Welcome! Provider Quality Advisory Group ZOOM Please double check - - PowerPoint PPT Presentation

Welcome! Provider Quality Advisory Group

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ZOOM

AGENDA

February 26, 2019

• 1. Overview of 2019 goals
• 2. Rebecca Hansen- Claims
• 3. DHS memo- Video Monitoring
• 4. PQAG meeting dates for 2019

• 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

2019 New Year & New Ideas

Rebecca Hansen Provider Relations Representative Phone: 608-245-3437 Toll Free: 800-963-0035 x3437

Claims & Payment Start to Finish

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?

Portal Review

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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 Medicaid Services

https://www.carewisc.org/providers/claims-and-authorization/ For Medicaid covered services such as Skilled Nursing, Medicaid Personal Care Services, PT/OT/ST and DME/DMS

• 1. Claim is scanned or

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!

How are Claims Processed?

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

Explanation Of Benefits EOB

Common reasons for delayed claim payment:

• Incomplete or mismatched

member data or provider data

• Not exact match with auth
• Possible duplicate
• Setup issues due to new or

changed contract or new placement

Common reasons for claim denials:

• Member not enrolled for DOS
• No auth/auth units exceeded
• Duplicate charges
• Incorrect code billed
• Missing required information
• Need primary EOB
• Timely filing exceeded

Claims Issues…..

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.

Denials?

Now what?

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.

Timely Filing

How to Appeal a Claim

If your claim is denied for a reason you are unable to correct (i.e. timely filing), you may submit a formal appeal for

• reconsideration. We recommend using the

Appeal form available on our website, but it is not required. Please include as much information as possible so we can make an accurate determination. You must have received a denial in order to appeal; do not submit an appeal with a new or corrected claim that has not yet been processed.

How to Correct a Claim

If your claim is denied due to your error, or you need to adjust the amount that was billed, please submit a corrected claim. There is an option to bill as Adjusted/Corrected on both the Claims Web Portal and paper claim

• forms. Spreadsheet claims that have

partial or full payment may not be adjusted via spreadsheet and must be submitted through the Portal or paper.

Appeals and Corrected Claims

If you are not sure whether to submit a Corrected Claim or an Appeal, please call the Provider Help Desk to clarify!

❑ 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

Just Keep Billing!

Questions?

▪ Electronic video monitoring and filming in BAL regulated facilities ▪ Reviews permissible and impermissible circumstances and locations for facility-initiated use

• f such equipment

▪ State statutes and administrative rules apply to specific assisted living facility types: AFH, CBRF, and RCAC.

DQA Memo 16-001

▪ 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

• n resident rights and gives examples.

▪ Rights can be violated even with a residents informed and written consent.

DQA Memo cont…

AFH & CBRF

AFH & CBRF

RCAC

The entire memo can be found at: https://www.dhs.wisconsin.gov/dqa/memos/16-001.pdf

DQA Memo 16-001

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

• n the look out for future
• pportunities and

communications similar to this.

Other Updates

When in doubt, reach out! Customer Service: 1-800-963-0035. Provider Help Desk: 1-855-878-6699

Questions or Comments?

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!

Thank You

April 23rd July 23rd Oct 22nd *All Meetings will be 2pm-3pm **Watch emails for information and update for locations

2019