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Presented by Mina Reynaga & Kristen Brice Provider Field Representatives Intro Introduction to NM Medicaid Medicaid.

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Presentation on theme: "Presented by Mina Reynaga & Kristen Brice Provider Field Representatives Intro Introduction to NM Medicaid Medicaid."— Presentation transcript:

1 Presented by Mina Reynaga & Kristen Brice Provider Field Representatives Intro Introduction to NM Medicaid Medicaid

2 Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL. For all contact, Claims, and Correspondence Addresses information go to the following link on the New Mexico Medicaid Web Portal: https://nmmedicaid.acs- https://nmmedicaid.acs- Email: Contact Xerox 2


4 Xerox Field Representative Provider Field Representative: Mina Reynaga (505) 246-9988 Ext. 8131233 Kristen Brice Ext. 8131216 E-mail: E-mail: Cc: 4

5 IMPORTANT! Electronic Funds Transfers (EFT) 5

6 All information will be verified and validated against the information ACS already has for the provider. While registering for EFT using the web portal, the Master Administrator will be asked to supply an e-mail address for receipt of notifications. This e-mail address will also provide a security purpose for EFT because a provider will be notified whenever a change is made to the banking information associated with EFT. 6

7 IMPORTANT! Electronic Funds Transfers (EFT) 7

8 Glossary of Terms

9 Visit the link below for a list of frequently used abbreviations. 9

10 History of Medicaid As he campaigned in 1964 Lyndon B. Johnson declared a “The War on Poverty.” He challenged Americans to build a “Great Society” that eliminated the troubles of the poor. Medicaid was created by the Social Security Amendment of 1965 which added Title XIX to the Social Security Act. 10

11 What is Medicaid? U.S. health coverage program for individuals and families with low incomes/resources. Medicaid is jointly funded by the federal and state governments and administered by the States. Largest funding source for health related services for low income people. 11

12 Medical Assistance Division Xerox FEE-FOR-SERVICE Molina\TPA OptumHealth SALUD! ISD It All Fits Together PROVIDER SCI DentaQuest CoLTS 12

13 New Mexico Medicaid Program

14 The Medical Assistance Division (MAD) of the Human Services Department (HSD) administers the Medicaid program for the State of New Mexico and establishes policies around benefits and claims processing. Medical Assistance Division (MAD) is comprised of the Director’s Office and several bureaus or units. To find out more about each office, bureau, or unit go to the following link 14

15 Medicaid Policy Manual Medicaid Policy Manuals are available for reference. Each manual contains basic Medicaid policy as well as specific provider type policy and billing instructions. Billing providers should become familiar with their manual and refer to it. 15

16 What Is HIPAA?:

17 HIPAA is?: The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. 17

18 HIPAA is?: The security and privacy of health data was also addressed. As the industry adopts these standards for the efficiency and effectiveness of the nation's health care system, the use of electronic data interchange will improve. NPI (National Provider Identifier) Electronic Billing (Payer Path, Clearing Houses) NM Medicaid Web Portal 18

19 New Mexico Medicaid Program Currently there are 23,102 New Mexico Medicaid providers and over 517,000+ New Mexicans are enrolled in the New Mexico Medicaid program. Eligibility: Who qualifies? Client eligibility is determined by the Income Support Division (ISD) of HSD or Social Security Office Eligibility is based upon family size, income, assets and other criteria (Often in association with the disability or age of an individual) Clients qualify for Medicaid under a specific category of eligibility (COE). The COE can also indicate a benefit package (full benefits, limited benefits, full benefits but may owe co-pays, etc.) 19

20 How to Apply for Medicaid Benefits In order to apply, clients must provide information about family, income, and assets to the ISD office in their local county, or if their eligibility is determined by the Social Security Department, the information is reported to the Social Security Department. 20

21 How to Apply for Medicaid Benefits Continued Once approved clients receive a blue plastic Medicaid ID card upon their eligibility being sent to Xerox. *The card itself is not proof of eligibility. Rather the card contains information that enables a provider to check on eligibility. In addition, a provider should always ask to see other recipient identification in order to assure that the patient is who he or she claims to be. Remember to verify that eligibility is current. Clients must inform their caseworker of any status changes. 21

22 NM Medicaid Blue Card 22

23 Ways to Check Eligibility On-Line Eligibility Inquiry—Web Portal Automatic Voice Response System (AVRS) (800) 820-6901 Xerox Eligibility Help Desk: (800)-705-4452 Monday - Thursday 8:00 a.m. - 5:00 p.m. Friday (Mountain Time) 8:00 a.m. - 4:00 p.m. 23

24 Medicaid Recipient COE examples 072: Medicaid full benefits 035: Pregnancy-related services only 029: Family Planning Benefits 074: Working Disabled Individuals 041: QMB - Age 65 and Over 044: QMB - Under 65 For a COE & description listing, go to: 24

25 New Mexico Human Services Department/Medical Assistance Division Medicaid Program Physical Health Program Managed Care Lovelace Presbyterian Molina Fee-for Service Utilization Review Third Party Assessor Contractor Molina Behavioral Health Program Statewide Entity for Behavioral Health – OptumHealth New Mexico Medicaid Program Structure CoLTS SALUD! Amerigroup UnitedHealthcare Community plan Blue SALUD! 25 DentaQuest Contracted by Molina Fiscal Agent Xerox

26 NM Medicaid Managed Care Organizations

27 SALUD! The managed care contracts provide for the delivery of medically necessary physical and behavioral health services to approximately 300,000 children and adults in New Mexico. 27

28 SALUD! Native Americans are not automatically enrolled in SALUD!, however, they can choose to be in SALUD!. Visit the link below for additional details regarding the Native American opt-in policy. Medicaid clients who are dual eligible (covered by Medicare and Medicaid) are enrolled in CoLTS and not SALUD!. 28

29 SALUD! Medicaid clients qualified under COE 029 – Family Planning Services Only are not in SALUD!. Medicaid clients in nursing homes or intermediate care facilities for the developmentally disabled are enrolled in CoLTS. 29

30 SALUD! Clients not excluded from SALUD! are enrolled in SALUD! about 4-6 weeks after they’ve qualified for Medicaid. During that 4 - 6 week interval, most recipients are in the Medicaid Fee-For-Service Program with claims processed by Xerox. The client receives a notice that they will be enrolled in SALUD! and have an opportunity to select their MCO. If they do not select a MCO by a certain date, they are automatically assigned to a MCO. The client has 90 days after assignment to change their SALUD!. 30

31 SALUD! Clients in SALUD! become members of a SALUD! Managed Care Organization (MCO) and receive their physical health care services from doctors, hospitals, pharmacies, and others who work with that MCO. Once enrolled in an MCO, the client is issued a member card by that MCO. This card is NOT their Medicaid eligibility card. It indicates they are a member of that MCO and has their MCO member ID on it. 31

32 SALUD! A newborn baby is enrolled in the same MCO as the mother, if the mother was enrolled in SALUD! on the baby’s date of birth. The baby’s birth must be reported to the ISD office for the enrollment to take place. 32

33 SALUD! Managed Care Organizations (MCO) Lovelace Healthcare: 800-808-7363 Molina Healthcare: 800-580-2811 Presbyterian Healthcare: 888-977-2333 Blue Cross Blue Shield of NM: 866-689-1523 33

34 Coordination of Long Term Services (CoLTS) CoLTS covers primary, acute, and long-term services in one coordinated and integrated program that incorporates Medicare and Medicaid services. Clients who are also eligible for Medicare and are in nursing facilities, or receive certain services such as Personal Care Option services in their home, are enrolled in a CoLTS MCO, not in Salud! CoLTS MCO: United Healthcare: 800-851-1878 Amerigroup: 800-600-4441 34

35 In all cases, providers must be enrolled in the MCO in order to be paid by the MCO. Providers must follow MCO requirements and submit claims to the MCO for clients who are enrolled in SALUD! or CoLTS on the date(s) of service (DOS). Xerox cannot pay physical health claims for clients enrolled in SALUD! or CoLTS on the claim’s DOS. Important Reminder 35

36 NM Medicaid Structure: Fee-for-Service (FFS)

37 Xerox is the Fiscal Agent for the New Mexico Medicaid Fee for Service program. 37

38 NM Medicaid Structure: Fee-for-Service (FFS) Clients who are not enrolled in SALUD! or CoLTS may obtain health care services from any provider who accepts Medicaid. This part of the Medicaid program is referred to as Medicaid “fee-for-service”. 38

39 NM Medicaid Structure: Fee-for-Service (FFS) Terms you may hear describing clients in the Medicaid fee-for- service program: “exempt” “Medicaid fee-for-service” “In regular Medicaid” “Medicaid traditional” 39

40 As the Fiscal Agent: Enrolls providers into the FFS Medicaid program. Processes health care claims for New Mexico’s Medicaid FFS program. Claims are processed according to the policies of the New Mexico Medicaid program. Issues payment to Medicaid providers. 40

41 As the Fiscal Agent Does Not: Make Medicaid Policy. Make exceptions to Medicaid Policy. 41

42 Full Medicaid Covered Services through Fee for Service (FFS) Medicaid. Inpatient Hospitalization Outpatient Hospital Services Physician Services Lab & Radiology Services Home Health Nursing Facilities Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services for Children Prescription Drugs Vision and Hearing Services Organ Transplants Behavioral Health Services Podiatrist Services Dental Services Physical, Occupational and Speech Therapies Rehabilitative Services ICF/MR Case Management Emergency Hospital Services Hospice Transportation Services Prosthetic Devices Personal Care 42 **Some procedure codes within these services may not be covered and some may require prior authorization**.

43 Insure New Mexico Programs

44 2012 Federal Poverty Level Guidelines Household size100%133%150%200%300%400% 1$11,170$14,856$16,755$22,340$33,510$44,680 2$15,130$20,123$22,695$30,260$45,390$60,520 3$19,090$25,390$28,635$38,180$57,270$76,360 4$23,050$30,657$34,575$46,100$69,150$92,200 5$27,010$35,923$40,515$54,020$81,030$108,040 6$30,970$41,190$46,455$61,940$92,910$123,880 7$34,930$46,457$52,395$69,860$104,790$139,720 8$38,890$51,724$58,335$77,780$116,670$155,560 for each additiaonal person add $3,960$5,267$5,940$7,920$11,880$15,840 Insure New Mexico! Health Care Coverage Guidelines 185%: New MexiKids, New Mexiteens, Family Planning & Pregnancy 200%: State Coverage Insurance (SCI) 235%: Children's Health Insurance Program (CHIP) 250%: Working Disabled Individuals Program (WDI) 44

45 Behavioral Health Services

46 Services provided by a Behavior Health Provider are administered by Optumhealth. Prescription drugs prescribed by a Behavioral Health Provider are also administered by OptumHealth. It is the provider type, not the service or the diagnosis that is used to determine if it is Behavioral Health Service. For clients enrolled in CoLTS, Medicare crossovers are paid by the CoLTS MCOs (Amerigroup, UnitedHealthcare). 46

47 Behavioral Health Services Behavioral Health Providers should access Optumhealth’s website for information. 47

48 NM Medicaid Utilization Review

49 Utilization Review (UR) Prior Authorization (PA) Some services in the Fee For Service program require prior authorization in order for the claim to be eligible for payment. The PA is issued based upon medical necessity, but does not guarantee the client’s Medicaid eligibility. (Eligibility must still be verified). 49

50 Utilization Review (UR) The UR contractor for New Mexico is Molina TPA (Third Party Assessor) All claims for Waiver and PCO providers require an authorization. Waiver providers – Contact the Case Manager to obtain or follow up on a Prior Authorization. PCO providers – Contact Molina TPA (Third Party Assessor). (505) 348-0311 ( in Albuquerque) (866) 916-3250 (Toll free) 50

51 Utilization Review (UR) How do you determine if/when a Prior Authorization (PA) is required? Call Molina. They can tell you if a PA is required and the procedures for getting a Prior Authorization. Molina TPA (Third Party Assessor) (505) 348-0311 ( in Albuquerque) (866) 916-3250 (Toll free) Also, consult the Medicaid program and policy manuals and billing manuals for prior authorization requirements. Authorizations for EMSA Emergency Medical Service for Aliens (review contact Molina TPA.). 51

52 Utilization Review (UR) cont… Out of State Providers - When submitting a claim on the CMS-1500 claim form for a New Mexico Medicaid client, please attach the Prior Authorization to the claim. If the claim is submitted with the Prior Authorization number located in form locator 23, the claim will deny. Reminder: all out of state providers require a prior authorization for services rendered to a New Mexico Medicaid client. Dental Providers need to submit requests for prior approval to: DentaQuest USA, LLC 12121 North Corporate Parkway Mequon, WI 53092 If you have questions or concerns, regarding your prior approval requests that have been submitted to DentaQuest for review, please contact DentaQuest Customer Service at: 1-800-417-7140 (toll free) 52

53 Medicaid Management Information System (MMIS)

54 Medicaid Management Information System (MMIS). Omnicaid is the name of New Mexico's MMIS. Xerox maintains Omnicaid to process claims and issue payments to Medicaid providers for their services to Medicaid clients. Some data that MMIS contains includes provider information, client information, claims history, and payment history. 54

55 NM Medicaid Web Portal

56 The Xerox New Mexico Medicaid Web Portal  Billing Instructions  Trainings  FAQ’s  HSD Link  RA Newsletter 56

57 Categories of Eligibility with Limited Benefits

58 029 - Family Planning Which services are covered? Medical Claims and Institutional Claims: The system examines the revenue code, procedure code, and any related diagnosis codes on the line. The service is covered by the Family Planning Medicaid (FPM) if a combination of the approved code sets are used to identify the service: Procedure Code and the diagnosis codes must be contraceptive management or screening and treatment for sexually transmitted diseases. Institutional Claims only: The revenue code and diagnosis are on the approved code lists. 58

59 029 - Family Planning Waiver Which services are NOT covered by this COE? Treatment of conditions not related to contraception, sterilization, or sexually transmitted diseases. Hysterectomies for the sole purpose of sterilization and pregnancy terminations are not covered. 59

60 0029 – Service not Family Planning Related Why does this denial occur when the service was actually for Family Planning? Procedure code, diagnosis code, or revenue code not recognized as family planning related. If rendered service is family planning related, resubmit claim using alternate codes. You can verify if a code is covered by contacting the Provider Relations Help Desk. Do not bill Medicaid client for services that can be billed using an alternate approved codes. If you are not able to locate a suitable alternative code for your service but feel the service should be paid under this benefit package, please contact the FPM Program Manager at MAD. 60

61 035 – Pregnancy Related (presumptive) Covered Services Presumptive: Presumptive Eligibility (PE) is short-term (60 days or less) Medicaid coverage for children up to age 19 or for pregnant women. Medical Claims and Institutional Claims: The system examines the revenue code, procedure code, and any related diagnosis codes on the line. The service is covered by Pregnancy Related Services Only (PRSO) if a combination of the code sets are used to identify the service: Procedure Code and the diagnosis code are relating to a pregnancy or complications of pregnancy. Note: Inpatient stay not covered under presumptive eligibility, the individual must first complete the eligibility process. 61

62 035 – Pregnancy Related (non- presumptive) Covered Services Medical Claims and Institutional Claims: The system examines the revenue code, procedure code, and any related diagnosis codes on the line. The service is covered by Pregnancy Related Services Only (PRSO) if a combination of the code sets are used to identify the service: Procedure Code and the diagnosis code are relating to a pregnancy or complications of pregnancy and conditions that may complicate the pregnancy. Institutional Claims only: The revenue code and diagnosis are relating to a pregnancy or complications of pregnancy and conditions that may complicate the pregnancy. 62

63 041, 044 – Qualified Medicare Beneficiary (QMB) MEDICAID covers the co-insurance and deductible on MEDICARE covered services only after MEDICARE has paid. If service is not covered by MEDICARE, MEDICAID WILL NOT PAY. 63

64 Categories of Eligibility with Co-pays 071 FM 1 – CHIP (Children’s Health Insurance Program) 074 – WDI (Working Disabled Individuals) Clients with these COEs may owe co-pays for some services; Native American Exempt (NAX) clients are excluded from all co- payments. Copayment Schedules are available on the Eligibility Inquiry on the Web Portal. 64

65 Other Categories of Eligibility

66 CMS (Children’s Medical Services) Children’s Medical Services is part of the Family Health Bureau in the Public Health Division of the Department of Health, and is federally funded through Title V and State General Funds to serve as a safety net for medical management, payment for medical services, diagnostic studies and service coordination for Children and Youth with Special Health Care Needs (CYSHCN). CMS is billed similar to regular Medicaid (FFS) with the following differences: Always use the 14 digit CMS client ID number that begins with 07 off of the MAD 309 form Always enter the PA number in box 23 of the CMS-1500 form (If the PA number is 8 digits, add 2 zeroes in front of it.) All claims for Children’s Medical Services (CMS) clients must have the CMS prior authorization number entered on the claim. 66

67 CMS (Children’s Medical Services) CMS claims can be submitted electronically. However, if the claims denies for eligibility, submit the claim on paper and attach the paper authorization issued by CMS, which is either the CMS 309 form, CMS Card letter or CMS Registration. If a CMS PA for a pharmacy service is not on file, the provider needs to first contact the Point of Sale Helpdesk and then fax the CMS PA to them: Point of Sale Helpdesk 800-365-4944 67

68 Prior Authorization

69 Prior Authorizations for Pharmacy Claims Point of Sale Helpdesk 800-365-4944 69

70 What do I do if I get a denial pertaining to a Prior Authorization? Access the Web Portal’s Prior Authorization inquiry. Verify the PA/Claim discrepancy the denial pertains to. Make claim corrections or follow up with your respective authorizing agency to have PA information changed/corrected. 70

71 Timely Filing

72 Timely Filing Limits 90 days from the date of service for all providers. Exceptions to the 90 day timely filing limit: Schools, the filing limits are 120 days for the initial filing period and 120 days for the grace period (rather than 90 days). IHS and Tribal 638 compact facilities, the filing limit is 2 years from the date of service with no additional grace period. 72

73 Timely Filing Limits For a claim which met the initial filing period, but was denied, partially denied, or requires an adjustment, there is an additional one-time 90 day grace period counted from the date of payment or denial, during which the claim can be re-filed or an adjustment submitted to Xerox. It is to the provider’s advantage to resubmit a claim, if necessary, within the initial 90 day filing period in order to have the greatest amount of time in which to re-file or submit an adjustment during the 90 day grace period if another re-filing or adjustment is necessary. 73

74 Timely Filing Limits The claim may be re-filed during the 90-day grace period as many times as necessary, but claims filed after the 90 day grace period will be denied. 74

75 Timely Filing Limits Exceptions to the filing limit: When other primary payers have denied or made payment on a claim, the filing limit of 90-days is counted from the date of payment or denial by the other party, but not to exceed 210 days from the date of service. A provider should file claims in sufficient time with other payers to allow submission in time to meet the Medicaid 210 day limit. When the recipient has retroactive eligibility, the initial filing limit is 120 days from the date the eligibility was added to the eligibility file and was therefore available to providers. 75

76 Timely Filing Denials Exceptions to the filing limit: When the provider was not originally enrolled as a MAD provider on the date of service, the filing limit of 90 days is counted from the date the provider was notified of their enrollment, but must not exceed 210 days from the date of service. A provider should submit a provider participation agreement in sufficient time to allow processing and still meet the Medicaid 210 day limit for submitting the claim. When a claim previously paid by a Medicaid managed care organization is recouped from a provider due to retroactive disenrollment of the client from the managed care organization, the filing limit of 90 days is counted from the date of the managed care organization’s notice or recoupment from the provider. 76

77 Timely Filing Denials Re-filing Claims and Submitting Adjustments When resubmitting a claim or requesting an adjustment on a claim that is past the 90 day filing limit but originally met the filing limit, the “TCN” number which appears on the remittance advice (RA) will be used by Xerox to evaluate the claim. The provider must supply that TCN number in order for Xerox to be able to evaluate the claim. 77

78 Timely Filing Denials Re-filing Claims and Submitting Adjustments CMS 1500 form: Put the TCN in block 22 on the paper form. Leave the “Code” blank, and put the TCN in the “Original Reference No.” field. UB Form: Put the TCN in Form Locator 64 “Document Control Number” (DCN) matching the appropriate payer line, using a paper form. Dental Claim Form: Enter the TCN number in Box 35 beginning on the left side. 78

79 Timely Filing Helpful Hints There are two filing limits to meet - the initial filing limit and the grace period limit. Continuing to re-file a claim does not continue to extend the filing limit. It is to the provider’s advantage to file or request an adjustment on the most recently filed claim that met the original filing limit. When requesting an adjustment on an adjusted claim, use the TCN of the final payment or denial, not the credit record which has a negative amount on the RA. The filing limit does not apply when the provider is returning an overpayment to the Medicaid program. When submitting a paper claim each claim needs a cover letter and any necessary attachments explaining what the claim. 79

80 Electronic Claim Submissions

81 Electronic Claim Submission All Fee For Service claims within 90 days from the initial date of service that do not require an attachment for payment must be submitted electronically. For any assistance regarding Electronic Claims Submissions, contact the HIPAA Helpdesk. or call 800-299-7304 81

82 Three Ways to Submit Claims Electronically PayerPath – Free HIPAA Compliant web-based claims entry system. The URL to the registration form for PayerPath submissions is: *Pay attention to the RA Newsletter, for upcoming updates to PayerPath. Through a Clearinghouse EDI Gateway The URL for additional information regarding EDI Gateway electronic submissions is: 0to%20ACS%20EDI.pdf 82

83 Claim Form Instructions

84 Where to get a copy of claim form instructions Click on Provider Information 84

85 Where to get a copy of claim form instructions Scroll down Open file 85

86 Claim Reference Tools

87 What is a Transaction Control Number (TCN)? The TCN is a unique number assigned to each and every claim.This number contains information about the claim and can be used to identify the claim when calling provider services. 87

88 The first digit indicates what the claim “media” is: 2 = electronic crossover 3 = other electronic claim 4 = system generated claim or adjustment 8 = paper claim The last two digits of the year the claim was received The numeric day of the year. This is the Julian Date - this represents the date the claim was received by ACS: this claim - the 323rd day of 2008, or November 18, 2008 Batch number The claim number within the batch. 30832300085000001 What is a Transaction Control Number (TCN)? 88 The twelfth digit in an adjustment/ void TCN will either be: 1= Debit 2= Credit

89 Claim follow up Check for claim status on the Web Portal. Claim specific search capability is available using the web portal to locate specific claims quickly. 89

90 Claim follow up Reading the Remittance Advice (RA) The Remittance Advice, also known as an Explanation of Benefits (EOB), is produced weekly. The RA lists Claims Xerox has processed for a particular provider, explaining which claims are pending, paid, or denied, and the reason for any denials. A financial summary is also included in the RA. 90


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