Physician, Advanced Nurse Practitioner & Physician Assistant. January 2017

Transcription

1 Physician, Advanced Nurse Practitioner & Physician Assistant January 2017

2 Overview Enrollment requirements Member information Covered and non-covered services Service authorization Reimbursement Claims management Case management services 2

3 Provider Enrollment 3

4 Physician or Osteopath Provider participation/enrollment requirements: Active license from AK Division of Occupational Licensing to practice medicine or osteopathy Enrolled physicians may receive reimbursement for covered medical services to eligible members To be reimbursed for laboratory services, submit a copy of the lab s CLIA certificate of waiver or certificate of registration Complete, sign and submit a Physician Provider Addendum with enrollment 4

5 Advanced Nurse Practitioner Provider participation/enrollment requirements: Active license from AK Division of Occupational Licensing to practice as an advanced nurse practitioner of any specialty Enrolled, independently practicing ANPs may receive reimbursement for covered medical services to eligible members To be reimbursed for laboratory services, submit a copy of the lab s CLIA certificate of waiver or certificate of registration 5

6 Physician Assistant Provider participation/enrollment requirements: Active license from the AK Division of Occupational Licensing to practice as a physician assistant (PA) Must be supervised by a currently enrolled physician Must be affiliated with a health professional group as a rendering-only provider Complete, sign and submit a Physician Assistant Provider Addendum 6

7 Nurse Midwife Provider participation/enrollment requirements: Occupational license (all specialties) Enroll as individual The department will pay an ANP certified as a nurse midwife for services for a normal vaginal delivery performed at a free-standing birth center licensed under AS (7 AAC b) 7

8 Locum Tenens To be reimbursed for services rendered, a locum tenens must: Obtain a license or permit through Alaska s Division of Occupational Licensing Enroll as a provider in AK Medicaid and obtain a Medicaid Contract ID Enrollment will only be approved for the period on the license or permit Process usually takes eight weeks to receive permit 8

9 Group Enrollment Members of Health Professional Groups must first enroll individually Provider types who may enroll as part of an HPG and bill directly for their services: Physician Advanced nurse practitioner/nurse midwife Certified registered nurse anesthetist Physician assistant may enroll as part of HPG but may not bill directly for services PAs must be enrolled under supervision of an enrolled physician, but physician is not required to be a member of the same HPG as the PA 9

10 Laboratory CLIA Certificate of Waiver is needed to perform tests that are simple laboratory examinations and procedures that have an insignificant risk of an erroneous result List available on the FDAs website Bill using a QW modifier CLIA Certificate of Registration is needed for all else Certificate must be submitted with enrollment application or to Provider Enrollment unit before lab tests are billed 10

11 Imaging Provider State certification Current mammography equipment certification issued by the U.S. Food and Drug Administration (FDA) All mobile X-ray units must be certified annually 11

12 Out-of-State Provider Out-of-state providers are required to enroll with Alaska Medicaid to be reimbursed for services to AK Medicaid members To enroll in Alaska Medical Assistance, the provider must: Meet licensing requirement of that state Be enrolled in that state s Medicaid program 12

13 Non-Covered Providers Psychologists If contracted by a psychiatric facility, hospital, Community Mental Health Clinic, or Federally Qualified Health Center Individually practicing psychologists may enroll separately Social workers Naturopaths 13

14 National Provider Identifier Individual Type 1 NPI requires individual enrollment with Alaska Medical Assistance Organizational Type 2 NPI requires group enrollment with Alaska Medical Assistance 14

15 Member Information 15

16 Member Eligibility Always verify member eligibility Eligibility period: One month Exceptions: Denali KidCare Emergency services for some aliens Other limited eligibility categories Eligibility codes are listed in section I in billing manual 16

17 Member Eligibility (cont.) Always verify member eligibility by using one of the following options: Request to see the member's Medical Assistance coupon or card that shows the current month of eligibility; photocopy for your records Call Automated Voice Response System (AVR): (Toll-free) Verify via Alaska Medicaid Health Enterprise website Complete Conduent Member Eligibility Fax form Phone Provider Inquiry or (Toll-free) 17

18 Denali Care Card 18

19 Denali KidCare Card 19

20 Disability Exam Coupon 20

21 CAMA Coupon 21

22 Care Management Program Coupon 22

23 Cost Sharing Physician: $3.00 per provider Inpatient hospital stays: $50.00 per day, maximum of $ per hospital admission Outpatient hospital: 5% of Medicaid allowed amount Prescription Drugs prior to 5/18/2014 $2 for each prescription drug that is filled or refilled Prescription Drugs 5/18/2014 and after $0.50 for each prescription drug $50 or less $3.50 for each prescription drug more than $50 23

24 Cost Sharing Exemptions Services provided to member under the age of 18 when service was rendered Services provided at a LTC facility or an ICF Services provided to a pregnant woman, including the postpartum period Family planning services and supplies Emergency services IHS beneficiaries receiving services at IHS facilities, including IHS members referred or transferred to a non-ihs facility Hospice 24

25 Covered and Non-Covered Services 25

26 Behavioral Health AK Medicaid reimburses enrolled physicians who directly render medically necessary, covered and appropriate mental health services A physician must be a psychiatrist to provide mental health services in a licensed and certified psychiatric hospital or facility, general acute care hospital, LTC facility, or ICF/IDD Service authorization must be obtained for outpatient psychotherapy exceeding 10 hours in a state fiscal year per member AK Medicaid does not reimburse physicians for group psychotherapy provided to members in an inpatient psychiatric hospital facility or an acute care hospital offering psychiatric services 26

27 DC:0-3R Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood Revised Use is supported but not required Aid for accurately reporting diagnoses for infants and toddlers with mental health or developmental disorders Clinical records must support given diagnosis through assessment processes May be ordered through 27

28 Screening and Brief Intervention Services SBIRT Screening, brief intervention, and referral to treatment Public health approach to early intervention and treatment for members with or at risk for substance use disorders Appropriate CPT codes: Audit/dast min Audit/dast over 30 min 28

29 SBIRT (cont.) Incorporating SBIRT into normal practice routines can: Decrease frequency and severity of drug and alcohol use Reduce the risk of trauma Increase percentage of patients entering substance abuse treatment 29

30 SBIRT (cont.) Eligible providers: Physicians Advanced nurse practitioners Physician Assistants EPSDT screeners RHC/FQHC Community Health Aides/practitioners Tribal Clinics Community behavioral health clinics Mental health physician clinics 30

31 SBIRT (cont.) Additional information: The Substance Abuse and Mental Health Services Association providers screening instruments and tools at Division of Behavioral Health Mental Health Physician Clinic manual at Community Behavioral Health Clinic manual at 31

32 Early and Periodic Screening, Diagnosis, and Treatment Services (EPSDT) Goals: Provide every child the opportunity for good health Promote regular, periodic, preventive health services and early detection & treatment of disease Screenings must comply with CMS requirements for lead screening and should comply with all other minimum recommendations found in the Bright Futures guidelines, available at Serves children under 21 years of age 32

33 Dental Fluoride Varnish Physicians, nurse practitioners and physician assistants may be reimbursed for dental fluoride varnish applications and oral evaluations Must have completed appropriate Oral Health or Caries Risk Assessment training Subject to coverage limitations Maximum of four topical fluoride varnish applications per calendar year Two oral evaluations per calendar year for patients >3 only 33

34 Immunizations For information on the Alaska Immunization Program Immunization helpline: In Anchorage: CDC Immunization Schedules Patient eligibility requirements to receive state-supplied vaccines Vaccine distribution enrollment information 34

35 Immunizations (cont.) Bill Alaska Medical Assistance appropriate Current Procedure Terminology (CPT) code for administration (as appropriate) Other covered vaccines not available from DPH are reimbursable when billed with appropriate injectable drug code 35

36 Drugs/Prescriptions Alaska Medical Assistance covers prescription medications when prescribed or dispensed by an enrolled physician, ANP or PA For additional information, see the Pharmacy Billing Manual The Preferred Drug List is available at 36

37 Drugs/Prescriptions (cont.) Electronic transmission Oral Communication Written on tamper-resistant paper Printed on plain paper with tamper-resistant features Tamper-resistant prescription form requirements: Serial number NPI One feature to prevent unauthorized copying One feature to prevent erasure or modification One feature to prevent counterfeit prescription forms 37

38 Drugs/Prescriptions (cont.) Drugs that require service authorization are listed in the Prior Authorized Drug list and Interim Prior Authorized Drug List at Prescribers request drug SAs by calling or faxing the Magellan Medicaid Administration Clinical Call Center, unless otherwise indicated Pharmacy initiates SA request in some cases see documentation for details 38

39 Human Growth Hormone Available to members under 21 years of age diagnosed by a board certified pediatric endocrinologist Pharmacist obtains SA Prescribing provider should send or make available diagnosis information to expedite SA process SA requested on Human Growth Hormone Authorization request form Form available at 39

40 Prescriptions Refills AK Medicaid does not cover refills until: 75% of supply is used 93% of narcotic analgesic is used Early refills of a controlled substance due to loss, theft, spilling or other means of destruction are not covered by AK Medicaid Pharmacies may request override for early refills of non-controlled substances from Magellan Medicaid Administration Clinical Call Center 40

41 Dispensing Providers Physicians, podiatrists, ANPs, PAs, IHS clinics and RHC/FQHCs may enroll separately as dispensing providers Must provide: Proof of active licensure as a pharmacist or retail pharmacy Active DEA license Completed, signed Dispensing Provider Addendum 41

42 Dispensing Providers (cont.) Follow billing guidelines/covered services in pharmacy provider manual Dispensing providers are reimbursed for the medications they dispense, but are not eligible to receive a dispensing fee Payment is less cost sharing amount 42

43 Covered Drugs Covered drugs include, but not limited to: Prescription drugs of manufacturers that have signed a U.S. Centers for Medicare and Medicaid Services rebate agreement Compound prescriptions if at least one ingredient requires a prescription for dispensing Regular legend drugs Growth hormone when service authorized 43

44 Non-Preferred Medications Prescriptions for non-preferred medications (not on the PDL) must contain documentation of medical necessity Patient allergy Contraindications FDA approved multiple indications Ineffective treatment Brand name medication will not be covered if a therapeutically equivalent generic medication is available unless: The brand-name medication is on the PDL Prescriber indicated brand-name medically necessary drug or allergic to the inert ingredients of the generic drug 44

45 NDC Pricing Payment for physician-administered drugs will be based on NDC and NDC quantity Exception- Payments currently based on per diem rates or a percentage of provider charges Bill the NDC for the actual drug that is administered Record the NDC into the patient record 45

46 NDC Claims Identified on 837I and UB-04 claims by revenue codes Identified on 837P and CMS-1500 claims by HCPCS codes Usually J codes Include on your claims: NDC number NDC units of measurement Numeric quantity Corresponding HCPCS values and units 46

47 NDC Structure NDC consists of 11 digits in three sections 47

48 NDC Structure (cont.) Product label indicates: Submit on claim as: Product label indicates: Submit on claim as: Product label indicates: How would you submit this on a claim? The correct answer is

49 NDC Units NDC billing unit standard: UN = unit ML = milliliter GR = gram F2 = International Unit 49

50 NDC Reporting Electronic Claims 837P: Loop 2410: Field CTP04 Enter quantity Field CTP05 Enter unit of measure Example: CTP****2*UN~ Field LIN02 Enter qualifier N4 Field LIN03 Enter NDC without hyphens: Example: LIN**N4* ~ HCPCS information will continue to be entered in Loop 2400, Field SV1 50

51 NDC Reporting Claim Form Professional claim forms: Enter NDC information in the shaded area of Field 24 Enter the qualifier N4 immediately followed by the 11 digit NDC code without hyphens in Field 24a Enter the NDC unit of measure followed by a total quantity field of 9 characters ( ) in the shaded area of Field 24d 51

52 Services in LTC Facilities Initial Evaluation & Management (E/M): One visit per physician per patient stay Certified Intermediate Care Facility (ICF) or Skilled Nursing Facility (SNF) Subsequent or established care visits: Minimum legal requirements for subsequent physician visits are once every 30 days for the first 90 days, every 60 days thereafter Additional visits may be covered with medical need Documentation must be attached to claim 52

53 Sterilization Funded only for mentally competent individuals 21 years of age or older Member must grant voluntary, informed consent by signing a Consent for Sterilization form Only the Consent for Sterilization form will be accepted 53

54 Sterilization (cont.) Oral advice to member about: About the procedure Alternative methods of family planning and birth control Sterilization is considered irreversible Discomforts and risks of surgery Benefits and/or advantages of surgery That no federal benefits will be withdrawn if the individual decides not to be sterilized 54

55 Sterilization (cont.) Medicaid consent form signature: At least 30 days but not more than 180 days between informed consent & date of sterilization At least 72 hours between informed consent and sterilization in emergency Rendering physician must sign and date the consent form Form must accompany all claims: Surgeon s professional fees Facility fees 55

56 Sterilization Consent may not be obtained from anyone who is: In labor of childbirth Under the influence of alcohol or other drugs Seeking/obtaining an abortion Deemed incompetent by a court of law 56

57 Consent for Sterilization Form (First half of form) 57

58 Consent for Sterilization Form (Second half of form) 58

59 Hysterectomy Covered when performed for medical reasons NOT for sterilization Service authorization from Qualis Health or Consent form required and must be signed prior to surgery Form must be submitted with all claims: Surgeon s professional fees Facility fees 59

60 Hysterectomy Consent Form (First half of form) 60

61 Hysterectomy Consent Form (Second half of form) 61

62 Abortion Payment for therapeutic abortion will be covered if the claim for physician s services includes Certificate to request federal (Medicaid) funds for Abortion, stating that the procedure is necessary to save the life of the mother or to terminate a pregnancy that is the result of an act of rape or incest Payment is at discretion of Medical Assistance Other therapeutic abortions may be reimbursable in compliance with Alaska court order 62

63 Certificate to Request Funds for an Abortion (First half of form) 63

64 Certificate to Request Funds for an Abortion (Second half of form) 64

65 Surgical Assistants Physicians, advanced nurse practitioners, or physician assistants acting as surgical assistants are covered for certain procedures Licensed practical nurses, registered nurses, interns, and residents in training do not qualify for payment for the services they render when acting as a surgical assistant Second assistant may be covered with proper documentation from surgeon explaining the need for the second assistant 65

66 Anesthesia Services Covered when administered by: Anesthesiologist Certified registered nurse anesthetist Bill in accordance with current edition of the ASA Relative Value Guide Reimbursed at lesser of billed charges or calculation based on ASA procedure base unit value and time 66

67 Obstetrical Care Routine obstetrical care is covered when performed by a physician AK Medicaid covers services for a normal vaginal delivery performed by an ANP certified as a nurse midwife Routine global obstetrical care: May only be billed AFTER antepartum, delivery, and postpartum care have occurred May only be billed when the patient has third party coverage Oxytocin is considered part of a delivery and NOT separately reimbursed 67

68 Obstetrical Care (cont.) Non-global obstetrical care: Antepartum care Appropriate Evaluation & Management (E/M) codes Delivery and postpartum care Delivery only Postpartum care only Billable once per member 68

69 Ordering Covered Services Physicians, ANPs, and other health care practitioners, within the scope of their license, may order the following to be performed by enrolled and licensed professionals: Lab and X-ray Physical and occupational therapy Speech and language therapy Nutrition 69

70 Laboratory Services Must be medically necessary Must be ordered or performed by appropriately licensed professionals Include professional and technical components of laboratory procedures The following services are considered incidental to laboratory procedures and are not separately reimbursable: Handling and conveyance of specimens Routine venipuncture performed with a laboratory procedure When a provider interprets a diagnostic laboratory test performed offsite, the provider should bill only for the professional component and be sure to use the appropriate modifier 70

71 Imaging Services Must be medically necessary Imaging services are authorized through Qualis Professional & technical components of imaging procedures are covered CAMA patients are eligible to receive services in a free-standing facility but not in an outpatient hospital setting Imaging services: Magnetic Resonance Imaging (MRIs) Magnetic Resonance Angiography (MRAs) Positron Emission Tomography (PET) Scans Single-photon emission computed tomography (SPECT) 71

72 Therapy Services Occupational therapy Physical therapy Speech-language pathology Hearing services Outpatient therapy and speech-language pathology must be prescribed by a physician, ANP or PA (except initial evaluation) Audiology services must be prescribed by an audiologist, otologist, otolaryngologist, or a physician acting within the scope of his/her license and training 72

73 Nutrition Services Services available to Medical Assistance eligible, at risk nutritionally members under 21 years of age and adult members who are pregnant Coverage includes: Initial assessment per calendar year Up to 12 hours per calendar year for counseling and follow-up Additional visits require service authorization from referring provider 73

74 Infant Formulas/Medical Food For members under 5 with medical condition requiring formula other than WIC contract formula SA required Enteral Nutrition Prescription Request Form must be completed by an enrolled physician or other health care provider with prescriptive authority ENPR is available at 74

75 Tobacco Cessation Counseling Physician, ANP or PA may provide counseling or Order counseling by a pharmacist when a prescription for tobacco cessation medication is dispensed to member Drug therapy is covered for members who wish to quit Nicotine replacement and Chantix are covered See Pharmacy billing manual for more information Alaska Quit Line

76 Telemedicine Telemedicine is covered if the service is: Covered under traditional, non-telemedicine methods Provider by a treating, consulting, presenting or referring provider Appropriate for provision via telemedicine Covered services are limited to: Initial visit One follow-up visit Consultation to confirm diagnosis Diagnostic, therapeutic or interpretive services A psychiatric or substance abuse assessment Psychotherapy Pharmacological management 76

77 Telemedicine (cont.) Interactive Provider and patient interact in real time using video/camera and/or dedicated audio conference equipment Store-and-forward A provider sends digital images, sounds or previously recorded video to a consulting provider at a different location. The consulting provider reviews the information and reports back his or her analysis Self-monitoring Patient is monitored in his or her home via a telemedicine application, with the provider indirectly involved from another location 77

78 Telemedicine (cont.) Services that are non-covered for telemedicine: Use of telemedicine equipment and systems Services delivered by phone that is not part of a dedicated audioconference system Services delivered by fax Services inappropriate for telemedicine consult billing manual for complete list 78

79 Travel for Medical Care Medical necessity Service authorization Coverage limited to out of town travel to nearest facility/provider or nearest IHS Facility Transportation is covered for out of town travel and for local travel in some circumstances Accommodations and meals are covered for out of town travel when same-day travel are not possible For more information, see section III of your billing manual or attend Arranging Patient Travel training session 79

80 Non-Covered Services Include, but not limited to: Services that are not medically necessary Services provided outside scope of license ANP serving as primary surgeon Operating room assistance provided by a resident-in-training, intern, registered nurse or LPN Infertility or impotence treatment Plastic or cosmetic services for enhancement purposes 80

81 Non-Covered Services (cont.) Include, but not limited to: Educational services and supplies Interpreter services Medical testimony Travel by the provider Special reports Office supplies No-show or cancelled appointments Experimental or investigative services 81

82 Non-Covered Services (cont.) Include, but not limited to: Swimming therapy Programs to include overall fitness Vaccine products that are available for free Services billed using non-covered CPT or HCPCS codes Selected special services and report codes Gender reassignment surgical procedures or sequelae Case management services 82

83 Non-Covered Services: Age Restricted Not covered for members over 21 years of age Chiropractic manipulation Preventive E/M exam services ( , ) Not covered for members under 21 years of age Sterilization 83

84 Service Authorization 84

85 Service Authorization Some services require service authorization (SA) before they are rendered Fee schedule indicates need for SA The rendering physician must initiate and obtain the SA prior to rendering services when possible Urgent/emergent within 24 hours or one business day SA requirements, procedures, and forms are included in provider billing manuals 85

86 Conduent Service Authorization Services in excess of service limitations Selected Pharmaceutical drugs Any surgical procedure identified in the fee schedule as requiring service authorization that is NOT on the Qualis pre-certification list (ex. rhinoplasty or blepharoplasty) DME Hearing aids Home infusion Transportation and accommodation 86

87 Conduent Service Authorization Form 87

88 Conduent Service Authorization Form (cont.) 88

89 Certificate of Medical Necessity (CMN) Certificates of Medical Necessity are used to request: Durable medical equipment Supplies Prosthetics and Orthotics Audiology equipment Hearing aids For all categories, only items and services requiring service authorization need to be requested using the CMN 89

90 CMN (cont.) Refer to DME fee schedule for lists of items which require authorization Fee schedules are posted at Select Documentation>Documents & Forms>Fee Schedules, then appropriate fee schedule under DME Quantities should be appropriate for 30 day period Larger quantities require written medical justification 90

91 CMN (cont.) 91

92 CMN (cont.) 92

93 CMN (cont.) 93

94 CMN (cont.) 94

95 Completing the CMN Physician, ANP or PA acting within scope of their license completes: Demographic information Section A: Clinical information Section B: Clinical assessment of need for prescribed services or item(s) and plan Ordering provider s attestation and signature DME/SME provider completes: Demographic information Section C: Requested services or items Section D: Supplier attestation, signature and date 95

96 Childbirth SA Conduent and Qualis share responsibility for authorizing certain maternal/newborn admissions 96

97 Qualis Health Service Authorization Selected inpatient and outpatient procedures and diagnoses, regardless of length of stay Qualis pre-certification list All inpatient hospital continued stays exceeding three (3) days Outpatient imaging TEFRA Acute inpatient and residential psychiatric treatment Qualis Provider Portal 97

98 Qualis Health Hours of operation: Monday Friday 6:30a.m. 5:00p.m. (AKT) Utilization Management Phone Fax Case Management Phone or Fax

99 Billing and Reimbursement 99

100 Pricing Methodology Reimbursed at the lesser of billed charges or the Resource Based Relative Value Scale (RBRVS) fee schedule RBRVS Methodology [(RVUw x GPCOw) + (RVUp x GPCIp) + (RVUm x GPCIm)] x Fee schedule EPSDT - Reimbursed at 100% of Resource Based Relative Value Scale (RBRVS) for all provider types for Evaluation and Management services 100

101 Physician or Osteopath Professional services In state: Lesser of billed charges or RBRVS rate Out of state: Lesser of billed charges or rate Lab Lesser of billed charges or Medicare fee schedule Supplies Only non-routine office medical and surgical supplies are separately reimbursable 101

102 Advanced Nurse Practitioner Professional services In state: Lesser of billed charges or 85% of RBRVS rate Out of state: Lesser of billed charges or rate established by the provider s state Medicaid agency Supplies Only non-routine office medical and surgical supplies are separately reimbursable 102

103 Surgical Services Multiple surgical procedures Same patient, same operative session (same day), same surgeon Higher value procedure is reimbursed at lesser of billed charge or 100% of RBRVS Each additional procedure is lesser of billed charges or 50% of RBRVS Bilateral surgery Bill as a single line using appropriate CPT code for bilateral procedure Lesser of billed charges or 150% of RBRVS rates 103

104 Surgical Services (cont.) Surgical assistants Lesser of billed charges or 25% of RBRVS for provider type 2nd assistants are covered at same rate, but explanation of medical need must accompany claim LPNs, RNs, and interns not separately reimbursed Co-surgeons Lesser of billed charges or 125% of RBRVS Reimbursement divided equally between surgeons 104

105 Surgical Services (cont.) Surgical care & management: When preoperative, surgery and postoperative care are provided by same provider, they are not separately reimbursable When different providers are providing different components of care, bill with CPT for surgery and appropriate modifier Preoperative and/or Postoperative Reimbursed at lesser of billed charges or 10% of RBRVS rate Surgery only Reimbursed at lesser of billed charges or 80% or RBRVS 105

106 Anesthesia Services Use procedure codes and corresponding basic unit values in American Society of Anesthesiologists (ASA) relative value guide Lesser of billed charges or calculation based on ASA procedure base unit value + time Base unit value is $42.90 Time unit (10 minutes) is $

107 Independent Laboratory Services Laboratory services reimbursed at lesser of billed charges or Medicare established fee schedule Out-of-state reimbursement is lesser of billed charges or own state s Medicaid rate 107

108 Imaging Services Lesser of billed charges or 100% of RBRVS Out of state reimbursement is lesser of billed charges or own state s Medicaid rate 108

109 Unlisted Codes Reimbursement 50% of billed charges, upon approval Written explanation attached to claim Will require review 109

110 Attachments 110

111 Billing Medicaid as Secondary AK Medicaid is payer of last resort If patient has other insurance, it must be billed first, except in a few circumstances If other insurance has paid more than the AK Medicaid allowed amount, you do not need to bill AK Medicaid 111

112 Billing Medicaid as Secondary (cont.) When billing Medicaid as a secondary payer Record the other insurance information and payment on the billing form Include the EOB from the other payer(s) as an attachment with your claim form If billing electronically, fax EOB in using the Fax Attachment Cover Sheet and same procedure as any other attachment 112

113 Medicare Crossover Claims Coordination of Benefits Agreement (COBA) National standard requirement implemented by the Centers for Medicare and Medicaid Services Provides automatic claim coordination of benefits (crossover) service from Medicare to Medicaid Affects claims submitted for Dual Eligibles those who are eligible for both Medicare and Medicaid 113

114 VA Eligible Members If a member is eligible for VA, Medicare and Medicaid, providers must exhaust Medicare and VA benefits before billing Medicaid Veterans with resource code N may use either VA or Medicaid and do not need a VA denial letter to bill AK Medicaid Veterans with an N2 resource code need either EOB showing non-coverage or a Medicaid denial letter from the AK VA healthcare system 114

115 VA Eligible Members (cont.) If a member is eligible for VA, Medicare and Medicaid, providers must follow these steps: 1. Bill VA first and receive a formal denial (in writing) from VA or Medicaid denial letter (if the veteran has denial letter, this step is not needed) 2. Bill Medicare correctly 3. Bill AK Medicaid correctly and attach denial from VA and the MRN 115

116 Claims Management 116

117 Timely Filing of Claims All claims must be filed within 12 months of the date you provided services to the patient The 12-month timely filing limit applies to all claims, including those that must first be filed with a third-party carrier 117

118 Claims Status Inquiry Claim status inquiry form Online through Health Enterprise: Login to your account On the Claims tab, select Claim Status Inquiry Enter the search criteria for the claim or claims for which you are looking Call Provider Inquiry 118

119 Claims Status Inquiry Claim status inquiry form Online through Health Enterprise: Login to your account On the Claims tab, select Claim Status Inquiry Enter the search criteria for the claim or claims for which you are looking Call Provider Inquiry 119

120 Electronic Claim Status Inquiry If you are HIPAA compliant for filing a 276 inquiry and receive a 277 response, you may check claim status electronically You must successfully test on these transactions Contact Conduent Electronic Commerce Customer Support (ECCS) coordinator You must have some form of practice management software that supports these transactions Refer to Companion Guides for electronic transactions information: Refer to Implementation Guides for electronic transactions information: 120

121 Claim Inquiry Form 121

122 122 Life of a Claim

123 Transaction Control Number (TCN) Once received, all claims are entered into the system, either electronically or by data entry, and assigned a TCN. TCNs are unique to each claim and determined by multiple submission factors The format of this number is YYJJJMBBBBDDDDDDT YYJJJ - Year and the current Julian calendar date M - Media source code BBBB - Conduent internal use DDDDDD - Conduent internal use T - Transaction code 123

124 Transaction Control Number Media Source Codes Transaction Type Codes 1 - Web submitted claims 2 - Electronic crossover claims 3 - EMC claims 4 - System generated claims 8 - Paper Claims 9 - Pharmacy 0 Original claim 1 Void 2 Credit of adjustment 3 Debit of adjustment 124

125 Claims Processing After being assigned a TCN, all claims enter the automated adjudication process. Automated Adjudication Claims that are automatically processed Manual Adjudication If the claim has certain attachments, requires specific or specialized justification to process or is for a diagnosis or procedure that requires review, it will be suspended from the automated process for manual processing by a claims representative 125

126 Claim Resolution All claims will adjudicate to a final status of paid or denied. Paid All paid claims will be reflected on your RA There may or may not be EOB exceptions Denied All denied claims will have EOB exceptions listed on your RA Look through all of the EOB codes, not just the first few, to decide whether or not to correct and resubmit Also use to determine if other actions, such as an appeal may be appropriate 126

127 RA Sections RAs are separated into several different sections, each containing very important information regarding claims processing. RAs contain: Cover Page RA Messages Adjudicated Claims Adjustments Voids In-Process Claims Explanation of Benefits Financial Transactions Summary Helpful Tip: Review all areas of your Remittance Advice. It will help you identify any errors, ways to correct denied claims, and prevent future issues. It also contains helpful notes, reminders, and training opportunities, as well as useful accounting information throughout. 127

128 Suspended Claims Common reasons for suspended claims: Review third-party liability and any attached Explanation of Benefits (EOB) Review medical justification Manual pricing If all necessary documentation was properly submitted, no action is required by the provider while a claim is in suspended status unless contacted by DHSS or Conduent for further documentation 128

129 Understanding Exception Codes RA includes exception codes and a brief description indicating what action the provider needs to take Documentation> Documents & Forms> Exception Codes Provider Inquiry In Anchorage , option 1 Toll-Free in AK , option 1 Claims data is reviewed in a hierarchical order Some exceptions will stop the claims processing Additional exceptions may result after initial exceptions are corrected 129

130 Case Management 130

131 Qualis Health Case Management Case management is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual s health needs through communication and available resources to promote quality and cost effective outcomes Focuses on helping medically complex patients receive appropriate medical care Comprehensive care plan is developed in collaboration with patient, family, attending physician and other appropriate providers 131

132 Qualis Health Case Management (cont.) Assess the member s situation and challenges Provide information and resources Coordinate services provided by involved health care providers Discharge plan and assess patient transition from acute care to home environment 132

133 Qualis Health Case Management (cont.) Case management is a voluntary program for members Members may be referred by providers, family members, state agencies, care coordinators or others Some conditions trigger automatic routing to case management for review Potential cases are referred to the State for determination For more information, see Provider Manual on 133

134 Additional Information 134

135 Alaska Medicaid Compliance & Ethics Training Compliance & Ethics: Alaska Medicaid 101 is a computer-based training which includes an interactive video presentation and a supplemental handbook This training serves to: Familiarize providers with the responsibilities and requirements associated with being a Medicaid provider Guide providers through the laws and regulations Medicaid providers must follow The training is available at Select Provider>Compliance & Ethics Alaska Medicaid provides a certificate for completing this training Please direct any questions to the Provider Training department at or

136 Additional Resources Alaska Medicaid Health Enterprise website at Information necessary for successful billing Includes provider-specific Medicaid billing manuals and fee schedules You may also call: Provider Inquiry Eligibility only , option 1,2 or (toll-free), option 1,1,2 Claim status and other inquiries , option 1,1 or (tollfree), option 1,1,1 EDI Coordinator Electronic transaction inquiries , option 3 or (toll-free), option 1, 4 136

137 2016 Conduent Business Services, LLC. All rights reserved. Conduent and Conduent Design are trademarks of Conduent Business Services, LLC in the United States and/or other countries.