Presentation on theme: "Pick a button or take a break!. Star Date 2010. Captains Log Short – Doyle Medi-Cal Phase 2 Short – Doyle Medi-Cal Phase 2 – We have entered the new realm."— Presentation transcript:
Pick a button or take a break!
Star Date Captains Log Short – Doyle Medi-Cal Phase 2 Short – Doyle Medi-Cal Phase 2 – We have entered the new realm What did not comply with Federal HIPPA Standards What did not comply with Federal HIPPA Standards – DMC Billing then Phase 1 Collaborative Effort between Collaborative Effort between – ADP - DMH - DHCS
System Overview File Submission File Submission ITWS ITWS DHCS SD/MC Phase 2 DHCS SD/MC Phase 2 ADPs role ADPs role State Controllers Office State Controllers Office 837P / 997 / P / 997 / 835
Claim Submission and Adjudication
SDMC Phase 2 Claims Payment Process SMART DHCS State Controllers Office ITWS ADP Trading Partners 837 Warrants SD/MC P2 System Claim Payment File Claim Summary File ADP
Claims File Submission Claims are submitted by ADP Trading Partners via ITWS Claims are submitted by ADP Trading Partners via ITWS ITWS tracks and validates file submissions ITWS tracks and validates file submissions – Ensures zip and file name are the same – Ensures that no duplicate file names have been used ITWS ADP Trading Partners 837
Initial DHCS Processing ITWS sends the 837 file to DHCS for processing ITWS sends the 837 file to DHCS for processing DHCS performs SNIP validation on the file using Edifecs software DHCS performs SNIP validation on the file using Edifecs software Once validation is complete a 997 acknowledgement is returned to ITWS Once validation is complete a 997 acknowledgement is returned to ITWS – In some circumstances a 997 is not returned The 997 indicates if the file was accepted or rejected by DHCS The 997 indicates if the file was accepted or rejected by DHCS ITWS 837 DHCS 997 SD/MC P2
DHCS Adjudication Once validation is complete, accepted claims files are adjudicated All applicable business rules are applied Eligibility is verified at the beneficiary level via a MEDS interface Based on the collective results of all business rules, claims are approved or denied for payment The amount of payment is calculated for all approved claims All available reasons for denial are identified Denied claims are sent for immediate 835 processing Approved claims are sent to ADPs SMART system for processing of payment Claims Adjudication ADP SMART System DHCS Denials
Accounting and SCO Interface ADP processes approved claims for payment by SCO Appropriate approvals are secured Warrant requests are forwarded to SCO for payment Warrants are paid to counties and direct providers Warrant information is returned to ADP ADP Trading Partners ADP State Controllers Office Warrants
The Payment Piece ADPs SMART sends warrant information to DHCS DHCS 835 processes all available claim information at the time the process runs – – This may include both approved and denied claims on the same file 835 transaction file is sent to ITWS for posting Claims Adjudication ADP SMART System DHCS Denials 835 Processing ADP Trading Partners 835 ITWS
ADP SMART System Approvals 837P at DHCS DENIALS SCO Why doesnt my 835 match my 837? 837P 835 TRADING PARTNER
What happened to my claim??
What does an EDI file look like
Can you read an 837P? ISA*00* *00* *30* *ZZ*SDMCPHASETWOADP*100114*0928*U*00401* *0*T*: GS*HC* *SDMCPHASETWOADP* *0928*1401*X*004010X098A1ST*837*1401BHT*0019*00*711347* *0928*CHREF*87*004010X098A1 NM1*41*2*LOS ANGELES COUNTY*****46* PER*IC*RICHARD LUGO*TE* NM1*40*2*ADP*****46*SDMCPHASETWOADPHL*1**20*1 NM1*85*2*ALCOHOL AND DRUG PROGRAM*****XX* N3*1000 SOUTH FREMONT AVE N4*ALHAMBRA*CA*91803REF*EI* HL*2*1*22*0SBR*P*18*******MCNM1*IL*1*SUTTER*RAYMOND****MI* M N3*ELM ST N4*WILMINGTON*CA*90638DMG*D8* *MNM1*PR*2*ADP*****PI*20CLM*A *11.34***57::1*Y*A*Y*Y*B………………………………..SE*73*1401GE*1*1401IEA*1*
ISA*00* *00* *ZZ*SDMCPHASETWOADP*30* *100114*1906*U*00401* *0*T*: GS*HP*SDMCPHASETWOADP* * *190658*1*X*004010X091A1ST*835*1401BPR*I*11.34*C*CHK************ TRN*1* * *ADPREF*EV* DTM*405* N1*PR*20 N3*1700 K Street N4*Sacramento*CA*95811 N1*PE*ALCOHOL AND DRUG PROGRAM*XX* REF*TJ* LX*1CLP*A *2*11.34*11.34**MC* *57*1NM1*QC*1*TIMELESS*AMANDA****HN* M NM1*74*1*TIMELESS*AMANDA****C* ,39, M,50,N, ADP P dat DTM*050* SVC*HC:H0020:HG*11.34*11.34**1.00DTM*472* REF*6R*20002AMT*ZK*6.98AMT*ZL*4.36AMT*B6*11.34SE*22*1401GE*1*1IEA*1*
ISA*00* *00* *ZZ*SDMCPHASETWOADP*30* *100114*1752*U*00401* *0*T*: GS*FA*SDMCPHASETWOADP* * *17 52*1*X*004010X098A1 ST*997*0001AK1*HC*1401AK2*837*1401AK5*AAK9*A*1*1*1SE*6*0001GE*1*1IEA*1* file coming back to TP
HL*2*1*22*0 SBR*P*18**MEDICAL ADP DRUG C/O DEPARTMENT OF ALCOHOL AND DRUG PROGRAM*****MC NM1*IL*1*ANDERSON*SXF-WARPITA*DIANE***MI* M N3*1625 CAPITOL AVE N4*SACRAMENTO*CA*95814DMG*D8* *MNM1*PR*2*ADP*****PI N3*1700 "K" STREET N4*SACRAMENTO*CA*95814CLM*1111TRAIN*65.61***55::1*Y*A*Y*Y*BREF*EA*36435HI*BK:30440NM1*82*1*BENNETT*ANDRIA****XX* NM1*FA*2*PLAINS MEDICAL SYSTEMS INC*****XX* N3*1133 COLOMA WAY #C N4*ROSEVILLE*CA*95661LX*1SV1*HC:H0004*65.61*UN*1***1DTP*472*D8* REF*6R* Loop and Claim information
Are we even speaking the same language? Programs are intuitive and Easy to use Programs are intuitive and Easy to use The Companion Guide The Companion Guide The Companion Guide Appendix The Companion Guide Appendix ADP FAQs ADP FAQs Vendor Interface documentation Vendor Interface documentation County procedures, records and systems County procedures, records and systems
New Definitions Bridge Resubmission and Resubmit Bridge Resubmission and Resubmit Adjudicated - Approved or Denied Adjudicated - Approved or Denied ACN ACN PCCN PCCN Replacement Replacement Void Void Delay Reason Code Delay Reason Code Claim Submitter ID Claim Submitter ID
Bridge Resubmission A bridge resubmission is a resubmission in Phase 2 of a claim that was denied in Phase 1. Files are differentiated by the filename which contains BR in it. Trading Partner must submit the BR form to their analyst.
Resubmit – Phase 2 There is no such thing as a resubmit in Phase 2. Trading Partners must use a replacement or void claim to make changes to originals.
Adjudicated – Approved or Denied If a claim is approved, the amount approved will be on an 835. If a claim is denied, there will be an adjustment reason code on the 835 (page 20 of CG appendix) which describes the reason for the adjustment. – – Claims can be completely denied or partially denied depending on the circumstances.
Attachment Control Number ACN Attachment Control Number (page 55 of 837 CG) This is the number in PWK06 in the 837 that references the paperwork being sent in to ADP. FMAB analysts use this number to match the claim with paperwork being sent in for Manual Override and certain Delay Reason Codes.
Payer Claim Control Number PCCN Payer Claim Control Number (page 27 of 835 CG): Payer Claim Control Number (page 27 of 835 CG): Unique identifier on the 835 in CLP07 that is generated by DHCS. Unique identifier on the 835 in CLP07 that is generated by DHCS. This number must be used to identify prior claims in a void or replacement claim. This number must be used to identify prior claims in a void or replacement claim.
Replacement A replacement claim will have a 7 in CLM05-03 (page 49 of 837 CG). The PCCN of the original claim must be put in REF02 (page 58 of 837 CG). A replacement claim essentially voids out the original claim and replaces it with the new replacement claim.
VOID A void claim will have a 8 in CLM05-03 (page 49 of 837 CG). The PCCN of the original claim must be put in REF02 (page 58 of 837 CG). Void claim voids out the original. – – This is a final action and a voided claim cannot be replaced. There are several examples of void and replacement claims in the CG Appendix.
Delay Reason Code, DRC Delay Reason Code (page 15 of CG Appendix): Codes that will bypass late claim edits based on specific circumstances. DRCs 4 and 11 require ADPs approval prior to being used. DCR 8 certified and submitted by TP Must include a user generated ACN
Claim Submitter ID Unique number generated by the county for each claim to track from creation to payment (page 49 of 837P CG) Unique number generated by the county for each claim to track from creation to payment (page 49 of 837P CG) Echoed back on 835 for payment and denials Echoed back on 835 for payment and denials CLM01 on 837P ties to CLP01 on the 835 CLM01 on 837P ties to CLP01 on the 835
New Drug Medi-Cal Forms Bridge Resubmission – Phase 1 denied only Bridge Resubmission – Phase 1 denied only DMC Claims Adjustments ADP 5035c DMC Claims Adjustments ADP 5035c Good Cause Certification - ADP 6065 A/B Good Cause Certification - ADP 6065 A/B Multiple Billing Overide – ADP 7700 Multiple Billing Overide – ADP 7700 Claim Submission – Cnty Contracted ADP Claim Submission – Cnty Contracted ADP Claim Submission – Cnty Operated ADP Claim Submission – Cnty Operated ADP
Getting help from DHCS https://mhhitws.cahwnet.gov/systems/sdmc/docs/public/short_doyle_-_medi- cal_phase_ii.asp
Getting Help from ADP
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