Claim submission guidelines for LTC/SNFs to Managed Care - - PowerPoint PPT Presentation

Claim submission guidelines for LTC/SNF’s to Managed Care Organizations that participate in MMAI and/or ICP

Presented by: The Illinois Association of Medicaid Health Plans 1

Identifying Identifying the correct payer source the correct payer source

• MMAI, LTSS, & ICP
• Eligibility & Enrollment
• MEDI System and ID cards
• Managed Care Organizations
• Coverage Map
• Enrollment Examples

Billing Billing for skilled and custodial for skilled and custodial

• Skilled Care
• Custodial Care
• Submission methods
• Facility claim form
• Professional claim form
• Billing Requirements
• Taxonomy Codes
• Rejections and Denials
• Patient Credit File

How How to handle discharg to handle discharges, chang es, changes in MCO’s, es in MCO’s, and Part B and Part B

• Care Coordination
• Changing MCO’s
• Health Plan Discussions
• Health Risk Assessments
• Quality

Standardized Billing Standardized Billing Procedures Procedures

• MCO Standardization Project
• Standardized Billing Procedures
• Room & Board
• Bed holds
• Oxygen
• Therapy
• Hospice

Presented by: Illinois Association of Medicaid Health Plans 2

Presented by: Illinois Association of Medicaid Health Plans 3

• MMAI = Medicare Medicaid Alignment Initiative
• This is a demonstration program and not to be confused with Medicare Advantage
• New beginning 3/1/14
• Enrollees must have full Medicare (Parts A, B, and D) and Medicaid (not including spend down)
• Limited services areas include two regions:
• Greater Chicago Region (including all of Cook county)
• Central Region
• When enrolled with MMAI, the MCO will become the primary payer for both

both Medicare and Medicaid services

• Includes Service Package 1 for medical services
• Includes Service Package 2 for LTC/HCBS services
• Members who qualify for MMAI have several enrollment options:
• To select and enroll with the MCO of their choice
• If no selection made, they will be passively enrolled and assigned to an MCO
• To “opt out” of the program
• For those members who “opt out” of the MMAI program
• Medicare

Medicare will remain their primary carrier, not the MCO

• An MCO will become their Medicaid carrier for LTSS services only, as they will still be required to be enrolled with an MCO because

they are living in a LTC/SNF or receiving HCBS services

• For MMAI members, this will have the ability to change MCO’s on a monthly basis if they choose or opt out. This

is unlike the ICP program where they can only change MCO’s within their first 90 days, and are then locked in until their anniversary date

Presented by: Illinois Association of Medicaid Health Plans 4

Long Term Support Services New beginning 3/1/14 Only for dually eligible members that have chosen to “opt out” of the

MMAI program

Individuals receiving waivers or living in a LTC facility will be required to

enroll with an MCO in the LTSS program

Limited program that includes

• Transportation
• Behavioral health services
• HCBS
• LTC
• EXCLUDES acute medical care

The limited benefits will be administered the same as the ICP

Presented by: Illinois Association of Medicaid Health Plans 5

• ICP = Integrated Care Plan
• Is made up of 2 components
• Service Package 1 = Medical, pharmacy, behavioral health 5/1/2011
• Service Package 2 = LTC & HCBS/waivers (except DD) 2/1/2013
• Medicaid only plan for individuals who are Seniors and People with Disabilities who 19 years

and older

• Multiple services areas including Chicago Region, Central Region, Rockford Region, and Quad

Cities

• Now expanding to include the 606 zip code
• Chicago residents will have effective dates beginning 3/1/14
• For those eligible, enrollment in the ICP is mandatory

mandatory with one of the MCO’s in the service region

• Enrollment Options:
• Members may select to enroll with the MCO of their choice
• If no selection is made, they will be auto-assigned to an MCO
• Members can change MCO’s within their first 90 days and are then locked in with that MCO

until their anniversary date

Presented by: Illinois Association of Medicaid Health Plans 6

Eligibility requirements and processes remain the

same in order for someone to move into a LTC facility on a permanent basis

The Illinois Department on Aging and one of its

Care Coordination Units like Catholic Charities, Great Lakes, etc. will complete the assessment (Determination of Need).

The LTC needs to coordinate with the

Department of Human Services and the Department of Healthcare and Family Services for Medicaid eligibility

Presented by: Illinois Association of Medicaid Health Plans 7

Enrollment information can be found at: http://enrollhfs.illinois.gov/ There are three ways to enroll for ICP:

• Online

Online: Go to Enroll.

• Pho

Phone ne: Call 1- 1-877- 877-912- 912-8880 8880 (TTY 1-866-565-8576). The call is free.

• Mail

Mail: Fill out the form you got in the mail. Then send it back to us in the envelope we gave you. If you don’t have the form, call Client Enrollment Services.

• For MMAI the enrollment process is limited to
• Pho

Phone ne: Call 1- 1-877- 877-912- 912-8880 8880 (TTY 1-866-565-8576). The call is free.

• Mail

Mail: Fill out the form you got in the mail. Then send it back to us in the envelope we gave you. If you don’t have the form, call Client Enrollment Services

• No web enrollment option is available due to Federal regulation
• Website allows for:
• Viewing of materials
• Compare health plans and Value Added Benefits
• Review provider networks

Presented by: Illinois Association of Medicaid Health Plans 8

LTC

DHS HFS

HFS

LTC MCO

DHS

LTC HFS>>MCO

Presented by: Illinois Association of Medicaid Health Plans 9

Mailing ¡ Date ¡ Por.on ¡of ¡ Popula.on ¡ Expected ¡Mailings ¡ Earliest ¡Es.mated ¡ Voluntary ¡ Enrollment ¡Effec.ve ¡ Date ¡ Earliest ¡Es.mated ¡ Passive ¡Enrollment ¡ Effec.ve ¡Date ¡ non-­‑LTC/Waiver ¡Announcement ¡Group ¡1 ¡ 1/29/2014 ¡ 43.75% ¡ 38,853 ¡ 3/1/2014 ¡ non-­‑LTC/Waiver ¡Announcement ¡Group ¡2 ¡ 2/6/2014 ¡ 31.25% ¡ 27,752 ¡ 3/1/2014 ¡ non-­‑LTC/Waiver ¡Announcement ¡Group ¡3 ¡ 2/26/2014 ¡ 25.00% ¡ 22,202 ¡ 4/1/2014 ¡ non-­‑LTC/Waiver ¡Passive ¡Enrollment ¡(PE) ¡Group ¡1 ¡ 3/1/2014 ¡ 12.50% ¡ 9,133 ¡ 4/1/2014 ¡ 6/1/2014 ¡ non-­‑LTC/Waiver ¡PE ¡Group ¡2 ¡ 3/25/2014 ¡ 12.50% ¡ 9,133 ¡ 5/1/2014 ¡ 6/1/2014 ¡ non-­‑LTC/Waiver ¡PE ¡Group ¡3 ¡ 4/11/2014 ¡ 12.50% ¡ 9,133 ¡ 6/1/2014 ¡ 7/1/2014 ¡ non-­‑LTC/Waiver ¡PE ¡Group ¡4 ¡ 4/15/2014 ¡ 12.50% ¡ 9,133 ¡ 6/1/2014 ¡ 7/1/2014 ¡ non-­‑LTC/Waiver ¡PE ¡Group ¡5 ¡ 5/4/2014 ¡ 12.50% ¡ 9,133 ¡ 6/1/2014 ¡ 8/1/2014 ¡ non-­‑LTC/Waiver ¡PE ¡Group ¡6 ¡ 6/1/2014 ¡ 12.50% ¡ 9,133 ¡ 7/1/2014 ¡ 8/1/2014 ¡ non-­‑LTC/Waiver ¡PE ¡Group ¡7 ¡ 7/18/2014 ¡ 12.50% ¡ 9,133 ¡ 9/1/2014 ¡ 10/1/2014 ¡ non-­‑LTC/Waiver ¡PE ¡Group ¡8 ¡ 8/13/2014 ¡ 12.50% ¡ 9,133 ¡ 10/1/2014 ¡ 11/1/2014 ¡ LTC/Waiver ¡Announcement ¡Group ¡1 ¡ 5/12/2014 ¡ 12.50% ¡ 6,119 ¡ 7/1/2014 ¡ LTC/Waiver ¡Announcement ¡Group ¡2 ¡ 5/16/2014 ¡ 12.50% ¡ 6,119 ¡ 7/1/2014 ¡ LTC/Waiver ¡Announcement ¡Group ¡3 ¡ 5/21/2014 ¡ 25.00% ¡ 12,238 ¡ 7/1/2014 ¡ LTC/Waiver ¡Announcement ¡Group ¡4 ¡ 5/23/2014 ¡ 12.50% ¡ 6,119 ¡ 7/1/2014 ¡ LTC/Waiver ¡Announcement ¡Group ¡5 ¡ 6/11/2014 ¡ 37.50% ¡ 18,357 ¡ 8/1/2014 ¡ LTC/Waiver ¡PE ¡Group ¡1 ¡ 6/30/2014 ¡ 25.00% ¡ 10,575 ¡ 8/1/2014 ¡ 9/1/2014 ¡ LTC/Waiver ¡PE ¡Group ¡2 ¡ 7/22/2014 ¡ 12.50% ¡ 5,287 ¡ 9/1/2014 ¡ 10/1/2014 ¡ LTC/Waiver ¡PE ¡Group ¡3 ¡ 8/7/2014 ¡ 12.50% ¡ 5,287 ¡ 9/1/2014 ¡ 11/1/2014 ¡ LTC/Waiver ¡PE ¡Group ¡4 ¡ 9/3/2014 ¡ 12.50% ¡ 5,287 ¡ 10/1/2014 ¡ 11/1/2014 ¡ LTC/Waiver ¡PE ¡Group ¡5 ¡ 9/11/2014 ¡ 25.00% ¡ 10,575 ¡ 11/1/2014 ¡ 12/1/2014 ¡ LTC/Waiver ¡PE ¡Group ¡6 ¡ 9/19/2014 ¡ 12.50% ¡ 5,287 ¡ 11/1/2014 ¡ 12/1/2014 ¡ Presented by: Illinois Association of Medicaid Health Plans 10

Presented by: Illinois Association of Medicaid Health Plans 11

Presented by: Illinois Association of Medicaid Health Plans 12

All members when enrolled in Medicaid will receive an ID card from HFS

with their Recipient Identification Number (RIN)

Once the resident is enrolled with an MCO, they will receive a second ID

card; this time from the MCO. This card will contain the resident’s RIN, along with the MCO’s phone number and claim information and pharmacy info

MMAI ID cards and ICP ID cards will look different Using the resident’s RIN, you can log onto MEDI to determine if the

member is currently with HFS or with a specific MCO

Access MEDI by going to:

• http://www.myhfs.illinois.gov/

The REV system should also reflect the residents MCO, the effective

dates, and the program the resident is enrolled in (MMAI, LTSS, or ICP)

Presented by: Illinois Association of Medicaid Health Plans 13

Presented by: Illinois Association of Medicaid Health Plans 14

Presented by: Illinois Association of Medicaid Health Plans 15

Presented by: Illinois Association of Medicaid Health Plans 16

Map of regions/products http://www2.illinois.gov/hfs/sitecollectiondocuments/ccexpansionmap.pdf

Managed ¡Care ¡Organiza.ons ¡ MCO ¡ ICP ¡ MMAI ¡ Service ¡Region ¡ICP ¡ Service ¡Region ¡MMAI ¡ Aetna ¡ X ¡ X ¡ Chicago, ¡Rockford ¡ Chicago ¡ BCBSIL ¡ X ¡ X ¡ Chicago ¡ Chicago ¡ Cigna-­‑HealthSpring ¡ X ¡ X ¡ Chicago ¡ Chicago ¡ Community ¡Care ¡Alliance ¡of ¡IL ¡ X ¡ Rockford ¡ N/A ¡ Health ¡Alliance ¡ X ¡ X ¡ Central ¡ Central ¡ Humana ¡ X ¡ X ¡ Chicago ¡ Chicago ¡ IlliniCare ¡ X ¡ X ¡ Chicago, ¡Rockford, ¡Quad ¡CiVes ¡ Chicago ¡ Meridian ¡ X ¡ X ¡ Chicago, ¡Central, ¡Metro ¡East ¡ Chicago ¡ Molina ¡ ¡ X ¡ X ¡ Central ¡ Central ¡

Presented by: Illinois Association of Medicaid Health Plans 17

Look up the member in either the MEDI system or the Rev system Identify the program they are enrolled in:

• MMAI (Medicare and Medicaid)
• LTSS (Limited Medicaid only—Dual Eligible)
• ICP (Medicaid only)

Identify the MCO they are/were enrolled at the time of service Confirm the effective dates

• This is important since MMAI members can change plans on a monthly

basis

• LTSS and ICP members can change only in their first 90 days, and annually

thereafter

• LTSS can elect to go back to MMAI at any time
• Effective dates for all programs are the 1st of any given month

If no MCO is listed, the State is responsible for payment

Presented by: Illinois Association of Medicaid Health Plans 18

Resident comes to your facility on January 11 who is not

enrolled in Medicare or Medicaid

On January 29th receive Medicaid eligible notification Enrollment letters sent to member Member enrolls in health plan April 15 What is their effective date with the MCO?

• June 1st

Who do I bill?

• January 11-May 31st the State as you do today
• Beginning June 1st the MCO

Presented by: Illinois Association of Medicaid Health Plans 19

February 17 a new resident comes to your facility They are currently enrolled in Medicaid They are not eligible for Medicare You check MEDI or Rev and determine that they are with one of the

MCO’s

Call the MCO for an authorization and to start the care coordination

relationship

In March you submit a bill to the MCO for services 2/17-2/28 In March, check MEDI or Rev again to ensure member has not changed

MCO’s

In April, bill MCO for 3/1-3/31

Presented by: Illinois Association of Medicaid Health Plans 20

• March 3 and you have a resident currently living in your facility for a year
• They have both Medicare and Medicaid
• On July 22 they receive a letter from Client Enrollment Services for enrollment in

the MMAI program

• When are they effective?
• September 1st if they chose to enroll in a specific MCO
• November 1st if they are passively enrolled with an MCO
• Who do I bill for services?
• Check MEDI or Rev to determine which MCO the member has
• Follow your current billing process for services through either August 31 or October 31
• Bill MCO beginning with the residents effective date
• MCO will be the payer for both Medicare and Medicaid services
• Because this member is enrolled in MMAI, they could change MCO’s on a monthly

basis, be sure to check MEDI or Rev often

• Be sure to call the MCO for authorization

Presented by: Illinois Association of Medicaid Health Plans 21

• March 3 and you have a resident currently living in your facility for a year
• They have both Medicare and Medicaid
• On July 22 they receive a letter from Client Enrollment Services for enrollment in the MMAI

program

• They chose to “opt out” of MMAI and are therefore enrolled in LTSS (Limited Medicaid only—

Dual Eligible Member)

• When are they effective?
• September 1st if they chose to enroll in a specific MCO
• The soonest they would be passively enrolled with an MCO would be November 1st
• Who do I bill for services?
• Check MEDI or Rev to determine which MCO the member has
• Follow your current billing process for services through either August 31 or October 31
• Bill MCO beginning with the residents effective date
• MCO will be the payer for Medicaid LTC services only
• Any new Medicare services would need to be billed to Medicare
• Because this member is a dual eligible, they can opt to re-enroll in MMAI at any time after they

have opted out. Be sure to check MEDI or Rev on a monthly basis

• Be sure to call the MCO for authorization

Presented by: Illinois Association of Medicaid Health Plans 22

Presented by: Illinois Association of Medicaid Health Plans 23

Medicare Part A (Hospital Insurance) covers skilled nursing

care in a skilled nursing facility (SNF) under certain conditions for a limited time

Medicare-covered services include, but aren’t limited to:

• Semi-private room
• Meals
• Skilled Nursing Care
• Physical and occupational therapy
• Speech-language pathology services
• Medical social services
• Medications
• Medical supplies and equipment used in the facility
• Ambulance transportation (when other transportation endangers

health) to the nearest supplier of needed services that aren’t available at the SNF

• Dietary counseling

Presented by: Illinois Association of Medicaid Health Plans 24

Source: http://www.medicare.gov/coverage/skilled-nursing-facility-care.html

People with Medicare are covered if they meet ALL of these

conditions:

• They have Part A and have days left in their benefit period
• They have had a qualifying hospital stay
• The doctor has decided they need daily skilled care given by, or under the

direct supervision of, skilled nursing or rehabilitation staff.

• Services are provided in a SNF that is certified by Medicare
• Services are needed for a medical condition that was either:

A hospital related medical condition A condition that started while getting care in the skilled nursing facility for a hospital related medical condition

A doctor may order observation services to help decide whether

the patient needs to be admitted to the hospital as inpatient. During the observation time, the patient is considered outpatient and this time cannot be counted towards the 3-day inpatient hospital stay needed for Medicare to cover the SNF stay

Presented by: Illinois Association of Medicaid Health Plans 25

Source: http://www.medicare.gov/coverage/skilled-nursing-facility-care.html

Coverage for Skilled Nursing is for 100 days If there is a break in care that lasts for more than

30 days a new 3-day hospital stay is required to qualify for additional SNF care

• The new hospital stay doesn’t need to be for the same

condition

If the break in skilled care lasts for at least 60

days in a row, this ends your current benefit period and renews your SNF benefits. This means the maximum coverage would again be 100 days of SNF benefits

Presented by: Illinois Association of Medicaid Health Plans 26

Source: http://www.medicare.gov/coverage/skilled-nursing-facility-care.html

Non-skilled, personal care, such as help with activities of daily

living like bathing, dressing, eating, getting in or out of a bed or chair, moving round, and using the bathroom. It may also include care that most people do themselves, like using eye drops.

Custodial Care Facility: A facility, which provides room, board,

and other personal assistance services, generally on a long term basis and which does not include a medical component

Long Term Care: A variety of services that help people with

health or personal needs and activities of daily living over a period of time. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes, and assisted living facilities. Most long-term care is custodial care. Medicare doesn’t pay for this type of care if it is the only kind of care you need.

Presented by: Illinois Association of Medicaid Health Plans 27

Source: http://www.cms.gov/apps/glossary/default.asp?Letter=S&Language=English

• Electronic Submission
• Usually through clearinghouses
• Institutional (room & board) 837i
• Professional services 837p
• Paper Submission
• Institutional UB04
• Professional CMS1500
• Other
• Individual MCO’s might have other options like:
• Websites
• Portals
• Special instructions
• Claims should be submitted on the correct forms
• They should be original forms and not photocopied
• There should be no writing or markings on the form
• Claims may be rejected if the claims are not submitted properly
• Supporting documentation and or medical records may be submitted if required by the MCO
• If submitting a corrected claim, for a paper claim, it is then “OK” to write “Corrected Claim”
• n the top so it doesn’t deny as a duplicate
• Corrected claims can also be submitted electronically for EDI claim

Presented by: Illinois Association of Medicaid Health Plans 28

Room and board services must be submitted

• n the institutional claim form
• 837i for electronic claims
• UB04 for paper claims

Professional services must be submitted on

the professional claim form

• 837p for electronic claims
• CMS1500 for paper claims

Presented by: Illinois Association of Medicaid Health Plans 29

HFS will be looking for LTC to use the following taxonomy

codes when submitting claims

• 310400000X – Assisted Living Facility – used by Provider Type 028

(Supported Living Facility)

• 311500000X – Dementia Special Care – used by Provider Type 028

(Supported Living Facility-Dementia Care Unit) or by Provider Type 038 (LTC MI Demonstration-Dementia Care)

• 314000000X – Skilled Nursing Facility – used by Provider Type

033 and 034 (Nursing Facility and State Operated Long Term Care Facility)

• 313M00000X – Nursing Facility/Intermediate Care Facility – used

by Provider Type 033 and 034 (Nursing facility and State Operated Long Term Care Facility)

Presented by: Illinois Association of Medicaid Health Plans 30

• A rejection is a claim that never makes it into the MCO’s claim system, usually

because the information is not complete or it is inaccurate

• Examples:
• You may submit a claim for Mickey Mouse, but the RIN was not included on the claim.

This claim would be rejected by the MCO

• A claim for Mickey Mouse would be submitted and you included the RIN, but the

member was never enrolled with that MCO’s. Because there would be no matching ID for that member, the claim would reject

• If you submitted a professional claim with revenue codes the claim may reject
• If the Provider NPI would be missing the claim would reject
• Dates of service may be missing and the claim would reject
• Provider taxonomy code might be missing the claim would reject
• A missing diagnosis code could cause the claim to reject
• It is recommended that the LTC facilities implement processes to review and

work rejected claim reports to determine why the claim was rejected by the

• MCO. Usually only the LTC facility can fix the claim
• Rejected claim reports should be worked timely by the LTC facilities. Rejected

claims that are not resolved/resubmitted correctly by the LTC facility may later be rejected for timely filing by the MCO should they be corrected

Presented by: Illinois Association of Medicaid Health Plans 31

A denied claim is one that was successfully received at

the MCO but could not be adjudicated for payment

Partial denial is when part of the claim was adjudicated

for payment or one to several lines within the claim denied

The most typical denials for claims are:

• Duplicate claims
• No authorization on file
• Claim not submitted within the timely filing guidelines
• Member not on the patient credit file
• Member not valid on the date of service

What to do when you get a denied claim?

• Look at the reason code for the denial
• This will be on your provider remittance
• Some plans may also have this information online for you to

view

Presented by: Illinois Association of Medicaid Health Plans 32

Denial ¡Reason ¡Code ¡ Process/Next ¡steps ¡

Duplicate ¡ 1) ¡Check ¡to ¡see ¡if ¡a ¡previously ¡claim ¡was ¡submi[ed ¡to ¡the ¡MCO ¡ ¡ 2) ¡Review ¡original ¡claim ¡for ¡payment ¡status ¡or ¡denial ¡ 3) ¡Submit ¡a ¡corrected ¡claim ¡for ¡the ¡original ¡claim ¡for ¡reconsideraVon ¡ 4) ¡Provide ¡documentaVon ¡that ¡shows ¡second ¡claim ¡is ¡not ¡a ¡duplicate ¡ 5) ¡If ¡unclear, ¡called ¡the ¡MCO's ¡provider ¡service ¡phone ¡number ¡ Timely ¡Filing ¡ 1) ¡Know ¡Vmely ¡filing ¡agreements ¡for ¡each ¡MCO ¡as ¡they ¡could ¡be ¡different ¡ 2) ¡Prevent ¡Vmely ¡filing ¡denials ¡by ¡submibng ¡R&B ¡charges ¡to ¡the ¡MCO's ¡on ¡a ¡monthly ¡basis ¡ ¡ 3) ¡Review ¡MEDI ¡and ¡submit ¡claims ¡for ¡residents ¡in ¡your ¡faciliVes ¡ 4) ¡Call ¡MCO ¡provider ¡services ¡for ¡assistance ¡ No ¡authorizaVon ¡on ¡file ¡ 1) ¡All ¡LTC ¡residents ¡require ¡an ¡authorizaVon ¡to ¡be ¡in ¡a ¡LTC ¡facility ¡ 2) ¡Check ¡MEDI ¡and ¡determine ¡which ¡MCO ¡the ¡resident ¡is ¡enrolled ¡with ¡ 3) ¡Obtain ¡authorizaVon ¡ 4) ¡Call ¡MCO ¡provider ¡services ¡if ¡claim ¡has ¡denied ¡for ¡no ¡auth ¡for ¡next ¡steps ¡ 5) ¡Call ¡MCO ¡provider ¡servives ¡and ¡provide ¡authorizaVon ¡number ¡for ¡adjudicaVon ¡ PaVent ¡Credit ¡File ¡ 1) ¡Work ¡with ¡each ¡MCO ¡to ¡determine ¡the ¡paVent ¡credit ¡file ¡adjustment ¡process ¡ 2) ¡Members ¡might ¡take ¡a ¡few ¡months ¡to ¡appear ¡on ¡the ¡paVent ¡credit ¡file ¡ ¡ 3) ¡There ¡may ¡be ¡retroacVvity ¡on ¡the ¡paVent ¡credit ¡file ¡regarding ¡paVent ¡liability ¡ 4) ¡Call ¡the ¡MCO's ¡provider ¡services ¡line ¡to ¡discuss ¡next ¡steps ¡ Member ¡not ¡valid ¡on ¡the ¡date ¡of ¡service ¡ 1) ¡Check ¡MEDI ¡to ¡determine ¡who ¡was ¡the ¡correct ¡MCO ¡on ¡the ¡date ¡of ¡service ¡ 2) ¡Call ¡MCO ¡to ¡have ¡claim ¡adjusted ¡if ¡claim ¡was ¡submi[ed ¡correctly ¡ 3) ¡Submit ¡claim ¡to ¡correct ¡MCO ¡if ¡claim ¡was ¡submi[ed ¡to ¡prior ¡MCO ¡in ¡error ¡

Presented by: Illinois Association of Medicaid Health Plans 33

• This file is the official notification from HFS that the members on

this file are approved to be in Long Term Care Facilities and their financial responsibility

• The file contains key items such as RIN, Member Name, Facility/

Provider ID, Hospice Provider ID, patient credit amounts and effective/end dates

• File is received on a monthly basis from HFS on or around the 10th
• f the month
• Just as there is a delay in DHS notifying HFS regarding members

approved for LTC, there is then also a delay in the information being

• n the patient credit file

Presented by: Illinois Association of Medicaid Health Plans 34

• Ultimately, the state is responsible for all elig

Ultimately, the state is responsible for all eligibility determinations for Medicaid, Home and ibility determinations for Medicaid, Home and Community Based Services, and LTC. As you are aw Community Based Services, and LTC. As you are aware, there is a delay betw are, there is a delay between DHS and HFS een DHS and HFS processing processing LTC applications. As a result, MCO’s have been instructed by HFS not to pay claims LTC applications. As a result, MCO’s have been instructed by HFS not to pay claims until the member is officially determined to be elig until the member is officially determined to be eligible and appears on the patient credit file. ible and appears on the patient credit file.

• MCO’s do not own the process that determines eligibility and therefore can not expedite the receipt
• f a person on the patient credit file, nor can we solve for this
• There are two key drivers that produce the patient credit file are: Eligibility for LTC & Patient Income
• Once the member is on the patient credit file, claims will be processed, and any patient credit

will be subtracted from the payment

• It is important to note, that claims should be submitted to the MCO’s for processing, with the

understanding that if the member is not on the file, the claim will deny

• KEY POINT: Most if not all of the MCO’s have timely filing

KEY POINT: Most if not all of the MCO’s have timely filing requirements in their contracts. It requirements in their contracts. It is better to submit a claim and have it denied as not on the patient credit file and have it is better to submit a claim and have it denied as not on the patient credit file and have it adjusted, that to receive a denial for timely filing adjusted, that to receive a denial for timely filing and have to g and have to go throug

• through a provider

h a provider reconsideration process reconsideration process

• You should discuss with the MCO’s their process for handling these denials once the member

does appear on the patient credit file

• There may also be retroactivity regarding the patient credit amount, and again an individual

discussion with the MCO’s should be had to determine how they are handling retroactivity

Presented by: Illinois Association of Medicaid Health Plans 35

Presented by: Illinois Association of Medicaid Health Plans 36

• The MCO’s primary focus, is take care of the needs of our members. The MCO’s accomplish

this by having Integrated Care Teams that work to service the member in a holistic manner that in medical, behavioral health, and social needs

• The Integrated Care Teams are most successful when they partner with the provider

communities that attend to the needs of the members. This would include the member’s primary care provider, specialists, and long term care facilities

• The Integrated Care Team has a 360 degree view of the care being provide
• Care Management defined and required of MCO’s states:
• “Services that assist Enrollees in gaining access to needed services, including medical, social, educational

and other services, regardless of the funding source for the services. Care Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services (both Medicare and Medicaid) required to meet an Enrollee’s needs across the continuum of care.”

• MCO’s take a person centered approach to care coordination and the development of the

member’s care plan.

• A care plan is defined as: “An Enrollee-centered, goal-oriented, culturally relevant, and logical, written

plan of care with a service plan component, if necessary, that assures that the Enrollee receives, to the extent applicable, medical, medically-related, social, behavioral, and necessary Covered Services, including long-term services and supports, in a supportive, effective, efficient, timely and cost-effective manner that emphasizes prevention and continuity of care.”

Presented by: Illinois Association of Medicaid Health Plans 37

• Benefits
• MCO may provide additional services not traditionally available
• MCO may offer value added benefits
• LTC will be involved in the member’s plan of care
• By removing silos and forming relationships with the care coordination teams, this

helps to remove roadblocks and open lines of communication regarding your resident’s care

• With the introduction of care coordination we are better able to marrying skilled

care with custodial for a smoother continuum of care

• Care coordination helps to find providers and be a resource for the needs of your

residents

• LTSS only members will not have the full spectrum of benefits
• Documentation and communication will be key. Just like in state audits, if it is not

documented it didn’t happen. We can work together to ensure members are receiving the care and treatment they need

Presented by: Illinois Association of Medicaid Health Plans 38

MCO’s are required to complete a Health Risk Assessment (HRA)

• n all members, including those living in LTC facilities within

their first 90 days of joining an MCO

For short term members in an sub-acute setting, an HRA will not

be completed unless the MCO was unable to previously locate the member

Face to face visits

• May be completed by the MCO, or
• May be completed by a delegated organization or SNFist

There are continuity of care requirements for new enrollees to a

health plan

• MMAI—180 days
• ICP—90 days
• If transferring between health plans –90 days

Presented by: Illinois Association of Medicaid Health Plans 39

• Any time a member changes MCO’s, an authorization is required to be in a LTC facility for both

skilled and custodial

• Call them once you are aware of the change and establish a new authorization to avoid unnecessary claim

denials

• Transition of care:
• If an MCO authorizes services, the existing authorization is still to be honored by the receiving MCO
• This includes for services for out of network providers
• Communication between the providers, members, LTC facility, and the MCO will be key to ensure the

transition

• Member effective dates are always the first of the month
• MMAI members can change on a monthly basis, although we do not encourage that because it does disrupt

care coordination efforts and the relationships between the LTC, the MCO, and the resident but ultimately this is the member’s choice

• ICP and LTSS members have an initial 90 days to change plans and are then locked in until their anniversary

date

• Understanding the provider network is important. Existing provider relationships and

participation status with the new MCO should be reviewed prior to the change.

• What am I the LTC responsible for when a member does change an MCO?
• The old MCO’s are mandated to provide transition of care documents to the new MCO
• LTC facilities should call to obtain a prior authorization
• Review eligibility dates on MEDI or Rev and submit claims to the correct MCO
• Work with the MCO’s and their care coordination teams for positive health outcomes for the member

Presented by: Illinois Association of Medicaid Health Plans 40

Quality of care is a key component of the ICP and MMAI programs Multiple quality measures and benchmarks that are reported to CMS and

HFS

Some examples include but not limited to:

• Percent of plan members who got a vaccine (flu shot) prior to flu season
• Percent of members with a problem falling, walking or balancing who discussed it

with their doctor and got treatment for it during the year

• Percentage of members 18-85 years of age who had a diagnosis of hypertension and

whose blood pressure was adequately controlled (<140/90) during the measurement year

• Percentage of all long-stay residents in a nursing facility with an annual, quarterly,

significant change or significant correction MDS assessment during the selected quarter (3-month period) who were identified as high risk and who have one or more Stage 2-4 pressure ulcer(s)

Collaboration, documentation, and communication between the LTC

staff and the Integrated Care Teams will be critical

Presented by: Illinois Association of Medicaid Health Plans 41

Contracted LTC providers could receive referrals

for new residents for:

• Skilled care
• Custodial

Sources on a case by case basis could include:

• Individuals being discharged from ER
• Individuals being discharged from an inpatient stay
• Direct move from Custodial to Skilled Care within same

facility

• Supportive Living Facility
• Disclaimer: Please check with the MCO to understand their authorization

process regarding incoming residents

Presented by: Illinois Association of Medicaid Health Plans 42

We recognize the importance of member choice While there are services for HCBS services, those

are for individuals who want to live in the

• community. For those individuals who live in LTC

that wish to remain, we respect the members choice provided they meet the level of need in the DON

Care coordination is highly involved Discharge planners to ensure the home is safe

and there are the necessary supports

Presented by: Illinois Association of Medicaid Health Plans 43

Do the benefits change?

• No. Benefits remain the same for Part B services

Who do I bill?

• If the member is enrolled in the MMAI program, you would bill the MCO

Is authorization required for these services?

• Authorization requirements may vary by MCO, please check with the MCOs

If a resident is receiving services that are covered under Part B,

would those service be covered as part of a transition of care to the new MCO?

• Yes

Can the facility provide Part B services or are they required to use

a vendor?

• The LTC facility has the choice

Presented by: Illinois Association of Medicaid Health Plans 44

Billing for Medicare Part B services for DME

include the following requirements:

• A SNF may not bill for DME furnished to its Part A

inpatients as necessary DME must be supplied to the beneficiary as part of the SNF services.

• A SNF may not bill for DME furnished to its Part B

inpatients or outpatients

However, a SNF may qualify as a supplier and enroll with the National Supplier Clearinghouse. In such cases, the SNF is given a separate supplier number to bill outpatient DME to the DMERC. The DMERC will furnish billing guidelines for use of Form CMS-1500 and payment will be made directly to the SNF as a supplier

Presented by: Illinois Association of Medicaid Health Plans 45

Source: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c07.pdf

Alternative claim submission methods Grievances & Appeals Pharmacy Transportation Authorizations PCP changes Claim rejections and denials Care Coordination Quality initiatives

Presented by: Illinois Association of Medicaid Health Plans 46

Presented by: Illinois Association of Medicaid Health Plans 47

Pur Purpose: se: To align and streamline the billing requirements and processes of the Managed Care Organizations in order to simplify the billing process for Long Term Care facilities.

Limitations Limitations: Not all elements related to billing and managed care process can be standardized due to anti-trust rules. In addition, each MCO has different operating systems, processes, and contracts. While the Standardization Process has streamlined billing requirements you will continue to see

• differences. We recommend you build relationships with each of

the MCOs and their provider relations teams and to understand those differences.

Presented by: Illinois Association of Medicaid Health Plans 48

Revenue code 190 should be used when billing

for residents in LTC

Revenue codes 191-194 should be billed,

depending on severity and

• 19x Subacute Care

190 General Classification 191 Subacute Care-level I Skilled Care 192 Subacute Care-level II Comprehensive Care 193 Subacute Care-level III Complex Care 194 Subacute Care-level IV Intensive C

Revenue code 194 should be billed for

individuals on vents at vent facilities

Presented by: Illinois Association of Medicaid Health Plans 49

While not a reimbursable service due to

changes in the 2012 SMART Act, bed hold days should still be billed to the MCO’s to ensure continuity of care

Revenue codes that should be used are:

• 180—General
• 182—Patient Convenience
• 183—Therapeutic Leave
• 185—Nursing Home (for hospitalization)
• 189—Other Leave of Absence

Presented by: Illinois Association of Medicaid Health Plans 50

• HFS provided guidance related to oxygen claims in October 2013:

http://www.slfillinois.com/html/101713n1.html

• LTC facilities are responsible for providing the first tank of oxygen on a monthly basis and are

not allowed to bill for the 1st tank

• Tank is defined as:
• One “H” tank (6900 liters) or
• Two “E” tanks (623 liters) or
• 20 pounds of liquid oxygen
• In order to bill for oxygen, LTC facilities must be registered as a DME provider type 63 with the

State

• If you are not registered as a provider type 63 for DME, your claims will reject
• It is strongly recommended that you contact the MCO’s and let them know if you are registered as a DME

provider with HFS

• Oxygen claims must be billed separately from the R&B claims and done so on the professional

claim form

• The following are the appropriate HCPCS codes for oxygen claims:
• E0441--stationary oxygen contents, gaseous
• E0442--stationary oxygen contents, liquid (recently opened


retroactively)

• E0443--portable oxygen contents, gaseous
• E0444--portable oxygen contents, liquid
• We are confirming the billing requirements for oxygen as it relates to vent facilities

Presented by: Illinois Association of Medicaid Health Plans 51

If the member is an MMAI member and the therapy is

considered a Part B service, then therapy claims should be billed to the MCO

Services may need to be pre-authorized with the MCO and

are subject to service limitations

If this is not a Part B service or if Part B has been

exhausted, LTC facilities will not be reimbursed for therapy as it is included in your per diem rates—therapy should continue to be billed regardless of reimbursement

Outside agencies that provide therapy services that are not

affiliated with the LTC facility should submit claims to the MCO for adjudication

Presented by: Illinois Association of Medicaid Health Plans 52

A Medicare beneficiary who resides in an SNF or

NF may elect the hospice benefit if:

• The beneficiary is eligible for Medicaid and the facility is

being reimbursed for the beneficiary’s care by Medicaid, and

• The hospice and the facility have a written agreement

under which the hospice takes full responsibility for the professional management of the individual’s hospice care and the facility agrees to provide room and board to the individual

A beneficiary could be in a SNF under the SNF

benefit for a condition unrelated to the terminal condition and simultaneously be receiving hospice for the terminal condition

Presented by: Illinois Association of Medicaid Health Plans 53 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

• The State Medicaid Agency (and here it would be the MCO’s) pays the hospice the

daily amount allowed for room and board while the patient is receiving hospice care, and the hospice pays the facility. Room and board services include the performance of personal care services, assistance in activities of daily living, socializing activities, administration of medication, maintaining the cleanliness of a resident’s room, and supervising and assisting in the use of durable medical equipment and prescribed therapies

• Whenever Medicaid is involved, the hospice sends a copy of the election form to

the State Medicaid Agency at the time of the election, and also notifies them when the patient is no longer receiving hospice care

• For dually eligible beneficiaries, they must elect the benefit under both programs

at once

• They should also contact the MCO’s for authorization
• Detailed hospice billing instructions can be found at:

http://www2.illinois.gov/hfs/SiteCollectionDocuments/hospicehandbook.pdf

Presented by: Illinois Association of Medicaid Health Plans 54 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf

Presented by: Illinois Association of Medicaid Health Plans 55