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 p2 Missouri Care Member Card p3 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. p4 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) p5 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. p6 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 p7 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. p8 Claims Information p9 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 p 10 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 p 11 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 p 12 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. p 13 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. p 14 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. p 15 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. p 16 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. p 17 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. p 18 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 p 19 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 p 20 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. p 21 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. p 22 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. p 23 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 p 24 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.” p 25 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. p 26 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 p 27 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 p 28 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 p 29 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 p 30 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. p 31 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. p 32 Question and Answer Session p 33
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