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Mercy Maricopa Integrated Care Doing the right thing for the right reason.

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Presentation on theme: "Mercy Maricopa Integrated Care Doing the right thing for the right reason."— Presentation transcript:

1 Mercy Maricopa Integrated Care Doing the right thing for the right reason

2 Claims overview Submitting clean claims and encounters

3 Claim Submission Tips Provide complete member information: – Member ‘s Name – Member’s Date of Birth – Member’s ID Number – Member’s Address It’s always important to verify that the information provided by the member matches the member’s ID card. Watch for name variations and changes. It is also important to verify eligibility prior to services being rendered, unless an urgent/emergent situation. Problems with member information could cause an unnecessary delay or possible claim denial. 3

4 Claim Submission Tips Provide complete provider information (CMS 1500 (02-12) Form): – Rendering Provider ID – NPI – (Box 24J): o Providers who require an NPI number - (provide NPI number in the field next to NPI. o Providers who are atypical (do not require an NPI) – provide AHCCCS ID in the field next to NPI. – Federal Tax Identification Number (Box 25) – TIN (Check EIN). Only use SS if provider does not have a TIN. – Signature of Physician or Supplier Including Degrees or Credentials (Box 31) – signature of the rendering physician/ supplier. – Service Facility Location Information (Box 32) – address where services were rendered: o Box 32a – Servicing Provider NPI o Box 32b – AHCCCS ID – Billing Provider Information & Phone # - (Box 33) – provider “pay to” information. o Box 33a – Billing provider NPI o Box 33b – AHCCCS ID 4

5 Claim Submission Tips Attach Primary Carrier’s Explanation of Benefits – If another health plan or Medicare is the primary insurer and benefits have been provided or denied, submit a copy of the primary insurer’s Explanation of Benefits in compliance with Coordination of Benefits rules. Include All Diagnosis Codes: – Refer to ADHS DBHS Covered Services Guide under Billing for Services Section. ICD-9-CM diagnosis codes must be used when submitting claims/encounters (see the International Classification of Diseases – 9 th Revision – Clinical Modification Manual). – Be sure to bill ICD-9-CM diagnosis codes to the specificity required – i.e., 4 th or 5 th digit must be provided if required. – Effective 10/1/14, the industry will be moving to ICD-10. 5

6 Claim Submission Tips Each individual claim line (Box 24 in CMS 1500 (02/12) Form) must include: – Date of service – Place of service – Procedure code and modifier, if applicable (Services must be consistent with the Arizona Department of Health Services (ADHS)/Division of Behavioral Health Services (DBHS) Allowable Procedure Code Matrix – Appendix B.2). – Charge amount (include charge amount regardless of the contractual arrangement with MMIC or MMA). – If a CMS 1500 (02/12) form is more than 6 lines long, the total charge field must only be billed on the last page of the claim. – Units 6

7 Timely Filing Limitations New Claim Submissions Claims must be filed on a valid claim form within 180 days (6 months) from the date services were performed, unless there is a contractual exception. Exceptions to this are as follows: – Within 180 days from date of discharge for 24-hr. level of care (Level I); – Within 180 days of the last day of the month or the discharge date, whichever is earlier, when billing monthly for longer treatment episodes of care at a 24-hr. level facility; – Within 180 days of the claim settlement for third party claims. This date is based on the date of the other carrier’s EOB that must be attached to the claim you submit to Mercy Maricopa. 7

8 Timely Filing Limitations Claim Resubmissions Resubmissions must be filed within 365 days (1 year) from the date of provision of covered services or eligibility posting deadline, whichever is later. The only exception is if a claim is recouped, the provider is given an additional 60 days from the recoupment date to resubmit a claim. MMIC is Secondary Payer If other insurance is primary, you must submit the claim within 180 days to preserve your appeal rights. Submit the other insurance EOB along with the claim submission as soon as received from the primary insurance. If Mercy Maricopa does not receive a claim within the above timelines, the claim will be denied. 8

9 Claim Resubmission Tips Paper claim resubmissions: – Must write “Corrected Claim” or “Resubmission” across the top of the claim. – Mercy Maricopa has a Resubmission Form you may fill out and attach to your resubmission (available at under the forms section.www.MercyMaricopa.org – When billing a claim that has more than 6 service lines and requires additional CMS 1500 (02-12) forms, please include the total charge amount on the last page of the submission (this does not apply to electronic claims). 9

10 Claim Resubmission Tips Electronic Claim Resubmissions: – If billing a resubmission electronically, you must submit with: Professional claims - A status indicator of 7 in the submission form location and the Original Claim ID field will need to be filled out. Facilities – In the Bill Type field, the last number of the 3 digit code should be a 7. – If you need to submit attachments to your claims, please submit by paper, as we currently do not accept attachments. This is currently under testing and we will let you know when this is available. 10

11 Interpretive Services Billing When billing Interpretive Services, you must bill as follows: 11 HCPCS CodeModifierDescription T1013 Staff delivering services is also interpreting T1013Q6Separate but employed staff interpreting T1013CRExternal vendor used

12 Claim Address ClaimsMail ToElectronic Submission* Medical & Behavioral Health Mercy Maricopa Integrated Care and Mercy Maricopa Advantage Medical Claims P. O. Box Phoenix, AZ Through Electronic Clearinghouse DentalMercy Maricopa Integrated Care and Mercy Maricopa Advantage Dental Claims P. O. Box Phoenix, AZ Through Electronic Clearinghouse RefundsMercy Maricopa Integrated Care and Mercy Maricopa Advantage Attention: Finance Department P.O. Box Phoenix, AZ Not Applicable 12

13 Claim Submission Formats 13 ServiceClaim Form Type Medical and professional services Paper - CMS 1500 (02-12) Form Electronic – 837P Hospital inpatient, outpatient, skilled nursing and emergency room services Paper - CMS UB-04 Form Electronic – 837I General dental servicesPaper - ADA 2006 Claim Form Electronic – 837D Dental services that are considered medical services (oral surgery, anesthesiology) Paper - CMS 1500 (02-12) Form Electronic – 837P

14 Top Reasons for Claim Denials Missing or invalid CPT/HCPCS code Missing or invalid diagnosis code Missing or inaccurate place of service code Missing name and/or degree level of provider (when required) Missing or invalid NPI 14

15 Primary Contact Information For Claims: Mercy Maricopa Integrated CareMercy Maricopa Advantage Until 4/1/ contact Magellan at: (phone number to be updated) TTY/TDD 711 For Health Plan Assistance: CVS Caremark: Phone: Phone: Phone: Provider Relations: Website: Phone: Phone: Fax: Mercy Maricopa Provider 15

16 Electronic Tools Mercy Maricopa Integrated Care offers several electronic tools to help expedite payment to you: – Electronic Claim Submission (EDI) – Electronic Funds Transfer (EFT) – Electronic Remittance Advice (ERA) 16

17 Electronic Claims Submission (EDI) The benefits of electronic claims submissions include: – Accurate submission and immediate notification of submission errors (level 2 report) – Faster processing resulting in prompt payment In order to submit electronic claims you need the following: – Agreement with an electronic clearinghouse – Software in your office or facility to transmit electronic claims 17

18 EDI Vendors for Mercy Maricopa 18 Vendor Payer ID For Mercy Care (MCP) Claims* Payer ID for Mercy Maricopa Claims** Contact Information Southwestern Provider Services (SPSI) (Institutional) – MCPU (Professional) - MCP Emdeon , Option 1 for Sales Relay Health RELAY-ME ( ext. 2) SPSI offers a no cost solution – no transaction fees. Other EDI Vendors may apply set-up and licensing fees which the provider would be responsible for. *Payer ID used for physical health claims for GMHSA Members who are covered under the MCP Plan. **Payer ID used for both physical health and behavioral health claims for SMI members – Mercy Maricopa **Payer ID used for behavioral health claims for GMHSA members – Mercy Maricopa **Payer ID used for behavioral health claims for Non-Title XIX SMI – Mercy Maricopa

19 Electronic Funds Transfer (EFT) The benefits of electronic funds transfer include: – Automatic deposit of payment for covered services – Faster receipt of payment – No paper checks to deposit – Easier verification of payment In order to receive electronic funds transfer you need the following: – Submit your claims electronically (preferred) – Bank account number – A voided check or savings account deposit slip – A signed Electronic Funds Transfer (EFT) enrollment form available under the Provider Forms section of the Mercy Maricopa Integrated Care website, 19

20 Electronic Remittance Advice (ERA) The benefits of electronic remittance advice include: – Electronic file of processed claims from Mercy Care – Electronically post payments to your Practice Management system – Faster reconciliation of account receivables – Simplified reconciliation process – Received day after electronic funds transfer In order to receive electronic remittance advice you need the following: – Submit your claims electronically (preferred) – Receive electronic funds transfer (preferred) – Ability to accept HIPAA standard 835 electronic remit transactions – Ability to accept direct receipt of 835 transactions 20

21 ICD-10 Implementation Mercy Maricopa Integrated Care is on track to meet the ICD-10 implementation date of 10/1/14. – We will be working with high volume providers to test ICD-10 prior to the implementation date. Please make sure that you are in compliance with the ICD- 10 implementation date of 10/1/14 in order to avoid unnecessary delays or denials of your claims. ICD-10 Are you Ready?

22 CMS 1500 (02-12) Form Changes The National Uniform Claim Committee (NUCC) recently updated the CMS-1500 form to CMS 1500 (02-12) version. Please access the NUCC website for additional information regarding the form change, including detail on what changes were made. The NUCC website is at: Full instruction is provided on our website to fill out this form at: 22

23 Changes made to CMS 1500 Form Changes made include: Some field names have been changed to better reflect use. Some field names changed to Reserved for NUCC use, as field is not used via the 837P electronic submission. Diagnosis code fields: o Instead of 4 diagnosis codes, there are now 12 diagnosis codes that can be listed. o Accommodates ICD-10 change effective 10/1/14 to hold alpha characters and allow up to 7 characters. o The decimal points have been removed.

24 Transitioning to the Updated Form NUCC has approved the following transition timeline: – January 6, 2014: Payers begin receiving and processing paper claims submitted on the revised 1500 Claim Form (version 02/12). – January 6 through March 31, 2014: Dual use period during which payers continue to receive and process paper claims submitted on the old 1500 Claim Form (version 08/05). – April 1, 2014: Payers receive and process paper claims submitted only on the revised 1500 Claim Form (version 02/12). This timeline aligns with Medicare's transition timeline. 24

25 UB-04 Form No changes have been made to UB-04 form, as it was previously changed in 2004 to be ICD-10 compliant. Full instructions to fill out this form are located on our website under Provider Notices:

26 ADA 2006 Form No changes have been made to ADA 2006 form. Full instructions to fill out this form are located on our website under Provider Notices:

27 Mercy Maricopa Values Our Partnership with the Provider Community that serves our Members! 27

28 Thank you


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