MHS UB-04 Prior Authorization Top Denials

1. MHS UB-04 Prior Authorization Top Denials October 20, 2009

2. CLAIM PROCESS

3. Claim Process -Top 10 Denials • Time Limit For Filing Has Expired (EX 29) • Claims must be received within 120 calendar days of the date of service (Contracted Providers) • Exceptions • 120 days from DOS for Participating Providers • Exceptions: Newborn, Third Party Liability, and Eligibility delays (filing limit 365 days) • 365 days from DOS for Non Participating Providers • Bill Primary Insurer 1st (EX L6) • Verify other insurance (TPL). Medicaid is the payer of last resort • MHS requires a copy of the primary EOP

4. Claim Process -Top 10 Denials • Coverage Not In Effect When Service Provided (EX 28) • Check eligibility at each visit prior to submitting claims to ensure that you are billing the correct carrier • Non Covered Service For Package B Member (EX BP) • Package B allows for pregnancy related services only • Pregnancy related diagnosis must be on claim for service to be coverage

5. Claim Process -Top 10 Denials • Not a MCO Covered Benefit (EX 50) • Service must be covered by Indiana Medicaid • Carve Out Services not paid by MHS • Please Resubmit to Cenpatico For Consideration (EX 54) • Cenpatico (CBH) handles all behavioral health claims for MHS members

6. Claim Process -Top 10 Denials • Authorization Not On File (EX A1) • Prior Authorization should occur at least two (2) business days prior to the date of service. All non elective inpatient/outpatient services must be prior authorized with MHS at least two (2) business days prior to the date of service • All urgent and emergent services must be called to MHS within two (2) business days after service/admit

7. Claim Process -Top 10 Denials • Claim and Auth Service Provider Not matching (EX HP) • Authorization on file does not match date of service billed • Claim and Auth Provider Specialty Not Matching (EX HS) • Authorization on file does not match provider billing service • Denied By Medical Services (EX EB) • Authorization related denial

8. Claim Process - Billing With Ease NEWBORNS • No prior authorization or referral is required for normal newborn nursery. • Newborn’s RID number is required for payment.

9. Claim Process - Billing With Ease HOSPITAL STAYS • Hospital stays under 24 hours are not billable as inpatient and must be submitted as outpatient services. Medical Management will not approve inpatient less than 24 hours. • 72-hour observation may be available for stays that may not meet medically necessary inpatient admissions.

10. Claim Process – Claim Filing • EDI SUBMISSION Preferred method of claims submission • Immediate Confirmation of receipt • Faster payment processing • Less expensive than paper submission • MHS Payor ID 39186 • It is the responsibility of the provider to review the error reports received from the Clearinghouse • ERF / ERA available • Contact EDI@centene.com with questions

11. Claim Process – Claim Filing • Paper Submission Managed Health Services PO Box 3002 Farmington, MO 63640-3802

12. Claim Process – Resubmission • Clearly mark RESUBMISSION or CORRECTED CLAIM at the top of the claim. • Must attach EOP, documentation, and explanation of the resubmission reason. • May use the Provider Claims Adjustment Request Form. • Providers have 67 calendar days from the date they receive their EOP to file a resubmission.

13. Claim Process – Claim Adjustment • If you need to make an adjustment to a paid claim, you can do so by submitting the adjustment request on paper with the adjustment request form. • Attach a MHS Provider Adjustment Form along with documentation, including EOP (if available) explaining reason for resubmission • Claim adjustments requests must be submitted within 67 days of the date of the MHS EOP

14. Claim Process – Dispute Resolution PROVIDERS HAVE 67 CALENDAR DAYS FROM THE DATE OF RECEIPT OF THE EOP TO FILE AN OFFICIAL DISPUTE OR APPEAL WITH MHS • Verbal inquiries can be made by calling the MHS Provider Inquiry Line at 1-877-MHS-4U4U (647-4848). • A verbal inquiry is not considered a dispute or appeal and does not top the 67 calendar days from the date of receipt of the EOP to file dispute or appeal

15. Claim Process – Dispute Resolution INFORMAL CLAIM DISPUTE/OBJECTION Level One Appeal • 1ST step in the appeals process • Should be made in writing by using the Dispute/Objection form • Submit all documentation supporting your objection • Send to MHS within 67 calendar days of receipt of the MHS EOP • A call to Provider Inquiry does not reserve appeal rights

16. Claim Process – Dispute Resolution FORMAL CLAIM DISPUTE/OBJECTION Level Two Appeal (Administrative) • Submit the Formal Claims Dispute (Administrative Appeal) with all supporting documentation to the MHS appeals address: Managed Health Services Attn: Appeals P.O. Box 3000 Farmington, MO 63640-3800 • MHS will acknowledge your appeal within 5 business days • Provider will receive notice of determination within 45 calendar days of the receipt of the Appeal

17. Provider Inquiry Services Call us at 1-877-647-4848. We are ready to help you! • Knowledgeable, friendly staff available 8:00-6:00 EST • Focused commitment to professional service • Claims address P.O. Box 3002 Farmington, MO 63640 • Dispute & appeal processes (67 days from receipt of EOP) • Appeal address P.O. Box 3000 Farmington, MO 63640

18. Utilization Management (Prior Authorization)

19. Utilization Management PRIOR AUTHORIZATION Prior Authorization is an approval from MHS to provide services designated as needing approval prior to treatment and/or payment. REFERRAL A referral is a request (verbal, written, or telephonic communication) by a PMP for specialty care services.

20. Utilization Management • Prior Authorization (PA) should be initiated through the MHS referral line at 1-877-MHS-4U4U (647-4848) • The PA process begins at MHS by speaking with the MHS non-clinical referral staff. • Prior Authorizations can also be submitted online via our website at www.managedhealthservices.com. Additional documentation may be required to be sent via fax for approval of authorization.

21. Utilization Management Self Referrals • Podiatrist • Chiropractic • Family Planning • Immunizations • Routine Vision Care • Routine Dental Care • Mental Health by Type and Specialty • HIV/AIDS Case Management • Diabetes Self Management

22. Utilization Management Services that require a prior authorization regardless of contract status: • All elective hospital admissions two business days prior All urgent and emergent hospital admissions (including NICU) require notice to MHS by the 2nd business day after admission • Transition to hospice • Newborn deliveries by 2nd business day • Rehabilitation facility admissions • Skilled nursing facility admissions • Transition of care • Transplants, including evaluations

23. Utilization Management Services that require a prior authorization regardless of contract status: • Cardiac rehabilitation • Hearing aides and devices • Home care services, including home hospice • In-home infusion therapy • Orthopedic footwear • Orthotics and prosthetics >$250 • Respiratory therapy services • Pulmonary rehabilitation

24. Utilization Management Services that require a prior authorization regardless of contract status: • Abortions (spontaneous only) • Assistant Surgeon • Blepharoplasty • Cholecystectomies • Circumcision (any patient over 30 days old) • Hysteroscopy and Hysterectomy • Therapies, excluding evaluations • Dental Surgery for members >5 y/o &or general anesthesia is requested • Dialysis

25. Utilization Management Services that require a prior authorization regardless of contract status: • Experimental or investigational treatment/services • Genetic testing or counseling • Home care services • Implantable devices including cochlear implants • Infertility services • Injectable Drugs (greater than $100 per dose • Mammoplasty • Nutritional counseling (non-diabetics only) • Pain Management Programs including epidural, facet and trigger point injections • PET, MRI, MRA and Nuclear Cardiology/SPECT scans

26. Utilization Management Services that require a prior authorization regardless of contract status: • Scar revision/cosmetic or plastic surgery /Septoplasty /Rhinoplasty • Spider/Varicose veins • Specific DME services (listing on Quick Reference Guide)

27. Utilization Management Hospital Services • All elective inpatient/outpatient services must be prior authorized with MHS at least 2 business days prior to the date of service. • All urgent and emergent services must be called to MHS within 2 business days after the admit. *Failure to prior authorize services will result in claim denials.

28. Utilization Management TRANSFERS • MHS requires notification and approval for all non-emergent transfers, at a minimum 3 (three) business days advance notice. • MHS requires notification within three (3) business days following all emergent transfers. Transfers are inclusive of, but not limited to the following: • Facility to facility • Level of care changes

29. Utilization Management To initiate the authorization, referral staff will require the following information: • place of service: outpatient, observation or inpatient • service type: elective, emergent or transfer • service date • name of admitting physician • CPT code for proposed services • primary and any secondary diagnosis • contact name and numberto obtain clinical information

30. Utilization Management The MHS CM will review all available clinical documentation; apply Milliman Care Guidelines, and seek Medical Director input as needed. • PA for Observation Level of Care (up to 72 hours) is not required for contracted facilities • If the provider requests an inpatient level of care for a covered/eligible condition/procedure and documentation supports an outpatient/observation level of care, the case will be sent for a Medical Director review

31. Utilization Management Denial of Request and Appeal Process If MHS denies the requested service: • MHS CM will notify the provider verbally within one business day of the denial, provide the clinical rationale, and explain appeal rights • A formal letter of denial explaining denial rationale and appeals rights will be mailed within the next business day • If denial is based on Milliman Care Guidelines, provider has right to obtain a copy of the guidelines in which denial is based • If member is still receiving services the provider has the right to an expedited appeal which must be requested by the attending physician

32. Utilization Management Denial of Request and Appeal Process If MHS denies the requested service: • If the member has already discharged- an appeal must be submitted in writing from the attending physician within 60 days of the denial • The attending physician has the right to a Peer to Peer discussion • Peer to Peer discussions and Expedited Appeals are initiated by calling MHS at 1-877-MHS-4U4U (647-4848) and asking for the Appeal Coordinator

33. Utilization Management • MEDICAL NECESSITY GRIEVANCE AND APPEALS Managed Health Services Attn: Appeals Coordinator 1099 North Meridian Street, Suite 400 Indianapolis, IN 46204 • Determination will be communicated to the provider within 20 business days of receipt

34. MHS - Need To Know

35. MHS – Need to Know www.managedhealthservices.com & 1-877-MHS-4U4U (647-4848)

36. Need to Know - MHSWebsite • www.managedhealthservices.com • Enhanced website – Access for both contracted/non-contracted groups • On-line Registration – Multiple Users • Provider Directory Search Functionality • Enhanced Claim Detail • Direct Claim Submission (Professional Claims only) • Printable EOP • On-line prior authorization guide and submission • Claim Auditing Software Tool • Downloadable Eligibility Listing • Printable, Current Forms and Manual

37. Need to Know - MHSWebsite Upcoming Enhancements • Direct claim submission UB04 – 2010 • Claim resubmission – 2010 • Claims Xtend – 2010

38. Need to Know – Provider Education MHS generates a Provider Watch Bulletin of helpful tips and Plan updates to billing office locations for all participating providers on a quarterly basis. All providers can review this bulletin on the MHS website at www.managedhealthservices.com.

39. Questions and Answers