Presentation on theme: "October 2010 HP Annual Workshop"— Presentation transcript:
1 October 2010 HP Annual Workshop MDwise – CMS 1500(08-05) Quick Tips to avoid Claim denial A guide for claim adjudicationOctober 2010HP Annual WorkshopAPP0043 (09/10
2 Purpose for today’s presentation Claim adjudication for Managed Care Medicaid- MDwiseTop claims denials and rejected submissionsYou received a denial… now what ?How to file a claim dispute and appealQuick tips for claims adjudication (including prior authorization)
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 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 Claims Filing LimitIn-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 MDwise Delivery Systems Hoosier AllianceMethodistProHealthSelect HealthSt. CatherineSt. FrancisSaint Margaret MercySt. VincentTotal HealthWishard
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
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.
11 Third Party LiabilityMDwise 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.Hoosier Healthwise
12 General claims overview Out of network providersSend paper or electronic claims to the appropriate MDwise delivery system.Submit claims within 365 days of date of service
14 Top claims denials Duplicate claim Claim/Service lacks information which is needed for adjudicationCoverage not in effect at the time the service was providedPayment denied/reduced for absence of, or exceeded, precertification/authorizationNon-covered chargesThe referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the servicePast the timely filing limitPayment adjusted due to member having primary insurance payer/coordination of benefitsCharges exceed fee schedule or maximum allowable amountDiagnosis code is non-covered or invalid
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 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 Top rejected claimsRejected 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 presentValid authorization numberCurrent ICD-9*If there is a 4th or 5th digit, the more general digit code may not be usedDate of Illness or last menstrual periodFederal Tax IDProvider NPIRID numberAll claims must be legible
19 Pre-Claims Submission/Check List (CMS 1500) It is necessary to confirm all of the items on the check list priorto 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?Hoosier Healthwise
21 So your claim has denied… now what? Claims InquiryIn 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 claimIf a delivery system fails to make a determination or the Provider disagrees with the determination, the provider should forward their appeal to:MDwise Corporate atP. O. BoxIndianapolis, INAttention: Grievance Coordinator
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 Quick tips for claims for adjudication Quick tips to avoid denied claimsCMS 1500 (08-05)Audience participation
24 Quick Tips – audience participation 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
27 Quick tip CMS 08-05 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
30 Quick tips CMS 08-05Example 3.Patient presents for a sick visit for low back pain and after chart review is found to need an annual exam and immunizationsHow is this claim submitted for adjudicationTeam captains will have 60 seconds to enter data elements on sample CMS form) 21-24
33 Example 4Patient 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
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?
43 Tie Breaker answer Hoosier Alliance Methodist ProHealth Select Health St. CatherineSt. FrancisSaint Margaret MercySt. VincentTotal HealthWishard
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 Quick tips tools for claims submission Inside of folders:Prior authorization formsQuick contact sheetsProvider Tool KitProgram informationCMS linkCDC linkWell Child First Poster
46 Thank you from the staff at MDwise and our Delivery Systems