ProviderOne Tribal Training

1. ProviderOneTribal Training Deb Sosa Katie Delgado Matt Ashton Gary Monroe

2. Today�s training: Show how to use ProviderOne to conduct business with Washington Medicaid Prepare you to submit practice claims in ProviderOne Introduce a step by step Billing and Resource Guide that outlines the billing process Ensure you know how to get help when you practice submitting claims 2

3. As a result of this session, you will be able to use ProviderOne to: Check Client Eligibility Submit Direct Data Entry Claims using NPI, Taxonomy Codes, and New Client ID Adjust or Void a Paid Claim Resubmit Denied Claims Obtain your Remittance Advice 3

4. Training Modules Tribal Policy Updates Basic Navigation Highlights Check Client Eligibility LUNCH Submit Claims Obtain the Remittance Advice Practice Submitting Claims Now 4

5. Module 1 Tribal Policy Updates Policy Requirements Existing Policies- System Edits Hitting ProviderOne Driven After Stabilization Deb Sosa Deborah.Sosa@dshs.wa.gov 5

6. New Eligibility Policy New eligibility policy coming out- exempting tribal income and resources through possession by way of treaty rights- Gaming revenues not exempted 6

7. Federal Policy Facility/ program alignment with federal policy for �like� programs accreditation and deeming And/or certification for compliance with State plan Dependent on service category- Licensing requirements New clinicians linked to facility NPI for claims to pay CPA signature submitted to Provider Enrollment 7

8. Tribal Policy Reminders Reminder: Expedited disenrollment for tribal members enrolled in ALL managed care programs Federal policy allows tribal members to have access to IHS or 638 facilities for health services Treaty right for federally recognized tribal members and descendents only 8

9. Encounters & Facility Encounters � new limits are around the client. Limit of 4 � one of each categorical claim per client per day Even if a client is seen at a different facility a second encounter in the same category of service is NOT payable EXCEPT if it is an emergency Needs to be documented on the claim and in the clinic record 9

10. New System Edit (Current Policy) Clinician NPI (rendering provider number) required on any claim submitted Claims submitted for facilities that have combined FFS and encounters into one facility NPI CDP clinician NPI�s are delayed until after Go-Live 10

11. After ProviderOne Stabilization Current Federal coding and billing policies applied to ALL Medicaid Providers CPT/CDT/HCPCS procedure codes (will still receive encounter) Prior authorization and service limits- will begin applying to tribal claims Required rendering provider NPI�s on all claims 11

12. Tribal Policy Updates Behavioral Health systems Changes will come as part of the redesign and alignment with the Washington State Medicaid Plan for Rehabilitative Services Verification of program eligibility for encounter billing based on IHS facility list 12

13. Tribal Policy Updates Please bookmark HRSA website Health Care Assistance in Washington http://hrsa.dshs.wa.gov/ 13

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15. Module 2 Basic Navigation Highlights 15

16. Basic Navigation Highlights Log On and Off Change Your Password View Alerts Access On-Line Help Basic Navigation New Resources Available 16

17. Log into ProviderOne Access the ProviderOne at web site https://www.waproviderone.org Enter your Domain, Username, and Password supplied to you by your system administrator Username and Password are case sensitive Push the button to continue 17 Talk about reset passwordTalk about reset password

18. Change Your Password The password must contain: at least 8 characters at least one letter at least one number at least one of the following special characters: , . ! @ # $ % ^ & * ( ) _ + - < > 18 If you are logging into ProviderOne with a password created by ProviderOne or your system administrator, you will be required to create a new password. If you enter an invalid Domain Name or Username three times, ProviderOne will display the Logout page and you will have to start over. If you enter an invalid password three times, your user account will be locked. Your System Administrator must unlock your account before you can login. If your password has expired, ProviderOne will direct you to the Change Password page and you will have to create a new password. It is important to answer your secret question. It is used to help reset your password. You cannot use your previous 5 passwords when changing you password every 120 days. If you are logging into ProviderOne with a password created by ProviderOne or your system administrator, you will be required to create a new password. If you enter an invalid Domain Name or Username three times, ProviderOne will display the Logout page and you will have to start over. If you enter an invalid password three times, your user account will be locked. Your System Administrator must unlock your account before you can login. If your password has expired, ProviderOne will direct you to the Change Password page and you will have to create a new password. It is important to answer your secret question. It is used to help reset your password. You cannot use your previous 5 passwords when changing you password every 120 days.

19. Select the Profile to Use 19 They may not know about super userThey may not know about super user

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22. Accessing help and logging out 22 This is located in the upper left had cornerThis is located in the upper left had corner

23. Navigation Path The Path displays all ProviderOne pages you have opened to get to current page Click on any page in the Path to return to that page 23 This is a great navigation shortcut. This is a great navigation shortcut.

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25. New Resources 25

26. ProviderOne Billing and Resource Guide intended to: Strengthen instructional materials that apply to nearly all provider types Respond to provider requests for step by step training materials Serve as foundation for program specific billing instructions Ease the transition to ProviderOne 26

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30. Module 3 Check Client Eligibility 30

31. Changes with ProviderOne 31 New Client Services Card New Client ID number Programs are now called �Benefit Service Packages�

32. Check Client Eligibility Determine if the Client Has Medical Assistance Review Client Benefit Service Package Identify the Primary Payer 32 Explain new term BSP on this slideExplain new term BSP on this slide

33. Check Client Eligibility Log into ProviderOne with Profile: EXT Provider Eligibility Checker EXT Provider Eligibility Checker-Claims Submitter EXT Provider Super User EXT Provider Managed Care (PCCM only) Under Client, Select �Benefit Inquiry� on your Provider Portal homepage 33

34. 34 Check Client Eligibility Will auto populate with today�s dateWill auto populate with today�s date

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36. Unsuccessful Eligibility Check 36 Write up stuff and have Gary reviewWrite up stuff and have Gary review

37. If the client is eligible, the first thing you will see is a segment like this: 37

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39. Client Eligibility Some BSPs you might see include: LCP-MNP (Medicaid) GA (State Only) QMB (Medicare) ERSO (Medicaid) For a complete list of BSPs, please see Appendix E in the ProviderOne Billing and Resource Guide 39 Old program codesOld program codes

40. Identify the Primary Payer Check to see if the client is in a managed care plan 40 If there is an RSN listed here, the client is Medicaid. If there is not an RSN listed here, the client is on a state only funded program. If there is an RSN listed here, the client is Medicaid. If there is not an RSN listed here, the client is on a state only funded program.

41. Identify the Primary Payer Check to see if the client has Medicare or commercial private insurance 41

42. Determine if the client is restricted to a provider or pharmacy 42

43. Determine if the client has a spenddown amount Spenddown is like an insurance deductible Clients must incur medical expenses equal to their excess income before Medical Assistance covers services 43 Only the LCP-MNP clients are affected by Spenddown. Only the LCP-MNP clients are affected by Spenddown.

44. Demo Examples 44 Client ID 200082867WA Client ID 200083827WA Client ID 200082867WA Client ID 200083827WA

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46. Module 4 Submit Claims 46

47. Changes with ProviderOne NPI (National Provider Identifiers) Replaces Old Medicaid Provider Numbers Taxonomy Codes Client Date of Birth, Gender, and Last Name Required on Claims Submit Electronic Backup to Claims (DDE) Submit Electronic Medicare Crossovers Resubmit a Denied Claim (DDE) 47

48. Submit Claims Identify Proper Taxonomy to Place on Claims Submit DDE Claims and Back-up Medicare Crossovers Claim Status Inquiry Adjust or Void a Claim Resubmit a Denied Claim 48

49. Taxonomy Codes Federal taxonomy codes indicate a provider�s type, specialty, and subspecialty Taxonomy codes need to be on your provider file for: Group Performing/Rendering DSHS requires taxonomy codes on your claim. If the taxonomy code is not on your claim it will deny 49 NPI numbers are generic and do not tell us the specialty/subspecialty of the provider. Current provider numbers have this information imbedded into them. Need to make sure that provider understands that they will need to register all servicing providers for FFS and encounter numbers if listed or if they work in the office. This is as simple as entering the NPI number on the encounter file as the majority of the tribes have completed the registration for the FFS numbers. Some providers are having claims denied due to this activity not being done. NPI numbers are generic and do not tell us the specialty/subspecialty of the provider. Current provider numbers have this information imbedded into them. Need to make sure that provider understands that they will need to register all servicing providers for FFS and encounter numbers if listed or if they work in the office. This is as simple as entering the NPI number on the encounter file as the majority of the tribes have completed the registration for the FFS numbers. Some providers are having claims denied due to this activity not being done.

50. Taxonomy Codes Example 208D00000X (Medical) 50

51. Taxonomy Codes for Tribes 51 These taxonomy codes are being given to all tribes for the 5 main programs. We are requesting that all tribes use these taxonomy codes as the primary for these five major programs Note: your taxonomy codes you bill DSHS do not need to match what you reported to the feds These taxonomy codes are being given to all tribes for the 5 main programs. We are requesting that all tribes use these taxonomy codes as the primary for these five major programs Note: your taxonomy codes you bill DSHS do not need to match what you reported to the feds

52. 52 Listing of additional taxonomy codes that tribes may bill with that are services outside the 5 maim programs. Listing of additional taxonomy codes that tribes may bill with that are services outside the 5 maim programs.

53. Questions on Taxonomy? Review the Taxonomy Fact Sheet at http://hrsa.dshs.wa.gov/providerone/Providers/Fact%20Sheets/P1PR009%20taxonomy.doc Contact the ProviderOne help desk at ProviderOne@dshs.wa.gov or call 800-562-3022, option 2, then option 4 53

54. Log into ProviderOne and select one of the following profiles: EXT Claims Submitter EXT Provider Eligibility Checker-Claims Submitter EXT Provider Super User Select �On-Line Claims Entry� from the Provider Portal 54 Play Claims Video

55. 55 Restate the hyperlinks to the �Billing Instructions�. Also show again the quick navigation buttons to move from section to section �Billing Provider, Subscriber, Claims, Service� Remind provider to not use the �Backspace Button� When entering the taxonomy codes it is made up of a combination of 2 digits, 2 digits, 5 digits, and a X. Example 123412345XRestate the hyperlinks to the �Billing Instructions�. Also show again the quick navigation buttons to move from section to section �Billing Provider, Subscriber, Claims, Service� Remind provider to not use the �Backspace Button� When entering the taxonomy codes it is made up of a combination of 2 digits, 2 digits, 5 digits, and a X. Example 123412345X

56. 56 Demo pay to later in presentationDemo pay to later in presentation

57. 57 Last Name, DOB, and gender are now required. Plus marks are called �Expanders�Last Name, DOB, and gender are now required. Plus marks are called �Expanders�

58. Needs EOB backup 58

59. 59 Diagnosis codes do not require decimal point.Diagnosis codes do not require decimal point.

60. If you answer yes, the Medicare data entry panel opens in the �Basic Line Item� section 60

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63. Return to the top of the page 63 Pop up blocker needs to be offPop up blocker needs to be off

64. If you click cancel, the following appears: 64 MUST CLICK OK IN ORDER TO SUBMIT CLAIM. IF YOU DO NOT CLICK OK HERE, YOUR CLAIM WILL NOT BE SUBMITTED (Get screen shot with X if it exists) MUST CLICK OK IN ORDER TO SUBMIT CLAIM. IF YOU DO NOT CLICK OK HERE, YOUR CLAIM WILL NOT BE SUBMITTED (Get screen shot with X if it exists)

65. If you click OK, the following appears: 65

66. The details page will display when electronic backup is added: 66

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68. Cover Sheets All paper backup documentation needs a cover sheet Find cover sheets at http://hrsa.dshs.wa.gov/download/document_submission_cover_sheets.html 68

69. Cover Sheets Cover sheets and back-up can be faxed to 1-866-668-1214 or mailed to: Electronic Claim Backup Documentation PO Box 45535 Olympia, WA 98504-5535 For more information on cover sheets, please see the ProviderOne Billing and Resource Guide (Appendix G) 69

70. DEMO Examples 70

71. Inquire on the status of a claim 71 Encourage them to use client ID and date search to see how many times claim was submitted or adjusted, etc.Encourage them to use client ID and date search to see how many times claim was submitted or adjusted, etc.

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74. Claim details, continued 74

75. Adjusting or Voiding a Claim 75

76. Adjusting or Voiding a Paid Claim 76 Even though ProviderOne says 4 years, DSHS policy is 2 years. This is good example of how the system may allow you to do something different than policy.Even though ProviderOne says 4 years, DSHS policy is 2 years. This is good example of how the system may allow you to do something different than policy.

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78. ProviderOne displays the Adjust Claim page and pre-fills the data entry fieldswith values from the selected claim 78

79. Adjusting a Claim from the Old System You can look up the new TCN to adjust in ProviderOne If you already know the ICN from the old system, you can convert it to the new TCN by putting a 9 in front of the ICN and 3 zeros at the end (930911155991009186000) ProviderOne will not recognize ICNs from the old system 79

80. Resubmitting a Denied or Voided Claim 80

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83. 83 Make your changes and click submitMake your changes and click submit

84. Demo Examples Adjust/void Resubmit denied or voided claims 84

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86. Module 5 Obtain the Remittance Advice 86

87. Changes with ProviderOne No More Paper Remittance Advice (RA) Old EOB Codes Replaced by the HIPAA Adjustment Reason and Remark Codes New Layout � Similar Information From the Old RA Save and View the RA Electronically � No Need to Print! ProviderOne Will Save the Last 4 Years of RAs 87

88. Access Your Remittance Advice 88 ProviderOne will have approximately 8 weeks of pre loaded RA�sProviderOne will have approximately 8 weeks of pre loaded RA�s

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90. 90 RA NewsletterRA Newsletter

91. 91 The summary page is now located at the beginning of the RA. This information used to be at the end of the RA. The summary page is now located at the beginning of the RA. This information used to be at the end of the RA.

92. 92 Every denied claim will have an adjustment reason code. Some claims will also have a remark code to give additional information. The code explanation will not appear in the RA. You will have to go to the website (next slide). If you print a paper copy of the RA, there is only 3 lines per page. Every denied claim will have an adjustment reason code. Some claims will also have a remark code to give additional information. The code explanation will not appear in the RA. You will have to go to the website (next slide). If you print a paper copy of the RA, there is only 3 lines per page.

93. Adjustment Reason Codes The Department will be moving to the HIPAA Adjustment Reason and Remark codes: Claim Adjustment Reason Codes (CARC) Remittance Advice Remark Codes (RARC) The definition of these codes will also be printed at the end of the RA The HIPAA codes are available at http://www.wpc-edi.com/products/codelists/alertservice 93

94. Adjustment Reason Codes 94 Make sure to explain this is just an example, not a real claim. There are two different remark codes, one for each line. The codes are real example from the website. Make sure to explain this is just an example, not a real claim. There are two different remark codes, one for each line. The codes are real example from the website.

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96. Module 6 Practice Submitting Claims Now 96 Use the website listed here for information on readiness, client ID crosswalkUse the website listed here for information on readiness, client ID crosswalk

97. Practice What You Learned Providers requested hands on training � You can practice what you have learned in your office, at your own pace Your assignment is to: Go back to your office and enter a handful of claims Apply what you have learned Take additional Webinars if needed We will determine how ready tribes are for go-live based on your practice claims 97

98. 98 In the first several weeks of expanded testing Only 11% of test claims were paid 71% denied 18% suspended Top 3 reasons for denial of test claims #1 �missing/incorrect taxonomy codes #2 �missing/incorrect ProviderOne Client ID #3 �missing/incorrect National Provider Identifier (NPI) Why Practice? We are hoping this training will help you avoid these issues.We are hoping this training will help you avoid these issues.

99. 99 Why Practice? We are hoping this training will help you avoid these issues.We are hoping this training will help you avoid these issues.

100. What Can You Test Now? Client Eligibility Claim Submission with New Data Elements Put note �Tribal Encounter� on practice claims Adjustments/Voids Resubmit Denied Claims Claim Inquires RA to see if your test claims paid 100

101. How to Practice Go to https://www.waproviderone.org/edi Test, verify and practice claims here Submit real claims with NPI, Taxonomy, and Client ID Change the date of service on your claim Get new client ProviderOne IDs at https://fortress.wa.gov/dshs/npicaphrsa/FrontDoor.aspx For details on how to practice, go to http://hrsa.dshs.wa.gov/ProviderOne/EPRT.htm 101 Same log-on informationSame log-on information

102. Resources Contact our help desk if you need assistance at 1-800-562-3022 option 2, then option 4 or ProviderOne@dshs.wa.gov Sign up for additional online training at http://hrsa.dshs.wa.gov/providerone/SystemTraining.htm 102

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