Welcome! Provider Quality Advisory Group
ZOOM Please double check that you are on mute Please help us record who is in attendance by emailing your name and title to pscs@carewisc.org If you have questions during the meeting please use the chat feature and select “everyone” for your question.
February 26, 2019 1. Overview of 2019 goals AGENDA 2. Rebecca Hansen- Claims 3. DHS memo- Video Monitoring 4. PQAG meeting dates for 2019
2019 New Year & New Ideas 1. What to expect in 2019 1. New format- our goal is to provide a more efficient method of attending PQAG meetings 2. Offer learning opportunities throughout the year that will pertain to your contract or service area 3. Information sharing opportunity
Claims & Payment Start to Finish Rebecca Hansen Provider Relations Representative Phone: 608-245-3437 Toll Free: 800-963-0035 x3437
Portal Review Provider Portal https://secure.healthx.com/carewisconsin What is it, what is it used for? Authorization Portal https://providerportal.carewisc.org What is it, what is it used for?
Place a picture over white space for computer screen Delete this text after adding a new picture Images can be hyperlinked to websites
Place a picture over white space for computer screen Delete this text after adding a new picture Images can be hyperlinked to websites
Place a picture over white space for computer screen Delete this text after adding a new picture Images can be hyperlinked to websites Prior Auth- for https://www.carewisc.org/providers/claims-and-authorization/ Medicaid For Medicaid covered services such as Skilled Nursing, Medicaid Services Personal Care Services, PT/OT/ST and DME/DMS
How are Claims 1. Claim is scanned or Processed? electronically entered for processing 2. Claim is checked for member match/provider match/ authorization/pricing 3. If there are issues or questions, claim is reviewed by CW staff 4. Claim is paid!
Explanation Of Benefits EOB What is an EOB? EOB stands for Explanation of Benefits (also referred to as a remit) and outlines exactly how all claims on a given check were processed
Claims Issues….. Common reasons for claim Common reasons for denials: delayed claim payment: • Member not enrolled for DOS • Incomplete or mismatched • No auth/auth units exceeded member data or provider data • Duplicate charges • Not exact match with auth • Incorrect code billed • Possible duplicate • Missing required information • Setup issues due to new or • Need primary EOB changed contract or new • Timely filing exceeded placement
Denials? Now what? What are some common denial codes and what do they mean? • 04-Charges incurred outside coverage dates • 19-Precertification/authorization/notification absent • AE-Please resubmit claim with corresponding primary carrier EOB • AH-Please resubmit with valid HCPCS coding • BR-Denied for incorrect revenue code. Please review your admission agreement and resubmit with correct code • GL-Plan timely filing limit exceed • MN-Not a covered condition/service • N3-Date range not valid with units submitted. • ND-Medicaid allowance exceeded.
Timely Filing SUBMIT CLAIMS ON TIME Avoid Denials Avoid Appeals Avoid Confusion Contract Requirements for Timely Filing The provider must submit the claim no later than sixty (60) calendar days after the last date of service.
Appeals and If you are not sure whether to submit a Corrected Corrected Claim or an Appeal, please call the Provider Help Desk to clarify! Claims How to Correct a Claim How to Appeal a Claim If your claim is denied due to your If your claim is denied for a reason you are error, or you need to adjust the amount unable to correct (i.e. timely filing), you that was billed, please submit a may submit a formal appeal for corrected claim. There is an option to reconsideration. We recommend using the bill as Adjusted/Corrected on both the Appeal form available on our website, but Claims Web Portal and paper claim it is not required. Please include as much forms. Spreadsheet claims that have information as possible so we can make partial or full payment may not be an accurate determination. You must have adjusted via spreadsheet and must be received a denial in order to appeal; do submitted through the Portal or paper. not submit an appeal with a new or corrected claim that has not yet been processed.
Just Keep Billing! ❑ When in doubt, just keep billing! ❑ This will ensure your claims meet timely filing ❑ Claims can always be corrected ❑ Claims will be paid faster in the long run if you bill, even without all the “right” information
Questions?
DQA Memo 16-001 ▪ Electronic video monitoring and filming in BAL regulated facilities ▪ Reviews permissible and impermissible circumstances and locations for facility-initiated use of such equipment ▪ State statutes and administrative rules apply to specific assisted living facility types: AFH, CBRF, and RCAC.
DQA Memo cont … ▪ Each Facility Type (AFH, CBRF and RCAC) has their own set of statutes and rules regarding resident rights to PRIVACY. ▪ The memo identifies how video monitoring or filming would infringe on resident rights and gives examples. ▪ Rights can be violated even with a residents informed and written consent.
AFH & CBRF
AFH & CBRF
RCAC
DQA Memo 16-001 The entire memo can be found at: https://www.dhs.wisconsin.gov/dqa/memos/16-001.pdf
Other Updates Care Wisconsin recently opened two Request for Proposals for facility expansion in Brown and Dane Counties. An email went out with details earlier this month. Be on the look out for future opportunities and communications similar to this.
Questions or Comments? When in doubt, reach out! Customer Service: 1-800-963-0035. Provider Help Desk: 1-855-878-6699
Thank You Thank you for joining us via Zoom! Please help us record who is in attendance by emailing your name and title to pscs@carewisc.org Feedback is also welcome!
2019 April 23 rd July 23 rd Oct 22 nd *All Meetings will be 2pm-3pm **Watch emails for information and update for locations
Recommend
More recommend
