1. Welcome to Nebraska Total Care

2. Provider Relations
Each provider will have a Nebraska Total Care Provider Relations Representative assigned to them. This team serves as the primary liaison between the Plan and our provider network and is responsible for:
HEDIS/Care Gap Reviews
Demographic Information/Provider add, term, roster management, send to
Facilitating inquiries related to administrative policies, procedures, and operational issues
Monitoring performance patterns, claims denial trends
Assisting in Provider Portal registration and PaySpan
Trouble Shooting Claim Issues
Authorization concerns/inquires
Education and training
Main contact for Nebraska Total Care

3. Provider Relations – Issues Workflow
Call NTC Provider Services
Contact NTC PR Representative

4. Website and Secure Portal Tools

5. Secure Provider Portal - Updates
Add additional clinical to an authorization request that is in process

6. Secure Provider Portal - Updates
Notification of Pregnancy Forms now online

7. Secure Provider Portal - Updates
Claims Submissions
Upload 837 files directly to the secure provider portal

8. Claims Clean Claim Exceptions
A claim that is received for adjudication in a nationally accepted format in compliance with standard coding guidelines and does not have any defect, impropriety, lack of any required documentation or particular circumstance requiring special treatment that prevents timely payment.
A clean claim must also include NTC’s published requirements for adjudication, such as: NPI Number, Tax Identification Number, or medical records, as appropriate.
NPI in box 24J must match name in box 31
Exceptions
A claim for which fraud is suspected
A claim for which a third party resource should be responsible

9. Claims
Claim Payment
Clean claims will be adjudicated (finalized paid or denied) within 15 days (electronic), and 30 days (paper), following receipt of the claim.
Timely Filing Guidelines
Initial Filing – 180 calendar days from the date of service (Professional)
Initial Filing – 180 calendar days from the date of discharge (Hospital)
Coordination of Benefits (Nebraska Total Care as secondary) – 180 calendar days from the primary payer’s determination
Corrected/Reconsideration/Disputes – 90 calendar days from the receipt of payment/denial notification

10. Current Claims Issues Denials
Authorization denials- claims denying for “no authorization” when there is an authorization on file, or claims denying for “no authorization” when an authorization is not needed (i.e. Inpatient, ER, Observation, professional fees, office visits)
Missing invoice – Anything listed on fee schedule with RNE does not require invoice. NTC pays at 25% billed charges.
Provider specialty not matching service billed – ZC claim denial
Invalid diagnosis – DX claim denial
Depo-Provera invoice needed – Invoice is not required with modifier (J3490-TH)
Invalid or missing modifiers- IM denial
CAH claims – Invalid or missing bill type
PT/OT/ST – new CPT codes
92 Paid in full denials, (claims are not paying some are tied to COB, others tied to global)

11. Current Claims Issues Rates Adjustments COB issues Enhanced PCP rates
Medicare primary – NTC should pay up to the Medicare allowable
Not capturing deductible/coinsurance portion
Non-covered Medicare services or needing primary EOB
Commercial primary – NTC should pay up to the lesser of the commercial insurance allowable or the Medicaid fee schedule allowable.
Enhanced PCP rates
CAH rates – update rates to 2017 cost-to-charge ratio
RHC rates – hospital owned & independent
599 Chip Unborn claims (bill under mom’s first and last name and dob, unborn ID)

12. Claims
A claim reconsideration should only be made when a provider has received an unsatisfactory response to their claim inquiry.
You can submit a reconsideration online at Nebraskatotalcare.com, on the secure Provider Portal.
You can mail a paper reconsideration to the address below.
Contact your Provider Relations Representative to inquire on status.
A response to an approved adjustment will be provided by way of check with an accompanying Explanation of Payment (EOP)
Nebraska Total Care Attn: Claims Reconsiderations P. O. Box Farmington, MO

13. Utilization Management
Prior Authorization requirements:
Reference Web portal Prior Authorization “Pre-Auth Checker”
Determine if Prior Authorization is required
Prior Authorization required for some services
Prior Authorization of services of Inpatient or Outpatient events, PT/OT/ST (except for evaluation and re-evaluation), DME
Inpatient admissions
Including submission of clinical criteria (anything that can support the authorization request)
Clinical Criteria is based on Interqual Criteria

14. Utilization Management
Prior Authorization Requests
Telephonic options directly to Utilization Management team
Fax lines dedicated to specific roles
Dedicated Concurrent Review
Prior Auth request, Nurse, Behavioral Health
Website
After submitting prior authorization, a reference number will be given upon submission, once approved or denied OP(Outpatient), IP (Inpatient) authorization number will be provided with service approve and DOS span.

15. Contact Us
Phone Number: TDD/TTY: Website:

16. Questions???