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Provider Handbook 8/1/2014
The purpose of this handbook is to give an overview
of Community Care Connections of Wisconsin
(CCCW) to current and prospective service
providers.
What is Family Care………………………………………….…4
What is Community Care Connections of WI……...5
Who is Eligible for Services………………………………...6
Family Care Benefit Package……………………………...7-8
Family Care Roles…………………………………………………9
Family Care Outcomes………………………………………..10
How Do I Become a Provider………………………………11
Provider Network Directory…………………..12
Change of Information…………………………...12
Notification & Authorization of Services…………….14
Determining Services…………………………….14
Notification of Services………………………….14
Authorization of Services……………………….14
Billing & Appeal Information……………………………….16
Submitting Claims……………………………….….16
Reimbursement Information………………….17
Submission Deadlines…………………………….18
How to Appeal a Denied Claim……………….19
Provider Communication…………………………………….20
When to Contact…………………………………….20
Provider Quality Standards…………………………………22
Program Integrity………………………………………………..25
Critical Incidents………………………………………………...26
Member Grievance & Appeal……………………………..28
Cultural Competency………………………………………….28
Confidentiality…………………………………………………….29
Community Resource Department Contacts…….. 30
CCCW Office Contacts…………………………………………31
ADRC Office Contacts………………………………………….32
Additional Information & Forms
Claims & Billing………………………………………33
Contact Information:
To obtain the name of a member’s Member
Support Coordinator, call CCCW’s main line
at:
(715) 345-5968
(877) 622-6700 (Toll Free)
(715) 204-1799 (TTY)
CCCW Website
Please visit our website at
www.mycccw.org
It provides information for providers,
members and the general public.
Provider Handbook
Page 3
I am very pleased to take this opportunity to welcome you, and to thank you for choosing to become a
provider of the Community Care Connections of Wisconsin (CCCW) Provider Network. Your contract
with our organization to provide long term care goods and/or services through the Wisconsin Family
Care Program to our membership is very important to CCCW.
CCCW recognizes the important role our provider organizations play in supporting and meeting the
individual outcomes of each one of our members throughout the CCCW Family Care service region. It is
our full intent to become a working partner with you in providing valued service to our members.
CCCW maintains an up-to-date website (www.mycccw.org)that has a section devoted to provider issues
and opportunities, so make sure that you visit our Website regularly to remain aware of what is going on
with CCCW activities and specifically with CCCW provider relations.
Again, welcome to our Provider Network and thank you for choosing to do business with our
organization!
Sincerely,
James G. Canales, CEO
Community Care Connections of Wisconsin
Provider Handbook
Page 4
What is Family Care?
Family Care (FC) is an innovative program that provides the full range of long-term care services through
one flexible benefit program that provides assistance through interdisciplinary care management.
Members who participate in FC partner with a care management team to work together and help
members identify their needs and outcomes. Supports are then identified to assist members to meet
their outcomes.
Family Care is Based on the Following Principles:
Choice: To give members better choices about the services and supports available to meet their needs.
Access: To improve members’ access to services.
Quality: To improve the overall quality of the long-term care system by focusing on achieving members’
health and social outcomes.
Cost-Effective: To create a cost effective long-term care system for the future.
Family Care has two major organizational components:
Aging and Disability Resource Centers (ADRC): A single entry point where individuals and their families
can get information about a wide range of resources available to them in their local community.
Eligibility, assessment, and referrals to Family Care occur through the Aging and Disability Resource
Centers.
Managed Care Organization (MCO): Manage and deliver the Family Care benefit, which combines
funding and services from a variety of existing programs into one flexible long-term care benefit,
tailored to each individual’s needs, circumstances and preferences.
Provider Handbook
Page 5
What is Community Care Connections of Wisconsin?
Mission:
Community Care Connections of Wisconsin identifies and supports the strengths and preferences of
members, creates community connections, and coordinates quality, cost-effective, and individualized
long-term care services available through Wisconsin’s Family Care Program.
Community Care Connections of Wisconsin (CCCW) has contracted with the State of Wisconsin’s Department of Health Services (DHS) to administer the Family Care program in Ashland, Barron, Bayfield, Burnett, Douglas, Iron, Langlade, Lincoln, Marathon, Polk, Portage, Price, Rusk, Sawyer, Washburn, and Wood
counties. CCCW coordinates and is responsible for quality assurance and billing, as well as for
contracting with providers throughout the five counties. This contracting process is called Provider
Network Development, and these providers deliver the services needed by our members. Service
providers must be high-quality, member-centered, cost-effective and outcome-based.
The goal of CCCW is to support members in achieving their long-term care outcomes in the most
effective and cost-effective manner possible. CCCW strives to provide the right services, at the right
time, in the right place, in the right way, for the right cost, and for the right reasons. CCCW pays for
services that support members in pursuing personal goals or outcomes by using managed care
principles. CCCW helps to ensure that there continues to be enough money to serve all eligible people
who have long-term needs by being creative, efficient, and flexible.
CCCW puts members at the center of a Team. The Team provides the resources and information
members need to make informed decisions about their lives. CCCW is committed to working with
members to find safe, health, and fair ways to meet personal outcomes. CCCW uses a set of principles
that can be expressed by the acronym RESPECT.
Relationships. Relationships between a member, his/her Member Support Coordinators and service providers are based on a caring and respectful attitude.
Empowerment to make choices. Members participate in planning their own care, services, and supports.
Services to meet individual needs. Services are provided in a manner that is prompt, easy to access, and tailored to meet unique needs and circumstances.
Physical and mental health. Services are intended to help members achieve their optimal level of health and functioning.
Enhancement of member self-worth. In every way possible, services maintain and enhance a member’s sense of self-worth as well as community recognition of a member’s value.
Community and family participation. Members are supported so they may develop and maintain friendships and remain active in their communities. Family, friends, and neighbors are encouraged to remain involved through an informal network of family and community supports.
Tools for independence. Members are supported and encouraged to achieve maximum self-sufficiency and independence.
Provider Handbook
Page 6
Who is eligible for CCCW Services?
CCCW provides services to individuals that meet the following four criteria:
1. A resident of Ashland, Barron, Bayfield, Burnett, Douglas, Iron, Langlade, Lincoln, Marathon, Polk, Portage, Price, Rusk, Sawyer, Washburn, or Wood county; and
2. Is one or more of the following:
At least 18 years old and have a physical disability; or
At least 18 years old and have a developmental disability; or
Are over sixty five years of age; and have a long-term care need; and
3. Is financially eligible as determined by a review of income and assets; and
4. Is functionally eligible as determined by a review of health and ability to function in day-to-day
activities, as determined by the Long Term Care Functional Screen.
The Aging and Disability Resource Center (ADRC) determines an individual’s eligibility for the Family Care
program. (See page #32 for ADRC locations and contact information.)
Individuals are enrolled in Family Care after they have gone through the financial and functional
eligibility process with the Aging and Disability Resource Center and a county economic support unit.
Once these have been completed, the individual will meet with an enrollment counselor to talk about
what enrollment means. An ADRC enrollment counselor will discuss the member’s options and try to
answer any questions the member/guardian may have about Family Care and obtaining services from
CCCW. The ADRC will refer the individual to CCCW upon enrollment. Enrollment in CCCW is voluntary.
However, members must maintain functional and financial eligibility to continue in the Family Care
Program.
Medicaid Services
Members who enroll in the Family Care program are also eligible for Medicaid (Title 19). These
members receive acute and primary services by accessing their Medicaid Card.
In addition to the “card services”, CCCW also offers a wide array of services within its own benefit
package to meet member’s needs and outcomes.
It is important for the provider to understand what services are included in the Family Care benefit
package to ensure the appropriate payer source is being billed for services rendered.
A list of services available in the CCCW benefit package is on the following pages. Members are found
eligible at the following two different levels which are determined by use of the Long Term Care
Functional Screen: Nursing Home and Non-Nursing Home level of care. Members found eligible at the
Nursing Home level are offered a more expansive benefit package to meet their needs.
It is important to have close communication with the CCCW staff for any member in our program to
clarify this information.
Provider Handbook
Page 7
Family Care Benefit Package
Nursing Home Level of Care
Benefit
Non-Nursing Home Level of Care Benefit
Medicaid State Plan Services
Alcohol and Other Drug Abuse (AODA) Day Treatment Services, in all settings
x x
Alcohol and Other Drug Abuse (AODA) Services, except inpatient or physician provided
x x
Case Management x x
Community Support Program (CSP) x x
Durable Medical Equipment and Medical Supplies, except hearing aids, hearing aid batteries, prosthetics, and family planning supplies
x x
Home Health x x
Mental Health Day Treatment Services, in all settings x x
Mental Health Services, except inpatient or physician provided
x x
Nursing, including respiratory care, intermittent and private duty
x x
Occupational Therapy, in all settings except inpatient hospital
x x
Personal Care x x
Physical Therapy, in all settings except inpatient hospital
x x
Speech and Language Pathology, in all settings except inpatient hospital
x x
Medicaid Transportation, except ambulance and common carrier
x x
Nursing Facility including Intermediate care for the Mentally Retarded (ICF-MR) or Institute for Mental Disease (IMD) for those age 65 and older
x
*Full definitions of Medicaid State Plan services, which may be helpful in identifying appropriate alternate or “in lieu of” services are found in DHS 107.
Provider Handbook
Page 8
Nursing Home Level of Care
Benefit
Non-Nursing Home Level of Care Benefit
Home and Community-Based Waiver Services
Adaptive Aids x
Adult Day Care Services x
Adult Residential Care – 1-2 bed adult family homes x
Adult Residential Care – 3-4 bed adult family homes x
Adult Residential Care – CBRF x
Adult Residential Care – RCAC x
Communication Aids x
Consumer Education and Training x
Counseling and Therapeutic Resources x
Daily Living Skills Training x
Day Center Services/Treatment x
Day Services for Children x
Financial Management Services x
Home Delivered Meals x
Home Modifications (environmental accessibility adaptations)
x
Housing Counseling x
Personal Emergency Response Systems (PERS) x
Prevocational Services x
Relocation Services x
Respite Care Services x
Skilled Nursing Services x
Specialized Medical Equipment and Supplies x
Specialized Transportation Services x
Supported Employment x
Supportive Home Care x
Vocational Futures Planning and Support x
Provider Handbook
Page 9
Family Care Roles
The Inter-Disciplinary Team:
The Inter-Disciplinary Team (IDT) is a group of people who work together to reach a common goal. Each
person on the team contributes his/her own ideas. When an individual becomes a member of CCCW,
they become the center of the IDT. In general, the goal of the team is to provide the members with
supports and services so that they can live a more independent and healthy life. Members help identify
their personal outcomes and, along with their IDT, create a plan that lists members’ outcomes and
needs along with the resources they will need. The team includes the following members:
Member:
The member is the most important part of the IDT. His/her involvement and contribution are
critical to ensure that long-term care outcomes are achieved and needs are met. The member’s
team will involve the member in the process to identify personal goals or outcomes: from
assessment to plan development, provider arrangements, service delivery, and evaluation of
member satisfaction with services provided.
Community Resource Coordinator:
The Community Resource Coordinator helps members identify and address their support needs
as identified in their assessment. Examples of areas members may evaluate with their
Community Resource Coordinators are employment, transportation, supportive home care, or
outpatient mental health services. All of the services the member receives through CCCW are
driven by the Member-Centered Plan and resulting Individual Service Plan that is written with
the member. The Member Support Coordinators help to arrange and monitor the service and
supports included in the member’s service plan.
Health & Wellness Coordinator
The Health & Wellness Coordinator evaluates members’ health care needs and coordinates
health care services with members. The Health & Wellness Coordinator helps or works with
others to make sure the member receives ongoing, individualized support for the member’s
long-term care and health care concerns. The Health and Wellness Coordinator will provide
prevention and wellness education to members and other people in the member’s life, including
the use of influenza and pneumonia vaccines, if applicable and appropriate.
Guardian:
If guardian has been appointed for a member, that person is always part of the team.
Others as Member Determines:
Members may wish to include other people as part of the team. Adult children or therapists are
examples of others that members may choose to be part of their team.
Provider Handbook
Page 10
Family Care Outcomes
Family Care provides a wide range of services and supports specially designed for each individual
member. The general outcomes that Family Care assists members to achieve are:
I decide where and with whom I live
I make decisions regarding my supports and services
I decide how I spend my day
I have relationships with family and friends I care about
I work or do things that are important to me
I am involved in my community
My life is stable
I am respected and treated fairly
I have privacy
I have the best possible health
I feel safe
I am free from abuse and neglect
This list of general outcomes serves as a guide to further develop each member’s personal outcomes.
CCCW expects that contracting providers will partner with us to assist members in meeting their
outcomes. This strong, collaborative partnership is the foundation to supporting member outcomes.
Family Care may not be able to help members obtain everything they want out of life. In addition,
CCCW may not always purchase services to help members achieve their outcomes. The things members
do for themselves, or that members’ family and friends do for them, are still a very important part of
any plan to help members achieve their personal outcomes.
Provider Handbook
Page 11
JOINING THE CCCW PROVIDER NETWORK
How do I Become a Provider?
To provide and manage care for our members, Community Care Connections of Wisconsin (CCCW) has
developed a network of providers under contract. CCCW is committed to ensuring that our provider
network is adequate to meet the needs of our members. We are equally committed to ensuring our
providers demonstrate competency and quality in the provision of service to our members.
CCCW considers requests for contracting based on the following criteria:
Proposed services are in the Family Care benefit package
CCCW needs additional providers for the proposed services in order to meet member capacity
or choice
The proposed provider’s mission and vision compliment the Family Care outcomes and the
CCCW mission
The provider meets applicable licensing and/or certification standards as they apply to the
services to be provided
The provider is willing and able to sign and adhere to all components of a contract with CCCW
including, but not limited to:
Agree to CCCW rate
Follow contractual requirements related to authorizations and billing
Maintain ongoing communications with CCCW staff
Meet or exceed quality assurance expectations set by CCCW
If a potential provider is interested in joining the CCCW Provider Network:
1. Potential provider will be directed to complete an application, which is available at:
www.mycccw.org
2. Once this information is returned, and CCCW Provider Contract Manager deems
appropriateness of provider for inclusion in the Provider Network, a contract may be sent to the
provider along with all other pertinent information;
3. When the signed contract and other information are returned, the Provider is added to the
Provider Network Directory (copy available at www.mycccw.org).
After CCCW receives your signed contract back you will be a Provider available for use by CCCW
members (exclusions may apply).
Provider Handbook
Page 12
What Happens after We Sign a Contract?
Provider Network Directory
As a contracted provider your agency’s name, contracted service type(s), and your phone number will
be added to the provider network directory. This directory assists the Member and Interdisciplinary
Team to select the agency they would like to provide their service(s).
A list of current providers is available at www.mycccw.org or upon request.
Change of Contact Information
It is important that you keep us informed as to any changes in your address, telephone number, or other
contact information, such as email address or contract administrator name. Please contact the
Community Resource Department to report any such changes.
Changes may be submitted on-line at:
www.mycccw.org
OR
Community Care Connections of Wisconsin
3349 Church Street, Suite 1
Stevens Point, WI 54481
(715) 345-5968
(877) 622-6700 (Toll Free)
(715) 204-1799 (TTY)
(715) 345-5725 (FAX)
Email: [email protected]
Criminal Background Checks
In order to protect the members served, providers are required to comply with the provision of
applicable Wisconsin Statutes (Chapter 48 and Chapter 50), the Caregiver Background Check and
Investigation Legislation, and applicable administrative rules of the State of Wisconsin, Department of
Health Services.
If an employee or designee of your agency has actual, direct contact with Family Care members, you
must ensure that background checks are conducted on all those assigned to do work with our members.
You must retain in your personnel files all pertinent information, including the Background Information
Disclosure (BID) Form and/or search results from the Department of Justice, the Department of Health
Services, and the Department of Regulation and Licensing, as well as out-of-state records, Tribal Court
proceedings and military records.
Provider Handbook
Page 13
After the initial background check, you must conduct a new background check every four (4) years, or at
any time within that period when you have reason to believe a new check should be obtained. You
must maintain the results of this background search, on your own premises, for at least the duration of
the contract. As part of a quality check, CCCW’s Community Resource staff may audit your personnel
files to assure compliance with the State of Wisconsin Caregiver Background Check Policy.
You must refrain from assigning any individual to conduct any work under this contract who does not
meet the requirement of this law. Employee in this paragraph shall mean an employee or prospective
employee, and any subcontractors, agents, or designees assigned to perform any work with CCCW’s
members. You are required to notify CCCW’s Community Resource staff in writing within one (1)
business day if an employee has been charged with or convicted of any crime specified in HFS 12.07(2).
Records
Each provider agency must maintain and upon request, furnish to CCCW any and all information
requested by CCCW related to the quality and quantity of services provided through their contract. This
includes written documentation of care and services provided, including dates of services, properly
executed payrolls, time records, invoices, contracts, vouchers or other official documentation evidencing
in proper detail the nature and propriety of the services provided. Accounting and other financial
management records must also be maintained and available upon request in a form and manner
consistent with all applicable state and federal laws and principles of proper accounting and financial
management.
Room and Board in Residential Facilities
For members residing in a certified or licensed residential setting (which may be an adult family home,
community based residential facility, or a residential care apartment complex), as part of the member’s
approved service plan, CCCW will pay for the support and supervision portion of the care. CCCW will
also contract with the provider for the rent and food portion of the facilities cost, also known as Room &
Board. CCCW will directly pay the residential provider for Room & Board based on the contracted rate.
Because Room & Board is not in our member benefit package, CCCW is required to bill the
member/payee/guardian to recover the Room & Board costs up to a maximum amount set by State
Guidelines. The amount billed to the member is based on their income as well as allowable deductions
such as prescription, medical, dental and vision co pays. CCCW will also allow a deduction for health
insurance premiums as well as most court ordered fees related to guardianship. The member/guardian
will be informed of the Room & Board rate upon entering a residential facility. CCCW will bill Room &
Board monthly. Room & Board is different from, and billed in addition to Cost Share (which is calculated
by Economic Support and also based on income and allowable deductions).
Provider Handbook
Page 14
NOTIFICATION & AUTHORIZATIONS
Determining Services
Together with the member, the Community Resource Coordinator and Health & Wellness Coordinator
utilize a process called the Resource Allocation Decision (RAD) method. This process is used for all
decisions that will impact a member’s care plan.
The seven steps of the RAD process are:
1. Identification of the Core Problem
2. Identification of the Members Outcome
3. Assessment of the Core Problem
4. Exploring Options and Brainstorming
5. Application of any appropriate policies and procedures
6. Effectiveness of the Proposed Options
7. Explain, Dialogue and Negotiation with the Member
While completing the RAD process, the member and IDT staff identifies various ways to address the core
problem which could include both informal and paid supports.
When the member and IDT staff determines that a paid support must be utilized they refer to the
Provider Network Directory to identify a service provider.
Notification of Member Services with Your Agency
When the team selects your agency to provide support or services for a member you will receive written
notification or telephone contact from the CCCW Member Support Coordinator(s).
Within 3 to 5 business days you will receive a letter of authorization in the mail. If this authorization is
incorrect or not received, contact the CCCW Member Authorization Department.
Authorization of Services
Prior Authorization Request
All services provided to members must be authorized by CCCW prior to the delivery of services. Written
authorization for services is required prior to billing for services. In addition, the total amount of
services provided may not exceed the amount authorized in writing by CCCW.
CCCW has the final authority in determining member authorization for services and amount of services
to be provided. Providers will not be reimbursed for unauthorized services provided to members or
provided in amounts that exceed those authorized. Please notify all of your employees and designees of
the CCCW prior authorization requirements.
You must only provide services to members in the amounts authorized by CCCW. You will be
responsible for the cost of any services provided that exceed the authorized amount. Under no
Provider Handbook
Page 15
circumstances are you able to seek payment from the member or their family for the cost of services
exceeding the total amount(s) authorized by CCCW.
Prior Authorization Processing
A provider or member/guardian can request services from the member’s Inter-Disciplinary Team. Upon
receipt of such request, the team will either authorize or deny the request. When services are
authorized, a written authorization for each and every service to be provided will be sent to the provider
specifying the specific service to be provided, the amount of service (number of units) to be provided,
and the duration of services to be provided.
Providers or members/guardians may request additional service authorization(s) (new/additional
service(s)) or extensions of existing authorizations by contacting the member’s Inter-Disciplinary Team.
The team will consider all requests for new/additional services or extensions of existing authorizations;
however, the mere factor of a request does not in any way imply that there will be any change in service
level, service type, or duration of service.
Prior Authorization for Emergency Services
You must notify the Inter-Disciplinary Team immediately in an emergency situation. They will work with
you to immediately authorize any services that are needed.
To obtain the name of a member’s Support Coordinator, call CCCW’s main line at:
Monday – Friday 8:00 am – 4:30 pm
(715) 345-5968
(877) 622-6700 (Toll Free)
(715) 204-1799 (TTY)
If an incident occurs after business hours, or on a weekend or holiday, and there is a need for an immediate authorization, please contact the On-Call Crisis Center, who can be reached by calling: (715) 345-5968 (877) 622-6700 (Toll Free)
Provider Handbook
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BILLING & APPEAL INFORMATION
Preparing and submitting Claims
Community Care Connections of Wisconsin (CCCW) has selected WPS Health Insurance to process all claims transactions. With any claim that is submitted to WPS it must be received within 90 days of date of service and accepted as a clean claim. WPS will reject all claims that do not include the elements of a clean claim or are not filed within the required timelines. Clean paper claims which are filed timely to WPS will generally be processed within 7 to 10 business days of receipt. Clean claims filed on an Excel Spreadsheet (for applicable providers) are generally processed within 2 to 5 business days of receipt. Definitions: Clean Claim - is a complete and accurate claim that includes all provider and member information necessary to process the claim including all appropriate service and authorization codes. Filed Timely – claims must be filed within (ninety) 90 calendar days from the date of service if there is not a third party payor and (ninety) 90 days from the date of the EOB with claims of a third party payor. The claim filing timeline does not end with the original claim submission. If a claim is rejected or denied back to the provider, the provider must submit a corrected claim within the original 90 calendar days from the date of service. Business Days - a business day is any day including Monday to Friday and does not include weekends or holidays. Claims may be submitted to WPS for authorized services using any of the following options:
Paper Claims (clean paper claims which are filed timely to WPS will generally be processed within 7 to 10 business days of receipt)
Submit to: Community Care Connections of Wisconsin c/o WPS Insurance Corporation PO Box 7310 Madison WI 53707-7310
Electronic Filing
WPS Excel Spreadsheet (clean claims filed on an Excel Spreadsheet are generally processed within 2 to 5 business days of receipt) Spreadsheet submitters will go to the MoveIT process with a goal of Spring 2012 and the email below will no longer be valid
Submit to: [email protected]
It is a requirement that providers must accept payment made by CCCW and/or any third party payers
as payment in full. Providers are prohibited from billing, charging, or seeking remuneration or
compensation from or having any recourse against CCCW members.
Provider Handbook
Page 17
Reimbursement Information
CCCW will pay 90% of all clean paper claims that receive advance authorization within thirty (30)
calendar days of receipt and 90% of clean electronic claims within twenty (20) calendar days of receipt.
All payments will be made via direct deposit to Provider, unless provider has requested an exception in
writing.
The chart below provides you with a general timeline for payment receipt. Note that dates may vary due to the timing of processing and/or holidays. Day claims received by WPS Electronic by 4 PM Spreadsheet received prior to this day Paper claims entered by WSP
If received EDI, spreadsheet, or paper
claim is keyed by 4 p.m. on:
Claim is processed
by WPS
AN EFT Direct
Deposit will be made on
Check Cut Week Following
Check Sent Week
Following
Saturday/Sunday/Monday Tuesday Monday Monday Tuesday
Tuesday Wednesday Monday Monday Tuesday
Wednesday Thursday Monday Monday Tuesday
Thursday Friday Wednesday Wednesday Thursday
Friday Saturday Wednesday Wednesday Thursday
**These are approximate time frames, based on a clean claim and provided WPS does not have to
“PEND” claims.
**WPS processes spreadsheet at 9 AM daily, if received after that time, it will be processed next
business day.
**Paper checks are dated Monday or Wednesday, the actual check is sent out the following Tuesday or
Thursday.
**Electronic Funds Transfers (EFT) are sent to banks on Monday or Wednesday, but there is a 1-2
business day “banking lag”, depending on the bank. Credit union deposits tend to take 1-3 business
days.
If you have any questions regarding the status of your payment, contact the WPS Call Center Monday
through Friday between 8:00am and 4:30pm at 800-223-6016.
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Submission Deadlines
Providers must bill CCCW no later than 90 days from the time services are provided.
CCCW is the payer of last resort. The provider must bill other primary payers first. In the event the
primary payer denies the claim or makes only a partial payment on the claim, provider must submit a
clean claim to WPS within 90 days of the date of Explanation of Benefits from primary payor source.
**Copies of all claims and billing information, codes, and forms are located in Appendix A of the
Provider Handbook. This information is available at www.mycccw.org.
Provider Handbook
Page 19
How to Appeal a Denied Claim:
All payments and/or denials are accompanied by an Explanation of Benefits (EOB) or rejection notice, which gives the specific explanation of the payment amount or specific reason for the payment denial. Any inquiry regarding the rejection/denial should be directed to WPS Call Center Monday through Friday between 8:00 AM and 4:30 PM at 800-223-6016 If you have further questions or concerns prior to filing a formal appeal, please contact Dawn Trzebiatowski, Member Authorization Manager at 715-204-1720. If you dispute this initial decision, you may appeal by submitting a separate letter, within 60 calendar days of the initial denial or partial payment to:
Chief Financial Officer
Community Care Connections of Wisconsin 3349 Church Street, Suite 1
Stevens Point, WI 54481 The letter must clearly be marked as “Formal Appeal”. It must contain the provider’s name, member’s name, service code (billing code), date of service, date of rejection, reason(s) claim merits reconsideration and any supporting documentation. Each member must be on their own letter. If CCCW fails to provide a written response within 45 calendar days of the date of receipt of the appeal, or you are dissatisfied with CCCW’s response to your request for reconsideration, you may appeal to the Department of Health Services (DHS). This appeal must be submitted in writing within 60 calendar days of CCCW’s final decision to:
MCO Contract Administrator Bureau of Long-Term Support
1 West Wilson Street, Room 518 PO Box 7851
Madison, WI 53707-7851 DHS will solicit written comments from all parties to the dispute prior to making the decision. DHS has 45 calendar days from date of receipt of written comments to respond to this appeal. Providers must accept DHS’s determinations regarding appeals of disputed claims. The MCO agrees to pay providers within 45 calendar days of receipt of a DHS final determination in favor of the provider.
Provider Handbook
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COMMUNICATION
Reporting
CCCW strives to ensure good communication with service providers. For questions, please contact the
following:
When to Contact CCCW Member Support Coordinators:
A member needs services authorized by CCCW
Express concerns voiced by a member or on behalf of a member related to care or needs
Scheduling an appointment for a member
Follow up results from appointments
A member has a change in condition
Medical, personal or financial changes
A member is hospitalized or visits the ER
Death of member
A medication is changed, added or deleted
A room change for members in residential settings
Planning a staffing
A critical incident has occurred with a Member and is reported according to Critical Incident
Reporting Standards
When to Contact CCCW Community Resource Department:
Questions about CCCW contract and/or expectations
Update service provider information
Change in services provided
Report receipt of Statement of Deficiency or Letter of Clearance
When to Contact WPS Call Center:
800-223-6016
Available 8:00a.m. – 4:30p.m
Has my claim been paid yet?
Why was my claim rejected?
Why did I receive partial payment?
When was my check mailed?
How do I submit a corrected claim?
I need a copy of my explanation of benefits.
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Page 21
When to Contact CCCW Member Authorization Department:
715-204-1738 or 877-622-6700
Available 8:00a.m. – 4:30p.m
I need more hours/units on my authorization
I need a different code authorized
I haven’t received my authorization
Having WPS handle both the claims processing as well as the claims customer service will provide you with timely and consistent answers to your questions regarding all of our claim services. In addition, the WPS Call Center offers a 24/7 Interactive Voice Response (IVR) system to check claim status. Callers can immediately or at anytime opt out of the system to talk to a live person.
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PROVIDER QUALITY STANDARDS
Quality Program
Provider quality is of utmost importance, as it is providers that give the hands-on care and services to
our members. CCCW has developed service standards and will use service-specific quality measurement
tools to ensure quality of care and services. We continually work with providers to further develop our
Provider Quality Program and will provide resources and information to providers as it specifically
relates to their area of service provision. The provider Quality Program focuses on Provider
Credentialing/Licensing, Cultural Competency, Ethics, Program Integrity, Member Safety, Accessibility,
Provider Satisfaction, Recognizing Excellent Provider Performance, Empowerment, Service Standards,
and Education.
Provider Quality Council
The Provider Quality Council is a standing sub-committee of CCCW's Quality Committee that includes
additional stakeholders with interests specifically related to CCCW's network of providers. Areas of
specific interest to the council include: communications between CCCW and providers; developing
service-specific quality benchmarks or guidelines, provider contracts, service authorizations and
provider payments, provider education, and maintaining a member-centered focus to ensure that
everyone involved in planning and delivering services works to ensure positive experiences that enhance
members' lives.
The Provider Quality Council members are determined by the CCCW Quality Committee. Providers that
have questions, concerns, and/or comments may contact any of the Provider Quality Council members
to bring your item to the Council’s attention.
The Provider Quality Council members and contact information are listed at www.mycccw.org.
Member Satisfaction Survey
CCCW will perform an annual member satisfaction survey to measure how satisfied members are with
CCCW. In addition, CCCW has providers that send out their own member satisfaction surveys as part of
their quality program and provide the results to CCCW as a quality update. We encourage all providers
to consider participating in this type of quality process.
Provider Satisfaction Survey
CCCW will request that providers complete a satisfaction survey on annual basis during the first quarter.
As part of the survey, providers will be asked to assess the quality of the provider service relations. This
survey is developed by the members of the CCCW Provider Quality Council.
Provider Comment/Complaint Form
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A Comment/Complaint Form is used when members of the community would like to comment about a
provider that they feel has gone above and beyond in service provision. CCCW recognizes providers that
perform services in a manner that exceeds our expectations.
The form is also used as a quality alert when members of the community have concerns relating to a
specific provider. Provider Comment/Complaint Forms are completed by individuals and submitted to
CCCW’s Provider Network Department for processing and follow-up.
Submittal form is available at www.mycccw.org.
Provider Meetings
CCCW will sponsor periodic meetings in various areas of the region to communicate with and provide
education opportunities for providers.
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PROGRAM INTEGRITY
CCCW is committed to protecting the integrity of its managed care program. CCCW follows operational
initiatives that were created to prevent, detect, and correct instances of fraud and abuse. Instances of
fraud and abuse could be detrimental to CCCW, our members, and our personnel, and would violate our
commitment to program integrity. Fraud and abuse could harm CCCW’s viability. CCCW has developed
policies and procedures specifically relating to Program Integrity and will investigate all allegations of
fraud and abuse.
Definitions
“Fraud” shall mean, any intentional deception or misrepresentation made by a person or entity with the
knowledge that the deception or misrepresentation could result in some unauthorized benefit to the
perpetrator, itself, or some other person or entity. It includes any act that constitutes fraud under
applicable federal or state law.
Examples of Fraud:
Falsification of Provider Credentials
Intentionally performing or billing improperly (a provider that intentionally denies appropriate
services or intentionally submits false billing claims)
“Abuse” shall mean a practice that is inconsistent with sound fiscal, business, or medical practices, and
results in unnecessary program costs or reimbursement for services that are not medically necessary or
that fail to meet professionally recognized standards or contractual obligations for health care. It also
includes beneficiary practices that result in unnecessary cost to the program. It includes any act that
constitutes abuse under applicable federal or state law.
Program Integrity Compliance
Providers must not provide services or bill in a manner that would be considered a violation of our
Program Integrity policy, including committing fraud and/or abuse. In addition, providers must contact
the Program Integrity Compliance Officer to report any and all instances of alleged Program Integrity
violations.
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Program Integrity Continued…
Reporting
All instances of alleged Program Integrity violations should be reported directly to the CCCW Program
Integrity Compliance Officer. The CCCW Program Integrity Compliance Officer can be reached at:
Community Care Connections of Wisconsin
c/o Program Integrity Compliance Officer
3349 Church Street, Suite 1
Stevens Point, WI 54481
(715) 345-5968
(877) 622-6700 (Toll Free)
(715) 204-1799 (TTY)
(715) 345-5725 (FAX)
Investigating
There are specific timelines established in investigating Program Integrity violation allegations.
Investigations of all violation allegations will be conducted expediently by the Program Integrity
Compliance Officer receiving the complaint.
**A complete copy of the Program Integrity Policy is available at:
www.mycccw.org
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CRITICAL INCIDENTS
Definitions
“Critical Incidents” are circumstances, events or conditions resulting from action or inaction that results in death, serious harm to the health, safety, or well-being of a member or to another person as a result of the member’s actions, results in substantial loss in the value of the personal or real property of a member or another person as a result of the member’s actions, results in unexpected death, or poses immediate and serious risk to the health, safety, or well-being of a member.
Adverse Events are circumstances, events, or conditions that result from either action or inaction that are undesirable or unintended, did not result in any serious harm to a member’s health, safety or well-being and indicates or may indicate a quality issue with the services provided
Examples of Critical Incidents/Adverse Events are:
a) Falls b) Medication Errors c) Missing Person d) Health Related Incident involving Emergency Personnel e) Harm to Health, Safety or Well-being of Member f) Change in condition lasting more than one day g) Self harm or harm to others h) Suicide Attempt i) Property Damage j) Violation of Members Rights k) New diagnosis, or exacerbation (worsening or reoccurrence) of a known disease or illness. l) Hospitalization, ER/Urgent Care visit, or unscheduled doctor appointment m) Any incident requiring abuse/neglect/exploitation investigation
The purpose of informing the MCO of critical incidents and adverse events is to ensure the collaboration
of provider and MCO. This collaboration will allow both parties to ensure the coordination of care in the
following ways:
To help reduce risk for individual members and for all members. To promote health and safety. To evaluate actions and/or individuals that contributes to an event. To improve provider quality standards. To anticipate and monitor potential quality concerns. To identify and document positive provider experiences. To identify themes of incidents and streamline mechanisms to improve the standard of
practice. To provide a systematic approach to monitor and respond to incidents. To provide a feedback mechanism to the provider network, quality and care management
departments regarding the quality of all services provided.
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“Abuse” shall mean any of the following, if done intentionally, negligently, or recklessly:
An act, omission, or course of conduct by another that is not reasonably necessary for treatment or
maintenance of order and discipline and that does at least one of the following:
Results in bodily harm or great bodily harm to a member, or
Intimidates, humiliates, threatens, frightens, or otherwise harasses a member.
The forcible administration of medication or treatment with the knowledge that no lawful
authority exists for the administration or performance.
“Neglect” means an act, omission, or course of conduct by another that, because of the failure to
provide adequate food, shelter, clothing, medical care or dental care, creates a significant danger to the
physical or mental health of a member.
”Crime” means conduct which is prohibited by state or federal law and is punishable by fine or
imprisonment or both. Conduct punishable only by forfeiture is not a crime.
“Client Rights” means rights in Family Care as outlined in member application materials and the CCCW
Member Handbook.
Reporting Critical Incidents
All individuals or entities providing services to CCCW’s members are required to report critical incidents
as defined above by CCCW within one (1) business day from the time the provider becomes aware of the
incident/situation. This can be accomplished by calling the member’s Member Support Coordinator(s).
A voice mail left for one or both of the Member Support Coordinators is an acceptable form of
reporting.
Providers must ensure immediate safety of the person served and take any necessary steps to assure
that the member is protected from risk or continued harm.
Providers are required to cooperate with CCCW in investigating an alleged unforeseen event through
access to records, staff, and any other relevant sources of information requested.
If an incident occurs after business hours, or on a weekend or holiday, and you require CCCW assistance, please report the incident to the On-Call Crisis Center, who can be reached by calling (715)345-5968 or (877) 622-6700. If you have any questions regarding reporting requirements please contact the Community Resource Department at (715) 204-1770 or email [email protected]. Your member’s team is also available to answer questions.
Use of Isolation, Seclusion, and Physical Restraint
Providers are prohibited from use of any restrictive measures not part of an agreed upon care plan, including applicable DHS approvals. All providers must comply with Ch. 51.61(1)(i) Wis. Stats and HFS
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94.10 Wis. Adm. Code, in the use of isolation, seclusion, and physical restraints, which may not be used without specific case-by-case approval from the Department of Health Services, using the procedures specified by the Department of Health Services. CCCW Member Coordinator(s) will work with you in establishing a plan.
MEMBER GRIEVANCE AND APPEAL
Member Grievance and Appeal System
CCCW members have the right to register a grievance or appeal when they are not satisfied with any aspect of their care. CCCW shall be notified in writing of all CCCW member complaints filed in writing against the Provider. Provider agrees to fully cooperate with CCCW in researching and resolving complaints and grievances regarding Provider’s services. Such cooperation will include furnishing information to CCCW within fifteen (15) business days of its request, or within requested number of business days if the grievance is expedited.
There are two ways that the grievance and appeal process may touch you as a provider. The member has a grievance or appeal related to your services, or the member needs you assistance in filing a grievance or appeal related to CCCW or another provider. This section will describe your role and responsibilities in the two situations mentioned above. To learn more about the member grievance and appeal process, see the CCCW Member Handbook which is available on our website at www.mycccw.org.
If a member contacts you regarding a complaint against you as a provider, direct the member to call the Member Rights Specialist for assistance.
If a member asks you for assistance regarding a grievance or appeal that is not about you as a provider, you may review with them the instructions in the member’s copy of the CCCW Member Handbook or direct them to call the Members Rights Specialist.
CULTURAL COMPETENCY
Cultural Values
You must provide services in a manner that honors a member’s beliefs and is sensitive to cultural diversity. You must foster an attitude and communicate in a way that respects members’ cultural backgrounds.
Cultural Competency
You must foster and encourage cultural competency. There are essential elements that contribute to the ability to become more culturally competent. These elements include:
Value diversity,
Be conscious of the “dynamics” inherent when cultures interact,
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Institutionalize cultural knowledge, and
Develop adaptations to service delivery reflecting an understanding of diversity between and within cultures.
These elements must be manifested at every level of service delivery. They should be reflected in attitudes, structures, policies, and services. Being competent means learning new patterns of behavior and effectively applying them in the appropriate settings.
Cultural Preference
Members have a right to choose providers from the CCCW Provider Network and choose services based on cultural preferences.
CONFIDENTIALITY
Provider Requirement
You must maintain confidentiality of all member information that is generated or received. You must also be in compliance with all State and Federal confidentiality requirements.
You must comply with the Federal regulations implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to the extent those regulations apply to the services you provide or purchased with funds provided under contract with CCCW.
Reporting
You must immediately report all allegations of confidentiality violations to CCCW Community Resources Department and include your plan of action to address the violation if substantiated.
Investigating
CCCW Community Resources Department will work with you in investigating any instances of alleged violation and will work with you to resolve substantiated violations.
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COMMUNITY RESOURCES AREAS OF RESPONSIBILITY
Director of Operations Northern Region
Kris Kubnick [email protected] 715-301-1889
Director of Community Resources Department Central Region
Colleen Seemann [email protected] 715-996-1624
Senior Provider Relations Manager
Stacey Covi (Central) [email protected] 715-818-5136
Krista Love (Northern) [email protected] 715-638-2760
Provider Contracting Manager
Jill Flugaur (Central) [email protected] 715-204-1760
Melissa Michel (Northern) [email protected] 715-685-2857
Debra Magowan (Northern) [email protected] 715-638-2773
Katie Culver (Northern) [email protected] 715-638-2766
Provider Relations Manager Central Region Quality
Trista DeRosa [email protected] 715-204-1824
Provider Relations Coordinator-AFH certification
Tina Plachetka (Central) [email protected] 715-301-1702
Gabriel England (Northern) [email protected] 715-762-8571
Provider Relations Coordinator- Provider Support
Emmy Lou Eron (Central) [email protected] 715-204-1770
Chris Blackstone (Northern) [email protected] 715-638-2763
Community Resources Managers
Cathy Derezinski (Central) [email protected] 715-204-1807
Chelsey Drifka (Central) [email protected] 715-204-1852
Marci Griesbach (Central) [email protected] 715-996-1619
Carolyn Schulein (Central) [email protected] 715-996-1630
Tricia Lazare (Central) [email protected] 715-539-0520
Dennis Brauer (Northern) [email protected] 715-638-2764
Rebecca Hrdlicka (Northern) [email protected] 715-236-5050
Shirley Scherer (Northern) [email protected] 715-236-5069
Commonunity℠ Program Coordinator
Michelle Glodowski (Central) [email protected] 715-204-1758
Tracy Reichert (Northern) [email protected] 715-635-5411
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Community Care Connections of Wisconsin
Administrative Headquarters
3349 Church Street, Suite 1
Stevens Point, WI 54481
(715) 345-5968
(877) 622-6700 (Toll Free)
(715) 204-1799 (TTY)
Regional Offices:
Antigo Office
211 State Highway 64
Antigo, WI 54409
(715) 523-1000
Ashland
400 3rd Avenue Suite 200
Ashland WI 54806
Centuria
1001 State Hwy 35
Centuria WI 54824
Hayward
15618 Windrose Lane Suite 108
Hayward WI 54843
Ladysmith
5273 State Hwy 27 Suite 4
Ladysmith WI 54848
Marshfield Office
503 East Ives Street Suite 320
Marshfield, WI 54449
(715) 996-1635
Merrill Office
1401A East Main Street
Merrill, WI 54452
(715) 539-6500
Park Falls
1151 4th Avenue WI 54552
Park Falls WI 54552
Rice Lake
2500 South Main Street
Rice Lake WI 54868
715-544-8800
Spooner
514 Service Road
Spooner WI 54801
Superior
3712 Tower Avenue
Superior WI 54880
Stevens Point Office
3349 Church Street Suite 1
Stevens Point, WI 54481
(715) 345-5968
Wausau Office
1200 Lakeview Drive, Suite 100
Wausau, WI 54403
(715) 301-1899
Wisconsin Rapids Office
2821 8th Street South Suite 12
Wisconsin Rapids, WI 54494
(715) 818-5100
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Aging & Disability Resource Centers (ADRC)
Visit www.dhs.wisconsin.gov/LTCare/adrc for
more information about ADRCs or refer to the
CCCW Contact Sheet
ADRC of Barron, Rusk and Washburn Counties
Phone (888) 538 - 3031
ADRC of Central Wisconsin
Serves residents of Langlade, Lincoln,
Marathon, and Wood Counties
Phone (888) 486 - 9545
ADRC of Douglas County
Phone (866) 946 - 2372
ADRC of the North
Serves residents of Ashland, Bayfield, Iron,
Price, and Sawyer Counties
Phone (866) 663-3607
ADRC of Northwest Wisconsin
Serves residents of Burnett and Polk Counties
and the St. Croix Chippewa Tribe
ADRC of Portage County
Serves residents of Portage County
Toll Free (866) 920-2525
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APPENDIX A
FIELD DESCRIPTIONS FOR CCCW CLAIM FORM
Box Description
1 Member Identification # CCCW assigned number which uniquely identifies a member
2 Member Name Member first and last name associated with Member Identification #
3 Member Date of Birth Member date of birth associated with Member Identification #
4 Provider NPI # National Provider Identification # (must be present if submitting medical services)
5 Account (Invoice) Number Number that identifies the invoice for the provider
6 Provider Telephone # Contact number for provider
7 Provider TAX/EIN/SSN Unique number to identify provider
8 Facility Name Facility where the services were rendered
9 Facility Address Facility street address
10 City/State/Zip Code Facility city, state and ZIP code
11 Provider CCCW Reference # CCCW assigned provider number
12 Provider Name Physician’s or suppliers billing name
13 Billing Address Physician’s or suppliers billing address
14 City/State/ZIP Code Physician’s or suppliers city, state, ZIP code
15 Date of Services (MM/DD/YY) From/To Date of Service, Date Span or Individual Date of Service
16 Service Code Procedure code that identifies the service provided
17 Modifier Code(s) used to identify specific information regarding service code billed
18 Authorization Number Unique number assigned to specific date of service and service code
19 Units Billed Number of units billed by the provider
20 ($) Unit Cost Dollar amount billed for one unit of service
21 ($) Total Charges Amount of money requested for payment for service rendered
22 Total Charge Total amount of money requested for payment for services rendered
23 Authorized Signature Signature of provider and date
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FAMILY CARE CLAIM SUBMISSION TIPS
Tips for Timely Processing Here are a few tips to ensure smooth and timely processing of your claim submissions
Include all required data elements on the claim form
File claims electronically whenever possible
Compare claim and service authorization information to make sure they match
Claim Billing Reminders Please make sure the information on the claim matches the information on the service authorization.
Member Eligibility The member must be eligible for Family Care during the time the service was provided
Service Code Bill the appropriate service code with its corresponding Auth #
Units Should not exceed the number of authorized units
If the billed units exceed the authorized units, only the authorized units will be paid
Other Insurance EOB/EOMB – The Medicare EOMB or Primary Insurance EOB information should be included with your electronic claim submission or attached to the paper claim form
Disclaimer Codes – When the primary carrier disallows or denies payment, Medicare or other health insurance disclaimer codes should be billed on your electronic or paper claim
COB DISCLAIMER CODES Medicare Codes
M5 Provider is not Medicare Certified M7 Medicare disallowed or denied payment M8 Non-Covered Medicare services
Other Insurance Codes OP-D Denied by commercial health insurance or commercial HMO OP-Y Non-covered commercial health or HMO service
Important Data Elements Submitting a claim with all the key data elements/information will ensure your claims are processed quickly and accurately
Data Element Key Information
Authorization Number Providers should bill using the Auth # found on the Service Authorization
Member Information Name
Date of Birth
ID Number
Provider Information Billing and Servicing Address
Tax-ID Number (TIN,EIN,SSN)
Date of Service The dates of service should be within the service authorization date span
Service Code - HCPCS/CPT/Revenue Codes
Electronic filing – One unique code should be used per claim
Paper claims – multiple codes can be used and the Auth # should be submitted on the same line as the corresponding service code
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Modifiers Should be billed exactly as shown on the Service Authorization
Charge Amount The amount charged for the service
Number of Units/Days of service provided
Should be reported as a whole number
Procedure Codes billed as a time unit (15 minutes = 1 unit), use the unit number, instead of the time
Claim Form Information
HCFA (CMS 1500)
Authorization Number should be entered in Box 23
Multiple authorizations and service codes may be billed if the authorization numbers are clearly indicated next to the corresponding service in box 24-J
UB04 (CMS 1450)
Authorization Number should be entered in Box 63
Physical therapy Medicare Claims o The original UB04 submitted to Medicare may be used
Claim Submission Options
Claim Submission Options o You may submit claims for authorized service using any of the following options
Paper Claims
o HCFA (CMS 1500) o UB04 (CMS 1450) o CCCW Form
Electronic Filing
o Procedure Code – only one unique procedure code must be billed per claim o WPS Excel Spreadsheet
Electronic Filing WPS has developed EDI solutions to accommodate any provider’s situation – regardless of the claim volume or current automation capabilities. Providers who are interested in filing CCCW claims electronically can choose from four different billing options. Option 1 Obtain PC-Ace Pro32 Claim Entry Software
The software is provided by WPS at no charge to the provider
The claim entry software provides a stand-alone solution that creates a patient database
The software allows claim entry and claim submission to WPS
The PC-ACE Pro32 software can be downloaded from the following website http://www.wpsic.com/edi/pcacepro32.shtml
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Option 2 Choose a software program from a vendor
The vendor software should already be approved for WPS electronic claims submission
A list of approved vendors can be viewed on the following website http://www.wpsic.com/edi/pdf/edi_connection.pdf
Option 3 Choose a clearinghouse or billing service
The clearinghouse or billing service should be approved by WPS to submit claims electronically
A list of approved clearinghouses and billing services can be viewed on the following website http://www.wpsic.com/edi/pdf/edi_connection.pdf
Option 4 Develop your own EDI program
The program should be developed using the ANSI X12 837 Implementation Guidelines
Option 5 WPS Excel Spreadsheet
Contact CCCW Member Authorization Department for spreadsheet and password
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FAMILY CARE CLAIM EOB EXPLANATION CODES
WPS Code Explanation/Denial
NM THE AUTHORATION NUMBER IS INVALIED WITH THE SERVICE/SUPPLY BILLED. PLEASE
RE-BILL USING THE CORRECT AUTHORATION NUMBER WITHIN THE TIMELY FILING
LIMIT.
NO THE CLAIM EXCEEDED THE NUMBER OF AUTHORIZED UNITS FOR THIS SERVICE.
NP THE SERVICE/SUPPLY BILLED DOES NOT MATCH WHAT WAS AUTHORIZED. PLEASE RE-
BILL USING THE CORRECT SERVICE/SUPPLY CODE WITHIN THE TIMELY FILING LIMIT
SI THE PROVIDER OF SERVICE WAS NOT AUTHORIZED TO PROVIDE THIS SERVICE.
S8 THE NPI NUMBER FROM THE CLAIM IS NOT VALID. PLEASE SUBMIT WITH THE CORRECT
NPI NUMBER WITHIN THE TIMELY FILING LIMIT.
4F THE CHARGE EXCEEDS THE AUTHORIZED CONTRACTED FEE FOR THIS SERVICE.
25 THE DATE OF SERVICE IS EITHER BEFORE OR AFTER THE DATE RANGE AUTHORIZED.
27 SERVICES PROVIDED AFTER THE TERMINATION DATE, ARE NOT COVERED.
28 SERVICES PROVIDED PRIOR TO THE EFFECTIVE DATE ARE NOT COVERED.
29 CHARGES MUST BE SUBMITTED ON A TIMELY BASIS IN ORDER TO BE CONSIDERED FOR
PAYMENT
22 WE NEED THE PRIMARY CARRIER'S NOTICE OF PAYMENT OR DENIAL TO PROCESS THIS
CHARGE.
EM WE NEED THE MEDICARE EXPLANATION OF BENEFITS TO PROCESS THIS CHARGE.
MA PLEASE RESUBMIT THIS CLAIM TO MEDICARE WITH THE INFORMATION THEY
REQUESTED. WHEN MEDICARE HAS DETERMINED THEIR BENEFITS, SEND THE
EXPLANATION OF MEDICARE BENEFITS TO US FOR PROCESSING.
ID PLEASE RESUBMIT THIS CLAIM TO THE PRIMARY CARRIER WITH THE INFORMATION
THEY REQUESTED. WHEN THE PRIMARY CARRIER HAS DETERMIND THEIR BENEFITS,
SEND THE CLAIM AND THE EXPLANATION OF THE PRIMARY CARRIER BENEFITS TO US
FOR PROCESSING.
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GK THE CLAIM WAS NOT SUBMITTED TO THE PATIENT’S PRIMARY CARRIER IN A TIMELY
MANNER. REQUEST A REVIEW WITH THE DELAY REASON TO THE PRIMARY CARRIER.
WHEN THE PRIMARY CARRIER HAS REACHED THEIR CONCLUSION, SEND THE
EXPLATION OF BENEFITS WITH THE CLAIM TO US FOR PROCESSING.
MT THE CLAIM WAS SUBMITTED TO MEDICARE IN A TIMELY MANNER. REQUEST A
REVIEW WITH THE DELAY REASON TO MEDICARE. WHEN MEDICARE HAS REACHED
THEIR CONCLUSION, SEND THE EXPLANATION OF MEDICARE BENEFITS WITH THE
CLAIM TO US FOR PROCESSING.
AG THIS SERVICE/SUPPLY WAS SUBMITTED WITHOUT A PRIOR AUTHORIZATION
NUMBER. PLEASE RE-SUBMIT THE SERVICE/SUPPLY WITH THE AUTHORIZATION NUMBER AS ASSIGNED BY THE FAMILY CARE MANAGED CARE ORGANIZATION.
BU DURING THE PROCESSING OF THIS CLAIM, THIS LINE WAS BUNDLED INTO ANOTHERLINE
FOR PROCESSING.
CE THE EXPLANATION OF BENEFITS RECEIVED FROM THE PRIMARY INSURER DOES NOT
REFLECT THE ORIGINAL PAID OR DENIED CHARGES. PLEASE SUBMIT A COPY OF THE
ORIGINAL EXPLANATION.
CI THE MODIFIER(S) BILLED ON THE CLAIM DO NOT MATCH THOSE AUTHORIZED. PLEASE RE-BILL WITH THE CORRECT MODIFIER(S) WITHIN 90 DAYS FROM THE DATE OF SERVICE OR 90 DAYS FROM MEDICARE'S OR THE PRIMARY CARRIER'S DETERMINATION. CONTACT THE CUSTOMER'S CARE MANAGER WITH QUESTIONS.
CN THE PROVIDER OF SERVICE WAS NOT AUTHORIZED TO PROVIDE THIS SERVICE. PLEASE CONTACT THE CUSTOMER'S CARE MANAGER WITH QUESTIONS.
CX THE PROCEDURE CODE, DIAGNOSIS CODE, AND/OR REVENUE CODE IS NOT VALID.
PLEASE RESUBMIT WITH A VALID CODE.
DU THIS CLAIM IS A DUPLICATE TO A PREVIOUSLY RECEIVED CLAIM THAT IS CURRENTLY
BEING REVIEWED FOR PROCESSING.
EM WE NEED THE MEDICARE EXPLANATION OF BENEFITS TO PROCESS THIS CHARGE.
FC THIS PAYMENT CALCULATION WAS BASED ON THE FAMILY CARE OR MEDICAID FEE
SCHEDULE.
I3 THESE CHARGES ARE NOT COVERED AS THEY WERE BILLED IN ERROR BY THE PROVIDER
OF SERVICE.
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NO THE CLAIM EXCEEDED THE NUMBER OF AUTHORIZED UNITS FOR THIS SERVICE.
SG THE NPI NUMBER IS MISSING FROM THE CLAIM. PLEASE REBILL THE CLAIM WITH THE NPI NUMBER WITHIN THE TIMELY FILING LIMIT FROM THE DATE OF SERVICE OR FROM THE DATE OF MEDICARE'S OR THE PRIMARY CARRIER'S DETERMINATION
SU IN ORDER TO PROCESS BENEFITS CORRECTLY, THIS LINE WAS SPLIT FOR PROCESSING.
WS THESE CHARGES WERE SUBMITTED UNDER AN INCORRECT CUSTOMER NUMBER. WE
WILL PROCESS THESE CHARGES UNDER THE VALID NUMBER. TO AVOID DELAYS IN THE
FUTURE, PLEASE USE THE CORRECT NUMBER 0NUMBER.
18 WE'VE ALREADY PROCESSED THIS CHARGE.
22 WE NEED THE PRIMARY CARRIER'S NOTICE OF PAYMENT OR DENIAL TO PROCESS THIS CHARGE.
23 CLAIM REDUCED BECAUSE CHARGES HAVE BEEN PAID BY ANOTHER PAYER AS PART OF
COORDINATION OF BENEFITS, WHICH MAY INCLUDE MEDICARE PAYMENTS. COORDINATION OF BENEFITS WITH YOUR PRIMARY PLAN OF COVERAGE MAY RESULT IN EITHER A REDUCED PAYMENT OR NO PAYMENT.
25 THE DATE OF SERVICE IS EITHER BEFORE OR AFTER THE DATE RANGE AUTHORIZED
.
WPS EXCEL FORM SUBMISSION INSTRUCTIONS
ENTRY INSTRUCTIONS: 1. Excel spreadsheet is formatted with data protection that will only allow entry of data with specific
format. *For more details click in each Heading row on the Excel Spreadsheet.
2. Cell format is only allowed for the following functions: *Delete row *Sort data *Copy & paste (only allowed if copying data from one WPS Excel Form to another WPS Excel Form).
3. Do not leave a blank row between service lines on the Excel Form. 4. Claim with missing information (i.e. Member Number, Date of Service, Charged Amount, Units) will
not be processed. 5. Each row of data on the Excel Spreadsheet will be processed as a single line claim. 6. Multiple customers can be submitted on the same Excel Spreadsheet. 7. Excel Spreadsheet has to be password protected to secure data.
*Contact WPS or CCCW for password. 8. Professional (HCFA) and Institutional (UB) services can be submitted on the same spreadsheet. 9. Email Excel spreadsheet to:
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CONTACT: 1. General claim questions contact CCCW: (877) 622-6700 or (715) 204-1738 2. General Excel claim submission questions contact WPS:
Email: [email protected] Phone: Kit Lee at (608) 226-2608 Katie Sullivan at (608) 226-2623 Herb Held at (608) 221-7103
WPS EXCEL FORM DATA ENTRY INSTRUCTIONS PROVIDER INFORMATION: ENTRY INSTRUCTIONS: Provider TAX ID/EIN/SSN Key the 9-digit numeric number from the Authorization form.
Do not key special characters such as dash or slash.
Provider NPI # Exempt provider leave the field blank. Non-Exempt provider key the 10-digit numeric NPI number that starts with 1 or 2. Do not key special characters such as dash or slash.
Location Leave the field blank. This field is reserved for WPS.
Provider Reference # Key the Provider Reference number from the Authorization form.
SERVICING PROVIDER FACILITY INFORMATION: Servicing Provider Facility Name Key the Servicing Provider Facility Name from the Authorization
form. Servicing Provider Facility Address Key the Servicing Provider Facility Address from the
Authorization form. City Key the Servicing Provider City from the Authorization form.
Do not abbreviate city name.
State Key the 2-character postal state code. Zip Code Key the 5-digit postal Zip Code. BILLING or PAY-TO PROVIDER INFORMATION: Billing or Pay-to Provider Name Key the Billing or Pay-to Provider Name from the Authorization
form.
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Billing or Pay-to Provider Address Key the Billing or Pay-to Provider Address from the
Authorization form. City Key the Billing or Pay-to Provider City from the Authorization
form. Do not abbreviate.
State Key the 2-character postal State Code. Zip Code Key the 5-digit postal Zip Code. OTHER INFORMATION: Group Name Leave the field blank. This field is reserved for WPS. Pend Leave the field blank. This field is reserved for WPS. Open Text Note section. CLIENT INFORMATION: ENTRY INSTRUCTIONS: Member # Key the member number from the Authorization form.
Member number must be a 9-digit numeric number. Do not key special characters such as dash or slash.
First Name Key the member First Name from the Authorization form. Last Name Key the member Last Name from the Authorization form. Date of Birth Key the member Date of Birth from the Authorization form.
Member Date of Birth must be 2-digit month, 2-digit day, 4-digit year. Do not key special characters such as dash or slash. Example: July 4, 2009 should be keyed as 07042009.
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WPS EXCEL FORM DATA ENTRY INSTRUCTIONS DATA ENTRY INSTRUCTIONS WILL ALSO BE DISPLAYED IN THE EXCEL CLAIM SUBMISSION FORM WHEN CLICKING IN EACH HEADING CLAIM INFORMATION: ENTRY INSTRUCTIONS: Authorization # Key the Authorization number from the Authorization form.
Service submitted without appropriate Authorization number will be denied.
Date of Service (Start Date) Key the Date of Service (Start Date) that is cover under the Authorization number. Do not submit claim for future date. Do not submit two different years on the same service line. Date of Service must be 2-digit day, 2-digit month, 2-digit year. Example: February 14, 2009 should be 021409.
Date of Service (End Date) Key the Date of Service (End Date) that is cover under the Authorization number. Do not submit claim for future date. Do not submit two different years for the same service line. Date of Service must be 2-digit day, 2-digit month, 2-digit year. Example: February 14, 2009 should be 021409.
Bill Type This information is optional. Key the 3-digit or 4-digit numeric Bill Type.
Service Code (Revenue Code) Key the Service Code from the Authorization form.
Do not key the HCPCS/CPT code if submitting claim with Revenue Codes. Example of Revenue Codes: 0131, 0159, 0242, 0243. Service Code (HCPCS/CPT Code) Key the Service Code from the Authorization form. Example of HCPCS/CPT Codes: T2003, S5170, 99499, 96600.
Modifier (1) This information is only required for certain situation. Key the 2-character modifier code.
Modifier (2) This information is only required for certain situation. Key the 2-character modifier code.
Disclaimer Codes This information is optional.
Example of valid disclaimer codes: M1, M5, M7, M8, OP-Y, OP-D.
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Total Units Key the total units. Total Units cannot be greater than 4 digits per service line. The Total Units field is formatted to round number with decimal to the nearest whole number. Example: 1.2 units will be rounded down to 1 unit. 1.5 units will be rounded up to 2 units.
Total Charges ($) Key the total charges. The Total Charges field is formatted as currency with two decimal. Example: 1 dollar will be formatted to $1.00 The total charged amount cannot be greater than $99,999.00 per service line.
Account # or Invoice # This information is optional. The account# or invoice# cannot be greater than 17 characters
per service line.
