1 / 15

Texas Hospital Association

Texas Hospital Association . August 27, 2013. Agenda. Opening Remarks Richard Schirmer Operational Update Sue Williams Claims Processing Sue Williams Question & Answer Session Wrap & Adjourn. Operations Update.

titus
Download Presentation

Texas Hospital Association

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. Texas Hospital Association August 27, 2013

  2. Agenda • Opening Remarks Richard Schirmer • Operational Update Sue Williams • Claims Processing Sue Williams • Question & Answer Session • Wrap & Adjourn Proprietary and Confidential

  3. Operations Update • Approaching Steady State • Most Inventories are “normalized” • Aging Profile has been largely achieved • Performance Metrics rapidly improving • Timeliness • Quality • Refocus on Process Improvements and Innovation Proprietary and Confidential

  4. Operations Update • Revalidations • Approximately 30% of providers have been revalidated over the past 2 years • Revalidations are expected to continue • Website Notification Link: https://www.novitas-solutions.com/enrollment/revalidation/mailing.html • New Mailing Addresses • P.O. Boxes & Zip Codes – effective July 29th • Old Addresses will work for a year • Website will be updated and notices published Proprietary and Confidential

  5. Operations Update • Reduced Wait Times across all queues • Call Completion Rate >90% • Improving quality Telephone Customer Service Proprietary and Confidential

  6. Operations Update Telephone Customer Service Proprietary and Confidential

  7. Operations Update • EDI Connections • Changes To Connectivity • Letters sent to all EDI Trading Partners on June 28, 2013 • Dial-up • Secure File Transfer Protocol (SFTP) • Phone number for dial up modem transmissions and URL (SFTP) changes • JL Customers (DC, DE, MD, NJ, PA ) • Begin using the new connections on July 29, 2013 • All JL should be using the new connections by September 27, 2013 • JH Customers (AR, CO, LA, NM, MS, OK, TX) Including Indian Health Services, and Veteran Affairs • Because of recent changes due to cutover activities, you may use the July 29th through September 27th transition period as an opportunity to begin using the new connections • We encourage you to use the new connections by September 27, 2013 but it is not required. Proprietary and Confidential

  8. Operations Update • Medical Review • Listing of pre-payment reviews found on the website: • Current service wide prepayment reviews - Part A : • DRG 227 -  Cardiac Defibrillator Implant without Cardiac Catheter without Major Complication/Comorbidity • DRG 243   Permanent Cardiac Pacemaker Implant with Complications/Comorbidity • DRG 244   Permanent Cardiac Pacemaker Implant without Complication/Comorbidity /Major Complication/Comorbidity • DRG 251   Percutaneous Cardiovascular Procedure without Coronary Artery Stent without  Major Complication/Comorbidity • DRG 287   Circulatory Disorders except AMI with Cardiac Catheter without Major Complication/Comorbidity • DRG 470   Major joint replacement or reattachment of lower extremity without Major Complication/Comorbidity • DRG 673   Other Kidney and Urinary Tract Procedures with Major Complication/Comorbidity • DRG 714 (Edit# 5H008):  Transurethral Prostatectomy without Complication/Comorbidity /Major Complication/Comorbidity Proprietary and Confidential

  9. Communications • Web Redesign • Phased Approach

  10. Claims Processing • Credit Balances & Voluntary Refunds • Providers should initiate adjustments • Eliminates positive credit balance submissions • Reduces the voluntary refund inventory • Credit Balance Status Tool • Fax to network drive capability • Revision of stem cell medical record development process • Automation (ECPS Events) • Submission of cancel claims with a medically denied line • Ongoing process Proprietary and Confidential

  11. Claims Processing National Claims Processing Issues • Medically Unlikely Edits • 51MUE- FISS implemented a fix on 7/9/13. Claims were released on 7/10/13 with the exception of those for ambulance services and a small number hitting edit 51MUE (20 in the TX region). Ambulance claims are being held in location SMMUEA. The fix is being tested and should be in place by 8/30. • 52MUE - FISS implemented a fix on 7/9/13. Claims were released on 7/10/13 • 53MUE - The fix is being tested and should be in place by 8/30. • 54MUE- No claims are in the hold location Proprietary and Confidential

  12. Claims Processing National Claims Processing Issues • Reason Code 30940 is received when attempting to adjust a claim with a medically denied line – The Issue is being research by the shared system maintainer, however, the adjustments can be performed utilizing DDE. • Claims are incorrectly cycling to CWF multiple times and are ultimately receiving reason code 39925 – Correction was implemented on 7/22/13. The claims being held required an additional step. They are now processing Proprietary and Confidential

  13. Claims Processing National Claims Processing Issues • Claims are recycling for reason code 39918/39919 when there is a  prior payment - FISS has acknowledged that there is an issue. The fix is tentatively scheduled for 11/4/13. • Claims are still receiving CWF MSP edits U6805 and U6825 incorrectly - Part A Claims Processing has been provided a workaround.  The fix is tentatively scheduled for 1/6/14. • MSP claims are rejecting with a Reason Code (34050 – 34549) that is not related to the MSP records at the Common Working File (CWF). Correction is tentatively scheduled for 9/3/13. Proprietary and Confidential

  14. Claims Processing National Claims Processing Issues • Claims for Reason Codes 39071, 39072, and 39073 may be looping, while others are rejecting for MSP appropriately. FISS is working to resolve this issue.  Claims will suspend to SMLOOP until system modifications are made, which are tentatively scheduled for October. • CWF IURs – Incarcerated Beneficiaries: For Part A claims automatic and instant recoupments are occurring, sometimes times inappropriately for beneficiaries who had a previous incarceration. This is an emerging issue and details are evolving. Proprietary and Confidential

  15. Jurisdiction H Contacts • Contact Information • David Vaughan, Vice President and JH Project Manager • 717-526-6600 • David.Vaughan@Novitas-Solutions.com • Steve Holubowicz, Director , Audit & Reimbursement • 414-918-2662 • Steve.Holubowicz@Novitas-Solutions.com • Debra Fulfer, Manager, Provider Outreach and Education • 214-273-7001 • Debra.Fulfer@Novitas-Solutions.com

More Related