Provider Claims Training - FL MMA (Medicaid)€¢ Overview of Optum MMA • Overview of Agency Contracting ... mental health number on the back of the ID card to verify benefits and

Provider Claims Training - FL MMA (Medicaid)

June 2015

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Agenda• Introductions

• Overview of Optum MMA

• Overview of Agency Contracting

• Overview of ALERT Process

• Overview of Claim Submission Guidelines (CMS-1500 and UB04)– Supervisory Protocol and Rostered Clinicians – Placement of NPI Number (CMS-1500)– Placement of Billing vs. Rendering Clinician Information (CMS-1500)– Required fields for the UB04

• Overview of Provider Express Claim Submission Process

• Questions & Answers

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Introductions

Presentation will be hosted by the following Optum Staff:

• Network– Amy Rice, Director Provider Services, SE Region– Jean Higgins, Senior Network Manager– Rosalind Rokita, Senior Network Manager– Jennifer Durgee-Hemminger, Network Manager– Rebeca Oliva Arzola, Network Manager

• Provider Express– Karen Faith, Senior Communications Specialist

• Claims– Brandon Curtis, Business Process Analyst

• Clinical Team– Jennifer Walsh, Care Advocate

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MMA Regions & Counties

Optum Regions

Counties

Region 3

Effective: 05/01/2014

Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union

Region 4


Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia

Region 7


Brevard, Orange, Osceola, and Seminole

Region 11


Miami-Dade and Monroe

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How to Identify Our Members

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•2014 Card

•2015 Card


Overview of Agency Contracting• Rostered Clinicians

Each agency supplies a roster of independently licensed clinicians who render services to their clientele

Only independently licensed clinicians can be loaded in Optum’s systems under the agency contract

If claims are submitted with rostered clinicians who are not licensed, the claims will be unable to be processed until submitted with the licensed supervising clinician.

• Supervisory Protocol

Non-independently licensed clinicians are required be supervised by an individually licensed clinician who is rostered under the agency contract

Non-independently licensed clinicians cannot be loaded in Optum’s systems and cannot bill for services under their own name

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Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 7

OVERVIEW OF ALERT PROCESS


Overview of ALERT Process

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Effective May 22, 2015

• Prior authorization for many Outpatient and Telemental Health Services (codes listed below) is no longer required for Florida Medicaid (MMA) members

• Optum will apply algorithm to identify practice management patterns that appear to fall outside of typical patterns

• When a pattern of care is atypical or does not match guidelines for service level, a telephonic review for medical necessity will be initiated

•Use of the applicable code modifiers are required for billing of services



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Reimbursement Policy – Claims Editing This notice provides information about Florida Medicaid coverage limits and their associated claim edits. Reimbursement policies establish processes to ensure accurate and appropriate claim processing in accordance with industry standards. These processes serve to identify potentially inappropriate billing and/or utilization of services. Requests for medical records may be made for administrative review (not based or used for Medical Necessity). In those cases, record requests outline what is to be submitted; please provide requested records within defined time-frames. Optum provides education and support as a component of our process.

Coverage and Limitations The Florida Agency for Health Care Administration (AHCA) has published policy that enrolled providers must comply with in order to obtain reimbursement. The claims edits for Florida Medicaid conform to the reimbursement policies as published in the Community Behavioral Health Services Coverage and Limitations Handbook published by ACHA and effective in March 2014. The edits identified from that publication will be updated in our systems as new publications and changes are made.



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Chapter 3 of the Handbook, “Reimbursement and Fee Schedule” including Appendix A “Procedure Codes and Fee Schedule” details the reimbursement and service limitations that pertain to the specific procedure codes, Healthcare Common Procedure Coding System (HCPCS) Level II codes.

The Handbook specifies reimbursement limitations by HCPCS code and modifier code, which include, but are not limited to: •· Duplicate services billed that will not be reimbursed on the same Date of Service to the same recipient •· Maximum daily limits for services for reimbursement for the same recipient •· Maximum monthly limits for services for reimbursement for the same recipient •· Maximum fiscal year (July 1 to June 30) limits for services for reimbursement for the same recipient •· Services which will not be reimbursed when billed on the same Date of Service at the same time as other billed services for the same recipient

For daily, monthly and fiscal year limits the impacted HCPCS codes include:

Even when a written authorization lists a range of CPT and/or HCPCS codes, payment for any specific code is subject to ongoing administrative review of benefit limits. For a full list of services that are separately reimbursable please see the Community Behavioral Health Services Coverage and Limitations Handbook March 2014. Claim submissions not in compliance with these rules will be denied.

Additional information can be obtained by reviewing the Handbook maintained by AHCA: Community Behavioral Health Services Coverage and Limitations Handbook March 2014: http://www.flrules.org/Gateway/reference.asp?No=Ref-03749


Services Requiring Authorization: 800-582-8220

•Inpatient Hospital•Crisis Stabilization Unit•Statewide Inpatient Psychiatric Program (SIPP)•Psychological Testing•Specialized Therapeutic Foster Care – Level I, Level II, Crisis Intervention•Therapeutic Group Care Services

*If you are not certain whether an authorization is required, please call the mental health number on the back of the ID card to verify benefits and authorization requirements.

Authorization Required


UBH Level of Care Guidelines

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Requesting Online Authorizations• Please note that the Auth Request feature on Provider Express is only for

requesting auths for the following routine psychotherapy procedure codes: 90791, 90832, 90834, 90846, 90847, 90849, 90853, 99241, 99242, and 99243.

• This information is noted on the Auth Request Step 1 and Step 3 pages, as highlighted below in the orange rectangle.

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OVERVIEW OF CLAIM SUBMISSION GUIDELINES

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Claim Submission Guidelines• Optum follows claim submission guidelines as defined by the following

organizations:CMS (Centers for Medicare & Medicaid Services) HIPAA (Health Insurance Portability and Accountability Act) NUCC (National Uniform Claim Committee)

• Claims address: P.O. Box 30760, Salt Lake City, UT 84130• UBH Electronic Payor ID is 87726• Providers may also submit their claims through www.providerexpress.com• Claims must be submitted within 90 days of the date of service unless

otherwise specified by contract.• Clean claims are processed within contractual guidelines/requirements• Clearinghouse Info: Provider can use vendor of choice• Claims Customer Service: 866-673-6315

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Claim Submission Guidelines

• Provider hints to avoid denials:Obtain authorization if neededMake sure the provider on the claim form matches

provider on the authorization and that services billed match authorization in systemRendering licensed clinician must be listed on

claim formRendering licensed clinician must be loaded in

UBH claims payment systemIf you have not submitted claims to Optum

previously or your credentialing application is in process, you MUST submit a copy of your W9 with your claims to ensure claims will be procesed.

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Claims Form – CMS 1500

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Claims Form – CMS 1500 Provider Section

• Box 31: Enter the name and licensure of the independently licensed clinician who is supervising delivery of services or directly rendering the services; the name and license should be the same as it appears on the agency roster

• Only independently licensed clinicians should appear in Box 31

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Claims Form – CMS 1500 Provider Section

• Box 33: Agency name, address, and phone number • Box 33a: Agency NPI number

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Claims Form – UB04


Claim Form – UB04

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Form Locator

(FL) Number

Required Field? Description and Instructions

1 Required Billing provider’s name, address and telephone number. This is the street address. The pay-to address (such as a P. O. Box) is entered in FL 2.

4 Required Type of bill: Must be 3 digits and a valid combination 5 Required Federal Tax ID number: Must be entered6 Required Statement Covers Period: The beginning and ending service dates for the claim. Enter valid date

in mmddccyy format. 8b Required Patient Name: Last name, first name, middle initial 10

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Required

Required

Patient Date of Birth: Enter valid date in mmddccyy format.

Patient Sex: M for male; F for female; U for unknown


Claim Form – UB04

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Form Locator

(FL) Number

Required Field Description and Instructions

42 Required Revenue Code: Enter valid 4-digit revenue code (one per line). Use 0001 to indicate the “Total” line after all appropriate revenue codes have been listed. Line 23 Only - “Page _ of _” section: Only “0001” can be used on this line since it can be the “Total” line. If the claim is multiple pages, do not put “0001” here except on the last page.

46 Required Service Units: Must be numeric and no more than 7 digits.

47 Required Total Charges: Must be numeric and no more than 11 digits. Amount on revenue code 0001 line must equal sum of charges on all other lines. Line 23 Only - “Page _ of _” section: Total Charges: If “0001” is entered in FL 42, line 23, enter the sum of all charges entered on previous lines in FL 47, line 23. Up to 11 digits can be entered. If “0001” has been entered on another line, the total of all charges must be entered on that line.


Claim Form – UB04

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Form Locator

(FL) Number


56 Required NPI: The billing provider’s NPI is REQUIRED if billing provider is a health care provider. Enter the billing provider’s NPI number. Otherwise, leave blank.

Form Locator

(FL) Number


58a, b & c Required Insured’s Name: Enter the insured’s name on the applicable payer line. For Medicaid, the insured’s name is always the name of the patient, even in cases of organ or other tissue donors for a Medicaid insured patient.

60a, b & c Required Insured’s Unique ID: Enter the appropriate insured’s ID number applicable to the payer line. For example, if the payer on line A is Medicare, enter the insured’s Medicare ID. For the Medicaid payer line, the insured’s ID is always the patient’s Medicaid ID. The Medicaid ID can be 9, 10 or 14 digits, all numeric.


Claim Form – UB04

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Form Locator

(FL) Number


58a, b & c Required Insured’s Name: Enter the insured’s name on the applicable payer line. For Medicaid, the insured’s name is always the name of the patient, even in cases of organ or other tissue donors for a Medicaid insured patient.

60a, b & c Required Insured’s Unique ID: Enter the appropriate insured’s ID number applicable to the payer line. For example, if the payer on line A is Medicare, enter the insured’s Medicare ID. For the Medicaid payer line, the insured’s ID is always the patient’s Medicaid ID. The Medicaid ID can be 9, 10 or 14 digits, all numeric.

66 Required Diagnosis and Procedure Code Qualifier (ICD Version Indicator): Always a 9 unless (or until) the ICD version 10 is mandated.

67 Required Principal Diagnosis Code: Enter principal diagnosis code in the white area of this field. This is an ICD-9-CM diagnosis code.


State Table MatchCMS 1500

UB04


OVERVIEW OF PROVIDER EXPRESS CLAIM SUBMISSION PROCESS


Claim Entry – Step 1 (Express/Short Form)• Users can file professional MH/SA

claims online using Claim Entry• Group logins can choose the

supervising or other independently licensed rendering provider from the dropdown list, or choose “+ New Provider” (at the bottom of the dropdown) to add a provider not yet on the list

• Users can search for a member using an authorization number, OR Member ID, Name/DOB, or My Patients*

• The express form is considered the default claim – however, if a claim needs additional information, such as paperwork or notes, the user can file the long form by answering “Yes” where indicated

• *My Patients is a list of names the user can build using the Eligibility search tool.


Claim Entry – Step 2 • Once the member

information is found, Provider Express will bring up the claim form. The member info is auto-filled in at the top, and the required fields for the user are highlighted in orange

Please note: when billing for non-rostered providers, the supervising clinician’s name and NPI should be used in filing the claim


Claim Entry – Step 3 & 4

• Allows for users to review basic information on the claim before sending it for submission

• Once the user clicks to submit the claim, Step 4 then yields the same information as in Step 3 above, with the addition of a confirmation number, which is the user’s assurance that the claim has been successfully submitted

• Provider Express recommends users print out this page – the confirmation number can be used to look up the status of this claim, and can be used by Provider Express tech support staff to aid in assistance as needed


Claim Inquiry

• This feature allows users to look up the status of claims paid to the individual or group, based on the login

• There are three options to use in the search: My Patients, Member ID, or Name/DOB

• Optional – Dates of Service date ranges may be adjusted as shown

• The default date range is 180 days back from the current date


Claim Inquiry - Summary• Any claims found within the parameters of the criteria entered will be

displayed • Users can click on the member’s name to get to the detail list on that

claim

• Claim details vary depending on claim status


• The detail list includes the date(s) of service• To get to the full detail, just click on a date

Claim Inquiry – Detail List

• Users can chat online with claim reps by clicking on the link in the upper right - “Have questions about claim status?” (or on the previous screen “Can’t find claim status online?”)


Claim Inquiry – Detail

• Clicking on the date of service will bring up the full detail for the claim• Again, information available will vary depending on the status of the

claim


Provider Relations Resources

•Call Provider Service line at 877-614-0484 or•Call or Email the Network Manager for your Area/Region

Amy S. Rice, Director Behavioral Network Services, SE Region

[email protected]

Jennifer Durgee-HemmingerNetwork Manager (Regions 3 and 4)

[email protected]

Jean Higgins, Senior Network Manager (Region 7)

[email protected]

Rebeca Oliva Arzola, Network Manager (Region 11)

[email protected]

Rosalind Rokita, Senior Network Manager (Long Term Care as well as Medicaid SME)

[email protected]

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Accessing a Copy of Today’s Presentation• providerexpress.com > 1 Our Network > 2 Welcome to the Network >

3 Florida (FL) > 4 Government Programs Information > 5 FL MMA Information/Training

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Provider Claims Training - FL MMA (Medicaid)€¢ Overview of Optum MMA • Overview of Agency Contracting ... mental health number on the back of the ID card to verify benefits and