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Iowa Medicaid Enterprise

Welcome to

FALL TRAINING

2006

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Agenda

• Medicaid Overview

• General Billing Guidelines

• Break!

• NPI and The Iowa NPI Verification Tool

• Provider-Specific Training

• Questions and Answers

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Iowa Medicaid

• Iowa Medicaid provides health care coverage for financially-needy parents with children, children, people with disabilities, elderly people, and pregnant women.

• The goal is for Iowa Medicaid Members to live healthy, stable, and self-sufficient lives.

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Iowa Medicaid

• In Fiscal Year 2006, the average monthly Medicaid enrollment was 297,000 members

• Growth of approximately 4 percent is projected for Fiscal Year 2007

• The average Iowa cost per member is $2,200 a year. But costs vary widely

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Iowa Medicaid

• More than half of Medicaid members are children, but they account for only 17% of the expenditures

• 10% are elderly, but they account for 25% of expenditures

• 16% are disabled, but they account for half of the expenditures

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IME Facts

• Per month:– Average over 29,000 phone calls to Provider Services – Average 1,445 written inquiries– Respond to an average of 664 e-mails– Process over 900 new provider enrollments, 1670

changes– Average 1.5 million claims processed

• 85% electronic• 338,610 Medicaid members as of 7/31/06• 36,000 Iowa Medicaid providers

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3% Fee Increase

FY ‘06

3% Increase Effective July 1, 2005-All processing of claims has occurred-Adjustment Reason 40-Questions

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3% Fee IncreaseFY ‘07

• The 3% fee increase for Fiscal Year 2007 is still pending final approval of the State Plan Amendment that has been submitted to CMS. The IME will work together with CMS to ensure that the approval will occur as soon as possible.

• Due to the implementation of weekly payment cycles, the IME will be unable to give providers a separate remittance advice for the affected claims. However, we are researching methods of assisting provider in identifying the affected claims.

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Top 10 Denial Reasons

1. Exact duplicate claim

2. Member not eligible

3. Missing or Invalid MediPass referral number

4. Third-party insurance should have been billed primary

5. Medicare should have been billed primary

6. Missing or Invalid member ID number

7. Procedure/Treating Provider conflict

8. Medicare paid amount is zero 9. Fragmented billing of medical services

10. Procedure/Provider Type conflict

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Payment Cycles

• On August 7, 2006, the IME began weekly payment cycles

• Electronic Funds Transfer (EFT)• Electronic Claims Submission

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Contact Information

What should you do if your claim denies?- Check your remittance advice for a specific denial reason.- Then, fix your claim and resubmit.

What if you need additional assistance?Please call and let us assist you:

1-800-338-7909 or locally at 515-725-1004.Email us at: imeproviderservices@dhs.state.ia.us

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CONTACTINFORMATION

IME

Addresses

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CONTACT INFORMATIONCONTINUED

IME

Phone

Numbers

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ELVS

Eligibility 24 hours a day, 7 days a week!

Verify:

•Spend Down

•Lock-In

•Insurance

•Managed Health Care information

•NEW!! Vision and Dental Eligibility

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How Can I Make the IME Work for Me?

Use the IME’s internet based Web Portal Access

Sign up for Electronic Funds Transfer (EFT)

for your Medicaid Payments

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IME Website

WWW.IME.STATE.IA.US

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ELECTRONIC CLAIMS SUBMISSION

EDISS(ELECTRONIC DATA INTERCHANGE SUPPORT SERVICES)

800-967-7902EMAIL: EDI@NORIDIAN.COM

www.noridianmedicare.com

PC ACE PRO32 SOFTWARE

(It’s Free!)

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ELECTRONIC CLAIMS SUBMISSION

• All providers need to complete the appropriate EDI paperwork in order to submit electronic claims to the IME EDISS.

•The claims registration forms (837P, 837I, or 837D) along with the EDI Enrollment form must be completed.

• If using PC-ACE Pro32, complete the PC-ACE Pro32 Software Sublicense Agreement as well.

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Claims Submission Issues

• Do not use red ink or any light-colored ink– Any light print will not show up on a scanned document

• Do not use high-lighters on any document– Highlighted documents will be blacked out by the scanner

• Position data in the center of each box• Use the original “Drop-out” red and white CMS-1500 and UB-92 claim forms.• Claims must include a valid Medicaid Provider number, member ID and dates

of service in the correct boxes • Diagnosis codes and procedure codes can not include descriptions• On the 1500, do not use the diagnosis code in Column E• On a UB, do not give the name of the attending physician • On a UB, do not put your rate in Column 44• The dental form can not be used as a Prior Authorization form

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Claim Submission Issues(cont)

• Indicate both the dollars and cents for the sub-charges and total charges

• The total charge box must be completed

• If the claim has multiple pages, total only the last page

• Do not staple or tape documents to the inside of envelopes

• Inquiry forms should not be used to submit claims

• Clear direction on Medicare EOBM

• SIQ forms must be updated at the IME prior to claim submission

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Credit/Adjustment Request

 

When to request a Credit or an Adjustment?•Request a Credit if you want the IME to take back an entire payment on a claim.

•Request an Adjustment when there is a correction to be made on a claim (date of service, number of units, primary payment, late insurance payments, etc).

Where do I find the form?

•www.ime.state.ia.us (click on “Providers”, then “Forms”)

•Provider Manual

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Credit/Adjustment RequestContinued

The Credit/Adjustment Request Form has three sections that must be completed.

• In Section A, choose “Credit” or “Adjustment”.

•In Section B, note the 17-digit TCN number found on the remittance advice.

• In Section C, sign and date the request.

•Do not submit a Credit/Adjustment Request if the claim is denied.

•Requests must be submitted one year or sooner after the date of original payment.

IOWA MEDICAID PROGRAM

CREDIT/ADJUSTMENT REQUEST (If the claim is DENIED, DO NOT USE THIS FORM. Resubmit the corrected claim.)

(DO NOT USE RED INK.) SECTION A: Check the appropriate box and follow the steps that are outlined

X CLAIM ADJUSTMENT

a) Attach a completed claim copy, with corrections made directly on the claim, OR b) Attach a copy of the remittance advice, with corrections made directly on the remittance, AND c) Complete Sections B and C.

CLAIM CREDIT (NOTE: This will result in Medicaid retracting the claim payment.)

d) Attach a remittance copy. e) Complete Sections B and C

SECTION B: This section MUST be filled out completely in order to process: 1. 17-DIGIT TCN: 0-00000-00-000-0000-00

2. 7 DIGIT PAY-TO-PROVIDER NUMBER: 1234567

3. PROVIDER NAME: Jeremy Morgan

CITY: Des Moines STATE: IA ZIP: 50315

4. 8-DIGIT MEMBER STATE ID NUMBER: 1234567A

5. REASON FOR ADJUSTMENT OR CREDIT: ___A short explanation or description of what you are asking

for.

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

SECTION C: Signature and Date REQUIRED Signature

DATE: 10/03/05

RETURN ALL REQUESTS TO:

IOWA MEDICAID ENTERPRISE PO BOX 36450

DES MOINES, IA 50315

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Provider Inquiry

How can I get an answer in writing?Use the Provider Inquiry Form

www.ime.state.ia.us or the Provider Manual

Submit a Provider Inquiry when you have a question regarding a claim and need to receive the answer in writing. Attach the Provider Inquiry Form to a claim and any documentation required.

Fill the form out completely- include the 17-digit TCN number found on the remittance advice, describe the situation, and note your provider number, address, and phone number. Also, be sure to sign and date the form.

 

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Provider Inquiry Continued

When to use:–To initiate an investigation into a claim denial

When not to use:–To add documentation to a claim

–To update/change/correct a paid claim

•Mail Provider Inquiries to: IME

PO Box 36450

Des Moines, IA 50315

    

  

 

Fall 2005 Iowa Medicaid Enterprise 1

PROVIDER INQUIRY Attach supporting documentation. Check applicable boxes: Claim copy Remittance copy

Other pertinent information for possible claim reprocessing.

1. 17-DIGIT TCN

2. NATURE OF INQUIRY

I N Q U I R Y

A

1. 17–DIGIT TCN

2. NATURE OF INQUIRY

I N Q U I R Y

B

Provider Signature/Date: MAIL TO: IME Provider

Services P. O. BOX 36450 DES MOINES IA 50315

IME Signature/Date:

7-digit Medicaid Provider ID#

Telephone

Provider Please Complete:

Name Street City, St Zip

(FOR IME USE ONLY)

PR Inquiry Log #

Received Date Stamp:

470-3744 (Rev. 07/05)

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Third-Party Liability

•Medicare

• Other Insurance

• Updating to the IME

• Using the SIQ form

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Guidelines for Medicare Crossovers

• Coinsurance and deductibles only

•Information needed on the EOMB copy

•TPL payment

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Prior Authorization

Mail your requests to:Iowa Medicaid Enterprise

Medical Prior AuthorizationsPO Box 36478

Des Moines, IA 50315

Questions? 888-424-2070

     515-725-1009 (Local)     515-725-1356 (Fax)

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Timely Filing Guidelines

Initial Filing• Must be filed within 12 months of the first date of service

• The date of submission must be shown beside the signature on paper claims

• Medicare crossovers must be filed within 24 months of the first date of service

ExceptionsExceptions to the 12 month filing limit are considered in only two cases:

• Retroactive Eligibility

• Third-party related delays

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Timely Filing Guidelines Continued

Resubmissions

• If a claim is filed timely but denied, an additional 12 month follow up period is allowed.

• These claims must be submitted on paper with the original filing date noted.

Claim Adjustments

• Requests for claim adjustments must be made within 12 months of the payment date.

• Claim credits or partial refunds are not subject to a time limit.

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Iowa Administrative Code 441

79.9(4) Recipients must be informed before the service is provided that the recipient will be responsible for the bill if a non-covered service is provided.

The member must be informed of the date and procedure that will not be covered by Medicaid.

This information must be noted in the patient’s file.

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Iowa Medicaid Eligibility Cards

Green Card: Traditional fee-for-service Medicaid members. Also Medically Needy Members who have met their spenddown

Pink Card: Managed Health Care members (MediPASS and HMO)

Blue Card: Lock-in recipients

Violet Card: Qualified Medicare Beneficiaries (QMB), as well as Alien-Status individuals with limited benefits

IowaCare Card: Members are covered if seen at the University of Iowa

Hospitals and Clinics, Broadlawns Medical Center, and the State’s four Mental Health Institutions at Cherokee, Clarinda, Independence, and Mt. Pleasant

Notice of Decision: Presumptively eligible women. Coverage is for:

•Women who have or may have breast or cervical cancer. Applies to all Medicaid covered services

•Pregnant women. Applies to ambulatory prenatal care only

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• For information about the Iowa Plan, members may call 800-317-3738. • Providers may call the ELVS line for Iowa Plan eligibility at 800-338-7752 or 515-323-3693. • For information regarding the Iowa Plan, providers should call Magellan at 800-638-8820.

Iowa Plan for Behavioral Health

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Managed Health Care

• Comprised of MediPASS and any HMO contracted with DHS.

• Primary Care Providers can be one of the five provider types that provide primary care services.

• Managed Care is mandatory in many counties in the State of Iowa.

• Providers of care must obtain a referral from the provider listed on the member’s Medicaid Eligibility Card.

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The Medically Needy Program

This program provides medical coverage to people who incur high medical expenses but have too much income or resources to qualify for regular Medicaid.

Enrolled members are eligible for payment of all services covered by Medicaid except:

–Care in a nursing facility

–Care in an intermediate care facility for the mentally retarded

–Care in an institution for mental disease

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The Medically Needy Program

SpenddownIf a member’s income exceeds a set amount, the individual will be required to “spenddown” some of their income by paying for a portion of outstanding medical expenses before receiving a Medicaid Card.

Submitting ClaimsIf a member has not met spenddown, he/she will not have a Medicaid card. A Medically Needy member is responsible for payment of services used to meet spenddown.

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Lock-InProgram

To refer members with potential issues in utilizing Medicaid services, contact Iowa Medicaid Medical Services at 800-383-

1173 or 515-725-1008 and press the option for medical inquiries.

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Exception To Policy

Providers or members may request an Exception to Policy in order to have a member receive a service that is not normally covered by Iowa Medicaid.

Mail or fax the request to:

Department of Human Services

Appeals Section   

1305 E Walnut Street, 5th Floor    Des Moines, IA 50319    FAX (515) 281-4597

OR….

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Exception To Policy

Complete the Exception to Policy form online at

http://www.dhs.state.ia.us/forms/470-3888.htm .

You will receive a letter signed by the Director if the request is approved.

Submit an original claim form with a copy of the approval letter to:

Exception Processing

Hoover State Office Building

1305 E. Walnut

Des Moines, IA 50315

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Education and Outreach

The Education and Outreach Staff is a pro-active team

that provides training for providers. We can help you with the following:• Pro-active Educational Issues   • On-site Training Sessions for Providers• PC ACE Pro32 software• Fall Training!

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Break Time!!

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National Provider Identifier (NPI)

What is NPI?- The NPI is the standard unique health care identifier for providers. The old health care provider identifiers are being replaced by the new NPI. The new NPI number will be the primary identification for the provider after May 23rd, 2007. All entities covered by HIPAA will have to obtain a NPI number by May 23rd, 2007.

Why do I need an NPI?- Due to federal regulations, starting May 23rd, 2007, providers must start using the NPI system. Under HIPAA, all providers covered must register, obtain, and use the HIPAA identification code when making transactions between covered entities.

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National ProviderIdentifier (NPI)

(continued)

How do I get an NPI?-To register for your National Provider Identifier (NPI) number click on:

https://nppes.cms.hhs.gov/NPPES/Welcome.doThe NPPES site will instruct you on how to register and obtain an NPI.

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National ProviderIdentifier (NPI)

(continued)

– IME will gather all providers’ NPI number(s) between October and the end of December 2006

– This process is web-based through the Iowa NPI Verification Tool

– This tool is operational and ready to be accessed effective October 9, 2006

– It is an easy-to-use web portal developed to gather your NPI number(s)

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Email Confirmation

You will receive the following email:You have created a new account with the Iowa NPI Verification Tool.To complete the account creation process, please click on the following link and fill out the

Registration Confirmation Form.http://www.xjseries.com:8080/iowaNpi/completeReg.seam You will be asked to supply a Confirmation Code. Your unique Confirmation Code is shown

below. Confirmation Code = xxxxxxxxxxx The most accurate way to enter the Confirmation Code is to cut and paste from this email to

the form.Once the account has been established, please access the home page using the following link:

https://www.imeservices.org  

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