Transcript Document

MHS FORMS
October 8, 2008
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MHS WEBSITE
• WWW.MANAGEDHEALTHSERVICES.COM
• Enhanced website – Access for both contracted/noncontracted groups
• On-line Registration – Multiple Users
• Provider Directory Search Functionality
• Enhanced Claim Detail
• Direct Claim Submission
• Prior Authorization
• Code Auditing Software Tool
• Downloadable Eligibility Listing
• Printable, Current Forms and Manual
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MHS – Need to know
All forms available on website:
WWW.MANAGEDHEALTHSERVICES.COM
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Claims
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PROVIDER ADJUSTMENT REQUEST FORM
Please utilize this form to request a review of claim payment received that does not
correspond with the payment expected.
Note: Requests must be submitted within 60 business days
of the original disposition of the claim.
All fields in the box immediately below are required information.
Provider Name:_______________________ Provider Tax ID#:____________________
Control Number:______________________ Date (s) of Service:___________________
Member Name:_______________________ Member
Number:_____________________
Reason for adjustment request:
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Request Date:________________________
Denied for no authorization; authorization # _____________________ obtained
Denied for no authorization; no referral required
Denied for timely filing in error (please attach proof of timely filing)
Paid to incorrect provider
Incorrect payment
Other (please explain below)
Requestor Name/Title:__________________ Phone Number
:____________________
Note: If the claim requires a correction, such as a valid procedure, location code, or
modifier, please circle the claim number on the EOP and attach it along with a copy
of the new CMS-1500 or UB-92 marked “RESUBMISSION”.
Mail completed form(s) and attachments to:
Managed Health Services
P.O. Box 3002
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INFORMAL CLAIM DISPUTE / OBJECTION FORM
(Level I Administrative and Claims Appeals)
Applicability:
Use this form or your letterhead to file a written request to begin the MHS Informal Claim Dispute / Objection Resolution
Process, in accordance with the MHS Provider Manual (Provider Appeals) and Indiana regulations (405 IAC 1-1.6-1
through 1-1.6-6). This is Step 1 of the Administrative or Claim Payment Appeal process. You must pursue an Informal
Dispute / Objection before you may file a Formal Appeal.
Time Limits / When to File:
The claim(s) in question must have originally been submitted to MHS in a timely manner:

MHS Contracted Providers have 120 calendar days from date of service to file a claim

Non-contracted Providers have 365 calendar days from date of service to file a claim.
All providers have 60 calendar days from receipt of the MHS Explanation of Payment (EOP) to file an
Informal Dispute / Objection with MHS.
What to file (check list):

This form or written Request for Informal Claims Dispute / Objection Resolution on your letterhead

Copies of original MHS EOP showing how the claim(s) in question were processed

Copies of any subsequent MHS EOP’s or other determinations on the claim(s) in question

Documentation of any previous attempt you have made to resolve the issue with MHS

Other documentation that supports your request for reprocessing or reconsideration of the claim(s), such as:
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Records or documentation previously requested by MHS to resolve the claim
Proof of timely filing or documentation to support reasonableness of filing date
Documentation to support request for exception to MHS Plan policy, benefit limitations, authorization requirements
Documentation to support paying claims otherwise denied by coding or other audits
All fields in this box must be completed:
Provider Name
Member Name
Provider Tax ID#
Member (RID) Number
Requestor Name
Requestor Title
Date of this Request
Requestor Phone Number
Claim Number(s)
Date(s) of Service
Reason for Informal Claims Dispute / Objection (why you think MHS should pay the claim(s), adjust or reconsider
them and how attached documentation supports your request). Attach additional sheets needed.
Where to File:
Send form or written Informal Dispute/Objection letter with relevant attachments by first class, priority or express U.S. mail to:
Managed Health Services
Post Office Box 3000
Attn: Appeals Department
Farmington, MO 63640-3800
MHS will make all reasonable efforts to review your documentation and respond to you within 30 calendar days. If you do not
receive a response within 30 days, consider the original decision to have been upheld. At that time (or upon receipt of our
response if sooner), you will have up to 60 calendar days to initiate a Formal Claim Appeal.
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Provider Administration
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Managed Health Services
Non Contracted Provider Set up Information Form
Please fax requested information to the attention of NonPar SetUps file at (866) 9124244. Please ensure all information requested below is provided to enable accurate
set up in a timely manner. Failure to provide this information may result in claim
payment delays. Thank you in advance for your cooperation.
Completed W-9 Form/Tax ID (please only send one)
Provider Name:
Provider Gender: Male or Female
Provider Indiana Medicaid Number:
Facility Name (if applicable):
Group Provider Indiana Medicaid Number (if applicable):
Individual NPI #:
Taxonomy code:
Billing address:
Physical Address:
Office Phone Number:
Provider Specialty:
County:
Contact Name:
Contact Number:
If you have any questions, please feel free to contact me at 1-877-647-4848 x20300
*Effective immediately, we will need the individual Medicaid Provider # along with
the group Medicaid # (if applicable) the NPI # & Taxonomy code.
*Please allow 10-14 business days for the information to be added to our system.
*Please know that our system will only allow ONE billing address per Tax ID #.
*Please only send one W-9.*
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Request for Provider Disenrollment
Accepting Provider Information
NETWORK USE ONLY:
Disenrollment Effective:
TERMING PROVIDER
Panel Size:
Current Number of Members:
Panel Specification:
Panel Status:
All Women:
Hospital Priv:
Yes
Yes
No
No
Open
OB Only:
Delivery Priv:
Hold
Yes
Full
No
Yes
No
Age Restrictions:
ACCEPTING PROVIDER
Specialty:
Contract Entity
Individual
Medicaid #
Group Med#
(Including Alpha Location)
Panel Size:
Current Panel:
Accepting Total Membership
Other:
Does Panel need to Be Increased?
Panel Status:
Open
Hold
Do Panel Restrictions Allow Move?
OB Members only
PED Members only
Yes, (Attach letter from Provider)
No
Full
Yes, (Attach Web Interchange Printout)
Has the Provider Agreed to Accept Membership?
See Attached “Additional Accepting Providers”
No
YES, (Attached Letter)
No
Yes
No
Required Signatures (Only One is Required)
Manager of Provider
Relations
Date:
Director/VP Network
Management
Date:
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Member Services
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Hoosier Healthwise
Pre-birth Selection Form
*All fields must be completed*
Today’s date: __________ Name of staff completing form: ________________________
Member’s Name: _________________________________________________________
Member’s Hoosier Healthwise RID#: ____________and Social Security #: ___________
Member’s Address:________________________________________________________
_______________________________________________________________________
Phone number where member can be reached (write none if no phone): ______________
Full name of Hoosier Healthwise PMP member is selecting for
baby:___________________________________________________________________
Address of PMP___________________________________________________________
_______________________________________________________________________
PMP ID Number_____________________________
Mother’s estimated due date: ___________________
Mother’s signature: _______________________________________________________
If PMP panel is full, PMP must sign below authorizing the addition to his/her panel.
PMP Signature__________________________________ Date__________________________
If Mother is a MHS member, please fax form to MHS at 866-912-1629
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Full Panel Add Request
Fax Form to MHS 1-866-912-1629
** All fields must be complete for processing** ** Please print legibly – except signatures**
Date of Request
___________________________
Contact Name
___________________________Contact Telephone __________________
Member Information
Hoosier Healthwise ID Number
_____________________________________________
Member Name
_____________________________________________
Social Security Number
_____________________________________________
Member Address
_____________________________________________
_____________________________________________
Member (or parent/guardian signature)
_____________________________________________
Date Signed
_____________________________________________
Provider Information
As a PMP, I agree to add the above Hoosier Healthwise member to my full panel.
Physician Name (print)
_____________________________________________
Physician Signature
_____________________________________________
Physician Provider ID Number
_____________________________________________
MAXIMUS Use Only
Date Received ____________________________________________________
Date Approved___________________________________________________
Date Denied _____________________________________________________
Return Code/Reason______________________________________________
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Managed Health Services (MHS) Hold Panel Add Request
Fax Form to MHS: 1-866-912-1629
** All fields must be complete for processing** ** Please print legibly – except signatures**
Date of Request
___________________________
Contact Name
___________________________Contact Telephone __________________
Member Information
Hoosier Healthwise ID Number
_____________________________________________
Member Name
_____________________________________________
Social Security Number
_____________________________________________
Member Address
_____________________________________________
_____________________________________________
Member (or parent/guardian signature)
_____________________________________________
Date Signed
_____________________________________________
Provider Information
Why do you wish to add this member to your panel? Please check only one – Reason is required.
 This is an established patient I have treated in the past 24 months from today’s date. (One page of
documentation required)
 This is a family member of an already established patient that I have treated within the past 24 months from
today’s date. (One page of documentation required)
 I am the patient’s Primary Physician in the primary insurance plan for this member. (One page of
documentation required)
As a PMP, I agree to add the above Hoosier Healthwise member to my panel that is on hold.
Physician Name (print)
_____________________________________________
Physician Signature
_____________________________________________
Physician Provider ID Number
_____________________________________________
MAXIMUS Use Only
Date Received _____________
Date Approved_____________
Date Denied _______________
Return Code/Reason______________________________________________
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Managed Health Services
Connections Referral Form
Use this form to refer a member to MHS for a visit from a MHS CONNECTIONS
Representative.
Date:
Member Name:
Hoosier Healthwise #:
Member Address:
Member Phone #:
Provider Fax # & Contact Name:
Please check the reason for the referral:
Non-Compliance
Violent Behavior
Missed Appointments (minimum of three)
Other (please explain):
Please give details as to the reason for the referral and your expectation of the
CONNECTIONS visit:
Provider Name:
Provider Phone Number:
Please fax completed form to your
MHS CONNESTION Representative
Fax Number 1 (866) 518-6035
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Medical Management
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Phone number 1-877-MHS-4U4U
(1-877-647-4848)
Managed Health Services
Prior Authorization Form
1099 N. Meridian St.
Suite 400
Indianapolis, IN 46204
Prior Authorization Request
Line: 1-877-MHS-4U4U,
Option# 2
Fax Number 1-866-912-4245
PA# ___________________
Section 1
(To be completed by Requesting Provider/Vendor)
Please Print Clearly
PROVIDER INFORMATION
Requesting Provider/Vendor:
Street Address:
City:
Provider/Vendor Phone #
MHS Provider Number:
Section 2
State:
Zip Code:
Provider/Vendor Fax #
(To be completed by Requesting Provider/Vendor)
HOOSIER HEALTHWISE MEMBER INFORMATION
Member Name as shown on the Hoosier Healthwise card:
ICD 9 Code
HCFA#
DOB:
______/______/______
Section 3
(Directions: Provider/vendor must complete the following boxes – Start Date, Stop Date, Service Code, Narrative Description, and Number of Units Requested. The
MHS Case Managers will complete the last four boxes marking either, Approved, Denied, No PA Required or Rejected, after line tem request has been evaluated for
medical necessity. If request is rejected this means either more detailed clinical information is required to determine Medical Necessity or PA form has not been
completed or is incorrect. (See area under Case Managers Comments below.) Providers should submit another request again after corrections have been made.
Requested
Start Date
Requested
Stop Date
A Rejection is not the same as a Denial.
Service
Code
Narrative Description
Number of
Units
Requested
Request
Rejected
(See
below)
No PA
Required
Request
Approved
Request
Modified
Approved
Request
Denied
Please attach any and all clinical documentation. (Include prognosis and rehabilitation potential.) A current plan of treatment and
progress notes, as to the necessity, effectiveness and goals of therapy services (PT, OT, ST, Audiology, Home Health) must be
attached.
Location of surgery:
□ Inpatient
L.O.S.
□ Outpatient
For authorizations, all records pertinent to the ejrej to theeeeeeee
Case Manager Comments:
PLEASE NOTE:
If the Rejection Box is marked, this does not mean that your request is Denied. Please re-submit your request after
completing the following:
□
PA Request Form incomplete.
□
More detailed clinical documentation required. Please include the following:
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1099 N. Meridian Street, Suite 400
Indianapolis, IN 46204
Office:1-877-647-4848
Notification of Asthma - Fax
To:
Fax:
Asthma Case Management Team From:
Provider/Clinic Name: _______________________________
- Medical Management
Phone: ___________________
1-866-694-3653
Phone: 1-877-647-4848, Option 2
Fax: ______________
Pages:
Date:
Member Name: _____________________________
DOB: ________________
Medicaid #: ________________________________
Dx code: _____________
Please check mark ALL risk factors associated with this MHS member.
___ Adverse Environmental Factors
____ Noncompliance with meds/action plan
___ Age > 13 years
____ Noncompliance with
Physician/Provider appts
___ Allergies
____ Other: ______________________
___ Behavioral/Psychosocial Health Issues
____ Rescue meds only
___ ER visit > 2 w/in last 6 months
____ Rescue meds w/steroid
___ Hospital admit w/in last 30 days
____ Smoking
WARNING: THIS FAX TRANSMISSION MAY CONTAIN
CONFIDENTIAL MEDICAL INFORMATION
The medical information that may be contained in this FAX transmission is
CONFIDENTIAL AND PRIVILEGED. It is unlawful for unauthorized persons to review, copy, disclose, or disseminate confidential
medical information. If the reader of this warning is not the intended recipient, or the intended recipient’s agent, you are hereby
notified that you have received this transmission in error; please notify us immediately at the telephone number listed above. It is also
requested that you immediately transmit the information received in error to our office at the above address by mail. MHS will
reimburse you for this expense. Thank you.
CONFIDENTIAL per IC 24-2-3, Chapter 3 Trade Secrets, also cited as the Uniform Trade Secrets Act.
Authorized Signature:
Revised 6/05
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Questions and Answers
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