MDwise CMS1500 Presentation P0075

1
(No Transcript)
2
Topics for Today

• Who is MDwise?
• MDwise network model
• MDwise delivery systems
• CMS 1500
• Out-of-Plan Claims
• Claims Filing Limits
• 7. Claims and Questions

• 8. MDwise Customer Service
• 9. Claims Dispute Resolution
• 10. Referrals Prior Authorization
• 11. Who to Call with Questions

3
Indiana Health Coverage Programs2007
4
Who is MDwise?

• Based on a network model
• Not for profit
• Provider sponsored
• Policy direction comes from community board and
  participating providers
• Created to focus on Medicaid and CHIP managed
  care only
• Mission to serve low income families

5
MDwise Provider Network Model

• MDwise contracts with risk-bearing entities (i.e.
  large safety net hospitals, health plans, etc.)
• Each entity develops its own integrated
  healthcare delivery system and maintains
  contracts with physicians, hospitals, other
  providers.
• Each entity follows common rules, participates in
  common programs developed for all MDwise systems.
• All care must be coordinated inside the members
  delivery system, where the provider has a
  contract.

6
What do MDwise delivery systems do?
Some functions are delegated by MDwise to be
handled at the local hospital delivery systems

• Medical Management overseen by Medical Director
  who is local to the same delivery system
• Claims Payment claims paid in-house by
  delivery system
• Network Development contracts with providers
  (PMPs, Specialists, Ancillary, DME, Home Health,
  Hospital)

7
MDwise Delivery Systems
8
CMS 1500MDwise vs. Fee-For-Service

• Generally, follow the same guidelines as IHCP
  Manual
• Form Field 14 Date of Current Illness
  Required if for payment of pregnancy-related
  services
• Form Field 23 Prior Auth Number - Required
• Form Field 25-Federal Tax ID Number - Required

9
Submitting Out-of-Plan Claims
Send MDwise Claims to P.O. Box
441423 Indianapolis, IN 46244-1423 OR Find
the Delivery System Claims Addresses at our web
site www.mdwise.org
10
Claims Filing Limits

• In-Network Providers have a filing limit that
  ranges from 90 to 180 days, depending on their
  contract with the Delivery System.
• Out-of-Network Providers have 365 days from the
  date of service to file a claim.

11
MDwise Customer Service

• MDwise Customer Service is available with a LIVE
  VOICE - 24 hours a day, 7 days a week
• Phone [phone]
• [phone] (Indianapolis area)
• Fax [phone]
• Website www.mdwise.org

12
Claims Dispute Resolution Process

• Informal Claims Resolution
• Call Delivery System to inquire about claim
• Delivery System must respond within 30 calendar
  days of inquiry
• Formal Claims Resolution Must be in writing
• Provider has 60 calendar days
• From receiving written denial
• After delivery system fails to make determination
• From delivery systems response to the informal
  inquiry
• MDwise has three tracks for formal claims dispute
  resolution
• Out-of-Network provider disputes
• In MDwise, in Delivery System disputes
• In MDwise, but Out-of-Delivery System disputes

13
Formal Claims Dispute Resolution Process

• Out-of-Network Appeals-
• Send written appeal to corporate office. Tell us
  the specific reason why you are appealing the
  denial.
• MDwise Claims Appeals
• P.O. Box 441423
• Indianapolis, IN 46244-1423
• Claims appeal presented to panel for review and
  determination. Provider can be present for the
  review, upon request.
• Written reply within 45 calendar days (failure to
  respond in 45 calendar days shall have the effect
  of overturning the denial)
• Provider has 60 calendar days from the date of
  the appeal decision to submit written request for
  binding arbitration, or, another binding
  resolution process agreeable to both provider and
  MDwise. Written reply within 5 days of
  determination. The non-prevailing party pays
  fees and expense of arbitration.

14
Formal Claims Dispute Resolution Process

• In MDwise, In-Delivery System Appeals
• Must be resolved at delivery system level
  whenever dispute involves a matter addressed
  under contract.
• In MDwise, but Out-of Delivery System Appeals
• First, send any claims appeal to the delivery
  system that is responsible for payment.
• Provider has 60 calendar days to appeal the
  decision in writing.
• Must be sent to MDwise corporate office.
• Review Committee will review and provide response
  within 30 days.
• If provider is not satisfied with decision (and
  dispute does not concern technical issue),
  provider has 60 calendar days to request review
  by Independent Review Organization (IRO).

15
Referrals Prior Authorization

• Referrals must come from PMP. (Sometimes not
  needed if in network.)
• Prior Authorization Call MDwise and ask for
  Medical Management. Out-of-delivery system PA is
  typically only given if services not available in
  network.
• If the request is for an out-of-delivery system
  provider, PA is always needed from the
  appropriate Medical Management Department.
• Call MDwise and ask for Medical Management staff
• 1-800-356-1204

16
Specialty Referrals

• PMP responsible for referring member to
  specialist
• For medical/surgical services that cannot be
  provided by PMP.
• PMP determines the level of services to be
  rendered by specialist.
• Authorization for specialty referrals is obtained
  by calling or faxing the request to medical
  management department.
• All subsequent treatments or referrals by
  specialists must be coordinated through members
  PMP dont assume they are authorized.

17
Specialty Referrals

• Services that require PA must be authorized prior
  to the services being rendered. Retroactive PA
  is only given in limited circumstances, on a
  case-by-case basis. When in doubt, call medical
  management.
• Referrals to out-of-network specialist providers
  may be approved for continuity of care (including
  auto-assigned pregnant members in their third
  trimester) and for specialties not available
  within the network.
• Questions regarding the specialty referral
  process or status of the request can be directed
  to the appropriate medical management department.

18
Newborn Referrals and PA

• The county DFC caseworker enters the babys RID
  number into the system. Claims cannot be
  submitted for baby until RID number is in system.
• MDwise is responsible for medically necessary
  services from out-of-network providers until
  eligibility can be verified in the IndianaAIM
  database. Claims cannot be submitted until the
  babys RID number is in the database.
• Once eligibility has been verified in IndianaAIM,
  prior authorization must be obtain in order for
  services from out-of-network providers to be
  covered.

19
Prior Authorization Process

• Process used to request authorization for
  medically necessary services
• Authorization or denial of services is handled by
  the Medical Management department in the delivery
  system where the members PMP belongs
• Call or fax the request to Medical Management
  department for a review if approved, an
  authorization number will be assigned and entered
  into the claim processing database
• All Out-of-Delivery System providers require
  authorization for services prior to being
  rendered
• Questions regarding PA process or the status of a
  PA request can be directed to the medical
  management department.

20
How do I know who to call for PA or other medical
management needs?

• MDwise web site (Provider page) www.mdwise.org
• Call MDwise Customer Service Department at
• [phone] or
• [phone] (Indianapolis)
• MDwise Quick Reference Sheet

21
Have questions or problems?

• Contracted Providers - Each delivery system has
• 1. Provider Relations Representative
• 2. Medical Director
• 3. Medical Management department
• 4. Claims department
• Non-Contracted Providers
• MDwise Customer Service Live voice 7 days a
  week, 24 hours a day
• Provider Relations Department at corporate office
  Dan Westlake, Sherri Miles, Karen Goss,
  Gretchen Atkins
• Member Services and Outreach Member Advocates
• MDwise website

22
P0075 (9/06)