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Nursing Home and Hospice Billing Training 2018
Presented by Field Representatives
Kinzie Baker &
Liz Lovell-Poynor
Wyoming Medicaid General Manual
Chapter 1- General Information
Chapter 2-Getting Help When You Need It
Chapter 3-Provider Responsibilities
Chapter 4-Utilization Review
Chapter 5-Client Eligibility
Chapter 6-Common Billing Information
Chapter 7- Third Party Liability
Chapter 8-Electronic Data Interchange (EDI)
Chapter 9-Wyoming HIPPA Electronic Specifications
Chapter 10-Important Information
Provider Notifications
RA Banner
RA Payment Summary
* Bulletins
Provider Contact
It is important for all providers, both treating and pay-to providers, to maintain current and accurate contact information. Why it is important to update provider contact information?
o To receive up-to-date policy information o Receive updates when Medicaid needs a copy of your new license o Any other communication which needs to occur between Wyoming Medicaid
and providers To update your provider contact information, please do the following:
o Email, mail a request on office letterhead and include the following: NPI/Provider number & Name Provide contact information Update needed
Physical, correspondence, or financial address, provider phone or fax number, or email addresses on file
Date this change needs to go into effect Pay-to Providers can also update their contact information by logging into the
Provider Web Portal and going to “Update Provider Demographics” Email addresses on file can also be updated by speaking to a representative at
Provider Relations by calling 800.251.1268 options 1, 5, and then 0.
Quick Reference
When to write for help
Online resources
https://wymedicaid.portal.conduent.com/
Requesting a provider training visit
Getting Help
Provider Responsibilities
Eligibility
When can a client be billed?
Issues most commonly heard in call center:
Clients requested to troubleshoot claims or check PA status
Client billed or sent to collection
Billing and coding questions
Recordkeeping
Notes
Common billing Information
Service thresholds
Under 21
Over 21
NDC Conversion
Attachments
See web portal tutorial
Adjustments and Voids
Sterilization, Hysterectomy and Abortion Consent Form
Requesting Replacement RA’s
Timely filing
Telehealth
Attachment Troubleshooting
Paper-Attachment cover sheet
TCN
How to get the TCN
ACN (Attachment Control Number)
Electronic Attachments
How to complete
Common Attachment issues: Incomplete
ACN does not match
Legibility issues
Information on form does match claim
Rendering/treating provider listed as Pay-to
No Attachment indicated on claim
Adjustments & Voids
Paper Complete all required
information
Attach corrected clean claim and indicate on form
Attachments
Electronic How to complete
6-Adjustment
7-Replacement
Common Issues: All lines not included on
electronic adjustment
No changes made to the claim
Too many changes being made
Not all corrections made
Not attaching supporting documents
Notes
Third Party Payers
Unreported coverage
Provider not enrolled/No Opt out option
How to indicate TPL on a claim
Medicare/ No Opt out option
Third party Liability
Required Evaluations Prior to Admission
Pre Admission Screening and Resident Review (PASRR) Level 1
Completed via web portal
Cannot be corrected**
Required for all clients regardless of payment source
LT101
Valid for 90 days
Can be corrected with state approval**
Utilize portal to check for previously completed LT101’s
Only required for Medicaid clients
**Requests to delete a PASRR Level I can be sent to [email protected]
& requests to correct a LT101 can be sent to [email protected]
WYhealth - 888-545-1710
https://www.wyhealth.net/tpa-ap-web/?page=defaultRoot
Medicaid will not reimburse a nursing facility for services provided to any individual with MI or MR who is admitted prior to completion of a PASRR Level II. Payment will commence upon the date of determination of
appropriate placement.
No retroactive payment will be made.
If a PASRR Level II has been completed but is not reflected on the client file contact WYhealth
PASRR Level II
Attestation for Admission
* What is an Attestation Form?
When is an attestation form necessary?
Common Attestation Form issues:
Not completely filled out
No signature
Attest box not checked
Client not in the system
Client information incorrect
Scenario 1
Dates of service: 4/1/18-4/30/18
Admit date:04/01/18
Lt101 Provider referral date:3/30/18
PASRR Date: 03/30/18
Covered Days:30
Units billed: 30
Patient status: 30-Still a patient
Billed amount $5,230.00
Claim paid: $5,230.00
Scenario 2
Dates of service 04/01/18-04/30/18
Admit date 04/01/18
LT101 Provider Referral Date: 04/09/18
Date of PASRR: 4/13/18
Covered days: 30
Units billed: 30
Patient Status:30-Still a patient
Billed Amount: $5,230
Claim Denied 372,370
Scenario 3
Dates of service: 4/1/18-4/30/18
Admit date: 4/1/18
Lt101 Provider Referral Date:3/30/18
PASRR level1 Date: 3/30/18
No PASRR Level 2 on file
Covered days: 27
Units billed: 30
Patient Status:30-Still a Patient
Billed amount $4,987.00
Claim denied 373,078
Notes
Scenario 4
Dates of service:
04/01/18-04/30/18
Admit date: 9/15/17
LT101 Provider Referral Date: 3/27/18
Date of PASRR level 1: 9/13/17
Covered Days:30
Units billed: 30
Patient status: 30-Still a patient
Billed amount $5,230.00
Claim Denied
579
Patient contribution determination
Patient contribution changes
Patient contribution not applied to claim
Allocation discrepancies
Patient Contribution
Scenario 5
Dates of service: 4/1/18-4/30/18
Admit date: 11/8/17
Lt101 Provider referral date: 11/8/17
PASRR Level 1 date:11/8/17
Patient liability: $536.00
Covered days: 29
Units billed: 30
Total amount billed:$5,125.00
Patient status:20-Died
Claim denied
Scenario 6
Dates of service: 02/02/18-02/28/17
Admit date: 2/2/18
Lt101 Provider referral date: 2/2/18
PASRR Level 1 date: 2/2/18
Covered days: 27
Total amount billed:
$7,345.00
Patient status:30-still a patient
Medicare payment:
$6,592.00
Covered days
Patient status
Statement dates
Units billed
Leave days – not covered
Important Reminders
Notes
Hospice Services
Required Documentation
Hospice Benefit Election Form
Hospice Benefit Revocation Form
Hospice Services
* Hospice Lock-in
* Plan of care
* PA Requirements
* Services unrelated to
the terminal illness
Scenario 1
Line Rev Code Procedure code Dates of service Billed units
Line 1 0659 02/01/18-02/28/17 28
Claim Paid: $2,544.64
Scenario 2
Line Rev Code Procedure code Dates of service Billed units
Line 1 0659 04/01/18-04/15/18 15
Line Rev Code Procedure code Dates of service Billed units
Line 1 0659 G0494 04/01/18-04/15/18 15
Incorrectly billed due to # of days client has been in hospice
Correctly billed for client in hospice care beyond 61 days
Notes
Scenario 3
Line Rev Code Procedure code Dates of service Billed units
Line 1 0656 03/12/18-3/31/18 19
Claim for hospice services:
Line Rev Code Procedure code Dates of service Billed units
Line 1 0658 03/12/18-3/31/18 19
Claim for nursing home room & board:
Wyoming Medicaid Website
Welcome Page Manuals and Bulletins Fee schedule (NCCI)
Contact Us Forms
Provider Training Web Tutorials
https://wymedicaid.portal.conduent.com/index.html
Notes
Provider Portal
Claim Submission Refer to:
https://wymedicaid.portal.conduent.com/Training/Institutional_Tutorial_5.10.17.pdf
Attachments
Refer to: https://wymedicaid.portal.conduent.com/Training/Electronic_Attachments.pdf
Registering and adding users Refer to:
https://wymedicaid.portal.conduent.com/Training/Web_Portal_Registration_2_15_18.pdf
Continuity of Care Document – CCD Viewer
The CCD is a HITSP standard patient summary document that contains the following information from the THR Gateway: • Problems • Family & Social History • Immunizations • Vital Signs • Test Results • Medications • Procedures • Up 2 years claims history • Alerts • Allergies/Adverse Reactions • And more…
To request THR CCD Viewer access, please send an e-mail containing: • Clinic Name • Address • Phone Number • Provider Names • Provider Email Addresses • Primary Contact To Andrea Bailey at: [email protected] Visit the website at: http://wyomingthr.wyo.gov/cc
d-viewer
The Program Integrity (PI) unit is responsible, through a coordinated process of education, reviews, audits, and appropriate corrective action plans, for ensuring the integrity and accountability of all payments made for healthcare services on behalf of a recipient.
What is the Program Integrity Unit?
Learn more about PI or report suspected abuse, fraud, or waste by visiting:
https://health.wyo.gov/healthcarefin/program-integrity/
Providers new to Medicaid should view the “Wyoming Medicaid Program Integrity” presentation.
Resources
Provider Relations 1.800.251.1268 (Option 1,5,0) o 9-5 MST Monday - Friday
o Fax Number
o 307.772.8405
EDI Services 1.800.672.4959 (Option 3) o 9-5 MST Monday – Friday
o EDI Enrollment Form
o Trading Partner Agreement
o WINASAP Software & Technical Support for WINASAP
o Technical Support for Vendors, Billing Agents, and Clearinghouses
o Provider Web Portal Registration
o Technical Support for Provider Web Portal & Password Resets
*Medical Policy 1.800.251.1268 (Option 1,1,4,3) o 9-5 MST Monday – Friday o Prior Authorizations (PAs) Requests for: o Surgeries requiring PAs o Hospice Services: Limited to Clients Residing in a Nursing Home
o Status of a Pending PA o How to Complete a PA Request o Authorizations of Medical Necessity for services prior to 11/1/17 o Denials for:
o WATRS -Ambulance claims/ regarding trip report o Invoices
* Third Party Liability (TPL) 1.800.251.1268 (option 2) o 9-5 MST Monday – Friday o Client accident covered by liability or casualty insurance or legal liability is being pursued o Estate and Trust Recovery o Medicare Buy-In status o Reporting client TPL o New insurance coverage o Policy no longer active o Problems getting insurance information needed to bill o Questions or problems regarding third party coverage or payers o WHIPP program
Questions???
