Post on 17-Nov-2021
September 12, 2014
Overview
Elderly Waiver Providers
working with UCare
Agenda
Part I - Introduction to UCare
Part II – Working with Clinical Services
Part III – Provider Assistance Call Center
Part IV – Claims Submission
Part V – Special Investigations Unit
Part VI – Working with UCare - Resources
Questions & Answers
UCare History
UCare is a nonprofit health maintenance organization (HMO) created in 1984.
Today, UCare is an independent HMO serving 437,111 members throughout Minnesota and Wisconsin.
Mission Statement: To improve the health of our members through innovative services and partnerships across communities.
Snapshot of UCare
437,111 members/4th largest HMO in state of Minnesota
UCare has a vast network (in Minnesota and Wisconsin) of providers that include:
physicians
specialists
hospitals
waivered providers
Elderly Waiver Providers
January 1, 2014 date DHS took over the oversight of Elderly Waiver Tier 1 providers.
Elderly Waiver providers without contracts.
UCare contracts directly for some extended waiver services, such as transportation, personal care assistants (PCA), and home health services covered through the waiver as "extended" services.
UCare Product Overview
2014 Service Area – MN & WI
UCare Products Exchange Products
UCare Choices
Fairview UCare Choices
Medicare Advantage (MA) plan – MN & WI
UCare for Seniors
Special Needs Plans (SNPs) – MN Only
UCare’s Minnesota Senior Health Options (MSHO)
UCare Connect (Special Need Basic Care – SNBC)
Minnesota Health Care Programs (MHCP) – MN Only
Prepaid Medical Assistance Program (PMAP)
MinnesotaCare (MNCare)
Minnesota Senior Care Plus (MSC+
Working with Clinical Services
Authorization Process of Elderly Waiver
Services.
• The Care Coordinator completes a face to face (
LTCC) assessment with the member regarding
needed services and ensures waiver eligibility to
include waiver budget.
• The case manager/care coordinator communicates
the approval of waivers services to the provider and
UCare via the Waiver Service Approval From.
• Reminder: Before providing EW services to a
UCare member, you need to obtain written
authorization through the Case Manager/Care
Coordinator or County Care Coordinator
Authorization Notification Process.
The WSAF (Waiver Service Approval Form) is sent
by the Case Manager/Care Coordinator to UCare
Clinical Intake via fax or secured e-mail.
Upon receipt of the WSAF, UCare will review the
approval, ensure the documented information is
complete and aligns with DHS EW related policy.
UCare will enter the authorization into the UCare
approval system and a copy of the authorization is
sent via mail to the member and provider.
In addition to the mailed provider letter, a copy is
also faxed to the provider.
Sample of UCare WSAF
https://www.ucare.org/providers/Documents/WaiverServiceAp
provalForm_rev6.2014.docx
Sample of UCare approval letter:
Resources
• Find other key guidelines in the Home and
Community Based Services chapter of our
Provider Manual -
https://ucare.org/providers/Resources-
Training/Provider-
Manual/Pages/ProviderManual_26.aspx
Provider Assistance Call Center
(PAC)
Who Do I Contact?
• Provider Assistance Center
612-676-3300 or 1-888-531-1493 (toll free).
– Available Monday – Friday, 7 am to 5 pm.
Serves as a resource if you have claim payment concerns that are trends, or have a significant impact on your accounts receivables.
What types of questions can the PAC help
with?
• Claims questions
• Benefit questions
• Authorization questions
• Provider Portal questions
• Credentialing/Contracting issues
• Eligibility
Claim Submission
Provider ID
If you are an EW provider and are in need of a
UCare provider number you may contact Rebecca
Walsh at 612-676-3624.
Typical turnaround time is 30 days for a provider
set up.
Submitting claims to UCare you need
an electronic clearinghouse
• MN-eConnect: UCare providers have free access
to submit claims for UCare members.
• www.mneconnect.com or 1-877-444-7194
• You can choose a different electronic
clearinghouse, but you need to be set up before
submitting claims to UCare.
• Find other essential billing and claim guidelines
• In the Claims Submission chapter of the UCare
Provider Manual: www.ucare.org/providers/Documents/Chapter_6.pdf
Submitting claims to UCare Bill all EW services to
UCare electronically using
the 837P Professional
claim transaction. (This
corresponds to the old
paper form called HCFA
1500, for those who are
familiar with that – but no
paper forms any more!)
The Rendering and Billing
segments are required –
how you complete them
varies, depending on your
provider setup, and there
are a couple submission
options.
Four Provider identifiers
• NPI
• UMPI
• Group Practice Number
• UCare Legacy Number
Which provider ID to use
Non-medical EW service providers: You can submit claims using
only your UCare Legacy and UCare Group Practice numbers. This
can streamline your claim processing, for example, if you have
multiple locations that share the same UMPI but have unique
UCare Legacy Numbers.
Here’s how:
Put your UCare Group Practice Number in loop 2010BB segment
REF02 (this was field 33B on the old paper HCFA) with qualifier
G2 in Ref 01, and your UCare Legacy Number in loop 2310B/segment
REF02 (field 24J on a paper form) with a G2 qualifier.
If you have an NPI
You have 2 options:
Put the NPI in loop 2010AA and leave the rendering loop blank
(UCare will accept the data and automatically place the billing
information in the rendering field).
OR
Put your UCare Group Practice Number in loop 2010BB / segment
REF02 (this was field 33B on the old paper HCFA) with qualifier
G2 in Ref 01, and your UCare Legacy Number in loop
2310B / segment REF02 (field 24J on a paper form) with a G2
qualifier.
If you have an UMPI
You have 2 options:
• Put the UMPI in loop 2010BB (field 33B on the paper HCFA)
and 2310B / segment REF02 (field 24J on a paper form) with
a G2 qualifier.
OR
Put your UCare Group Practice Number in loop 2010BB segment
REF02 (this was field 33B on the old paper HCFA) with qualifier
G2 in Ref 01, and your UCare Legacy Number in loop 2310B /
segment REF02 (field 24J on a paper form) with a G2 qualifier.
UCare member ID format
• The UCare member ID is always 11 digits (all
numbers).
• You need UCare member ID to bill UCare. The
Medicaid number won’t work (but you can use it
to look up the UCare member ID)
• The Medicaid number (PMI) is 8 digits – You can
use this to look up the UCare member ID in our
secure Provider Portal.
Special Investigations Unit
Fraud, Waste & Abuse Special Investigations Unit (SIU)
-Detects possible cases.
-Investigates cases.
-Recovers overpayments.
-Prevents future issues.
-Post-payment review.
Fraud, Waste, Abuse:
•Billing for services that didn’t
occur.
•Altering documentation/claims.
•Duplicate claims.
•Services not authorized.
It is a federal crime to provide false
information on waiver billings for Medical Assistance
(UCare) payment.
What are the rules? • Federal Regulations
• State Statute and Rules
9505.2175
• Provider Contract (county or UCare)
• UCare Provider Manual- Chapter 26
• MHCP (DHS) Provider Manual
• Include member’s name on each page
• Date of chart entry and date service rendered
• Length of time, if a time-based code
• Signature and title of person who rendered
• Legible
• Each individual service
Records:
Do NOT: • Do not bill for goods/services not furnished
• Do not bill the full amount authorized if the
member received less than the full amount (i.e.,
time based code)
• Do not bill more than authorized OR without an
approval from the Care Manager
• Do not bill services you know should be denied
• Do not bill solely based on the authorization
• DO: Bill based upon records of service or goods
actually rendered
Examples: • The member is out of the country visiting family from February 1
through March 31. Waiver provider is authorized 2 hours per
day 2 days per week and billing company knows they are
supposed to bill the same every week. So the claims are
submitted even though the member did not attend.
This is fraud/abuse.
• The care manager authorized the member to receive 3 hours
per day, but the member actually receives only 1 hour because
she has a neighbor come over who helps for free. Waiver
provider bills 3 hours anyway, because it was authorized.
This is fraud/abuse.
Kickbacks:
Compensation, bribe or rebate
Felony:$25,000 fine and/or 5 yrs. in prison
PROHIBITED:
• coupons providing discounts
• cash
• merchandise
• or other goods or services of value (gift cards)
• in exchange for utilizing services from a particular
provider.
Avoid: Influence
What can you do?
Follow the rules.
Tell us when you make a mistake and fix it.
Cooperate with SIU when we come onsite or
contact you.
Report Suspected Fraud/Abuse: UCare Special Investigations Unit
P.O. Box 52 Minneapolis, MN 55440-0052
Compliance@ucare.org
Anonymous reports can be made by calling
612-676-6525
Working with UCare- Resources
Provider Manual The Provider Manual can only be accessed online by logging on
to www.ucare.org/providers/Pages/ProviderManual.aspx.
Verifying a Member’s Eligibility
• Web Portal
Provider Portal, UCare’s secure web site.
A login and password is required.
• Interactive Voice Response (IVR)
Call Provider Assistance Center’s phone number 612-676-3300 or 1-888-531-1493 (toll free).
You will need the member’s UCare ID number and their date of birth.
Provider Portal
• UCare’s Provider Portal is our secure web portal
for providers to login and retrieve the following:
Verify member eligibility.
Check claims status.
Check referral/authorization status.
Locate participating providers.
Review current member roster.
• Log into Provider Portal by visiting our page at
www.ucare.org/providers
Provider Portal Location
Provider Portal UCare - Login
Please remember to
Notify UCare of changes in your business:
Moving location
Adding location
Closing location
If your license ends or changes in any way
Please do so within 60 days of the actual
effective date.
Quick Links
Additional Reminders
EW Wavier Requirement
Verify members eligibility monthly
Bill appropriate codes
Reimbursement from the DHS Fees Schedule
Overview of In-Service
UCare’s history which included the current enrollment
numbers.
Informed you on how Clinical Services works with providers
and members.
We provided you information on how the PAC should be you
first stop for provider questions.
Gave you information to help in submission of clean claims.
The SIU segment provided clear direction on record keeping
and defined Fraud, Waste and Abuse with examples.
Our last segment provided you with resources on our
website at your disposal.
Questions & Answers
Thank you -- We look forward to working with you!
Спасибо Merci شكرا Gracias
Ua Tsaug Mahadsanid آپ کا شکریہ