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Presented by
Aileen Sigler
Mary E. Muchow
Provider Outreach and Education
September 10, 2015
AAHAM Fall Meeting
• Eligibility
• Determine the Primary Payer
• Claim Status
• Getting Help
• Medical Review
• Appeals
• Other Resources
Agenda
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Verify Eligibility
• Interactive Voice Response System (IVR)
• CMS Secure Net Access Portal (C-SNAP)
• Direct Date Entry (DDE)
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Available Part A Benefits
InpatientFacility Type
Full DaysCoinsurance
DaysLifetime
Reserve Days
Hospital 60 3060 perlifetime
SkilledNursingFacility
20 80Not
Applicable
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CWF/HIQA
HIQACRO CWF PART A INQUIRY REPLY PAGE 01 OF 12
IP-REC CN xxxxxxxxxA NM xxxxxx IT x DB 06221926 SX M IN 52280
PN xxxxxx APP REAS 1 DATETIME 030814 143156 REQ xxxx
DISP-CODE 03 MSG POTENTIAL PROBLEM SITUATION
CORRECT xxxxxxxxxA NM IT DB SX
A-ENT 060191 A-TRM 000000 B-ENT 060191 B-TRM 000000 DOD 000000 LRSV 60 LPSY 190
DAYS LEFT FULL-HOSP CO-HOSP FULL-SNF CO-SNF IP-DED BLOOD DOEBA DOLBA
CURRENT 53 30 13 80 000 0 020114 021514
PRIOR 53 30 20 80 000 0 021013 022013
PARTB YR 14 DED-TBM 14700 BLD 3 YR 10 DED-TBM 15500 BLD 3 DI 0000000000
FULL-NAME
PER 2 PLAN-TYP HMO CURR ID H2663 OPT C ENR 010112 TERM 013112
PRIOR PLAN-TYP HMO PRIOR ID H2610 OPT C ENR 030110 TERM 033110
PART A YR BLD 3 PT APL 1156.00 OT APL 1920.00
CATASTROPHIC A: DED-TBM BLOOD CO-SNF FULL-SNF DOEBA DOLBA DED-APL
YEAR 89 0056000 03 008 142 000000 000000 0000000
ESRD: CODE-1 EFF DATE CODE-2 EFF DATE
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IVR
• Access claim information
– Patient eligibility
– Overlapping claims
– Discharge status
• Toll-free
• Speak or enter information
• Conversion tools
• Operating Guide
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C-SNAP
• Internet based tool
• Access to Medicare claims information– Patient eligibility
– Appeals status
– Duplicate RA
– Secure messaging
• 24 hours a day
• Additional information not offered on IVR
• Registration required
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Determine Primary Payer
• Medicare Secondary Payer (MSP) questionnaire
– Recommended
– Dated
– No signature required
– Retain for 10 years
Yes
No 10 years
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Obtain Information
• Verify information
– Each admission
– Every encounter
– Start of care
• Exceptions and special circumstances
– Reference lab
– Recurring services
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MSP Categories
Medicare
Working Aged
Disabled
End-Stage RenalDisease (ESRD)
Workers’ Compensation
(WC)
Federal Black Lung (BL)
No Fault Insurance
Liability Insurance
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HIQACOP CWF PART A INQUIRY REPLY PAGE 10 OF 10
IP-REC CN XXXXXXXXXX NM KADIDDLEHOPPER IT C DB 07041926 SX F
SUBSCRIBER NAME: CLEMENTINE KADIDDLEHOPPER POLICY NUM:
EFF DTE: 12/01/2000 TRM DTE: 08/31/2013 PATIENT REL: 01 PATIENT
MSP CODE: A = WORKING AGED IS INSURED
INSURER INFORMATION:
NAME : BLUE CROSS/BLUE SHIELD REMARKS CD: 1 2 3
ADDRESS 1 : 4321 FIRST AVENUE
ADDRESS 2 :
CITY METROPLEX STATE MN ZIP CODE 12345
GROUP NUM :
TYPE : A = INSURANCE OR INDEMNITY
EMPLOYER INFORMATION:
NAME : FANNIE’S FETA FARM
ADDRESS 1 : 789 HIGHWAY 617
ADDRESS 2 :
CITY : ROQUEFORT STATE WI ZIP CODE 67890
EMPLOYEE : ID NUMBER INFO NONE
PF1=INQ SCREEN PF3/CLEAR=END PF7=PREV PF8=NEXT
HIQA
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Coordination of Benefits
• Identify all possible payers
• Maintain and update information
• Coordinate payments to avoid duplication
• Transmit claim to secondary payer
• Recover overpayments
• Do not process claims
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Benefits Coordination & Recovery Center (BCRC)
• Collect, manage and maintain MSP info
• Payment recovery for Non-GHPs
– Liability
– No-fault
– Workers’ Compensation
• (855) 798-2627 8 a.m. – 8 p.m. ET
• Fax number and mailing address based on reason for contact
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Commercial Repayment Center (CRC)
• Payment recovery associated with Group Health Plans
– Working Aged
– Disability
– End Stage Renal Disease
• (855) 798-2627 8 a.m. – 8 p.m. ET
• Fax and mailing address on CMS website
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Remittance Advice
From Claim to PaymentSubmission
Medicare
Contractor
Edits/Audits
(Drivers)
Non-Payable
Development Payable
Received
Documentation No Documentation
Received
Non-PayablePayableNon-Payable
Front End Edits
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CLAIM STATUS
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Claim Status
• Check regularly
– Claims Summary
– Claim Count Summary
– IVR
– C-SNAP
• Keep claims moving
• Take additional action
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Claims Summary
• Inquiries (01)
– Claims (12)
• List of pending and processed claims
• Sort or narrow results
– Medicare number
– Status/Location
– Type of bill
– From and/or through dates
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MAP1701 WISCONSIN PHYSICIANS SERVICE
MAIN MENU FOR REGION MUCICM0S
01 INQUIRIES
02 CLAIMS/ATTACHMENTS
03 CLAIMS CORRECTION
04 ONLINE REPORTS VIEW
ENTER MENU SELECTION: 01
Main Menu
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Inquiries (01)
MAP1702 WISCONSIN PHYSICIANS SERVICE
INQUIRY MENU
BENEFICIARY/CWF 10 HCPC CODES 14
DRG (PRICER/GROUPER) 11 DX/PROC CODES 15
CLAIMS 12 ADJUSTMENT REASON CODES 16
REVENUE CODES 13 REASON CODES 17
CLAIM COUNT SUMMARY 56 ANSI REASON CODES 68
CHECK HISTORY FI ZIP CODE FILE 19
ENTER MENU SELECTION: 12
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MAP1741 M E D I C A R E A O N L I N E S Y S T E M
SC CLAIM SUMMARY INQUIRY
NPI XXXXXXXXXX
HIC PROVIDER S/LOC P B9997 TOB XXX
OPERATOR ID YMADDE08 FROM DATE TO DATE DDE SORT
MEDICAL REVIEW SELECT
HIC PROV/MRN S/LOC TOB ADM DT FRM DT THRU DT REC DT
SEL LAST NAME FIRST INIT TOT CHG PROV REIMB PD DT CAN DT REAS NPC #DAYS
s XXXXXXXXXX XXXXXX P B9997 XXX 010108 010108 011008 012808
KILLION J 4500.00 3790.67 013108 37192
Claims (12)
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Claim DetailMAP1711 M E D I C A R E A O N L I N E S Y S T E M CLAIM PAGE 01
SC 17 INST CLAIM INQUIRY SV:
HIC XXXXXXXXX TOB XXX S/LOC T B9997 OSCAR UB-FORM
NPI 1111111111 TRANS HOSP PROV PROCESS NEW HIC
PAT.CNTL#: TAX#/SUB: TAXO.CD:
STMT DATES FROM 010108 TO 011008
LAST KILLION FIRST JASON MI D DOB 04061907
ADDR 1 WPS HOME OFFICE 2 OMAHA NE
3 4
5 6
ZIP 68101 SEX M MS S ADMIT DATE 010108 HR 01 TYPE 1 SRC 1 D HM STAT 01
COND CODES 01 02 03 04 05 06 07 08 09 10
OCC CDS/DATE 01 02 03 04 05
06 07 08 09 10
SPAN CODES/DATES 01 02 03
04 05 06 07
08 09 10 FAC.ZIP 55555
DCN
V A L U E C O D E S - A M O U N T S - A N S I MSP APP IND
01 A1 1024.00 PR 1 02 18 244.46 03 19 186.63
04 20 369.43 05 80 9.00 06
07 08 09
31201 38038 <== REASON CODES
PRESS PF3-EXIT PF5-SCROLL BKWD PF6-SCROLL FWD PF8-NEXT
MAP1881 M E D I C A R E A O N L I N E S Y S T E M OP: CNA50790
SC REASON CODES INQUIRY DT: 102207
PLAN REAS NARR EFF MSN EFF TERM EMC HC/PRO PP CC
IND CODE TYPE DATE REAS DATE DATE ST/LOC ST/LOC LOC IND
1 31201 E 082399 T T
TPTP A B NPCD A B HD CPY A B NB ADR CAL DY C/L C
------------------------------NARRATIVE------------------------------------
ON THE FIRST OCCURRENCE CODE, THE DATE EXCEEDS THE THRU DATE.
CORRECT AND RESUBMIT IF APPROPRIATE.
PROCESS COMPLETED --- NO MORE DATA THIS TYPE
PRESS PF3-EXIT PF6-SCROLL FWD PF8-NEXT
Reason Codes (17)
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MAP1712 M E D I C A R E A O N L I N E S Y S T E M CLAIM PAGE 02
SC INST CLAIM INQUIRY REV CD PAGE 01
HIC XXXXXXXXX TOB XXX S/LOC P B9997 PROVIDER 1111111111
TOT COV
CL REV HCPC MODIFS RATE UNIT UNIT TOT CHARGE NCOV CHARGE SERV DT
1 0120 500.000 00009 00009 4500.00
2 0001 4500.00
37192 <== REASON CODES
PRESS PF2-1712 PF3-EXIT PF5-UP PF6 DOWN PF7-PREV PF8-NEXT PF10-LEFT
Claim Detail
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MAP171D M E D I C A R E A O N L I N E S Y S T E M CLAIM PAGE 02
SC INST CLAIM INQUIRY
DCN XXXXXXXXXXXXXX 03 HIC XXXXXXXXX RECEIPT DATE 020108 TOB XXX
STATUS P LOCATION B9997 TRAN DT 013108 STMT COV DT 010108 TO 011008
PROVIDER ID 1111111111 BENE NAME KILLION, JASON
NONPAY CD GENER HARDCPY MR INCLD IN COMP CL MR IND
TPE-TO-TPE USER ACT CODE WAIV IND MR REV URC DEMAND
REJ CD MR HOSP RED RCN IND MR HOSP-RO ORIG UAC
MED REV RSNS
OCE MED REV RSNS
1 HCPC/MOD IN SERV -----REASON-CODES------
REV HCPC MODIFIERS DATE COV-UNT COV-CHRG ADR
0120 9 4500.00 FMR
ORIG ORIG REV MR ODC
OCE OVR CWF OVR NCD OVR NCD DOC NCD RESP NCD# OLUAC
NON NON DENIAL OVER ST/LC MED ------------ANSI------------
LUAC COV-UNT COV-CHRG REAS CODE OVER TEC ADJ GRP ------REMARKS------
TOTAL LINE ITEM REASON CODES
37192 <== REASON CODES
PRESS PF2-1712 PF3-EXIT PF5-UP PF6 DOWN PF7-PREV PF8-NEXT PF10-LEFT
Claim Detail
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Claim Detail
MAP1716 M E D I C A R E A O N L I N E S Y S T E M CLAIM PAGE 06
SC INST CLAIM INQUIRY
HIC XXXXXXXXX TOB XXX S/LOC P B9997 PROVIDER 1111111111
MSP ADDITIONAL INSURER INFORMATION
1ST INSURERS ADDRESS 1
1ST INSURERS ADDRESS 2
CITY ST ZIP
2ND INSURERS ADDRESS 1
2ND INSURERS ADDRESS 2
CITY ST ZIP
PAYMENT DATA --- DEDUCTIBLE 1024.00 COIN CROSSOVER IND
PARTNER ID
PAID DATE 013114 PROVIDER PAYMENT 3790.67 PAID BY PATIENT
REIMB RATE RECEIPT DATE 010114 PROVIDER INTEREST
CHECK/EFT NO 0001368304 CHECK/EFT ISSUE DATE 013114 PAYMENT CODE CHK
PRICER DATA
DRG 195 OUTLIER AMT TTL BLNDED PAYMT FED SPEC
GRAMM RUDMAN ORIG REIMBURSEMENT AMT .00 NET INL
TECH PROV DAYS TECH PROV CHARGES
OTHER INS ID CLINIC CODE
37192 <== REASON CODES
PRESS PF3-EXIT PF7-PREV PAGE
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Claim Count Summary
• Inquiries (01)
– Claim Count Summary (56)
• Total claim count and dollar amount by status/location
• Track cash flow
• Identify potential problems
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Inquiries (01)
MAP1702 WISCONSIN PHYSICIANS SERVICE
INQUIRY MENU
BENEFICIARY/CWF 10 HCPC CODES 14
DRG (PRICER/GROUPER) 11 DX/PROC CODES 15
CLAIMS 12 ADJUSTMENT REASON CODES 16
REVENUE CODES 13 REASON CODES 17
CLAIM COUNT SUMMARY 56 ANSI REASON CODES 68
CHECK HISTORY FI ZIP CODE FILE 19
ENTER MENU SELECTION: 56
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Claim Count Summary (56)
MAP1371 M E D I C A R E A O N L I N E S Y S T E M
SC CLAIM SUMMARY TOTALS INQUIRY
PROVIDER XXXXXX S/LOC CAT
NPI 1111111111
S/LOC CAT CLAIM COUNT TOTAL CHARGES TOTAL PAYMENT
GT 466 3,467,059.40 220,406.91
P B9996 TC 41 1,054,204.77 220,406.91
P B9996 11 41 1,054,204.77 220,406.91
S B0100 TC 1 1,200.00 00.00
S B0100 13 1 1,200.00 00.00
S B6001 TC 1 200.00 00.00
S B6001 13 1 200.00 00.00
S B9099 TC 95 864,738.20 00.00
S B9099 11 36 850,782.35 00.00
S B9099 13 4 7,346.25 00.00
S B9099 14 55 6,609.60 00.00
S MAXXC TC 4 650.00 00.00
S MAXXC 13 4 650.00 00.00
S MDAWN TC 10 17,230.00 00.00
S MDAWN 12 10 17,230.00 00.00
S MDIAZ TC 2 200.00 00.00
PROCESS COMPLETED --- PLEASE CONTINUE
PLEASE MAKE A SELECTION, ENTER NEW KEY DATA, PRESS PF3-EXIT, PF6-SCROLL FWD
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Claims Tips
• Tips
– Direct access to the Multi-Carrier System (MCS)
– Direct access to the Fiscal Intermediary Shared System (FISS)
– Nightly & weekend maintenance
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GETTING HELP
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Getting Help
• CMS
• WPS Medicare
• Call Center
• Correction Line
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CMS.gov
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J5 MAC/J5 National Part A Home Page
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J5 MAC Part B Home Page
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Call Center
Provider Self-Service
Tier 1
Tier 2
Tier 3
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Correction Line (Part A)
• Claim in suspense, but not in TB9997
• Provider knows specific change to make
• Not all claims can be worked
• Closed on Friday
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Remittance Advice
• Standard Paper Remit (SPR)
• Electronic Remittance Advice (ERA)
• Final claim adjudication
• Payment information
• Reason for and values of adjustment
– Group Code
– Claim Adjustment Reason Code (CARC)
– Remittance Advice Remark Code (RARC)
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MEDICAL REVIEW
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Definition
• Collection and clinical review of record
• Ensures payment is made only for services that meet requirements
– Coverage
– Coding
– Medical necessity
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Goal
• Reduce inappropriate payments
– Identify patterns of errors through data analysis
– Address billing errors
– Publish guidance
– Prevent future instances
• Benefits for providers
– Reduced error rate
– Decreased denials
– Increased educational opportunities
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Process
• Data analysis
• Verification of billing/coverage
• Determine severity of problem
• Implement appropriate corrective action
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Types• General edits
– All providers subject to
• Targeted edits– Specific to single provider or provider types
– PCA (Probe)
• Pre-pay– Claim will edit for review prior to reimbursement
• Post-pay– Claim has processed and then pulled for review
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Part A Pre-Pay Review
• Status/Location SB6000/SB6001/SB6099
• Reason code
– Describes review and what to send
– Usually begin with a 5
• Submit documentation
– Medical Review Cover Sheet or DDE print
• Claim moved to SMRDOC when received
• 56900 on day 46 if not received
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Part A Post-Pay Review
• Letter sent with details
• Submit documentation within 30 days
– Copy of letter with records
– Do not use Medical Review Cover Sheet
• 56900 on day 46 if not received
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Part B Medical Review
• May be
– Automated or complex
– Pre-payment or post-payment
• Additional Documentation Requests will be sent for records, when needed
• MR web page includes
– helpful articles
– links to needed forms
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Submission of Records in C-SNAP
• For Probe or ADR
– Immediate confirmation
– Links to claim
– Viewable for 75 days
– Track status through completion
• For appeal requests (Part B only)
• Claims in RTP (Part A)
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Review Decision Information
• Detailed claim review results
– Pre-payment ADR (Part A only)
– Post-payment Medical Review (Part A and B)
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PCA Process
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Probe Reviews
• Provider Specific
– 20 - 40 claims
– Single provider
– Similar services
• Service Specific
– 100 claims
– Multiple providers
– Similar services
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APPEALS
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Levels of Appeal
1• Redetermination by WPS Medicare
2• Reconsideration by Qualified Independent Contractor (QIC)
3• Administrative Law Judge (ALJ)
4• Medicare Appeals Council
5• Judicial Review in Federal District Court
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Level 1: Redetermination
• Submit within 120 days to WPS Medicare
• Decision within 60 days
– Fully or partially unfavorable decisions
• Medicare Redetermination Notice (MRN) issued
– Fully favorable decisions
• Claim adjusted with notice via Remittance Advice (RA) & Medicare Summary Notice (MSN)
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Level 2: Reconsideration
• Qualified Independent Contractor (QIC)– Maximus – Part A
• Changed to C2C effective March 2, 2015
– C2C – Part B
• Must file within 180 days of receipt of redetermination – State reasons for disagreeing with
redetermination decision
• QIC decisions generally made within 60 days of request
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Level 3: ALJ Hearing
• Amount in controversy must be met
– Minimum $$ amount that can be appealed
• AIC determined by request date – not DOS
• Three appealable situations– Appealing QIC’s reconsideration determination
– QIC failed to make a timely decision
– Review of QIC’s dismissal of request for reconsideration
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Submitting Appeal to the ALJ
• Refer to Reconsideration decision letter from QIC for procedures to submit appeal
– Submit within 60 days
• Send to entity specified in the QIC’s reconsideration
• CMS Form 20034 A/B (not required)
• Hearings generally held via video-teleconference or telephone
• Decisions within 90 days
– May be delayed due to volume
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Aggregation of Claims
• AIC for CY 2015 is $150
• Two or more claims may be combined
– Individual or multiple appellants
– Part A or Part B
• Services must be similar or related, or involve a common issue of law and fact
– Appellant(s) must specify all claims involved
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Level 4: Medicare Appeals Council
• Submit within 60 days of ALJ decision – Appeal Form DAB-101 (not required)
– Must specify issues and findings being contested
• Decisions within 90 days
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Level 5: Judicial Review in U.S. District Court
• Send written request within 60 days of receipt of the Appeals Council’s decision
• Procedures listed within decision
• AIC for CY 2015 is $1,460
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Summary of Appeal Levels
Type of AppealTime Limit
AIC Decision
Redetermination 120 $0 60
Reconsideration 180 $0 60
ALJ 60 $150 90*
Medicare Appeals Council
60 $0 90
Federal District Court
60 $1,460 ?
*may be delayed due to volume 75
Do Not Appeal
• Claims that are not finalized
• Claims denied for non-receipt of medical records– 56900 reason code
• Claims containing clerical errors or corrected with adjustment– Human or mechanical errors
– Minor omissions
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Reasons for Dismissal
• Missing information
• No signature
• Not filed timely
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Appeals Navigator
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OTHER RESOURCES
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On Demand Training
• Available on website
– J5 MAC Part A/Part B>>Training>>On Demand Training
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Top Phone/Written Correspondence Frequently Asked Questions
• Available on website
– J5 MAC Part A/Part B>>FAQ>>Departmental>>Customer Service FAQs
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Contact Us
• Includes Telephone/Mailing Information and mechanism to e-mail us a question
• Use link in upper right corner of any web page
• Do not include protected health information (PHI) or personally identifiable information (PII)
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CMS Medicare Learning Network (MLN)
• Includes educational products, web-based training courses, MLN Connects® National Provider Call Program, MLN Connects® Provider eNews, Provider Electronic Mailing lists and more
– https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html
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Disclaimer: WPS Medicare has produced this material as an informational reference. Every reasonable effort has been made to ensure the accuracy of this information at the time of publication, however, WPS Medicare makes no guarantee that this information is error-free and bears no liability for the results or consequences of the misuse of this information. The provider alone is responsible for correct submission of claims. The official Medicare Program provisions are contained in the relevant laws, regulations and rulings and can be found on the Centers for Medicare & Medicaid Services (CMS) website at www.cms.gov.
Thank You for Attending
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