Correcting MCO Information

1. Correcting MCO Information This module is for discussing how to correct MCO information on Patient and Encounters

2. MCO # 3 – Passport/Amerihealth 6 – Coventry 7 – Kentucky Spirit 8 – Wellcare 9 - Humana

3. Medicaid Payor Codes 2 – KY Medicaid 22 – HANDS 23 – Passport 24 – Amerihealth 26 – Coventry 27 – KY Spirit 28 – Wellcare 29 - Humana

4. We will cover 3 different scenarios. We will cover 4 Scenarios in this power point. • Claim billed to KY Medicaid but should have billed to an MCO • Claim billed to MCO but should have billed KY Medicaid • Claim billed to MCO but denied • Claim billed to the wrong MCO

5. The claim billed to KY Medicaid and should have billed to an MCO, take the following steps to correct. Scenario #1

6. Now Report 578 looks like this

7. EOB Codes 24 & N30 These codes mean that the claim should have been billed to a Managed Care Organization

8. On Patient Registration, set the visit date to the date the patient was originally seen.

9. Set your Reason for Visit.

10. Set the Medicaid MCO and the MCO Member #

11. Ask for a PEF and Registration Label. DO NOT check ‘Additional Pef?’.

12. DO NOT print the labels. You may hand write the corrections on the CH-5 with the effective date and initial and date

13. For GUI users, here is the path to get to the NERI screen.

14. Call up the patient’s NERI screen

15. Select the encounters and put the MCO# in the Par# field and transmit.

16. For GUI users, here is the path to get to the PERI screen.

17. If you call up the PERI, it will now reflect that the MCO has been added to the encounter.

18. The CPOD will not be necessary for this scenario.

19. After the corrections have been made and the MCO # has been added via the NERI screen, the PEF will automatically bill off to the correct MCO at the next billing.

20. Check the appropriate invoice register report the following week to verify services billed.

21. Adjust off the A/R Invoice that was set up for KY Medicaid

22. It is your agency’s decision on when to adjust off the invoice that was set up for KY Medicaid. DPH recommends adjusting after next invoice register is created.

23. The claim billed to an MCO and should have billed to KY Medicaid. Scenario #2

24. Now your MCO report will look like this.

25. Call up the patient’s NERI screen

26. Select the encounters and remove the MCO# in the Par# field and transmit.

27. After the MCO # has been removed via the NERI screen, the PEF will automatically bill off to KY Medicaid at the next billing.

28. You will not need to CPOD this claim. It should bill off automatically.

29. Adjust off the Invoice that was set up for Managed Care at your agency’s discretion.

30. The claim billed to the correct MCO but denied. Scenario #3

31. Example of denied claim

32. If denial was due to registration errors, make the appropriate corrections on registration screen.

33. Pull up the encounter, make correction if needed, and re-transmit.

34. On the encounter history screen, the PC field is the payor code. Since the payor code is 26, we know that it billed or will bill to Coventry.

35. For GUI users, here is the path to get to the PARI screen.

36. PARI Inquiry – Payor codes & MCO #

37. For GUI users, here is the path to get to the CPOD screen.

38. When requesting the CPOD screen, make sure you enter the correct PEF# and the payor code you are wanting to rebill. In the example below, we are rebilling PEF#19581689 and those services that went to payor code 26.

39. The CPOD screen will only pull the services that went to payor code 26. Information on the screen can be added, edited or removed.

40. Make sure you enter the correct A/R invoice number. If the services are paid, this is the invoice that the money will be posted.

41. After you make changes and enter the A/R Invoice #, transmit. These services will bill on the next billing cycle.

42. If you still type commands in the old way, the CPOD will be executed as shown below. If no services are pulled, verify your payor code on the PEF.

43. For claims rebilling to Passport, they can’t be rebilled electronically. You will need to change the Print HCFA? Flag to Y.

44. The claim billed to the wrong MCO. Scenario #4

45. On Patient Registration, set the visit date to the date the patient was originally seen.

46. Set your Reason for Visit.

47. Correct the MCO# and verify the MCO Member # is correct.

48. Ask for a PEF and Registration Label. DO NOT check ‘Additional Pef?’.

49. DO NOT print the labels. You may hand write the corrections on the CH-5 with the effective date and initial and date

50. Call up the patient’s NERI screen