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NCTracks for DMH

NCTracks for DMH. NCTIDE April 2014. Rate Denials. Researching Rate Denials. Steps Used for Finding Rates During Claims Processing. Series of Steps Done first with Benefit Plan Assigned to the Claim Detail, the with ‘DMHAD’

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NCTracks for DMH

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  1. NCTracks for DMH NCTIDE April 2014

  2. Rate Denials

  3. Researching Rate Denials • Steps Used for Finding Rates During Claims Processing • Series of Steps Done first with Benefit Plan Assigned to the Claim Detail, the with ‘DMHAD’ • Benefit Plan, Billing Provider NPI/Atypical Number, Rendering Provider NPI/Atypical Number, Rendering Provider Locator, Recipient ID • Benefit Plan, Billing Provider NPI/Atypical Number, Recipient ID • Benefit Plan, Billing Provider NPI/Atypical Number, Rendering Provider NPI/Atypical Number, Rendering Provider Locator • Benefit Plan, Billing Provider NPI/Atypical Number, Rendering Provider NPI/Atypical Number • Benefit Plan, Billing Provider NPI/Atypical Number • Benefit Plan

  4. Researching Rate Denials, continued • EOB 1660 – No Rate on File • Finding Existing Rates • Log on to the Operations Portal • Navigate: Reference/Rates/DMH Rate Search • Enter Procedure Code • Will show ALL active rates that exist • May be overwhelming • Enter Billing Provider NPI/Number • Will limit results to only those rates in effect for the LME/MCO

  5. Establishing/Changing Rates • Rate Load Form • What is a Change vs. New Rate • Change – Rate or End-Date • Everything else is a New Rate • Values to specify • Use NPIs, not legacy numbers • LME/MCO determination of level of specificity • Can create a Billing Provider specific for DMHAD which would be used for all claims for that procedure code for that LME/MCO (most generic) • Can create a Billing Provider, Rendering Provider Location, Recipient, Benefit Plan specific rate that will only be used for a claim that matches those specific values (most specific) • Submit form to Jay Dixon – Jay.Dixon@dhhs.nc.gov

  6. National Correct Coding Initiative (NCCI) Edits

  7. NCCI Edits • Developed by Centers for Medicare and Medicaid Services (CMS) • Purpose – to promote correct coding methodologies and control improper payments • Updated annually • Two categories – Code Pair Edits and MUEs • Code Pair Edits prevent improper payment when certain codes are billed together • MUE limit the maximum number of units of service allowable

  8. NCCI Edits, continued Medically Unlikely Edits www.cms.gov Medicare Coding – National Correct Coding Initiative Edits Medically Unlikely Edits Scroll to bottom – Files listed under related links Code to Code Edits www.cms.gov Medicare Coding – National Correct Coding Initiative Edits NCCI Coding Edits Scroll to bottom – Files listed under related links

  9. NCCI Edits, continued • DMH followed DMA decisions • EOBs • 00585 – Claim denied. Procedure code billed is on the Medical Unnecessary Event table for NCCI • 49270 – NCCI Physician edit • 49280 – NCCI Outpatient Hospital Services edit • Details to be provided in spreadsheet

  10. 00013 – Provider is not Eligible on Date of Service 03522 – Rendering Provider is not Eligible on Date of Service WHAT IS THE DIFFERENCE?? 08536 – Invalid Rendering Provider 03523 – Rendering Provider not on File 08328 – Attending Provider not Eligible on Service Date

  11. 00013 – Provider is not Eligible on Date of Service Usually because the rendering provider has been terminated • Log on to the Operations Portal • Do a Claim Search using the TCN of the claim • Click on the hyperlink returned • Navigate to the Line tab • Click on the rendering provider hyperlink • Provider Status on Name and Address tab is ‘Terminated’ • Will always also receive EOB 03522 Use the provider upload process to reactivate the provider in NCTracks • On the Health Plan tab, the Provider’s enrollment in one or more health plans has been end-dated Use the provider upload process to reactivate the provider in the appropriate health plan(s) • Provider Status on Name and Address tab is ‘Active’ but Location assigned to the claim detail has been end-dated The provider will have to use the Manage Change Request process to reactivate the location

  12. 03523 – Rendering Provider not on File There is no record for the NPI/atypical number submitted as the rendering provider on the claim line • Log on to the Operations Portal • Do a Claim Search using the TCN of the claim • Click on the hyperlink returned • Navigate to the Line tab • Click on the rendering provider hyperlink • System will return you to Claim Header tab with message ‘No details found’ Use the provider upload process to add the provider to NCTracks

  13. 08328 – Attending Provider not Eligible on Service Date Either the Rendering Provider NPI/Atypical number was blank OR the Rendering Provider NPI/Atypical number was the same as the Billing Provider NPI/Atypical number • Log on to the Operations Portal • Do a Claim Search using the TCN of the claim • Click on the hyperlink returned • View the Billing Provider NPI/Atypical number on the Header tab • Navigate to the Line tab • View the Rendering Provider NPI/Atypical number Resubmit the claim with the appropriate rendering provider NPI/Atypical number

  14. 08536 – Invalid Rendering Provider The taxonomy submitted for the billing provider and the taxonomy submitted for the rendering provider are not compatible • Log on to the Operations Portal • Do a Claim Search using the TCN of the claim • Click on the hyperlink returned • View the Billing Provider taxonomy on the Header tab • Navigate to the Line tab • View the Rendering Provider taxonomy • If the rendering provider taxonomy is one of the following, the billing provider taxonomy must be 193400000X: • 101YA0400X, 1041C0700X, 101YM0800X, 103T00000X, 106H00000X, 101YP2500X, 363LP0808X, 364SP0808X, 364SP0809X, 364SP0807X, 364SP0810X, 364SP0811X, 364SP0812X, 364SP0813X, or blank Resubmit the claim with 193400000X as the billing provider taxonomy

  15. Miscellaneous Denials

  16. 00082 – Service is not Consistent with/or not Covered for this Diagnosis • Issue: Diagnosis submitted on the detail isn’t valid for the benefit plan that is assigned to the detail • If the benefit plan assigned is DMHAD, then this is a result of another issue. Otherwise… • Log on to the Operations Portal • Do a Claim Search using the TCN of the claim • Click on the hyperlink returned • Navigate to the Line tab • Make note of the diagnosis code and assigned benefit plan • Click on the hyperlink for the procedure code • Scroll to the bottom • Click on the hyperlink for the benefit service group that corresponds to the benefit plan • Click on a line under Benefit Service Group Detail • Make note of the list number listed in the Diagnosis Range line • Navigate to Admin/System List Search • Enter the list number • Click on the hyperlink for the Diagnosis List Resubmit claim with an appropriate diagnosis code

  17. 02310 – Procedure Code is not Covered or not on File for Dates of Service Will also always receive EOB 8599 – Line not covered by combination of recipient, provider, and benefit plan • If these are the only two ‘denying’ edits, problem is usually that the recipient doesn’t have eligibility established on the date of service • Log on to Operations Portal • Do a Claim Search using the TCN of the claim • Click on the hyperlink returned • Navigate to the Line tab • Make note of the date of service (DOS) • Navigate to the Header tab • Click on the hyperlink for the Recipient ID • Determine if eligibility exists for DOS • If so, click on the line and retrieve the Date Modified • Return to the Claim Header tab • Determine if Adjudication Date was prior to Date Modified If eligibility does not exist, submit 834 transaction to add recipient eligibility and resubmit the claim. If eligibility exists and was updated after the Adjudication Date, just resubmit the claim.

  18. NCTracks Reports for DMH

  19. Recipient Information Reports • BR12008-R0010 – Recipient Count per Eligibility Program Report • Lists by benefit plan, all of the recipients actively enrolled in the benefit plan – includes Medicaid and Health Choice enrollment • Produced monthly • BR12008-R0011 – Active recipient Enrollment Report • Lists recipient enrollment by recipient ID – includes Medicaid and Health Choice enrollment • Produced weekly • BR12009-R0010 – Client Eligibility Expiration Alert by Rendering Provider Report • Lists, in recipient ID order, all recipients for whom eligibility is expiring in the next two months – includes rendering provider information • Produced weekly • Downloadable to Excel • BR12010-R0010 – Client Eligibility Expiration Alert Report • Lists recipients for whom eligibility is expiring in the next two months • Produced daily

  20. Financial Information Reports • FR88200-R0190 – Denied Claims by Claim Type and EOB Report • Lists by EOB the number of claims that denied for that EOB • Produced after each checkwrite • Remittance Advice • Lists all of the claims processed • Produced after each checkwrite • Different section for each type of claim • ‘Denied’ claims come before ‘Paid’ claims • Medicaid claims come before DMH claims • TOTAL AMOUNT ORIGINAL – search term to move easily through the RA • FR88200-R0200 – Detail Expenditure Report • Lists by Company/Account/Center the claims that were paid • Produced each checkwrite • FR88200-R0215 – Detail Expenditure – Zero Paid Claims Report • Lists all of the Single Stream Funded claims • Produced each checkwrite • FR18100-R0030 – Budget Tracking Report • Lists each company/account/center for which a budget is established • Shows checkwrite, monthly, and yearly expenditures

  21. QUESTIONS???

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