Transcript Title

2009 Indiana Health Coverage
Provider Programs Seminar
Top 10 Claims Denial and Prior Authorization/CMS (08-05)
October 22, 2009
Hoosier Healthwise
Noon-12:45 p.m.
P0380 (09/09)
Today’s discussion
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6.
CMS ( 08-05)Overview
Top Ten (10) Claims Denial
Common coding errors
Claims disputes and appeal
Prior authorization
Discussion with MDwise Delivery System
Representatives
Hoosier Healthwise
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CMS 08-05
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Revised form, which
accommodates the reporting of
the National Provider Identifier
“NPI”
Hoosier Healthwise
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Bill Types for CMS 08-05
Types of services
Audiology services
Care Coordination services
Chiropractic services
Family Planning, FQHC’s, RHC’s,
Medical services
Oral surgery
Durable Medical Equipment/Home
Medical Equipment (DME/HME
Medical supplies
Radiological services
Types of services
Professional component,
technical component, or global
component
Medical rehab (MRO) services
Outpatient mental health services
Hoosier Healthwise
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Bill Types for CMS 08-05
Types of services
Types of services
Anesthesiology assistant services
Physician assistant services, Advanced
practice nurse credentialed in
psychiatric or mental health nursing
Optical Services
Optometric services
Anesthesia services
Laboratory services
Medical services-professional
component
Renal dialysis services
Surgical services
Podiatric services
Therapy services-physical,
occupational, speech, and mental health
•
Hoosier Healthwise
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NPI (CMS 08-05)
NPI
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The National Provider Identifier is the unique identifier
assigned for each individual provider. The NPI is a national
identifier and should be included on all claims submissions for all
types of health plans.
All Providers who are not exempt are reminded to report your
NPI to the Indiana Health Care Program (IHCP). Claims Payment
depends on an accurate NPI being reported for all MDwise
Programs.
Hoosier Healthwise
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Top Ten Claims Denial CMS 08-05
What is the number one cause for claims denial
for MDwise claims?
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MDwise Top Ten Claims Denial
(CMS 08-05)
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4.
Duplicate claim
Claim/Service lacks information which is needed for adjudication
Coverage not in effect at the time the service was provided
Payment denied/reduced for absence of, or exceeded, precertification/authorization
5. Non-covered charges
6. The referring/prescribing/rendering provider is not eligible to
refer/prescriber/order/perform the service
7. Past the timely filing limit
8. Payment adjusted due to member having primary insurance
payer/coordination of benefits
9. Charges exceed fee schedule or maximum allowable amount
10. Diagnosis code is non-covered or invalid
Hoosier Healthwise
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Pre-Claims Submission/Check List
(CMS 08-05)
It is necessary to confirm all of the items on the check list prior
to rendering services and submitting a claim.
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*Presumptive
Is the member eligible for services today?
What IHCP Plan is the member enrolled in ? ( Hoosier Healthwise (Anthem,
MDwise, MHS) , Care Select, Traditional, Presumptive Eligibility)*
Is the member enrolled in the Healthy Indiana Plan?
Who is their Primary Medical Provider (PMP)?
Does the member have primary health insurance other than Medicaid or HIP?
Eligible members are not eligible for any INPATIENT SERVICES.
Hoosier Healthwise
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Claims submission and Inquiries
(CMS 08-05)
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*Please
Providers are encouraged to submit their claims electronically- see quick
contact sheet for payor information
Providers need to submit all Medical and Behavioral Health delivery
system claims where the member is assigned.* Except for Family planning
which are submitted to the Family planning address on the quick contact
sheet (ProHealth Family planning should be sent to the medical claims
address)
Providers should contact the applicable delivery system for specific
instruction on electronic claims submission
note that all electronic claims must be submitted using the HIPAA compliant transaction and codes sets.
Hoosier Healthwise
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What do you do when your claim is denied?
(CMS 08-05)
Claims Inquiry
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In and out of network providers need to contact the MDwise Delivery System
to inquire about a claims denial.
MDwise Delivery Systems are required to respond within 30 calendar days of
inquiry to the provider with the decision of the inquiry.
Appeals/Dispute-Must be in writing & include the following
*Providers
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have 60 calendar days to file an appeal and must include the following documentation:
Appeal form, remittance advice and a copy of the claim.
If a delivery system fails to make a determination or the Provider disagrees with
the determination, the provider should forward their appeal to:
MDwise
Corporate at P. O. Box 441423
Indianapolis, IN 46244-1423
Attention: Grievance Coordinator
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Claims Filing Limit (CMS 08-05)
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In-Network Providers have a filing limit of 180 days.
Out-of-Network Providers have 365 days from the date of service to file
a claim.
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Third Party Liability (CMS 08-05)
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MDwise is always the payor of last resort (Medicaid)
MDwise contracts with Health Management Solutions (HMS) to work
with coordination of benefit issues.
MDwise does not have a 90 day rule, providers should work with
delivery system on a case by case basis.
Hoosier Healthwise
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Eligibility (CMS 08-05)
It is the responsibility of ALL providers to check
eligibility at the time of each visit.
Indiana Health Coverage Programs (IHCP) Benefit
Packages: MDwise & IHCP administered Plans
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Package A
Package B
Package C
Package P
Care Select
Right Choices (restricted card)
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Prior Authorization (CMS 08-05)
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Role of Medical Management (CMS 08-05)
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MDwise Medical Management functions are done at a Delivery System
level.
Medical Management focuses on the outcome of treatment with an
emphasis on:
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Appropriate screening activities
Reasonableness and medical necessity of all services
Quality of care reflected by the choice of services provided, type of provider
involved and the setting in which the care was delivered
Prospective and concurrent care management
Evaluation of standards of care/guidelines for provision of care
Best practice monitors
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Role of Medical Management (CMS 08-05)
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Medical Management service authorization activities conducted by the
Medical Management staff include:
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Preauthorization of inpatient and selected outpatient services, including
pharmaceutical referral management, concurrent review and
retrospective review on selected inpatient and outpatient services
authorization and denial notification.
Hoosier Healthwise
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Contacting Medical Management (CMS 08-05)
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*note-
Contact members Medical Management Department for services that
require authorization ( see quick contact sheet)
Prior authorization forms are available online or by contacting the
MDwise members Medical Management Department
To obtain the correct Medical Management Department, check eligibility for members delivery system.
Hoosier Healthwise
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Referral to Specialist (CMS 08-05)
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A prior authorization number may not be required when referring to a
in-network provider.
Please refer to the Delivery System Medical Management Department or
provider directory for assistance in locating an in-network provider.
Retroactive authorizations are not typically given or guaranteed (contact
the members Medical Management Department for special
circumstances).
Hoosier Healthwise
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Self referral Services (CMS 08-05)
MDwise members can self refer to:
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Family Planning (see quick contact sheet for MDwise family planning addresses)
Emergency Services
Vision
Podiatry
Chiropractic
Dental (submit all dental claims to EDS)
HIV/AIDS Case Management
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Out-of- Network Authorizations (CMS 08-05)
Members of MDwise Delivery Systems that require
covered services not available within the
MDwise network must have prior authorization
from the delivery systems Medical Management
Department, this includes between MDwise
Delivery Systems (before services are rendered)
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Prior authorization for DME (CMS 08-05)
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Please contact the member’s Delivery System Medical Management
Department for approved providers and Durable Medical Equipment
(DME) prior authorization requirements.
Prior authorization forms are available online at www.MDwise.org
Hoosier Healthwise
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Pharmacy Authorizations (CMS 08-05)
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All providers and specialists providing care to MDwise members are
required to utilize the MDwise Pharmacy Drug Listing (PDL).
The PDL is updated on a regular basis. The PDL is available hard copy
and online at www.MDwise.org.
Perform Rx 800-558-1655
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Behavioral Health Authorizations (CMS 08-05)
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Standardized forms for Behavioral Health:
Primary Medical Provider Coordination Form
Therapy/Outpatient Treatment Form (OTR) Form
Psychological Testing Form
Neuropsychological Testing Form
These forms can be found on our website
www.MDwise.org/providers/forms/behavioralhealth
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Discussion with Delivery System Representatives
(CMS 08-05)
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Thank You CMS 08-05 & Drawing
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