IHCP Annual Workshop October 2017 MDwise UB-04 HHW-HIPP0519( - - PowerPoint PPT Presentation

Exclusively serving Indiana families since 1994.

IHCP Annual Workshop October 2017

MDwise UB-04

HHW-HIPP0519( 10/17)

APP0216 (9/15)

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• Who is MDwise?
• Provider Enrollment: Are you a MDwise contracted provider?
• General Claims Information
• Claim Submission
• Top claims denials and rejected submissions
• You received a denial…now what?
• How to file a claim dispute and appeal
• Quick Tips for claims adjudication
• Resources
• Questions

Agenda

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MDwise is:

• A local, not-for-profit company serving Hoosier Healthwise and

Healthy Indiana Plan members

• Exclusively serving Indiana families since 1994
• Over 400,000 members
• 2,000 primary medical providers

Who is MDwise?

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Delivery System Model What is a delivery system model?

• MDwise serves its Hoosier Healthwise and HIP members under

a “delivery system model”

• The basis of this model is the localization of health care around

a group of providers

• These organizations, called “delivery systems” are comprised of

hospital, primary care, specialty care, and ancillary providers

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IHCP Overview

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• In order to receive reimbursement from MDwise, the

provider must:

• Be registered and be actively eligible with the Indiana Health

Coverage Program (IHCP)

• Be enrolled with the appropriate MDwise delivery system
• Obtain a prior authorization if the provider is out of network
• Complete all required elements on the UB-04 form
• Submit claim to appropriate MDwise delivery system claims

payer

Provider Enrollment/Prior to Submitting a Claim

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• Claims processing for Hoosier Healthwise is delegated to the

MDwise delivery systems

– CMCS pays Hoosier Healthwise claims for:

• St.

Vincent

• St. Catherine / Select Health

– Claims vendor pays all other Delivery Systems

• All HIP claims are processed by the claims vendor
• If uncertain of the members delivery system, please refer to:

– Web Interchange – https://interchange.indianamedicaid.com/Administrative/logon.aspx – MDwise Provider Portal

General Claims Information – Delivery System

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For Example:

• If a provider renders service for a MDwise Eskenazi Health

member, the provider would submit their claim to the MDwise Eskenazi Health address, or using the MDwise Eskenazi payor ID. If the same provider rendered services to a MDwise IU Health member, the provider would submit claim to MDwise IU Health, following the same submission directions. General Claims Information – Delivery System

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Verifying Eligibility – Provider Portal

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Member Eligibility

• When a member’s RID number is entered in the MDwise

provider portal you will see: – The IHCP program the member is enrolled in – What delivery system they are assigned to – Assigned PMP – PMP assignment history General Claims Information

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General Claims Information Member Information

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General Claims Information

Timelines

• Claim Submission

– Contracted providers must submit claims to MDwise within 90 days of the date of rendering the service – When MDwise is secondary, claim must be submitted within 90 days

• f the date on the primary EOB
• Claim Inquiry
• One Form for all MDwise Programs
• Claims Inquiry Forms

– http://www.mdwise.org/for-providers/forms/claims/ – Customer Service: 1.800.356.1204

• Claim Disputes

– Submit dispute within 60 days of the date on EOB

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General Claims Information Secondary Insurance Submissions

• When the member has other insurance:

– Provider must submit claims to the other insurance carrier before submitting to the MDwise delivery system

• Submitting a secondary claim to MDwise

– Must be submitted within 90 days of the date on the EOB – Claim must be submitted with a copy of the EOB

• Be sure to verify member eligibility for the date of service

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For Hoosier Healthwise:

• Paper claims should be submitted to:

MDwise HHW Excel Claims P .O. Box 331550 Corpus Christi, TX 78463-1550

• CMCS pays Hoosier Healthwise claims for:
• St.

Vincent

• St. Catherine / Select Health
• All electronic EDI
• Change Health/Emdeon/Web MD Payer ID: 35191

Claims Submission Information

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For Healthy Indiana Plan:

• Paper claims should be submitted to:

MDwise HIP Claims P .O. Box 331609 Corpus Christi, TX 78463-1609

• All electronic EDI
• Change Health/Emdeon/WebMD Payer ID: 31354

Claims Submission Information

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• Rejected claims are different than denied claims

– Rejected claims are returned to the provider or electronic data interchange (EDI) source without registering in the claim processing system – A letter with the rejection reason will be sent by the claims processor – Since rejected claims are not registered in the claims processing system, the provider must resubmit the corrected claim within the claims timely filing limit

• Denied claims will include an EOB with a denial code
• Rejected claims do not extend the timely filing limit

– Providers have only 90 days from the date of service

Rejected vs. Denied Claims

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• Completely fill out the claim form
• Confirm member eligibility at the time of service
• Make sure Provider Profile is accurate on Provider Healthcare

Portal

– Providers must report NPI to IHCP

• Follow correct coding guidelines for claims submission
• Verify payer information before claims are submitted
• Submit claims and corrected claims timely
• Inquire or dispute claims within contractual timeline
• Include the provider NPI and taxonomy code on all claims

Quick Tips to Avoid Claims Denial or Rejections

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Hoosier Healthwise

So your claim is denied…now what? Claim Denial

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• Claims Inquiry

– Providers should contact MDwise Customer Service

• 1-800-356-1204
• Follow prompts for 2016 or 2017 claims
• Appeals for Hoosier Healthwise and HIP

– Must be in writing to the appropriate Delivery System – Providers have 60 calendar days to file an appeal and must include the following documentation:

• Appeal form, remittance advice and a copy of the claim

– If a delivery system fails to make a determination or the provider disagrees with the determination, the provider should forward their appeal to: MDwise P . O. Box 441423 Indianapolis, IN 46244-1423 Attention: Appeals Coordinator

So Your Claim Has Been Denied...Now What?

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The MDwise Claim Dispute team utilizes an electronic dispute process:

• 1. Provider completes the Claims Dispute Form found at www.mdwise.org on the

For Providers page, under Claim Forms

• 2. Completed form and supporting documents are sent via email

– cdticket@mdwise.org

• 3. Received email is routed to a Claims Dispute work queue where a ticket number

will be issued and an email notification will be sent back immediately

• 4. The Claim Dispute team will review the submitted dispute and work the cases to

resolution (uphold or overturn)

• 5. Once a resolution is reached, the claims payer will be notified of the need to

reprocess the claim, if necessary

• 6. An email notification will then be sent to the provider, referencing the dispute and

ticket number, on the resolution determination

General Claims Information - Timelines

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Important:

• Items that do no constitute a dispute include:

– Corrected Claims – New Claims – Medical Records – Attachments, including but not limited to:

• Consent forms
• MSRP on IHCP website
• Invoices

– Recoupments

General Claims Information - Timelines

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MDwise response timelines:

• Claim Submission

– 30 Business Days

• Claim Inquiry

– 30 Business Days

• Claim Dispute

– 30 Business Days

• Claim Appeal

– 45 Calendar Days

General Claims Information - Timelines

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• IHCP Claims and Billing Procedure Modules

– Section 2: UB-04 Claims Form information

• Types of services billed using UB-04
• Admission and Duration Requirements
• Use of ICD Procedure Codes
• UB-04 Claim Form Instructions
• Submitting Electronic Claims
• MDwise Provider Tip Sheets

– Third Party Liability – Vision Claims

Resources

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• MDwise Provider Tip Sheets

– Third Party Liability – Vision Claims

• http://www.mdwise.org/for-providers/tools-and-

resources/additional-resources/

• MDwise Provider Manuals

– http://www.mdwise.org/for-providers/manual-and-overview/

• MDwise Provider Relations Territory Map
• http://www.mdwise.org/for-providers/contact-information/
• MDwise Customer Service
• 1.800.356.1204
• IHCP Provider Modules

– Indianamedicaid.com

Resources

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Questions