Agenda UB04 Claim Form Frequently Used Forms Prior Authorization KyHealth Net ICD-10 Billing Points Member Eligibility Information Contact Lists

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2 Agenda UB04 Claim Form Frequently Used Forms Prior Authorization KyHealth Net ICD-10 Billing Points Member Eligibility Information Contact Lists 2

3 Each provider type has a unique set of Billing Instructions on the website. All of the required field locators for your facility can be found in these instructions. NOTE HOSPITAL BILLERS: Type of bill 117 or 137 can only be used when billing electronically using the 837I. These are not valid for paper billing nor when billing via KYHealth Net. UB04 Claim Form 3

4 TPL Lead Form is used to notify Ky Medicaid that a primary commercial policy terminated, or has not responded in over 120 days from the providers billing date. This form is NOT to be used for Medicare or Medicare Replacement policies. FORMS - TPL Lead Form 4

5 This can be used to change a PAID claim. Adjustments / Voids via KyHealth Net are the equivalent to this form. FORMS - Adjustment and Claim Credit Request 5

6 Cash Refund form is sent when you refund money to KY Medicaid. Make your check payable to the Kentucky State Treasurer. FORMS - Cash Refund Form 6

7 The prior authorization process does NOT verify anything except medical necessity. It does not verify eligibility or age. The prior authorization letter does not guarantee payment. It only indicates that the service is approved based on medical necessity. If the individual does not become eligible for Kentucky Medicaid, loses Kentucky Medicaid eligibility, or ages out of the program eligibility, services will not be reimbursed despite having been deemed medically necessary. Prior Authorization should be requested prior to the provision of services except in cases of: Retro-active Member eligibility Retro-active provider number Providers should always completely review the Prior Authorization Letter prior to providing services or billing. Access the kymmis website to obtain blank Prior Authorization forms. AuthorizationForms.aspx Prior Authorization 7

8 KYHealth Net 8

9 KYHealth Net is compatible with Windows 7, Internet Explorer 8, and Adobe 9. If your computer utilizes Windows 7 and Internet Explorer 9 or 10 please check these options and make updates. To determine what Windows version you are using: Go to your Internet Explorer Click on Help (to see what version of IE your computer has) Click on About Internet Explorer KYHealth Net Helpful Information 9

10 Click on Tools, Compatibility View Settings Add the website KYHealth Net Helpful Information 10

11 If you are using Windows 8 and Internet Explorer 10: Windows 8 and Internet Explorer 10 come loaded with scripting turned off. This needs to be set to allow scripting on at the user s end. You may need your facilities technical support to assist in this update. KYHealth Net Helpful Information 11

12 Calls frequently received by our EDI (Electronic Data Interchange) call center: KYHealth Net Password needs reset. This can be accomplished at the providers desk if a security question is on file for you. On the KYHealth Net web portal under My Information, take a moment to set up a security question and answer. Once it is set, you may press the Reset Password link. This will send an to the address on file so that you can reset your own password. KYHealth Net Helpful Information 12

13 Your security question must be answered exactly as you entered the answer when you set it up. If you answer the security question with a capital letter starting the word, the answer you enter must begin with a capital. After this is answered 3 times incorrectly, a call must be made to the EDI call center to have your access unlocked. KYHealth Net Helpful Information 13

14 Other calls frequently received by our EDI (Electronic Data Interchange) call center: My office manager is out of the office on leave and reset our password before she left. I don t know what the new password for our office is. PASSWORDS SHOULD NEVER BE SHARED. Any person who must access KYHealth Net must have their own user name and password. The system administrator must grant access and delete access to this secure website. KYHealth Net Helpful Information 14

15 WHO All providers will be affected by ICD-10 implementation. WHEN October 1, 2015 WHY ICD-9 has nearly reached its capacity for growth at approximately 13,000 codes. With ICD-10, the number of existing codes will increase to approximately 68,000. ICD-10 is more clinically accurate and allows for greater detail within a single diagnosis code. ICD-10 Fundamentals 15

16 CMS recommends the following 5 key steps in planning the transition to ICD Plan your Journey Train your team Update your processes Engage your vendor and payers Test your system and processes Courtesy of CMS ICD-10 Planning your ICD-10 Journey 16

17 3-5 characters First character is numeric or alpha Characters 2-5 are numeric Always at least 3 digits 3-7 characters 1 st character is alpha (all letters except U are used 2 nd character is numeric Characters 3-7 are alpha or numeric Alpha characters are not case-sensitive. ICD - 10 Diagnosis Code Structures 17

18 PCS is a type of surgical procedure coding new to ICD-10 and was created for use by hospitals and in inpatient hospital settings ONLY. PCS codes require all 7 characters, unlike current surgical procedure codes (using the ICD-9 CM coding) that require only 3-4 characters. Each character is either alpha (not case sensitive) or numeric. ICD-10-PCS 18

19 General Equivalence Mapping (GEMs) The GEMS are a crosswalk tool developed by CMS and Centers for Disease Control and Prevention (CDC) for use by all providers, and payers. To obtain more information about the GEMs and ICD-10, visit the CMS website GEMS will not supply every combination of coding. They will give basic help in mapping. ICD-10 Resources 19

20 ICD - 10 Additional Resources 20

21 The Department for Medicaid Services, in conjunction with HP Enterprise Service, is preparing for ICD-10 readiness. HP is accepting beta testers. To become a beta tester, you simply contact the EDI Helpdesk KY_EDI_Helpdesk@hp.com with the following information: Your trading partner ID with KY Medicaid Company Name Testing Contact information Testing contact address Phone number What claim type are you testing Notifications from KY Medicaid (if different from testing contact) Contact name address ICD - 10 Testing 21

22 Testing allows trading partners the opportunity to gain feedback on the testing results. Were modifications needed to accommodate the test claims; Were the results as you anticipated; and Were unusual results found ICD - 10 Testing 22

23 Is there a direct crosswalk from ICD-9 to ICD-10? Due to the increased specificity of ICD-10 codes, there will not be a direct crosswalk from ICD-9 to ICD-10. Will everyone be affected? All Providers will be affected by ICD-10 implementation, except Dental providers who bill strictly on the ADA claim form for KY Medicaid. ICD - 10 Frequently Asked Questions 23

24 In accordance with federal regulations, claims must be received by Medicaid no more than 12 months from the date of service, or six months from the Medicare or other insurance payment date, whichever is later. Received is defined in 42 CFR (d) (5) as The date the agency received the claim as indicated by its date stamp on the claim. Kentucky Medicaid includes the date received in the Internal Control Number (ICN). The ICN is a unique number assigned to each incoming claim and the claim s related documents during the data preparation process. ICN was received May 1 st. Billing Points - Timely Filing 24

25 For claims more than 12 months old to be considered for processing, the provider must attach documentation showing timely receipt by DMS or HP Enterprise Services and documentation showing subsequent billing efforts, if any. To process claims beyond the 12 month limit, you must attach to each claim form involved, a copy of a Claims in Process, Paid Claims, or Denied Claims section from the appropriate Remittance Statement no more than 12 months old, which verifies that the original claim was received within 12 months of the service date. Billing Points - Timely Filing 25

26 Additional documentation that may be attached to claims for processing for possible payment is: A screen print from KYHealth Net verifying filing within 12 months from date of service, such as the appropriate section of the Remittance Advice or from the Claims Inquiry Summary Page (accessed via the Main Menu s Claims Inquiry selection); Billing Points - Timely Filing 26

27 Billing Points - Timely Filing 27

28 Aged claims for Members whose eligibility for Medicaid is determined retroactively may be considered for payment if filed within one year from the eligibility issuance date. Claim submission must be within 12 months of the issuance date. A copy of the KYHealth Net card issuance screen must be attached behind the paper claim. Billing Points - Timely Filing 28

29 A copy of the Medicare Explanation of Medicare Benefits received 12 months after service date but less than six months after the Medicare adjudication date. A copy of the commercial insurance carrier s Explanation of Benefits received 12 months after service date but less than six months after the commercial insurance carrier s adjudication date. Billing Points - Timely Filing 29

30 Check Member Eligibility prior to services being rendered. Updates can occur nightly and the member may lose eligibility or be placed in a different type of coverage so check the day of the service. Types of Member Eligibility to watch for: QMB-only Members have Medicare, and Medicaid serves as a Medicare supplement only. These members have coverage for coinsurance and/or deductible amounts after Medicare or a Medicare Replacement policy. If Medicare denies, Medicaid denies as well. QMB-only members have a Program code Z. SLMB members do not have Medicaid coverage; Kentucky Medicaid pays a "buy-in" premium for SLMB Members to have Medicare, but offers no claims coverage. SLMB members have Program codes of ZL, ZQ, and ZJ. Member Eligibility Program Codes 30

31 Medical benefits for persons whose care is overseen by a Managed Care Organization (MCO) are similar to those of Kentucky Medicaid, but billing procedures and coverage of some services may differ. Providers with MCO questions should contact that particular MCO provider services area: Passport Health Plan at WellCare of Kentucky at Humana Caresource at Anthem Blue Cross Blue Shield at Aetna Better Health of KY at NOTE: When an MCO pays then recoups the money due to a retroactive change in member eligibility, the MCO must send a Void through their system to update the Medicaid history files. Managed Care Organizations 31

32 Presumptive Eligibility (PE) is a program that offers certain individuals and pregnant women temporary medical coverage. A treating physician or hospital may issue an Identification Notice to an individual if it is determined that the individual meets the criteria specified. PE benefits are in effect up to 60 days from the date the Identification Notice is issued. Presumptive Eligibility 32

33 Covered services for a presumptive eligible pregnant woman shall be limited to ambulatory prenatal services delivered in an outpatient setting and shall include services furnished by a primary care provider, including: A family or general practitioner; A pediatrician; An internist; An obstetrician or gynecologist; A physician assistant; A certified nurse midwife; or An advanced practice registered nurse Presumptive Eligibility Pregnancy 33

34 Covered services for a Presumptive Eligible Pregnant Woman include: Laboratory services; Radiological services; Dental services; Emergency room services; Emergency and nonemergency transportation; Pharmacy services; Services delivered by rural health clinics; Services delivered by primary care centers, federallyqualified health centers, and federally-qualified health center look-alikes; or Primary care services delivered by local health departments. Services related to labor and delivery are not a covered service for PE members. Presumptive Eligibility Pregnancy 34

35 As part of the Affordable Care Act, a determination of presumptive eligibility can be made by a certified hospital participating in the Medicaid program. Covered services for a presumptive eligible individual who is not pregnant, and who meet the income guidelines shall include services furnished by a primary care provider, including: A family or general practitioner; A pediatrician; An internist; An obstetrician or gynecologist; A physician assistant; A certified nurse midwife; or An advanced practice registered nurse Presumptive Eligibility Non-Pregnancy 35

36 Other covered services for a presumptive eligible individual who is not pregnant include: Laboratory services; Radiological services; Dental; Emergency room services; Emergency and non-emergency transportation; Pharmacy services; Services delivered by rural health clinics; Services delivered by primary care centers, federally-qualified health centers and federally-qualified health center look-alikes; Primary care services delivered by local health departments; or Inpatient or outpatient hospital services provided by a hospital. Services related to labor and delivery are not a covered service for PE members. Presumptive Eligibility Non- Pregnancy 36

37 Responsibilities of the granting Presumptive Eligibility provider includes: The determination of member eligibility based on guidelines set forth by CMS and KY Medicaid; Retaining the original member information worksheet in the patient record; Printing of the PE eligibility card for the members use; Discussing with the member what services are and are not a covered service according to the type of PE coverage granted; Encouraging the member to apply for full Medicaid after their visit because PE benefits are time limited for up to 60 days of coverage and granted once per calendar year or once per pregnancy. Presumptive Eligibility Grantors Responsibility 37

38 Find your Billing Instructions and more at com 38

39 Click on Provider Billing Instructions to see the list of provider types. 39

40 Open your Billing Instruction based on your provider type. 40

41 DEPARTMENT PHONE NUMBER OR WEB ADDRESS ROLES HP Provider Billing Inquiry Claim status and billing questions (Providers Only) EDI Helpdesk Electronic billing, Electronic RA s, PIN request and password resets Carewise Prior Authorization, Waiver Eligibility Department for Medicaid Services Member Services Department for Medicaid Services Provider Enrollment Questions or updates to a members file Program.integrity@ky.gov Questions or updates to the provider file or enrolling as a new provider DCBS Contact Center phone/index.aspx HP Provider Field Representatives Member eligibility, patient liability (MAP 552), hospice election and termination Varies by County Varies by County Provider training, conference calls, association meetings, provider visits, and any escalated issue. (Providers only) CONTACTS 41

42 MCO CONTACTS 42

43 KY MEDICAID PROVIDER FIELD REPRESENTATIVES 43

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