Missouri Care
MSMA 2014 Insurance Conference
April 24, 2014
MO022611_PRO_PRS_ENG State Approved MMDDYYYY
©WellCare 2013 MO_05_13
© 2013 WellCare Health Plans Inc. All rights reserved.
Missouri Care
Missouri Care has been a MO HealthNet managed care health
plan since 1998. We serve 54 counties in Eastern, Central and
Western Regions of Missouri. Our mission is to provide access to
quality health care for the members we serve.
Missouri Care provides coverage for the following MO HealthNet
programs:
o MO HealthNet for Kids
o MO HealthNet for Pregnant Women
o Medical Assistance for Families
o Children’s Health Insurance Program
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Missouri Care Member Card
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Missouri Care Member Card – CMPCN
Missouri Care announced their partnership with the Children’s Mercy Pediatric Care Network
(CMPCN) effective February 1, 2014. CMPCN is an integrated pediatric network operated by the
Children’s Mercy Hospital System. CMPCN provides delegated medical management services
to Missouri Care members who are part of that network. Missouri Care members who are part of
this network can be identified by the CMPCN logo on their ID card.
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Prior Authorizations
• All providers must verify that authorization has been obtained prior to rendering
services to a member
• A change in procedure or date requires a change in authorization within 24
hours
• Some procedures differ in PA requirements depending on where the procedure
is performed
• All new providers must get authorization for EVERY service until they are given
an effective date. This includes providers joining already contracted groups.
• All out-of-network services require PA
• PA decisions/responses:
o Within 24 hours for urgent services
o Within 2 business days for routine services
• An authorization number does not guarantee payment (e.g. loss of eligibility, or
service rendered on date other than authorized)
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Requesting Authorizations – Missouri Care
Missouri Care handles Authorization/Pre Certification for members who are not part of the
CMPCN network**
The Missouri Care website includes an Authorization Look-Up Tool to help providers
determine which services require authorizations – You can search quickly and easily by CPT
code.
Missouri Care authorizations may be requested by three methods – see Quick Reference
Guide for specifics:
o On-line through Secure Provider Portal - preferred method for those services it can be
used for.
o Fax: forms are available on our website – fax # 1-866-946-2052
o For Urgent Authorization Requests and Admission Notifications – call
1-800-322-6027
** except for a special programs handled by our vendor Care Core - see next slide for specifics.
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Requesting Authorizations – Missouri Care
Care Core processes were put in place effective 4/1/2014
Care Core National is our in-network vendor for the following programs: Advanced Radiology,
Cardiology, Pain Management and Sleep Diagnostics.
Contact Care Core for all authorization related submissions for the services listed above
rendered in Places of Service (POS): 11, 12*, 22, 24 & 49*
Urgent Authorizations and Provider Services 1-888-333-8641
Authorization Request Submissions Fax 1-866-896-2152
Web submissions may be submitted via the Care Core Provider Web Portal. A searchable
Authorization Lookup and Eligibility Tool is also available online.
*Applies only to Sleep Diagnostics
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Requesting Authorizations – Missouri Care
members in the CMPCN Network
CMPCN provides delegated medical management services for Missouri Care members who are part
of the CMPCN network. Preauthorization requests related to Missouri Care members in this network
should be directed as follows:
Prior Authorization Phone ... 1-877-347-9367
Prior Authorization Fax ....... 1-888-670-7260
Clinical Services Phone…….1-888-670-7262
*
Please check the CMPCN website at http://www.cmpcn.org for related preauthorization forms,
prior authorization quick guide and code lookup.
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Claims Information
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Timely Filing – Missouri Care
• Missouri Care as Primary Payer
o 1st submission is defined by contract
o Standard is 180 days
• Missouri Care as Secondary Payer
o Within 365 days from DOS for first submission or resubmission
o Within 90 days from the date of the primary EOB if that is longer
than 365 days from date of service
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Electronic Claim Submission Methods
o Relay Health, a division of McKesson, is WellCare’s Preferred vendor
Payer ID 1844 -Professional
Payer ID 8551-Institutional
o
Clearing House other than Relay Health
Payer ID 14163-Professional or Institutional
o
Via MO Care Portal
www.missouricare.com
This is only for participating providers and you will have to login to the Portal
No functionality to send secondary claims
o
Via MD-Online
www.mdon-line.com
Free to MO Care/WellCare providers
Professional Claims only (CMS 1500)
Capability to send secondary claims electronically
o Via Administep
www.administep.com
Free to MO Care/WellCare providers
Professional and Institutional Claims (CMS1500 and UB04)
Capability to send secondary claims electronically
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Paper Claim Submission
Paper Claims
We use Optical Character Recognition (OCR) to efficiently and accurately transfer claims
information into the claims processing system
o Must be on the red and white claim form
o Cannot hand write on the claim
o Cannot put a sticker on the claim
o Paper Claims Mailing Address:
Missouri Care Claims
PO Box 31224
Tampa, FL 33631-3224
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Claim Rejection vs. Claim Denial
o
Claim Rejection – refers to those cases where the claim data did not pass the "front-end" edit
process. The provider needs to correct the data and re-submit the claim. Depending on where
and when in the process the claim was rejected, it may not be visible in many of our systems,
particularly our claims adjudication system. Rejected claims are validated and evaluated by the
EDI department.
For support from WellCare for EDI tracking and liaison assistance if needed with the
clearinghouse or any general EDI questions please email use the EDI group email at [email protected]
o
Claim Denial - is when WellCare receives a claim, completes the adjudication process, and
determines that a claim line will not be paid. These claims are validated and researched by the
claims department and the claims processors. Denials can result from missing or incorrect data
on a claim. If the denial is a result of missing or incorrect information then these situations may
be resolved by submitting a corrected claim.
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Common Mistakes on NEW 1500 Claim Form
Missouri Care/WellCare will only accept typed original (red and white) CMS-1500 claim forms on the 02/12 version.
Missouri Care has identified common mistakes with the submission of the New CMS 1500 (OMB-0938-1197 Form 1500 02-12)
version (02-12) claim form. Listed below are five common mistakes resulting in the new CMS 1500 claim form not being
submitted correctly to Missouri Care resulting in claim rejections.
o
The new 1500 form requires the identification of the ICD being submitted in the “ICD Ind.” (Box 21) on the claim form. The
only acceptable values in this field are “9” for ICD-9 or “0” for ICD-10. We have noticed this field being left blank incorrectly.
o
The previous version of the CMS 1500 claim form only allowed four diagnosis codes in Box 21 listed as 1-4. The new CMS
1500 Claim Form version 02-12 allows 12 diagnosis codes listed with A-L as the allowable values for these fields. Diagnosis
Codes are listed in order left to right. If a provider’s billing system is not mapped to the new form the diagnosis codes are
incorrectly displaying on the new CMS 1500 Form.
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Common Mistakes on NEW 1500 Claim Form
o
For the new CMS 1500 claim form the Diagnosis Pointers must match the new Box 21 Diagnosis labels. The
correct values for the Diagnosis Pointer field is the Diagnosis Code letter(s) from Box 21 of the new CMS 1500
claim form applicable for the service listed claim form.
o
The new 1500 Claim Form requires Qualifier Codes for provider numbers other than the NPI Provider Number for
Boxes 17, 17a and 17b.
The new requirement s for Box 17 requires the Referring, Ordering or Supervising provider’s name (First Name,
Middle Initial, Last Name) and credentials of the provider and the two digit qualifier to the left of the name if a
provider name is entered in Box 17. The Qualifier Codes are as follows:
DN (Referring Provider)
DK (Ordering Provider)
DQ (Supervising Provider)
A common mistake is the required provider Qualifier Code in Box 17 is missing or invalid on the claims submitted
when a name is entered in Box 17.
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Common Mistakes on NEW 1500 Claim Form
o
Due to the scan code at the top of the new CMS 1500 claim form, the data is printing too high on the lines if
providers do not update the mapping for their printers. This causes the data to report in the wrong area of the
claim form. As a result, the claims are not readable by the claims scanning software.
Please Note: These are Rejected Claims and you do not need to follow the instructions for submitting a
Corrected Claim.
Questions? For questions or support from WellCare for rejections, EDI Tracking and Liaison Assistance, if needed with
the clearinghouse, or any general 837 EDI questions please contact our EDI Team directly by email at [email protected] or by calling our Customer Service Department at 1-800-322-6027.
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Corrected Claims
The Correction Process involves two transactions:
1. Reversal of the original claim - The original claim will be reversed and noted with an adjustment reason code
RV059.
“Payment Reversal – Payment lost/voided/missed.” This process will deduct the prior payment. The Payment
Reversal for this process may generate a negative amount, which may be offset from future payments rather than
on the EOP that is sent out for the newly submitted corrected claim.
2. Adjudication of corrected claim - The corrected claim will be processed with the newly submitted information
and noted with an adjustment code CL025 “Adjusted per corrected bill.” This process will pay out the newly
calculated amount on a new claim with a new claim number.
The Void Process involves the following transaction:
Reversal of the original claim - The original claim will be reversed and the subsequent claim submitted with an 8
(Void/cancel of prior claim) will be processed as a zero payment and noted with an adjustment reason code
RV059 “Payment Reversal – Payment lost/voided/missed.” This process will deduct the prior payment or zero net
amount if applicable.
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Corrected Claims
To submit a Corrected or Voided Claim electronically (EDI):
• For Institutional and Professional claims, providers must include the original Missouri Care claim number in Loop
2300 segment REF*F8 with the claim’s Frequency Code (CLM05-3) of 7 (Replacement of prior claim) or 8 (Void/
cancel of prior claim). Please refer to the 5010 Implementation Guides or Missouri Care’s Companion Guides for
complete details.
To submit a Corrected or Voided Claim on paper:
• Institutional claims, the provider must include the original Missouri Care claim number and bill frequency code per
industry standards.
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Corrected Claims
Professional claims, the provider must include the original Missouri Care claim number and bill frequency code
per industry standards. When submitting a Corrected or Voided claim, enter the appropriate bill frequency code left
justified in the left-hand side of Box 22.
Please Note: Any missing, incomplete or invalid information in any field may cause the claim to be rejected. If you
handwrite, stamp, or type “Corrected Claim” on the claim form without entering the appropriate Frequency Code
“7” or “8” along with the original claim number as indicated above, the claim will be considered a first-time claim
Submission
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Provider Billing and Address Changes
Incorrect claim denials or payments will occur if the provider information we have in our system
does not match the provider information on submitted claims.
Prior written notice is required for any of the following changes:
•
1099 mailing address
•
Tax Identification Number (Tax ID or TIN) or Entity Affiliation (W-9 required)
•
Group name or affiliation
•
Physical or billing address
•
Telephone and fax number
•
Panel changes
•
Directory listing
Thirty (30) day advance notice is recommended. You may submit the advance notice of these
changes via any of these methods:
Email:
[email protected]
Fax:
1-866‐946‐1105
Mail:
Missouri Care
Attention: Provider Operations, 2404 Forum Blvd, Columbia, MO 65203
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Use of NPI and Preauthorization Number on
1500 Form
• NPI is required.
• If a preauthorization number was obtained, providers must
include this number in the appropriate data field on the claim.
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Claim Edits and Coding Guidelines
Missouri Care uses a commercial software package which relies
upon Government Programs and other industry standards in the
development of its bundling guidelines.
We also update internal payment systems in response to
additions, deletions, and changes to Government Sponsor, CMS,
and other industry standards.
We follow MO HealthNet’s Billing Guidelines. If you are unsure how to
bill refer to www.dss.mo.gov/mhd website for Training Booklets and the
Fee Schedule for required modifiers.
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Top 5 Common Billing Mistakes
1.
2.
The member has no coverage with Missouri Care on the date of service.
•
Eligibility can change from day to day, so it is important to verify eligibility before services are performed.
•
Eligibility can be verified by calling the Interactive Voice Response (IVR) Unit at (573) 635-8908 or through the web at
eMoMed (www.emomed.com).
The CPT/HCPS code billed is not a payable service on the MO HealthNet Fee Schedule.
•
You can determine if a service is payable by checking the online fee schedule at:
http://www.dss.mo.gov/mhd/providers
3. Modifiers are missing, incorrect, or are in incorrect order
•
We follow MO HealthNet’s Billing Guidelines. If you are unsure how to bill refer to www.dss.mo.gov/mhd website for
related information
•
Generally, Missouri Care expects the modifiers to be billed in the same order as they appear on MO HealthNet’s –
Missouri Medicaid Physicians Fee Schedule (located at dss.mo.gov/mhd/providers  Fee Schedules). There are
three exceptions to this which are covered on the next slide.
4. Prior Authorization required but not obtained.

Check authorization rules on the Missouri Care, Care Core, or CMPCN websites to determine if authorization is
required
5. Duplicate claim denial as the result of not following guidelines for submitting a Corrected Claim.

Review instructions for submitting corrected claims on previous slides.
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Multiple Modifier Order
Generally, Missouri Care expects the modifiers to be billed in the same order as they appear on the MO
HealthNet Physicians Fee Schedule. Informational modifiers should be billed after the MO HealthNet
required modifiers.
For example, for ‘Other Service’ billed with code H2025, the modifiers HX and HQ should be billed as
H2025 HX HQ.
Specific Exceptions
•
Consistent with MHD’s Physician’s provider manual (Section 9.6), for partial EPSDT screenings, the
modifiers indicating a partial screen should be billed first (e.g., 99381 52 EP).
•
For Durable Medical Equipment (DME) services, the modifiers indicating whether an item is new (NU)
rental (RR) or repair (RB) should be billed in the first field; if other modifiers are appropriate, those
modifiers should be billed in the order on the Missouri Medicaid Physicians Fee Schedule.
•
For surgery services, the modifiers related to ‘Postoperative Services’ (modifier 55), ‘Without Postoperative
Services’ (modifier 54), and ‘Assistant Surgery’ (modifier 80) should be billed in the first field; if other
modifiers are appropriate, those modifiers should be billed in the order listed on the Missouri Medicaid
Physicians Fee Schedule
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Balance Billing
Missouri Care members should not be billed, or reported to a collection agency for
any covered services your office provides.
Missouri Code of State Regulations Title 13 CSR 70-4.030 states “When an enrolled
Medicaid provider provides an item or service to a Medicaid recipient eligible for the
item or service on the date provided, there shall be a presumption that the provider
accepts the recipient’s Medicaid benefits and seeks reimbursement from the
Medicaid agency in accordance with all the applicable Medicaid rules.”
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Claim Payment Dispute Process
•
The Claim Payment Dispute process is designed to address claims when there is disagreement regarding
reimbursement.
•
Claim payment disputes must be submitted to Missouri Care within 365 days from the date of service on
the claim.
•
Please include the claim information and a brief description of why you are disputing the claim.
Three Ways to File a Claim Dispute
o Mail written claim payment dispute or fax claim payment dispute to 1-877-277-1808
o Call our Customer Service Team at 1-800-322-6027 and follow the necessary prompts.
o Sign in to the secure web portal - click on “claims inquiry” and an e-mail will be sent on your behalf to
the Customer Service Team.
Claims Dispute Resolution Process
o
If, after reviewing your Claim Dispute, the Claims Dispute Team determines the claim was processed
incorrectly, the claim will be adjusted and the adjustment will appear on a future remit.
o
If the Claims Dispute Team agrees with the processing of the claim and not adjustment is determined
to be necessary, the Claims Dispute Team will call with this update. If they are unable to reach the
individual who filed the dispute, then a letter is mailed.

If the provider disagrees with the determination, they may file a formal appeal with supporting
documentation to our Appeals Department.
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Overpayments Identified by Provider
If a provider independently identifies an overpayment, the provider can perform
one of the following:
• Send a corrected claim (refer to the Corrected Claims or Voided Claims
handout);
• Use the below address to send a refund and explanation of the overpayment
WellCare Health Plans, Inc.
Recovery Department
PO Box 31584
Tampa, FL 33631-3584
• Contact Provider Services to arrange an off-set against future payments
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Electronic Remits & Electronic Funds Transfer
•
Missouri Care issues checks and remits on a daily basis (excluding
weekends), so it is very beneficial to sign up for ERA and EFT to avoid
frequent trips to the bank and manual posting.
•
Missouri Care has partnered with PaySpan Health to provide EFT/ERA
solutions.
•
Call 1-877-331-7154 or email [email protected] to
register
•
Please see the Provider Resource Guide for additional information
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Missouri Care Partners
• MTM Transportation Services
o Provides transportation services to and from medical appointments
o Contact Number for Members: 1-800-322-6027
• Informed Health Line: 24 Hour Nurse Line
o Provides answers to member’s questions 24/7
o Contact number: 1-800-919-8807
• DentaQuest
o Provides dental coverage for eligible members
o Contact Number for Providers: 1-800-322-6027
• March Vision
o Provides routine vision services for eligible members
o Contact number for providers: 1-800-322-6027
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Transportation Benefits
Missouri Care offers rides to health care and dental
appointments to members at no cost.
Members may either:
 Schedule a ride by calling 1-800-322-6027 at least three days before the
appointment
 Be reimbursed for gas for their own vehicles by calling 1-800-322-6027 at
least one day before the appointment
 If a member needs to cancel a ride or mileage reimbursement, the
member should call 1-800-322-6027 as soon as possible
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Missouri Care Website – www.MissouriCare.com
•
Claims Submission Status and Inquiry – Submit a claim, check the status of a
claim, and customize and download reports.
•
Member Eligibility and Co-pay Information – Search the member database
for member effective and term dates, plan type, PCP contact and co-pay
information.
•
Authorization Requests – Submit authorization requests online, attach clinical
documentation and check authorization status. You may also print and/or save
copies of authorization forms once received in your online mailbox.
•
Authorization Look-Up Tool – Search quickly and easily by CPT code.
•
Additional Provider Reporting – Review a list of active members and receive
up-to-date information for those members who have been registered or admitted
as an inpatient to a medical facility.
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Missouri Care Website
•
Provider News – View and download our latest announcements.
•
Your Inbox – Receive notices and key reports regarding claims, eligibility
inquiries and authorization requests in your personal provider inbox.
•
Provider Look-Up Tool – Search the online Provider Directory by location,
distance and/or specialty type to refer members to in-network services.
•
Provider Manual – View and download a complete copy of your Provider
Manual.
•
Forms and Documents – View and download template forms and documents
for appeals, authorizations, claims and more.
The Provider Resource Guide has instructions for how to register as a user.
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Question and Answer Session
p 33