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1 SPRING 2010 PHYSICIAN/PA/ARNP MEDICAID WORKSHOP KENTUCKY
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SPRING 2010PHYSICIAN/PA/ARNP
MEDICAID WORKSHOP
KENTUCKY
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Agenda
•How Medicaid Works•Reference List•Communications•Aspects of Electronic Billing•5010•Websites available•Going Green with Remittance Advices•Co-pay•Member ID’s•Billing Scenarios•Points to Remember•Top Denials•Questions•Evaluation
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How Medicaid Works
Department for Medicaid Services
Medicaid Policy/Enrollment
Local DCBS office HP Enterprise Services
SHPSDepartment for Medicaid Services (DMS) and Medicaid Policy enforces the rules andregulations that were designed by Legislation.
The Local DCBS office enrolls members who apply according to the rules and regulations.
HP Enterprise Services, the KYMMIS contractor, can only process claims according to the rules andregulations that Medicaid has designed.
HP Enterprise Services has the prior authorization contract, but SHPS who is the subcontractor for HPEnterprise Services, can only issue prior authorizations according to the rules and regulations that Medicaidhas designed.
CMS
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Representative ListBrenda Orberson502-209-3053
[email protected] Allen Barren Boyle Casey
Clinton Cumberland Estill Green JacksonLaurel Lincoln Madison McCreary MetcalfeMonroe Pulaski Rockcastle Russell SimpsonWarren Wayne Whitley
Penny Germinaro502-209-3278
[email protected] Breathitt Boyd Carter ClayElliot Greenup Floyd Harlan JohnsonKnott Knox Lawrence Lee LewisLeslie Letcher Martin Magoffin Morgan
Owsley Perry Pike Rowan
Vicky Hicks502-209-3050
[email protected] Bourbon Clark Fleming Fayette
Garrard Jessamine Menifee Mercer MontgomeryNicholas Powell Wolfe Woodford
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Leigh Ann Hayes502-209-3087
[email protected] Bracken Campbell Carroll GallatinGrant Jefferson Kenton Pendleton OldhamOwen Trimble
Kristy Cabell502-209-3051
[email protected] Ballard Breckinridge Bullitt ButlerCaldwell Calloway Carlisle Christian CrittendenDaviess Edmonson Franklin Fulton GravesGrayson Hancock Hardin Harrison Hart
Henderson Henry Hickman Hopkins LarueLivingston Logan Lyon Marion Marshall
Mason Mccracken Mclean Meade MuhlenbergNelson Ohio Robertson Scott ShelbySpencer Taylor Todd Trigg Union
Washington Webster
Representative List
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Reference ListPhone Numbers
Web addresses
Departments
EDI Helpdesk 800-205-4696 [email protected]
HP Provider Billing Inquiry 800-807-1232 [email protected]
SHPS 800-292-2392
Provider Enrollment 877-838-5085
Member Services 800-635-2570
Passport 800-578-0775
Fraud 800-372-2970
Medicaid Policy 502-564-2687
Departments
KY Medicaid www.chfs.ky.gov/dmsFee Schedule, Regulations, Provider updates, Provider Enrollment
HP Website www.kymmis.comForms, Workshop updates, Billing Instructions, KyHealth Net guide,Provider Directory
KyHealth Net http://home.kymmis.comImmediate claim adjudication, Member Eligibility, Claim status PA, andRA’s.
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Communications
Departments
HP Provider Inquiry Claim status, denials, RA’s, any billing questions, membereligibility, PA’s and limitations. (for providers only)
EDI Helpdesk Electronic billing, electronic RA’s, PIN #, and passwordreset.
Provider Field Representative Provider Workshops, training, one on one provider visits,mini-workshops, association meetings, teleconferencesand escalated problems. (not for claim status and forproviders only)
Medicaid Policy Questions concerning coverage, rate and regulations
Medicaid Provider Enrollment Questions or updates to the provider file, such as:NPI/Taxonomy, updating address, EFT’s and enrollment ofproviders.
SHPS Prior Authorization Prior Authorizations
Local DCBS office Eligibility updates
Member Services Question on member files, such as: program codeinformation and member eligibility. (for providers andmembers)
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Communications
•Department for Medicaid Services uses the following publications and tools tocommunicate information to providers:
RA BannerMessage boardKyHealth Net main pageProvider LettersAll WebsitesProvider Representatives
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Aspects of Electronic Billing•All claims submitted via paper or electronically appear in the claims inquiry area ofthe KyHealth Net.
•Claims submitted via 837 or KyHealth Net are processed faster because manualintervention is not required.
•KYMMIS Website holds DDE User Manuals and Companion Guides forrequirements providers must follow for proper claim submission.
•Provider may view, adjust and void paid claims and resubmit denied claims.This functionality is available for all claims submitted.
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5010
•The format you use to submit 837 transactions to health insurance carriers will beupgraded in the coming months. The Centers for Medicare and Medicaid Services(CMS) are switching from the Health Insurance Portability and Accountability Act(HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12version 5010 and from National Council for Prescription Drug Programs (NCPDP)version 5.1 to NCPDP version D.0.
•This will be fully implemented by January 1, 2012.
•Please contact your vendors and clearinghouses to be surethey are compliant before January 1, 2012.
•More information will be forthcoming for changes specific toKentucky Medicaid.
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Medicaid’s Website
www.chfs.ky.gov/dms
Fee Schedule
Regulations
Kymmis Website
Provider Directory
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KYMMIS Website
www.kymmis.com
KyHealth NetClaims Submission/InformationMember Information
Provider Directory
Billing Instruction,Forms and Workshop Updates
Letters and Notifications
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KyHealth Net Website
http://home.kymmis.com
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KyHealth Net WebsiteHome Page
http://home.kymmis.com
Discontinue Paper RA
Resume Paper RA
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RA Viewer
View weekly RA
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RA Viewer
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Remittance Advice
•Available on the pay-to provider RA viewer of the KyHealth Net.
•Available prior to receipt of the hard copy version.
•Even if the provider has opted out of receiving paper RAs, RAs will be available onthe KyHealth Net for six months.
•To obtain RAs older than six months, providers may contact Provider Inquiry.
•RAs on the KyHealth Net are image files of the paper RAs.
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Format for larger print on RA
ChoosePreferences
ChooseImageOptions
Enlarge to 125
Click Ok,Then print
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Member Eligibility Co-pay Steps
1. Check Benefit Plan to determine if the service you are providing has a
copay.
2. Look at copay indicator to determine if copay is applicable. If there is an
“N”, then do not go any further. If there is a “Y”, continue.
3. View cost share for the quarter “Y” means cost share has been met and
an “N” means cost share has not been met. If a “Y” is present do not
collect a copay. If an “N” and copay indicator is “Y” you collect a copay.
(unless the out of pocket has been met)
View out of pocket, if it has been met, no co-pay from the member.
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Member ID’s
UseCurrentID
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SERVICE LIMITATIONS
Listing of limitations met
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Billing Scenarios•The Member ‘s Medicaid ID is entered in field 9a of the CMS 1500 claim form.Medicaid does not review field 1a.
•The member’s KenPAC provider NPI number must be in field 17b. This is theonly number that belongs in this field.
•The diagnosis cross reference must be billed on all claims.One digit field of either a 1, 2, 3, or 4.
•Billing for ARNP/CRNA – An ARNP or CRNA cannot be billed along with the physiciangroup. They must be billed under their own individual or ARNP/CRNA group number.
•Billing for Physician Assistant – In field 10d, enter the PA’s NPI number. In field 24denter the U1 modifier. In field 24j, enter the supervising Physician’s NPI.
•Twin baby claims – Bill with both twins on the same claim under Mom’s Medicaid ID number-notations of “TWIN A” and “TWIN B” are required on each line beside the procedure code.If baby has ID, can bill with baby’s ID number.
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Billing Scenarios
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Billing Scenarios
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Points to Remember
•Adjustments and Voids can only be done on “Paid” claims. If the claim has denied, itmust be resubmitted.
•Adjusting Paid Claims on KyHealth Net. Select the claim to adjust.Once changes are made, select the “Adjust” button.
•Once the steps have been completed, the new claim and ICN will display.Refer to the information at the top of the page to see how your new claim processed.
•Voiding Paid Claims, choose the claim to void and select the “Void” button.
•To verify the status or research the history of your Void, use the claim searchfunctionality from the Claims Inquiry tab to locate the original claim.
•Billing office visit restrictions – 99214 and 99215 limited to two per calendar year.
•Do not list the Medicaid member’s co-pay amount on the claim.
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Points to Remember
•For Medicare primary claims – If Medicare denies a services, that service is billed on aseparate claim than allowed amount from Medicare. Medicaid then becomes primary.
•If a Medicare crossover claim is billed paper, attach the Medicare coding sheet,which includes Medicare Replacement Policies. Medicare Replacements donot cross electronically.
•Member Program Codes to watch for:
Z-QMB Only-Medicaid only allows after Medicare, so if Medicare denies,Medicaid will deny.
ZJ, ZL, ZQ Buy-In Member-Medicaid is only paying the Medicare Premiums.No claims coverage.
• If receiving a new provider number, do not bill claims. If billing was done, money mustbe refunded and a new Prior authorization must be requested under new Provider number.
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Points to Remember
•If a claim is suspended, do not rebill the claim. A claim must be in a paid or deniedstatus before further action can be taken.
•When a spenddown applies to a member’s claim, the money amount billed to themember is shown on the Remittance Advice. Do not bill the member prior toMedicaid payment of a claim.
•If there is a shared NPI, Medicaid needs the correct taxonomy to identify the payto provider.
• Presumptive Eligibility – When a member has this benefit plan it will ONLY cover; Officevisits to a Primary Care provider and/or Health Department, laboratory services,diagnostic radiology services, dental services, Emergency services, transportation andprescription drugs.
• Co-pay – If a member has an office visit and a lab service on the same day at the sameprovider’s office, you only collect $3.00 for the lab service. You do not collect the$2.00 co-pay for the office visit.
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Points to Remember•Fields 11, 11c and 29 are used for Commercial insurance payments only. If a TPL(Commercial insurance) denies or does not pay money, leave these fields blank.
•TPL claims- When a payment is received from a commercial insurance, the claim maybe billed electronically. The money received must be entered on the claim,(no contractual amount). When no money is received from a commercial insurancethe claim must be billed on paper with the EOB attached to the back of the claim.
•When TPL makes payment on all charges submitted on the CMS 1500 claim form:Medicaid will calculate the Medicaid allowed amount per line. The TPL payment is thenapplied to the claim per detail until the TPL payment has been applied in its entirety.
•When TPL pays several lines of the CMS 1500 claim form but denies other lines:Two claims are billed. The first claim must hold lines paid by the primary carrierand carrier paid amount in field 29. The second claim must hold all charges deniedby the primary carrier. Bill by paper with the denial EOB attached.
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Top Denials•EOB 0102 Timely filing – All timely filing claims must be billed on paper withdocumentation attached behind the claims showing proof.
•EOB 0465 Member has other medical coverage – Medicaid is payor of last resort, alwaysbill the commercial insurance first. The commercial insurance information will be givenon the RA and KyHealth Net.
•EOB 2003 Member not eligible on dates of service – Verify the member’s eligibility eitherfrom KyHealth Net or voice response. Use the member’s current ID submitting claims.
•EOB 0921 TPL amount is equal to Medicare paid amount – Field 29 is only for TPL orCommercial insurance payment, do not list Medicare information on the claim.
•EOB 0146 Procedure code is not covered for provider type. If the procedure code is noton the fee schedule it is not a covered code for Medicaid.
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Top Denials
•EOB 0121 This service not payable for QMB only members – Program code of a “Z”,Medicaid will allow the charges after Medicare. If Medicare denies, Medicaid will deny.
•EOB 0260 Buy In - Program codes of “ZJ, ZL and ZQ”, the member does nothave claims coverage.
•EOB 3001 Prior Authorization does not match – Verify PA against informationsubmitted on claim.
•EOB 3595 Anesthesia units exceed 30 – If the units of service are greater than 30 youmust submit paper claim including the start and end time on the claim.
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True or False•A claim must be billed paper when a commercial insurance pays primary.
True or False
•If a member is KenPAC, a referral number is required.True or False
•Claim denied for timely filing, resubmit electronically.True or False
•Claim is in suspense, wait before you bill again.True or False
•Medicaid requires the referring physician in field 17b.True or False
•A provider should verify member eligibility before obtaining a Prior Authorization.True or False
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Questions?
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