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Welcome to Arkansas Medicaid

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Presentation on theme: "Welcome to Arkansas Medicaid"— Presentation transcript:

1 Welcome to Arkansas Medicaid
Education and support for therapy providers

2 Agenda Introductions Facilities Medicaid organization and requirements
Program overview Claims submission and billing tips Medicaid tools and support Discussion

3 Arkansas Medicaid Who does what? Division of Medical Services (DMS)
County offices EDS AFMC ConnectCare DMS – 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.

4 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.

5 DHS County Office County Case Workers Work directly with recipients.
Determine eligibility aid category and eligibility period. Assist with Primary Care Physician (PCP) assignments.

6 EDS Fiscal Agent Provider Enrollment Claims processing Remittance
Provider Assistance Medicaid Management Information System (MMIS)

7 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.

8 EDS Provider Enrollment Monday through Friday (8 a.m. - 5p.m.)
Toll-free in Arkansas: Local or out of state: Fax: Medicaid Provider Enrollment Unit EDS PO Box 8105 Little Rock,

9 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.

10 Number of claims (millions)
EDS Claim volume Number of claims (millions) State Fiscal Year EDI claims Total claims

11 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.

12 Month of State Fiscal Year 2004
EDS Claim adjudication Days Month of State Fiscal Year 2004

13 EDS EDI Support Center 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. Toll-free in Arkansas: Local or out of state:

14 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.

15 EDS Provider Relations Provider manuals and tools
Provider Assistance Center Help desk for software and vendors Workshops and presentations Individual provider training

16 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.

17 AFMC 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.

18 ConnectCare Managed Care helpline Enrolls recipients with PCP.
Educates recipients, county case workers, and providers about PCP requirements.

19 Contractual requirements for providers

20 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

21 Provider manual Section II essentials Scope of program
Prior authorization requirements Reimbursement Billing procedures

22 Provider manual Section III essentials
General – ECS, timely filing, forms Remittance and status reports Adjustments Other sources of payment (third-party payers)

23 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.

24 Recipient Primary responsibilities Select a PCP (most recipients).
Report changes in income or circumstances. Report TPL.

25 Medicaid program overview

26 Benefits Overview Arkansas Medicaid administers 42 programs. Here are just a few of the many benefits available to eligible recipients. Physician services Inpatient hospital Outpatient hospital Lab/x-ray Prescription Therapy (OT/PT/Speech) Mental health Emergency room Long term care Hospice Dentistry (under 21) Medical equipment

27 Benefits 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: Recipients with Medicare coverage Residents of an ICFMR Residents of LTC facilities Recipients on spend down aid categories Retroactively eligible recipients These recipients are not required to have a PCP to receive Medicaid services. Medicare as I said in an earlier example Residents of an Institutional Care Facility for the Mentally Retarded LTC Spend 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.

28 Benefit limits Therapy services Recipients under age 21:
Four evaluations per SFY Up to four 15-minute units per day Occupational, Physical, Speech Therapy Services Evals: 1 unit = 30 minutes Individual and group therapy Group Therapy: No more than 4 clients per group Evaluations for therapy services do not require prior authorization. See OT, PT, Speech manual –

29 Aid Categories

30 Aid 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 –

31 Aid Categories General classifications FR - Full benefits
MNLB – Medically needy, limited benefits AC - Additional cost sharing LB - Limited benefits

32 Aid Categories Limited benefits
These Medicaid recipients are limited to specific services according to their aid category.

33 Aid Category 01 ARKids First B Recipients may have limited services.
Recipients may have co-payment requirements.

34 Aid 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.

35 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. Developmental Disability Services If 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.

36 Aid Category *6 Medically Needy Exceptional
These recipients are eligible for the full range of Medicaid services except: Nursing Facility Personal Care

37 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. 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.

38 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. This category requires a TB diagnosis in order to bill for it.

39 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.

40 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. 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 service When they present a Medicaid ID card, that is not proof that they are eligible for services that day.

41 Aid 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.

42 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. When billing, you have to include a family planning diagnosis code PLUS a family planning procedure code.

43 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. This is the last Aid category. All Medicaid pays for is the Medicare premium.

44 Verify eligibility

45 Verify 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.

46 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: 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: 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

47 Verify 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 N ELIGIBILITY AUTHORIZATION #: TRACE #: RECIPIENT LAST NAME: DUGGER RECIPIENT FIRST NAME: JEFFERY RECIPIENT ID: 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 EDS 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 number DOB listed with Medicaid

48 Verify 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 N ELIGIBILITY/BENEFIT: 1 ACTIVE COVERAGE PLAN DESCRIPTION: 01ARKIDS 1ST ELIGIBILITY PERIOD: 01/01/ /01/2004 COUNTY: WHITE ELIGIBILITY/BENEFIT: R TPL INSURANCE TYPE: C1 COMMERCIAL TPL MEMBER #: TPL POLICY #: TPL GROUP #: 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: (continued next) Aid category Dates of eligibility County of residence TPL information Type of TPL Member number Policy number Group number Plan name Dates of coverage Type of coverage Name of insurer Company code Address

49 Verify 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 N ELIGIBILITY/BENEFIT: L PRIMARY CARE PROVIDER DATE TIME PERIOD: /01/2004 – 07/01/2004 LAST/ORG NAME: PCPLAST FIRST NAME: PCPFIRST NAME SUFFIX: MD TELEPHONE: ELIGIBILITY/BENEFIT: D BENEFIT DESCRIPTION SERVICE TYPE: AL VISION (OPTOMETRY) DATE TIME PERIOD: /20/1998 SERVICE TYPE: AM FRAMES PCP information PCP effective dates PCP’s name and phone number returned if applicable NOTE: Only benefits used will appear on eligibility in PES

50 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 You must go and view the supplemental eligibility response through Communication -> View Supplemental Eligibility Response. This is available only through batch submissions on PES.

51 Verify eligibility Supplemental Batch Response
SUPPLEMENTAL ELIGIBILITY BATCH RESPONSE RECIPIENT ID: 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 COUNT 1 TPL COMPANY CODE D02 TPL SUBSCRIBER NAME JEFF 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

52 Verify eligibility Supplemental Batch Response Last screening dates
(CONTINUED) SCREENINGS MEDICAL 2/01/2004 HEARING 2/01/2004 VISION 2/01/2004 DENTAL 2/01/2004 BUYIN PART A: 2/01/2004 PART B: 2/01/2004 Last screening dates Medicare effective dates

53 Submitting claims

54 Submitting claims EDS software

55 Submitting claims Online

56 Verify claim status 277 Response file header
CENTRAL ARKANSAS DOCTORS OFFICE Who information is coming from Submitter info and submitter ID Pay-To provider name and number

57 Verify claim status 277 Accepted response detail
DUGGER JEFFERY JEFFERY DUGGER Recipient information from the claim Good News! Assigned claim number (watch for this number on your next week’s remittance)

58 Verify claim status 277 Rejected response detail
DUGGER JEFFERY JEFFERY DUGGER Recipient information from the claim Rejection notification No claim number assigned. View the rejected response report for a more detailed explanation

59 Verify claim status Rejected response report
DUGGER 0001 Rejected claim information Total errors identified on claim Error(s) location and description

60 Submitting claims Other options Third party software vendor
Clearinghouse Paper

61 Billing tips Billing tips…

62 Procedure Code/Modifier
Billing tips Codes for speech therapy Procedure Code/Modifier Available units Description POS 92506 4 Evaluation for speech therapy 11, 12, 52, 56, 99 92507 Individual speech therapy 92508 Group speech therapy 92507 (52) Individual speech therapy by an assistant 92508 (52) Group speech therapy by an assistant

63 Procedure Code/Modifier
Billing tips Codes for speech therapy Procedure Code/Modifier Available units Description POS 92607 4 Initial evaluation for an augmentative/communication device 11, 12, 52, 56, 99 92608 2 Additional evaluation time

64 Procedure Code/Modifier
Billing tips Codes for occupational therapy Procedure Code/Modifier Available units Description POS 97003 4 Evaluation for occupational therapy 11, 12, 52, 56, 99 97530 Individual occupational therapy 97150 (U2) Group occupational therapy 91530 (52) Individual occupational therapy by an assistant 97150 (52)(U1) Group occupational therapy by an assistant

65 Procedure Code/Modifier
Billing tips Codes for physical therapy Procedure Code/Modifier Available units Description POS 97001 4 Evaluation for physical therapy 11, 12, 52, 56, 99 97110 Individual physical therapy 97150 Group physical therapy 97110 (52) Individual physical therapy by an assistant (52) Group physical therapy by an assistant

66 A 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. 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.

67 C 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. D Use therapy service code “D” for individuals from 5 through 20 years receiving services under an IEP through a school district.

68 E 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. 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 * These services codes are not counted toward school district matching funds 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).

69 Most common billing errors

70 We want to keep you from feeling like this…and needing these…

71

72 Top denials Common errors EOB 041 and 152 Method of correction
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.

73 Top denials Common errors EOB 254 or 267 Method of correction
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.

74 Top denials Common errors EOB 952 Method of correction
Service requires Primary Care Physician referral. Method of correction Resubmit the claim with the corrected PCP information required for adjudication.

75 Top 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 correction Verify that the service is not a duplicate bill. Resubmit the corrected claim.

76 Top denials Common errors EOB 103 Method of correction
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.

77 Top denials Common errors EOB 199 Method of correction
ARKids 1st B recipient is older than 18 years old. Method of correction ARKids 1st B recipient’s eligibility ends on their 19th birthday. The “from” DOS can not exceed the 19th birthday.

78 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.

79 Follow-up We have already discussed using the software and how to fill out claims, using modifiers. Suggestions for “after billing” with PES, Vendor/Clearinghouse, Paper

80 Tips Remittance and Status Report
Check your remittance and status report each week for: Paid claims Pending claims Denied claims

81 Billing flow PES submissions Successful report Batch response Accepted
Rejected ICN Rejected response report RA Correct and resubmit Paid Pending Denied Follow-up RA Do not resubmit Correct and resubmit

82 Billing flow Vendor/clearinghouse submissions Report Clearinghouse
(to EDS) Vendor (to EDS) Accepted Rejected Rejected ICN Response report Correct and resubmit RA Correct and resubmit Paid Pending Denied Follow-up RA Do not resubmit Correct and resubmit

83 Completed claim forms only.
Billing flow Paper submissions Mail claim Scanning/ICN Completed claim forms only. Incomplete forms returned to provider. Claim processed ICN RA Paid Process Denied Do not resubmit Correct and resubmit

84 Tips Six ways to check claim status
Verify claims on the remittance advice PES software Web site Voice response Claim inquiry form Provider Assistance Center or FIVE ways not to be on hold when checking claim status!

85 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.

86 Tools and support

87 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

88 Web site www.medicaid.state.ar.us
Give brief overview of site’s layout and navigation; then lead to provider information.

89 Provider Reference CD Demo

90 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: Local or out of state:

91 Contacts PAC phone menu 1 2 PAC: EDI: Other inquiries 1 3 2
1 2 PAC: Billing, eligibility, claim status EDI: Software, RAs Other inquiries 1 3 2 EDI/RA issues, PES, DDE, balancing, denials Provider Enrollment Claims, Prior Authorization, billing assistance, eligibility, adjustments

92 Contacts 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:

93 Contacts 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.

94 Discussion Thank you


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