Sage Screening Program 2010

1. Sage Screening Program 2010 Billing and Remittance

2. 1. The Sage Provider Agreement • It is our basis for doing business • It is the legal agreement between us • It is signed by both parties • MDH and your organization • It is cancelable by either party • With 30 day notice • It references the Provider Manual

4. The Sage Provider Agreement • Through it you agree to accept Sage reimbursement as payment in full • From all sources • Sage is payer of last resort • Send EOB with claim • You agree covered services are free to the patient • No carry-over to patient after insurance

6. 2. The Sage Claims Process • Your claim is received and entered into Sage Database within 2 weeks • Claim is “Validated” every 2 weeks • At Validation, a remittance advice is generated and mailed to you • Sage sends payment information through the state payment system • Payment usually is sent by the State within 2 weeks • Total time from receipt to payment should be 4 weeks (can be as long as 6 weeks)

7. 3. Sage-Covered Services • Diagnostic mam • Breast ultrasound • HPV test* • Breast bx • FNA • Endometrial bx* • Case Management • Office visit • Mammogram • CAD • Pap smear • Cytopathology • Physician interpretation • Colposcopy • Pathology charges * limited cases

8. 3. Sage-Covered Services • Current Procedural Terminology (CPT) codes listed on the Sage Screening Program Reimbursement Rates sheet are covered • Any other CPT codes will be automatically denied • The Sage Reimbursement Rate Sheet details these codes with the current $ • It can be found on the Web at MNSage.com

10. 4. Submitting Claims • Submit your claims on one of three forms: • CMS 1500 (formerly HCFA 1500) • UB 92 • The Sage Reimbursement and Billing Summary Sheet (to be discontinued)

11. Submitting Claims:Critical information on claims • Federal ID#, name, and address of organization to be paid • Date of Service (d.o.s.) • Encounter # for patient’s d.o.s. • Patient’s name • CPT code (including modifier) • Charge for the service provided • Amount paid by insurance

12. Submitting Claims • Bill patient’s insurance company first • Sage will pay any balance up to the allowable amount listed on the Sage Reimbursement Rate sheet • If the insurance has paid the allowable amount or more, it is not necessary to bill Sage • On your claim, show the amount of insurance paid per cpt code and attach the EOB • Claims must be received within 1 year from date of service

13. Submitting Claims:Special Case - Additional Mammographic Views • Encounter numbers for additional mammographic views should have an “A” added after the number that was used for the screening mammogram • This “A” must be included on claims for the additional mammographic view (Example: ABC 201A)

14. Submitting Claims:Special Case - Outpatient Breast Biopsies • Authorization needed — provider arranging the breast biopsy calls for authorization M# • Sage provides Outpatient Breast Diagnostic Procedure invoices- four copies of this invoice, complete with the patient’s name, encounter number and authorization number, can be sent to the person obtaining the authorization if desired

15. Submitting Claims:Special Case - Outpatient Breast Biopsies

16. Submitting Claims:Special Case - Outpatient Breast Biopsies • All charges associated with the breast biopsy—surgical consultation, biopsy, placement of wire, anesthesiology, and pathology are submitted “attached” to the OutpatientBreast Diagnostic Procedure invoice and, if applicable, the explanation of benefits. • If the Outpatient Breast Diagnostic Procedure form is not sent- Make sure the Sage Authorization or “M” number is on the claim

17. Submitting Claims:Special Case - Outpatient Breast Biopsies • All Professional charges associated with the breast biopsy should be submitted on the CMS1500, All Outpatient Hospital or Ambulatory Surgical Center charges should be submitted on a UB04. • If the Outpatient Breast Diagnostic Procedure form is not sent- Make sure the Sage Authorization or “M” number is on the claim

18. 5. Getting Paid • The Sage Remittance Advice explains the payment for your claims (or non-payment) • To match checks or deposits to the appropriate remittance advice, use the Sage payment number reflected as year, month, day • (example: Sage Payment #20060511)

20. Remittance Advice information • There are 4 categories of claims outcome • Paid • Suspend- Pending Visit • Suspend- Pending Test Results • Dissallowed • If you have questions on any claim call

21. Breast Biopsy Payment • Sage will reimbures professional fees according to the CMS PFS • Sage will reimburse lab tests according to the CMS CLFS • Sage will reimburse facility fees according to CMS OPPS

22. Payment by Check 04-23-06 MEDICAL CLINIC - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - TRANS NUMBER AGENCY & PHONE NUMBER VENDOR INVOICE AMOUNT - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - H12 50000000000 HEALTH 651-215-0486 SAGE PMT 20060409 2,503.03 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - DATE NUMBER VENDOR NAME NET 04/23/06 41100000 MEDICAL CLINIC 2,503.03 • Example of Check Stub From State of MN

23. Payment by Direct Deposit • Direct Deposit Payments are transferred electronically to the vendor's financial institution. The State website where you can find the payment information after a deposit is made is: http://www.mmb.state.mn.us/maps-eft?showall=1 • Vendors of Sage can apply to become an EFT vendor by contacting MN Management & Budget at that same website

24. 6. Contact for Billing/Remittance • 651-201-5630 or • Joanne Noot (Sage forms & procedures) 651-201-5628 • Shannon McNamara (breast biopsy billing issues) 651-201-5904

25. Thank You! • The End