1 / 55

Key Concepts - Provider

Key Concepts - Provider. New 10 digit Provider ID Provider ID/Service Location 123456789 A Fewer User ID Numbers Today : IDs for MMIS, PCSS, APAS, REVS Tomorrow: NewMMIS: 1 User ID and 1 Password. Key Concepts - Provider. Industry Standards

reeves
Download Presentation

Key Concepts - Provider

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Key Concepts - Provider • New 10 digit Provider ID • Provider ID/Service Location123456789A • Fewer User ID NumbersToday: IDs for MMIS, PCSS, APAS, REVSTomorrow:NewMMIS: 1 User ID and 1 Password

  2. Key Concepts - Provider • Industry Standards • Claim Level Processing - NewMMIS Adjudicate Multi-line Claims as a Single Claim with Multiple Lines: Consistent With Other Major Payers • Real-Time Processing of DDE Claims • NewMMIS Will Utilize the Standard UB-04 and CMS-1500 Claim Forms

  3. Region Year Julian Day Batch Sequence Key Concepts - Provider • Industry Standards • Ability to “Copy” a Claim Will Be Preserved • NewMMIS Replaces 12-digit TCN with13-digit ICN (Interchange Control Number)ICN Format: RRYYJJJBBBSSS

  4. Key Concepts - Provider • Electronic Attachments • NewMMIS Replaces Claims Attachment Form (CAF) • Providers can Submit Electronic Attachments with DDE Submissions for PA, PAS, Referrals, Claims, Provider Enrollment, MMQ, SCO/PACE enrollments etc.

  5. Key Concepts • Service Authorization Numbers • Service Authorizations Will Now Be Identified by a 10-character Number:S071240014 • 1st Character: ‘R’ for Referral, ‘P’ for Prior Authorization ‘S’ for Pre-Admission Screening 1st Character Julian Date Unique Sequential Number

  6. Five Steps in the Provider Scenario 1.0 Enroll a Provider & Maintain Profile 2.0 Access Provider On-Line Service Center 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered

  7. A Provider’s Scenario 1.0 Enroll a Provider & Maintain Profile 2.0 Access Provider On-Line Service Center 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered • How a Provider, Harriet Potter, gets enrolled in MassHealth, submits request for services and submits claims for payment • How Dr. Potter will access a variety of functions through the NewMMIS Provider on-Line Service Center 8

  8. 1.0 Enroll a Provider & Maintain Profile 2.0 Access Provider On-Line Service Center 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Start an Enrollment Application

  9. 1.0 Enroll a Provider & Maintain Profile 2.0 Access Provider On-Line Service Center 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Continue an Enrollment Application • The Provider Continues • To Complete the Application: • Service Locations • Address Type • Identification Info • Medicare Info • Personal Info • Specialty Info • License Info • Certification • Provider Relationships • Hospital Affiliation • Billing Intermediary • Trading Partner Agreement • Background Info • Attachments • Summary • Confirmation

  10. 1.0 Enroll a Provider & Maintain Profile 2.0 Access Provider On-Line Service Center 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Provider Application Workflow NewMMIS Provider Applications Provider Submits DDE App As the Provider begins an Enrollment Application, NewMMIS will present specific panels depending upon the Provider Type Legal Entity, Managed Care or Group details. An Application Tracking Number (ATN) is generated to the provider to log onto the Web Portal and save or submit an existing application.

  11. 1.0 Enroll a Provider & Maintain Profile 2.0 Access Provider On-Line Service Center 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Provider Application Workflow NewMMIS Provider Applications Provider Submits DDE App Workflow Review App Workflow CST Enters Application Approve Application & Generate ID Provider Submits Paper App Notify Providers

  12. Search by Provider ID or Legacy ID or NPI Address Type RemittanceInformationDBABillingCheck Mailing Search by Provider Type “Search for Active Therapists (192) in Boston?” ………… no problem!

  13. Provider Information Panel A - Warren A. Thomas B- Michael B. Thomas C- Michael C. Douglas Section 1:Details don’t change with a Multi-Location Provider 2 3 1 Sections 2 & 3 Service Location etc. when a Different Service Location is Chosen From the Drop Down Menu

  14. 1.0 Enroll a Provider & Maintain Profile 2.0 Access Provider On-Line Service Center 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Provider Maintenance

  15. 1.0 Enroll a Provider & Maintain Profile 2.0 Access Provider On-Line Service Center 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Provider Maintenance

  16. 1.0 Enroll a Provider & Maintain Profile 2.0 Access Provider On-Line Service Center 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Provider Preferences Check Mailing

  17. 1.0 Enroll a Provider & Maintain Profile 2.0 Access Provider On-Line Service Center 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Provider – Check Mailing Address

  18. 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 3.0 Submit Requests for Service Authorization 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Key Concepts – Provider The Provider Online Service Center gives you the tools to effectively manage your business with MassHealth electronically. Use these services to enroll as a MassHealth provider. Manage your profile information and submit and retrieve transactions. Enter data directly and modify individual transactions (i.e. claims submission, eligibility verification, MMQ, Prior Authorization, Pre-Admission Screening, and Referrals). View your notifications, contracts, reports, metrics, and financial data. Download most MassHealth forms and publications.

  19. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Verify Member Eligibility POTTER, HARRIET MD

  20. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Verify Eligibility – Member Info Bailey, Mary011 11 1111

  21. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Verify Member - Eligibility Panel

  22. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Verify Member – Eligibility Restrictions

  23. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Submit A Pre-Admission Screening Dr. Potter Submits a PAS for George Bailey

  24. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Submit A Pre-Admission Screening Drop Down to Select PAS Assignment Dropdown to Select Dr. Potter’s Choices Potter Harriet MD Bedford Falls Rehab Hospital Search Button to Find Facility or Attending Physician

  25. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Submit A Pre-Admission Screening Request has been saved with this PAS# S08000000B Length of Stay in Days 10000555555 7871 = Heartburn Save & System Returns PAS # After Edits Search Button to Find Diagnosis Code

  26. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered PAS Adding a Line Item: Requested Level of Care & Admission Type to PAS

  27. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered PAS Confirmation Bedford Falls Rehab

  28. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Update a Pre-Admission Screening S08000000B Entering PAS Number Produces Link to PAS Base Information S08000000B 100023924251 Bailey, George 01/30/08

  29. Update a Pre-Admission Screening 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered

  30. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Update Pre-Admission Screening Harriet Potter, MD Bedford Falls Rehab George Bailey Modify Reopens the PAS Base Information Panel for Changes

  31. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered PAS Flow Notification Approved Denied Modified PAS Unit NewMMIS Transaction Assignment Submits PAS Workflow Approved Denied Modified MassPRO Notification

  32. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Submit Prior Authorization

  33. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered PA – Enter Base Information 100023924251 POTTER, HARRIET MD TEST DIAGON ALLEY CLINIC AND EMPORIUM 7871

  34. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered PA – Enter Line Items

  35. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered PA – Line Items – Basic Medical Details

  36. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered PA – Submit for Confirmation Request has been saved with this Tracking# 103,401,225

  37. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Enter PA Request - Confirmation Request has been saved with this Tracking# 103,401,225 You are about to submit a Prior Authorization request for Member 1234443212 for the following procedures. Please verify the data and the click “Submit”.

  38. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered PA Flow Approved, Denied, Modified Notification PAUnit Workflow NewMMIS Transaction Assignment Submits PA’s PAUnit Workflow PAUnit Workflow

  39. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Submit A Referral for George Bailey

  40. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Submit A Referral for Harry Bailey POTTER, HARRIET MD BEDFORD FALLS PSYCHIATRY

  41. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Referral Confirmation George Bailey

  42. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Inquire About a Referral – 3 Ways 1. Inquire by the Referral Number: e.g.R08035001F 2. Search for Referrals Submitted toBedford Falls Psychiatry 3. Search for Referrals Submitted byBedford FallsPsychiatry to Another Provider

  43. 3.0 Submit Requests for Service Authorization 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 4.0 Submit a Claim for Services Rendered 5.0 Receive Payment for Services Rendered Referral Information – Update George Male Bailey Potter, HarrietBedford Falls Psychiatry

  44. 4.0 Submit a Claim for Services Rendered 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 5.0 Receive Payment for Services Rendered 3.0 Submit Requests for Service Authorization Submit A Claim – Billing & Services Billing and Service COB Procedure Attachments Confirmation Dropdown of Billing Provider ID Numbers 011000001111 – Bedford Falls Psychiatry Member Info

  45. 4.0 Submit a Claim for Services Rendered 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 5.0 Receive Payment for Services Rendered 3.0 Submit Requests for Service Authorization Submit A Claim – Billing & Services Billing and Service Place of Service Service Information Diagnosis Codes Total Charges

  46. 4.0 Submit a Claim for Services Rendered 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 5.0 Receive Payment for Services Rendered 3.0 Submit Requests for Service Authorization Submit A Claim – Billing & Services Coordination of Benefits Extended ServiceInformation Service Facility Provider List of Claim Notes Ambulance Transport and Certification Home Healthcare Plan

  47. Submit Claim – Coordination of Benefits 4.0 Submit a Claim for Services Rendered 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 5.0 Receive Payment for Services Rendered 3.0 Submit Requests for Service Authorization Coordination of Benefits (COB) Detail

  48. Submit Claim – Procedure 4.0 Submit a Claim for Services Rendered 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 5.0 Receive Payment for Services Rendered 3.0 Submit Requests for Service Authorization Procedure Professional Service Detail

  49. Submit Claim – Procedure (cont’d) 4.0 Submit a Claim for Services Rendered 2.0 Access Provider On-Line Service Center 1.0 Enroll a Provider & Maintain Profile 5.0 Receive Payment for Services Rendered 3.0 Submit Requests for Service Authorization Durable Medical Equipment Service Ambulance Service Home Oxygen Therapy Information

More Related