Presentation on theme: "Welcome to Arkansas Medicaid Education and support for therapy providers."— Presentation transcript:
Welcome to Arkansas Medicaid Education and support for therapy providers
Agenda Introductions Facilities Medicaid organization and requirements Program overview Claims submission and billing tips Medicaid tools and support Discussion
Division of Medical Services (DMS) County offices EDS AFMC ConnectCare Who does what? Arkansas Medicaid
DMS Administrators of Medicaid Medical Services – establishes policy for all programs. Provider Reimbursement – establishes reimbursement rates. TPL – validates Third-Party Liability information. Program Planning and Development – distributes policy.
DHS County Office County Case Workers Work directly with recipients. Determine eligibility aid category and eligibility period. Assist with Primary Care Physician (PCP) assignments.
EDS Fiscal Agent Provider Enrollment Claims processing Remittance Provider Assistance Medicaid Management Information System (MMIS)
EDS Provider Enrollment On January 3rd, 2005, EDS assumed responsibility for enrolling providers in the Arkansas Medicaid program. The EDS Provider Enrollment team processes new provider applications and assigns provider numbers upon successful completion of the application process. The EDS Provider Enrollment team also assists existing providers needing to renew, update, or change their demographic or group affiliation information.
EDS Provider Enrollment Monday through Friday (8 a.m. - 5p.m.) Toll-free in Arkansas: 800.457.4454 Local or out of state: 501.376.2211 Fax: 501.374.0746 Medicaid Provider Enrollment Unit EDS PO Box 8105 Little Rock, 72203-8105
EDS Claims processing EDS received more that 26 million Arkansas Medicaid claims last year and processed more than 23 million of them electronically with the Electronic Data Interchange (EDI) processing system. EDS supports electronic transactions every day, all day (and night) through the Internet, Provider Electronic Solutions (PES) software, vendor systems, clearinghouses, and paper submissions.
Claim volume EDS EDI claims Total claims Number of claims (millions) State Fiscal Year
EDS Claim adjudication Adjudication is the process of approving or denying a submitted claim. Providers benefit greatly when their Medicaid claims are processed quickly. Last year, EDS again beat its goal of taking claims from receipt to adjudication in a mere four days.
Claim adjudication EDS Days Month of State Fiscal Year 2004
EDS EDI Support Center Toll-free in Arkansas: 800.457.4454 Local or out of state: 501.376.2211 The EDI Support Center is open weekdays 8 a.m. to 5 p.m. to assist providers with electronic claim submission issues, 997 batch responses, PES software delivery and setup support, software training, and data transmission failures.
EDS Remittance 42% of 2003 payments to Arkansas Medicaid providers were made using electronic funds transfer (EFT). 49% percent of all providers are paid using EFT.
EDS Provider Relations Provider manuals and tools Provider Assistance Center Help desk for software and vendors Workshops and presentations Individual provider training
AFMC Liaison, utilization, reviews Acts as Medicaid policy liaison for providers and the state. Provides managed care, ARKids, and waiver quality assurance reviews. Provides utilization monitoring and quality reviews for PCPs. Reviews therapy claims.
AFMC Recipient complaints AFMC hosts the Medicaid Recipient Hotline. If a recipient has a complaint about services, a provider, or other problems relating to the program, they can call Medicaid Recipient Hotline from 8am to 4:30pm M-F. 1.888.987.1200
ConnectCare Managed Care helpline Enrolls recipients with PCP. Educates recipients, county case workers, and providers about PCP requirements. 1.800.275.1131
Contractual requirements for providers
Provider manual Section I essentials Available program services Contacts Recipient eligibility Recipient responsibility Provider participation guidelines Administrative remedies and sanctions Managed care program requirements PCP requirements and participation
Provider manual Section II essentials Scope of program Prior authorization requirements Reimbursement Billing procedures
Provider manual Section III essentials General – ECS, timely filing, forms Remittance and status reports Adjustments Other sources of payment (third-party payers)
PCPs Primary responsibilities Providing health education. Assessing medical conditions and initiating and recommending treatment or therapy. Referring to specialty physicians, hospital care, and therapists. Locating needed medical services. Coordinating prescribed medical and rehabilitation services with other professionals. Monitoring the enrollees prescribed medical and rehabilitation services.
Recipient Primary responsibilities Select a PCP (most recipients). Report changes in income or circumstances. Report TPL.
Medicaid program overview
Benefits Overview Physician services Inpatient hospital Outpatient hospital Lab/x-ray Prescription Therapy (OT/PT/Speech) Arkansas Medicaid administers 42 programs. Here are just a few of the many benefits available to eligible recipients. Mental health Emergency room Long term care Hospice Dentistry (under 21) Medical equipment
Benefits Recipients Recipients with Medicare coverage Residents of an ICFMR Residents of LTC facilities Recipients on spend down aid categories Retroactively eligible recipients Arkansas Medicaid operates as a managed care program. Most recipients are required to have a PCP and most services require PCP referral. Recipients that are not required to enroll with a PCP include:
Therapy services See OT, PT, Speech manual – 213.200 Benefit limits Recipients under age 21: Four evaluations per SFY Up to four 15-minute units per day
Overview All Medicaid recipients are assigned to an aid category with corresponding levels of coverage. These are listed in section one of the Arkansas Medicaid provider manuals. See Section I manual – 124.000
Aid Categories General classifications FR - Full benefits MNLB – Medically needy, limited benefits AC - Additional cost sharing LB - Limited benefits
Aid Categories Limited benefits These Medicaid recipients are limited to specific services according to their aid category.
Aid Category 01 ARKids First B Recipients may have limited services. Recipients may have co-payment requirements.
Aid Category 03 Childrens Medical Services (CMS) Services must be prior-authorized. This is a non-Medicaid category.
Aid Category 04 Developmental Disability Services This is a non-Medicaid category. DDS non-Medicaid provider ID number end with 86. DDS non-Medicaid recipient ID numbers begin with 8888. Only DDS non-Medicaid providers may bill for DDS non-Medicaid recipients.
Medically Needy Exceptional Nursing Facility Personal Care Aid Category *6 These recipients are eligible for the full range of Medicaid services except:
Aid Category *7 Spend down Recipients must pay toward medical expenses when income and resources exceed the Medicaid financial guidelines. Aid Category 07 BCC (Breast and Cervical Cancer) has full benefits.
Aid Category 08 Tuberculosis (TB) Recipient coverage includes drugs, physician services, outpatient services, rural health clinic encounters, Federally Qualified Health Center (FQHC), and clinic visits for TB related services only.
Aid Category *8 Qualified Medicare Beneficiary For QMB recipients, Medicaid pays Medicare premiums, coinsurance, and deductible. If the service provided is not a Medicare- covered service, then Medicaid will not pay for the service under the QMB policy. 8S – ARSeniors has full benefits.
Aid Category 61 Pregnant Woman Infants and Children Poverty Level (PW-PL) Contains both pregnant women and children. Providers must use the last three (3) digits of the Medicaid ID number to determine benefits. When the last three digits are: –100 series (101, 102, etc.) the recipient is eligible as an adult for pregnancy-related services only; –200 series (201, 202, etc.) the recipient is eligible as a child and receives a full range of Medicaid services. A pregnant teen may be eligible either as a child or as an adult. The last three digits of her ID number determine the services for which she is eligible. If the plan description is PW unborn ch-noster/FP cov then there is no sterilization or family planning benefit.
Aid Category 62 This is a temporary aid category that pays ambulatory, prenatal care services only. Delivery and hospitalization is not covered in this category. Pregnant Woman Presumptive Eligibility (PW-PE)
Aid Category 69 Family Planning Waiver (FPW) Medicaid pays for family planning preventative services only, such as birth control, counseling, etc. A claim for a recipient in this category must contain both a family planning diagnosis code and a family planning procedure code.
Aid Categories 58, 78, 88 Specified Low Income Medicare Beneficiary (SLIMB, SMB) Recipients are not eligible for any Medicaid services. Medicaid pays only their Medicare premium.
270 Eligibility Request Recipient eligibility is date specific; it may begin or end on any day. It is the provider s responsibility to check each recipient s eligibility on the date of service to ensure payment for claims.
Verify eligibility 271 Request Response File RECEIVED DATE:10/31/2003 ---------------------------------------------- I N F O R M A T I O N S O U R C E INFORMATION SOURCE:ARKANSAS MEDICAID SOURCE PRIMARY ID:123456789 ---------------------------------------------- P R O V I D E R I N F O R M A T I O N PROVIDER LAST NAME:DRLAST PROVIDER FIRST NAME:DRFIRST PROVIDER NUMBER:199999901 ---------------------------------------------- R E C I P I E N T I N F O R M A T I O N (continued next) Who information is coming from Pay-To provider name Pay-To provider number
Verify eligibility ---------------------------------------------- R E C I P I E N T I N F O R M A T I O N ELIGIBILITY AUTHORIZATION #:12345678901234 TRACE #:999999999999999 RECIPIENT LAST NAME:DUGGER RECIPIENT FIRST NAME:JEFFERY RECIPIENT ID:1999999991 RECIPIENT DOB:01/01/2000 ----------------------------------------------- E L I G I B I L I T Y I N F O R M A T I O N (continued next) EDS authorization number Trace number Recipient name as it appears with AR Medicaid Keyed ID number DOB listed with Medicaid 271 Request Response File cont.
Verify eligibility ---------------------------------------------- E L I G I B I L I T Y I N F O R M A T I O N ELIGIBILITY/BENEFIT:1 ACTIVE COVERAGE PLAN DESCRIPTION:01ARKIDS 1ST ELIGIBILITY PERIOD:01/01/2004-07/01/2004 COUNTY:731 WHITE ELIGIBILITY/BENEFIT:R TPL INSURANCE TYPE:C1 COMMERCIAL TPL MEMBER #:999999999 TPL POLICY #:7777777 TPL GROUP #:666666 PLAN NAME:ACME INSURANCE ELIGIBILITY PERIOD:01/01/2000 – 07/01/2004 COVERAGE 1:FULL COVERAGE LAST/ORG NAME:ACME INSURANCE COMPANY CODE:ABC ADDRESS LINE 1:P.O. BOX 1000 CITY:LITTLE ROCK STATE:AR ZIP:72201 (continued next) Shows coverage TPL information Aid category Dates of eligibility County of residence Type of TPL Member number Policy number Group number Plan name Type of coverage Dates of coverage Name of insurer Company code Address 271 Request Response File cont.
Verify eligibility 271 Request Response File cont. (continued previous) ---------------------------------------------- E L I G I B I L I T Y I N F O R M A T I O N ELIGIBILITY/BENEFIT:L PRIMARY CARE PROVIDER DATE TIME PERIOD: 01/01/2004 – 07/01/2004 LAST/ORG NAME:PCPLAST FIRST NAME:PCPFIRST NAME SUFFIX:MD TELEPHONE:5013746608 ELIGIBILITY/BENEFIT:D BENEFIT DESCRIPTION SERVICE TYPE:AL VISION (OPTOMETRY) DATE TIME PERIOD: 03/20/1998 ELIGIBILITY/BENEFIT:D BENEFIT DESCRIPTION SERVICE TYPE:AM FRAMES DATE TIME PERIOD: 03/20/1998 PCP information PCPs name and phone number returned if applicable NOTE: Only benefits used will appear on eligibility in PES PCP effective dates
Verify eligibility New in PES 2.04 and online Up to four recipient eligibility segments with matching recipient IDs EPSDT screening information Medicare A and B effective dates
Supplemental Batch Response ------------------------------------------ SUPPLEMENTAL ELIGIBILITY BATCH RESPONSE RECIPIENT ID:1999999991 PLAN CODE:01 PLAN DESCRIPTION 1:ARKIDS 1ST ELIGIBILITY BEGIN DATE:1/01/2004 ELIGIBILITY END DATE:7/01/2004 COUNTY CODE:731 COUNTY:WHITE TPL SEGMENT COUNT1 TPL COMPANY CODED02 TPL SUBSCRIBER NAMEJEFF DUGGER Recipient ID for this eligibility segment…up to 4 segments returned Plan code and description Dates of eligibility in this aid category Number of TPL segments TPL carrier code Name of policy holder Verify eligibility
Supplemental Batch Response (CONTINUED) -------------------------------------- SCREENINGS MEDICAL2/01/2004 HEARING2/01/2004 VISION2/01/2004 DENTAL2/01/2004 BUYIN PART A:2/01/2004 PART B:2/01/2004 Last screening dates Medicare effective dates Verify eligibility
Submitting claims Online
CENTRAL ARKANSAS DOCTORS OFFICE 1414141402 Verify claim status 277 Response file header Who information is coming from Pay-To provider name and number Submitter info and submitter ID
Verify claim status 277 Accepted response detail DUGGER JEFFERY 1999999991 JEFFERY DUGGER 0505101011111 Recipient information from the claim Good News! Assigned claim number (watch for this number on your next weeks remittance)
DUGGER JEFFERY 1999999991 JEFFERY DUGGER Verify claim status 277 Rejected response detail Recipient information from the claim Rejection notification No claim number assigned. View the rejected response report for a more detailed explanation
1414141402 1999999991 DUGGER 0001 Verify claim status Rejected response report Rejected claim information Total errors identified on claim Error(s) location and description
Submitting claims Other options Third party software vendor Clearinghouse Paper
Codes for speech therapy Procedure Code/Modifier Available units DescriptionPOS 925064Evaluation for speech therapy 11, 12, 52, 56, 99 925074Individual speech therapy11, 12, 52, 56, 99 925084Group speech therapy11, 12, 52, 56, 99 92507 (52)4Individual speech therapy by an assistant 11, 12, 52, 56, 99 92508 (52)4Group speech therapy by an assistant 11, 12, 52, 56, 99
Billing tips Codes for speech therapy Procedure Code/Modifier Available units DescriptionPOS 926074Initial evaluation for an augmentative/communicati on device 11, 12, 52, 56, 99 926082Additional evaluation time11, 12, 52, 56, 99
Billing tips Codes for occupational therapy Procedure Code/Modifier Available units DescriptionPOS 970034Evaluation for occupational therapy 11, 12, 52, 56, 99 975304Individual occupational therapy 11, 12, 52, 56, 99 97150 (U2)4Group occupational therapy11, 12, 52, 56, 99 91530 (52)4Individual occupational therapy by an assistant 11, 12, 52, 56, 99 97150 (52)(U1) 4Group occupational therapy by an assistant 11, 12, 52, 56, 99
Billing tips Codes for physical therapy Procedure Code/Modifier Available units DescriptionPOS 970014Evaluation for physical therapy 11, 12, 52, 56, 99 971104Individual physical therapy11, 12, 52, 56, 99 971504Group physical therapy11, 12, 52, 56, 99 97110 (52)4Individual physical therapy by an assistant 11, 12, 52, 56, 99 97150 (52)4Group physical therapy by an assistant 11, 12, 52, 56, 99
Billing tips Therapy service codes A Use therapy service code A for individuals from birth through 2 years receiving services under an Individualized Family Services Plan (IFSP) through the Division of Developmental Disability Services. B Use therapy service code B for individuals from birth through 5 years receiving services under an Individualized Plan through the Division of Developmental Disability Services.
Billing tips Therapy service codes C Use therapy service code C for individuals from 3 through 5 years receiving services under an Individualized Education Plan (IEP) through an education service cooperative. D Use therapy service code D for individuals from 5 through 20 years receiving services under an IEP through a school district.
Billing tips Therapy service codes E Use therapy service code E for individuals 18 years and older receiving services through the Division of Developmental Disabilities Services. F Use therapy service code F for individuals 18 years and older receiving services through individual or group providers not included in any of the previous categories (A-E). G Use therapy service code G for individuals from birth to 17 years receiving therapy/pathology services through individual or group providers not included in any of the previous categories (A-F).
Most common billing errors
Top denials Common errors EOB 041 and 152 Procedure code, revenue code, TOS/ modifier is invalid. Method of correction Verify the procedure code, TOS, and/or modifier in section II of the corresponding provider manual and resubmit the claim.
Top denials Common errors EOB 254 or 267 Recipient is totally or partially ineligible for dates of service. Method of correction Verify the recipient is eligible for all claim dates of service. Resubmit the claim/portion of the claim for the time of eligibility.
Top denials Common errors EOB 952 Service requires Primary Care Physician referral. Method of correction Resubmit the claim with the corrected PCP information required for adjudication.
Top denials Common errors EOB 469, 470 Duplicate billing. Claim is identical to another claim for DOS, performing provider, procedure, TOS, and price. Method of correction Verify that the service is not a duplicate bill. Resubmit the corrected claim.
Top denials Common errors EOB 103 Claim does not meet the timely filing requirements for Medicaid. Method of correction Claims must be received by EDS within 365 days from the To DOS. Claims received beyond this deadline will not be paid.
Top denials Common errors EOB 199 ARKids 1 st B recipient is older than 18 years old. Method of correction ARKids 1st B recipient s eligibility ends on their 19 th birthday. The from DOS can not exceed the 19 th birthday.
Billing tips When is a rejection a denial? Many claim rejections are billing errors. Correct these claims and resubmit them for processing. Recipients are only responsible for payment when a service is denied with an explanation of recipient responsibility. See the Explanation of Benefits (EOB) on the last page of the remit.
Tips Remittance and Status Report Paid claims Pending claims Denied claims Check your remittance and status report each week for:
PES submissions Billing flow Successful report RA ICN PaidPendingDenied Follow-up RA Do not resubmit Correct and resubmit Rejected response report Correct and resubmit Batch response AcceptedRejected
Vendor/clearinghouse submissions Billing flow Report Clearinghouse (to EDS) Vendor (to EDS) Rejected Correct and resubmit Response report PaidPendingDenied Correct and resubmit RA Follow-up RA Do not resubmit Accepted ICN
Paper submissions Mail claim Scanning/ICN Completed claim forms only. RA Claim processed PaidProcessDenied Do not resubmit Correct and resubmit Incomplete forms returned to provider. ICN Billing flow
Tips Six ways to check claim status Verify claims on the remittance advice PES software Web site Voice response 800.805.1512 Claim inquiry form Provider Assistance Center 800.457.4454 or 501.376.2211
Tips Claims Payment Cycle Electronic claims are paid on the next remittance advice. Paper claims that could have been sent electronically pay on a 30-day pay cycle.
Tools and support
Provider reference Benefits of e-media Easier distribution and maintenance More viewing options and free software More effective searching Print pages or sections as needed, as many as needed (including many forms) Save files to your computer Share files over a network
www.medicaid.state.ar.us Web site
Provider Reference CD Demo
Contacts Provider Assistance Center (PAC) Your first point of contact for billing, claim status, eligibility, and all other questions is the Provider Assistance Center: Monday through Friday 8 a.m. to 5 p.m. Toll-free in Arkansas: 800.457.4454 Local or out of state: 501.376.2211
PAC: Billing, eligibility, claim status Contacts PAC phone menu 800.457.4454 501.376.2211 1 EDI : Software, RAs 2 Other inquiries 0 Claims, Prior Authorization, billing assistance, eligibility, adjustments EDI/RA issues, PES, DDE, balancing, denials 2 Provider Enrollment 3 1
Contacts Electronic Data Interchange Toll-free in Arkansas: 800.457.4454 Local or out of state: 501.376.2211 The EDS EDI Support Center is open weekdays 8:00am to 5:00pm to assist providers with electronic claim submission issues, 997 batch responses, PES software delivery and setup support, software training, and data transmission failures.
Provider Reps Provider representatives handle billing and policy issues that have been escalated from the Provider Assistance Center. They are also available to visit your office by appointment. You may contact your representative by calling 501.374.6609 and entering their extension. See the Arkansas Medicaid Web site for your county s representative. Contacts