TR596MDwise UB92 Billing Presentation P0072 - PowerPoint PPT Presentation

1 / 22
About This Presentation
Title:

TR596MDwise UB92 Billing Presentation P0072

Description:

Delivery System must respond within 30 calendar days of inquiry ... Provider has 60 calendar days from the date of the appeal decision to submit ... – PowerPoint PPT presentation

Number of Views:35
Avg rating:3.0/5.0
Slides: 23
Provided by: MDw6
Category:

less

Transcript and Presenter's Notes

Title: TR596MDwise UB92 Billing Presentation P0072


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
UB92MDwise vs. Fee-For-Service
Generally, follow the same rules as
fee-for-service MDwise requires Federal Tax ID
in Form Field 5 Form Field 57 Due From
Patient not applicable to MDwise
patients Form Field 63a-63c Treatment
Authorization Codes Required by MDwise
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 1-800-356-1204
  • (317) 630-2831 (Indianapolis area)
  • Fax (317) 630-2835
  • 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
  • (800) 356-1204 or
  • (317) 630-2831 (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
P0072 (9/06)
Write a Comment
User Comments (0)
About PowerShow.com