Association Management Plus

NEW!! – Association Management Plus, LLC., will be closing it’s doors on July 31, 2011.

Association Management Plus, LLC., will be closing it’s doors July 31, 2011. Ms. Williams and Ms. Hoffmeyer have made the decision to close the business and pursue other opportunities. Ms. Hoffmeyer has accepted a position with Correct Coding Solutions, LLC., the CMS contractor responsible for the National Correct Coding Initiative (NCCI). Ms. Williams has accepted a position with the Coryden Group and will continue lobbying for the Indiana Academy of Ophthalmology (IAO) and serving as the Executive Director for the IAO and the Kentucky Academy of Eye Physicians & Surgeons (KAEPS). IAO and KAEPS members will see no change in the member benefits and services provided.

Therefore, effective July 29, 2011, Ms. Hoffmeyer will no longer be providing Medicaid consulting services or Medicaid seminars. We deeply appreciate the support you have provided us through your attendance at seminars, on-site requests, and telephone support services. If a viable referral resource for Medicaid services is identified, clients will be notifed and this page updated.

I have deeply enjoyed working with you all over the years and appreciate the confidence you have placed in me to assist you with your Medicaid compliance needs. I will miss you all!!  Maureen

Effective immediately, the list of covered diagnosis codes for Package B (pregnancy-only) members has been updated to include the V25 series of ICD-9 codes describing family planning services. Family planning services are covered for Package B members. Effective with this update, providers are no longer required to utilize a pregnancy or pregnancy-related diagnosis code on the claim for family planning services rendered to Package B members. This update applies to all members covered by Traditional Medicaid as well as any managed care entity (Anthem, MDwise, or MHS).

Refer to Indiana Health Coverage Programs Provider Banner Page BR201117 dated April 26, 2011 for the official reference. Note: The Banner written by Medicaid did omit the family planning codes created in 2011 (V25.11, V25.12, and V25.13). However, HP has confirmed they are on the list and available for use.

The following pdf file is a listing of Medicaid bills we are tracking. A weekly status update of these bills is provided in the Excel spreadsheets.

For more information about the 2011 Indiana General Assembly or these bills visit http://www.in.gov and click on “Legislative” in the lower right portion of the screen.

2011 Medicaid Bill Tracking – Bill Descriptions

• Bill Tracking Update – 5/01/2011
• Bill Tracking Update – 4/18/2011
• Bill Tracking Update – 4/1/2011
• Bill Tracking Update – 3/27/2011
• Bill Tracking Update – 3/18/2011
• Bill Tracking Update – 3/11/2011
• Bill Tracking Update – 3/4/2011
• Bill Tracking Update – 2/25/2011
• Bill Tracking Update – 2/20/2011
• Bill Tracking Update – 2/13/2011
• Bill Tracking Update – 2/6/2011
• Bill Tracking Update – 1/30/2011
• Bill Tracking Update - 1/21/2011

The purpose of this article is to clarify the correct reporting of vaccine services for Indiana Medicaid members.

The January 2011, Volume 3, Issue 1.1, of the VacZine newsletter issued by the Indiana State Department of Health contained an article regarding the new vaccine administration codes created by CPT for 2011. The article encouraged providers to begin using codes 90460-90461 to report vaccine administration for VFC services. This information is incorrect. There is no change in the manner or billing process for reporting VFC or any other vaccine or injection service for the Indiana Medicaid Program. The following information provides a detailed description of the current policy for billing vaccines.  [Read More]

The Indiana Medicaid Program is undergoing a number of changes both now and in the coming months. One of the most significant is related to the reprocurement/recontracting between the State and the Medicaid Managed Care Organizations (MCOs), now referred to as Medicaid Managed Care Entities (MCEs), for the Hoosier Healthwise Risk Based Managed Care and Healthy Indiana Plan (HIP) populations.  Because of the number of plans and some of the outsourcing of services, it can become very confusing to indentify these plans and understand the requirements. The Medicaid Eligibility Verification System (EVS) will identify whether the member is Hoosier Healthwise Risk Based Managed Care or HIP and will provide information about the member’s plan of enrollment. It is absolutely imperative to verify eligibility at the time of each service to ensure that the claim is billed to the correct plan and that all plan requirements have been met before you render care, i.e., prior authorization.

The short explanation is: 

• The new contract cycle only affects the Hoosier Healthwise Risk Based Managed Care and Healthy Indiana populations. It does NOT affect Traditional Medicaid members such as those eligible for Medicare and Medicaid, those with Spenddown or Care Select enrollees. Regardless of what you decide related to managed care contracting, you will continue to be able to see these members as you always have (provided you are enrolled as an Indiana Medicaid Provider).
• For any Hoosier Healthwise (HHW) MCE with which you do not contract, you will be able to continue to see their Hoosier Healthwise Risk Based Managed Care members if you receive PRIOR authorization from the plan.
• For any Healthy Indiana Plan (HIP) MCE with which you do not contract, you will NOT be able to continue to see their HIP members. HIP does not contain an out-of-network benefit. Plans may authorize out-of-network care if no participating provider is available within a 60 mile radius. These situations will be assessed on a case-by-case basis if the MCE is contacted BEFORE you see the member.

The longer explanation is:

There are basically three MCEs serving Medicaid for 2011, Anthem, MDwise, and MHS. Some of the plans utilize a subcontractor(s) for processing certain claims (vision, family planning, behavioral health). MDwise is a unique system in that it is a delivery system based plan. At present there are nine different delivery systems, soon to be ten. Each delivery system operates independently. Some of the delivery systems do not process claims for family planning services based on religious objections.

Anthem Hoosier Healthwise Risk Based Managed Care – Effective April 1, 2011, in-network specialty providers must have a referral from the PMP. The referral will be communicated to the Plan by indicating the PMP as the “referring provider” in the appropriate fields of the claim form. All out-of-network providers must receive authorization from the plan BEFORE seeing the patient or the service(s) will be denied as non-covered. Members may not be billed for non-covered services, including out-of-network services, unless they are notified in advance that the service is not covered and why.

Anthem HIP – Effective January 1, 2011, Anthem HIP members will be linked to a PMP. Effective April 1, 2011, in-network specialty providers must have a referral from the PMP. The referral will be communicated to the Plan by indicating the PMP as the “referring provider” in the appropriate fields of the claim form. Out-of-network services are not covered by HIP. Anthem may authorize out-of-network services if no in-network provider is available within a 60 mile radius. These authorizations will be handled on a limited case-by-case basis when the Plan is contacted BEFORE the patient is seen. Members may not be billed for non-covered services, including out-of-network services, unless they are notified in advance that the service is not covered and why.

MDwise Hoosier Healthwise Risk Based Managed Care – MDwise operates several MDwise delivery systems including Hoosier Alliance. Each delivery system is independently responsible for processing claims for its members. The catholic-based delivery systems do not processing claims for family planning services due to religious objections. While the services are covered, claims are sent to a separate payer.  All out-of-network providers must receive authorization from the plan BEFORE seeing the patient or the service(s) will be denied as non-covered. Members may not be billed for non-covered services, including out-of-network services, unless they are notified in advance that the service is not covered and why.

MDwise HIP – MDwise HIP members will continued to be linked to a PMP, as is the current requirement. Out-of-network services are not covered by HIP. MDwise may authorize out-of-network services if no in-network provider is available within a 60 mile radius. These authorizations will be handled on a limited case-by-case basis when the Plan is contacted BEFORE the patient is seen. Members may not be billed for non-covered services, including out-of-network services, unless they are notified in advance that the service is not covered and why.

MHS Hoosier Healthwise Risk Based Managed Care – There are no significant changes to the processes for PMPs and in-network specialty providers. All out-of-network providers must receive authorization from the plan BEFORE seeing the patient or the service(s) will be denied as non-covered. Members may not be billed for non-covered services, including out-of-network services, unless they are notified in advance that the service is not covered and why.

MHS HIP – 2011 is the first year that MHS will offer a HIP product. MHS HIP members will be linked to a PMP. Out-of-network services are not covered by HIP. MHS may authorize out-of-network services if no in-network provider is available within a 60 mile radius. These authorizations will be handled on a limited case-by-case basis when the Plan is contacted BEFORE the patient is seen. Members may not be billed for non-covered services, including out-of-network services, unless they are notified in advance that the service is not covered and why.

Hoosier Healthwise Risk Based Managed Care Contract – If you are currently contracted with any of the Medicaid Managed Care Entities (MCEs), those contracts will expire on December 31, 2010 as that is the end of the contract cycle between the MCEs and the State of Indiana. Earlier this year, a contract reprocurement initiative was conducted and the State selected the same three vendors, Anthem, MDwise, and MHS, to recontract with the State to serve the Hoosier Healthwise Risk Based population (pregnant women, families, and children). As part of this recontracting, the State bundled the Healthy Indiana Plan (HIP) into the contracts with these entities. As a result, all three Managed Care Entities (MCEs) will be providing coverage for both the Hoosier Healthwise and Healthy Indiana Plan enrollees. You may have been contacted by contracting departments for Anthem, MDwise, and/or MHS to enter into contracts for the 2011 contract cycle.

• Due to the State initiative to combine the Hoosier Healthwise MCE contracts with the HIP MCE contracts, each of the MCEs will be able to determine whether they will require providers to contract to serve both populations or if they may chose to contract for only one or the other. If presented with a contract, be sure you READ CAREFULLY to determine if you are contracting for Hoosier Healthwise, HIP, or both.
• As part of the recontracting with the State, each of the MCEs has been required to utilize a standard 90-day filing limit for claim submission. This limitation will be applied to claims submitted by contracted “in-network” providers. Out-of-network providers will continue to have a 365-day filing limit for claims. However, remember that the filing limit, whether 90 or 365 days applies to the INITIAL submission of the claim only. Once the claim has been filed and adjudicated, if the provider disagrees with the payment determination (denied or paid less than anticipated) ALL providers (in- and out-of-network) must file a corrected claim, file an adjustment, or submit a Level 1 appeal (Dispute) within 60 days of the date on the original EOB. A phone call to the plan’s Customer Service Department to inquire about a claim, even if they tell you they will resubmit the claim, does not “hold” or “restart” your filing limit. Failure to take one of these actions within 60 days will result in non-payment for failure to meet the filing limit. As a result, MCE claims should always be first on your list of follow-up claims.  Filing and re-filing limit exceptions will be made in situations in which the member has other insurance resources, newborn members in which the assignment of the RID number delayed the claim, or other special circumstances evaluated on a case-by-case basis.
• Effective January 1, 2011, with the new contract cycle, all HIP members will be required to have a Primary Medical Provider (PMP).  Previously, MDwise was the only HIP plan that required a PMP assignment. Moving forward, any HIP eligible member will need to select a Plan and PMP. The Hoosier Healthwise and HIP applications are being revised to include an area for Plan selection, to encourage enrollees to select their Plan at the time of enrollment. If the member has not selected a Plan by the 14th day of their eligibility, they will be auto-assigned to a Plan. Whether self-selected or auto-assigned, the Plan will contact the member to assist them in selecting a PMP. If no PMP is actively selected, the Plan will auto-assign the member.
• Each MCE has been given discretion to set PMP panel sizes. As a result, the minimum and maximum panel sizes will vary from Plan to Plan and will be outlined during the PMP contracting phase. All PMP auto-assignments, PMP changes, panel holds, full-panel adds, and PMP disenrollments will be handled directly by the PMP, not MAXIMUS, as has been the case in the past.
• Remember: The HIP legislation specifically excluded from coverage out-of-network provider services. Coverage for out-of-network providers is only available on a very limited basis (no in-network provider in a 60 mile radius) with PRIOR approval and authorization from the member’s HIP plan. If you render care without contacting the Plan they will provide a retroactive authorization and you will have no choice but to write off the charge. You will not be permitted to bill the member.
• HEDIS Bonuses: Several plans have HEDIS incentive money available for various performance measures. Anthem’s 2010 HEDIS materials state that the provider “must be an active participating Anthem provider, servicing Hoosier Healthwise members, on the scheduled 2011 payout date to be eligible for the additional compensation.” You should carefully review HEDIS bonus incentive documents from each plan to determine if you will receive the HEDIS payouts if you decide not to contract for the 2011 cycle.
• When verifying eligibility be sure to determine:
  • if the patient is or is not eligible on the date of service;
  • in which benefit plan the member is enrolled to assess if your service is covered (Package B, Package E, Package P have limited benefits);
  • if the member is enrolled in Medicaid Fee-For-Service, Hoosier Healthwise Risk Based Managed Care, Healthy Indiana Plan, or Indiana Care Select; and
  • if enrolled in Hoosier Healthwise Risk Based Managed Care or Healthy Indiana, in which plan is the member enrolled (who pays the claim).

Association Management Plus, LLC (AMPlus) recently met with Anthony Pelezo, M.D., Medicaid Medical Director, and discussed the upcoming implementation of the NCCI for Medicaid claims. Additionally, AMPlus participated in the NCCI virtual seminar conducted by HP on October 8, 2010. Some important information and clarifications regarding the implementation were obtained and are listed below.

• The application of NCCI edits will be handled by an external vendor, McKesson. After claims are received by HP the claim data will be transmitted by HP to McKesson. McKesson will then run the claims through NCCI files and apply any bundling edits to the claim based on the Column I/Column II, Mutually Exclusive, and/or Medically Unlikely Edits (MUEs). If applicable, McKesson will apply edit overrides, based on the presence of modifiers. The claim data will then be transmitted back to HP to finish the adjudication cycle. This process will not affect the time-frames in which claims are processed, other edits applied by HP related to Medical Policy and coverage, or the information provided on the Remittance Advice notifying a provider of all errors on a particular claim. 
• The NCCI Medicaid edits were scheduled to be implemented on October 28, 2010. This date has been delayed. The new implementation date has not yet been announced. The delay was caused by some unforeseen technical difficulties with transmitting claim data to McKesson. Monitor the IHCP website for information about the revised implementation date.
• The NCCI edits were to be effective for all claims on or after October 1, 2010. However, CMS did not specify whether the October 1st date was to be applied to claims received or claims with dates of service. This has now been clarified and will apply to claims with dates of service on or after October 1, 2010.
• Once the edits are turned on, all claims with dates of service on or after October 1, 2010, that have already been processed will have to be reprocessed by HP to apply the NCCI edits. This may result in retroactive NCCI denials for bundling, excessive units of service, or medically unlikely services. When HP reprocesses the claims, any overpayments as a result of the NCCI bundling will be recouped via the accounts receivable process. HP will notify providers of the mass reprocessing date(s) once they have been established.
• Several standard NCCI edits have been identified as conflicting with existing Indiana Medicaid policies and billing instructions. Indiana Medicaid has requested permission from CMS to deactivate these particular edits. As new conflicts are identified, additional requests for permission to deactivate edits will be submitted by Medicaid. It should be noted, Medicaid must request and receive permission from CMS before it may deactivate any NCCI edit. At this time, the following conflicts have been identified and permission has been requested and granted to deactivate the edits (this list is not all inclusive):
  • Indiana Medicaid policy directs providers to unbundle OB services and to bill lab services separately from the OB services. NCCI edits related to 59425 and 59426 billed with -U1, -U2, and -U3 modifiers and/or when billed with certain lab services identified in BT201036 have been deactivated.
  • MUE edits regarding limitations for blood glucose testor reagent strips, per 50 strips (A4253). MUE limitation is 2 units; Indiana Medicaid policy allows 4 units (200 test strips). The MUE limitation has been deactivated.
  • MUE edits regarding the limitation on lancets, per box (A4259). The MUE edit allows 1 unit; Indiana Medicaid policy allows 2 units per month. The MUE limitation has been deactivated.
• If a claim “hits” an MUE edit for excessive units of service, the detail line will be denied in its entirety, the system will not cut back the reimbursement to the number of allowed units. The provider will have to correct and resubmit the claim to be reimbursed.
• When billing services for a span of dates, the “From” and “To” dates must equal the number of units submitted in the “Units” field or the detail will deny. For example, if the member is seen in the inpatient setting from 10/01/2010 through 10/10/2010 and the physician codes 99231 for each date, the claim may be reported with 10/01/2010 in the “From” field, 10/10/2010 in the “To” field and 10 in the “Units” field. However, if the physician did not see the patient on 10/05/2010, the provider cannot report 10/01/2010 through 10/10/2010 with 9 units. The detail would have to be split into 2 service lines with 10/01/10 through 10/04/2010 and 4 units on one line and 10/06/2010 through 10/10/2010 with 5 units of the second line. When billing span dates, all services must occur within the same calendar month; 10/25/2010 through 11/02/2010 with 9 units would not be allowed.
• Providers should continue to use modifiers as appropriate when reporting services. If a claim hits an NCCI edit at McKesson, their system will look at the claim to determine if a modifier is present that would justify an override of the edit.
  • CMS has identified that some providers often append modifier -59 to override an edit when another modifier has been or should have been used instead. Providers should not routinely append modifier -59 just to override the edits. Modifier -59 should only be used if NO OTHER modifier is applicable and the services reported represent a different session or encounter, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury or area of injury in extensive injuries.  Note:  a procedure or surgery is not “different” merely because it has a separate CPT code. If the additional procedure or surgery is performed at the same site during the same surgical session or is integral to the primary procedure, even though it is identified by a separate CPT code, it is considered bundled and should not be reported with modifier -59 to force the payment.
  • Modifiers -RT and -LT:  These modifiers should be used when appropriate to identify procedures performed on paired organs. The appropriate use of these modifiers will allow McKesson to override an edit when the claim indicates that the service was performed on different sites, as evidenced by -RT and -LT.
  • Anthony Pelezo, MD, Medicaid Medical Director, has informed AMPlus that appropriate modifier use, particularly with respect to modifiers -25, -57, and -59, will be a very high priority for the new Fraud and Abuse contractor/system that is due to be implemented by January 1, 2011. The new contractor has not yet been announced.  
• NCCI edits do not apply coverage determinations or policy determinations so implementation of these bundling edits will not change Medicaid covered services or billing instruction. Some providers have expressed concern about consultation codes. As Medicare does not cover consultations there is concern that this will be reflected in the NCCI and claims will be denied. The NCCI file listed on the CMS NCCI Coding Page does not contain any bundling edits for consultation codes. Consultations will continue to covered and will be edited based on existing Medicaid policies for coverage and frequency. 
• Medicaid NCCI Edit Updates:  The NCCI edits are updated on a quarterly basis. The timing of the first update will be determined based on the date that the edits are actually turned on. Watch your Medicaid publications for additional information about the quarterly updates.
• Medicaid Managed Care:  The federal requirement to use NCCI editing does not extend or apply to Medicaid managed care entities (MCEs). Therefore, the Indiana Medicaid MCEs are not required to use these edits. However, AMPlus has been informed that both Anthem and MHS have been using NCCI editing for Medicaid claims and the MDwise plans are in the process of implementing NCCI editing for their Medicaid claims. It should be noted that while they state they are using NCCI editing, they obtain their bundling logic from other vendors that may add other proprietary bundling logic or modify the bundling logic to be consistent with their stated policies and reimbursement methods. So, do not assume the editing for each of the MCE and HP will be identical.
• NCCI Bundling Denial Appeals:  To appeal an NCCI edit (Column I/Column II, ME, or MUE) denial the provider must submit an Administrative Review request within 7 calendar days of the receipt of the denial. To submit an Administrative Review, complete the Indiana Health Coverage Programs Inquiry form located in the Forms section of the IHCP website. You must clearly note: Administrative Review Request on the form, state the reason you disagree with the bundling and include documentation that supports separate payment for the services in question (documentation may include office notes, operative notes, admit/discharge summaries, radiology reports, etc). The form and envelope must be marked: Attn: Health Care Administrative Review Specialist. This process should also be utilized for cases in which bundling edits conflict with established Medicaid policies and billing instructions. The provider should state the policy and how it conflicts with a particular NCCI edit. If Medicaid is in agreement, they will submit a request to CMS to deactivate the edit.
• NCCI Edit Concerns:  If a provider believes an NCCI edit is generally incorrect or inappropriate (across the board for any payer using the NCCI editing system), he/she should contact Correct Coding Solutions, LLC. CMS has approved these edits for Medicaid use and the IHCP is required to use the edits as created by Correct Coding Solutions, unless the IHCP or a provider can show just cause as to why an edit is inappropriate. Information should be sent to:  National Correct Coding Solutions, LLC, PO Box 907, Carmel, IN  46082-0907, Attn:  Niles Rosen, M.D., Medical Director or Linda Dietz, RHIA, CCS, CCS-P, Coding Specialist.
• During a previous presentation, Dr. Pelezo stated that the edits have been set up by CMS to promote appropriate coding. Therefore, if a provider submits codes which are considered bundled by the NCCI, Medicaid has been directed to allow payment for the lesser valued service, which is usually the Column I or component code. Providers that do not change inappropriate coding patters will be underpaid and will have to submit a void/replacement (aka, Adjustment) to receive correct reimbursement. Medicaid has requested a waiver from CMS to allow them to pay the higher valued code but at this time permission has not been granted and it is not expected.
• To obtain a copy of the Power Point presentation from the HP virtual workshop visit www.indianamedicaid.com, click on Provider Education on the menu on the right side of the screen, click on Archived Workshop Presentations on the left side of the screen, and scroll down to National Correct Coding Initiative to open/download/print the presentation. Handout material from various other presentations are included on this page as well.
• Additional Information: Additional information about NCCI and Medicaid NCCI can be obtained at the following websites:
  • Medicare: http://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp
  • Medicaid: http://www.cms.gov/MedicaidNCCICoding/
  • Correct Coding Solutions, LLC:  http://correctcodingsolutions.com/

Many claim denials are the result of sending claims to the wrong address or not including the required information on/with the claim. The following table provides a description of the various claim types, required attachments, special notes/considerations, and the correct Medicaid address.

Each of the Medicaid plans have reported very similar top denial reasons for professional claims (CMS-1500). The following list contains the most frequently encountered denials with the method of correction. Due to variances in the specific frequency for each payer, these items are not necessarily in highest volume order. 

Patient covered by primary insurer – please bill insurer first

Always verify eligibility!! If the member is covered by one of the Risk-Based Managed Care Organizations (MCOs), the other insurance data on Web interChange may not be the most up-to-date information. If your MCO claim is denied, contact the MCO to request information about the other insurance. Anthem and MHS have on-line eligibility systems to provide information about other insurance. If the member’s plan (Traditional, Care Select, or MCO) states that other insurance is available you must submit a claim to that insurer and provide proof of denial before the plan will pay your claim. If the other insurer denies the claim for “no coverage in effect” provide the denial to the plan to have the other insurance end-dated. Submitting the denial with the claim will allow your claim to process but will not trigger a review of the other insurance listed. For Traditional and Care Select members, send a copy of the denial to the TPL Department. For MCO members, submit a copy of the denial as an Appeal or to your Field Representative.

Coverage not in effect on date of service/patient covered by Medicaid Risk Based Managed Care entity

Always verify eligibility before rendering care! Just because they were Traditional Medicaid or MHS the last time you saw them does not mean they have not changed plans. Be sure your staff understand the different plans and update the financial class information as appropriate.  

 Service not covered for Package B member

Always verify eligibility! If the member is enrolled in Package B they do not have full Medicaid benefit. They have coverage for only pregnancy-related care, complications, family planning, transportation, and pharmacy services. If the services fall within the definition of coverage, a pregnancy diagnosis MUST be utilized as the primary diagnosis code, even if you are treating a complication such as diabetes. Flagging the charge ticket as Package B will help communicate to the claims entry staff to review the diagnosis before the claim is submitted.

 Limit for timely filing has expired

The filing limit for Traditional Medicaid and Care Select is 365 days from the date of service. Any claim with a date of service greater than 1 year must have documentation to support a waiver of the filing limit. Claims staff will not research any claim. It is the provider’s responsibility to submit the data with a paper claim or using the Attachment Cover Page following the submission of an electronic claim. It should be noted that the MCOs do not permit a 1 year filing limit for contract providers. Each MCO has varying filing limits and the time limit generally applies to the initial claim submission. Once the claim has been submitted, the provider then has 60 days from the date of the EOB/EOP to file a corrected claim or submit an appeal. Failure to submit the initial claim within the specified time limit or file the correction/appeal within the 60 day limit will result in a denial. The plan then has complete discretion as to whether or not they will waive the limit, most will not. 

Authorization not on file/no authorization for service

Providers may search by CPT code for Traditional Medicaid and Care Select members to determine if prior authorization is necessary. This feature is available on the Medicaid website using the Fee Schedule. Currently, the MCOs do not have an on-line search engine to determine authorization requirements. When in doubt, call! All out-of-network providers (except self-referral services) require authorization before providing care. Most inpatient admissions require authorization, If authorization for the inpatient stay is not obtained none of the providers furnishing care during the confinement will be paid. Don’t assume the hospital obtained the authorization; always call to verify that authorization has been obtained. If authorization is not obtained prior to rendering the service, the plan has total discretion whether or not to provide a retro-authorization, regardless of medical necessity. Most plans will not retro-authorize care.

Duplicate of a previously processed claim

Claims submitted/processed by Traditional Medicaid and Care Select will only hit as an exact duplicate if a previous claim for the same member, same provider, same code, and same date of service show as previously paid. This includes claims that paid $0. Generally, if the claim shows on a paid page of the Medicaid RA, it cannot be resubmitted; an adjustment will be required. This is true for claims containing surgical procedures. If you have received this denial message, Medicaid is trying to tell you that you cannot just rebill the denied claim or denied detail. Rather, an adjustment (void/replacement) is necessary to correct the claim. For all MCOs, a claim will hit as a duplicate if another claim for the same member, same provider, same code(s), same date of service have been processed, regardless of whether they paid or denied. If a claim has been denied, a corrected claim must be submitted. When submitting a correction, be sure to mark the claim as “Corrected Claim” to prevent the duplicate denial. 

Patient covered by Medicare, bill Medicare first or QMB recipient bill Medicare first

This denial is often caused by claims being mailed to the wrong address, mis-routed by Medicaid, or because of a benefit limitation.

• If the member has Medicare and Medicare has paid the claim and you are billing to obtain the allowable Medicare coinsurance and/or deductible be sure the claim is submitted as a Medical Crossover to the correct PO Box. Also, be sure you have completed the crossover information in Item 22 of the claim form (or electronic field).
• If Medicare has denied the service it is not considered a crossover and is mailed to the Medicaid Medical Claims PO Box and a copy of the Medicare Remit is required. No information should be entered in Item 22.
• If the member is covered by a Medicare HMO/Replacement Plan, do not complete Item 22 of the claim; enter the amount paid by the HMO in Item 29; always submit a copy of the HMO EOB/EOP; and mail the claim to the Medicaid Medical Claims PO Box, these claims are not considered crossovers.
• If the denial states the member is QMB please bill Medicare first, review the Medicare Remit. If Medicare has covered the service it should be filed to the Medical Crossover PO Box with Item 22 completed with the crossover data. If Medicare denied the service, review the Medicaid eligibility.
• If the member is listed as QMB only there is no secondary payment available. For QMB only members Medicaid only covers the applicable portion of the Medicare coinsurance and/or deductible. If the member was notified in advance that Medicare and Medicaid do not cover the service, the member may be billed.

MDwise participates in 3 Medicaid Programs; MDwise Care Select, Hoosier Healthwise, and HIP. Not all of these MDwise Programs have network affiliations. Many assume when they see “MDwise” on eligibility that the member has a specific network affiliation. Not true… 

The “Managed Care” section of the Web interChange will convey the type of managed care, Care Select or Hoosier Healthwise. 

The “Managed Care Entity Name” will convey with which managed care company the member is enrolled (Advantage, Anthem, MDwise, or MHS). 

It is critical to review both sections to determine if a network is applicable. 

Let’s face it, Medicaid reimbursement has not kept pace with the cost of doing business. It is extremely unlikely that the rates will be increased anytime soon. Implementing a few simple procedures can save you time and money and allow your Medicaid reimbursement to go further. Medicaid reimbursement does not cover your cost to touch a claim once, let alone twice! 

• Require eligibility verification at the point of scheduling and the point of service for all Medicaid members. Track eligibility related denials to educate staff and add accountability. Implementing this procedure does require that schedulers and front office staff are educated about the eligibility verification systems, the various benefit packages, the various plans, and requirements for certain benefit packages and coverage plans.
• Revise the financial class listings in your practice management system to mirror exactly the plan name as it is listed on the Medicaid eligibility verification systems. This will make it easier for staff to select the correct insurer. With the various MDwise plans, it is not uncommon for staff to select the wrong plan. 
• Create a system to communicate when a member is enrolled in a special/limited benefit package that requires non-standard coding i.e., Package B members. Office supply stores charge about $40 for a custom red-ink stamp. When the member presents for care and eligibility is verified, if the member is Package B (or a member of some other special/limited plan) the charge ticket/encounter form/route slip is stamped. When the charge is entered, the big red “Package B” or “B” or “special coding” stamped on the ticket will alert the charge entry staff/coder to review the charge carefully and apply any special applicable coding. If you are trying to correct these claims on the back end, you are wasting staff resources and costing yourself money.
• Create a system to communicate services that require special coding for Medicaid claims, such as vaccines/immunizations. Medicaid requires that all vaccines/immunizations for children be reported with the primary diagnosis code of V20.2, not the vaccine/immunization specific diagnosis code. The next time you revise your charge ticket/encounter form/route slip, next to the vaccine/immunization specific diagnosis code in parenthesis include (use V20.2 for Medicaid). The doctor will not have to do anything differently but the staff will remember to use the correct primary diagnosis code for Medicaid members when they enter the claim.
• Newborn claims CANNOT be billed with the mother’s recipient ID number (RID); they must be submitted with the newborn’s RID number. In some instances the assignment of the RID number can take several months. In most cases the number has been assigned within 60 days but has not been disseminated to providers. To obtain a newborn RID number, contact HP Customer Service and provide them with the Case Number indicated at the bottom of the Web interChange eligibility transaction for the mother and the newborn’s date of birth. Using the Case Number they can determine all family members associated with the mother. Once the RID number is obtained, run eligibility on that number to obtain the spelling of the first and last name of the newborn, as indicated in the Medicaid system.
• The member’s name must be entered on the claim EXACTLY as it appears in the HP eligibility verification system i.e., Web interChange, even if it is spelled wrong, is different from the spelling/name on the member’s other insurance or Medicare card. Set up an alert in your practice management system to either flag the front office to mark the charge ticket/encounter form/route slip or to flag the charge entry staff to make sure the name is entered to match the Medicaid system.