CLAIMS BILLING & ADJUDICATION TRAINING 2011-2012

1. CLAIMSBILLING & ADJUDICATIONTRAINING2011-2012 April 26, 2012 Debra A. Schuchert Director of Network Operations & Compliance

2. Authorization & Claims ProcessingS.T.A.R.S. Training Manuals • S.T.A.R.S Training Manual # 1 – Support Coordinators The manual identifies the step by step process used by Support Coordinators to create an authorization number, for procedures codes/units on services rendered to a consumer. An authorization # must be approved by Synergy before a provider can bill a claim in the STARS systems. • S.T.A.R.S. Training Manual # 2 – Claims Processing The manual identifies the step by step process used by providers when submitting a claim for a consumer after the service has been rendered. Providers will submit a claim on either a UB92 form or a HCFA 1500 form. Claim Adjudicators can also submit claims for providers when requested. (I.e. Inpatient Hospital stays, Network 180, and Camp)

3. Synergy’s Procedure Code List with Descriptions / Fee Schedule • Synergy’s Fee Schedule is located on the “G” drive & is identified as 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

4. Direct Contracts Limited Case Agreements Residential /SubcontractsList • 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 D-WCCMHA. 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.

5. Claims Policies & Procedures The following Claim policies and procedures are located on the “G” drive under Claims Department. C-001 New Paper Claims Submission into STARS C-002 Claims Adjudication C-003 Family & Friend Respite Billing& Payment Process (09-30-2008 policy discontinued) C-004 Medicaid Claims Verification Audit Review C-005 Coordination of Benefits C-006 Camp Stay Reimbursement C-007 Claims Override Process C-008 Ability to Pay • Policy # C-004 has been revised as of 03-28-12. • C-OO4c – Medicaid Claims Verification Audit Results form • C-OO4g – Acknowledgement Letter - Documentation - Identifies time frame providers have to submit requested documentation.

6. Claims Department Meeting Minutes • The Claims Department meeting minutes are identified by fiscal year and located on the “G” drive under the Claims Department.

7. Fair Employment PracticeFEP • Synergy and all Direct Contract Providers are responsible for submitting a Fair Employment Practice (FEP) application to the Agency for approval. The Agency produces the FEP Certificate. All Certificates must be renewed upon expiration date. The certificates can be issued for a one, two or three year period. • Synergy has complied with all the requirements of the Wayne County Business Certification Program & has established Compliance with Wayne County’s Fair Employment Practices Resolution. Therefore, Synergy Partners, LLC has been issued the Wayne County Human Relations Certificate (FEP). • Synergy is responsible for submitting the following to D-WCCMHA (Agency) annually or whenever provider changes occur. (I.e. additions, deletions, address changes etc.) • D-WCCMHA 1st Tier Subcontractor List • Fair Employment Practice Certificates on all Direct Contract providers

8. D-WCCMHA MCPN Medicaid/Other Individual Claims Verification Audit • The verification audit is due to the Agency on a “quarterly” basis. • A 10% (5% Medicaid consumers & 5% Non-Medicaid consumers) are randomly sampled and a report is produced by Bessie T. – 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. • A summary is then submitted to the Agency for review

9. 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

10. Claims Variance Report • The report is reviewed monthly by the Claim Adjudicator. Each Claim Adjudicator reviews the claims submission amount from the previous month to the current month, and completes a comparison review on any amount that is over 20% . • The usual variance will occur when the provider does not submit their claims/billing within the established time frames. 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 Timely Waiver Form is required. The form requires the provider to identify the reason for the delay in submitting the claims. When the provider submits a claim over 90 days from the date of service an edit will appear on the adjudication screen alerting the Claim Adjudicator that an Administrative Review Form is required. The form requires the provider to identify the reason for the delay in submitting the claims. Documentation is required due to lateness of claim submission.