Medicaid 101 School-Based Health Care Services

October 2014

Jim Harvey, SBHS Program ManagerMatt Ashton, Provider Relations Consultant

2

SBHS Program Overview

The School-Based Health Care Services (SBHS) website is located at Washington State Health Care Authority School-Based Health Care Services for Children in Special Education

SBHS Website Resources

• Latest updates• Reminders• Understanding the Program Updates• Intergovernmental Transfer Process (IGT)

flowchart• How to contact the fiscal staff regarding

invoices and the IGT process

• National Provider Identifier (NPI) instructions

• How to contact the SBHS Program Specialist

• Locating the SBHS Medicaid Provider Guide (MPG)

• SBHS WACs• Provider Update Form (PUF) requirements

3

What is the SBHS Program?• The SBHS program reimburses school districts

for covered health-care-related services provided to Medicaid-eligible children in Special Education. These services must:

– Be included in the child’s current Individualized Educational Program

– Be medically necessary– Be provided by a licensed heath care

practitioner– Be diagnostic, evaluative, habilitative, or

rehabilitative in nature– Identify, treat, and manage the education-

related disabilities4

SBHS Program Overview

SBHS Program Website•Latest updates•Reminders•Program updates•Claiming•Provider Qualifications Requirements•Resources•Contact and Medicaid Customer Service

5

Who Delivers School-Based Health Care Services?

6

SBHS Program Overview

• Covered Services:– Evaluations when the child is determined to have a disability,

and needs special education and health care-related services. – Re-evaluations to determine whether a child continues to need

special education and health care-related services. 

• Direct health-care-related services, including: – Audiology services– Counseling services– Nursing services– Occupational therapy services– Physical therapy services– Psychological services– Psychological assessments– Speech-language therapy services

7

SBHS Program Overview

• Covered Services:– Audiology services– Counseling services– Nursing services– Occupational therapy services– Physical therapy services– Psychological services– Psychological assessments– Speech-language therapy services

8

SBHS Program Overview

Non-Covered Services

9

What Documentation Requirements are there for School Districts?

Sufficient documentation must support and justify the billed and paid claims,

and be maintained for a minimum of six years from the date of service.

10

Processing a Claim

Claim entered into ProviderOne

ProviderOne

•Assign a Transaction Control Number (TCN)•Verifies the e-claim and direct data entry claims

History and Claims Analysis

Suspended Claim

•Authorization•Eligibility•Coordination of Benefits (COB)•Program limitations•Invoice school district for local match requirement•Intergovernmental Transfer process

Final Claim Disposition

• Remittance Advice generated

• Warrant issued

• Electronic Funds Transferred

11

What about third-party liability?

School districts may rebill a denied claim only after doing both the following:•Receiving a denial letter or Explanation of Benefits (EOB) from the child’s primary insurance carrier. •Forwarding the written denial with the claim to the agency’s Coordination of Benefits section.

12

SBHS OverviewSBHS reminders:•RAs are a good source for checking compliance. The paid section of the RA can be used to check against a child’s file for completed treatment notes. You will want to make sure notes have:

– Documented activities and interventions– The child’s name– The child’s ProviderOne Identification– The child’s date of birth– The date of service, time-in/time-out, and the

number of billed units– Identified if treatment was for individual or group

therapy (if applicable)

13

SBHS Overview• School districts must submit their required

local matching funds within one hundred twenty (120) days from the date HCA sends an invoice to the district.

• School districts bear full responsibility for all submitted billing information completed by them or their billing agent. – A good practice to perform is to communicate with

the billing agent at least monthly.

14

ProviderOneProviderOne

15

Accessing ProviderOneAccessing ProviderOne

16

Before logging into ProviderOne:• Make sure you are using Microsoft

Internet Explorer version 6.0 and above

• Turn OFF the Pop Up Blocker

• Make sure you are using a PC (MACs are not supported by ProviderOne)

ProviderOne UsersProviderOne Users

17

ProviderOne Security web page link:http://www.hca.wa.gov/medicaid/providerone/pages/phase1/security.aspx

How to Get Access into the How to Get Access into the SystemSystem

• Review the ProviderOne Security Manual at http://www.hca.wa.gov/medicaid/providerone/pages/phase1/security.aspx

• New provider who do not have the correct form to access ProviderOne, should email ProviderOne Security at provideronesecurity@hca.wa.gov. In the subject line enter Request for Provider Supplemental Information Request Form 18

How to Get Access into the How to Get Access into the SystemSystem

19

• The Provider Supplemental Information Request form is for a newly enrolled Facility, Clinic, Individual Provider, or a new Office Administrator.

• Complete the form and fax it in to 360-586-0702 for ProviderOne access.

How to Set Up a UserHow to Set Up a User

20

• Log in with the System Administrator profile

• Click on Maintain Users

• The system now displays the UserList screen

• Click on the Add button

How to Set Up a UserHow to Set Up a User

• Adding a user

• Fill in all required boxes that has an asterisk (*)

• The address is not needed here21

How to Set Up a UserHow to Set Up a User

To Display the new user• In the With Status box display In Review, then

click Go • The user’s name is displayed with In Review status.• Click the box left of the user’s name, then click the

Approve button to approve this user.

22

How to Set Up a UserHow to Set Up a UserAdding Profiles

• Get here by clicking on the users name on the previous screen.

• On the Show menu click on Associated Profiles.

23

How to Set Up a UserHow to Set Up a UserAdding Profiles

• Click on the Add button to select profiles

24

How to Set Up a UserHow to Set Up a UserAdding Profiles

Highlight Available Profiles desired• Click double arrow and move to Associated

Profiles box then click the OK button.

25

How to Set Up a UserHow to Set Up a UserAdding Profiles

To Display the new profiles•In the With Status box display All, then click Go.•The profiles are displayed with In Review status.•Click the box left of the profile name, then click the Approve button. Profiles will then be approved.

26

How to Set Up a UserHow to Set Up a UserHow to set up a user’s password

27

How to Manage a UserHow to Manage a UserHow to reset a password•Enter the new temporary password and click Save

28

To lock or unlock a User, click this box!

How to Manage a UserHow to Manage a UserHow to end a user in ProviderOne

• Enter the end date and click the save button.• The account will be removed from view after the

system refreshes overnight.

29

How can we help?How can we help?

30

Enrolling Servicing ProvidersEnrolling Servicing Providers

31

Enrolling Servicing ProvidersEnrolling Servicing Providers

Log into ProviderOne using the File Maintenance or Super User profile

32

• Under Provider click on the hyperlink Manage Provider Information

• At the Business Process Wizard click on Step 15: Servicing Provider Information

Enrolling Servicing ProvidersEnrolling Servicing Providers

When the Add Servicing Provider screen opens, click on the Add button.

On the Add Servicing Provider screen:Enter the provider’s NPI number or ProviderOne IDEnter their Start Date at your school districtClick on the Confirm Provider button

33

Enrolling Servicing ProvidersEnrolling Servicing Providers

If the provider is already entered in ProviderOne their name will be confirmed.

•Click the OK button to add the provider to your list.•Remember to click Step 17: Submit Modification for Review.•Provider Enrollment will review the school district’s request.http://www.hca.wa.gov/medicaid/providerenroll/pages/enroll.aspx#provider

34

Adding New Servicing ProvidersAdding New Servicing ProvidersThere are two ways to add a new servicing provider to your domain:

• Follow the steps in the previous slide. When you Confirm the servicing provider and they are not currently in the system, follow the next several enrollment steps.

• In the ProviderOne portal click Initiate New Enrollment.

35

Click on Individual to add the servicing provider to your Domain.

At the Basic Information page for the rendering provider enrollment:

• Most important is to check the SSN radio button!• When filling in the rest of the data fields be sure

to select Servicing Only as the Servicing Type.

36

Adding New Servicing ProvidersAdding New Servicing Providers

• Once the Basic Information page is complete click the Finish button.

• The basic information on the enrollment application is submitted to ProviderOne which generates an application number.

• Be sure to record this application number for future use to tracking the status of the enrollment application. Now click OK.

37

Adding New Servicing ProvidersAdding New Servicing Providers

The steps with the RED arrow are required for the SBHS program.

38

Adding New Servicing Adding New Servicing ProvidersProviders

Checking Medicaid EligibilityChecking Medicaid Eligibility

39

How Do I Check Eligibility In How Do I Check Eligibility In ProviderOneProviderOne

Select the proper user profile

Note: There are three different profiles that can be used for checking Medicaid eligibility in ProviderOne:

• EXT Provider Eligibility Checker

• EXT Provider Eligibility Checker-Claims Submitter

• EXT Provider Super User

Select Benefit Inquiry under the Client section of the Provider Portal

40

How Do I Obtain Eligibility In How Do I Obtain Eligibility In ProviderOneProviderOne

An unsuccessful check would look like this:

Use one of the search criteria listed along with the dates of service to verify eligibility.

• The child is not eligible for your search dates; or

• Check your keying!

41

Successful Eligibility CheckSuccessful Eligibility Check

Note: The eligibility information can be printed out using the Printer Friendly Version link located in the upper left corner. 42

Successful Eligibility CheckSuccessful Eligibility CheckAfter scrolling down the page the first entry is the Client Eligibility Spans which show:•The eligibility program (CNP or MNP only)•The date span for coverage

43

Coordination of Benefits Coordination of Benefits InformationInformation

Successful Eligibility Successful Eligibility CheckCheck

• Will display phone number and any policy or group numbers on file with WA Medicaid for the commercial plans listed.

• For school districts who do direct data entries, the Carrier Code (Insurance ID) is found under the Coordination of Benefits Information.

44

Gender and Date of Gender and Date of Birth UpdatesBirth Updates

A large number of claims are denied due to mismatching between birth dates in the provider's record and the ProviderOne's client eligibility file. School districts can send a secure email to mmishelp@hca.wa.gov with the child's ProviderOne ID, child’s name, and the correct birth date. The same process is true if school districts find a gender mismatch.

45

Coverage status can change at any time!• Verify Medicaid eligibility before submitting a claim• Print the Benefit Inquiry results for student

records

If eligibility changes after this verification, HCA will honor the printed screen shot.

oException: Medicaid-eligible children in Special Education with commercial insurance coverage who are loaded after eligibility verfication; commercial insurance must be billed first.

Verifying EligibilityVerifying Eligibility

46

Reading the Remittance Reading the Remittance Advices (RAs)Advices (RAs)

47

Reading the Remittance Advice Reading the Remittance Advice (RA)(RA)

How do I retrieve the PDF file for the RA?• Log into ProviderOne with a Claims/Payment

Status Checker, Claims Submitter, or Super User profile.

• ProviderOne should open a list of available RAs.

• Click on the RA/ETRR Number in the first column to view an entire RA.

At the Payment heading click on the hyperlink View Payment to view payments to the school district.

48

Reading the Remittance Advice Reading the Remittance Advice (RA)(RA)

The Summary Page of the RA shows:• Billed and paid amount for paid claims• Billed amount of denied claims• Provider adjustment activity (Provider

Adjustments)• Total amount of adjusted claims

49

Reading the Remittance Advice Reading the Remittance Advice (RA)(RA)

Provider Adjustments:• These adjustment amounts can carry over to

the next RA until the amount is resolved or reduced by the amount paid out for previous claims adjudicated.

• Claims that cause carry over adjustment amounts will be on previous RAs.

• Credits will have a check number applied on the RA (e.g., JVAH0223344556677800).

• ProviderOne automatically sends the credit after 180 days.

50

Reading the Remittance Advice Reading the Remittance Advice (RA)(RA)

51

Reading the Remittance Advice Reading the Remittance Advice (RA)(RA)

EOB Codes• The Adjustment Reason Codes; and • The Remark Codes for denied claims &

payment adjustments are located on the last page of the RA.

• The complete list of Federal codes can be located on http://www.wpc-edi.com/reference/

52

Online Services

• ProviderOne Billing and Resource Guide

Click Resource Guide

53

Online ServicesHelpful links related to Medicaid eligibility•For the following fact sheets, use the hyperlink listed below

Client Services Card Fact Sheet Client Eligibility Verification Fact Sheet Interactive Voice Response Fact Sheet http://www.hca.wa.gov/medicaid/provider/pages/factsheets

.aspx

•E-Learning webinar on how to check eligibility in ProviderOne http://www.hca.wa.gov/medicaid/provider/Pages/webinar.aspx

•Self-paced online tutorial on how to check Medicaid eligibility at http://www.hca.wa.gov/medicaid/ProviderOne/pages/phase1/tutorials.aspx

•ProviderOne Billing and Resource Guide

54

Online Services• Visit the providers training website for links to recorded

webinars, E-learning, and resource manuals at http://www.hca.wa.gov/medicaid/provider/pages/training.aspx.

• Provider Enrollment’s website is located at http://www.hca.wa.gov/medicaid/provider/pages/newprovider.aspx. The Provider Enrollment Unit is available to assist with enrolling servicing providers under the school district’s billing NPI number. They can be reached at 800-562-3022 ext. 16137.

• ProviderOne billing questions can be forwarded to the Provider Relations Unit or to the SBHS Program Manager.

55

Questions?Questions?For more information, please contact

Jim Harvey, Program ManagerSchool-Based Health Care Services for Children in Special

EducationCommunity Services/Health Care ServicesHealth Care Authority Direct: 360-725-1153Fax: 360-725-1152

Matt Ashton, Provider Relations ConsultantProvider RelationsHealth Care AuthorityDirect: 360-725-1614

56