CLAIMS BILLING & ADJUDICATION TRAINING 2010-2011

1. CLAIMSBILLING & ADJUDICATIONTRAINING2010-2011 May 5, 2011 Debra A. Schuchert Director of Network Operations & Compliance

2. Authorization & Claims ProcessingS.T.A.R.S. Training Manuals • S.T.A.R.S Training Manual # 1 – Supports Coordinators The manual identifies the step by step process used by Support Coordinators to create an authorization number, for procedures codes/units on services rendered to a consumer. • S.T.A.R.S. Training Manual # 2 – Claims Processing The manual identifies the step by step process used by providers when submitting a claim for a consumer after the service has been rendered.

3. ClaimsS.T.A.R.S. – Enhancements • Enhancements have been made to the S.T.A.R.S. system in an effort to adjudicate claims accurately. • In the S.T.A.R.S. system click on Synergy Claim Management • Click on Step (1) Adjudicate Claims Submitted by Providers & then click on View Claims by Provider the (3) three enhancements appear. You must click each box one at a time & click search • Only show claims that are out of balance (Allowed Amount less than Total Billed) • Only show claims that are under-billed (Billed Amount less than Fee Schedule Amount) • Only show claims that are duplicates • Then click on Step (2) Approve Adjudicated Claims for Payment • The providers have the capability to “View the Debit/Credit Transactions” on the billing side under Provider Management. Providers can view the reason, original batch #, date of service, & consumer information. This will assist the provider in their cash posting process and record keeping.

4. General Fund Benefits Package The General Fund Benefits Package has been approved for General Fund Consumers. • Synopsis of D-WCCMHA General Fund Benefits Plan/Developmental Disabilities – Describes the Covered GF Service, Procedure Code, and Notes/ Descriptions. • D-WCCMHA Benefit Plan Covered Services – Newsletter from the Agency that defines Benefit Plans. • The Exhibit A has revised to include a column that identifies General Fund Procedure Codes & Rates. • Additional procedure codes have been added to the Fee Screen for General Fund consumers. • 96105 – Assessment –Other Assessment Testing for Speech & Language • 96111 – Assessment – Developmental Testing • The GF codes have been added to the following PROVIDERS - Exhibit A • Adult Well Being Services • Building Bridges • Goodwill Industries of Greater Detroit • Services to Enhance Potential (STEP) • The Futures Health Core, Inc. • Wayne Center

5. Procedure Codes /Modifiers The additional modifiers have been added to the existing procedure codes. • H2000 TS Behavior Management Review • H2014 TP Skill Building Assistance – (Enhanced Staffing for Gentle Teaching & or Play Project Planning) • H2023 ME Supported Employment – (Micro-Enterprise/Everything Michigan) • H2015 MI MicHolding

6. D-WCCMHA MCPN Medicaid/Other Individual Claims Verification Audit • The verification audit is due to the Agency on a “quarterly” basis. • A 10% (5% Medicaid consumers & 5% Non-Medicaid consumers) are randomly sampled and a report is produced by Bessie T. – Chief of IT & Security • The Claim Adjudicators review the claims and answer the questionnaire that list questions concerning eligibility, services rendered, documentation substantiating the services rendered, appropriate CPT/HCPCS & revenue codes billed, third party fees collected, Ability to Pay determinations made, etc. • A summary is then submitted to the Agency for review

7. Claims Reports Listed below are the current reports identified under the Claims Department: • Leave of Absence (3806 Form) – Quarterly • *D-WCCMHA 1st Tier Subcontractor List (F.E.P.) • *Fair Employment Practices - FEP Certificates • Residential Occupancy Report - Monthly • Providers-No Rate Reduction Report • D-WCCMHA – Synergy Data Base Report • *D-WCCMHA – Quarterly Medicaid / Other Individual Claims Verification (Audit) - Quarterly • Direct & Limited Case Agreements “Mailing” List • Provider “Contact” Information List • *Direct – Limited Case Agreement-Residential List • WBE/MBE Declaration List • Provider License & Liability List • *Claims Variance Comparison Report • Specialized Residential Providers License # • Providers EIN-NPI-Medicaid # List • Provider Billing Denial List • Provider Accreditation List • *Client Budget Report • *Override Report - Monthly

8. Direct Contracts Limited Case Agreements Residential /SubcontractsList • The Direct Contracts, Limited Case Agreements, & Residential –Subcontracts through Wayne Center are identified on a List located on the “G” drive under the Claims Department. • Direct Contracts (37 Contracts) The providers are listed as 1st Tier Subcontracts with D-WCCMHA. Fair Employment Practice (F.E.P.) Certificates are required for these providers, with the exception of Network 180/ Kent County Community Mental Health Authority because this provider is out of Wayne County. • Limited Case Agreements (26 Agreements) The provider is servicing one consumer or the services are for a limited time frame. • Residential Homes (35 Sub-Contracts through Wayne Center) The provider is servicing the consumer/consumers in a residential home. We may have one or more consumers at each home.

9. Client Budget Report • The Client Budget Report identifies consumers that have a different fee screen rate than the original rate assigned to the consumer based on clinical needs. • There has been an enhancement made in S.T.A.R.S that will allow us to identify a date range of Client Budgets entered into the system.

10. Override Report • Monthly report that identifies a claim that was adjudicated as an override. • Override Reasons: • Two providers billing for the same procedure code and same date of service (Three shifts worked a.m., p.m., and midnights) • Two providers billing same date of service. Procedure code with a modifier and without a modifier (H2015 & H2015 U1) • Two different staffing agencies providing service on the same date of service. (One agency in the a.m. & the other in the p.m.) • Additional units approved from the original authorization of units • Two different staff people attended the Person Centered Plan meeting • Exception to the standard rule of 24 hours daily of 1:1 staffing (The consumer requires more than one staff person for each shift)

11. Claims Variance Report • The report is reviewed monthly by the Claim Adjudicator. Each Claim Adjudicator reviews the claims submission amount from the previous month to the current month, and completes a comparison review on any amount that is over 20% . • The usual variance will occur when the provider does not submit their claims/billing within the established time frames. When the provider submits a claim over 60 days from the date of service, an edit will appear on the adjudication screen alerting the Claim Adjudicator that a Timely Waiver Form is required. The form requires the provider to identify the reason for the delay in submitting the claims. When the provider submits a claim over 90 days from the date of service an edit will appear on the adjudication screen alerting the Claim Adjudicator that an Administrative Review Form is required. The form requires the provider to identify the reason for the delay in submitting the claims. Documentation is required due to lateness of claim submission.

12. Synergy’s Procedure Code List with Descriptions / Fee Schedule • Synergy’s Fee Schedule is located on the “G” drive & is identified as FEE SCREEN • The Fee Schedule identifies the following: • Procedure Code Descriptions • Revenue Code (In Patient Hospital Stay) • Procedure Code • Modifier • COB Requirements • Units • Rate with typical authorization • Internal Modifier

13. Claims Policies & Procedures • The following Claims policies and procedures are located on the “G” drive under the Claims Department folder. • C-001 New Paper Claims Submission into STARS • C-002 Claims Adjudication • C-003 Family Friend Respite Billing & Payment Process (09-30-08 Policy discontinued) • C-004 Medicaid Claims Verification Audit Review • C-005 Coordination of Benefits • C-006 Camp Stay Reimbursement • C-007 Claims Override Process • C-008 Ability to Pay

14. Claims Department Monthly Meeting Minutes • The Claims Department Monthly Meeting Minutes are located on the “G” drive under the Claims Department folder. • The minutes are identified by each fiscal year.

15. Fair Employment PracticeFEP • Synergy and all Direct Contract Providers are responsible for submitting a Fair Employment Practice (FEP) application to the Agency for approval. The Agency produces the FEP Certificate. All Certificates must be renewed upon expiration date. The certificates can be issued for a one, two or three year period. • Synergy has complied with all the requirements of the Wayne County Business Certification Program & has established Compliance with Wayne County’s Fair Employment Practices Resolution. Therefore, Synergy Partners, LLC has been issued the Wayne County Human Relations Certificate (FEP). • Synergy is responsible for submitting the following to D-WCCMHA (Agency) annually or whenever provider changes occur. (I.e. additions, deletions, address changes etc.) • D-WCCMHA 1st Tier Subcontractor List • Fair Employment Practice Certificates on all Direct Contract providers

16. Provider Performance Audits • Annual on site audits are conducted on selected providers. The Claims Department coordinates efforts with the Quality Management Department when conducting the on-site audits. • The Claims Adjudicators have a Performance Monitoring Audit Tool that is used for each provider. The documents are reviewed and the specific audit forms are completed. Each provider receives a detailed audit report explaining the findings. • The Claim Adjudicator will also conduct “random” internal audits on providers when issues arise or on selected procedure codes. There are specific reports that are completed for these audits. • The Internal Corporate Compliance Investigation Report • Corporate Compliance Response to a Governmental Inquiry or Investigation

17. STARS CLAIM BILLING & ADJUDICATIONMerriechris Atwood Claim Adjudicator • Billing a claim in S.T.A.R.S (Training Mode) • Adjudicating a claim in S.T.A.R.S