1. Presentation by EDS Provider Field Consultants Claim Adjustment Process

2. 2October 2009 Agenda Session Objectives Web interChange Replacement Feature Types of Adjustments When to Submit a Paper Adjustment Request Adjustment Forms Adjustment Filing Limitations Timely Processing Guidelines Where to Submit Adjustment Requests Helpful Tools Questions

3. Claim Adjustment Process 3October 2009 Session Objectives Following this session, providers will be able to: Demonstrate knowledge of the Web interChange Replacement functions Understand the different types of paid claim adjustments Determine when and how to file a paid claim adjustment Understand the impact of the filing limit on adjustments and replacements

4. Claim Adjustment Process 4October 2009 Types of Adjustments Check-related adjustments Noncheck-related adjustments Retroactive rate adjustments Mass adjustments Voids and Replacements Reprocessing (Region 80) Each managed care organization (MCO) may establish and communicate its own criteria for claim adjustments

5. Claim Adjustment Process 5October 2009 Check-related Adjustments Provider sends a check in the amount of the excess payment with the adjustment form and appropriate documentation if an over payment has been made Also referred to as a refund, can be for a partial payment or the entire payment on a claim First two digits of the internal control number (ICN) (region code) are 51

6. Claim Adjustment Process 6October 2009 Noncheck-related Adjustments Initiated by the provider due to an underpayment or an overpayment Does not include a refund check from the provider Types of noncheck-related adjustments: –Underpayment adjustment – the adjustment was requested because the provider was underpaid –Partial payment adjustment – the adjustment was requested because the provider was overpaid; overpayment amount is deducted from future claim payments through an accounts receivable offset –Full claim adjustment – the adjustment was requested because the provider was overpaid on the entire claim; the entire claim is recouped First two digits of the ICN (region code) are 50

7. Claim Adjustment Process 7October 2009 Retroactive Rate Adjustments The rate-setting contractor for long- term care facilities initiates retroactive rate adjustments Retroactive rate adjustments are a result of minimum data set (MDS) field audits Claims paid for the dates of service affected are reprocessed, and can result in increased or decreased payments First two digits of the ICN (region code) are 55

8. Claim Adjustment Process 8October 2009 Mass Adjustments The Office of Medicaid Policy and Planning (OMPP), EDS, or Affiliated Computer Services (ACS) can initiate a mass adjustment Mass adjustment requests are applied to change a large number of paid claims at one time Mass adjustments can apply to many providers, or just one provider Mass adjustments can be used when a system problem caused claims to be paid incorrectly, or when a rate for a procedure code changed retroactively First two digits of the ICN (region code) are 56

9. Claim Adjustment Process 9October 2009 Adjustment Limitations: Electronic and Paper Claims Adjustments cannot be performed for the following scenarios: –Change member name –Change member ID (RID) –Change billing provider number/NPI Providers should submit a new claim to correct these types of errors A paper adjustment cannot be performed on a claim in a denied status

10. Claim Adjustment Process 10October 2009 Web interChange Replacement Feature

11. Claim Adjustment Process 11October 2009 Live Demonstration: Replace This Claim

12. Claim Adjustment Process 12October 2009 Replacing a Claim Providers are encouraged to perform all adjustment activities via Web interChange Avoid submitting paper adjustments when possible Do not submit duplicate paper adjustment requests Web interChange vs. Paper

13. Claim Adjustment Process 13October 2009 Replacement Feature Edits for Replacements 0121 – Claim denied due to an electronically submitted replacement Cause: ICN has already been adjusted Resolution: Must use the most recent ICN for the replacement process

14. Claim Adjustment Process 14October 2009 Replacement Feature Filing Limits for Replacements One-year filing limit for replacement requests –The system compares the last date of claim activity and the date of the current activity to make sure that a year has not passed –Web interChange will not display a Replace This Claim button on claims that are past the filing limit These replacements must be submitted on paper –If the date of service on the claim is greater than one year from the date of the replacement request, proof of timely filing is required to avoid a full recoupment of the paid amount –The filing limit does not apply to crossover claims

15. Claim Adjustment Process 15October 2009 Attachments for Electronic Claims Following are the steps to mail paper attachments for electronic claims submitted via Web interChange: On the Claim Submission screen, click the Attachment button Create an attachment control number (ACN) –The ACN can be numbers, letters, or a combination of letters and numbers and can be up to 30 characters in length –Each paper attachment submitted must include a unique ACN –If an attachment has more than one page, the ACN must be written on each page of the document Select the Report Type Code – Indicates the type of attachment being sent to EDS Transmission code – Indicates the type of delivery method used for documentation transmission –“BM” (By Mail) is the only acceptable value for this field Once completed, click Save and Close

16. Claim Adjustment Process 16October 2009 Attachments for Electronic Claims The provider must send an IHCP Claims Attachment Cover Sheet for each set of attachments associated with a specific claim. A copy of the IHCP Claim Attachment Cover Sheet can be found on the IHCP Web site at www.indianamedicaid.com under the Forms link > Claim Forms (Non-Pharmacy) section The provider must complete the following information on the IHCP Claims Attachment Cover Sheet: –Billing provider service location address –Billing NPI and ZIP Code + 4 –Date(s) of service on the claim –Member identification number (IHCP RID number) –ACN –Number of pages associated with each attachment (do not count the cover sheet in the page count)

17. Claim Adjustment Process 17October 2009 Attachments for Electronic Claims Paper attachments for electronic claims must be mailed to the IHCP at the following address: EDS Claims Attachments P.O. Box 7259 Indianapolis, IN 46207 The EDS Claims Support Unit will review each Claims Attachment Cover Sheet for completeness and accuracy of the number of ACNs to the number of attachments –If errors are found, the cover sheet and attachments are returned to the provider for correction and resubmission If the attachments are not received within 45 days of claim submission, the claims auto deny

18. Claim Adjustment Process 18October 2009 Attachments for Electronic Claims Explanation of benefit (Medicare or Commercial carriers) Invoices Transportation run tickets Sterilization/hysterectomy consent forms Past filing limit documentation Consultation reports Periodontal chart Claim Attachment Examples

19. Claim Adjustment Process 19October 2009 Replacement Features Replacement is a change to an original claim, whether same day, same week, or post financial –Most recently paid claim indicates, that is the most recent ICN assigned for that claim Replacement is a HIPAA term for an adjustment

20. Claim Adjustment Process 20October 2009 Replacement Features An electronically submitted replacement claim can be performed for a previously submitted electronic or paper claim Only noncheck-related replacements are accepted electronically Check-related replacements (adjustments) continue to be submitted on paper

21. Claim Adjustment Process 21October 2009 Replacement Features If the Indiana Health Coverage Programs (IHCP) receives a replacement claim for an original claim that has been through a financial cycle (has appeared on an RA), the first two digits of the replacement claim ICN are one of the following: –61 - Provider-initiated replacement containing attachments and/or claim notes –62 - Provider-initiated replacement with no attachments and/or claim notes

22. Claim Adjustment Process 22October 2009 Paper Adjustment Process When to Submit a Paper Adjustment Check-related adjustment When the date of the adjustment request is more than one year from the most recent RA date

23. Claim Adjustment Process 23October 2009 Adjustment Forms Types of adjustment forms –CMS-1500, Dental, Crossover Part B Paid Claim Adjustment Request –UB-04 Inpatient/Outpatient Crossover Adjustment Request –Pharmacy Paid Claim Adjustment Request All relevant information on the form must be completed, or the form will be returned Attach copies of the Medicare and/or Third Party Liability (TPL) remittance notices, if necessary The ICN of the most recently adjusted claim must be included on the Adjustment Request Form

24. Claim Adjustment Process 24October 2009 CMS-1500, Dental, Crossover Part B Paid Claim

25. Claim Adjustment Process 25October 2009 UB-04 and Inpatient/Outpatient Crossover Adjustment Request

26. Claim Adjustment Process 26October 2009 Adjustment Form RTP Claim in denied status No primary insurance explanation of benefits (EOB) for TPL adjustments Requests to override benefit limitations Nonspecific narratives No approved prior authorization on file Return to Provider

27. Claim Adjustment Process 27October 2009 Adjustment Filing Limitations The EDS Adjustment Unit must receive non-pharmacy paid claim adjustment requests within one year of the last processing action When a service is allowed by Medicare, a crossover claim is not subject to the one-year filing limit Medicare denied services are not considered crossover claims, and therefore are not exempt from the one-year filing limitation Providers may obtain a waiver of the one-year filing limit for adjustment requests by providing the appropriate documentation with the request

28. Claim Adjustment Process 28October 2009 Past Filing Limit Documentation Commonly accepted documentation to waive filing limit –Dated paper Remittance Advices (RAs) with ICNs, bills, claim forms, letters to and from insurers or the insured –Dated EOBs from the primary insurer –A print-screen of the Web interChange Claim Inquiry screen, showing all the times the claim has been filed –Written Inquiry responses, Indiana Prior Review and Authorization Request Decision Forms, letters to and from the county offices, EDS field consultants, and the member

29. Claim Adjustment Process 29October 2009 Waiver of Filing Limit EDS may waive filing limit due when the following can be documented: –EDS, state, or county error or action has delayed payment –The provider has made reasonable and continuous attempts to resolve a claim problem –The provider has made reasonable and continuous attempts to bill and collect from a TPL, before billing the IHCP –A member has been enrolled in the IHCP retroactively –A provider has been enrolled in the IHCP retroactively

30. Claim Adjustment Process 30October 2009 How to Submit Claims for Filing Limit Waiver Access Claim Submission in Web interChange to create and submit the claim Click the Attachments button and follow the Attachments process to mail the past filing documentation Place supporting documentation in chronological order behind the Attachment Cover Sheet Address any gaps in filing limit documentation Electronic Claims

31. Claim Adjustment Process 31October 2009 How to Submit Claims for Filing Limit Waiver Submit legible and signed (if necessary) paper claims with the appropriate documentation – photocopies are acceptable Attach required supporting documentation Place supporting documentation in chronological order behind the adjustment form Attach individual documentation trail to each claim Use correct address for claim type; there is no separate address for filing limit claims –Note: Do not send claims to the Written Correspondence address Address any gaps in filing limit documentation Paper Claims

32. Claim Adjustment Process 32October 2009 Timely Processing Guidelines EDS is required to process 90 percent of noncheck-related adjustments within 30 days EDS is required to process 100 percent of noncheck-related adjustments within 45 days Providers should contact EDS Customer Service if an adjustment does not appear on an RA within 45 days of submission, plus mail time Providers should contact ACS for questions regarding pharmacy adjustments

33. Claim Adjustment Process 33October 2009 Where to Submit Adjustment Requests Forward noncheck-related and underpayment adjustment requests to: EDS Adjustments P.O. Box 7265 Indianapolis, IN 46207-7265 Forward check-related adjustments to: EDS Refunds P.O. Box 2303, Dept. 130 Indianapolis, IN 46206-2303 ACS State Healthcare, ACS-Indiana Drug Rebate P.O. Box 2011332 Dallas, TX 75320-1332 Returning Un-cashed IHCP Checks EDS Finance Department 950 N. Meridian, Suite 1150 Indianapolis, IN 46204-4288

34. Claim Adjustment Process 34October 2009 Where to Submit Adjustment Requests Send refunds for CA-PRTF claims to: EDS/CA PRTF Refunds P.O. Box 7247 Indianapolis, IN 46207 Send MFP refunds to: EDS/MFP Refunds P.O. Box 7194 Indianapolis, IN 46207

35. Claim Adjustment Process 35October 2009 Resources IHCP Web site at www.indianamedicaid.comwww.indianamedicaid.com FSSA Web site at www.in.gov/fssawww.in.gov/fssa IHCP Provider Manual (Web, CD-ROM, or paper) Customer Assistance –1-800-577-1278, or –(317) 655-3240 in the Indianapolis local area Written Correspondence –P.O. Box 7263 Indianapolis, IN 46207-7263 Provider Relations field consultant –View a current territory map and contact information online at http://www.indianamedicaid.com/ihcp/ ProviderServices/pr_list_frameset.htm http://www.indianamedicaid.com/ihcp/ ProviderServices/pr_list_frameset.htm

36. Claim Adjustment Process 36October 2009 Questions

37. EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal opportunity employer and values the diversity of its people. © 2009 Hewlett-Packard Development Company, LP. Office of Medicaid Policy and Planning (OMPP) 402 W. Washington St, Room W374 Indianapolis, IN 46204 EDS, an HP Company 950 N. Meridian St., Suite 1150 Indianapolis, IN 46204