TR590Managed Health Services MHS UB92 Billing Presentation

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Managed Health Services
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Managed Health Services
Who Are We

• MHS Indiana
• Centene Corporation
• Betty Brinn Foundation
• Centene Foundation for Healthcare Quality

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Managed Health Services
Our Guiding Principles

• Physician Directed
• Nurse Mediated
• Member Empowered

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Managed Health Services
Mishawaka
Indiana Office Locations

Merrillville
Fort Wayne
Muncie
Indianapolis
Indiana counties with MHS membership
MHS Indiana office locations
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Managed Health Services
Member Empowerment

• Nursewise
• 24/7 toll free nurse advice line
• Bi-lingual staff
• Member Services
• CONNECTIONS Program
• Transportation
• Statewide vendor reached through toll-free number
• Health Education in the Community
• Participation in local health fairs

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Managed Health Services
Coordinated Care Nurse Mediated

• Preventive Care
• Disease / Care Management
• OB Programs
• Immunization Initiatives
• Asthma/Diabetes Initiative
• Focused Utilization Management
• Team Concept (Physician, Nurse,
  Social Worker, Coordinator)
• Work in Partnership with Doctors

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Managed Health Services
Provider Empowerment

• Physician Committees
• Compensation
• Pharmacy and Therapeutics
• Quality Management
• Provider Driven Programs
• Pharmacy Gold Card Program
• Member Restricted Card Program
• Practicing Physicians in Key MHS Roles
• Access to Key MHS Leadership

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Managed Health Services
Whats New for 2007

• Behavioral Health Carve-In
• Members Pick-A-Plan
• Pay For Performance
• Member Initiatives
• E Health
• Enhanced Web Portal

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Managed Health Services
UB92 Billing

• CLAIMS

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Provider Inquiry Services

• Call us at 1-800-414-9475 we are ready to help
  you
• Knowledgeable, friendly staff available 800-500
• Focused commitment to professional service
• Filing limits dependant upon contract status
• Claims address P.O. Box 3002 Farmington, MO
  63640
• Dispute appeal processes (60 days from EOP)
• Appeal address P.O. Box 3000 Farmington, MO
  63640
• Follow IHCP requirements

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Claims Submission

• May be submitted electronically (preferred) or on
  UB92
• Providers should check electronic submission
  report daily to ensure claims were received by
  MHS
• Providers may use Clear Claim Connection to check
  the status of claims at www.managedhealthservices.
  com
• Filing timelines
• 120 days from DOS for Participating Providers
• Exceptions Newborn, Third Party Liability, and
  Eligibility delays
• (filing limit 365 days)
• 365 days from DOS for Non Participating Providers

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Resubmitted Claims

• If you need to resubmit a denied claim, the
  claim must be submitted on paper and should be
  clearly marked at the top with the word
  RESUBMISSION
• Attach a Claim Adjustment Form stating the reason
  for resubmission and include the EOP (if
  applicable)
• Resubmitted claims must be received within 60
  days of the EOP date

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Adjusted Claims

• If you need to make an adjustment to a paid
  claim, you can do so by calling Provider Inquiry
  or you may submit on paper with the adjustment
  request form.
• Attach a Provider Adjustment Form along with
  documentation, including EOP (if available)
  explaining reason for resubmission
• Claim adjustments must be submitted within 60
  days of the date of the MHS EOP

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Third Party Liability

• If a member has TPL on file but no longer has
  other coverage or the member has other coverage
  but the information is not on file take the
  following steps
• Contact Provider Inquiries with the TPL
  information so that changes can be made to the
  TPL file
• Send an update notification to EDS via the
  WebInterchange

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Third Party Liability

• Claims will deny L6 if TPL is on file with MHS
• What if I dont agree with MHS TPL indication
• Call provider inquiries
• Resubmit claim with EOB attached
• Reminder TPL claims must be submitted within 60
  days of the date of the primary insurers EOB

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Third Party Liability

• MHS updates member TPL information through
• A monthly file from EDS
• Phone call from providers
• Receipt of an EOB with claim
• MHS always verifies new TPL

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UB92 Billing

• Common Denial Codes
• Other/Third Party Liability (L6)
• Timely filing (29)
• No authorization (A1)
• Authorization and provider/provider location not
  matching (HS, HT, HL)
• Diagnosis code missing digit (4D, 3D)
• Duplicate (18)

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EMERGENCY ROOM PAYMENT

• The Emergency Department claims will be
  categorized by the primary ICD-9 diagnosis code.
• Diagnosis categorized as emergency
• Contracted facilities negotiated rate
• Non-contracted facilities may be paid in
  accordance with state established rates.
• Diagnosis categorized as a not an obvious
  emergency
• Contracted facilities negotiated rate
• Non-contracted facilities, if the code is
  categorized as not an obvious emergency, an EOP
  goes to the facility to request the ED records.
  These records must sent within 45 days from the
  EOP date.

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Claims Dispute Resolution

• Request for adjustments and claim inquiries
• Informal claim objection and dispute resolution
• Written
• Within 60 days of EOP
• Formal dispute resolution
• Written
• Follows informal process

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Referrals and Prior Authorization
Referrals and Prior Authorization
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Referrals and Prior Authorization

• What is the difference between a referral and
  prior authorization?
• A referral is a request (verbal, written or
  telephonic communication) from the PMP made to
  MHS or directly to a MHS contracted specialist
  for specialty care services.
• Prior authorization is an approval from MHS to
  provide inpatient or outpatient services.
  (Includes an authorization number)
• Both are handled at MHS Medical Management
  Department by trained nurses

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Referrals to Non Participating Providers

• Referrals to Non-Participating Specialists
  Require Prior Authorization (PA) from MHS
• Must be placed at least 2 business days in
  advance of date of service
• PA numbers are provided at time of call-Start
  with A or R
• PMP to PMP referrals are not authorized except
  for the following circumstances
• Members who are pregnant (high risk 3rd
  trimester)
• Continuity of care
• Inappropriate assignment
• Geographical hardship

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PA for Labs and X-Rays

• Labs and X-Rays do not require PA (or referral)
  when performed at a contracted facility
• Labs and X-Rays preformed at a non-contracted
  facility do not need prior authorizations when
  performed as stand alone services.

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Self Referral Services

• Podiatrist
• Chiropractic
• Family Planning
• Routine Vision Care
• Routine Dental Care
• Mental health by Type and Specialty
• HIV/AIDS Case Management
• Diabetes Self Management
• Individualized Education Plan (IEP) for Schools

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Prior Authorization

• Services that require a prior authorization
  regardless of contract status
• Inpatient Admissions (including Acute Rehab,
  Acute Mental Health, Skilled
• Nursing Facilities, etc.)
• Transplant Evaluation and Procedures
• Sleep Studies
• Pain Management (professional and facility
  services)
• Therapies (PT, OT, ST, Cardiac Rehab,
• Pulmonary Rehab) Excluding Initial Evaluations
• DME gt500.00

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Prior Authorization (cont)

• Home Health Care
• Orthotics/Prosthetics gt250.00
• Urgent Care (depending on billing practice)
• Specialty Referrals to Infertility, Oral
  Surgeon, Plastic and Reconstructive Surgeon, Out
  of Network Specialists
• Injectable medications over 100.00 (excluding
  Oncology drugs)
• Human Growth Hormone
• Transportation Contact LCP at 1-800-508-7230

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Prior Authorizations

• The PMP or Specialist must initiate
  prior-authorization of
• elective/routine procedures at least two (2)
  business days
• prior to the requested date of service
• If required PA is not obtained claim payment will
  be denied
• Medical Management Department
• 1-800-464-0991
• Fax [phone]

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Surgical Prior Authorizations

• The following outpatient procedures require
  prior authorization, even if performed at a MHS
  contracted location
• Abortions Reduction Mammoplasty
• Blepharoplasty Otoplasty
• Cochlear Implant Varicose Vein Treatment
• Dental Surgery Scar Revision
• Gastric Bypass Surgery Rhinoplasty/Septoplasty
• Vagus Nerve Stimulator
• Sterilization (Hysterectomy, Tubal Ligation, and
  Vasectomy)
• ALL OTHER OUTPATIENT SURGERIES PERFORMED
• AT CONTRACTED FACILITIES DO NOT REQUIRE A PA.

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UB92 Billing

• Voluntary Sterilization/Tubal Ligation/Vasectomy/H
  ysterectomy
• Member consults with PMP
• Indiana State Form 46314/10-93 is signed at least
  30 days but no more than 6 months prior to
  procedure, or
• acknowledgement of receipt of hysterectomy
  information provided to MHS either before or
  after the procedure, but before the claim is
  submitted
• AND
• Form is submitted to MHS after procedure is
  completed and forms are signed and dated by both
  parties. The form should be provided to MHS
  before the claim is submitted to MHS.
• Fax to Medical Management [phone]

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Hospital Stays

• Hospital stays under 24 hours are not billable as
  inpatient and must be submitted as outpatient
  services
• Med Management will not approve inpatient less
  than 24 hours

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Newborns

• No prior authorization or referral is required
  for members who are less than 30 days old
• Except for NICU Admissions and if baby is not
  discharged with mom.
• MHS MUST be notified by calling Medical
  Management at [phone]
• The newborns RID number is required for payment

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Transfers

• MHS requires notification and approval for all
  non-emergent
• transfers, at a minimum, within 1 (one)
  business day prior to the transfer.
• MHS requires notification within 2 (two) business
  days following
• all emergent transfers.
• Transfers are inclusive of, but not limited to,
  the following
• Facility to facility (including newborns
  transferred to another hospital)
• Level of care changes (including newborns in
  special care nursery or NICU)

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Nursery

• Nursery level does not include services that
• Would normally be considered special care nursery
  level of care
• Would not normally be rendered in a normal
  newborn nursery setting
• Would normally be rendered in a NICU level of
  care
• Special Care Nursery and NICU level of care
  services require MHS authorization within 2
  business days of the start of the service.
• Call Medical Management at 1-800-464-0991

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Medical Necessity Appeals

• Medical Necessity Grievances (Level I)
• Medical Necessity Appeal (Level II)
• Expedited Medical Necessity Appeals

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Questions and Answers