As we begin to discuss the …..

1. Everything you always wanted to know about Out of State Medicaid billingbut were afraid to ask…June 14, 2013

2. As we begin to discuss the ….. (Authorization, Billing, Collection) ….. we must also consider the

3. 1. Registration • Identify the State / Medicaid Plan • Title XIX or Managed Medicaid / MCO • Copy of insurance card • Card # vs. Identification # • Each patient has unique ID number including newborns • Mom’s plan may differ from child (State vs. MCO)

4. Driver’s License • Patient demographics help identify State • Registration address match – residence / visitor / student / rehab facility • Primary Insurance Coverage • Medicare / Other Insurance • Utilizing Patient Accounting system to help identify insurance coverage trends

5. 2. Eligibility • Active coverage on date of service / Non-Covered • Gaps in coverage • Spend Down • “Flip – Flop” in coverage between Title XIX or Managed Medicaid / MCO

6. Max Benefits – Service Limits • ER Visit / Clinic / Therapy • Max visits per day / year • Service Types – Limited Coverage • Family Planning • Free Care • Patient Responsibility • Co-Pays

7. 3. Enrollment • Active Provider with State • May be needed to determine eligibility • Many MCO’s allow non-participating providers to submit claims / some require enrollment • Application / Documentation / Claim filing limits • ACA Requirements - SS#, DOB, home address for CEO/CFO/Board of Directors

8. When is it Cost Effective?? • Location – Bordering State, specialty hospital, vacation / tourist destination – will you see patients more than once? • Application length / requirements vs. reimbursement • Length of Contract – one time per group of claims, yearly, open ended with provider maintenance • Application Fees • Will State retroactively activate provider to cover all claims?

9. Be Prepared … • Some States require physicians to be registered as well in order for the facility to be reimbursed • OPRA (Ordering, Prescribing, Referring, Attending) • Streamlined Enrollment vs. Fee for Service

11. A. Authorization • Will State / MCO allow you to submit a request without active enrollment? • Does the State / MCO have a specific form? • How long is the notification window? • Border vs. Out of State • Border is treated as “In-State” • Will retro authorizations be allowed?

12. Service types requiring authorization • Title XIX vs. Managed Medicaid / MCO • All Inpatient MCO and typically Outpatient elective services require approval • Elective MRI, CT Scans, Molecular Labs • Extended Newborn Stays • L & D • Some States require ER notification • Supplying Clinical Information – registration sheet without concurrent review or follow-up

13. B. Billing • Filing Limits - Title XIX vs. MCO • Submission Methods • Paper vs. Electronic • Submission waivers • Claim Submission Address • In State / Out of State may have different addresses (Claim vs. Clinical information)

14. Attachments • Medical Records • ER Certification Forms • Transmittal Sheets • Provider Activation Letters • Waiver Forms • Patient Statements / Notes / Registration sheets • Other Insurance payment or denials / EOB’s • Enrollment Welcome Letters • W-9 forms (1st time billing to MCO)

15. Paper Claims • Pink vs. Black & White • Handwritten Data • Data Formatting • Billing Address vs. Service Address • Form Locator usage varies State to State • Required vs. Conditional form locators • Allowable / Covered Revenue & HCPCS codes • Payer Name / NPI / Legacy Provider # • Taxonomy Codes / Physician NPI

16. Additional reasons why claims are rejected/unprocessed • Having Staples • Folding • Handwritten Date Format (MMDDYYYY) • Multiple Page Claims • Physical Signature on Claims • Specific claim form for certain charges • Bill Labs separately on HCFA 1500

17. C. Collection • Be prepared before initiating contact with the payer • Method of Access • Telephone • Special phone numbers for OOS providers • Web portal • Level of access for the function you’re performing

18. Information required by payer to verify PHI • Provider number / NPI / Tax ID • Provider Name • Patient ID #, Name, DOB • Service Date, Charge Amount • Previous History • Call Tracking # / Reference # / Appeal # • Claim Number(s) from prior submissions • Document the name of the provider service representative

19. “No Claim on File” – Why? • Was claim received & unprocessed? • Do they have a rejection file? • Confirm mailing address • Reconfirm eligibility • Automated response – opt out for a representative • Don’t be afraid to ask additional questions if the information you’re provided doesn’t fall in line with what you know about the payer • Ask to speak with a supervisor

20. Claim is “In Process” • Date of receipt? • Typical length of processing time? • Attachments required with claim submission? • Reason for delay? • Back log • System Conversion • Manual Pricing • Action needed by provider? Enrollment issues? • Claim number or call tracking number for future reference

21. Claim “Denied” – Where do we go from here? • When / Why / Claim number from denial? • Be specific with changes/corrections to be made • Does payer require a re-billed or corrected claim? • Timeframe to resubmit a corrected claim / appeal? • How does payer accept re-submissions? • Facsimile / Web Portal • Overnight / Certified • Required attachments / documentation? • Dedicated address for resubmission?

22. Claim “Paid” • When / Amount / Claim number • Check vs. EFT • Check number / Deposit Date • Payment Methodology • Internal / payer set fee schedule • Mirror provider’s home State Medicaid rate • All lines paid • If not, can they be reconsidered for payment • Service not covered by payer vs. not covered under provider’s contract

23. Rules to live by… • Ask to speak to a supervisor or manager • Try to establish a positive relationship • Ask if a claim or appeal can be reprocessed internally • Communicate trends & patterns with all departments • Maintain reference guides / manuals • Sign up for distribution lists / e-mail updates • Out of State Medicaid is one of the most “fluid” payers by virtue of the number of State agencies and Managed Care plans involved…

24. Thank You! Ron Premorpremo@allstatesmedicaid.comLynn Carpenter-Whitelwhite@allstatesmedicaid.comAll States Medicaid, Inc. 2 South Main StreetMilford, MA 01757Phone: 508-482-9600Fax: 508-482-9627