Provider Annual Training 2009 General Policies and  Procedures

Provider Annual Training 2009 General Policies and Procedures PowerPoint PPT Presentation


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2. How can you receive information from the IME?. IME Website- www.ime.state.ia.usProvider Services phone lineRemittance Advice commentsEmail UpdatesInformational Letters. 3. Iowa Medicaid provides health care coverage for children, financially-needy parents with children, people with disabi

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Provider Annual Training 2009 General Policies and Procedures

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1. Provider Annual Training 2009 General Policies and Procedures Housekeeping: Bathrooms Vending machines Questions as we go We’ve brought our claims processing program with us on laptops, so if you have specific claims issues or questions, we will try to research them during the presentation. If you haven’t already turned yours in, you may do so after the presentation. We may not be able to fully research or answer your questions as we go along, but we will gather questions that aren’t answered and get back to you. Housekeeping: Bathrooms Vending machines Questions as we go We’ve brought our claims processing program with us on laptops, so if you have specific claims issues or questions, we will try to research them during the presentation. If you haven’t already turned yours in, you may do so after the presentation. We may not be able to fully research or answer your questions as we go along, but we will gather questions that aren’t answered and get back to you.

2. 2 How can you receive information from the IME? IME Website- www.ime.state.ia.us Provider Services phone line Remittance Advice comments Email Updates Informational Letters

3. 3 Iowa Medicaid provides health care coverage for children, financially-needy parents with children, people with disabilities, elderly people, and pregnant women.

4. 4 Iowa Medicaid As of January 2009: Total Medicaid enrollment was 389,305; compared to 262,361 in March 2003 MediPASS enrollment was 157,709; compared to 68,572 in March 2003 Lock-In enrollment was 198; compared to 186 in 2003. Enrollment has gone up a little under 100,000 people since March 2003.Enrollment has gone up a little under 100,000 people since March 2003.

5. 5

6. 6 IME Call Center Facts In January 2009 Provider Services call center received 31,343 phone calls with an average wait time of 30 seconds. Pharmacy Point of Sale department received 4,272 calls with an average wait time of 13 seconds. The Pharmacy Prior Authorization line received 1,763 calls with an average wait time of 11 seconds. Member Services received 12,791 calls with an average wait time of 15 seconds.

7. 7 More IME Facts In January 2009 Over 1763 Prior Authorization requests TPL updated or added over 26,196 insurance records Over 1.5 million claims were processed.

8. 8 www.ime.state.ia.us/Providers/Training Claims address: IME PO Box 150001 Des Moines, IA 50315 Correspondence address: IME PO Box 36450 Des Moines, IA 50315 IME Provider Services 800-338-7909 515-725-1004 (Des Moines area) ELVS 800-338-7752 515-323-9639 (Des Moines area)

9. 9 www.ime.state.ia.us Download forms Access provider manuals Access Informational Releases Find links to the Web Portal for claims submission and eligibility information Provider training documents

10. 10 Web Tools Mass Emails Online Remittance Advices See Informational Letter 652 for enrollment instructions Register at www.imeservices.org During our last annual training, we mentioned that we were building new tools for providers to access information more quickly and efficiently. This year, we have these tools in place. During our last annual training, we mentioned that we were building new tools for providers to access information more quickly and efficiently. This year, we have these tools in place.

11. 11 Member Eligibility and History

12. 12 Medical Assistance Card Current card is sent out annually. No specific eligibility month or program will be indicated on the card. Providers must verify eligibility through ELVS or the Web Portal. No change for IowaCare card in that it will still be sent to the member monthly. See Informational Letter 632.

13. 13 Medical Assistance Card

14. 14 ELVS Voice response system Eligibility information available 24/7 Providers can verify: Monthly eligibility Spenddown TPL insurance Managed Health Care information ELVS will tell providers what is left on a patient’s spenddown. A number of insurance companies are listed on ELVS. For those that aren’t, please contact the Provider Services phone line. ELVS will tell providers what is left on a patient’s spenddown. A number of insurance companies are listed on ELVS. For those that aren’t, please contact the Provider Services phone line.

15. 15 Web Portal Available 24/7 Check eligibility Check claim status Submit batch claims Access enrollment forms at http://www.edissweb.com/cgp/forms/enrollment.html On web portal, the most recent TCN is available to aid in adjustments. Checking claim status online will save providers a phone call. Eligibility will state monthly eligibility, limitations on vision and dental services, managed care information, and any TPL information. On web portal, the most recent TCN is available to aid in adjustments. Checking claim status online will save providers a phone call. Eligibility will state monthly eligibility, limitations on vision and dental services, managed care information, and any TPL information.

16. 16 IowaCare and IowaCare Card Explain blended types and IFPN and Iowa Care OBExplain blended types and IFPN and Iowa Care OB

17. 17 Updating TPL to the IME Complete the Supplemental Insurance Questionnaire (SIQ) found at http://www.ime.state.ia.us/Providers/Forms.html Form #470-2826 The SIQ form can be emailed to [email protected] or faxed to 515-725-1352 It can take 10 days for TPL to be updated Members can NOW call Member Services to update their insurance information Providers can download the form, fill it out and email it to our revenue collections (TPL) department. Providers can download the form, fill it out and email it to our revenue collections (TPL) department.

18. 18 Release of Medical Records May release member’s bills and medical records if member requests them Release medical bills if a subpoena is received Do not release bills or records on trauma-related claims to the member or the member’s representative until IME has authorized release

19. 19 I-MERS Iowa Medicaid Electronic Records System Web-based patient management tool Billed diagnosis, drugs and procedures Name and phone of rendering provider Quick link on Provider Home page at www.ime.state.ia.us The I-MERS program gives Medicaid Providers access to all claims billed for any given member. This includes paid and denied claims. This program is meant to aid in patient management and to assist providers by giving them information about what services members have been receiving. The program has been expanded to include: Home Health Agencies Pharmacies Hospitals Physicians (MD, Do, and nurse practitioners)The I-MERS program gives Medicaid Providers access to all claims billed for any given member. This includes paid and denied claims. This program is meant to aid in patient management and to assist providers by giving them information about what services members have been receiving. The program has been expanded to include: Home Health Agencies Pharmacies Hospitals Physicians (MD, Do, and nurse practitioners)

20. 20 Billing

21. 21 Electronic Claim Submission Survey results show that providers who bill electronically are experiencing: Faster claim adjudication Cleaner claim payment Providers deal with less paper Claims sent electronically can be in the Medicaid claims processing system in as little as three days. A lot of the issues experienced when billing paper can be avoided when billing electronically. Providers deal with less paper Claims sent electronically can be in the Medicaid claims processing system in as little as three days. A lot of the issues experienced when billing paper can be avoided when billing electronically.

22. 22 Electronic Claim Submission #2 Providers must enroll with EDISS; link on IME Home page under Tools (Electronic Data Interchange) PC-ACE Pro32- Free software available through DHS Link to PC-ACE Pro32 Instructions on the IME Provider Home page under Quick Links Providers must check their confirmation reports to insure that the claims have not rejected

23. 23 Top Claim Denial Reasons Duplicate claim Member not eligible Missing or invalid MediPASS referral number Third-party insurance should have been billed primary Medicare should have been billed primary Missing or invalid member ID number Procedure/provider type conflict Missing/Invalid NPI, taxonomy and/or Zip Code These are not in any particular order Please wait 10 days if mailing claims before resending For Medicare crossovers- please allow 3 to 4 weeks before sending on paper These are not in any particular order Please wait 10 days if mailing claims before resending For Medicare crossovers- please allow 3 to 4 weeks before sending on paper

24. 24 Claims Submission Issues Data must be contained in the proper field Handwritten claims are difficult to process Both dollars and cents must be indicated for the total charge. J-code drugs must be rebatable and billed with a rebatable NDC code NPI, taxonomy code, and zip code must be billed as verified with the IME For waiver providers- there is now a template online so that you do not have to hand write your claims. Do not use red (or light colored) ink or highlighter of any color Position data to be processed in the center of the box on the claim form. Use commercially produced claim forms. No copies will be processed. Provider number, member Medicaid number, and the dates of service are required on all forms. Diagnosis code and procedure codes cannot include a description. Do not place the actual diagnosis code on the detail line on the CMS-1500 form. Use the corresponding #1-4 from box 21. On a UB04 do not put a rate in column 44. Indicate both the dollars and cents for the total charge. $1058 will process as $10.58. $1058.00 will process as $1058.00 Do not use a dash to indicate either cents or negative numbers. The total charge box must be completed. Totals must only appear on the last page, no subtotals can be used. Do not staple or tape documents to the inside of the mailing envelope. Inquiry forms should not be used to submit claims. Supplemental Insurance Questionnaire (SIQ) forms must be updated by the IME before the claim is submitted. Attaching a denial from the other insurance with your claim will not update the member’s file. All J-code drugs must be rebatable and billed with a rebatable NDC code. If billing electronically, print and review claim confirmation report.   For waiver providers- there is now a template online so that you do not have to hand write your claims. Do not use red (or light colored) ink or highlighter of any color Position data to be processed in the center of the box on the claim form. Use commercially produced claim forms. No copies will be processed. Provider number, member Medicaid number, and the dates of service are required on all forms. Diagnosis code and procedure codes cannot include a description. Do not place the actual diagnosis code on the detail line on the CMS-1500 form. Use the corresponding #1-4 from box 21. On a UB04 do not put a rate in column 44. Indicate both the dollars and cents for the total charge. $1058 will process as $10.58. $1058.00 will process as $1058.00 Do not use a dash to indicate either cents or negative numbers. The total charge box must be completed. Totals must only appear on the last page, no subtotals can be used. Do not staple or tape documents to the inside of the mailing envelope. Inquiry forms should not be used to submit claims. Supplemental Insurance Questionnaire (SIQ) forms must be updated by the IME before the claim is submitted. Attaching a denial from the other insurance with your claim will not update the member’s file. All J-code drugs must be rebatable and billed with a rebatable NDC code. If billing electronically, print and review claim confirmation report.  

25. 25 Iowa Administrative Code 441 79.9(4) Recipients must be informed before the service is provided that the recipient will be responsible for the bill if a non-covered service is provided. Give an example here for providers. Also, remind that a MediPASS claim with no referral is a non-covered claim and member should be aware that they will be responsible for the charges. From Member- Judges are now asking for proof if the member signed a waiver agreeing to be responsible for the charges. Give an example here for providers. Also, remind that a MediPASS claim with no referral is a non-covered claim and member should be aware that they will be responsible for the charges. From Member- Judges are now asking for proof if the member signed a waiver agreeing to be responsible for the charges.

26. 26 Important NPI Information All NPIs must be verified with IME. If billing electronically providers must verify NPIs with both IME and EDISS. Claims may need to be billed with these three identifiers: NPI Taxonomy code Billing zip code No legacy number anywhere. NPI, taxonomy code, and zip code must match with what was used when NPI was verified. If providers are having problems, call Provider Services. *Same as with Medicare- for claims to crossover from MedicareNo legacy number anywhere. NPI, taxonomy code, and zip code must match with what was used when NPI was verified. If providers are having problems, call Provider Services. *Same as with Medicare- for claims to crossover from Medicare

27. 27 Timely Filing Guidelines #1 Claims must be filed within 365 daysof the through date of service. Medicare crossovers must be filed within 24 months of the first date of service.

28. 28 Timely Filing Guidelines #2 Resubmissions If a claim is filed timely but denied, an additional 365 days from the denial date is allowed New Update- Claims up to 2 years from the date of service may be submitted electronically, as it is no longer required to attach the remittance advice denial. See Letter #772- Update on Timely Filing

29. 29 Timely Filing Guidelines #3 Claim Adjustments Requests for claim adjustments must be made within 365 days of the payment date Claim credits are not subject to a time limit Discussion of adjustment form will follow

30. 30 Exceptions to the Timely Filing Guidelines Retroactive eligibility Needs to be billed with retro letter Within 365 days of letter’s date Third-party related delays Need to include reason for delay Within 365 days of TPL payment Retro- provider will receive NOD from member or case worker at DHS. Send to the address listed on the reference materials online. TPL delays- attach a copy of the remittance advice from TPL showing the delay to the claim for processing. Retro- provider will receive NOD from member or case worker at DHS. Send to the address listed on the reference materials online. TPL delays- attach a copy of the remittance advice from TPL showing the delay to the claim for processing.

31. 31 NDC Updates An NDC code must be included on all claims for J code drugs with the following exceptions: J7321-J7324, J2788, and J2790- J2792 See Informational Letter 593 for claim entry directions Update: as of 2/1/09 See Informational letters 593, 647 & 693, and 803 for additional information. There is an NDC FAQ online For service dates on or after 12/17/2007 (for HCFA) and 05/01/2008 (for Part B), all Jcodes need NDC, except the following: 1. Devices (J7321, J7322, J7324 and J7323) 2. Rhogam (J2788, J2790, J2791, J2792) If the claim line has a Jcode and an NDC, the claim will not be denied for NDC if: 1. The NDC on claim is present on rebatable list with the dates of service falling within the validity range, or, 2. For dates of service after 01/31/2009, If the NDC has Multiple-source indicator as "1" (indicating multiple source drug) and Drug-top20-indicator as "Y" on the PDD Master file. Logic for Outpatient claims: All of the above, plus: 1. For dates of service more than 10/01/2008: If the claim line has a "UD" modifier, indicating 340B provider, then the line is not denied. There is an NDC FAQ online For service dates on or after 12/17/2007 (for HCFA) and 05/01/2008 (for Part B), all Jcodes need NDC, except the following: 1. Devices (J7321, J7322, J7324 and J7323) 2. Rhogam (J2788, J2790, J2791, J2792) If the claim line has a Jcode and an NDC, the claim will not be denied for NDC if: 1. The NDC on claim is present on rebatable list with the dates of service falling within the validity range, or, 2. For dates of service after 01/31/2009, If the NDC has Multiple-source indicator as "1" (indicating multiple source drug) and Drug-top20-indicator as "Y" on the PDD Master file. Logic for Outpatient claims: All of the above, plus: 1. For dates of service more than 10/01/2008: If the claim line has a "UD" modifier, indicating 340B provider, then the line is not denied.

32. 32 APC (Ambulatory Payment Classification) Implemented on October 1, 2008 (based on date of service) Methodology: Covered Charges X facility’s cost to charge ratio (cost report) 72-Hour Rule under APC Critical Access Hospitals, under APC the 72-hour rule no longer applies. NON-Critical Access Hospitals, the APC rule will affect the 72-hour rule as follows: Outpatient/Outpatient services within 72-hours may be billed separately. Inpatient/Outpatient services within 72 hours (admit to admit) of each other will still need to be combined.

33. 33 Guidelines for Medicare Crossovers Medicaid will pay coinsurance and deductibles (unless SLMB) Necessary information must be added to the EOMB copy See Informational Letters 638, 658, 687 and 693 for information needed on EOMB TPL payment declaration if applicable   - Member ID number   - NPI (of Group/Billing provider)   - Taxonomy Code   - Zip Code (of facility- this zip code must be the same as what was verified with IME)   - Third party liability payment amount or “TPL denied”- if applicable   - Write “MEDICARE” or “MEDICARE HMO” in bold letters at the top of the EOB (unless these words are already preprinted by the intermediary)   - Write the type of claim form used to submit to Medicare (“CMS-1500” or “UB-04”). If billing for a UB-04, please include the type of bill (Example: 111, 131, etc.)         SITUATIONAL REQUIREMENTS:   - If submitting a cross-over claim for a J-code drug, you must now include a copy of the CSM-1500 claim form to report the NDC along with the usual Medicare EOB. The NDC is in box 24A: enter qualifier “N4” followed by the NDC number in the gray area above the date of service.   - If the right side of the EOB is cut off so that the cents amount does not appear, then write in the cents amount. Just the cents, not the total the total including dollars.   - If the headers are shaded across the top of the Medicare EOB, write the names of the columns above the header.   - Member ID number   - NPI (of Group/Billing provider)   - Taxonomy Code   - Zip Code (of facility- this zip code must be the same as what was verified with IME)   - Third party liability payment amount or “TPL denied”- if applicable   - Write “MEDICARE” or “MEDICARE HMO” in bold letters at the top of the EOB (unless these words are already preprinted by the intermediary)   - Write the type of claim form used to submit to Medicare (“CMS-1500” or “UB-04”). If billing for a UB-04, please include the type of bill (Example: 111, 131, etc.)         SITUATIONAL REQUIREMENTS:   - If submitting a cross-over claim for a J-code drug, you must now include a copy of the CSM-1500 claim form to report the NDC along with the usual Medicare EOB. The NDC is in box 24A: enter qualifier “N4” followed by the NDC number in the gray area above the date of service.   - If the right side of the EOB is cut off so that the cents amount does not appear, then write in the cents amount. Just the cents, not the total the total including dollars.   - If the headers are shaded across the top of the Medicare EOB, write the names of the columns above the header.

34. 34 Exception to Policy Request an Exception to Policy at: http://www.dhs.state.ia.us/dhs/appeals/ask_exception.html If an Exception to Policy has been approved, submit claim with a copy of the Exception to Policy approval letter to the address on the approval letter. What is an exception to Policy? What is an exception to Policy?

35. 35 Retroactive Eligibility May receive a Notice Of Decision from DHS granting retroactive eligibility Claims must be submitted with a copy of the Notice of Decision within 365 days of the letter issue date Please see reference materials online at: http://www.ime.state.ia.us/Providers/Training

36. 36 Credits and Adjustments When to credit vs. adjust Use most recently paid TCN If crediting, do not send a refund check Include either a new corrected claim or a copy of the remittance advice with corrections Include appropriate documentation If asked about electronic adjustments- state that we are describing the paper process in training, but if there are any questions regarding submitting electronic adjustments, please send email to [email protected] asked about electronic adjustments- state that we are describing the paper process in training, but if there are any questions regarding submitting electronic adjustments, please send email to [email protected]

37. 37

38. 38 Provider Inquiry When to use: To initiate an investigation into a claim denial To request Medical Services review When not to use: To add documentation to a claim To update/change/correct a paid claim

39. 39

40. 40 Tamper Resistant Prescription Pads Effective April 1, 2008 Additional criteria to be met by October 1, 2008 For details, please refer to Informational Releases 688 & 746

41. 41 Fraud To report instances of possible fraud or abuse, contact one of the following telephone numbers: Medicaid Fraud Control Unit 800-831-1394 Medicaid Surveillance & Utilization Review 877-447-8610 or 515-725-1346 (Des Moines area)

42. 42 Miscellaneous Topics

43. 43 Iowa Plan for Behavioral Health State wide plan that covers most Medicaid members Most services are billed to the Iowa Plan contractor, currently Magellan Behavioral Health Services Members not enrolled with the Iowa Plan have services paid through the IME ** Contractor MAY change** Contractor MAY change

44. 44 Lock IN For members who have misused Medicaid Members can be restricted to: One Primary Care Physician (PCP) One specialty care provider One hospital One pharmacy Referrals must be obtained from the member’s lock-in PCP

45. 45 Managed Health Care (MediPASS) One of the five provider types that provide primary care services Managed Care is mandatory in many counties Treating provider must obtain a referral from the MediPASS provider It is not appropriate to maintain a list of MediPASS numbers Providers can use member enrollment forms when they find that a member is not enrolled with their clinic. Provider may have the member complete the form at the office. Disenrollment Process- Remember that when disenrolling a member, as the MediPASS provider must treat or refer until the disenrollment is complete and the member has been successfully changed to a new MediPASS provider. (1 month?) May request the current disenrollment calendar from [email protected] Providers can use member enrollment forms when they find that a member is not enrolled with their clinic. Provider may have the member complete the form at the office. Disenrollment Process- Remember that when disenrolling a member, as the MediPASS provider must treat or refer until the disenrollment is complete and the member has been successfully changed to a new MediPASS provider. (1 month?) May request the current disenrollment calendar from [email protected]

46. 46 Medically Needy Also known as Spenddown Typically 2 month certification periods Annual Medical Assistance Cards Claims must be billed to the IME

47. 47 QMB/SLMB QMB (Qualified Medicare Beneficiary) QMB with Spenddown SLMB (Special Low Income Medicare Beneficiary) SLMB with Spenddown QMB: Member has Medicare as primary- Medicaid will pay Medicare coinsurance/deductible/psych reduction ONLY. Provider must submit the EOMB. QMB with Spend down: Medicaid will automatically pay members Medicare coinsurance/deductible/psych reduction. Provider may submit Medicare Non-Covered charges to Medicaid for spend down consideration. The claim must be submitted indicating that this is “Not a Medicare Covered Benefit” with the Medicare denial attached. SLMB: Member has Medicare as primary- Medicaid will pay Medicare DIRECTLY for the yearly premium on this member. Medicaid will NEVER pay a provider directly for their claims. Provider needs to bill the member for all services. SLMB with Spend down: Member has Medicare as primary- Medicaid will pay Medicare DIRECTLY for the yearly premium on this member. Medicaid will NEVER pay a provider directly for their claims… However, when the member has a SPEND DOWN in addition to SLMB, all charges should be billed to Medicaid on a claim form to be considered for Spend down. NOTE: Once the spend down has been met the member will still not be eligible for payment by the IME, meeting his/her spend down will simply assist a family member within their home to be eligible for Iowa Medicaid coverage. QMB: Member has Medicare as primary- Medicaid will pay Medicare coinsurance/deductible/psych reduction ONLY. Provider must submit the EOMB. QMB with Spend down: Medicaid will automatically pay members Medicare coinsurance/deductible/psych reduction. Provider may submit Medicare Non-Covered charges to Medicaid for spend down consideration. The claim must be submitted indicating that this is “Not a Medicare Covered Benefit” with the Medicare denial attached. SLMB: Member has Medicare as primary- Medicaid will pay Medicare DIRECTLY for the yearly premium on this member. Medicaid will NEVER pay a provider directly for their claims. Provider needs to bill the member for all services. SLMB with Spend down: Member has Medicare as primary- Medicaid will pay Medicare DIRECTLY for the yearly premium on this member. Medicaid will NEVER pay a provider directly for their claims… However, when the member has a SPEND DOWN in addition to SLMB, all charges should be billed to Medicaid on a claim form to be considered for Spend down. NOTE: Once the spend down has been met the member will still not be eligible for payment by the IME, meeting his/her spend down will simply assist a family member within their home to be eligible for Iowa Medicaid coverage.

48. 48 Smoking Cessation Medicaid covers smoking cessation counseling & Nicotine replacement products Prior Authorization is required on some products See Informational Letter 679 for complete details

49. 49 Adult Routine Physicals Payable for both regular Medicaid and IowaCare adult members Members may receive annual preventative physicals and pap smears from any enrolled Medicaid physician See Informational Letters 640 and 789 for complete details

50. 50 Iowa Family Planning Network This program only covers family planning services Those in the IFPN may receive family planning services from any Iowa Medicaid provider Members can have IowaCare and IFPN See Informational Letters 483 and 485

51. 51 Provider Services Outreach Staff Outreach Staff provides the following services: On-site training PC-Ace training Escalated claims issues Please send an email to [email protected]

52. You Have Now Completed General Policies & Procedures Thank you! Click for the Online Evaluation We will be talking aWe will be talking a

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