Secrets to Successful Claim Submission Claims Team Info Share 2013

1. Secrets to Successful Claim Submission Claims Team Info Share 2013

2. Overview • Our goal • Introduction of claims’ staff • Provide information to successfully submit claims • Review most common denial • Provide reference resources • Answer questions

3. Introduction • The Claims Team within MeckLINK consists of 10 staff members working to assist you with any questions you may have regarding claims. In the Claims Division we have: • Faye Sanders – Claims Manager • Wendy Ricks – Contract Compliance Auditor • 2 Senior Claims Processors • Lynn Harrington • Joseph Lambert

4. Introduction • 6 Claims Processors • Carla Gaddy • Shakelia Pharr • Tenisha Littlejohn • Sonia Foggie • Vivian Coleman • Willene Rogers Each provider has an assigned Claims Processor to answer questions and assist in resolving claim issues.

5. Claims Division Responsibilities • Process and pay claims within 30 days of approval. • We gather, research and analyze reports to provide feedback to providers. There are two reports that we run daily: • The Denial Report • The Exceptions Report

6. Claims Division Responsibilities • The Denial Report • This report details the denials by provider for all claims submitted and have gone through adjudication. The data taken from this report is used to inform providers of their denials and to assist in detecting trends in denials and system issues.

7. Claims Division Responsibilities • The Exceptions Report • This report helps us to identify claims submitted into the Alpha system but because of missing information, the claim did not go through the processing stages. The reason a claim would fall on this report is that it is missing necessary identifiable information to continue processing: • The provider’s NPI • The provider’s ID number • The patient’s ID number

8. Steps to a ‘Clean Claim’ • What is a ‘clean claim’ • Clean claims are claims that will bypass edits in the Alpha system and process with a payment.

9. Steps to a ‘Clean Claim’ • There are several steps that should be taken to ensure your claim submissions will bypass edits in the Alpha system.

10. Steps to a ‘Clean Claim’ • Provider Data Once you have obtained your contractual agreement with MeckLINK you should: • Get connected • Review your contract • Are all of the sites listed • Is the correct NPI number mapped to each location • Do we have the correct taxonomy codes • Are all practitioners or licensed staff within your agency listed in Alpha • Is the licensing data for practitioners correct, current and complete.

11. Steps to a ‘Clean Claim’ • Are all services listed • Verify that the Advantage address is correct

12. Steps to a ‘Clean Claim’ • Consumer Data • Ensure he/she is a MeckLINK consumer • Make sure the consumers’ coverage is active. • Verify the consumers’ benefit plan (State or Medicaid).

13. Steps to a ‘Clean Claim’ • Enrollment: • For enrollment information call the Customer Service Call Center at 704 -336-6404. • Medicaid enrollment information is received from the State by way of GEF (Global Eligibility File) and downloaded into Alpha. • State enrollment information can be updated by the practitioners in Alpha.

14. Steps to a ‘Clean Claim’ • Authorizations • Verify that a SAR (Service Authorization Request) has been submitted. • Did I enter the correct diagnosis for the population (MH/SA/IDD) • Is the correct site listed where the service will be provided? • Did I enter the correct amount of units. • What dates of service will this authorization cover?

15. Steps to a ‘Clean Claim’ Authorization • Ensure that the SAR has been approved. • Did they approve all the units requested? • Was the SAR denied for additional information? If the SAR has been denied and additional information is needed, the reviewer will notate what information is required in the designated field.

16. Steps to a ‘Clean Claim’ • The UM (Utilization Management) Division will be able to assist you with any questions regarding SARs and authorizations. • Contact the Customer Service Call Center if you do not know your contact. 704-336-6404

17. Question Contact • Contact your dedicated Provider Relations Specialist • Customer Service Call Center • Contact our Utilization Management Division • Contact your dedicated Claims Processor • I need my provider information updated. • Consumers’ enrollment data is in need of updates. • There is a question about authorizations. • Claims are still denying.

18. Overview • During this discussion, we will review the following items below: • Top claim denial reasons • Taxonomy codes • Innovations claims • Quick Reference Links

19. Goals • Our goal is to provide you with understanding and tools to decrease the timeliness of payment of claims that have denied due to edits in Alpha MCS.

20. Top Claim Denial Codes • 4-Basic units • 3-Authed units exceeded • 40-Weekly limit exceeded • 18-Incorrect member-Patient not enrolled on date of service • 7-Client has other insurance which covers service • 9-Clinician not licensed to provide service

21. 4-Basic Units • The total number of basic units also know as unmanaged visits has been exceeded. For certain services, usually Evaluations and Outpatient Therapy, Adults receive 8 unmanaged visits and children 16 unmanaged visits without an authorization. Basic units are renewed at the beginning of every fiscal year, and they follow the patient across providers. • We are aware of the issues with claim denials for unmanaged service codes. We are currently working with IT and Alpha to resolve this issue and appreciate your patience. Provider will be notified when this issue is resolved.

22. 3-Auth units exceeded • The service on the claim was authorized, but the provider has gone over the amount of approved units on the authorization. The Alpha system validates this by seeing if the total consumed units is greater that the number of authorized units. • Providers will need to keep track of the units and services provided for each consumer served. Once the units on the authorization have been exhausted, the provider will need to submit a new SAR for the service. If the authorized units are truly exceeded, please don’t re-bill claims as this will result in a denial.

23. 40-Weekly limit exceeded • The service has a limitation on the amount of units that can be billed per week. Either the claim has exceeded that limit or that claim in addition to other claims (for that same week and service) has exceeded the limit. Provider is responsible for keeping track of the units by limiting the occurrence of billable services. It is important to remember that this denial is based on unit frequency and not total units authorized. Providers should not request a new SAR for additional units unless there is an emergent or crisis situation that requires the need to do so. Re-bill claims only if services were billed in error. Claims that were entered correctly but denied due to Benefit plan revisions, please contact your dedicated claims representative to re-adjudicate these claims.

24. 18-Incorrect Member-Patient not enrolled on date of service • The consumer either was not enrolled in the insurance on date of service or never enrolled in it. For Medicaid consumers, MeckLINK receives a Global Eligibility File each month that updates eligibility status in Alpha. • Providers should verify that consumer information on claim is correct and that coverage is in place for the date of service on the claim. This is why it is important to verify the enrollment data prior to submitting claims. If information is incorrect on the claim, please make necessary corrections and resubmit. If information on the claim is correct, please contact your dedicated Claims Processor. There are instances when a consumer’s Medicaid eligibility uploads incorrectly or does not show in Alpha, and may cause a claim to deny incorrectly. Claims staff are responsible for relaying this information to appropriate IT staff who will research and send corrections or updates to the State.

25. 7-Client has other insurance • Client has other insurance that should pay for service. For clients that have other primary insurance (ex Medicare, and other third party insurance), providers should bill services first through the insurance carrier prior to submitting to MeckLINK. Please contact your dedicated Claims Processor if you have questions.

26. 9-Clinican not licensed to provide service • Clinician who performed the service does not have the licensed required to perform that service. • Provider will need to check to make sure the correct Rendering NPI# was entered on the claim as well as ensuring that all clinician licenses are up to date. As communicated in the provider hot sheets, the provider should send license renewals to their dedicated Provider Relations Specialist within 10 days of the license expiration date so Alpha can be updated accordingly. This will help prevent claims from denying in error. If information on the claim is incorrect, please contact Provider Relations Specialist to make necessary changes and/or updates before resubmitting the claim. If information on claim is correct, please contact your dedicated Claims Processor.

27. Taxonomy codes • The provider should make sure that the clinician information is updated in NCTracks. Once updates have been made, please relay this information to your designated Provider Relations Specialist to ensure clinician information in Alpha matches information in NC Tracks. • Taxonomy codes are required on claims. While the system currently bypasses this edit; it will be made mandatory 10/1/2013. • Please be sure to read weekly provider hot sheets for updates regarding taxonomy codes.

28. Innovation Claims • Providers should make sure they are billing with the right service code and description before submitting these claims.

29. Quick Reference Links • Claims Manual http://charmeck.org/mecklenburg/county/AreaMentalHealth/ForProviders/Provider%20Library2/Claims%20Manual.pdf • Denial Guide http://charmeck.org/mecklenburg/county/AreaMentalHealth/ForProviders/Provider%20Library2/Denials%20Guide.pdf • Place of Service Crosswalk (under Waiver Information) http://charmeck.org/mecklenburg/county/AreaMentalHealth/ForProviders/Pages/ProviderDocuments.aspx • Claims Agency Assignments http://charmeck.org/mecklenburg/county/AreaMentalHealth/ForProviders/Provider%20Library2/Claims%20Agency%20Assignments-Hot%20Sheet%20and%20Public%20Website.pdf • Provider Hot Sheets http://charmeck.org/mecklenburg/county/AreaMentalHealth/ForProviders/Pages/HotSheets.aspx • Taxonomy code look up http://ncmmis.ncdhhs.gov/taxonomy.asp • Report system issues for Alpha MCS Provider Portal http://charmeck.org/mecklenburg/county/AreaMentalHealth/ForProviders/Pages/HelpRequest.aspx • NCTracks https://www.nctracks.nc.gov/content/public?version=portal-jwap-trunk-10065-15243-production&why=Root

30. Questions and Answers