provider number/NPI
•
Change patient liability amount (LTC)
•
Change net billed amount (TPL claims)
•
Change copay information
•
Change certification code (Care Select)
28
October 2010
ADJUSTMENT
Claims Adjustment
Electronic Voids & Replacements
Voids
•
Is the HIPAA-approved term used to describe the
deletion or cancellation of an entire claim.
•
Can be completed on the same day or in the
same week that the original claim was submitted,
as well as after the original claim payment is
finalized (after an RA has been created).
•
Can be performed on paid claims only (that is, it
cannot be performed on a claim in a denied status)
•
Can be performed for a previously submitted
electronic claim or paper claim
29
October 2010
VOID
IM
CLA
VOID
CLA
IM
Claims Adjustment
Electronic Voids and Prior Authorization
Voids
•
Prior-authorized units are added to the thencurrent balance when a claim is voided
•
Providers can view the updated balance in Web
interChange using the PA Inquiry function
—Updated
units can be viewed within two hours
of the void taking place
•
30
Updated units are restored to the PA balance
immediately following the completion of a paper
adjustment
October 2010
VOID
IM
CLA
VOID
CLA
IM
Claims Adjustment
Electronic Voids and Replacements
Replacements
•
The HIPAA-approved term is used to describe the correction
of a claim that has already been submitted
•
Can be completed on the same day or in the same week that
the original claim was submitted, as well as after the payment
is finalized
•
Can be performed on paid and denied claims
•
Can only be submitted for noncheck-related adjustments
•
Check-related adjustments must be submitted on paper
•
Paper adjustment form instructions are available in the IHCP
Provider Manual, Chapter 11, Section 3
31
October 2010
32
October 2010
Thank you!
33
October 2010