Presentation on theme: "Welcome to Arkansas Medicaid"— Presentation transcript:
1Welcome to Arkansas Medicaid Education and supportfor therapy providers
2Agenda Introductions Facilities Medicaid organization and requirements Program overviewClaims submission and billing tipsMedicaid tools and supportDiscussion
3Arkansas Medicaid Who does what? Division of Medical Services (DMS) County officesEDSAFMCConnectCareDMS – A division of DHS, DMS sets policy and establishes the rules for all Medicaid programs.County office – determines recipient eligibility for Medicaid, enrolls recipients in Medicaid and determines which aid category a recipient qualifies for, usually includes District Social Security offices in most instances for SSI aid categories too.EDS – EDS is the fiscal agent for Arkansas Medicaid. We adjudicated claims according to the policy DMS sets. Perhaps our most important role for you is we send out the money$$$. EDS also processes EFTs, paper checks, billing help desks, web presence, and effective January 3rd, will begin performing provider enrollment.AFMC – is the Quality Improvement Organization for Arkansas Medicaid. They assist physicians and the state by reporting on utilization rates for programs such as ARKids or PCP requirements and work to educate the provider community on Medicaid policy.ConnectCare – Is Medicaid’s managed care program. Assist recipients and physicians with PCP issues.
4DMS 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.
5DHS County Office County Case Workers Work directly with recipients. Determine eligibility aid category and eligibility period.Assist with Primary Care Physician (PCP) assignments.
6EDS Fiscal Agent Provider Enrollment Claims processing Remittance Provider AssistanceMedicaid Management Information System (MMIS)
7EDS 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.
8EDS Provider Enrollment Monday through Friday (8 a.m. - 5p.m.) Toll-free in Arkansas:Local or out of state:Fax:Medicaid Provider Enrollment UnitEDSPO Box 8105Little Rock,
9EDSClaims processingEDS 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.
10Number of claims (millions) EDSClaim volumeNumber of claims (millions)State Fiscal YearEDI claims Total claims
11EDS 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.
12Month of State Fiscal Year 2004 EDSClaim adjudicationDaysMonth of State Fiscal Year 2004
13EDSEDI Support CenterThe 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.Toll-free in Arkansas:Local or out of state:
14EDSRemittance42% of 2003 payments to Arkansas Medicaid providers were made using electronic funds transfer (EFT).49% percent of all providers are paid using EFT.
15EDS Provider Relations Provider manuals and tools Provider Assistance CenterHelp desk for software and vendorsWorkshops and presentationsIndividual provider training
16AFMC 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.
17AFMC Recipient complaints 1.888.987.1200 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.
18ConnectCare Managed Care helpline Enrolls recipients with PCP. Educates recipients, county case workers, and providers about PCP requirements.
20Provider manual Section I essentials Available program services ContactsRecipient eligibilityRecipient responsibilityProvider participation guidelinesAdministrative remedies and sanctionsManaged care program requirementsPCP requirements and participation
21Provider manual Section II essentials Scope of program Prior authorization requirementsReimbursementBilling procedures
22Provider manual Section III essentials General – ECS, timely filing, formsRemittance and status reportsAdjustmentsOther sources of payment (third-party payers)
23PCPs 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.
24Recipient Primary responsibilities Select a PCP (most recipients). Report changes in income or circumstances.Report TPL.
26BenefitsOverviewArkansas Medicaid administers 42 programs. Here are just a few of the many benefits available to eligible recipients.Physician servicesInpatient hospitalOutpatient hospitalLab/x-rayPrescriptionTherapy (OT/PT/Speech)Mental healthEmergency roomLong term careHospiceDentistry (under 21)Medical equipment
27BenefitsRecipientsArkansas 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:Recipients with Medicare coverageResidents of an ICFMRResidents of LTC facilitiesRecipients on spend down aid categoriesRetroactively eligible recipientsThese recipients are not required to have a PCP to receive Medicaid services.Medicare as I said in an earlier exampleResidents of an Institutional Care Facility for the Mentally RetardedLTCSpend down: recipient is medically eligible but not financially eligible.Retroactively eligible. Someone who spends down and becomes eligible has their benefits coverage can go backwards.
28Benefit limits Therapy services Recipients under age 21: Four evaluations per SFYUp to four 15-minute units per dayOccupational, Physical, Speech Therapy ServicesEvals: 1 unit = 30 minutesIndividual and group therapyGroup Therapy: No more than 4 clients per groupEvaluations for therapy services do not require prior authorization.See OT, PT, Speech manual –
30Aid Categories 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 –
32Aid Categories Limited benefits These Medicaid recipients are limited to specific services according to their aid category.
33Aid Category 01 ARKids First B Recipients may have limited services. Recipients may have co-payment requirements.
34Aid Category 03 Children’s Medical Services (CMS) Services must be prior-authorized.This is a non-Medicaid category.When you see this aid category, it ALWAYS requires a Prior Authorization from CMS.
35Aid 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.Developmental Disability ServicesIf you get an eligibility back with a recipient ID beginning with 8888, you can not bill for those services unless your Provider ID number ends in an 86.
36Aid Category *6 Medically Needy Exceptional These recipients are eligible for the full range of Medicaid services except:Nursing FacilityPersonal Care
37Aid 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.Spend Down we’ve talked about. (medically eligible but financially not eligible)Exception to this is an 07 BCC. They get full benefits.07 BCC recipient has been diagnosed with Breast Cancer. They get chemo or treated for a sore throat.
38Aid 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.This category requires a TB diagnosis in order to bill for it.
39Aid 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.
40Aid Category 61Pregnant 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.The last three digits determine the services this recipient is eligible for receiving.This could apply to Physician’s and Therapists. A 16 year old comes in for services and aid category 61 comes back with a Recipient ID ending in 135.She is not eligible for therapy, or a yearly physical. The service has to be related to pregnancy.Be sure and check eligibility before you see the patient and on the day of the visit. (DOS) date of serviceWhen they present a Medicaid ID card, that is not proof that they are eligible for services that day.
41Aid Category 62 Pregnant Woman Presumptive Eligibility (PW-PE) This is a temporary aid category that pays ambulatory, prenatal care services only. Delivery and hospitalization is not covered in this category.Ambulatory means capable of walking.Delivery and hospitalization is NOT COVERED.
42Aid 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.When billing, you have to include a family planning diagnosis code PLUS a family planning procedure code.
43Aid Categories 58, 78, 88Specified Low Income Medicare Beneficiary (SLIMB, SMB)Recipients are not eligible for any Medicaid services.Medicaid pays only their Medicare premium.This is the last Aid category.All Medicaid pays for is the Medicare premium.
45Verify eligibility 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.Read top and emphasize daily nature of eligibility and spanning the dates again.
46Verify 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 EINFORMATION SOURCE: ARKANSAS MEDICAIDSOURCE PRIMARY ID:P R O V I D E R I N F O R M A T I O NPROVIDER LAST NAME: DRLASTPROVIDER FIRST NAME: DRFIRSTPROVIDER NUMBER: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 fromPay-To provider namePay-To provider number
47Verify eligibility 271 Request Response File cont. R E C I P I E N T I N F O R M A T I O NELIGIBILITYAUTHORIZATION #:TRACE #:RECIPIENT LAST NAME: DUGGERRECIPIENT FIRST NAME: JEFFERYRECIPIENT ID:RECIPIENT DOB: 01/01/2000E 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 numberTrace numberRecipient name as it appears with AR MedicaidEDS authorization number is the number the claims processing system maintains when a provider checks eligibility.Recipient ID is the ID entered by the provider.Keyed ID numberDOB listed with Medicaid
48Verify eligibility 271 Request Response File cont. Shows coverage E L I G I B I L I T Y I N F O R M A T I O NELIGIBILITY/BENEFIT: 1 ACTIVE COVERAGEPLAN DESCRIPTION: 01ARKIDS 1STELIGIBILITY PERIOD: 01/01/ /01/2004COUNTY: WHITEELIGIBILITY/BENEFIT: R TPLINSURANCE TYPE: C1 COMMERCIALTPL MEMBER #:TPL POLICY #:TPL GROUP #:PLAN NAME: ACME INSURANCEELIGIBILITY PERIOD: 01/01/2000 – 07/01/2004COVERAGE 1: FULL COVERAGELAST/ORG NAME: ACME INSURANCECOMPANY CODE: ABCADDRESS LINE 1: P.O. BOX 1000CITY: LITTLE ROCKSTATE: ARZIP:(continued next)Aid categoryDates of eligibilityCounty of residenceTPL informationType of TPLMember numberPolicy numberGroup numberPlan nameDates of coverageType of coverageName of insurerCompany codeAddress
49Verify eligibility 271 Request Response File cont. PCP information (continued previous)E L I G I B I L I T Y I N F O R M A T I O NELIGIBILITY/BENEFIT: L PRIMARY CARE PROVIDERDATE TIME PERIOD: /01/2004 – 07/01/2004LAST/ORG NAME: PCPLASTFIRST NAME: PCPFIRSTNAME SUFFIX: MDTELEPHONE:ELIGIBILITY/BENEFIT: D BENEFIT DESCRIPTIONSERVICE TYPE: AL VISION (OPTOMETRY)DATE TIME PERIOD: /20/1998SERVICE TYPE: AM FRAMESPCP informationPCP effective datesPCP’s name and phone number returned if applicableNOTE: Only benefits used will appear on eligibility in PES
50Verify eligibility New in PES 2.04 and online Up to four recipient eligibility segments with matching recipient IDsEPSDT screening informationMedicare A and B effective datesYou must go and view the supplemental eligibility response through Communication -> View Supplemental Eligibility Response. This is available only through batch submissions on PES.
51Verify eligibility Supplemental Batch Response SUPPLEMENTAL ELIGIBILITY BATCH RESPONSERECIPIENT ID:PLAN CODE: 01PLAN DESCRIPTION 1: ARKIDS 1STELIGIBILITY BEGIN DATE: 1/01/2004ELIGIBILITY END DATE: 7/01/2004COUNTY CODE: 731COUNTY: WHITETPL SEGMENT COUNT 1TPL COMPANY CODE D02TPL SUBSCRIBER NAME JEFF DUGGERRecipient ID for this eligibility segment…up to 4 segments returnedPlan code and descriptionDates of eligibility in this aid categoryNumber of TPL segmentsTPL carrier codeName of policy holder
56Verify claim status 277 Response file header CENTRAL ARKANSAS DOCTORS OFFICEWho information is coming fromSubmitter info and submitter IDPay-To provider name and number
57Verify claim status 277 Accepted response detail DUGGERJEFFERYJEFFERY DUGGERRecipient information from the claimGood News!Assigned claim number (watch for this number on your next week’s remittance)
58Verify claim status 277 Rejected response detail DUGGERJEFFERYJEFFERY DUGGERRecipient information from the claimRejection notificationNo claim number assigned. View the rejected response report for a more detailed explanation
59Verify claim status Rejected response report DUGGER 0001Rejected claim informationTotal errors identified on claimError(s) location and description
60Submitting claims Other options Third party software vendor ClearinghousePaper
62Procedure Code/Modifier Billing tipsCodes for speech therapyProcedure Code/ModifierAvailable unitsDescriptionPOS925064Evaluation for speech therapy11, 12, 52, 56, 9992507Individual speech therapy92508Group speech therapy92507 (52)Individual speech therapy by an assistant92508 (52)Group speech therapy by an assistant
63Procedure Code/Modifier Billing tipsCodes for speech therapyProcedure Code/ModifierAvailable unitsDescriptionPOS926074Initial evaluation for an augmentative/communication device11, 12, 52, 56, 99926082Additional evaluation time
64Procedure Code/Modifier Billing tipsCodes for occupational therapyProcedure Code/ModifierAvailable unitsDescriptionPOS970034Evaluation for occupational therapy11, 12, 52, 56, 9997530Individual occupational therapy97150 (U2)Group occupational therapy91530 (52)Individual occupational therapy by an assistant97150 (52)(U1)Group occupational therapy by an assistant
65Procedure Code/Modifier Billing tipsCodes for physical therapyProcedure Code/ModifierAvailable unitsDescriptionPOS970014Evaluation for physical therapy11, 12, 52, 56, 9997110Individual physical therapy97150Group physical therapy97110 (52)Individual physical therapy by an assistant(52)Group physical therapy by an assistant
66A B Billing tips Therapy service codes 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.BUse therapy service code “B” for individuals from birth through 5 years receiving services under an Individualized Plan through the Division of Developmental Disability Services.
67C D Billing tips Therapy service codes 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.DUse therapy service code “D” for individuals from 5 through 20 years receiving services under an IEP through a school district.
68E F G Billing tips Therapy service codes Use therapy service code “E” for individuals 18 years and older receiving services through the Division of Developmental Disabilities Services.FUse 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* These services codes are not counted toward school district matching fundsUse 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).
72Top denials Common errors EOB 041 and 152 Method of correction Procedure code, revenue code, TOS/ modifier is invalid.Method of correctionVerify the procedure code, TOS, and/or modifier in section II of the corresponding provider manual and resubmit the claim.
73Top denials Common errors EOB 254 or 267 Method of correction Recipient is totally or partially ineligible for dates of service.Method of correctionVerify the recipient is eligible for all claim dates of service. Resubmit the claim/portion of the claim for the time of eligibility.
74Top denials Common errors EOB 952 Method of correction Service requires Primary Care Physician referral.Method of correctionResubmit the claim with the corrected PCP information required for adjudication.
75Top denials Common errors EOB 469, 470 Method of correction Duplicate billing. Claim is identical to another claim for DOS, performing provider, procedure, TOS, and price.Method of correctionVerify that the service is not a duplicate bill. Resubmit the corrected claim.
76Top denials Common errors EOB 103 Method of correction Claim does not meet the timely filing requirements for Medicaid.Method of correctionClaims must be received by EDS within 365 days from the “To” DOS. Claims received beyond this deadline will not be paid.
77Top denials Common errors EOB 199 Method of correction ARKids 1st B recipient is older than 18 years old.Method of correctionARKids 1st B recipient’s eligibility ends on their 19th birthday. The “from” DOS can not exceed the 19th birthday.
78Billing 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.
79Follow-upWe have already discussed using the software and how to fill out claims, using modifiers.Suggestions for “after billing” with PES, Vendor/Clearinghouse, Paper
80Tips Remittance and Status Report Check your remittance and status report each week for:Paid claimsPending claimsDenied claims
81Billing flow PES submissions Successful report Batch response Accepted RejectedICNRejectedresponse reportRACorrect and resubmitPaidPendingDeniedFollow-up RADo not resubmitCorrect and resubmit
82Billing flow Vendor/clearinghouse submissions Report Clearinghouse (to EDS)Vendor(to EDS)AcceptedRejectedRejectedICNResponse reportCorrect and resubmitRACorrect and resubmitPaidPendingDeniedFollow-up RADo not resubmitCorrect and resubmit
83Completed claim forms only. Billing flowPaper submissionsMail claimScanning/ICNCompleted claim forms only.Incomplete forms returned to provider.Claim processedICNRAPaidProcessDeniedDo not resubmitCorrect and resubmit
84Tips Six ways to check claim status Verify claims on the remittance advicePES softwareWeb siteVoice responseClaim inquiry formProvider Assistance Center orFIVE ways not to be on hold when checking claim status!
85Tips 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.
87Provider reference Benefits of e-media Easier distribution and maintenanceMore viewing options and free softwareMore effective searchingPrint pages or sections as needed, as many as needed (including many forms)Save files to your computerShare files over a network
88Web site www.medicaid.state.ar.us Give brief overview of site’s layout and navigation; then lead to provider information.
90Contacts 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 Friday8 a.m. to 5 p.m.Toll-free in Arkansas:Local or out of state:
91Contacts PAC phone menu 1 2 PAC: EDI: Other inquiries 1 3 2 12PAC:Billing, eligibility, claim statusEDI:Software, RAsOther inquiries132EDI/RA issues, PES, DDE, balancing, denialsProvider EnrollmentClaims,Prior Authorization, billing assistance, eligibility, adjustments
92Contacts Electronic Data Interchange 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.Toll-free in Arkansas:Local or out of state:
93Contacts 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 and entering their extension.See the Arkansas Medicaid Web site for your county’s representative.