Transcript Claims & Reimbursement Training Seminar

Western Highlands Network
Claims & Reimbursement
Training Seminar
Training Agenda
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NPI
Current Events
Deficit Reduction Act / False Claims Act
Claim Submissions
Remittance
Denial and Resolution
Technical Assistance
Information Resources
NPI
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Overview
Claim Submission
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DDE
837
CMS-1500
Provider Registration
Claim Adjudication
WH EOB / 835
National Provider Identification (NPI)
The Health Insurance Portability and
Accountability Act (HIPAA) of 1996 requires
the adoption of a standard unique identifier
for health care providers. The NPI Final Rule
issued January 23, 2004 adopted the NPI as
this standard.
What is NPI
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The NPI is a 10-digit, intelligence free numeric
identifier (10 digit number). Intelligence free means
that the numbers do not carry information about
health care providers, such as the state in which
they practice or their provider type or specialization.
The NPI will replace health care provider identifiers
in use today in HIPAA standard transactions.
Those numbers include Medicare legacy IDs (UPIN,
OSCAR, PIN, and National Supplier Clearinghouse
or NSC).
The provider’s NPI will not change and will remain
with the provider regardless of job or location
changes.
Have an NPI does not
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Ensure a provider is licensed or credentialed
Guarantee payment
Enroll a provider in a health plan
Turn a provider into a covered provider
Require a provider to conduct HIPAA
transactions.
Why the NPI
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Simpler electronic transmission of HIPAA
standard transactions
Standard unique health identifiers for health
care providers, health plans, and employers
More efficient coordination of benefits
transactions
Who can apply for the NPI
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All health care providers (e.g., physicians, suppliers, hospitals,
and others) are eligible for NPIs. Health care providers are
individuals or organizations that render health care.
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All health care providers who are HIPAA-covered entities,
whether they are individuals (such as physicians, nurses,
dentists, chiropractors, physical therapists, or pharmacists) or
organizations (such as hospitals, home health agencies, clinics,
nursing homes, residential treatment centers, laboratories,
ambulance companies, group practices, HMOs, suppliers of
durable medical equipment, pharmacies, etc.) must obtain an
NPI to identify themselves in HIPAA standard transactions.
Western Highlands’ Direct Data Entry
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Optional NPI claims entry available
April 20, 2008 – May 14, 2008
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May 15, 2008, WH requires NPI claims
entry. Claims entered after May 14,
2008 will deny without the appropriate
NPI data.
ASC X12N 837 004010X098A1, Health
Care Claim Professional
 Loop 2010AA – Billing Provider
 NM108 and NM109 – Submit either NPI (typical
provider) or tax ID number (atypical provider)
 N403 – Add 4-digit extension to zip code (do not
submit dash) – MUST match the appropriate
location of the billing provider
 REF01 – Must submit either legacy provider
number (if provider is atypical), SSN, or EIN
Attending Provider
 Loop 2310B – Attending Provider
 NM108 and NM109 – Submit either NPI
(typical provider) or tax ID number (atypical
provider)
 REF is only required if the Attending
Provider is atypical
Service Facility Location
 Loop 2310D – Service Facility Location
 NM108 and NM109 – Submit either NPI
(typical provider) or tax ID number (atypical
provider)
 N403 – Add 4-digit extension to zip code
(do not submit dash) – MUST match the
appropriate location at which the service
was provided
 REF is only required if the Service Facility
Location agency is atypical
837 – Test/Approval
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837 w/NPI must be tested with WH prior to
acceptance of claim submission
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Notify Diane Overman, 225-2785 ext. 2173 or via
e-mail [email protected]
Test for format, content, and HIPAA compliancy
Provide feedback to resolve discrepancies
Upon approval you may submit 837
CMS-1500
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Typical w/NPI
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(Rendering)
Block 24I, ID Qualifier = “ZZ”
Block 24J (upper), Rendering Provider = Taxonomy
Block 24J, (lower), Rendering Provider = NPI
Atypical w/out NPI
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Block 24I, ID Qualifier = 1D
Block 24J, (upper), Rendering Provider = WH Provider
ID
Block 24J, (lower), Rendering Provider = <Blank>
CMS-1500 (Billing Provider)
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Typical
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Block 33 = Billing Provider Info & Ph#, = Address, Zip+4
Block 33a = NPI
Block 33b = “ZZ” and Taxonomy
Atypical
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Block 33a = WH Provider ID
CMS-1500 (Service Facility Location
Information)
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Typical
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Block 32 = Address to include zip+4
Block 32a = NPI
Block 32b = “ZZ” and Taxonomy
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Atypical
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Block 32 = Address to include zip+4
Mapping Solution
 Atypical claim submission validated against
NPI registration
 If an NPI is submitted WH will crosswalk the
NPI to legacy according to registration.
 Address zip+4
NPI Registration
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Submit a copy of the DMA NPI Registration
Or
Submit the WH NPI Registration
Both require a copy of NPPES certificate
WH Communication Bulletin #54, 2/19/2007
NPI EOB
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083
084
085
086
087
088
Missing or Invalid Attn Prov NPI
Missing or Invalid Service Location
NPI
Missing or Invalid Zip +4
Missing or Invalid Atypical PIN
Missing or Invalid Taxonomy Number
Invalid Combo Loc NPI Zip +4
WH EOB / 835
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WH EOB
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Include both legacy and NPI attending
835 – HIPAA Compliant
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Will not include legacy number
Current Events
Timely Filing Limit (TFL), WHN Communication
Bulletin #67
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Temporarily lifted through April resume May 1, 2008,
DOS July 1, 2007 - present
State funded claims finalized within 60 days from the
date of service
June 2, 2008, 5:00 pm, end of fiscal year TFL (July 1,
2007 – April 30, 2008)
Provisionally Licensed provider H-code
reimbursement ends June 30, 2008
MOS = Maintenance of Service
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Maintenance of Service:
Therapeutic Foster Care and Targeted Case
Management
Maintenance of Service applies to requests for authorization where
a denial or reduction of service has occurred for a concurrent
request and a valid appeal notice has been received by DHHS or
OAH/Office of Administrative Hearing.
Value options will be notified after the request for appeal has been
received by the Hearing office. Value Options will enter the
Maintenance of Service authorization within (5) five business days
after the Hearing Office sends confirmation that an appeal has been
requested.
MOS—Maintenance of Service –con’t
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The units that are authorized can be viewed in Provider
Connect, located on ValueOptions’ website at
www.valueoptions.com Providers can also contact
ValueOptions’ EDI Helpdesk (888.247.9311) for
instructions on how to use Provider Connect.
No letter or authorization notice will be sent to the LME
for MOS.
MOS authorizations seen in Provider Connect will
appear as a standard authorization. There is no
distinction to indicate that it is a MOS authorization.
Submit Claims on the WH Claims Resolution Inquiry
form with the CMS1500 and provider connect screen
print of the authorization. Mail or fax to WHN
828.258.1225.
Deficit Reduction Act
False Claims Act
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Law
Policy
What is a false claim?
Penalties
Your Role
Whistleblower Provision
How/Who to Report
Law
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False Claims Act established under
section 3729 through 3733 of title 31,
United States Code
 Federal law that prohibits an individual
or organization who receives money
from the federal government from
submitting a request for payment
knowing that such request contains
false information.
Policy
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Available within the Western Highlands’
Network Standards of Conduct/Ethics policy
available to providers through the WH
website.
WHN Communication Bulletin # 68
What is a False Claim
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Submitting a claim for services that were not
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Delivered
Documented
Different than what was delivered
Submitting a claims for services paid by a
source other than the federal government, or
paid for by the government under a different
program (e.g. Medicaid instead of Medicare)
What is a False Claim (cont)
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Submitting a claim for services that were not
“medically necessary”
Submitting a claim for services which is
coded as “more complex” than otherwise
indicated in the patients record, in order to
receive higher reimbursement
What is a False Claim (cont)
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The person must “knowingly” submit a false
or fraudulent claim.
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This includes actual knowledge, “deliberate
ignorance”, or “reckless disregard”.
Penalties
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Civil penalties up to $10,000 fine per claim
plus double or treble damages, (criminal) up
to $25,000 fine and/or 5 years in jail.
Role
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Your duty to report fraud, waste, and abuse
Need not be certain the violation has
occurred in order to report it.
WH encourages you to seek guidance on any
question related to potential or actual
violations of laws and regulations
Whistleblower Protections
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The False Claims Act provides protection for
employees who report suspected false claims
against retaliation
How/Who to Report
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Report in person, telephone, or writing
Who to report
 Immediate Supervisor/Program Director
 Compliance Officer
 A toll-free anonymous and confidential method
is through the National Hotline Services, Inc.,
Confidential Compliance Hotline
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1-800-826-6762
Resources for verifying eligibility
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Basic Medicaid Billing Guide located on DMA’s website
http://www.ncdhhs.gov/dma/medbillcaguide.htm
1-800-688-6696, menu option 1, for phone inquires
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NC Medicaid Automatic Voice Response (AVR) System
1-800-723-4337
270/271
HIPAA Compliant Health Care Eligibility Benefit Inquiry and
Response Electronic Transaction.
Value Added Networks (VANs)
Interactive eligibility verification that providers may contract
with Medicaid for access to real time consumer eligibility.
The transaction fee is eight cents per inquiry.
Retro-Medicaid Refunds
When a State funded consumer obtains retroMedicaid
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Submit a refund using the WH Claims Resolution Inquiry
Form with the WH EOB indicating the refunded services
WH will apply refund to next payment, transaction
presented on the WH EOB
WH will initiate a retro-Medicaid refund upon notice from
DMA eligibility inquiry/verification and State funded
recoupment
DDE
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A WH web-based claims entry product
Complement the 837 and / or offer an electronic
claims submission method alternative
Complete/submit a Care Coordination
Information System (CCIS) - User ID
Assignment Request form
DDE continued
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Individual user ID/Password
IT requirements
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Internet Explorer 6.0, 98 or newer
High-speed Internet
Generates a report of accepted claims
Immediate claim acceptance feedback
Direct Data Entry User’s Manual
Exceptions to the Electronic Claim
Submissions :
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Void & Replace
COB – Coordination of Benefits
CAP MR/DD Waiver Supplies
First Party Payment
Claims Resolution Inquiry Form
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Appeals
Void
Void & Replace
Time Limit Override
Third Party COB
Refunds
Other
File the Claims Resolution Inquiry form with a new CMS
1500, and a copy of the WH EOB - Invoice
Claims Resolution Inquiry
WESTERN HIGHLANDS NETWORK
CLAIMS RESOLUTION INQUIRY
MAIL TO:
WESTERN HIGHLANDS NETWORK
356 BILTMORE AVENUE
ASHEVILLE, NC 28801
Fax To: (828)258-1225
Please Check: _____ Appeals ______ Void & Replace ______ Time Limit Override ______ Third Party Override
_____ Refunds _____ Other _____________________________________________________________
Include relative Western Highlands EOB (Explanation of Benefits) and a CMS-1500 (08/05)
Provider Name ________________________________________________________________________________________
Consumer’s Name: ________________________________________ Western Highlands ID: _________________________
Date of Services: From: _____/_____/_____ to _____/_____/_____ Check Number: _____________________________
Procedure Code: _______________________________________________________________________________________
Please Specify Reason for Inquiry Request:
Point of Contact Name: (Print)
Signature:
Date:
TO BE USED BY WESTERN HIGHLANDS NETWORK ONLY
Approving Authority Signature/Date: __________________________________________
Remarks:
Western Highlands Network 04/03/2007
Phone #:
Approved: ___ Disapproved: ___
Reimbursement
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WH provides an Explanation of Benefits – Invoice
and 835 Remittance Advice
EOB and 835s are sent to your agencies mailbox
Payments are mailed
State funded prompt payment
WHN is mandated to review claim / invoice submissions
within (18) calendar business days after receipt and
shall:
A) Approve payment
B) Notify Provider within that time frame if
claims/invoice are denied or if further information is
necessary
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Denial and Resolution
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Duplicate Service
Authorization
Unit Limitations
Attending Provider Numbers
Service Level Numbers
WH Explanation of Benefits – Invoice
Codes
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EOB codes and description table is available
at the WH Website and at the end of the WH
EOB
WH EOB 064 - Duplicate Service
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A previously submitted claims was paid,
typically caused by either incorrect AR
posting/flag setting or event summarization
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AR Posting
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Validate AR payment from previous EOBs
Summarize
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Summarize claim prior to submission
To correct submit a Claim Inquiry form void and replace
transaction
Authorizations
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063 - Incorrect Authorization (DDE)
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UA – Authorization for these services does not exist or incorrect
authorization
OA – Claim exceeds the units of service authorized
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Authorization presented doesn’t support the consumer
(consumer, provider, procedure code, and DOS)
A valid authorization, but the authorized units of service have
been applied to previous payments, balance is zero.
PP – Partial Payment
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A valid authorization, but the total units billed were reduced to the
balance of remaining authorized units.
Unit Limitations
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080 - Less than minimum daily limits
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Occurs when a service requires a daily minimum
units of service and units billed were less than the
minimum
081 - More than maximum daily limits
Attending Provider
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033 - Missing Attending Provider ID
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Claim was billed w/out an attending provider ID
034 - Invalid Attending Provider ID
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Adjudication system compares the billed ID to the
registered ID and service
Proper attending must coincide with service delivery
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Outpatient Behavioral Health services require the
individual attending provider DMA enrollment number
Enhanced Benefits require the DMA Community
Intervention number with the relative alpha suffix
Other services require the Western Highlands provider
number specified in your contract
036 - CPT code requires Medicaid ID
Attending Provider
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Confirm proper number was billed with service.
Common error is an Enhanced Benefit billed with
an individual clinician’s enrollment or a Western
Highlands provider ID
Verify enrollment number from source
Verify number was registered with WH. If not,
follow instructions in WHN Communication Bulletin
#12
Verify ID number billed matches the number
registered
Service Level Number
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045 - EB Not Med Elig Inv Attd Number
051 - Invalid or absent service level
number
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A service level number consists of the
Community Intervention Number (Core
Number) plus the alpha suffix that coincides
with the enhanced benefit service
Core Number: 83xxxxx
Service Level Number 83xxxxxA
Attending Provider – Tips to remember
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Enhanced Benefit Services, enter the DMA
Community Intervention Number with the alpha
suffix. Example: 83xxxxx (+) Alpha Character
representing the Enhanced Service.
Outpatient Behavioral Health (OBH) service, the
DMA individual clinician’s Medicaid enrollment
number.
Neither an Enhanced Service nor OBH service,
enter your agency’s Western Highland’s provider
number. Example: 36XXX
Technical Assistance
E-mail:
[email protected]
Phone:
(828) 225-2785 ext. 2191
Western Highlands Website:
http://www.westernhighlands.org/pr_reimbursement.htm
Additional Information Sources
CMS
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http://www.cms.hhs.gov/
NC Division of Medical Assistance
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http://www.dhhs.state.nc.us/dma/NPI.htm
IPRS website
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http://www.dhhs.state.nc.us/mhddsas/iprsm
enu/index.htm
NPPES
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https://nppes.cms.hhs.gov/NPPES/Welcome.
do
Thank you!
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Thank you for attending Western Highland’s
Claims & Reimbursement Training Seminar