Provider Waiver Orientation

1. Provider Waiver Orientation Sandhills Center LME/MCO

2. Financial Management and Monitoring • The Finance Department manages the financial resources of the LME/MCO. This includes: Management of accountability, availability of funds, claims processing and payment. • The Finance Department is responsible for ensuring compliance with General Statute 159 (The Local Government Fiscal Control Act) and other general accounting requirements. • The Finance/Claims Department supports providers through training and through its Claims Specialist Representatives.

3. Financial Management and Monitoring Your responsibility as a Contracted Provider is to: • Verify consumer insurance coverage at the time of referral, or admission, or each appointment, and on a quarterly basis. • Determine the consumer’s ability to pay using the Sliding Fee Schedule for all designated Non-Medicaid services based on your agency’s contract requirements.

4. Financial Management and Monitoring • Bill and report all first and third party payers prior to submitting claims to SHC. • Report all billing errors to SHC Claims Department. • Manage your agency’s Accounts Receivable. • Submit all documentation which is required for federal, state, or grant reporting. • Implement Internal Controls to support audits performed by Sandhills Center.

5. Financial Management and Monitoring • Network Providers shall maintain detailed records of the administrative costs and expenses incurred pursuant to their Contract with SHC. • This includes all relevant information relating to enrollees for the purpose of audit and evaluation by DMA. • Records shall be maintained and available for review during the entire term of this contract and for a period of five (5) years thereafter. • If an audit is in progress or audit findings are unresolved, records shall be kept until all issues are resolved.

6. Financial Management and MonitoringSHC’s responsibility to Providers is to: • Review Financial reports, financial statements and accounting procedures as applicable. • Monitor retroactive Medicaid eligibility and recovery of funds. • Issue payment and remittance advice (RA) on paid and denied claims. • Assist the Quality Management Dept with claims quality audit process.

7. Financial Management and Monitoring • Recover funds based on audit findings. • Audit providers for coordination of benefits (COB). • Manage and pay clean claims within the 48 day Prompt Pay Guidelines. • Report credible allegations of Fraud and Abuse

8. Provider requirements prior to submitting claims to Sandhills • Provider Contract has been completed and signed. • Login and Password has been requested for Provider Connect and Sandhills Direct Data Entry Web Tool if applicable. • Sharefile account has been set up. • Treatment Authorization Request has been entered and approved if required.

9. Share File Account • Once contract has been approved and signed, providers will receive notification that a Share file account has been set up. Notification will include URL address, User ID, password and provider instructions. • A submitter ID and our Receiver ID will also be included for 837 files.

10. How is Share File used • Providers will use to upload 837 files for processing. • Electronic files such as 999, 835 and 277 will be uploaded by the MCO for the provider. IT Department contact: edi@sandhillscenter.org

11. Claims Submission • Medicaid Claims should be submitted to Sandhills Center if the members Medicaid county of eligibility is within our 9 county catchment area: • Anson, Guilford, Harnett, Hoke, Lee, Montgomery Moore, Randolph, Richmond

12. Private Providers • Claims must be submitted within 90 days of Date of Service. • If a claim is denied, providers have an additional 90 days from the date of denial to correct the denial and resubmit.

13. Hospitals • Claims must be submitted within 180 days of Date of Service. • If a claim is denied, the hospital has an additional 180 days from the date of denial to correct the denial and resubmit.

14. Coordination of Benefits • Providers are responsible for billing Medicare and Third Party Insurance prior to billing Medicaid. • Current Medicaid Insurance edits will be used by HP to adjudicate SHC claims. • If a member has Medicare or Insurance and payment information is not included on the claim, the claim will deny.

15. Claims Submission Cont. • Checkwrite schedule is located on our website: www.sandhillscenter.org For Providers>Finance/Claims • Billing can be submitted daily. • Cutoff for weekly 837 files will be Wednesday at 5:00p.m. • Direct Data Entry will be 5:00 p.m. Thursday.

16. Claims Submission Cont. • MedicaidClaims can be submitted: • HIPAA standard EDI Transaction Files 837 Professional Health Care Claim 837 Institutional Health Care Claim Companion Guides are located on the SHC Website www.sandhillscenter.org For Provider>Finance/Claims

17. Claims Submission Cont. • Medicaid Claims can be submitted: • Sandhills Direct Data Entry Web Tool User Guide is located on the SHC Website www.sandhillscenter.org For Providers>Finance/Claims • Paper Claim

18. Sandhills Direct Data Entry Password • To request your DDE Web Tool login and password: Please fill out the Sandhills DDE request form located on our website: www.sandhillscenter.org Click on For Providers >Finance/Claims E-mail to billing@sandhillscenter.org

19. Medicaid Claims Adjudication • Sandhills has contracted with HP • Claims will adjudicate against all the current edits used by Medicaid. • Continue to use the same NPI billing logic as you did with NC Medicaid (HP) • Example:  If you are a CABHA submitting enhanced services, the CABHA NPI is your billing NPI and the Attending/Rendering is the NPI mapped to the Medicaid Provider Number for that service.

20. Denials • Providers 835 and Remittance Advice will include the current HIPAA Adjustment reason codes used by Medicaid. • A EOB crosswalk can be found on the SHC website: www.sandhillscenter.org For Provider>Finance/Claims

21. Adjustments/Correction • Adjustments can be handled three ways: Electronic 837 Sandhills Direct Data Entry Web Tool Submit “Claim Inquiry Resolution Form” – Form is located on SHC website www.sandhillscenter.org For Providers>Finance/claims

22. General Information-Medicaid • Providers will no longer require the member to pay a 3.00 copay. • Provider payment will include 3.00 copay amount. • System edits are in place to deny if 3rd party missing. • Providers will be held accountable. • Co-payments, deductibles, payment for missed appointments or other forms of cost sharing from Medicaid members, are prohibited.

23. IPRS Claims Submission • Can be submitted: • Provider Connect Web Portal User Guide is located on the SHC Website www.Sandhillscenter.org For Providers>Finance/Claims • HIPAA standard EDI Transaction Files 837 Professional Health Care Claim Companion Guides are located on the SHC Website www.sandhillscenter.org For Provider>Finance/Claims

24. Provider PaymentMedicaid and IPRS • Providers will have the option of receiving a paper check or electronic funds transfer. • An EFT request form is located on our website: www.sandhillscenter.org For Providers>Finance/Claims

25. Keeping Current It is the responsibility of the provider to research and stay abreast of new requirements and laws by utilizing all available resources: • Monthly Medicaid Bulletins • DMA and DMH Implementation Updates • SHC Communications/ Bulletins • SHC Website • Provider Connect News