basic billing 2013 ohio medicaid home care aides

Basic Billing 2013 Ohio Medicaid Home Care Aides

Ombudsman Kathy Frye Laura Gipson Dwayne Knowles Kenneth Morgan Jamie Speakes Meagan Lyle, Manager Office of Ohio Health Plans External Business Relations 2

Investigate and resolve billing issues Identify system and policy issues Speak at seminars for provider associations Conduct individual consultations with providers Conduct basic billing trainings 3

Agenda Medicaid Overview Policy Overview MITS Websites 4

Medicaid Overview 5

Covered Families and Children (Healthy Start and Healthy Families) Aged, Blind or People with Disabilities Home and Community Based Waivers Medicare Premium Assistance Hospital Care Assurance Program Medicaid Managed Care Ohio Department of Medicaid (ODM) 6

Covered Families and Children (Healthy Start and Healthy Families) Aged, Blind or People with Disabilities Home and Community Based Waivers Medicare Premium Assistance Hospital Care Assurance Program Medicaid Managed Care Ohio Department of Medicaid (ODM) 7

Ohio Medicaid Benefits Home Health Services Transportation services Physician Services Inpatient/ Outpatient Services Nursing Facility Dental services Durable medical equipment Hospice Services Behavioral Health Pharmacy Services Vision 8

Medical Necessity The fundamental concept underlying the Medicaid Program. All services must meet accepted standards of medical practice 9

Interactive Voice Response System (IVR) 1-800-686-1516 All calls are directed through the IVR prior to accessing the customer call center staff Providers are responsible for granting and maintaining IVR access for their billing entities or trading partners Provider Assistance staff are available weekdays from 8:00 am to 4:30 pm Because of HIPAA laws you must authenticate with your Provider Identification Number (PIN) to access Protected Health Information (PHI) 10

Ohio Ohio Medicaid Card for individuals not on a specific program under Medicaid Issued monthly 11

SPENDDOWNVS. PATIENT LIABILITY 12

Monthly Income When a consumers EXCEEDS There is a SPENDDOWN! Medicaids Need Standard 13

Medicaid Spenddown 5101:1-39-10 If a non-waiver consumer has an income that exceeds the Medicaid need standard, the consumer must incur medical expenses that will reduce his/her income to the Medicaid need standard. The department defines incurred expenses as expenses that the client is obligated to pay. When the spenddown amount is incurred, the consumer must contact his/her caseworker at his or her local CDJFS to be eligible for Medicaid. 14

Medicaid Spenddown (Continued) Three ways spenddown can be met: ONGOING: Routinely occurring medical expenses, of the same type and amount each month, that are not covered by Medicaid PAY-IN: The spenddown amount is paid to the CDJFS DELAYED: Medical expenses vary from month to month, must verify the incurred amount with the CDJFS 15

Medicaid Spenddown Example When a Medicaid consumers monthly income exceeds the need standard there is a Spenddown. Consumers Monthly Income $500.00 Medicaid Need Standard $400.00 = Spenddown$100.00 _ 16

PATIENT LIABILITY A consumer on a waiver program may have a patient liability instead of a spenddown. The department defines patient liability expenses as expenses that the client is obligated to pay. Refer to the consumers All Services Plan for the liability amount and the provider(s) who receives the liability payment. 17

Provider Agreement 5101:3-1-17.2 The provider agreement is a legal contract between the state and the provider. In that contract, you agreed to: Accept the allowable reimbursements as payment-in- full and will not seek reimbursement for that service from the patient, any member of the family, or any other person Maintain records for 6 years 18

Provider Agreement (Continued) You also agreed to: Render medically necessary services in the amount required Recoup any third party resources available Inform us of any changes to your provider profile within 30 days Abide by the regulations and policies of the state 19

Provider Reimbursement 5101:3-1-02 5101:3-1-60 The departments payment constitutes payment-in- full for any of our covered services Providers are expected to bill the department their usual and customary charges (UCC) The department reimburses the provider at the Medicaid rate (established fee schedule) or the UCC, whichever is the lesser of the two. 20

Coordination of Benefits 5101:3-1-08 Medicaid is the payer of last resort. Therefore, providers must obtain a payment or denial from other payers prior to billing Medicaid. Providers who have gone through reasonable measures to obtain all third party payments, but who have not received a payment (or received a partial payment) from other payers, may submit a claim to Medicaid requesting reimbursement for the rendered service(s) in accordance to OAC rule 5101:3-1-08. 21

Recipient Liability 5101:3-1-13.1 A Medicaid consumer cannot be billed: When a Medicaid claim has been denied Unacceptable claim submission Failure to request a prior authorization Retroactive Peer Review determination of lack of medical necessity 22

Medicaid Subrogation Rights 5101:3-1-08 Section 5101.58 of the Ohio Revised Code requires that a Medicaid consumer provide notice to the department prior to initiating any action against a liable third party The department will take steps to protect its subrogation rights if that notice is not provided For questions, contact the Coordination of Benefits Section (614-752-5768) 23

Electronic Funds Transfer (EFT) ODJFS suggests electronic funds transfer (EFT) for payment instead of paper warrants. Benefits of direct deposit include: Receipt of payment quicker: Funds are transferred directly to your account on the day paper warrants are normally mailed No more worry about lost or stolen checks or postal holidays delaying receipt of your warrant If you move your payment will still be deposited into your banking account For additional information and to begin receiving funds electronically, you will find the Direct Deposit/EFT form at: http://jfs.ohio.gov/OHP/provider.stm 24

Policy Overview 25

OAC Rules http://emanuals.odjfs.state.oh.us/emanuals/ http://emanuals.odjfs.state.oh.us/emanuals/ Based on your provider agreement, you are obligated to abide by the regulations and policies of the state. Therefore, you must read and understand all Ohio Administrative Code (OAC) rules that pertain to your provider type. To start, please refer to the OAC rules noted below: 5101:3-45-01, Definitions 5101:3-45-10, Conditions of Participation 5101:3-46-04, Covered Services, Requirements, Specifications 5101:3-46-06, Reimbursement Rates and Billing 26

Policy Updates Policy updates from Ohio Medicaid announce the changes to Ohio Administrative Code that may affect providers. There are two types of letters: Community Services Transmittal Letters (CSTL) Medical Assistance Letters (MAL) 27

STATE PLAN SERVICES VS. VS. WAIVER SERVICES 28

STATE PLAN SERVICES are services that all Medicaid recipients can receive if they are medically necessary and Ohio Administrative Code (OAC) rules allow those recipients to receive the services. ODJFS submits a State Plan to the federal government that describes how the Medicaid program is administered. Medicaid is an entitlement program. Therefore, all Medicaid recipients are entitled to receive State Plan services if they are medically necessary and allowable based on OAC rules. What are State Plan Services? 29

The term waiver refers to an exception to federal law that waives certain Ohio Medicaid eligibility requirements and allows eligible Medicaid recipients to cost effectively live in their communities instead of nursing homes or hospitals. Since waiver programs are not entitlement programs, only recipients enrolled on a waiver program can receive waiver services from that waiver program. What are Waivers? 30

Waiver Programs Administered By ODJFS The Ohio Home Care Waiver This waiver program serves recipients who are under the age of 60 and are not mentally retarded or developmentally delayed. The Transitions DD Waiver This is wavier is currently administered by the Ohio Department of Developmental Disabilities (DODD). The Transitions Carve-Out Waiver This is a waiver program for 60 year old (or older) recipients who were on the Ohio Home Care waiver. 31

Waiver Personal Care Services: T1019 Personal Care/Aide Services Waiver Programs Administered By ODJFS (Procedure codes) When an RN or LPN is providing a waiver service, the appropriate procedure code and modifier must be used. 32

Waiver Services, continued: H0045 - Out-of-Home Respite Care Services S0215 - Non-Emergency Transportation Services S5101 - Day Care Services, Adult Half Day S5102 - Day Care Services, Adult Full Day S5160 - Emergency Response ServicesInstallation S5161 - Emergency Response ServicesMonthly Fee S5165 - Minor Home Modifications S5170 - Home Delivered Meals T2029 - Specialized Medical Equipment Waiver Programs Administered By ODJFS (Procedure codes) 33

U1 is for infusion therapy, RNs only U2 is for the 2 nd visit on the same day U3 is for 3 rd (or more) visit on same day U4 is for a visit over 12 hours up to 16 hours HQ is the group modifier Waiver Programs Administered By ODJFS (Modifiers) 34

Services At a Glance Services At a Glance The Services-at-a-Glance chart has been developed as a way to quickly see the major components of State Plan and of Waiver Services. 35

Fix The Problem Before It Becomes A Problem That Cant Be Fixed. 36

Problems That Must Be Fixed Prior To Submitting Claims Follow the All Services Plan. Understand the terminology (e.g., state plan, waiver). Read and understand the OAC rules. Make sure your billing staff or billing company have all the information they need to submit claims for you (e.g., correct dates of service, procedure codes, modifiers). 37

BILL ALL WAIVER SERVICES ACCORDING TO THE ALL SERVICES PLAN ALL SERVICES PLAN ALL SERVICES PLAN 38

You or your agency must provide waiver services according to the All Services Plan. Contact your case manager for details. Waiver Services 39

When billing for waiver services for recipients on other waiver programs (e.g., PASSPORT), contact the appropriate state or county agency for billing instructions. other waiver programs Waiver Programs Administered By Other State Agencies 40

Key Points Follow the billing instructions. Bill all services in chronological order. Each line on a claim represents a visit or a service. Most services are billed in multiple units. Bill for services using the appropriate procedure code and modifier. Some services may require multiple modifiers. Only bill for the services noted on the All Services Plan. 41

CALCULATION FOR AIDE SERVICES EXAMPLE: Noted below is the Medicaid maximum calculation for a 12-hour independent aide visit. 12 (hours) x 4 = 48 (convert hours to units) 48 - 4 = 44 44 x $3.00 = $132.00 $132.00 + $18.61= $150.61 (Medicaid Maximum)Medicaid Maximum [(Total Units 4) x Unit Rate] + Base Rate = Medicaid Maximum 42

Medicaid Information Technology System (MITS) 43

MITS General Information Medicaid Information Technology System MITS is the new Web-based, Medicaid management system MITS design is based upon the Medicaid Information Technology Architecture (MITA) MITS is a.NET environment able to process transactions in real time 44

Provider Contracts In MITS, a provider will have a provider contract that determines the Medicaid population the provider is contracted to provide services to and receive reimbursement. If a provider provides aide services to ODJFS waiver clients, the provider will receive an ODJFS Waiver Personal Care contract. If a provider provides aides services to clients on the Individual Options waiver, the provider will receive an Individual Options contract. If providers have questions regarding their contract, they should contact Provider Enrollment (1-800-686-1516). MITS General Information 45

Internal Control Number (ICN) The ICN replaced the Transaction Control Number (TCN) All claims will be assigned an ICN 2010170357321 2010170357321 Region Code Calendar Year Julian Day Claim Type/Batch Number Number of Claim in Batch MITS General Information 46

Internal Control Number (ICN) Primary region codes new claim submission 10Paper Claim without attachment 11Paper Claim with attachment 20 Electronic 837 without attachment 21Electronic 837 with attachment 22Web Portal without attachment 23 Web Portal with attachment MITS General Information 47

Primary Region Codes, continued 50 Adjustment Non-check Related 51 Adjustment Check Related 52 Mass Adjustment Non-Check Related 53 Mass Adjustment Check Related 54 Mass Adjustment Void Transaction 55 Mass Adjustment Provider Retro Rates 56 Adjustment Void Non-Check Related 57 Adjustment Void Check Related 58 Adjustment Internet claims MITS General Information 48

Converted Claims Claims in MMIS were converted for historical purposes and are denoted by the ICN region code 40 Claims converted from MMIS to MITS can only be voided MITS General Information 49

System Requirements Technical Requirements Internet Access (high speed works best) Internet Explorer version 8.0 and above or Firefox 1.5 3.5 MAC Users-download Internet Explorer for MAC Turn off pop-up blocker functionality How do I Access the MITS Portal? Go to http://jfs.ohio.govhttp://jfs.ohio.gov The ODJFS Welcome Page displays Select the Medicaid Information Technology System (MITS) link 50

System Requirements 51

MITS Web Portal Navigation Copy, Paste, and Print features will work in the MITS Portal Back feature will not work in the MITS Portal MITS Web Portal access will time-out after 15 minutes of inactivity Navigation 52

Panel Help The ? button in the upper right corner of a panel may be selected to reveal panel information Navigation 53

Navigation Field Help Clicking a field title will open a box containing field information 54

Registration Ohio Medicaid Providers must create a MITS web portal account to access the system. Setting up the account can be a three step process. The Administrator Account Setup Agent Account Setup Assigning Agent Roles 55

Administrator Account Setup One account per billing NPI Only one person may set-up an Administrator Account Access to all secure information Responsible for assigning roles to agents Unlimited Agents Responsible for maintaining the providers MITS Portal account including demographic information Registration 56

Registration 57

Registration 58

Agent Account Setup Each Agent needs only one account Agents set up own accounts Administrator Account holder sets up Agent roles Each Agent account is role based Accounts setup by Pay to NPI Agent User ID remains the same Access to different NPIs can be granted Agents access may be revoked by role and NPI Registration 59

Registration 60

Registration 61

Registration 62

Registration Each agent is assigned one or more of the following roles Eligibility Prior Auth Search Prior Auth Submit Claim Search Claim Submission 1099 Information (includes remittance advices) 63

Agent Maintenance Panel Registration 64

MITS Web Portal Access Flowchart Provider Account Setup Agent Account Setup Provider Assigns Role(s) 1 3 2 Registration 65

Registration 66

Switch Provider Panel Registration 67

Reminder MITS Portal is Web based and as long as access is still active, agents will be able to log into your account(s) so remove their access as soon as they leave the office. Registration 68

Updating Provider Demographics Perform updates via the MITS Web Portal by selecting Providers and then Demographic Maintenance from the main menu Reminder: Per Ohio State Law, Providers must notify the State within 30 days of any change to demographics Registration 69

Re-enrollment Processes and Features All new providers or current providers who are re- enrolling must use the MITS Web Portal Check the status of re-enrollments via the MITS Web Portal 70

Re-enrollment 71

Re-enrollment 72

Application Tracking Number (ATN) The 6 digit ATN will be assigned at the beginning of the enrollment process Up to 3 days to complete the application Check status of applications once completed Re-enrollment 73

Re-enrollment 74

Providers can use the MITS Web Portal to search and verify recipients eligibility for benefit programs Eligibility information is found on the Eligibility Verification Request Panel Eligibility Verification 75

Eligibility Verification Verification of the following: MedicareManaged Care Benefit PlanLong Term Care Third Party 76

Eligibility Verification 77

Eligibility Verification 78

Claim Submission Methods of Claim Submission Electronic Data Interchange (EDI) MITS Web Portal Paper claims Paper claims will not be accepted after 1/1/2013 If you currently submit paper, plan for the transition now to either EDI or MITS portal 79

EDI Need to contract with a trading partner or create/or purchase own software. Fees for claims submitted Claims received electronically via the trading partner by 12:00 am Wednesday will be processed for adjudication over the weekend. No limit to number of claims you can submit each day. Portal Free submissions Providers need access to the internet. Claims received by 5:00 pm Friday will be processed for adjudication over the weekend. Limit of 50 claims per day, and this may change to unlimited claims in the near future. When the change occurs, providers will be notified. Comparison of EDI and Portal Claim Submission 80

Claim Submission Electronic Data Interchange Information for Trading Partners jfs.ohio.gov/OHP/tradingpartners/info.stm Companion Guides 837 Health Care Claim Professional EDI Information Guide Technical Questions/EDI Support Unit 614-387-1212 [email protected] 81

Claims Entry Format are divided into different sections called panels Each Panel will have an asterisk (*) for a portal required field. There are some fields that are situational for claims adjudication that do not have an asterisk, but are required for adjudication. Add/Delete/Copy Search Description Numeric Claim Submission 82

Billing instructions Billing instructions for submitting claims via the MITS Web Portal are accessible via eManuals, and these instructions will provide information that includes (but isnt limited to): Field level information; A brief explanation of options in drop down menus (e.g., Medicare Assignment, Release of Information); Provider specific information (e.g., which providers must enter diagnosis codes). Claim Submission 83

Multiple Visits in One Day If a provider is providing multiple visits in one day, all of the visits must be noted on a single claim. Claim Submission 84

Claim Submission 85

Claim Submission (Billing/Service Information Panel) Complete all of the appropriate fields. Fields marked with an asterisk (*) must be completed. If providers received patient liability payments from clients, denote the payment in the Patient Amount Paid field. 86

Claim Submission (Diagnosis Panel) A diagnosis is optional on claims with any of the following procedure codes: G0151, G0152, G0153, G0154, G0156, H0045, S0215, S5101, S5102, S5125, S5160, S5161, S5165, S5170, T1000, T1002, T1003, T1019, T2029. However, if one or more diagnoses are specified, then each claim line in the 'Detail' panel must point to (be associated with) at least one diagnosis. 87

Claim Submission (Other Payer Panel) Considering Medicaid is the payer of last resort, providers must receive a payment or denial from other payers (i.e., payers other than Medicaid) prior to submitting claims to Medicaid, and these claims must reflect the other payers payment and/or denial information. Submitting claims with Other Payer information will be discussed in a separate section of this presentation. 88

Claim Submission (Detail Panel) Complete all of the appropriate fields. Fields marked with an asterisk (*) must be completed. 89

Claim Submission (Attachment Panel) In most situations, home care aides will not include an attachment with claims. 90

Claim Submission (Delayed Submission/Resubmission Panel) If a claim was initially received within 365 days from the 1 st date of service on the claim, but the claim was adjusted or resubmitted within 180 days after the initial claim was paid or denied, denote the ICN of the initial claim. This process establishes timely filing for adjusted/resubmitted claims. 91

Claim Submission (Claim Status Panel) This panel denotes the status of claims. If the claim was submitted and the status is Not Submitted Yet refer to the top of the claim for error messages. Correct the errors (as noted in the error messages) and resubmit the claim. When the claim is appropriately submitted, the status of the claim will be: Paid, Denied, or Suspended 92

TPL Submission Other Payer Information Third-Party Liability (TPL) claims must be submitted EDI or via web portal HIPAA compliant adjustment reason codes and amounts are required Other payer information can be reported at the claim level (header) or at the line level (detail). This includes primary other payer payments or denials Allowed amount is required for other payer TPL. MITS will automatically calculate the allowed amount. 93

SUBMITTING COMMERCIAL PAYER DENIAL INFORMATION AT THE CLAIM LEVEL Click the Other Payer Amount and Adjustment Reason Code link to denote the appropriate CAS Group Code, ARC Amount, and ARC. 94

SUBMITTING COMMERCIAL PAYER PAYMENT INFORMATION AT THE CLAIM LEVEL Click the Other Payer Amount and Adjustment Reason Code link to denote the appropriate CAS Group Code, ARC Amount, and ARC. 95

Adjusting, Voiding, & Copying Claims Paid claims can be Adjusted Voided Copied 96

Adjusting, Voiding, & Copying Claims Adjusting paid claims Select the claim to adjust Change the necessary information within the header and detail, as applicable Click the adjust button 97

Adjusting, Voiding, & Copying Claims Adjusting paid claims Once you click the adjust button A new claim is created and assigned its own adjustment ICN Refer to the information in the Claim Status Information and EOB Information areas at the bottom of the page to see how your new claim processed. 98

Adjusting, Voiding, & Copying Claims Adjustment Terminology Original or active claim referred to as Mother Claim New adjusted or voided claim is referred to as the Daughter Claim Credit Balance If a claim adjusts for more than the original amount, the provider will receive an additional payment Account Receivable - If funds are due back to the state 99

Adjusting, Voiding, & Copying Claims Adjustment Example 2010220234001Originally paid $45.00 5010274127250Now paid $50.00 Credit Balance $5.00 2010220234001Originally paid $50.00 5010274127250Now paid $45.00 Account Receivable ($5.00) The providers additional payment. Money due to State. 100

Adjusting, Voiding, & Copying Claims Voiding paid claims Select the claim you wish to Void Click the void button at the bottom of the page The status of the original claim does not change however, the claim is flagged as non-adjustable in MITS An adjustment claim is automatically created and given a status of Denied 101

Adjusting, Voiding, & Copying Claims Void Example 2010220234001Originally paid $45.00 5610274127250Reversal Void Account Receivable ($45.00) 102

Adjusting, Voiding, & Copying Claims Copying Paid Claims Search and open the claim you want to copy At the bottom of the claim, select Copy claim Make your changes to the fields The submit and cancel buttons display at the bottom of the new page Select Submit when changes are made Claim is assigned a new ICN 103

Remittance Advice Remittance Advices for claims processed are available on the MITS Web Portal 104

Remittance Advice Pages are titled by claim type and outcome CMS 1500, Inpatient, Outpatient, Long Term Care, and Dental Medicare Crossovers A, B and C Paid, Denied, and Adjustments Adjustment Page Identifies the original claim header information and the new adjusted claim 105

Remittance Advice Financial Transactions Non-claim specific payouts Claim and non-claim refunds Accounts receivable tracking Summary Page Provides current payment information Per month information Year to date information 106

Informational pages Banner Messages Provides messaging to the provider community EOB Code Descriptions Provides a comparison of the codes to the description that appeared on claims on the paid, denied and adjustment pages TPL Information If a claim was not paid due to the recipient having another payer source (Third Party Liability) this section provides other insurance information Remittance Advice 107

Historical Remittance Advices (RA) created prior to MITS will continue to be available on the old Medicaid Provider Portal. Only the RA function will be active on the previous web portal, and it will continue to be available 18 months from August 2, 2011. MMIS Remittance Advices 108

Websites 109

ODJFS Main Website http://jfs.ohio.gov http://jfs.ohio.gov ODJFS Consumer Website http://jfs.ohio.gov/ohp/consumer.stm http://jfs.ohio.gov/ohp/consumer.stm ODJFS Provider Website http://jfs.ohio.gov/ohp/provider.stm http://jfs.ohio.gov/ohp/provider.stm MITS Website http://jfs.ohio.gov/mits/index.stm http://jfs.ohio.gov/mits/index.stm MITS eTutorial Website http://www.odjfs.state.oh.us/tutorials/MITS-External-Training http://www.odjfs.state.oh.us/tutorials/MITS-External-Training eManuals http://emanuals.odjfs.state.oh.us/emanuals http://emanuals.odjfs.state.oh.us/emanuals ODJFS Websites 110

http://www.myohiohcp.org CareStar Website Access the CareStar website for the following information: All Services Plans Training opportunities Basic information regarding background checks Finding new clients/cases 111

http://www.wpc-edi.com/reference/ Washington Publishing Website The Washington Publishing website provides adjustment reason codes (ARCs) that must be noted on claims that involve other payers. The common ARCs are noted below: 1 (Deductible) 2 (Coinsurance) 3 (Copayment) 45 (Contractual Obligation/Write-Off) 96 (Non-Covered Services) 112

Questions 113

basic billing 2013 ohio medicaid home care aides

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