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MHS CMS-1500

Prior Authorization Top Denials

October 22, 2009

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CLAIM PROCESS

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Claim Process -Top 10 Denials

• Time Limit For Filing Has Expired (EX 29)– Claims must be received within 120 calendar days of the

date of service (Contracted Providers)• Exceptions

– 120 days from DOS for Participating Providers– Exceptions: Newborn, Third Party Liability, and Eligibility

delays (filing limit 365 days)– 365 days from DOS for Non Participating Providers

• Bill Primary Insurer 1st (EX L6)– Verify other insurance (TPL). Medicaid is the payer of last

resort– MHS requires a copy of the primary EOP

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Claim Process -Top 10 Denials

• Coverage Not In Effect When Service Provided (EX 28)– Check eligibility at each visit prior to submitting claims to ensure

that you are billing the correct carrier

• Non Covered Service For Package B Member (EX BP)– Package B allows for pregnancy related services only– Pregnancy related diagnosis must be on claim for service to be

coverage

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Claim Process -Top 10 Denials

• Code Was Denied By Code Auditing Software (EX 57)– McKessen code audit analysis all claim line items and

code combinations by date of service during the auditing/processing of claims – Unbundling– Global– Assistant Surgeon

– Claim auditing software tool on web @ www.managedhealthservices.com assists in explanation on how MHS evaluates different code combinations

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Claim Process -Top 10 Denials

• Member Name/Number/Date Of Birth Do Not Match (EX MQ)– Member information on claim must match what is on file

with Indiana Medicaid

• This Service is Not Covered (EX 46)– Service must be coverable through Indiana Medicaid to be

eligible for reimbursement

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Claim Process -Top 10 Denials

• Authorization Not On File (EX A1)– Prior Authorization should occur at least two (2) business

days prior to the date of service. Non All elective inpatient/outpatient services must be prior authorized with MHS at least two (2) business days prior to the date of service

– All urgent and emergent services must be called to MHS within two (2) business days after service/admit

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Claim Process -Top 10 Denials

• Claim and Auth Service Provider Not matching (EX HP)– Authorization on file does not match date of service billed

• Claim and Auth Provider Specialty Not Matching (EX HS)– Authorization on file does not match provider billing

service

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Claim Process - Billing With Ease

• Newborns– Newborn’s RID number is required for payment.

• Consent Forms– Need to be attached to the claim form when submitted for

claim processing.

• NPI, Taxonomy, Tax ID Not on File with MHS Rejections– The system cannot make a one to one match based off of

the information provided on the claim.

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Claim Process – Claim Filing

• EDI SUBMISSION

Preferred method of claims submission– Immediate Confirmation of receipt– Faster payment processing– Less expensive than paper submission– MHS Payor ID 39186

• It is the responsibility of the provider to review the error reports received from the Clearinghouse

– ERF / ERA available– Contact EDI@centene.com with questions

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Claim Process – Claim Filing

On-line through the Managed Health Services website:

www.managedhealthservices.com– Provides immediate confirmation of received claims and

acceptance

• Paper Claims – Managed Health Services

PO Box 3002

Farmington, MO 63640-3802

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Claim Process – Resubmission

• Clearly mark RESUBMISSION or CORRECTED CLAIM at the top of the claim.

• Must attach EOP, documentation, and explanation of the resubmission reason.

• May use the Provider Claims Adjustment Request Form.

• Providers have 67 calendar days67 calendar days from the date they receive their EOP to file a resubmission.

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Claim Process – Claim Adjustment

• If you need to make an adjustment to a paid claim, you can do so by submitting the adjustment request on paper with the adjustment request form.

• Attach a MHS Provider Adjustment Form along with documentation, including EOP (if available) explaining reason for resubmission

• Claim adjustments requests must be submitted within 67 days of the date of the MHS EOP

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Claim Process – Dispute Resolution

PROVIDERS HAVE 67 CALENDAR DAYS FROM THEDATE OF RECEIPT OF THE EOP TO FILE ANOFFICIAL DISPUTE OR APPEAL WITH MHS

Verbal inquiries can be made by calling the MHS ProviderInquiry Line at 1-877-MHS-4U4U (647-4848).

A verbal inquiry is not considered a dispute or appeal and does not stop the 67 calendar days from the date of receipt of the EOP to file a dispute or appeal

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Claim Process – Dispute ResolutionINFORMAL CLAIM DISPUTE/OBJECTION

Level One Appeal

• 1ST step in the appeals process

• Should be made in writing by using the Dispute/Objection form

• Submit all documentation supporting your objection

• Send to MHS within 67 calendar days67 calendar days of receipt of the MHS EOP

• A call to Provider Inquiry does not reserve appeal rights

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Claim Process – Dispute ResolutionFORMAL CLAIM DISPUTE/OBJECTION

Level Two Appeal (Administrative)

Submit the Formal Claims Dispute (Administrative Appeal) with all supporting documentation to the MHS appeals address:

Managed Health ServicesAttn: AppealsP.O. Box 3000

Farmington, MO 63640-3800

MHS will acknowledge your appeal within 5 business days

Provider will receive notice of determination within 45 calendar days of the receipt of the Appeal

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Provider Inquiry Services

Call us at 1-877-647-4848. We are ready to help you!

• Knowledgeable, friendly staff available 8:00-6:00 EST• Focused commitment to professional service• Claims address P.O. Box 3002 Farmington, MO

63640• Dispute & appeal processes (67 days from receipt of

EOP)• Appeal address P.O. Box 3000 Farmington, MO

63640

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Utilization Management

(Prior Authorization)

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Utilization Management

REFERRAL

A referral is a request (verbal, written, or telephonic communication) by a PMP for specialty care services.

PRIOR AUTHORIZATION

Prior Authorization is an approval from MHS to provide services designated as needing approval prior to treatment and/or payment.

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Utilization Management

Self Referrals– Podiatrist – Chiropractic– Family Planning– Immunizations– Routine Vision Care– Routine Dental Care– Mental Health by Type and Specialty– HIV/AIDS Case Management– Diabetes Self Management

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Utilization Management

• Prior Authorization (PA) should be initiated through the MHS referral line at 1-877-MHS-4U4U (647-4848)

• The PA process begins at MHS by speaking with the MHS non-clinical referral staff.

• Prior Authorizations can also be submitted online via our website at www.managedhealthservices.com. Additional documentation may be required to be sent via fax for approval of authorization.

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Utilization Management

Services that require a prior authorization regardless of contract status:– All elective hospital admissions two business days prior

All urgent and emergent hospital admissions (including NICU) require notice to MHS by the 2nd business day after admission

– Transition to hospice– Newborn deliveries by 2nd business day– Rehabilitation facility admissions– Skilled nursing facility admissions– Transition of care– Transplants, including evaluations

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Utilization Management

Services that require a prior authorization regardless of contract status:– Cardiac rehabilitation– Hearing aides and devices– Home care services, including home hospice– In-home infusion therapy– Orthopedic footwear– Orthotics and prosthetics >$250– Respiratory therapy services– Pulmonary rehabilitation

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Utilization Management

Services that require a prior authorization regardless of contract status:– Abortions (spontaneous only)– Assistant Surgeon– Blepharoplasty– Cholecystectomies– Circumcision (any patient over 30 days old)– Hysteroscopy and Hysterectomy– Therapies, excluding evaluations– Dental Surgery for members >5 y/o &or general

anesthesia is requested– Dialysis

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Utilization Management

Services that require a prior authorization regardless of contract status:– Experimental or investigational treatment/services– Genetic testing or counseling– Home care services– Implantable devices including cochlear implants– Infertility services– Injectable Drugs (greater than $100 per dose– Mammoplasty– Nutritional counseling (non-diabetics only)– Pain Management Programs including epidural, facet

and trigger point injections – PET, MRI, MRA and Nuclear Cardiology/SPECT scans

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Utilization Management

Services that require a prior authorization regardless of contract status:– Scar revision/cosmetic or plastic surgery– Septoplasty/Rhinoplasty– Spider/Varicose veins– Specific DME services (listing on Quick Reference

Guide)

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Utilization Management

To initiate the authorization, referral staff will require the following information:

• place of service: outpatient, observation or inpatient

• service type: elective, emergent or transfer • service date• name of physician performing service• CPT code for proposed services• primary and any secondary diagnosis• contact name and number to obtain clinical

information

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Utilization ManagementDenial of Request and Appeal Process

If MHS denies the requested service:• MHS CM will notify the provider verbally within one business

day of the denial, provide the clinical rationale, and explain appeal rights

• A formal letter of denial explaining denial rationale and appeals rights will be mailed within the next business day

• If denial is based on Milliman Care Guidelines, provider has right to obtain a copy of the guidelines in which denial is based

• If member is still receiving services the provider has the right to an expedited appeal which must be requested by the attending physician

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Utilization ManagementDenial of Request and Appeal Process

If MHS denies the requested service:• If the member has already discharged- an appeal must be

submitted in writing from the attending physician within 60 days of the denial

• The attending physician has the right to a Peer to Peer discussion

• Peer to Peer discussions and Expedited Appeals are initiated by calling MHS at 1-877-MHS-4U4U (647-4848) and asking for the Appeal Coordinator

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Utilization Management

• MEDICAL NECESSITY GRIEVANCE AND APPEALS

Managed Health ServicesAttn: Appeals Coordinator

1099 North Meridian Street, Suite 400Indianapolis, IN 46204

• Determination will be communicated to the provider within 20 business days of receipt

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MHS - Need To Know

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MHS – Need to Know

• Member Services– Transportation– NurseWise– Healthy Reimbursement Account– Connections– Panel Change Requests

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MHS – Need to Know

• Adding a new provider– Provider must have Indiana Medicaid Linked to group before

MHS credentialing and set up process can begin.– Contact Provider Relations @ 877-647-4848 to obtain

Provider Enrollment Form for proper set up and Participation Provider Attestation to link provider to existing contract.

– Welcome letter will be issued once set up complete.– Obtain Prior Authorization for all services rendered to MHS

prior to confirmation of contracted status. Provider Inquires 877-647-4848

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MHS – Need to Know

www.managedhealthservices.com

&

1-877-MHS-4U4U (647-4848)

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Need to Know - MHS Website

• www.managedhealthservices.com • Enhanced website – Access for both contracted/non-contracted

groups• On-line Registration – Multiple Users• Provider Directory Search Functionality• Enhanced Claim Detail• Direct Claim Submission (Professional Claims only)• Printable EOP• On-line prior authorization guide and submission• Claim Auditing Software Tool• Downloadable Eligibility Listing• Printable, Current Forms and Manual

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Need to Know - MHS Website

Upcoming Enhancements

• Direct claim submission UB04 – 2010• Claim resubmission – 2010• Claims Xtend – 2010

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Need to Know – Provider Education

MHS generates a Provider Watch Bulletin of helpful tips and Plan updates to billing office locations for all participating providers on a quarterly basis. All providers can review this bulletin on the MHS website at www.managedhealthservices.com.

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Questions and Answers