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Western Highlands Network

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Western Highlands Network Claims & Reimbursement Training Seminar NPI Overview Claim Submission DDE 837 CMS-1500 Provider Registration Claim Adjudication WH EOB / 835 ... – PowerPoint PPT presentation

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Title: Western Highlands Network


1
Western Highlands Network
  • Claims Reimbursement Training Seminar

2
Training Agenda
  • NPI
  • Current Events
  • Deficit Reduction Act / False Claims Act
  • Claim Submissions
  • Remittance
  • Denial and Resolution
  • Technical Assistance
  • Information Resources

3
NPI
  • Overview
  • Claim Submission
  • DDE
  • 837
  • CMS-1500
  • Provider Registration
  • Claim Adjudication
  • WH EOB / 835

4
National Provider Identification (NPI)
  • The Health Insurance Portability and
    Accountability Act (HIPAA) of 1996 requires the
    adoption of a standard unique identifier for
    health care providers. The NPI Final Rule issued
    January 23, 2004 adopted the NPI as this
    standard.

5
What is NPI
  • The NPI is a 10-digit, intelligence free numeric
    identifier (10 digit number). Intelligence free
    means that the numbers do not carry information
    about health care providers, such as the state in
    which they practice or their provider type or
    specialization.
  • The NPI will replace health care provider
    identifiers in use today in HIPAA standard
    transactions. Those numbers include Medicare
    legacy IDs (UPIN, OSCAR, PIN, and National
    Supplier Clearinghouse or NSC).
  • The providers NPI will not change and will
    remain with the provider regardless of job or
    location changes.

6
Have an NPI does not
  • Ensure a provider is licensed or credentialed
  • Guarantee payment
  • Enroll a provider in a health plan
  • Turn a provider into a covered provider
  • Require a provider to conduct HIPAA transactions.

7
Why the NPI
  • Simpler electronic transmission of HIPAA standard
    transactions
  • Standard unique health identifiers for health
    care providers, health plans, and employers
  • More efficient coordination of benefits
    transactions

8
Who can apply for the NPI
  • All health care providers (e.g., physicians,
    suppliers, hospitals, and others) are eligible
    for NPIs. Health care providers are individuals
    or organizations that render health care.
  • All health care providers who are HIPAA-covered
    entities, whether they are individuals (such as
    physicians, nurses, dentists, chiropractors,
    physical therapists, or pharmacists) or
    organizations (such as hospitals, home health
    agencies, clinics, nursing homes, residential
    treatment centers, laboratories, ambulance
    companies, group practices, HMOs, suppliers of
    durable medical equipment, pharmacies, etc.) must
    obtain an NPI to identify themselves in HIPAA
    standard transactions.

9
Western Highlands Direct Data Entry
  • Optional NPI claims entry available April 20,
    2008 May 14, 2008
  • May 15, 2008, WH requires NPI claims entry.
    Claims entered after May 14, 2008 will deny
    without the appropriate NPI data.

10
ASC X12N 837 004010X098A1, Health Care Claim
Professional
  • Loop 2010AA Billing Provider
  • NM108 and NM109 Submit either NPI (typical
    provider) or tax ID number (atypical provider)
  • N403 Add 4-digit extension to zip code (do not
    submit dash) MUST match the appropriate
    location of the billing provider
  • REF01 Must submit either legacy provider number
    (if provider is atypical), SSN, or EIN

11
Attending Provider
  • Loop 2310B Attending Provider
  • NM108 and NM109 Submit either NPI (typical
    provider) or tax ID number (atypical provider)
  • REF is only required if the Attending Provider is
    atypical

12
Service Facility Location
  • Loop 2310D Service Facility Location
  • NM108 and NM109 Submit either NPI (typical
    provider) or tax ID number (atypical provider)
  • N403 Add 4-digit extension to zip code (do not
    submit dash) MUST match the appropriate
    location at which the service was provided
  • REF is only required if the Service Facility
    Location agency is atypical

13
837 Test/Approval
  • 837 w/NPI must be tested with WH prior to
    acceptance of claim submission
  • Notify Diane Overman, 225-2785 ext. 2173 or via
    e-mail diane_at_westernhighlands.org
  • Test for format, content, and HIPAA compliancy
  • Provide feedback to resolve discrepancies
  • Upon approval you may submit 837

14
CMS-1500 (Rendering)
  • Typical w/NPI
  • Block 24I, ID Qualifier ZZ
  • Block 24J (upper), Rendering Provider Taxonomy
  • Block 24J, (lower), Rendering Provider NPI
  • Atypical w/out NPI
  • Block 24I, ID Qualifier 1D
  • Block 24J, (upper), Rendering Provider WH
    Provider ID
  • Block 24J, (lower), Rendering Provider ltBlankgt

15
CMS-1500 (Billing Provider)
  • Typical
  • Block 33 Billing Provider Info Ph,
    Address, Zip4
  • Block 33a NPI
  • Block 33b ZZ and Taxonomy
  • Atypical
  • Block 33a WH Provider ID

16
CMS-1500 (Service Facility Location Information)
  • Typical
  • Block 32 Address to include zip4
  • Block 32a NPI
  • Block 32b ZZ and Taxonomy
  • Atypical
  • Block 32 Address to include zip4

17
Mapping Solution
  • Atypical claim submission validated against NPI
    registration
  • If an NPI is submitted WH will crosswalk the NPI
    to legacy according to registration.
  • Address zip4

18
NPI Registration
  • Submit a copy of the DMA NPI Registration
  • Or
  • Submit the WH NPI Registration
  • Both require a copy of NPPES certificate
  • WH Communication Bulletin 54, 2/19/2007

19
NPI EOB
  • 083      Missing or Invalid Attn Prov NPI
  • 084      Missing or Invalid Service Location
    NPI
  • 085      Missing or Invalid Zip 4
  • 086      Missing or Invalid Atypical PIN
  • 087      Missing or Invalid Taxonomy Number
  • 088      Invalid Combo Loc NPI Zip 4    

20
WH EOB / 835
  • WH EOB
  • Include both legacy and NPI attending
  • 835 HIPAA Compliant
  • Will not include legacy number

21
Current Events
  • Timely Filing Limit (TFL), WHN Communication
    Bulletin 67
  • Temporarily lifted through April resume May 1,
    2008, DOS July 1, 2007 - present
  • State funded claims finalized within 60 days from
    the date of service
  • June 2, 2008, 500 pm, end of fiscal year TFL
    (July 1, 2007 April 30, 2008)
  • Provisionally Licensed provider H-code
    reimbursement ends June 30, 2008

22
MOS Maintenance of Service
  • Maintenance of Service
  • Therapeutic Foster Care and Targeted Case
    Management
  • Maintenance of Service applies to requests for
    authorization where a denial or reduction of
    service has occurred for a concurrent request and
    a valid appeal notice has been received by DHHS
    or OAH/Office of Administrative Hearing.
  • Value options will be notified after the request
    for appeal has been received by the Hearing
    office. Value Options will enter the Maintenance
    of Service authorization within (5) five business
    days after the Hearing Office sends confirmation
    that an appeal has been requested.

23
MOSMaintenance of Service cont
  • The units that are authorized can be viewed in
    Provider Connect, located on ValueOptions
    website at www.valueoptions.com Providers can
    also contact ValueOptions EDI Helpdesk
    (888.247.9311) for instructions on how to use
    Provider Connect.
  • No letter or authorization notice will be sent to
    the LME for MOS.
  • MOS authorizations seen in Provider Connect will
    appear as a standard authorization. There is no
    distinction to indicate that it is a MOS
    authorization.
  • Submit Claims on the WH Claims Resolution Inquiry
    form with the CMS1500 and provider connect screen
    print of the authorization. Mail or fax to WHN
    828.258.1225.

24
Deficit Reduction ActFalse Claims Act
  • Law
  • Policy
  • What is a false claim?
  • Penalties
  • Your Role
  • Whistleblower Provision
  • How/Who to Report

25
Law
  • False Claims Act established under section 3729
    through 3733 of title 31, United States Code
  • Federal law that prohibits an individual or
    organization who receives money from the federal
    government from submitting a request for payment
    knowing that such request contains false
    information.

26
Policy
  • Available within the Western Highlands Network
    Standards of Conduct/Ethics policy available to
    providers through the WH website.
  • WHN Communication Bulletin 68

27
What is a False Claim
  • Submitting a claim for services that were not
  • Delivered
  • Documented
  • Different than what was delivered
  • Submitting a claims for services paid by a source
    other than the federal government, or paid for by
    the government under a different program (e.g.
    Medicaid instead of Medicare)

28
What is a False Claim (cont)
  • Submitting a claim for services that were not
    medically necessary
  • Submitting a claim for services which is coded as
    more complex than otherwise indicated in the
    patients record, in order to receive higher
    reimbursement

29
What is a False Claim (cont)
  • The person must knowingly submit a false or
    fraudulent claim.
  • This includes actual knowledge, deliberate
    ignorance, or reckless disregard.

30
Penalties
  • Civil penalties up to 10,000 fine per claim plus
    double or treble damages, (criminal) up to
    25,000 fine and/or 5 years in jail.

31
Role
  • Your duty to report fraud, waste, and abuse
  • Need not be certain the violation has occurred in
    order to report it.
  • WH encourages you to seek guidance on any
    question related to potential or actual
    violations of laws and regulations

32
Whistleblower Protections
  • The False Claims Act provides protection for
    employees who report suspected false claims
    against retaliation

33
How/Who to Report
  • Report in person, telephone, or writing
  • Who to report
  • Immediate Supervisor/Program Director
  • Compliance Officer
  • A toll-free anonymous and confidential method is
    through the National Hotline Services, Inc.,
    Confidential Compliance Hotline
  • 1-800-826-6762

34
Resources for verifying eligibility
  • Basic Medicaid Billing Guide located on DMAs
    website
  • http//www.ncdhhs.gov/dma/medbillcaguide.htm
  • 1-800-688-6696, menu option 1, for phone inquires
  • NC Medicaid Automatic Voice Response (AVR) System
  • 1-800-723-4337
  • 270/271
  • HIPAA Compliant Health Care Eligibility
    Benefit Inquiry and Response Electronic
    Transaction.
  • Value Added Networks (VANs)
  • Interactive eligibility verification that
    providers may contract with Medicaid for access
    to real time consumer eligibility.

    The transaction fee is eight cents
    per inquiry.

35
Retro-Medicaid Refunds
  • When a State funded consumer obtains
    retro-Medicaid
  • Submit a refund using the WH Claims Resolution
    Inquiry Form with the WH EOB indicating the
    refunded services
  • WH will apply refund to next payment, transaction
    presented on the WH EOB
  • WH will initiate a retro-Medicaid refund upon
    notice from DMA eligibility inquiry/verification
    and State funded recoupment

36
DDE
  • A WH web-based claims entry product
  • Complement the 837 and / or offer an electronic
    claims submission method alternative
  • Complete/submit a Care Coordination Information
    System (CCIS) - User ID Assignment Request form

37
DDE continued
  • Individual user ID/Password
  • IT requirements
  • Internet Explorer 6.0, 98 or newer
  • High-speed Internet
  • Generates a report of accepted claims
  • Immediate claim acceptance feedback
  • Direct Data Entry Users Manual

38
Exceptions to the Electronic Claim Submissions
  • Void Replace
  • COB Coordination of Benefits
  • CAP MR/DD Waiver Supplies
  • First Party Payment

39
Claims Resolution Inquiry Form
  • Appeals
  • Void
  • Void Replace
  • Time Limit Override
  • Third Party COB
  • Refunds
  • Other
  • File the Claims Resolution Inquiry form with a
    new CMS 1500, and a copy of the WH EOB - Invoice

40
Claims Resolution Inquiry
  • WESTERN HIGHLANDS NETWORK
  • CLAIMS RESOLUTION INQUIRY
  • MAIL TO
  • WESTERN HIGHLANDS NETWORK
  • 356 BILTMORE AVENUE
  • ASHEVILLE, NC 28801
  • Fax To (828)258-1225
  • Please Check _____ Appeals ______ Void
    Replace ______ Time Limit Override ______
    Third Party Override
  • _____ Refunds _____
    Other ____________________________________________
    _________________
  • Include relative Western Highlands EOB
    (Explanation of Benefits) and a CMS-1500
    (08/05)
  • Provider Name ___________________________________
    __________________________________________________
    ___
  • Consumers Name _______________________________
    _________ Western Highlands ID
    _________________________
  • Date of Services From _____/_____/_____ to
    _____/_____/_____ Check Number
    _____________________________
  • Procedure Code ________________________________
    __________________________________________________
    _____
  • Please Specify Reason for Inquiry Request

41
Reimbursement
  • WH provides an Explanation of Benefits Invoice
    and 835 Remittance Advice
  • EOB and 835s are sent to your agencies mailbox
  • Payments are mailed
  • State funded prompt payment
  • WHN is mandated to review claim / invoice
    submissions within (18) calendar business days
    after receipt and shall
  • A) Approve payment
  • B) Notify Provider within that time frame if
    claims/invoice are denied or if further
    information is necessary

42
Denial and Resolution
  • Duplicate Service
  • Authorization
  • Unit Limitations
  • Attending Provider Numbers
  • Service Level Numbers

43
WH Explanation of Benefits InvoiceCodes
  • EOB codes and description table is available at
    the WH Website and at the end of the WH EOB

44
WH EOB 064 - Duplicate Service
  • A previously submitted claims was paid, typically
    caused by either incorrect AR posting/flag
    setting or event summarization
  • AR Posting
  • Validate AR payment from previous EOBs
  • Summarize
  • Summarize claim prior to submission
  • To correct submit a Claim Inquiry form void and
    replace transaction

45
Authorizations
  • 063 - Incorrect Authorization (DDE)
  • Authorization presented doesnt support the
    consumer (consumer, provider, procedure code, and
    DOS)
  • UA Authorization for these services does not
    exist or incorrect authorization
  • OA Claim exceeds the units of service
    authorized
  • A valid authorization, but the authorized units
    of service have been applied to previous
    payments, balance is zero.
  • PP Partial Payment
  • A valid authorization, but the total units billed
    were reduced to the balance of remaining
    authorized units.

46
Unit Limitations
  • 080 - Less than minimum daily limits
  • Occurs when a service requires a daily minimum
    units of service and units billed were less than
    the minimum
  • 081 - More than maximum daily limits

47
Attending Provider
  • 033 - Missing Attending Provider ID
  • Claim was billed w/out an attending provider ID
  • 034 - Invalid Attending Provider ID
  • Adjudication system compares the billed ID to the
    registered ID and service
  • Proper attending must coincide with service
    delivery
  • Outpatient Behavioral Health services require the
    individual attending provider DMA enrollment
    number
  • Enhanced Benefits require the DMA Community
    Intervention number with the relative alpha
    suffix
  • Other services require the Western Highlands
    provider number specified in your contract
  • 036 - CPT code requires Medicaid ID

48
Attending Provider
  • Confirm proper number was billed with service.
    Common error is an Enhanced Benefit billed with
    an individual clinicians enrollment or a Western
    Highlands provider ID
  • Verify enrollment number from source
  • Verify number was registered with WH. If not,
    follow instructions in WHN Communication Bulletin
    12
  • Verify ID number billed matches the number
    registered

49
Service Level Number
  • 045 - EB Not Med Elig Inv Attd Number
  • 051 - Invalid or absent service level number
  • A service level number consists of the Community
    Intervention Number (Core Number) plus the alpha
    suffix that coincides with the enhanced benefit
    service
  • Core Number 83xxxxx
  • Service Level Number 83xxxxxA

50
Attending Provider Tips to remember
  • Enhanced Benefit Services, enter the DMA
    Community Intervention Number with the alpha
    suffix. Example 83xxxxx () Alpha Character
    representing the Enhanced Service.
  • Outpatient Behavioral Health (OBH) service, the
    DMA individual clinicians Medicaid enrollment
    number.
  • Neither an Enhanced Service nor OBH service,
    enter your agencys Western Highlands provider
    number. Example 36XXX

51
Technical Assistance
  • E-mail
  • billingquestions_at_westernhighlands.org
  • Phone
  • (828) 225-2785 ext. 2191
  • Western Highlands Website
  • http//www.westernhighlands.org/pr_reimbursement.h
    tm

52
Additional Information Sources
  • CMS
  • http//www.cms.hhs.gov/
  • NC Division of Medical Assistance
  • http//www.dhhs.state.nc.us/dma/NPI.htm
  • IPRS website
  • http//www.dhhs.state.nc.us/mhddsas/iprsmenu/index
    .htm
  • NPPES
  • https//nppes.cms.hhs.gov/NPPES/Welcome.do

53
Thank you!
  • Thank you for attending Western Highlands Claims
    Reimbursement Training Seminar
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