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Presented by Mina Reynaga Provider Field Representatives

Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL.. ACS Helpdesks. For all contact, Claims, and Correspondence Addresses information go to the following link on the New Mexico Medicaid Web Portal:https://nmmedicaid.acs-inc.com/nm/general/loadstatic.do?page=ContactUs.htm.

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Presented by Mina Reynaga Provider Field Representatives

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    1. Presented by Mina Reynaga Provider Field Representatives

    2. Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL. ACS Helpdesks

    3. For all contact, Claims, and Correspondence Addresses information go to the following link on the New Mexico Medicaid Web Portal: https://nmmedicaid.acs-inc.com/nm/general/loadstatic.do?page=ContactUs.htm ACS Info

    4. Important State Websites STATE WEBSITE: PROGRAM POLICY MANUAL http://www.hsd.state.nm.us/mad/policymanual.html BILLING INSTRUCTIONS http://www.hsd.state.nm.us/mad/billinginstructions.html REGISTERS AND SUPPLEMENTS: http://www.hsd.state.nm.us/mad/registers/

    5. 5 Provider Field Representative: Mina Reynaga (505) 246-9988 Ext. 233; (800) 282-4477 Ext 233 E-mail: Erminia.Reynaga@acs-inc.com ACS Field Representatives

    6. 6 IMPORTANT UPDATE! Electronic Funds Transfers (EFT) As of May 1, Medical Assistance Division policy requires payment to be made only via electronic funds transfer (EFT). As stated in section 8.302.2.9, MAD or its selected claims processing contractor issues payments to a provider using electronic funds transfer (EFT) only. Providers must supply necessary information in order for payment to be made. (Please see Program Policy Manual)

    7. 7 IMPORTANT UPDATE! Electronic Funds Transfers (EFT)

    8. 8 All information will be verified and validated against the information ACS already has for the provider. While registering for EFT using the web portal, the Master Administrator will be asked to supply an e-mail address for receipt of notifications. This e-mail address will also provide a security purpose for EFT because a provider will be notified whenever a change is made to the banking information associated with EFT. IMPORTANT UPDATE! Electronic Funds Transfers (EFT)

    9. 9 IMPORTANT UPDATE! Electronic Funds Transfers (EFT)

    10. 10 Registered Web Portal users are no longer mailed an RA. The current RA and newsletter are available on the web portal every Monday, along with last 8 RAs. Please download your RA for future reference REMINDER! Remittance Advice Update

    11. The Billing Process

    12. The Billing Process Check eligibility Get Prior Authorization (only if required) Submit the Claim Claim follow up

    13. Date of Service Make sure client is eligible on DOS Is the Client Fee for Service, SALUD!, or COLTS? Limited Benefits Check Category of Eligibility TPL or Medicare, Medicare Replacement Plans -There may be a payer primary to Medicaid The client may be required to pay a co-pay Eligibility Check List

    14. 14 Eligibility Ways to check eligibility: On-line Eligibility Inquiry Web Portal https://nmmedicaid.acs-inc.com Automatic Voice Response System (AVRS) 505-246-2219 or 800-820-6901. Medicaid Eligibility Verification System (MEVS)

    15. Eligibility Inquiry

    16. Eligibility Inquiry

    17. Eligibility Inquiry

    18. Web Portal Lock in Type

    19. Clients with SALUD Enrollment

    20. Eligibility Inquiry

    21. Eligibility Inquiry

    22. Eligibility Inquiry

    23. Eligibility Inquiry

    24. Keep in mind you are looking at real time information. This is exactly the information that someone at ACS looking in Omnicaid would find at that very moment. Eligibility Inquiry

    25. Eligibility Denials What do I do if I receive a denial pertaining to the patients eligibility? Verify the information on the Web Portal. You may need to correct the patients ID, DOB, Name, attach an authorization (CMS 309), or bill to another insurance company.

    26. Categories of Eligibility with Limited Benefits

    27. 029 - Family Planning Waiver Which services are covered? Medical Claims and Institutional Claims: The system examines the revenue code, procedure code, and any related diagnosis codes on the line. The service is covered by the Family Planning Waiver if a combination of the approved code sets are used to identify the service: Procedure Code and the diagnosis codes must be preventative pregnancy. Institutional Claims only: The revenue code and diagnosis are on the approved code lists. Diagnosis code V25.2 (Sterilization Diagnosis) is found on the claim.

    28. 029 - Family Planning Waiver Which services are NOT covered by this COE? Any service that is not preventative pregnancy.

    29. 0029 Service not Family Planning Related Why does this denial occur when the service was actually for Family Planning? Procedure code, diagnosis code, or revenue code not recognized as family planning related. If rendered service is family planning related, resubmit claim using alternate codes. You can verify if a code is covered by contacting the ACS help desk. Do not bill Medicaid client for services that can be billed using an alternate approved codes. If you are not able to locate a suitable alternative code for your service but feel the service should be paid under this benefit package please contact the FPW Program Manager at MAD.

    30. Which services are covered? Medical Claims and Institutional Claims: The system examines the revenue code, procedure code, and any related diagnosis codes on the line. The service is covered by Pregnancy Related Services Only (PRSO) if a combination of the code sets are used to identify the service: Procedure Code and the diagnosis code are relating to a pregnancy or complications of pregnancy. 035 Pregnancy Related (non-presumptive) Covered Services

    31. Which services are covered? (continued) Institutional Claims only: The revenue code and diagnosis are relating to a pregnancy or complications of pregnancy. 035 Pregnancy Related (non-presumptive) Covered Services

    32. 041, 044 Qualified Medicare Beneficiary (QMB) MEDICAID covers the co-insurance and deductible on MEDICARE covered services only after MEDICARE has paid. If service is not covered by MEDICARE, MEDICAID WILL NOT PAY.

    33. Categories of Eligibility with Co-pays 071 FM 1 SCHIP (State Childrens Health Insurance Program) 074 WDI (Working Disabled Individuals) Clients with these COEs may owe co-pays for some services NAX clients are excluded from all co-payments Copayment Schedules are available on the Eligibility Inquiry on the Web Portal.

    34. Other Categories of Eligibility

    35. CMS (Childrens Medical Services) CMS is like billing for a Medicaid client with the following differences: Always use the 14 digit CMS client ID number that begins with 07 off of the MAD 309 form Always enter the PA number in box 23 of the CMS-1500 form (If the PA number is 8 digits, add 2 zeroes in front of it.)

    36. Premium Assistance for Maternity (PAM) Eligibility Premium Assistance for Maternity (PAM) claims are covered by Fee for Service and has the same benefits as Category of Eligibility 035 - Pregnancy Related (non-presumptive) Services.

    37. Premium Assistance for Kids (PAK) Eligibility Premium Assistance for Kids (PAK) claims are not covered by Fee for Service, they are paid by the MCO health plan the client is enrolled in.

    38. Statewide Coverage Insurance (SCI) Eligibility Statewide Coverage Insurance (SCI) claims are not covered by Fee For Service, they are paid by the health plan the client is enrolled in. Call SCI for more client information 866-765-4148

    39. Complete list of Categories of Eligibility

    40. The Billing Process Check eligibility Get Prior Authorization (only if required) Submit the Claim Claim follow up

    41. Prior Authorization Requirements How do you determine if/when a Prior Authorization (PA) is required? Call Molina they can tell you if a PA is required and the procedures for getting a PA. Molina TPA (Third Party Assessor) (505) 348-0311 ( in Albuquerque) (866) 916-3250 (Toll free) Also, consult the Medicaid program and policy manuals and billing manuals for prior authorization requirements. Authorizations for EMSA review contact Molina TPA. Out of State Providers - When submitting a claim on the CMS-1500 claim form for a New Mexico Medicaid client, please attach the Prior Authorization to the claim. If the claim is submitted with the Prior Authorization number located in form locator 23, the claim will deny. Reminder: all out of state providers require a prior authorization for services rendered to a New Mexico Medicaid client

    42. Prior Authorization Requirements All claims for Waiver and PCO providers require an authorization. Waiver providers Contact your case Manager to obtain or follow up on a Prior Authorization. PCO providers Contact Molina TPA (Third Party Assessor) (505) 348-0311 ( in Albuquerque) (866) 916-3250 (Toll free)

    43. As of August 1, 2009 Dental Providers will need to submit your requests for prior approval to: DentaQuest USA, LLC 12121 North Corporate Parkway Mequon, WI 53092. If you have questions or concerns, regarding your prior approval requests that have been submitted to DentaQuest for review, Please contact DentaQuest Customer Service at 1-800-417-7140 (toll Free) Utilization Review (UR)

    44. Prior Authorization Requirements All claims for Childrens Medical Services (CMS) clients must have the CMS prior authorization number entered on the claim. CMS claims can be submitted electronically. However, if the claims denies for eligibility, submit the claim on paper and attach the paper authorization issued by CMS, which is either the CMS 309 form.

    45. Pharmacy Claim/CMS PA If a CMS PA for a pharmacy service is not on file, the provider needs to first contact the Point of Sale helpdesk and then fax the CMS PA to them: ACS Point of Sale Helpdesk 800-365-4944

    46. What do I do if I get a denial pertaining to a Prior authorization? Check the Web Portals Prior Authorization inquiry to verify the PA/Claim discrepancy the denial pertains to. Make claim corrections or follow up with your respective authorizing agency to have PA information changed/corrected.

    47. Prior Authorization Inquiry

    48. Prior Authorization Detail

    49. The Billing Process Check eligibility Get Prior Authorization (only if required) Submit the Claim Claim follow up

    50. Electronic Claim Submission You may submit Fee For Service claim electronically within 90 days from the initial date service.

    51. Three Ways to Submit Claims Electronically Payerpath Free HIPAA Compliant web-based claims entry system. The URL to the registration form for Payerpath is: http://www.hsd.state.nm.us/mad/hipaa.html TIE (Transaction Interface Exchange) the State of NMs HIPAA translator. If you have software that will generate a HIPAA compliant file you can directly submit the file to NM Medicaid via TIE. TIE is another free service. Through a Clearinghouse

    52. Three Ways to Submit Claims Electronically - Continued The URL to the registration form for TIE is: http://www.hsd.state.nm.us/mad/hipaa.html Fill out the Trading Partner agreement and Medicaid Provider Billing Agent application and mail it to the NMHSD. NOTE: Only Medicaid Primary claims can be submitted through Payerpath or the State translator.

    53. HIPAA2/5010 Electronic Claims Testing All electronic healthcare claims submitted for payment to the New Mexico Medicaid program must be upgraded to use the HIPAA Version 5010 standards by January 1, 2012. The current electronic claim version (4010) will not be accepted after December 31, 2011. (The federal government requires that all electronic claims submissions to New Mexico Medicaid (or any Medicaid program) comply with the new HIPAA X12 5010 transmission standards.) March 29, 2012 53

    54. Who do I contact ? If you would like to receive instructions and FAQs on testing, or if you have questions, please send your requests to the email address below. HIPAAHelpdesk@acs-inc.com If needed, a representative will contact you. March 29, 2012 54

    55. Effective September 1, 2010, the timely filing limit for Medicaid fee for service and Childrens Medical Services claims changed to: 90-days from the date of service for all providers except for schools and Indian Health Service and PL-638 tribally operated providers. Timely Filing Limits

    56. For a claim which met the initial filing period, but was denied, partially denied, or requires an adjustment, there is an additional one-time 90-day grace period counted from the date of payment or denial, during which the claim can be re-filed or an adjustment submitted to ACS. It is to the providers advantage to resubmit a claim, if necessary, within the initial 90-day filing period in order to have the greatest amount of time in which to re-file or submit an adjustment during the 90-day grace period if another re-filing or adjustment is necessary. The claim may be re-filed during the 90-day grace period as many times as necessary, but claims filed after the 90 day grace period will be denied. Timely Filing Limits

    57. Exceptions to the filing limit: When other primary payers have denied or made payment on a claim, the filing limit of 90-days is counted from the date of payment or denial by the other party, but not to exceed 210 days from the date of service. A provider should file claims in sufficient time with other payers to allow submission in time to meet the Medicaid 210 day limit. When the recipient has retroactive eligibility, the initial filing limit is 120 days from the date the eligibility was added to the ACS eligibility file and was therefore available to providers. Timely Filing Limits

    58. Timely Filing Denials Exceptions to the filing limit: When the provider was not originally enrolled as a MAD provider on the date of service, the filing limit of 90-days is counted from the date the provider was notified of the enrollment, but must not exceed 210 days from the date of service. A provider should submit a provider participation agreement in sufficient time to allow processing and still meet the Medicaid 210 day limit for submitting the claim. When a claim previously paid by a Medicaid managed care organization is recouped from a provider due to retroactive disenrollment of the recipient from the managed care organization, the filing limit of 90-days is counted from the date of the managed care organizations notice or recoupment from the provider.

    59. Timely Filing Denials Providers with Exceptions to the filing limit: For schools, the filing limits are 120 days for the initial filing period and 120 days for the grace period (rather than 90 days). For IHS and tribal 638 compact facilities, the filing limit is 2 years from the date of service with no additional grace period.

    60. Timely Filing Denials Re-filing Claims and Submitting Adjustments When resubmitting a claim or requesting an adjustment on a claim that is past the 90 day filing limit but originally met the filing limit, the TCN number which appears on the remittance advice (RA) will be used by ACS to evaluate the claim. The provider must supply that TCN number in order for ACS to be able to evaluate the claim.

    61. Timely Filing Denials Re-filing Claims and Submitting Adjustments CMS 1500 form: Put the TCN in block 22 on the paper form. Leave the Code blank, and put the TCN in the Original Reference No. field. UB Form: Put the TCN in Form Locator 64 Document Control Number (DCN) matching the appropriate payer line, using a paper form. Dental Claim Form: Enter the TCN number in Box 35 beginning on the left side.

    62. Timely Filing Helpful Hints There are two filing limits to meet - the initial filing limit and the grace period limit. Continuing to re-file a claim does not continue to extend the filing limit. So it is to the providers advantage to file or request an adjustment on the most recently filed claim that met the original filing limit. When requesting an adjustment on an adjusted claim, use the TCN of the final payment or denial, not the credit record which has a negative amount on the RA. The filing limit does not apply when the provider is returning an overpayment to the Medicaid program. When submitting a paper claim each claim needs a cover letter and any necessary attachments explaining what the claim.

    63. Claim Form Requirements

    64. Where to get a copy of claim form instructions

    65. Where to get a copy of claim form instructions

    66. CMS-1500 Claim Form Requirements All claims that do not require an attachment for payment must be submitted electronically. Professional claims are submitted on the 837P electronically and the CMS-1500 on paper. MAD requires that all paper CMS-1500 claim forms be on the original red claim forms. Photocopies of claim forms are returned to your billing office.

    67. UB-04 Claim Form Requirements All claims that do not require an attachment for payment must be submitted electronically. Professional claims are submitted on the 837I electronically and the UB-04 on paper. MAD requires that all paper UB-04 claim forms be on the original red claim forms. Photocopies of claim forms are returned to your billing office.

    68. ADA 2006 Claim Form Requirements All claims that do not require an attachment for payment must be submitted electronically. Professional claims are submitted on the 837D electronically and the ADA 2006 on paper. MAD requires that all paper ADA 2006 claim forms be on the original red claim forms. Photocopies of claim forms are returned to your billing office.

    69. The Billing Process Check eligibility Get Prior Authorization (only if required) Submit the Claim Claim follow up

    70. Check for claim status on the Web Portal. Claim specific search capability is available using the web portal to locate specific claims quickly. Claim follow up

    71. Claims Status Inquiry

    72. Claims Summary

    73. Claim Detail - Codes

    74. The Remittance Advice, also known as an EOB, is produced weekly. The RA lists claims ACS has processed for a particular provider, explaining which claims are pending, paid, or denied, and the reason for any denials. A financial summary is also included in the RA. Claim follow up Reading the Remittance Advice (RA)

    75. Reports and Data Files

    76. Reports and Data Files

    77. What is a Transaction Control Number (TCN)? The TCN is a unique number assigned to each and every claim. This number contains information about the claim and can be used to identify your claim when calling provider services 30832300085000001

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