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 How to handle discharg How to handle discharges, chang es, changes in MCO’s, es in MCO’s, MMAI, LTSS, & ICP and Part B and Part B � Eligibility & Enrollment Care Coordination � � MEDI System and ID cards Changing MCO’s � � Health Plan Discussions Managed Care Organizations � � Health Risk Assessments Coverage Map � � Quality Enrollment Examples � � Standardized Billing Standardized Billing Procedures Procedures Billing for skilled and custodial Billing for skilled and custodial MCO Standardization Project Skilled Care � � Standardized Billing Procedures Custodial Care � � Room & Board ◦ Submission methods � Bed holds ◦ Facility claim form � Professional claim form Oxygen ◦ � Billing Requirements Therapy ◦ � Taxonomy Codes Hospice � ◦ Rejections and Denials � Patient Credit File � 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 will remain their primary carrier, not the MCO Medicare ◦ 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: o Online Online: Go to Enroll. o Pho Phone ne: Call 1- 1-877- 877-912- 912-8880 8880 (TTY 1-866-565-8576). The call is free. o 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. o For MMAI the enrollment process is limited to o Pho Phone ne: Call 1- 1-877- 877-912- 912-8880 8880 (TTY 1-866-565-8576). The call is free. o 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 o No web enrollment option is available due to Federal regulation o Website allows for: o Viewing of materials o Compare health plans and Value Added Benefits o 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

Earliest ¡Es.mated ¡ Earliest ¡Es.mated ¡ Por.on ¡of ¡ Voluntary ¡ Mailing ¡ Date ¡ Expected ¡Mailings ¡ Passive ¡Enrollment ¡ Popula.on ¡ Enrollment ¡Effec.ve ¡ Effec.ve ¡Date ¡ 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

11 Presented by: Illinois Association of Medicaid Health Plans

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