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MSMA Insurance Conference

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1 MSMA Insurance Conference
MO HealthNet Billing & Updates Gina Overmann and Kim Morgan Provider Education Representatives MO HealthNet Division

2 Our Mission The purpose of the MO HealthNet Division is to purchase and monitor health care services for low income and vulnerable citizens of the State of Missouri. The agency assures quality health care through development of service delivery systems, standards setting and enforcement, and education of providers and participants. We are fiscally accountable for maximum and appropriate utilization of resources.

3 Missouri Medicaid: 868,226 Enrolled 438,250 in Managed Care Plans as of December 31, 2013 Continued
Data compiled from

4 Something Coming Soon MO HealthNet is in the process of implementing a policy on Early Elective Delivery Non-medically indicated deliveries prior to 39 weeks gestation will not be considered for payment by MO HealthNet Why? To Improve outcomes for both mother and child Missouri is not the first - other states and commercial insurance companies already have this type of policy in place Approximately 26% of the 2010 MO HealthNet deliveries were Early Elective Deliveries

5 MO HealthNet News Bulletin dated January 15, 2014
CMS-1500 (02-12) HEALTH INSURANCE CLAIM FORM Effective April 1, 2014: The CMS-1500 form (08-05) version is discontinued; only the revised CMS-1500 form (02-12) version is to be used. All rebilling of claims must use the revised CMS-1500 form (02- 12) version from April 1, 2014 and forward, even though earlier submissions may have been submitted on the prior CMS form (08-05) version. Billing instructions available in the bulletin. Contact NUCC at to obtain copies of the new form.

6 MO HealthNet News Bulletin dated February 3, 2014
PHYSICIAN BULLETIN – VACCINES FOR CHILDREN Provider-Based RHC’s and FQHC’s may not bill separately for the administration of an injection. Costs for these services are to be included in the RHC or FQHC cost reports. DHSS now offering additional vaccine for providers enrolled in VFC program. See bulletin for procedure code and reimbursement information.

7 Provider Protection against Nonpayment
Eligibility verification is key to a paid claim Bill claim as soon as possible with the diagnosis participant was being seen for on that date of service Double check that all pre-certs (if needed) are obtained before services are provided If a participant has a limited benefit plan be sure that they understand that if it is not covered by MO HealthNet they are responsible for payment



10 Hot Tip – February 25, 2013 Choosing the Correct Claim Form
Medicare Part C does not cross over automatically and needs to be filed electronically through eMOMED QMB eligible vs. non-QMB Hospital Inpatient, Hospital Outpatient, Physicians/Clinics handout

11 Hot Tip – cont’d QMB-eligible Participant
Hospital Inpatient claims – UB-04 Part C Institutional Crossover Hospital Outpatient claims – Medicare UB-04 Part C Professional Crossover Physicians & Clinics claims – Medicare CMS Part C Professional Crossover handout

12 Hot Tip – cont’d Non-QMB eligible Participant
Hospital Inpatient claims – UB-04 Hospital Outpatient claims – UB-04 Physicians & Clinics claims – CMS-1500 handout







19 In Person Workshops Now scheduling workshop training for 2014
See provider participation webpage for instructions on how to register



22 Webinar Training 2014 2nd Quarter Schedule is posted
Now scheduling webinar training for April – June See provider participation webpage for instructions on how to register

23 Audio-Visual Training
PowerPoint slide presentations for various programs and issues May use as refresher, quick reference, new staff training, etc. Print off or refer to as needed

24 Puzzled by the Terminology?

25 MO HealthNet Benefit Matrix



28 Eligibility Request

29 Understanding Eligibility

30 Spend Down Note: “Monetary Amount” = Spend Down amount due each month

31 Timely Filing 12 months from date of service for first claim submission. 24 months from the date of service to correct and re-file Medicare crossovers - 12 months from date of service or six months from date of the Medicare provider’s notice of an allowed claim, whichever date is later

32 Third Party Timely Filing Regulation
The 12 month timely filing deadline may be extended if a third party payer recoups a payment from the provider after the 12 month period. If this happens, the provider can submit a claim with documentation from the third party payer showing the recoupment to the following address. Third Party Liability Unit MO HealthNet Division PO Box 6500 Jefferson City, MO 65102 Telephone: 573/

33 MMAC Contact Information Missouri Medicaid Audit and Compliance PO Box 6500 Jefferson City, MO Telephone: 573/ Provider Enrollment can only be reached through at:

34 ICD-10 Federal law recently passed delaying ICD-10 implementation by at least one year to no earlier than October 1, 2015. The extension is an added opportunity to further prepare for ICD-10 in Missouri.

35 Providers Plan of Action?
What does my business/practice need to succeed with ICD-10 Training for coders (anatomy & physiology) Additional time for the coders to code Make sure your billing company has started the process for ICD -10 Look at your codes that you are using now and compare to ICD-10 codes –several free online translation tools (be sure to use a source you know or if you have a billing company have them do a translation for you)

36 CMS Link Discussing ICD-10
FAQ’s Provider Resources Planning Checklist

37 Top 10 Diagnosis Codes for Physicians & Clinics
V20.2 Routine Child Health Exam 585.6 End Stage Renal Disease 724.2 Lumbago Diabetes Mellitus w/o mention of complication, type II or unspecified Recurring Depression Psych-Severe V22.0 Supervision Normal 1st Pregnancy V22.1 Supervision Other Normal Pregnancy 311 Depressive Disorder NEC 496 Chronic Airway Obstruction NEC 401.9 Hypertension NOS

38 Reasons for Medical Claim Denials
Each slide contains the denial title, the claim adjustment reason code(s) on the left side and the remittance advice remark code(s) on the right side. The codes are listed on the provider’s remittance advice.

39 #1 Participant is enrolled in a Managed Care Health Plan CO 24 N59
If the provider is enrolled with the referenced managed care plan, file the claim with the plan If the provider is not enrolled with the plan - the provider cannot bill the plan, MO HealthNet, or the participant Attempt to obtain a referral from the participant’s Primary Care Provider (PCP) or the plan Emergency services exception Private pay arrangement

40 #2 Lock-In Recipient CO 16 N59
The patient is locked-in to a provider and no valid PI-118 form is on file The provider needs a valid PI-118 form from the lock-in provider on file If this was an emergency, file the claim with a CMN clearly documenting nature of the emergency service provided along with ER report Watch the dates on PI-118 form Also watch for the correct NPI for the lock-in provider in the event the patient is locked into a medical clinic, FQHC, or RHC

41 #3 Medicare Suspect CO N59 The eligibility file shows patient has Medicare Provider must file the claim to Medicare first Wait 30 days from the date of the Medicare provider’s notice of an allowed claim before filing a crossover claim to MO HealthNet using to prevent possible duplicate payments You must use the patient’s name that is on the MO HealthNet file when filing on

42 # 4 Non-covered diagnosis for Women’s Health Benefits participant PR B5 N30
This claim is for a female participant who had medical eligibility code 80 or 89 on the date of service and the claim did not have a primary diagnosis of family planning, V25-V25.9 If the service is unrelated to family planning, the participant is financially responsible for the cost of the services

43 #5 Post Op Visits vs. Surgical Claim CO 125 M144
Claims for an evaluation and management visit, a preventive medicine visit, inpatient hospital visit/observation or a similar physician service deny because of a paid claim in the system for a surgical procedure performed within the previous 30 days for a similar diagnosis The surgical code billed included post op care and the MO HealthNet reimbursement was $75 or more for the service The denied claim must be resubmitted on paper with notes

44 #6 One T1015 Per Day CO 16 CO B N20 A duplicate to a paid claim that is currently being processed or is in the paid claim history file. There is duplicate information on the same claim.

45 #7 Exceeds Timely Filing Limit CO 29 N59
A claim initially must be filed within 12 months of the date of service. A Medicare crossover claim must be filed within 12 months of the date of service or 6 months of the date of the Medicare provider’s notice of an allowed claim, whichever date is later. The final deadline to correct and re-file for all claims is 24 months from the date of service.

46 #8 Exact/Suspect Duplicate Claim CO 18 N111
A duplicate to a paid claim that is currently being processed or is in the paid claim history file. There is duplicate information on the same claim.


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