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Provider Waiver Orientation

Provider Waiver Orientation. Sandhills Center LME/MCO. Financial Management and Monitoring. The Finance Department manages the financial resources of the LME/MCO. This includes: Management of accountability, availability of funds, claims processing and payment.

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Provider Waiver Orientation

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  1. Provider Waiver Orientation Sandhills Center LME/MCO

  2. Financial Management and Monitoring • The Finance Department manages the financial resources of the LME/MCO. This includes: Management of accountability, availability of funds, claims processing and payment. • The Finance Department is responsible for ensuring compliance with General Statute 159 (The Local Government Fiscal Control Act) and other general accounting requirements. • The Finance/Claims Department supports providers through training and through its Claims Specialist Representatives.

  3. Financial Management and Monitoring Your responsibility as a Contracted Provider is to: • Verify consumer insurance coverage at the time of referral, or admission, or each appointment, and on a quarterly basis. • Determine the consumer’s ability to pay using the Sliding Fee Schedule for all designated Non-Medicaid services based on your agency’s contract requirements. • Report all first party required fees and third party payments and denials on the claim.

  4. Financial Management and Monitoring • Bill all first and third party payers prior to submitting claims to SHC. • Report all billing errors to SHC Claims Department. • Manage your agency’s Accounts Receivable. • Submit all documentation which is required for federal, state, or grant reporting. • Implement Internal Controls to support audits performed by Sandhills Center.

  5. Financial Management and Monitoring • Network Providers shall maintain detailed records of the administrative costs and expenses incurred pursuant to their Contract with SHC. • This includes all relevant information relating to enrollees for the purpose of audit and evaluation by DMA. • Records shall be maintained and available for review during the entire term of this contract and for a period of five (5) years thereafter. • If an audit is in progress or audit findings are unresolved, records shall be kept until all issues are resolved.

  6. Financial Management and Monitoring SHC’s responsibility to Providers is to: • Review Financial reports, financial statements and accounting procedures as applicable. • Monitor retroactive Medicaid eligibility and recovery of funds. • Issue payment and remittance advice (RA) on paid and denied claims. • Assist the Quality Management Dept with claims quality audit process.

  7. Financial Management and Monitoring • Recover funds based on audit findings. • Audit providers for coordination of benefits (COB). • Manage and pay clean claims within Prompt Pay Guidelines. • Report credible allegations of Fraud and Abuse

  8. Waiver Claims Administration Resources: • Sandhills website-www.sandhillscenter.org • Finance/Claims Section • Provider Manual

  9. Submission of Claims • All claims must be billed within 90 days from dateof service. Claims submitted beyond 90 days will be denied. • Providers must notify SHC Finance in writing if they anticipate not being able to meet this guideline. • Claims can be sent via: • Electronic 837 • Provider Connect • Paper: HCFA1500 UB04

  10. Submission of Claims - Electronic 837 • Testing and approval must occur before submitting a live 837 file to SHC. • A Submitter ID# is required. • To sign up and receive your Submitter ID# e-mail: billing@sandhillscenter.org • You will receive your number within 3 working days.

  11. Submission of Corrected Claims • Corrected Paid Claims and/or Unpaid claims – Must be submitted within 90 days from date of service. • Only the “Claims Inquiry/Resolution Form” must be completed and sent to Claims Dept. • SHC Website – www.sandhillscenter.org – Finance/Claims under Provider • DO NOT SUBMIT A CORRECTED CLAIM • Once request has been processed the Claims Specialist will contact you and advise if a corrected claim is required.

  12. Paid Claims and Denials Remittance Advice will be available via: • Electronic 835 • Paper Payments/Checks will be available via: • Electronic Fund Transfer (EFT) • To sign up, complete forms found on SHC website • Paper

  13. Items To Remember • Avatar/MSO system has the ability to identify members with 3rd party liability. • System edits are in place to deny or pend if 3rd party missing. • Providers will be held accountable. • Co-payments, deductibles, payment for missed appointments or other forms of cost sharing from Medicaid members, are prohibited.

  14. Keeping Current It is the responsibility of the provider to research and stay abreast of new requirements and laws by utilizing all available resources: • Monthly Medicaid Bulletins • DMA and DMH Implementation Updates • SHC Communications/ Bulletins • SHC Website • Provider Connect News

  15. Public Service Message Medicaid Fraud and Abuse Cost You! The North Carolina Department of Health and Human Services is asking anyone with knowledge of Medicaid fraud or abuse to report it by calling toll-free: 1-877-DMA-TIP1 (1-877-362-8471)

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