P0380 (09/09)

2009 Indiana Health CoverageProvider Programs SeminarTop 10 Claims Denial and Prior Authorization/CMS (08-05)

October 22, 2009Hoosier HealthwiseNoon-12:45 p.m.

Hoosier HealthwiseHoosier Healthwise

Today’s discussion

1. CMS ( 08-05)Overview 2. Top Ten (10) Claims Denial3. Common coding errors4. Claims disputes and appeal5. Prior authorization6. Discussion with MDwise Delivery System

Representatives

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Hoosier Healthwise

CMS 08-05

Revised form, which accommodates the reporting of the National Provider Identifier “NPI”

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Bill Types for CMS 08-05

Types of servicesAudiology servicesCare Coordination servicesChiropractic servicesFamily Planning, FQHC’s, RHC’s, Medical servicesOral surgeryDurable Medical Equipment/Home Medical Equipment (DME/HMEMedical suppliesRadiological services

Types of servicesProfessional component, technical component, or global componentMedical rehab (MRO) servicesOutpatient mental health services

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Bill Types for CMS 08-05Types of servicesAnesthesiology assistant servicesPhysician assistant services, Advanced practice nurse credentialed in psychiatric or mental health nursingOptical ServicesOptometric servicesAnesthesia servicesLaboratory servicesMedical services-professional componentRenal dialysis servicesSurgical services

Types of servicesPodiatric servicesTherapy services-physical, occupational, speech, and mental health

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NPI (CMS 08-05)

NPI The National Provider Identifier is the unique

identifier assigned for each individual provider. The NPI is a national identifier and should be included on all claims submissions for all types of health plans.

All Providers who are not exempt are reminded to report your NPI to the Indiana Health Care Program (IHCP). Claims Payment depends on an accurate NPI being reported for all MDwise Programs.

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Top Ten Claims Denial CMS 08-05

What is the number one cause for claims denial for MDwise claims?

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MDwise Top Ten Claims Denial (CMS 08-05)

1. Duplicate claim 2. Claim/Service lacks information which is needed for

adjudication3. Coverage not in effect at the time the service was

provided4. Payment denied/reduced for absence of, or exceeded,

pre-certification/authorization5. Non-covered charges6. The referring/prescribing/rendering provider is not eligible

to refer/prescriber/order/perform the service7. Past the timely filing limit8. Payment adjusted due to member having primary

insurance payer/coordination of benefits9. Charges exceed fee schedule or maximum allowable

amount10. Diagnosis code is non-covered or invalid

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Pre-Claims Submission/Check List (CMS 08-05)

It is necessary to confirm all of the items on the check list prior to rendering services and submitting a claim.

Is the member eligible for services today? What IHCP Plan is the member enrolled in ? ( Hoosier

Healthwise (Anthem, MDwise, MHS) , Care Select, Traditional, Presumptive Eligibility)*

Is the member enrolled in the Healthy Indiana Plan? Who is their Primary Medical Provider (PMP)? Does the member have primary health insurance other than

Medicaid or HIP?

*Presumptive Eligible members are not eligible for any INPATIENT SERVICES.

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Claims submission and Inquiries (CMS 08-05)

Providers are encouraged to submit their claims electronically- see quick contact sheet for payor information

Providers need to submit all Medical and Behavioral Health delivery system claims where the member is assigned.* Except for Family planning which are submitted to the Family planning address on the quick contact sheet (ProHealth Family planning should be sent to the medical claims address)

Providers should contact the applicable delivery system for specific instruction on electronic claims submission

*Please note that all electronic claims must be submitted using the HIPAA compliant transaction and codes sets.

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What do you do when your claim is denied?(CMS 08-05)Claims Inquiry

In and out of network providers need to contact the MDwise Delivery System to inquire about a claims denial.

MDwise Delivery Systems are required to respond within 30 calendar days of inquiry to the provider with the decision of the inquiry.

Appeals/Dispute-Must be in writing & include the following*Providers have 60 calendar days to file an appeal and must include the following documentation:

Appeal form, remittance advice and a copy of the claim. If a delivery system fails to make a determination or the Provider

disagrees with the determination, the provider should forward their appeal to:

MDwise Corporate at P. O. Box 441423 Indianapolis, IN 46244-1423 Attention: Grievance Coordinator

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Claims Filing Limit (CMS 08-05)

In-Network Providers have a filing limit of 180 days. Out-of-Network Providers have 365 days from the date of

service to file a claim.

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Third Party Liability (CMS 08-05)

MDwise is always the payor of last resort (Medicaid) MDwise contracts with Health Management Solutions

(HMS) to work with coordination of benefit issues. MDwise does not have a 90 day rule, providers

should work with delivery system on a case by case basis.

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Eligibility (CMS 08-05)

It is the responsibility of ALL providers to check eligibility at the time of each visit.

Indiana Health Coverage Programs (IHCP) Benefit Packages: MDwise & IHCP administered Plans Package A Package B Package C Package P Care Select Right Choices (restricted card)

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Prior Authorization (CMS 08-05)

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Role of Medical Management (CMS 08-

05)

MDwise Medical Management functions are done at a Delivery System level.

Medical Management focuses on the outcome of treatment with an emphasis on: Appropriate screening activities Reasonableness and medical necessity of all services Quality of care reflected by the choice of services provided,

type of provider involved and the setting in which the care was delivered

Prospective and concurrent care management Evaluation of standards of care/guidelines for provision of

care Best practice monitors

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Role of Medical Management (CMS 08-05)

Medical Management service authorization activities conducted by the Medical Management staff include:

Preauthorization of inpatient and selected outpatient services, including pharmaceutical referral management, concurrent review and retrospective review on selected inpatient and outpatient services authorization and denial notification.

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Contacting Medical Management (CMS 08-

05)

Contact members Medical Management Department for services that require authorization ( see quick contact sheet)

Prior authorization forms are available online or by contacting the MDwise members Medical Management Department

*note- To obtain the correct Medical Management Department, check eligibility for members delivery system.

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Referral to Specialist (CMS 08-

05)

A prior authorization number may not be required when referring to a in-network provider.

Please refer to the Delivery System Medical Management Department or provider directory for assistance in locating an in-network provider.

Retroactive authorizations are not typically given or guaranteed (contact the members Medical Management Department for special circumstances).

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Self referral Services (CMS 08-05)

MDwise members can self refer to: Family Planning (see quick contact sheet for MDwise family

planning addresses) Emergency Services Vision Podiatry Chiropractic Dental (submit all dental claims to EDS) HIV/AIDS Case Management

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Out-of- Network Authorizations (CMS 08-05)

Members of MDwise Delivery Systems that require covered services not available within the MDwise network must have prior authorization from the delivery systems Medical Management Department, this includes between MDwise Delivery Systems (before services are rendered)

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Prior authorization for DME (CMS 08-05)

Please contact the member’s Delivery System Medical Management Department for approved providers and Durable Medical Equipment (DME) prior authorization requirements.

Prior authorization forms are available online at www.MDwise.org

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Pharmacy Authorizations (CMS 08-05)

All providers and specialists providing care to MDwise members are required to utilize the MDwise Pharmacy Drug Listing (PDL).

The PDL is updated on a regular basis. The PDL is available hard copy and online at www.MDwise.org.

Perform Rx 800-558-1655

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Behavioral Health Authorizations (CMS 08-05)

Standardized forms for Behavioral Health: Primary Medical Provider Coordination Form Therapy/Outpatient Treatment Form (OTR) Form Psychological Testing Form Neuropsychological Testing Form These forms can be found on our website

www.MDwise.org/providers/forms/behavioralhealth

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Discussion with Delivery System Representatives(CMS 08-05)

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Thank You CMS 08-05 & Drawing

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