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MDwise – CMS 1500(08-05) Quick Tips to avoid Claim denial A guide for claim adjudication October 2010 HP Annual Workshop APP0043 (09/10.

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Presentation on theme: "MDwise – CMS 1500(08-05) Quick Tips to avoid Claim denial A guide for claim adjudication October 2010 HP Annual Workshop APP0043 (09/10."— Presentation transcript:

1 MDwise – CMS 1500(08-05) Quick Tips to avoid Claim denial A guide for claim adjudication October 2010 HP Annual Workshop APP0043 (09/10

2 2 Purpose for today’s presentation 1.Claim adjudication for Managed Care Medicaid- MDwise 2.Top claims denials and rejected submissions 3.You received a denial… now what ? 4.How to file a claim dispute and appeal 5.Quick tips for claims adjudication (including prior authorization)

3 3 Who is MDwise?  MDwise is a local, not-for-profit company serving Hoosier Healthwise, Care Select and Healthy Indiana Plan (HIP) members. We have been giving the best possible health care to our neighbors since In fact, we only take care of families living in Indiana. Our services are provided to more than 280,000 members in partnership with over 1,400 primary medical providers.

4 4 General claims processing overview for MDwise In the MDwise plan, claims processing is delegated to the MDwise delivery systems.  Example: If a provider renders service for a MDwise Wishard member, the provider would submit their claim to MDwise Wishard. If the same provider rendered services to a Methodist member, the provider would submit claim to MDwise Methodist.  If uncertain of the members delivery system, the provider may access this information on HP’s Web interChange at

5 5 Claims Filing Limit  In-Network Providers have a filing limit that ranges from 90 to 180 days, depending on their contract with the Delivery System.  Claims filing limit for 2011 will change to 90 days for all MCEs.  Out-of-Network Providers have 365 days from the date of service to file a claim.  It is the responsibility of ALL providers to check eligibility at the time of each visit.

6 6 MDwise Delivery Systems  Hoosier Alliance  Methodist  ProHealth  Select Health  St. Catherine  St. Francis  Saint Margaret Mercy  St. Vincent  Total Health  Wishard

7 7 General claims processing overview for MDwise  …when a members RID number is entered, along with the NPI, you will see:  The IHCP program the member is enrolled in.  The plan (MCE)  MDwise, what delivery system they are assigned to. Assigned PMP

8 8 Eligibility Screen

9 9 General claims processing overview for MDwise  Contractually, all in-network providers are required to submit claims within 180 days of date of service, unless the claims involves third party liability.  Providers are encourage to submit claims electronically for faster claim adjudication.  Note: MDwise behavioral health providers are required to submit claims within 90 days of date of service.

10 10 MDwise overview- Enrollment screen snapshot

11 11 Hoosier Healthwise Third Party Liability  MDwise is always the payer of last resort (Medicaid)  MDwise contracts with Health Management Solutions (HMS) to work with coordination of benefit issues.  MDwise does not have a 90 day rule, providers should work with delivery system on a case by case basis.

12 12 General claims overview  Out of network providers Send paper or electronic claims to the appropriate MDwise delivery system.  Submit claims within 365 days of date of service

13 13 Top Claims denials for MDwise

14 14 Top claims denials  Duplicate claim  Claim/Service lacks information which is needed for adjudication  Coverage not in effect at the time the service was provided  Payment denied/reduced for absence of, or exceeded, precertification/authorization  Non-covered charges  The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service  Past the timely filing limit  Payment adjusted due to member having primary insurance payer/coordination of benefits  Charges exceed fee schedule or maximum allowable amount  Diagnosis code is non-covered or invalid

15 15 Sample electronic claim submission

16 16 EDI format- 837 Professional  ST*837*987654~  BHT*0019*00*X2FF1* *1230*CH~  REF*87*004010X098A1~  NM1*41*2*ANDERSON MEDICAL GROUP*****46*P123~  PER*IC*ALICE WILSON*TE* ~  NM1*40*2*IHCP*****46*IHCP~  HL*1**20*1~  NM1*85*2*ANDERSON MEDICAL GROUP*****XX* ~  N3*4000 E MELROSE STREET~  N4*INDIANAPOLIS*IN*46204~  REF*24* ~

17 17 EDI Format cont  CLM*755555M*126***11::1*Y*A*Y*Y*C*AA:::IN~  DTP*484*D8* ~  DTP*435*D8* ~  DTP*439*D8* ~  DTP*096*D8* ~  PWK*AS*BM***AC*86576~  AMT*F5*35~  REF*9F*12~  REF*EA*D234345~  HI*BK:V723*BF:4660~  NM1*DN*1*WILSON*JOEL****34* ~  PRV*RF*ZZ*363LP0200X~  REF*1D* D~  LX*1~  SV1*HC:99396*110*UN*1***1:2*1~  DTP*472*RD8* ~  REF*6R*24210~  NM1*82*2*ANDERSON*MARTIN****XX* ~  PRV*PE*ZZ*207RI0001X~  LX*2~  SV1*HC:99000*16*UN*1**1:2*1~

18 18 Top rejected claims  Rejected claims are different than denied claims, which are registered in the claims processing system but do not meet requirements for payment under MDwise guideline. Example of rejected claims: DX code not present Valid authorization number Current ICD-9* If there is a 4 th or 5 th digit, the more general digit code may not be used Date of Illness or last menstrual period Federal Tax ID Provider NPI RID number All claims must be legible

19 19 Hoosier Healthwise Pre-Claims Submission/Check List (CMS 1500)  It is necessary to confirm all of the items on the check list prior  to rendering services and submitting a claim.  Is the member eligible for services today?  What IHCP Plan is the member enrolled in ? ( Hoosier Healthwise [ Anthem, MDwise, MHS ], Care Select, Traditional, Presumptive Eligibility) *  Is the member enrolled in the Healthy Indiana Plan?  Who is their Primary Medical Provider (PMP)?  Does the member have primary health insurance other than Medicaid or HIP?

20 20 So your claim has denied… now what?

21 21 So your claim has denied… now what?  Claims Inquiry  In and out of network providers need to contact the MDwise Delivery System to inquire about a claims denial.  MDwise Delivery Systems are required to respond within 30 calendar days of inquiry to the provider with the decision of the inquiry.  Appeals/Dispute-Must be in writing & include the following  * Providers have 60 calendar days to file an appeal and must include the following documentation:  Appeal form, remittance advice and a copy of the claim  If a delivery system fails to make a determination or the Provider disagrees with the determination, the provider should forward their appeal to: MDwise Corporate at P. O. Box Indianapolis, IN Attention: Grievance Coordinator

22 22 Electronic rejections  Rejected claims are returned to the provider or electronic data interchange (EDI) source without registering in the claim processing system.  Since rejected claims are not registered in the claims processing system, the provider must resubmit the corrected claim within the claims timely filing limit.

23 23 Quick tips for claims for adjudication  Quick tips to avoid denied claims  CMS 1500 (08-05)  Audience participation

24 24 Quick Tips – audience participation 1.Example : MDwise St. Vincent patient is referred to a specialist for outpatient surgery (hysterectomy). Surgery was rendered at Methodist Hospital. Provider submits outpatient claim for $3, and receives denial.  What are the missing elements that caused the claim to deny? (Hint: 2 necessary elements)  Team captains will have 60 seconds to enter data element (s) on sample CMS form) 21-24

25 25 Example 1

26 26 Example 1 answer

27 27 Quick tip CMS Example 2:  Outpatient setting (community mental health center)  Patient presents for manic depression and medicine therapy before meds are filled.  Patients sees therapist and psychiatrist on the same day.  ( How is this claim submitted for claims adjudication) Hint: member has already had 22 visits with a contracted provider.  ( team captains will have 60 seconds to enter data elements on sample CMS form) 21-24

28 28 Example 2

29 29 Example 2 answer

30 30 Quick tips CMS Example 3.  Patient presents for a sick visit for low back pain and after chart review is found to need an annual exam and immunizations  How is this claim submitted for adjudication  Team captains will have 60 seconds to enter data elements on sample CMS form) 21-24

31 31 Quick tip CMS Example 3

32 32 Example 3 Answer

33 33 Example 4  Patient is Package B and presents for family planning services ( post delivery).  How is this claim submitted for adjudication?  team captains will have 60 seconds to enter data elements on sample CMS form) 21-24

34 34 Example 4

35 35 Example 4 Answer

36 36 Example 5.  Dr. Good submits claim to MDwise Hoosier Alliance for primary care services rendered to patient “I don’t feel so good” and submits charges from his group A location. Group A location receives a denial. Why did the claim deny?

37 37 Quick Tip Denial… Example 5

38 38 Quick Tip Denial…  Example 5 claims form completion answer hint* All of the coding elements on the claim are correct.  Why did the claim deny?

39 39  Example 6  NCCI edit  Patient is sent to the lab for DX XXXXX. Labs submits claim two details same procedure codes. Second detail denied as dup. Why did this detail deny?

40 40 Example 6

41 41 Example 6 answer

42 42 Tie Breaker  Name all 10 MDwise Delivery systems

43 43 Tie Breaker answer  Hoosier Alliance  Methodist  ProHealth  Select Health  St. Catherine  St. Francis  Saint Margaret Mercy  St. Vincent  Total Health  Wishard

44 44 Quick Tips to avoid claims denial or rejections  Submit claims and corrected claims timely.  Inquire or dispute claims within contractual time line.  Check with medical mangement or online for services that require PA.  Follow correct coding guidelines for claims submission.  Check member eligibility at the time of service.  Verify payer id information before claims are submitted electronically.  Providers must report NPI to IHCP.

45 45 Quick tips tools for claims submission  Inside of folders: Prior authorization forms Quick contact sheets Provider Tool Kit Program information CMS link CDC link Well Child First Poster

46 46 Thank you from the staff at MDwise and our Delivery Systems


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