1. DEBRA A. SCHUCHERT DIRECTOR OF NETWORK OPERATIONS & COMPLIANCE CLAIMS BILLING & ADJUDICATION TRAINING 2014-2015

2. ICA’s Procedure Code List with Descriptions / Fee Schedule ICA’s Fee Schedule is located on the “G” drive & is identified as FEE SCREEN The Fee Screen identifies our procedural coding. When new regulations are instituted for coding, a committee meets to discuss all aspects of the code such as clinical description, # of units to be authorized, pricing etc. Upon approval of the procedure code, it is then entered in the ICA Fee Screen. The Fee Schedule identifies the following: Procedure Code Descriptions Revenue Code (In Patient Hospital Stay) Procedure Code Modifier COB Requirements Units Fee Screen/Schedule Rate Internal Modifier

3. Contracts The Direct Contracts, Limited Case Agreements, & Residential –Subcontracts through Wayne Center are identified on a List located on the “G” drive under the Claims Department. Direct Contracts The providers are listed as 1st Tier Subcontracts with DWMHA. Fair Employment Practice (F.E.P.) Certificates are required for these providers, with the exception of Network 180/ Kent County Community Mental Health Authority because this provider is outside of Wayne County jurisdiction.  Limited Case Agreements The provider is servicing one consumer or the services are for a limited time frame.  Residential Homes The provider is servicing the consumer/consumers in a residential home. We may have one or more consumers at each home.

4. Claims Billing & Adjudication The provider ‘s biller or Claim Adjudicator begins the billing /adjudication process once the consumer’s authorization is submitted by the Supports Coordinating Agency and approved by our Utilization Management staff. The authorization will appear under the consumer’s name and will allow the biller to chose the correct billing form. Once the form is selected the ICARE System populates certain sections of the billing form. The biller then begins to enter the following information: Date of Service Place of Service Procedure Code Charges Units Time of Service (when applicable to designated procedure codes) The provider ‘s biller or Claim Adjudicator then adjudicates the batch on their side and can identify immediately if there were any errors made upon their completion of the claim. The claim must be a “CLEAN” Claim when sending to ICA for adjudication. When the provider’s biller sends the claim for final adjudication with errors clearly identified by the edits in the ICARE System, the claim is returned to the provider with a detailed explanation of what the errors are. The provider’s biller must resubmit the claim again for re-adjudication. There are certain procedure codes that will duplicate, and will require an override to be completed in order to receive payment. (I.e. consumer must have a staff person with them while attending the Skill Building program). Also, if the provider’s biller submits a claim past the 60 day filing time period they must submit a Reconsideration form with a detailed explanation for approval by the CFO before the ICA Claim Adjudicator’s will adjudicate the claim and move it into the payment process.

5. Claims Policies & Procedures The following Claim policies and procedures are located on the “G” drive under Claims Department. The Claims policies are reviewed annually and updated accordingly. C-001New Paper Claims Submission into ICARE System C-002Claims Adjudication C-003Family & Friend Respite Billing& Payment Process (09-30-2008 policy discontinued) C-004 Medicaid Claims Verification Audit Review C-005Coordination of Benefits C-006Camp Stay Reimbursement C-007 Claims Override Process C-008Ability to Pay

6. Claims Meeting Minutes Minu tes The Claims Department meeting minutes are held on a monthly basis, and located on the “G” drive under the Claims Department.

7. DWMHA MCPN Medicaid/Other Individual Claims Verification Audit The verification audit is due to the Authority on a “quarterly” basis. 2% of Medicaid consumers & Non-Medicaid consumers are randomly sampled and a report is produced by the Chief of IT & Security. The Claim Adjudicators review the claims and answer the questionnaire that list questions concerning eligibility, services rendered, documentation substantiating the services rendered, appropriate CPT/HCPCS & revenue codes billed, third party fees collected, Ability to Pay determinations made, etc. DWMHA Audit is being submitted through MH-WIN.

8. Provider Performance Audits Annual on site audits are conducted on selected providers. The Claims Department coordinates efforts with the Quality Management Department when conducting the on-site audits. The Claim Adjudicators have a Performance Monitoring Audit Tool that is used for each provider. The documents are reviewed and the specific audit forms are completed. Each provider receives a detailed audit report explaining the findings. The Claim Adjudicator will also conduct “random” internal audits on providers when issues arise or on selected procedure codes. There are specific reports that are completed for these audits. The Internal Corporate Compliance Investigation Report Corporate Compliance Response to a Governmental Inquiry or Investigation

9. Timely Claims Submission When the provider submits a claim over 60 days from the date of service, an edit will appear on the adjudication screen alerting the Claim Adjudicator that a Reconsideration Review Form (60- Day Zero Pay Claims) is required. The form requires the provider to identify the reason for the delay in submitting the claims. A formal letter is to be attached and sent to the Chief Financial Officer for approval. Once approved the Claim Adjudicator will reconsider the claim in the ICARE System and move the claim into the payment process.