Welcome to Arkansas Medicaid Education and support for therapy providers.

Welcome to Welcome to Arkansas Arkansas MedicaidMedicaid

Education and support Education and support for therapy providersfor therapy providers

AgendaAgenda

• Introductions

• Facilities

• Medicaid organization and requirements

• Program overview

• Claims submission and billing tips

• Medicaid tools and support

• Discussion

• Division of Medical Services (DMS)

• County offices

• EDS

• AFMC

• ConnectCare

Who does what?Who does what?Arkansas MedicaidArkansas Medicaid

DMS DMS Administrators of MedicaidAdministrators of Medicaid

• Medical Services – establishes policy for all programs.

• Provider Reimbursement – establishes reimbursement rates.

• TPL – validates Third-Party Liability information.

• Program Planning and Development – distributes policy.

DHS County Office DHS County Office County Case WorkersCounty Case Workers

• Work directly with recipients.

• Determine eligibility aid category and eligibility period.

• Assist with Primary Care Physician (PCP) assignments.

EDS EDS Fiscal AgentFiscal Agent

• Provider Enrollment

• Claims processing

• Remittance

• Provider Assistance

• Medicaid Management Information System (MMIS)

EDS EDS Provider EnrollmentProvider Enrollment

• On January 3rd, 2005, EDS assumed responsibility for enrolling providers in the Arkansas Medicaid program. The EDS Provider Enrollment team processes new provider applications and assigns provider numbers upon successful completion of the application process.

• The EDS Provider Enrollment team also assists existing providers needing to renew, update, or change their demographic or group affiliation information.

EDS EDS Provider EnrollmentProvider Enrollment

Monday through Friday (8 a.m. - 5p.m.)Toll-free in Arkansas: 800.457.4454Local or out of state: 501.376.2211Fax: 501.374.0746

Medicaid Provider Enrollment Unit

EDSPO Box 8105 Little Rock, 72203-8105

EDSEDSClaims processingClaims processing

• EDS received more that 26 million Arkansas Medicaid claims last year and processed more than 23 million of them electronically with the Electronic Data Interchange (EDI) processing system.

• EDS supports electronic transactions every day, all day (and night) through the Internet, Provider Electronic Solutions (PES) software, vendor systems, clearinghouses, and paper submissions.

Claim volumeClaim volume

0

5

10

15

20

25

30

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

EDSEDS

EDI claims Total claims

Number of

claims (millions

)

State Fiscal Year

EDSEDSClaim adjudicationClaim adjudication

• Adjudication is the process of approving or denying a submitted claim.

• Providers benefit greatly when their Medicaid claims are processed quickly.

• Last year, EDS again beat its goal of taking claims from receipt to adjudication in a mere four days.

Claim adjudicationClaim adjudication

0

0.5

1

1.5

2

2.5

3

3.5

4

Jul-0

3

Aug-03

Sep-0

3

Oct-0

3

Nov-03

Dec-0

3

Jan-0

4

Feb-0

4

Mar

-04

Apr-04

May

-04

Jun-

04

EDSEDS

Days

Month of State Fiscal Year 2004

EDS EDS EDI Support CenterEDI Support Center

Toll-free in Arkansas: 800.457.4454Local or out of state: 501.376.2211

The EDI Support Center is open weekdays 8 a.m. to 5 p.m. to assist providers with electronic claim submission issues, 997 batch responses, PES software delivery and setup support, software training, and data transmission failures.

EDS EDS RemittanceRemittance

• 42% of 2003 payments to Arkansas Medicaid providers were made using electronic funds transfer (EFT).

• 49% percent of all providers are paid using EFT.

EDS EDS Provider RelationsProvider Relations

• Provider manuals and tools

• Provider Assistance Center

• Help desk for software and vendors

• Workshops and presentations

• Individual provider training

AFMC AFMC Liaison, utilization, reviewsLiaison, utilization, reviews

• Acts as Medicaid policy liaison for providers and the state.

• Provides managed care, ARKids, and waiver quality assurance reviews.

• Provides utilization monitoring and quality reviews for PCPs.

• Reviews therapy claims.

AFMC AFMC Recipient complaintsRecipient complaints

AFMC hosts the Medicaid Recipient Hotline. If a recipient has a complaint about services, a provider, or other problems relating to the program, they can call Medicaid Recipient Hotline from 8am to 4:30pm M-F.

1.888.987.1200

ConnectCare ConnectCare Managed Care helplineManaged Care helpline

• Enrolls recipients with PCP.

• Educates recipients, county case workers, and providers about PCP requirements.

• 1.800.275.1131

Contractual Contractual requirements for requirements for

providersproviders

Provider manualProvider manualSection I essentialsSection I essentials

• Available program services

• Contacts

• Recipient eligibility

• Recipient responsibility

• Provider participation guidelines

• Administrative remedies and sanctions

• Managed care program requirements

• PCP requirements and participation

Provider manual Provider manual Section II essentialsSection II essentials

• Scope of program

• Prior authorization requirements

• Reimbursement

• Billing procedures

Provider manualProvider manualSection III essentialsSection III essentials

• General – ECS, timely filing, forms

• Remittance and status reports

• Adjustments

• Other sources of payment (third-party payers)

PCPs PCPs Primary responsibilitiesPrimary responsibilities• Providing health education.

• Assessing medical conditions and initiating and recommending treatment or therapy.

• Referring to specialty physicians, hospital care, and therapists.

• Locating needed medical services.

• Coordinating prescribed medical and rehabilitation services with other professionals.

• Monitoring the enrollees’ prescribed medical and rehabilitation services.

Recipient Recipient Primary responsibilitiesPrimary responsibilities

• Select a PCP (most recipients).

• Report changes in income or circumstances.

• Report TPL.

Medicaid program Medicaid program overviewoverview

Benefits Benefits OverviewOverview

• Physician services

• Inpatient hospital

• Outpatient hospital

• Lab/x-ray

• Prescription

• Therapy (OT/PT/Speech)

Arkansas Medicaid administers 42 programs. Here are just a few of the many benefits available to eligible recipients.

• Mental health

• Emergency room

• Long term care

• Hospice

• Dentistry (under 21)

• Medical equipment

Benefits Benefits RecipientsRecipients

• Recipients with Medicare coverage• Residents of an ICFMR • Residents of LTC facilities• Recipients on spend down aid categories• Retroactively eligible recipients

Arkansas Medicaid operates as a managed care program. Most recipients are required to have a PCP and most services require PCP referral.

Recipients that are not required to enroll with a PCP include:

Therapy servicesTherapy services

See OT, PT, Speech manual – 213.200

Benefit limitsBenefit limits

Recipients under age 21:

• Four evaluations per SFY

• Up to four 15-minute units per day

Aid CategoriesAid Categories

Aid CategoriesAid CategoriesOverviewOverview

All Medicaid recipients are assigned to an aid category with corresponding levels of coverage. These are listed in section one of the Arkansas Medicaid provider manuals.

See Section I manual – 124.000

Aid CategoriesAid CategoriesGeneral classificationsGeneral classifications

• FR - Full benefits

• MNLB – Medically needy, limited benefits

• AC - Additional cost sharing

• LB - Limited benefits

Aid CategoriesAid CategoriesLimited benefitsLimited benefits

These Medicaid recipients are limited to specific services according to their aid category.

Aid Category 01Aid Category 01ARKids First BARKids First B

• Recipients may have limited services.

• Recipients may have co-payment requirements.

Aid Category 03 Aid Category 03 Children’s Medical Services Children’s Medical Services (CMS)(CMS)• Services must be prior-authorized.

• This is a non-Medicaid category.

Aid Category 04Aid Category 04Developmental Disability Developmental Disability ServicesServices• This is a non-Medicaid category.• DDS non-Medicaid provider ID number

end with 86.

• DDS non-Medicaid recipient ID numbers begin with 8888.

• Only DDS non-Medicaid providers may bill for DDS non-Medicaid recipients.

Medically Needy ExceptionalMedically Needy Exceptional

• Nursing Facility

• Personal Care

Aid Category *6Aid Category *6

These recipients are eligible for the full range of Medicaid services except:

Aid Category *7Aid Category *7Spend downSpend down

• Recipients must pay toward medical expenses when income and resources exceed the Medicaid financial guidelines.

• Aid Category 07 BCC (Breast and Cervical Cancer) has full benefits.

Aid Category 08Aid Category 08Tuberculosis (TB)Tuberculosis (TB)

Recipient coverage includes drugs, physician services, outpatient services, rural health clinic encounters, Federally Qualified Health Center (FQHC), and clinic visits for TB related services only.

Aid Category *8 Aid Category *8 Qualified Medicare Qualified Medicare BeneficiaryBeneficiary• For QMB recipients, Medicaid pays Medicare

premiums, coinsurance, and deductible.

• If the service provided is not a Medicare-covered service, then Medicaid will not pay for the service under the QMB policy.

• 8S – ARSeniors has full benefits.

Aid Category 61Aid Category 61Pregnant Woman Infants and Pregnant Woman Infants and Children Poverty Level (PW-PL)Children Poverty Level (PW-PL)

• Contains both pregnant women and children. Providers must use the last three (3) digits of the Medicaid ID number to determine benefits. When the last three digits are:

– 100 series (101, 102, etc.) the recipient is eligible as an adult for pregnancy-related services only;

– 200 series (201, 202, etc.) the recipient is eligible as a child and receives a full range of Medicaid services.

• A pregnant teen may be eligible either as a child or as an adult. The last three digits of her ID number determine the services for which she is eligible.

• If the plan description is “PW unborn ch-noster/FP cov” then there is no sterilization or family planning benefit.

Aid Category 62Aid Category 62

This is a temporary aid category that pays ambulatory, prenatal care services only. Delivery and hospitalization is not covered in this category.

Pregnant Woman Presumptive Pregnant Woman Presumptive Eligibility (PW-PE)Eligibility (PW-PE)

Aid Category 69Aid Category 69Family Planning Waiver (FPW)Family Planning Waiver (FPW)

• Medicaid pays for family planning preventative services only, such as birth control, counseling, etc.

• A claim for a recipient in this category must contain both a family planning diagnosis code and a family planning procedure code.

Aid Categories 58, 78, Aid Categories 58, 78, 8888Specified Low Income Medicare Specified Low Income Medicare

Beneficiary (SLIMB, SMB)Beneficiary (SLIMB, SMB)

• Recipients are not eligible for any Medicaid services.

• Medicaid pays only their Medicare premium.

Verify eligibilityVerify eligibility

Verify eligibilityVerify eligibility270 Eligibility Request270 Eligibility RequestRecipient eligibility is date specific; it may begin or end on any day. It is the provider’s responsibility to check each recipient’s eligibility on the date of service to ensure payment for claims.

Verify eligibilityVerify eligibility271 Request Response File271 Request Response File

RECEIVED DATE: 10/31/2003----------------------------------------------I N F O R M A T I O N S O U R C E

INFORMATION SOURCE: ARKANSAS MEDICAIDSOURCE PRIMARY ID: 123456789----------------------------------------------P R O V I D E R I N F O R M A T I O N

PROVIDER LAST NAME: DRLASTPROVIDER FIRST NAME: DRFIRSTPROVIDER NUMBER: 199999901----------------------------------------------R E C I P I E N T I N F O R M A T I O N

(continued next)

Who information is coming from

Pay-To provider name

Pay-To provider number


----------------------------------------------R E C I P I E N T I N F O R M A T I O N

ELIGIBILITYAUTHORIZATION #: 12345678901234

TRACE #: 999999999999999RECIPIENT LAST NAME: DUGGERRECIPIENT FIRST NAME: JEFFERYRECIPIENT ID: 1999999991RECIPIENT DOB: 01/01/2000-----------------------------------------------E L I G I B I L I T Y I N F O R M A T I O N

(continued next)

EDS authorization number

Trace number

Recipient name as it appears with AR Medicaid

Keyed ID number

DOB listed with Medicaid

271 Request Response File cont.271 Request Response File cont.


----------------------------------------------E L I G I B I L I T Y I N F O R M A T I O N

ELIGIBILITY/BENEFIT: 1 ACTIVE COVERAGEPLAN DESCRIPTION: 01ARKIDS 1STELIGIBILITY PERIOD: 01/01/2004-07/01/2004COUNTY: 731 WHITE

ELIGIBILITY/BENEFIT: R TPLINSURANCE TYPE: C1 COMMERCIALTPL MEMBER #: 999999999TPL POLICY #: 7777777TPL GROUP #: 666666PLAN NAME: ACME INSURANCEELIGIBILITY PERIOD: 01/01/2000 – 07/01/2004COVERAGE 1: FULL COVERAGELAST/ORG NAME: ACME INSURANCECOMPANY CODE: ABCADDRESS LINE 1: P.O. BOX 1000CITY: LITTLE ROCKSTATE: ARZIP: 72201

(continued next)

Shows coverage

TPL information

Aid category

Dates of eligibility

County of residence

Type of TPL

Member numberPolicy number

Group number

Plan name

Type of coverage

Dates of coverage

Name of insurer

Company code

Address

271 Request Response File cont.271 Request Response File cont.

Verify eligibilityVerify eligibility271 Request Response File 271 Request Response File cont.cont.

(continued previous)----------------------------------------------E L I G I B I L I T Y I N F O R M A T I O N

ELIGIBILITY/BENEFIT: L PRIMARY CARE PROVIDERDATE TIME PERIOD: 01/01/2004 – 07/01/2004LAST/ORG NAME: PCPLASTFIRST NAME: PCPFIRSTNAME SUFFIX: MDTELEPHONE: 5013746608

ELIGIBILITY/BENEFIT: D BENEFIT DESCRIPTIONSERVICE TYPE: AL VISION (OPTOMETRY)DATE TIME PERIOD: 03/20/1998

ELIGIBILITY/BENEFIT: D BENEFIT DESCRIPTIONSERVICE TYPE: AM FRAMESDATE TIME PERIOD: 03/20/1998

PCP information

PCP’s name and phone number returned if applicable

NOTE: Only benefits used will appear on eligibility in PES

PCP effective dates

Verify eligibilityVerify eligibilityNew in PES 2.04 and onlineNew in PES 2.04 and online• Up to four recipient eligibility segments with

matching recipient IDs• EPSDT screening information• Medicare A and B effective dates

Supplemental Batch ResponseSupplemental Batch Response

------------------------------------------SUPPLEMENTAL ELIGIBILITY BATCH RESPONSE

RECIPIENT ID: 1999999991PLAN CODE: 01PLAN DESCRIPTION 1: ARKIDS 1ST ELIGIBILITY BEGIN DATE: 1/01/2004ELIGIBILITY END DATE: 7/01/2004COUNTY CODE: 731COUNTY: WHITE

TPL SEGMENT COUNT 1

TPL COMPANY CODE D02TPL SUBSCRIBER NAME JEFF DUGGER

Recipient ID for this eligibility segment…up to 4 segments returned

Plan code and description

Dates of eligibility in this aid category

Number of TPL segments

TPL carrier code

Name of policy holder


Supplemental Batch ResponseSupplemental Batch Response

(CONTINUED)--------------------------------------

SCREENINGS

MEDICAL 2/01/2004HEARING 2/01/2004VISION 2/01/2004DENTAL 2/01/2004

BUYIN

PART A: 2/01/2004PART B: 2/01/2004

Last screening dates

Medicare effective dates


Submitting claimsSubmitting claims

Submitting claimsSubmitting claimsEDS softwareEDS software

Submitting claimsSubmitting claimsOnlineOnline

CENTRAL ARKANSAS DOCTORS OFFICE

1414141402

Verify claim statusVerify claim status277 Response file header277 Response file header

Who information is coming from

Pay-To provider name and number

Submitter info and submitter ID

Verify claim statusVerify claim status277 Accepted response 277 Accepted response detaildetail

DUGGERJEFFERY1999999991

JEFFERY DUGGER

0505101011111

Recipient information from the claim

Good News!

Assigned claim number (watch for this number on your next week’s remittance)

DUGGERJEFFERY1999999991

JEFFERY DUGGER

Verify claim statusVerify claim status277 Rejected response 277 Rejected response detaildetail

Recipient information from the claim

Rejection notification

No claim number assigned. View the rejected response report for a more detailed explanation

14141414021999999991DUGGER 0001

Verify claim statusVerify claim statusRejected response reportRejected response report

Rejected claim information

Total errors identified on claim

Error(s) location and description

Submitting Submitting claimsclaimsOther optionsOther options

• Third party software vendor

• Clearinghouse

• Paper

Billing tipsBilling tips

Billing tipsBilling tipsCodes for speech therapy Codes for speech therapy

Procedure Code/Modifi

er

Available units

Description POS

92506 4 Evaluation for speech therapy

11, 12, 52, 56, 99

92507 4 Individual speech therapy

11, 12, 52, 56, 99

92508 4 Group speech therapy 11, 12, 52, 56, 99

92507 (52) 4 Individual speech therapy by an assistant

11, 12, 52, 56, 99

92508 (52) 4 Group speech therapy by an assistant

11, 12, 52, 56, 99

Billing tipsBilling tipsCodes for speech therapy Codes for speech therapy


er

Available units

Description POS

92607 4 Initial evaluation for an augmentative/communication device

11, 12, 52, 56, 99

92608 2 Additional evaluation time

11, 12, 52, 56, 99

Billing tipsBilling tipsCodes for occupational Codes for occupational therapy therapy Procedure

Code/Modifier

Available units

Description POS

97003 4 Evaluation for occupational therapy

11, 12, 52, 56, 99

97530 4 Individual occupational therapy

11, 12, 52, 56, 99

97150 (U2) 4 Group occupational therapy

11, 12, 52, 56, 99

91530 (52) 4 Individual occupational therapy by an assistant

11, 12, 52, 56, 99

97150 (52)(U1)

4 Group occupational therapy by an assistant

11, 12, 52, 56, 99

Billing tipsBilling tipsCodes for physical therapy Codes for physical therapy


er

Available units

Description POS

97001 4 Evaluation for physical therapy

11, 12, 52, 56, 99

97110 4 Individual physical therapy

11, 12, 52, 56, 99

97150 4 Group physical therapy 11, 12, 52, 56, 99

97110 (52) 4 Individual physical therapy by an assistant

11, 12, 52, 56, 99

97150 (52) 4 Group physical therapy by an assistant

11, 12, 52, 56, 99

Billing tipsBilling tipsTherapy service codes Therapy service codes

AUse therapy service code “A” for individuals from birth through 2 years receiving services under an Individualized Family Services Plan (IFSP) through the Division of Developmental Disability Services.

BUse therapy service code “B” for individuals from birth through 5 years receiving services under an Individualized Plan through the Division of Developmental Disability Services.


C Use therapy service code “C” for individuals from 3 through 5 years receiving services under an Individualized Education Plan (IEP) through an education service cooperative.

D Use therapy service code “D” for individuals from 5 through 20 years receiving services under an IEP through a school district.


E Use therapy service code “E” for individuals 18 years and older receiving services through the Division of Developmental Disabilities Services.

F Use therapy service code “F” for individuals 18 years and older receiving services through individual or group providers not included in any of the previous categories (A-E).

G Use therapy service code “G” for individuals from birth to 17 years receiving therapy/pathology services through individual or group providers not included in any of the previous categories (A-F).

Most common billing Most common billing errorserrors

Top denialsTop denialsCommon errorsCommon errors

EOB 041 and 152 Procedure code, revenue code, TOS/ modifier is invalid.

Method of correctionVerify the procedure code, TOS, and/or modifier in section II of the corresponding provider manual and resubmit the claim.


EOB 254 or 267 Recipient is totally or partially ineligible for dates of service.

Method of correctionVerify the recipient is eligible for all claim dates of service. Resubmit the claim/portion of the claim for the time of eligibility.


EOB 952 Service requires Primary Care Physician referral.

Method of correction

Resubmit the claim with the corrected PCP information required for adjudication.


EOB 469, 470 Duplicate billing. Claim is identical to another claim for DOS, performing provider, procedure, TOS, and price.


Verify that the service is not a duplicate bill. Resubmit the corrected claim.


EOB 103Claim does not meet the timely filing requirements for Medicaid.

Method of correctionClaims must be received by EDS within 365 days from the “To” DOS. Claims received beyond this deadline will not be paid.


EOB 199ARKids 1st B recipient is older than 18 years old.


ARKids 1st B recipient’s eligibility ends on their 19th birthday. The “from” DOS can not exceed the 19th birthday.

Billing tipsBilling tipsWhen is a rejection a denial?When is a rejection a denial?• Many claim rejections are billing errors. Correct

these claims and resubmit them for processing.

• Recipients are only responsible for payment when a service is denied with an explanation of recipient responsibility. See the Explanation of Benefits (EOB) on the last page of the remit.

Follow-upFollow-up

TipsTipsRemittance and Status Remittance and Status ReportReport

• Paid claims

• Pending claims

• Denied claims

Check your remittance and status report each week for:

PES submissionsPES submissionsBilling flowBilling flow

Successful report

RA

ICN

Paid Pending

Denied

Follow-up RA Do not

resubmit

Correct and resubmit

Rejected response report


Batch response

Accepted Rejected

Vendor/clearinghouse Vendor/clearinghouse submissionssubmissions

Billing flowBilling flow

Report

Clearinghouse

(to EDS)

Vendor(to EDS)

RejectedRejected



Response report

Paid Pending

Denied

Correct and

resubmit

RA

Follow-up RA Do not

resubmit

Accepted

ICN

Paper submissionsPaper submissionsMail claim

Scanning/ICNCompleted claim forms

only.

RA

Claim processed

Paid Process

Denied

Do not resubmit


Incomplete forms returned to provider.

ICN

Billing flowBilling flow

TipsTipsSix ways to check claim Six ways to check claim statusstatus• Verify claims on the remittance advice

• PES software

• Web site

• Voice response 800.805.1512

• Claim inquiry form

• Provider Assistance Center 800.457.4454 or 501.376.2211

TipsTipsClaims Payment CycleClaims Payment Cycle

• Electronic claims are paid on the next remittance advice.

• Paper claims that could have been sent electronically pay on a 30-day pay cycle.

Tools and supportTools and support

Provider Provider referencereferenceBenefits of e-mediaBenefits of e-media

• Easier distribution and maintenance

• More viewing options and free software

• More effective searching

• Print pages or sections as needed, as many as needed (including many forms)

• Save files to your computer

• Share files over a network

www.medicaid.state.ar.www.medicaid.state.ar.usus

Web siteWeb site

Provider Reference Provider Reference CDCDDemoDemo

ContactsContactsProvider Assistance Center Provider Assistance Center (PAC)(PAC)Your first point of contact for billing, claim status, eligibility, and all other questions is the Provider Assistance Center:Monday through Friday8 a.m. to 5 p.m.Toll-free in Arkansas: 800.457.4454Local or out of state: 501.376.2211

PAC:Billing, eligibility, claim status

ContactsContactsPAC phone menuPAC phone menu

800.457.4454501.376.2211

1EDI:Software, RAs

2Other

inquiries

0

Claims, Prior Authorization, billing assistance, eligibility, adjustments

EDI/RA issues, PES, DDE, balancing, denials

2Provider

Enrollment

31

ContactsContactsElectronic Data InterchangeElectronic Data Interchange

Toll-free in Arkansas: 800.457.4454Local or out of state: 501.376.2211

The EDS EDI Support Center is open weekdays 8:00am to 5:00pm to assist providers with electronic claim submission issues, 997 batch responses, PES software delivery and setup support, software training, and data transmission failures.

Provider RepsProvider Reps

Provider representatives handle billing and policy issues that have been escalated from the Provider Assistance Center. They are also available to visit your office by appointment. You may contact your representative by calling 501.374.6609 and entering their extension.

See the Arkansas Medicaid Web site for your county’s representative.

ContactsContacts

Thank youThank you

Discussion Discussion

Welcome to Arkansas Medicaid Education and support for therapy providers.

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Transcript of Welcome to Arkansas Medicaid Education and support for therapy providers.