Presentation on theme: "MSMA Insurance Conference"— Presentation transcript:
1 MSMA Insurance Conference MO HealthNet Billing & UpdatesGina Overmann and Kim MorganProvider Education RepresentativesMO HealthNet Division
2 Our MissionThe 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 SoonMO HealthNet is in the process of implementing a policy on Early Elective DeliveryNon-medically indicated deliveries prior to 39 weeks gestation will not be considered for payment by MO HealthNetWhy? To Improve outcomes for both mother and childMissouri is not the first - other states and commercial insurance companies already have this type of policy in placeApproximately 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 FORMEffective 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 CHILDRENProvider-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 claimBill claim as soon as possible with the diagnosis participant was being seen for on that date of serviceDouble check that all pre-certs (if needed) are obtained before services are providedIf 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/Clinicshandout
11 Hot Tip – cont’d QMB-eligible Participant Hospital Inpatient claims – UB-04 Part C Institutional CrossoverHospital Outpatient claims – Medicare UB-04 Part C Professional CrossoverPhysicians & Clinics claims – Medicare CMS Part C Professional Crossoverhandout
30 Spend Down Note: “Monetary Amount” = Spend Down amount due each month
31 Timely Filing12 months from date of service for first claim submission.24 months from the date of service to correct and re-fileMedicare 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 UnitMO HealthNet DivisionPO Box 6500Jefferson City, MO 65102Telephone: 573/
33 MMAC Contact InformationMissouri Medicaid Audit and CompliancePO Box 6500Jefferson City, MOTelephone: 573/Provider Enrollment can only be reached through at:
34 ICD-10Federal 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-10Training for coders (anatomy & physiology)Additional time for the coders to codeMake sure your billing company has started the process for ICD -10Look 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’sProvider ResourcesPlanning Checklist
37 Top 10 Diagnosis Codes for Physicians & Clinics V20.2 Routine Child Health Exam585.6 End Stage Renal Disease724.2 LumbagoDiabetes Mellitus w/o mention of complication, type II or unspecifiedRecurring Depression Psych-SevereV22.0 Supervision Normal 1st PregnancyV22.1 Supervision Other Normal Pregnancy311 Depressive Disorder NEC496 Chronic Airway Obstruction NEC401.9 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 planIf the provider is not enrolled with the plan - the provider cannot bill the plan, MO HealthNet, or the participantAttempt to obtain a referral from the participant’s Primary Care Provider (PCP) or the planEmergency services exceptionPrivate 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 fileThe provider needs a valid PI-118 form from the lock-in provider on fileIf this was an emergency, file the claim with a CMN clearly documenting nature of the emergency service provided along with ER reportWatch the dates on PI-118 formAlso 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 N59The eligibility file shows patient has MedicareProvider must file the claim to Medicare firstWait 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 paymentsYou 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-V25.9If 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 diagnosisThe surgical code billed included post op care and the MO HealthNet reimbursement was $75 or more for the serviceThe denied claim must be resubmitted on paper with notes
44 #6 One T1015 Per Day CO 16 CO B N20A 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.