Claims & Reimbursement Training

1. Claims & Reimbursement Training Western Highlands Network Presented by: Servetta McDowell

2. Training Agenda NPI updates Upcoming deadline & updates Eligibility • Resources, and WHN policy Claim Submissions • Types of claim submissions Reimbursement • WHN’s mandated response time policy to Providers • Denials and resolution Deficit Reduction Act False Claims Act Information Resources • WHN website tools • CMS, DMA, and IPRS websites

3. NPI WHN offers the following billing options: Providers may continue their current billing practices – 837, DDE, CMS 1500 (08/05) Submit claims (08/05) with NPI & Legacy Number WHN is unable to accept NPI only billing without a legacy number Invoice & Activity log billing will continue to follow current policy and procedures

4. NPI WHN strongly encourages Providers to continue NPI registration and NPI billing implementation in preparation for future NPI implementation deadline WHN Communication Bulletin #60 NPPES https://nppes.cms.hhs.gov/NPPES/Welcome.do

5. Upcoming deadline & updates • Community Support Secondary Modifier • U3 represents Qualified Professionals • U4 represents Non-Qualified Professional • Services: H0036HA, H0036HB, and H0036HQ • Authorization based on primary modifier • Unit limitations based on primary modifier • Summarize service units based on secondary modifier • Effective with dates of service December 1, 2007 and forward

6. Upcoming deadline & updates • 60 day timely filing edit implementation • Effective with claims received on or after January 1, 2008 • July through November 1, 2007 dates of service finalized before January 1, 2008 to avoid a 60 day denial error • Finalizing a claim includes resolving the denial error(s). • WHN Communication Bulletin #67

7. Upcoming deadline & updates • WH will accept Medicaid claims up to 365 days from the date of service • WHN does strongly advise providers to submit Medicaid claims before 365 days from the date of service to avoid a Medicaid timely filing denial error.

8. Upcoming deadline & updates • December 2007 Medicaid Bulletin announces CPT revisions effective January 1, 2008 • NC Division of Medical Assistance • http://www.dhhs.state.nc.us/dma

9. Eligibility

10. Verifying eligibility • Does your agency’s business practices support verifying consumer eligibility?

11. Resources for verifying eligibility • Basic Medicaid Billing Guide located on DMA’s website http://www.ncdhhs.gov/dma/medbillcaguide.htm 1-800-688-6696, menu option 1, for phone inquires • NC Medicaid Automatic Voice Response (AVR) System 1-800-723-4337 • 270/271 HIPAA Compliant Health Care Eligibility Benefit Inquiry and Response Electronic Transaction. • Value Added Networks (VANs) Interactive eligibility verification that providers may contract with Medicaid for access to real time consumer eligibility. The transaction fee is eight cents per inquiry.

12. Eligibility • WHN has implemented the following policy, and procedures concerning eligibility: • When a consumer’s Medicaid eligibility is determined first by the provider, then the provider needs to submit a refund attached to the Claims Resolution Inquiry Form to WHN. • If WHN determines eligibility first, then an automatic recoupment will occur.

13. Types of Claim Submissions 837 Direct Data Entry Invoices & Activity Logs

14. 837 837 is an electronic file that the Provider creates to send to WHN WHN will follow Medicaid 837 Spec requirements 837 Medicaid Companion Guide is available on the DMA website Please contact Diane Overman at diane@westernhighlands.org for 837 Technical assistance

15. 837 NPI Updates Western Highlands will process an 837 in either the legacy format or with both legacy numbers and NPI. Western Highlands offers format and content testing in preparation of final NPI transition. Notify Diane Overman in advance.

16. Direct Data Entry (DDE) A web-based billing product developed by WHN Intended to complement the 837 and / or offer an electronic claims submission method for agencies unable to produce an 837

17. Direct Data Entry (DDE)

18. Direct Data Entry (DDE) continued Log in at website / user issued login Quick set up through website PC support requirements are Internet Explorer 6.0, 98 or newer, and High-speed Internet. Great resource for providers to work their agency’s denials and then resubmit corrected claims.

19. Direct Data Entry (DDE) - Features Immediate real-time feedback with authorizations, claim acceptance and denial codes Ability to generate a printed report of successfully submitted claims

20. Direct Data Entry(DDE) To request a Direct Data Entry (DDE) Information Package: Contact Servetta McDowell billingquestions@westernhighlands.org 828.258.3511 Ext. 2191 Fax: 828.258.1225

21. DDE UPDATES • Secondary Modifiers • The secondary modifier is required when billing for Community Support claims effective for dates of service December 1, 2007 and forward. • If your claim submission does not require Secondary Modifiers, tab to the next field. • Secondary Modifiers are two characters long, and all capital letters

22. DDE UPDATES • Secondary Modifiers continued • Denial error (077)Missing / Invalid 2nd Modifier: appears when incorrect data has been entered for the 2nd modifier. • Denial error (078)Secondary procedure modifier invalid for procedure on date of service: appears when a 2nd modifier is entered and it’s not required for the procedure code and / or date of service billed.

23. Exceptions to the Electronic Claim Submissions : • Void & Replace • CDSA Referral Number Targeted Case Management billing for children ages 4 to 12 years old • COB – Coordination of Benefits • CAP

24. Claims Resolution Inquiry Form • Developed by WHN to submit exceptions to Electronic Claim Submission pertaining to: - Appeals - Void & Replaces - Time Limit Overrides - Third Party Overrides - Refunds - Other

25. Claims Resolution Inquiry Form • WHN requires the Claims Resolution Inquiry form with a new CMS 1500, and a copy of the (EOB) Explanation of Benefits. • www.westernhighlands.org Select Providers/Reimbursement and Claims Procedures/Forms

26. CMS 1500Version (08/05)

27. CMS 1500 (08/05) Instructions on billing published in NC Medicaid Special Bulletin, June 2007, New Claim Form Instructions NC Division of Medical Assistance http://www.ncdhhs.gov/dma/bulletin.htm

28. Reimbursement Receiving reimbursement from WHN Denial issues and resolutions

29. Reimbursement WHN is mandated to review claim / invoice submissions within (18) calendar business days after receipt and shall: A) Approve payment B) notify Provider within that time frame if claims/invoice are denied or if further information is necessary

30. DENIALS AND RESOLUTIONS

31. Top Denial Issues Duplicate Service Prior Authorization required Quantity over approved limit Attending provider numbers Service level numbers

32. Duplicate Service • Claim has been previously submitted and reimbursed. • If the claim previously submitted and paid was for the incorrect amount of units due to not summarizing the claim, then a void and replace procedure will need to take place. • An indicator that reimbursements from previous EOB’s have not been posted to reflect payments received for services provided.

33. Prior Authorization required Claims require a WHN authorization number beside “Authorization Number” field in DDE CMS 1500 in block 23, Prior Authorization Number Verify the (LON) Letter of Notification authorization number Verify that the claim submission has the correct authorization number for the date of service, and the procedure code. The requirement is for procedure codes that require an authorization when billing

34. Authorizations – denial issues Incorrect or no authorization Denial error (063) Incorrect Authorization UA – Authorization for these services does not exist. Once error has been discovered, resubmit a clean claim if specified situation allows a claim resubmission

35. Authorizations – denial issues When a claim is billing over the authorized units allowed, the following denial will occur: OA –Claim exceeds the units of service authorized • If units are truly maxed out, claim can’t be reimbursed

36. Authorizations – denial issues When units billed are greater than the authorized units, the following occurs: • The claim is adjudicated • Payment is “cutback” based on remaining authorized units • EOB will state: (PP) Partial Payment

37. Authorizations – ValueOptions Questions about the ITR/ORF 2 must be resolved between the Provider and ValueOptions. Because Western Highlands is not the requestor, and does not receive copies of Inpatient Treatment Reports, the provider is responsible for negotiating unresolved authorizations with ValueOptions. WHN Communication Bulletin # 56

38. Authorizations – ValueOptions ValueOptions Provider Relations Team: • Delayed authorization letter inquiries • Authorization process inquiries • Develops and provides provider trainings • 1-888-247-9311

39. Authorizations – ValueOptions Western Highlands will offer assistance with: Resolving VO authorized claim denials based on a billing error Providers should contact VO about products available to assist with viewing authorizations online and verifying consumer eligibility

40. Authorizations – ValueOptions WHN has a turn around time of one day for entering authorizations into our system, once our agency receives VO letters

41. Unit Limitations edits • When units billed exceed units allowed daily, weekly, and monthly. • Example: Community Support Daily Unit Limitation: 32 units Weekly Unit Limitation: 112 units • Medicaid Special Bulletins, and Clinical Policies on the DMA website is a source for reviewing unit limitations

42. Unit Limitations edits • 837 and paper claim submissions will receive a cutback on the (EOB) Explanation of Benefits • DDE users will receive a denial message • Denial Codes (080) Less than minimum daily limits (081) More than maximum daily limits

43. Attending Provider – denial issues (33) Missing Attending Provider ID (34) Invalid Attending Provider ID (36) CPT code requires Medicaid ID Direct Data Entry (DDE) The Attending Provider Number belongs in the “PIN # - OBH or Enhanced Benefit” field The Individual Clinician’s Medicaid Direct Enrolled Number belongs in box 24 J shaded area (08/05) on CMS 1500; for Outpatient Behavioral Services

44. Attending Provider – denial issues • (33) Missing Attending Provider ID • (34) Invalid Attending Provider ID • (36) CPT code requires Medicaid ID • Denial Resolution: • Claim was not submitted with the Clinician’s Medicaid Enrollment number • Verify Clinician’s Enrollment Number • Resubmit Claim and make sure the Clinician’s Enrollment Number is written accurately

45. Attending Provider – denial issues • Denial resolution continued: • Make sure that claim was submitted with a valid Individual Clinician’s Medicaid Enrollment number • If not, resubmit claim with the valid Individual Clinician’s Medicaid Enrollment Number • To register a clinician’s Medicaid enrollment number with WHN view Communication Bulletin #12. • If claim was submitted with a valid number, contact the Business Office to verify registration

46. Enrolling Providers with WHN • All directly enrolled Medicaid providers must be registered with WHN in order to seek reimbursement from WHN. • WHN Communication #12 contains policy and procedures on provider registration • If you have enrollment inquiries, contact: Pat Potter at (828) 225-2785 ext. 2185

47. Service Level Number - denials Claims submitted for Enhanced Benefits require the following: • Direct Data Entry (DDE) The Service Level Number belongs in the “ PIN # - OBH or Enhanced Benefit” field • The Service Level Number represents the Legacy Number when billing on the CMS 1500 (08/05) in box 24 J, in the shaded area

48. Service Level Number - denials Invalid or absent service level number • Denial Code (51) Core Number: 83xxxxx Service Level Number: 83xxxxx (+) alpha suffix • Verify the accuracy of the service level that is being billed • Verify that the Service Level number is being submitted correctly on your claim submission

49. Service Level Number - denials DMA issued Community Intervention Letter The source document for obtaining your agency’s Service Level Numbers If a claim is denied and the accurate Service Level was on the submitted claim, contact the Business Office to verify that the number has been registered with WHN

50. Enhanced Benefit Registration • WHN requires a copy of a DMA Community Intervention Services Agency Provider Number Assignment letter. • When billing with a non-registered enhanced benefit for your agency, the following denial will occur: • (045) EB Not Med Elig Inv Attd Number • If you have enrollment inquiries, contact: Pat Potter at (828) 225-2785 ext. 2185