1

2

New 10 digit Provider ID

- Provider ID/Service Location

123456789A

Fewer User ID Numbers

Today: IDs for MMIS, PCSS, APAS, REVS

Tomorrow: NewMMIS: 1 User ID and 1 Password

Key Concepts - Provider

3

Industry Standards

Claim Level Processing - NewMMIS Adjudicate Multi-line Claims as a Single Claim with Multiple Lines: Consistent With Other Major Payers

Real-Time Processing of DDE Claims

NewMMIS Will Utilize the Standard UB-04 and CMS-1500 Claim Forms

Key Concepts - Provider

4

Industry Standards

Ability to “Copy” a Claim Will Be Preserved

NewMMIS Replaces 12-digit TCN with

13-digit ICN (Interchange Control Number)

ICN Format: RR YY JJJ BBB SSS Julian Day Batch SequenceRegion Year

Key Concepts - Provider

5

Electronic Attachments

NewMMIS Replaces Claims Attachment Form (CAF)

Providers can Submit Electronic Attachments with DDE Submissions for PA, PAS, Referrals, Claims, Provider Enrollment, MMQ, SCO/PACE enrollments etc.

Key Concepts - Provider

6

Service Authorization Numbers

Service Authorizations Will Now Be Identified by

a 10-character Number: S 07124 0014

1st Character: ‘R’ for Referral, ‘P’ for Prior Authorization ‘S’ for Pre-Admission Screening

1st Character Julian DateUnique Sequential

Number

Key Concepts

7

2.0 Access Provider On-Line Service Center

Five Steps in the Provider Scenario

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

8

8

A Provider’s Scenario

• How a Provider, Harriet Potter, gets enrolled in MassHealth, submits request for services and submits claims for payment

• How Dr. Potter will access a variety of functions through the NewMMIS Provider on-Line Service Center

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

9

Start an Enrollment Application 2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

10

Continue an Enrollment Application

Certification Provider Relationships

Hospital Affiliation Billing Intermediary

Trading Partner Agreement Background Info

Attachments Summary

Confirmation

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

The Provider ContinuesTo Complete the Application:

Service Locations Address Type

Identification Info Medicare Info Personal Info Specialty Info License Info

5.0 Receive Payment for

Services Rendered

11

Provider Application Workflow

NewMMIS

ProviderApplications

ProviderSubmits

DDE App

As the Provider begins an Enrollment Application, NewMMIS will present specific panels

depending upon the Provider Type Legal Entity, Managed Care or Group details.

An Application Tracking Number (ATN) is generated to

the provider to log onto the Web Portal and save or submit an existing application.

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

12

Provider Application Workflow

NewMMIS

ProviderApplications

Workflow

Workflow

ProviderSubmits

DDE App

Review App

CSTEnters

Application

ProviderSubmits

Paper App

Approve Application

&Generate ID

Notify Providers

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

13

“Search for Active Therapists (192) in Boston?” ………… no problem!

Search by Provider ID

or Legacy ID

or NPI

Search by Provider

Type

Address Type

RemittanceInformationDBABillingCheck Mailing

14

Provider Information Panel

1 32

Section 1: Details don’t change with aMulti-Location Provider

Sections 2 & 3 Service Location etc. when a Different Service Location is Chosen From the Drop Down Menu

A - Warren A. Thomas

B- Michael B. Thomas

C- Michael C. Douglas

15

Provider Maintenance 2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

16

Provider Maintenance 2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

17

Provider Preferences

Check Mailing

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

18

Provider – Check Mailing Address 2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

19

Key Concepts – Provider

Enter data directly and modify individual transactions (i.e. claims submission, eligibility verification, MMQ, Prior Authorization, Pre-Admission Screening, and Referrals).

View your notifications, contracts, reports, metrics, and financial data. Download most MassHealth forms and publications.

The Provider Online Service Center gives you the tools to effectively manage your business with MassHealth electronically. Use these services to enroll as a MassHealth provider. Manage your profile information and submit and retrieve transactions.

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

20

Verify Member Eligibility

POTTER, HARRIET MD

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

21

Verify Eligibility – Member Info

Bailey, Mary011 11 1111

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

22

Verify Member - Eligibility Panel 2.0 Access

Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

23

Verify Member –

Eligibility Restrictions 2.0 Access

Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

24

Submit A Pre-Admission Screening

Dr. Potter Submits a

PAS for George Bailey

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

25

Submit A Pre-Admission Screening

Drop Down to Select PAS AssignmentDropdown to

Select Dr. Potter’s Choices

Potter Harriet MD

Search Button to Find Facility or

Attending Physician

Bedford Falls Rehab Hospital

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

26

10000555555

Search Button to Find Diagnosis

Code

Length of Stay in Days

7871 = Heartburn

Submit A Pre-Admission Screening

Request has been saved with this PAS# S08000000BS08000000B

Save & System Returns PAS #

After Edits

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

27

Adding a Line Item:

RequestedLevel of Care

& Admission

Type to PAS

PAS 2.0 Access

Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

28

PAS Confirmation

Bedford Falls Rehab

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

29

Update a Pre-Admission Screening

S08000000B

S08000000B 100023924251 Bailey, George 01/30/08

Entering PAS Number

Produces Link to PAS Base

Information

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

30

Update a Pre-Admission Screening 2.0 Access

Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

31

Update Pre-Admission Screening

Bedford Falls Rehab

George Bailey

Harriet Potter, MD

Modify Reopens Modify Reopens the the PAS Base

Information Panel for Changes

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

32

PAS Flow

NewMMIS

TransactionAssignment

SubmitsPAS Workflow

MassPRO

PAS Unit

Approved Denied

Modified

Approved Denied Modified

Notification

Notification

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

33

Submit Prior Authorization 2.0 Access

Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

34

PA – Enter Base Information

100023924251

POTTER, HARRIET MD

7871

DIAGON ALLEY CLINIC AND EMPORIUMTEST

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

35

PA – Enter Line Items 2.0 Access

Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

36

PA – Line Items – Basic Medical Details

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

37

PA – Submit for Confirmation

Request has been saved with this Tracking# 103,401,225

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

38

Enter PA Request - Confirmation

Request has been saved with this Tracking# 103,401,225

You are about to submit a Prior Authorization request for Member 1234443212 for the following procedures. Please verify the data and the click “Submit”.

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

39

PA Flow

NewMMIS

TransactionAssignment

SubmitsPA’s

Workflow

PAUnit

Approved, Denied, ModifiedNotification

Workflow

PAUnit

PAUnit

Workflow

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

40

Submit A Referral for George Bailey 2.0 Access

Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

41

Submit A Referral for Harry Bailey

POTTER, HARRIET MD

BEDFORD FALLS PSYCHIATRY

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

42

Referral Confirmation

George Bailey

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

43

Inquire About a Referral – 3 Ways

1. Inquire by the Referral

Number:e.g.

R08035001F

2. Search for Referrals

Submitted to Bedford Falls

Psychiatry3. Search for

Referrals Submitted by Bedford Falls

Psychiatry to Another Provider

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

44

Referral Information – Update

Potter, HarrietBedford Falls Psychiatry

BaileyGeorge Male

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

45

Submit A Claim – Billing & Services

011000001111 – Bedford Falls PsychiatryDropdown of

Billing Provider ID Numbers

Member Member InfoInfo

COB AttachmentsProcedure ConfirmationBilling and Service

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

46

Service Service InformationInformation

Diagnosis Codes

Submit A Claim – Billing & Services

Place of Service

Total Charges

Billing and Service

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

47

Submit A Claim – Billing & Services

Extended ServiceInformation

Service Facility Provider

List of Claim Notes

Ambulance Transport and Certification

Home Healthcare Plan

Coordination of Benefits

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

48

Submit Claim – Coordination of BenefitsCoordination of Benefits (COB) Detail

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

49

Submit Claim – Procedure

Procedure

Professional Service Detail

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

50

Submit Claim – Procedure (cont’d)

Durable Medical Equipment Service

Ambulance Service

Home Oxygen Therapy Information

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

51

Inquire A Claim Status

011000001111 – Bedford Falls Psychiatry

Enter Member IDProcedure Code etc. to Narrow

Search

Inquire By ICN

2208036600010

Bailey, George

Inquire by Date of Service Range

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

52

Questions &

Answers

53

Inquire A Claim Status

George Bailey01/20/1946Male

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

54

TPL Claims – Key Concepts

RecoveryRecovery

Cost AvoidanceCost Avoidance

Matching with Multiple CMS/SSA Files and Third Party Carriers

Automated TPL Verification Process

User Maintained Other Insurance Plans Replacing TPL Matrix

Retro-active, Pay & Chase & User Defined Recovery

Enhance Up-front Cost Avoidance Capabilities

Comprehensive Tracking and A/R System Re-pricing Methodologies

Integration of MA21/MMIS TPL Data

Table Driven Re-pricing Methodologies

2.0 Access Provider On-Line Service Center

1.0 Enroll a Provider &

Maintain Profile

3.0 Submit Requests

for Service Authorization

4.0 Submit a Claim for

Services Rendered

5.0 Receive Payment for

Services Rendered

55

5555

Getting Ready

KickKickOffOff

MeetingsMeetings

InformationalInformational Meetings Meetings

Communications:Communications:Newsletters etc.

NewMMIS Overview & NavigationNewMMIS Overview & Navigation

E-Learning E-Learning

Classroom TrainingClassroom Training

SeptemberSeptember20072007

September 2007 September 2007 thru Go Livethru Go Live

Communications Center:http://newmmis-communication-center/http://newmmis-communication-center/

4-6 Weeks 4-6 Weeks BeforeBeforeGo-LiveGo-Live