Western Highlands Network Claims & Reimbursement Training Seminar
Training Agenda NPI Current Events Deficit Reduction Act / False Claims Act Claim Submissions Remittance Denial and Resolution Technical Assistance Information Resources
NPI • Overview • Claim Submission • DDE • 837 • CMS-1500 • Provider Registration • Claim Adjudication • WH EOB / 835
National Provider Identification (NPI) The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for health care providers. The NPI Final Rule issued January 23, 2004 adopted the NPI as this standard.
What is NPI • The NPI is a 10-digit, intelligence free numeric identifier (10 digit number). Intelligence free means that the numbers do not carry information about health care providers, such as the state in which they practice or their provider type or specialization. • The NPI will replace health care provider identifiers in use today in HIPAA standard transactions. Those numbers include Medicare legacy IDs (UPIN, OSCAR, PIN, and National Supplier Clearinghouse or NSC). • The provider’s NPI will not change and will remain with the provider regardless of job or location changes.
Have an NPI does not • Ensure a provider is licensed or credentialed • Guarantee payment • Enroll a provider in a health plan • Turn a provider into a covered provider • Require a provider to conduct HIPAA transactions.
Why the NPI • Simpler electronic transmission of HIPAA standard transactions • Standard unique health identifiers for health care providers, health plans, and employers • More efficient coordination of benefits transactions
Who can apply for the NPI • All health care providers (e.g., physicians, suppliers, hospitals, and others) are eligible for NPIs. Health care providers are individuals or organizations that render health care. • All health care providers who are HIPAA-covered entities, whether they are individuals (such as physicians, nurses, dentists, chiropractors, physical therapists, or pharmacists) or organizations (such as hospitals, home health agencies, clinics, nursing homes, residential treatment centers, laboratories, ambulance companies, group practices, HMOs, suppliers of durable medical equipment, pharmacies, etc.) must obtain an NPI to identify themselves in HIPAA standard transactions.
Western Highlands’ Direct Data Entry • Optional NPI claims entry available April 20, 2008 – May 14, 2008 • May 15, 2008, WH requires NPI claims entry. Claims entered after May 14, 2008 will deny without the appropriate NPI data.
ASC X12N 837 004010X098A1, Health Care Claim Professional • Loop 2010AA – Billing Provider • NM108 and NM109 – Submit either NPI (typical provider) or tax ID number (atypical provider) • N403 – Add 4-digit extension to zip code (do not submit dash) – MUST match the appropriate location of the billing provider • REF01 – Must submit either legacy provider number (if provider is atypical), SSN, or EIN
Attending Provider • Loop 2310B – Attending Provider • NM108 and NM109 – Submit either NPI (typical provider) or tax ID number (atypical provider) • REF is only required if the Attending Provider is atypical
Service Facility Location • Loop 2310D – Service Facility Location • NM108 and NM109 – Submit either NPI (typical provider) or tax ID number (atypical provider) • N403 – Add 4-digit extension to zip code (do not submit dash) – MUST match the appropriate location at which the service was provided • REF is only required if the Service Facility Location agency is atypical
837 – Test/Approval • 837 w/NPI must be tested with WH prior to acceptance of claim submission • Notify Diane Overman, 225-2785 ext. 2173 or via e-mail email@example.com • Test for format, content, and HIPAA compliancy • Provide feedback to resolve discrepancies • Upon approval you may submit 837
CMS-1500 (Rendering) • Typical w/NPI • Block 24I, ID Qualifier = “ZZ” • Block 24J (upper), Rendering Provider = Taxonomy • Block 24J, (lower), Rendering Provider = NPI • Atypical w/out NPI • Block 24I, ID Qualifier = 1D • Block 24J, (upper), Rendering Provider = WH Provider ID • Block 24J, (lower), Rendering Provider = <Blank>
CMS-1500 (Billing Provider) • Typical • Block 33 = Billing Provider Info & Ph#, = Address, Zip+4 • Block 33a = NPI • Block 33b = “ZZ” and Taxonomy • Atypical • Block 33a = WH Provider ID
CMS-1500 (Service Facility Location Information) • Typical • Block 32 = Address to include zip+4 • Block 32a = NPI • Block 32b = “ZZ” and Taxonomy • Atypical • Block 32 = Address to include zip+4
Mapping Solution • Atypical claim submission validated against NPI registration • If an NPI is submitted WH will crosswalk the NPI to legacy according to registration. • Address zip+4
NPI Registration • Submit a copy of the DMA NPI Registration Or • Submit the WH NPI Registration • Both require a copy of NPPES certificate • WH Communication Bulletin #54, 2/19/2007
NPI EOB • 083 Missing or Invalid Attn Prov NPI • 084 Missing or Invalid Service Location NPI • 085 Missing or Invalid Zip +4 • 086 Missing or Invalid Atypical PIN • 087 Missing or Invalid Taxonomy Number • 088 Invalid Combo Loc NPI Zip +4
WH EOB / 835 • WH EOB • Include both legacy and NPI attending • 835 – HIPAA Compliant • Will not include legacy number
Current Events Timely Filing Limit (TFL), WHN Communication Bulletin #67 • Temporarily lifted through April resume May 1, 2008, DOS July 1, 2007 - present • State funded claims finalized within 60 days from the date of service • June 2, 2008, 5:00 pm, end of fiscal year TFL (July 1, 2007 – April 30, 2008) Provisionally Licensed provider H-code reimbursement ends June 30, 2008
MOS = Maintenance of Service • Maintenance of Service: • Therapeutic Foster Care and Targeted Case Management • Maintenance of Service applies to requests for authorization where a denial or reduction of service has occurred for a concurrent request and a valid appeal notice has been received by DHHS or OAH/Office of Administrative Hearing. • Value options will be notified after the request for appeal has been received by the Hearing office. Value Options will enter the Maintenance of Service authorization within (5) five business days after the Hearing Office sends confirmation that an appeal has been requested.
MOS—Maintenance of Service –con’t • The units that are authorized can be viewed in Provider Connect, located on ValueOptions’ website at www.valueoptions.com Providers can also contact ValueOptions’ EDI Helpdesk (888.247.9311) for instructions on how to use Provider Connect. • No letter or authorization notice will be sent to the LME for MOS. • MOS authorizations seen in Provider Connect will appear as a standard authorization. There is no distinction to indicate that it is a MOS authorization. • Submit Claims on the WH Claims Resolution Inquiry form with the CMS1500 and provider connect screen print of the authorization. Mail or fax to WHN 828.258.1225.
Deficit Reduction ActFalse Claims Act • Law • Policy • What is a false claim? • Penalties • Your Role • Whistleblower Provision • How/Who to Report
Law • False Claims Act established under section 3729 through 3733 of title 31, United States Code • Federal law that prohibits an individual or organization who receives money from the federal government from submitting a request for payment knowing that such request contains false information.
Policy • Available within the Western Highlands’ Network Standards of Conduct/Ethics policy available to providers through the WH website. • WHN Communication Bulletin # 68
What is a False Claim • Submitting a claim for services that were not • Delivered • Documented • Different than what was delivered • Submitting a claims for services paid by a source other than the federal government, or paid for by the government under a different program (e.g. Medicaid instead of Medicare)
What is a False Claim (cont) • Submitting a claim for services that were not “medically necessary” • Submitting a claim for services which is coded as “more complex” than otherwise indicated in the patients record, in order to receive higher reimbursement
What is a False Claim (cont) • The person must “knowingly” submit a false or fraudulent claim. • This includes actual knowledge, “deliberate ignorance”, or “reckless disregard”.
Penalties • Civil penalties up to $10,000 fine per claim plus double or treble damages, (criminal) up to $25,000 fine and/or 5 years in jail.
Role • Your duty to report fraud, waste, and abuse • Need not be certain the violation has occurred in order to report it. • WH encourages you to seek guidance on any question related to potential or actual violations of laws and regulations
Whistleblower Protections • The False Claims Act provides protection for employees who report suspected false claims against retaliation
How/Who to Report • Report in person, telephone, or writing • Who to report • Immediate Supervisor/Program Director • Compliance Officer • A toll-free anonymous and confidential method is through the National Hotline Services, Inc., Confidential Compliance Hotline • 1-800-826-6762
Resources for verifying eligibility • Basic Medicaid Billing Guide located on DMA’s website http://www.ncdhhs.gov/dma/medbillcaguide.htm 1-800-688-6696, menu option 1, for phone inquires • NC Medicaid Automatic Voice Response (AVR) System 1-800-723-4337 • 270/271 HIPAA Compliant Health Care Eligibility Benefit Inquiry and Response Electronic Transaction. • Value Added Networks (VANs) Interactive eligibility verification that providers may contract with Medicaid for access to real time consumer eligibility. The transaction fee is eight cents per inquiry.
Retro-Medicaid Refunds When a State funded consumer obtains retro-Medicaid • Submit a refund using the WH Claims Resolution Inquiry Form with the WH EOB indicating the refunded services • WH will apply refund to next payment, transaction presented on the WH EOB • WH will initiate a retro-Medicaid refund upon notice from DMA eligibility inquiry/verification and State funded recoupment
DDE A WH web-based claims entry product Complement the 837 and / or offer an electronic claims submission method alternative Complete/submit a Care Coordination Information System (CCIS) - User ID Assignment Request form
DDE continued Individual user ID/Password IT requirements Internet Explorer 6.0, 98 or newer High-speed Internet Generates a report of accepted claims Immediate claim acceptance feedback Direct Data Entry User’s Manual
Exceptions to the Electronic Claim Submissions : • Void & Replace • COB – Coordination of Benefits • CAP MR/DD Waiver Supplies • First Party Payment
Claims Resolution Inquiry Form • Appeals • Void • Void & Replace • Time Limit Override • Third Party COB • Refunds • Other • File the Claims Resolution Inquiry form with a new CMS 1500, and a copy of the WH EOB - Invoice
Claims Resolution Inquiry WESTERN HIGHLANDS NETWORK CLAIMS RESOLUTION INQUIRY MAIL TO: WESTERN HIGHLANDS NETWORK 356 BILTMORE AVENUE ASHEVILLE, NC 28801 Fax To: (828)258-1225 Please Check: _____ Appeals ______ Void & Replace ______ Time Limit Override ______ Third Party Override _____ Refunds _____ Other _____________________________________________________________ Include relative Western Highlands EOB (Explanation of Benefits) and a CMS-1500 (08/05) Provider Name ________________________________________________________________________________________ Consumer’s Name: ________________________________________ Western Highlands ID: _________________________ Date of Services: From: _____/_____/_____ to _____/_____/_____ Check Number: _____________________________ Procedure Code: _______________________________________________________________________________________ Please Specify Reason for Inquiry Request: Point of Contact Name: (Print) Signature: Date: Phone #: TO BE USED BY WESTERN HIGHLANDS NETWORK ONLY Approving Authority Signature/Date: __________________________________________ Approved: ___ Disapproved: ___ Remarks: Western Highlands Network 04/03/2007
Reimbursement WH provides an Explanation of Benefits – Invoice and 835 Remittance Advice EOB and 835s are sent to your agencies mailbox Payments are mailed State funded prompt payment WHN is mandated to review claim / invoice submissions within (18) calendar business days after receipt and shall: A) Approve payment B) Notify Provider within that time frame if claims/invoice are denied or if further information is necessary
Denial and Resolution Duplicate Service Authorization Unit Limitations Attending Provider Numbers Service Level Numbers
WH Explanation of Benefits – InvoiceCodes • EOB codes and description table is available at the WH Website and at the end of the WH EOB
WH EOB 064 - Duplicate Service • A previously submitted claims was paid, typically caused by either incorrect AR posting/flag setting or event summarization • AR Posting • Validate AR payment from previous EOBs • Summarize • Summarize claim prior to submission • To correct submit a Claim Inquiry form void and replace transaction
Authorizations 063 - Incorrect Authorization (DDE) Authorization presented doesn’t support the consumer (consumer, provider, procedure code, and DOS) UA – Authorization for these services does not exist or incorrect authorization OA – Claim exceeds the units of service authorized A valid authorization, but the authorized units of service have been applied to previous payments, balance is zero. PP – Partial Payment A valid authorization, but the total units billed were reduced to the balance of remaining authorized units.
Unit Limitations • 080 - Less than minimum daily limits • Occurs when a service requires a daily minimum units of service and units billed were less than the minimum • 081 - More than maximum daily limits
Attending Provider 033 - Missing Attending Provider ID Claim was billed w/out an attending provider ID 034 - Invalid Attending Provider ID Adjudication system compares the billed ID to the registered ID and service Proper attending must coincide with service delivery Outpatient Behavioral Health services require the individual attending provider DMA enrollment number Enhanced Benefits require the DMA Community Intervention number with the relative alpha suffix Other services require the Western Highlands provider number specified in your contract 036 - CPT code requires Medicaid ID
Attending Provider • Confirm proper number was billed with service. Common error is an Enhanced Benefit billed with an individual clinician’s enrollment or a Western Highlands provider ID • Verify enrollment number from source • Verify number was registered with WH. If not, follow instructions in WHN Communication Bulletin #12 • Verify ID number billed matches the number registered
Service Level Number 045 - EB Not Med Elig Inv Attd Number 051 - Invalid or absent service level number • A service level number consists of the Community Intervention Number (Core Number) plus the alpha suffix that coincides with the enhanced benefit service Core Number: 83xxxxx Service Level Number 83xxxxxA
Attending Provider – Tips to remember • Enhanced Benefit Services, enter the DMA Community Intervention Number with the alpha suffix. Example: 83xxxxx (+) Alpha Character representing the Enhanced Service. • Outpatient Behavioral Health (OBH) service, the DMA individual clinician’s Medicaid enrollment number. • Neither an Enhanced Service nor OBH service, enter your agency’s Western Highland’s provider number. Example: 36XXX