Transcript 2005 June Workshops Presentation

2005 Coordinated Payor
Billing Workshops
Unisys
June 2005
Introduction.
Bureau for Medical Services
• Carla Parmelee, MMIS Program & Policy Coordinator
• Bonnie Meehan, Disease State Management Coordinator
Unisys
• Amanda Hiser, Provider Services Manager
• Virginia Leffingwell, Provider Representative
• Angie Richards, Provider Representative
Contact Information.
Member Services
• 888-483-0797
• 304-348-3365
Monday - Friday
Provider Services
• 888-483-0793
• 304-348-3360
Monday - Friday
Pharmacy Help Desk
Monday - Saturday
• 888-483-0801
8:00 am until 5:00 pm
8:00 am until 5:00 pm
8:30 am until 9:00 pm
Sunday
12:00 pm until 6:00 pm
Access AVRS using same phone numbers
• 24 hours a day, 7 days a week
Email Addresses
• [email protected]
• [email protected]
Mailing Addresses.
Claim Forms Mailing Address
Unisys
• PO Box 3765
NCPDP UCF Pharmacy
• PO Box 3766
UB-92
• PO Box 3767
HCFA-1500
• PO Box 3768
ADA-2002 Dental
Charleston, WV 25337
• PO Box 2254
Hysterectomy, Sterilization
and Abortion Forms
Charleston, WV 25328-2254
Mailing Addresses.
Provider Services Mailing Address
Unisys
• PO Box 2002
Charleston, WV 25327-2002
• PO Box 625
Charleston, WV 25322-0625
• Provider Relations,Member
Services
• Enrollment & EDI Help Desk
Dental Billing Information.
Anterior Teeth
• Permanent Teeth
- 6-11
- 22-27
• Primary Teeth
The following
procedure codes
may only be billed
on anterior teeth
• D2330
- C-H
• D2331
- M-R
• D2390
• D3346
• D3410 – requires prior
authorization
Dental Billing Information (cont).
Posterior Teeth
• Permanent Teeth: 1-5, 12-16, 17-21, 28-32
• Primary Teeth: A, B, I, J, K, L, S, T
The occlusal and buccal surfaces may only be billed on
posterior teeth
The following procedure codes may only be billed on
posterior teeth
•
•
•
•
•
D2391
D2392
D2393
D2394
D3421 – requires prior authorization
Timely Filing Policy.
To meet timely filing requirements for WV
Medicaid, claims must be received within one
year from the date of service
• The year is counted from the date of receipt to the “from” date on a
HCFA or the “admit” date on a UB-92
Claims that are over one year old must have been billed and
received within the one year filing limit.
The original claim must have had the following valid
information listed on it:
• Correct provider number
• Correct member number
• Correct date of service
• Correct type of bill
Timely Filing Policy (cont).
Claims that are over one year old must be submitted to
Provider Relations with a copy of the original remittance
advice
Services with dates of service over two years old are NOT
eligible for reimbursement
This policy is applicable to reversal/replacement claims
• If you submit a reversal/replacement claim with a date of service
that is over one year old, the replacement claim must be billed on
paper with a copy of the original remittance advice
• You are NOT allowed to add additional services to the replacement
claim
• If additional services are billed on the replacement claim that were
not billed on the original claim and the dates of service are over one
year old, the claim will be denied for timely filing
Medicare Primary Claims.
Timely Filing
• The normal WV Medicaid timely filing requirement for Medicare
primary claims is one year from the EOMB date
• These limits have been extended due to the claim processing
issues
- Timely filing will be overridden if the date on the EOMB is 07/01/2003
or after
- Once all of the Medicare primary claims have been processed, we will
post a message on the web portal indicating the date the normal timely
filing requirements will resume
Claims Processing
• The back log of all paper Medicare primary claims has been
processed
• Beginning 07/08/2005, the web portal is available to direct data
enter Medicare and TPL primary claims
TPL Primary Claims.
Timely Filing
• The normal WV Medicaid timely filing requirement for TPL primary
claims is one year from the date of service
• These limits have been extended due to the claim processing
issues
- Timely filing will be overridden if the date of service is 07/01/2003 or
after
- Once all of the TPL primary claims have been processed, we will post a
message on the web portal indicating the date the normal timely filing
requirements will resume
Claims Processing
• Unisys and BMS is in the process of reviewing the test results for
the TPL primary claims
• Providers will be notified via the web portal when Unisys is able to
process these claims on paper and electronically
TPL Primary Claims (cont).
Providers are required to bill insurance as primary before billing
Medicaid
• The only exceptions to this rule are EPSDT, pediatrics, and maternity care
visits
Providers cannot refuse to accept Medicaid due to the patient
having a primary payer
New TPL billing procedures
• Claims will be calculated the same as the Medicare primary claims are
• It is very important for providers to attach the insurance EOBs on all paper
•
•
•
•
claims, including denial reasons
If no EOB is attached with the coinsurance, deductible, and/or denial
reasons, the claims will pay $0.00
Coinsurance and deductible information must also be included on electronic
claims
When billing electronic claims, insurance EOBs must be sent to Unisys with
the provider number and member number listed on the EOB
Refer to Chapter 600, Section 620 for more details
Reversals / Replacement Claims.
Original Claims Processed in ACS System
• Reversals
- Only paid claims can be reversed
- Must be submitted on paper to Unisys
- Complete Reversal Form
- Checks cannot be submitted when the original claim was processed in
ACS system
• Replacement Claims
- Only paid claims can be replaced
- If you are replacing a claim which has been reversed, this claim must
be attached and cannot be submitted separately
- Timely filing guideline for replacement claims is two years from the date
of service
- The replacement claim must reflect all lines for which you are
requesting reimbursement
Reversals / Replacement Claims.
Original Claims Processed in Unisys System
• Reversals
- Only paid claims can be reversed
- Can be submitted on paper or via the web portal
- If you are billing these through the web portal, follow the instructions
closely that are listed under “FAQ”
• Replacement Claims
- Only paid claims can be replaced
- If the date of service on the replacement claim is less than one year
old, it can be submitted on paper or via the web portal
- If the date of service on the replacement claim is greater than one year
old, it must be submitted on paper with the original RA attached
- The replacement claim must reflect all lines for which you are
requesting reimbursement
- If you are billing these through the web portal, follow the instructions
closely that are listed under “FAQ”
Remittance Advice Changes.
Below are requested changes to the remittance advices that
are under review
• Adding the conflicting claims number and original date paid to
claims/lines that are denying as duplicates
• Display the HIPAA adjustment reasons and remark codes, rather
than the internal Unisys edits
• Add EOB to indicate when a claim pays $0.00 due to primary payer
paying more than Medicaid allows
• Print the HMO or PAAS information next to the member’s name
when a claim denies for edit 153 or 171(complete 06/17/2004)
• Addition of an adjustment reason to reversal/replacement claims
• Separate Medicare and TPL primary claims from Medicaid primary
claims (complete 05/13/2004)
Billing Information.
Electronic claims must be received by 5:00 pm on Wednesdays to be
considered for that week’s cycle
You must bill with valid procedure and ICD-9 codes for the billed date(s) of
service
• Consult the 2005 HCPCS, CPT, and/or ICD-9 code books
Outpatient hospital claims should not have ICD-9 surgical procedure
codes listed on the claim
Outpatient hospitals claims must use modifier TC on procedures that are
divided into professional and technical components
• See RBRVS Manuals/Spreadsheets for these codes
Inpatient hospital claims should not use CPT or HCPCS codes in block 44
on a UB92
Medicare primary claims processed incorrectly on the 05/27/05 remittance
advice.
• The paid claims will be reprocessed to recoup any overpayments.
• The denied claims will be reprocessed if they were denied inappropriately.
• Please note that the Medicare primary claims were not separate from the Medicaid
claims on this remittance advice. This is due to the claims processing incorrectly.
• All Medicare claims will be separate from the Medicaid claims again beginning with the
06/03/05 remittance advice.
Billing Information.
Rolling Month Service Limit Change 05/01/05
• Effective 05/01/05, the rolling month has been corrected to allow services to
be billed once each month
- Services should still be provided one month apart
• For example, if you bill on the 15th of one month, the
services should not be provided until the 15th of the next
month.
• If services are provided on the 15th of a month, this limit
will not allow for services to provided again on the 1st of
the next month
• Services that are provided throughout the month and have a rolling month
limit per calendar month should be billed by spanning the month
- For example, if the service limit is 200 services per month and
the services are being provided throughout the month, they
must be billed once a month by spanning the dates, the 1st thru
the 31st, the 1st thru the 28th, or the 1st thru the 30th
Thank you for
your attendance!
Unisys
June 2005