1. HP Provider Relations October 2011 Life of a Claim

2. Life of a Claim October 20112 Agenda – General requirements for reimbursement – System edits – Pricing methodologies – System audits – Suspended claims – Claim adjustments – Paper Remittance Advice – Helpful tools – Questions

3. Define General Requirements

4. Life of a Claim October 20114 Life of a Claim Before rendering services, provider must verify member’s eligibility and, if applicable, obtain prior authorization. If applicable, provider must first submit claim to member’s private insurance or Medicare. After the claim has been adjudicated (paid or denied) by these entities, then the provider can submit claim to the IHCP. IHCP claims are identified, tracked and controlled using a unique 13-digit internal control number (ICN) assigned to each claim by IndianaAIM. Based on claim type, provider type and member eligibility, IndianaAIM subjects the claim to systems edits, appropriate pricing methodology, and systems audits. NCCI edits are then applied. When adjudicated, the claim can be paid, denied or suspended. Provider can access their weekly remittance advice (RA) through Web interChange. If claim status is paid, appropriate reimbursement is sent to the provider.

5. Life of a Claim October 20115 Services Rendered to IHCP Members –To be reimbursed by the IHCP, the service provided must be covered by the IHCP –When a prior authorization (PA) is required, the PA must be requested and approved before the service is rendered –A provider can verify if a service is covered by the IHCP and whether or not it requires PA: By referring to the Fee Schedule, located on indianamedicaid.com indianamedicaid.com By contacting the HP Customer Assistance Provider Line

6. Life of a Claim October 20116 Prior Authorization –According to IHCP regulations, providers must request PA for certain services: To determine medical necessity When normal limits are exhausted for certain services –The main purpose of the PA process is to ensure that Indiana Medicaid funding is utilized only for those services that are: Medically necessary Appropriate Cost effective Note: PA is not a guarantee of payment

7. Life of a Claim October 20117 Claim is Processed by IndianaAIM –IndianaAIM reviews every procedure-coded claim to determine when a procedure code requires PA Based on the PA indicator on the IHCP Fee Schedule –Claims from providers located out of state also require PA PA verification Note: The PA belongs to the member, not to the provider

8. Life of a Claim October 20118 Prior Authorization Program/ServicesAdministered ByContact Information Traditional Medicaid and Carved-out Services ADVANTAGE Health Solutions SM 1-800-269-5720 Care Select ADVANTAGE Health Solutions SM 1-800-784-3981 MDwise1-800-356-1204 Hoosier Healthwise Managed Health Services (MHS) 1-877-647-4848 Anthem1-866-408-7187 MDwise (317) 630-2831 or 1-800-356-1204 Pharmacy Services (All Programs) Affiliated Computer Services (ACS) 1-866-879-0106

9. Explain System Edits

10. Life of a Claim October 201110 Claim is Processed by IndianaAIM –As part of processing a claim, IndianaAIM performs edits to verify that the required fields are completed and that the information included in these fields is valid –Claim data is validated against other IndianaAIM databases, such as the member, provider, and reference files –Those claims that do not pass the edits are denied or suspended for further review, depending on the specific edit failed System edits

11. Life of a Claim October 201111 Claim is Processed by IndianaAIM Example of system edits Edit CodeDescription 0228Provider Signature Missing 0264The Date of Service is Missing 0527Date Billed After ICN Date 0507The “From” Date is After the “To” Date 0545Claim Past Filing Limit 0513Recipient Name and Number Disagree 0644Covered by Private Insurance - Bill Prior to Medicaid 1010Rendering Provider Not a Member of the Billing Group 1025Billing Provider Not Enrolled for the Date of Service 1100Billing NPI Not Reported to a Legacy Provider Identifier 2008Recipient Ineligible for Level of Care Billed 3003Procedure Code Requires PA 4019Procedure Code Requires Attachment

12. Enroll Providers: An Overview of Provider EnrollmentAugust 201012 Claim is Processed by IndianaAIM CMS-1500 claims: − Claims in a paid status are sent to McKesson to apply NCCI editing − Claims in a denied status are not sent to McKesson − Claims from waiver providers are not subject to NCCI editing UB-04 Outpatient claims: − All outpatient claims are sent to McKesson to apply NCCI editing National Correct Coding Edits

13. Life of a Claim October 201113 Requirements Common to All Claim Types Name of provider Provider’s ID (NPI/LPI) Name of member Member’s Medicaid ID (RID) Date of service Services rendered Quantity/unitsAmount billed

14. Describe Pricing Methodologies

15. Life of a Claim October 201115 Claim is Processed by IndianaAIM –After claims have passed the system edits, they are subjected to pricing review –As part of this review, the system determines whether or not the claim can be automatically priced or needs to be suspended for manual pricing –This determination is based on: Claim type Procedure-specific pricing indicator Provider specialty Date of service Pricing methodology

16. Life of a Claim October 201116 Claim is Processed by IndianaAIM –The claim pricing process calculates the Medicaid-allowed amount for claims based on claim type, pricing modifiers, and defined pricing methodologies Based on the claim type, IndianaAIM directs the claim to the appropriate pricing methodology If a third-party liability (TPL) amount is present, the system subtracts this figure, plus applicable spend- down from the IHCP allowed amount to get the amount paid Pricing methodology

17. Life of a Claim October 201117 Claim is Processed by IndianaAIM Example of pricing methodologies Pricing MethodologyApplied to…. Diagnosis-Related Grouping (DRG)Inpatient Services Procedure Code Max Fee, or Revenue Code Flat Rate Outpatient Services Resource-Based Relative Value Scale (RBRVS) Medical Services Overhead Cost Rate/Staffing Cost Rate Home Health Services Max FeeDental Lab FeeLab Services Manual PricingDurable Medical Equipment Services State Maximum Allowable Cost (SMAC) Pharmacy Services

18. Detail System Audits

19. Life of a Claim October 201119 Claim is Processed by IndianaAIM –All programs under the IHCP umbrella (such as Traditional Medicaid and Care Select) have certain service limitations –The extent of these limitations is determined by the aid categories and defined by state and federal regulations –These regulations are usually referred to as the IHCP medical policy –The Office of Medicaid Policy and Planning (OMPP) is responsible for establishing medical policies System audits

20. Life of a Claim October 201120 Claim is Processed by IndianaAIM –IHCP medical policies are monitored and enforced by the auditing process –Audits: Compare current claims for a specific member against all other services on the claim history file that were rendered, billed, and finalized for that member Ensure that providers do not perform excessive or unnecessary services without medical justification Ensure that state and/or federal regulations regarding the frequency, extent, length of stay, and cost of service are followed System audits

21. Life of a Claim October 201121 Claim is Processed by IndianaAIM –Similar to system edits, if the claim fails any of the system audits, the claim may be: Systematically denied Systematically cut back to reduce the number of dollars paid on the claim, or Suspended  ….depending on the specific audit failed by the claim System audits

22. Life of a Claim October 201122 Claim is Processed by IndianaAIM Example of system audits Audit CodeDescription 5000Possible Duplicate 5001Exact Duplicate 6056Only One Hearing Aid Repair Per 12 Months Allowed for Recipients 18 and Older 6113DME Limited to $2,000 Per Recipient Per Calendar Year 6710Diabetic Test Strips are Limited to 2 Units Per Month 6011Professional / Technical Components For Radiology or Pathology Not Payable When Complete Procedure Already Paid 6701Procedure Code 93352 Must be Billed on the Same Day as 93350 and 93351 6034Global Surgery Payable at Reduced Amount When Component of Surgical Care Paid

23. Specify Suspended Claims

24. Life of a Claim October 201124 Claim is Adjudicated –The HP Resolutions Unit examines suspended claims and makes a decision based on approved adjudication guidelines for the date of service –The approved guidelines indicate the course of action that must be taken for each edit/audit –These guidelines are based on the medical policies established by the OMPP Suspended claims – Role of the HP Resolutions Unit

25. Life of a Claim October 201125 Claim is Adjudicated –Resolutions Unit team members have the following options when processing suspended claims, depending on the edit or audit failed: Add or change data (only used when the claim suspended due to data entry errors by HP) “Force” the claim to process by overriding the edit or audit Deny the claim Put the claim on hold (used when there is a system problem or a pending policy decision) Resubmit the claim to IndianaAIM for reprocessing Suspended claims – Role of the HP Resolutions Unit

26. Life of a Claim October 201126 Claim is Processed by IndianaAIM –Claims requiring medical policy review are placed in a suspended status by IndianaAIM –IndianaAIM enters the suspended internal control numbers (ICNs) onto a scheduler and automatically routes the suspended ICNs to the care management organization (CMO) to which the member is assigned ADVANTAGE Health Solutions for Traditional Medicaid and for their Care Select members MDwise for their Care Select members Suspended claims – Medical policy

27. Life of a Claim October 201127 Claim is Processed by IndianaAIM –A designated staff member reviews the scheduler and reassigns the suspended ICNs to additional staff members for resolution –Each ICN is processed according to the approved guidelines for the specific audit Based on the guidelines, the audit will be “forced” to a paid status, or the audit will fail (deny) Medical records are not requested from the provider during this process Medical documentation submitted with the claim, however, is reviewed Suspended ICNs should be completed within 30 days Suspended claims – Medical policy

28. Learn Claim Adjustments

29. Life of a Claim October 201129 Claim Adjustments –An adjustment is defined as a request to change historical data or reimbursement for a claim –Adjustments are necessary when there has been an overpayment or underpayment to the provider If a net overpayment is determined, IndianaAIM establishes an accounts receivable (A/R) and recoups the overpayment If an underpayment is determined, the provider is reimbursed the net difference in the current week’s payment amount

30. Life of a Claim October 201130 Claim Adjustments –Voids Is the Health Insurance Portability and Accountability Act (HIPAA)-approved term used to describe the deletion or cancellation of an entire claim Can be completed on the same day or in the same week that the original claim was submitted, or after the original claim payment is finalized (after an RA has been created) Can be performed on paid claims only; cannot be performed on a claim in a denied status Can be performed for a previously submitted electronic claim or paper claim Electronic voids and replacements

31. Life of a Claim October 201131 Claim Adjustments –Voids PA units are added to the then-current balance when a claim is voided Providers can view the updated balance in Web interChange using the PA Inquiry function within two hours of the void taking place Electronic voids and replacements

32. Life of a Claim October 201132 Claim Adjustments –Replacements Is the HIPAA-approved term used to describe the correction of a claim that has already been submitted Can be completed on the same day or in the same week that the original claim was submitted, as well as after the payment is finalized Do not replace claims more than one year after the date of service Can be performed on claims in paid, suspended, or denied status Can only be submitted for noncheck-related adjustments Check-related adjustments must be submitted on paper Paper adjustment form instructions are available in the IHCP Provider Manual, Chapter 11, Section 3 Electronic voids and replacements

33. Review Paperless Remittance Advice

34. Life of a Claim October 201134 Paperless Remittance Advice –Each week, a listing of all submitted claims displays on the Remittance Advice (RA) –The RA sorts the claim information according to claim type and status (paid, denied, and so on) –Access the Check/RA Inquiry feature of Web interChange to view and print the RA –The RA is available via Web interChange for four weeks After the fourth week, the oldest RA is purged and is no longer available online

35. Life of a Claim October 201135 Paperless Remittance Advice

36. Find Help Resources Available

37. Life of a Claim October 201137 Helpful Tools Avenues of resolution –IHCP Provider Manual, Chapter 10 (Web, CD, or paper), available at indianamedicaid.com indianamedicaid.com –Customer Assistance Local (317) 655-3240 All others 1-800-577-1278 –Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN 46207-7263 –Provider field consultant

38. Q&A