Prepaid CCN Encounter Data April 18, 2011 Sharon Jackson Darlene White.

1 Mercer Agenda  Overview  Transaction Set Supplemental Instructions  Repairable Denials  Testing and EDI Certification  Continuous Quality Assurance  System Generated Reports  CCN Generated Reports  Provider Registry

2 Mercer Overview  Beginning November 2011 DHH will phase-in implementation of services in the CCN program  DHH will require CCNs to submit encounters to the FI in a HIPAA compliant 837 provider-to-payer-to-payer COB format  Encounters are defined as paid claims for medically related services provided by a CCN to a DHH Medicaid enrollee, including claims from subcapitated providers  CCNs must be prepared be begin submitting encounters to the FI within 60 days of the beginning of operations  CCNs are to submit 95% of encounters no later than the 25 th calendar date following the month that they were processed

3 Mercer Transaction Set Supplemental Instructions  CCNs are to use IG guidance for creating transactions  In addition, Molina has provided Companion Guides and Billing Instructions which can be found at  The DHH Systems Companion Guide provides additional guidance about how to submit 837I or 837P based on Provider Type  DHH has supplemental instructions for the submission of: – Financial fields – NPI, Taxonomy and 9-digit zip code – Newborn birth weight and newborn Medicaid ID – Category II CPT Codes – Use of BHT06 – Use of 2300, MEDICAL RECORD NUMBER, REF02 and REF01

4 Mercer Transaction Set Supplemental Instructions Cont.  The BHT06 is used to indicate the type of billed service being sent: fee-for-service (claim) or encounter. Use a value of RP when the entire ST-SE envelope contains encounters.  RP is used when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. If the RP value is not used, either the entire batch of encounters will be rejected, or the batch will be processed as claims, which will result in the denial of every claim.  The CCN ICN is to be populated in loop 2300, MEDICAL RECORD NUMBER, REF02, data element 127. A reference identification qualifier value of EA is to be used in REF01, data element 128.

5 Mercer Repairable Denials  Some denials that occur during MMIS processing can be corrected and resubmitted  Section 3 of the Systems Companion Guide provides a list of repairable denials and instructions for the Adjustment process  Section 7 of the Systems Companion Guide includes line adjustment processes requires submitting the following values in loop 2300 segment CLM05-3: – CLM05-3 submit a value of 7 – REF01 submit a value of F8 – REF02 submit the original reference number

6 Mercer Transaction Testing and EDI Certification  The FI test protocols can be found at and choosing EMC  Upon request by the CCN, the FI will provide an application and approval form to become a submitter  CCNs must test and certify with EDIFECS prior to testing with the FI  When the submitter is ready to test the encounters are to be sent to the FI EDI Coordinator using submitter number  When all forms are received and approved and the EDI has verified the test encounters the submitter will be notified  CCNs must submit a test plan to DHH and the FI with systematic plans for testing 837I and 837P

7 Mercer Transaction Testing and EDI Certification Cont.  CCN Encounter Test Plan – Tier 1  Obtain a Medicaid ID from the FI  Enroll with the FI to receive a trading partner number  Pass EDIFECS testing  Code RP in the X12 field TX-TYPE-CODE  Populated the CCN ICN in loop 2300, MEDICAL RECORD NUMBER, REF02, data element 127. Use a reference identification qualifier value of EA in REF01, data element 128 – Tier II  DHH will instruct CCNs on how many test encounters to submit  Tier II is complete when over 50% of encounters successfully pass MMIS edits – Tier III  The FI will move the CCN into production

8 Mercer Continuous Quality Improvement  CCNs are to keep track of all MMIS edits that cause denials  Repairable denials are to be corrected  DHH and CCNs will meet every 3 months or as needed to discuss encounter data quality  CCNs are expected to have investigated the root cause of denials  As data issues are discussed, CCNs must incorporate corrective action steps  DHH will keep track of the volume of encounters as well as the volume of repairable encounters  If a CCN believes the issue lies with the FI, there will be a dispute resolution process

9 Mercer System Generated Reports  The FI will create a series of files for the CCNs  The file layouts are found in Appendix D of the Systems Companion Guide  Molina CCN-W-001 will serve as a high level summarization of the MMIS errors. It will produce the overall [encounter] count with the disposition of the MMIS paid or denied status and overall percentages that paid and denied  Molina CCN-W-005 will produce the overall edit code disposition, edit code posted and the number of edit codes from the submission  Molina CCN-W-010 lists all encounters and their error codes and is a detailed listing by header and line item of the edits

10 Mercer CCN Generated Reports  The CCN will be required to generate and submit the CMS 416 EPSDT Participation Report to DHH each quarter of the FFY  The 416 is due to DHH no later than March 1 st after the FFY reporting period concludes  CCNs will produce a denied claims report monthly only for those denials listed below: – Lack of documentation to support medical necessity – Prior Auth not on file – Member has other primary insurance – Claim submitted after filing deadline – Service not covered by CCN  FQHC and RHC Quarterly reports (see Appendix E for details)

11 Mercer Provider Registry  For providers not already participating in Medicaid fee-for-service it may be necessary for CCNs to provide a detailed registry of provider information in order for the provider to be added to an encounter provider file  Alternatively, DHH may require all CCN providers to complete a full application form and be certified by DHH as participating providers

12 Mercer Questions?  The DHH CCN-P Systems Companion Guide provides additional detailed instructions and guidance for encounter reporting