hp provider relations october 2011 web interchange advanced functions

HP Provider RelationsOctober 2011

Web interChange Advanced Functions

Web interChange Advanced Functions October 20112

Agenda– Session Objectives

– Administrator Request Form

– Administrator Functions

– User Functions

– Researching a Claim

– Online Adjustments

– Claim Attachments and Notes

– Crossover and TPL Claims

– Clear Claim Connection

– Upcoming changes ICD-10

– Prior Authorization

– Helpful Tools – Avenues of Resolution

– Questions


ObjectivesFollowing this session, providers will:

– Understand how to obtain Web interChange administrator access and functions

– Know how to view and edit your provider profile

– Know how to manage passwords

– Know how to develop user lists

– Understand void and replacement functions

– Understand how to add claim attachments

– Understand when to add claim notes

– Perform crossover claim billing

– Know how to update and bill TPL information

– Understand prior authorization inquiry and submission

Request Administrator Access


Administrator Request Form

– The Administrator Request Form is used to designate at least one individual to act as the administrator for Web interChange

– A link to the form can be found on the "How To Obtain an ID" page

– Submit a letter of acknowledgement on your company’s letterhead from the organization’s owner, indicating you are approved as an administrator for your organization • Providers may have multiple administrators• A separate form for each administrator is required• Multiple administrators may be listed on the letter of acknowledgement

– If the organization has multiple provider numbers (LPIs), only one Administrator Request Form for each administrator is needed• List the individual LPIs and provider names to the letter of acknowledgement• Administrators are linked to the nine-digit LPI, not to individual locations


Administrator Request Form

– Complete and mail the Administrator Request Form to:

HP Enterprise Services

Electronic Solutions Help Desk950 N. Meridian StreetSuite 1150Indianapolis, IN 46204-4288

– Request Form and letter may be faxed to (317) 488-5185• Turnaround time is 5-7 days

– To remove an administrator, mail or fax a letter signed by the owner• The letter should include the provider LPIs and administrator’s name and user ID


Password Reset – Administrator

– Administrators may reset their users’ passwords

– Administrators may reactivate their users’ IDs when "Inactive - For Lack of Use" (not logged on for 90 days)

– Administrators may reset their own password utilizing the "Reset Password" function

– An administrator who is "Inactive - For Lack of Use" must be reactivated by the EDI Solutions Service Desk

• Contact EDI Solutions Service Desk at 1-877-877-5182, or (317) 488-5160

Learn Administrator Functions


Web interChange Administrator MenuWeb interChange home page


Administrator FunctionsCreate user

HIPAA compliance mandates that each user have an individual user ID


Administrator FunctionsGroup administration

Assign users to a group with the appropriate level of access


Administrator FunctionsView group reports


Administrator Functions

– User Administration• Create User

• Update User

• Reset Password

• Reactivate User

– Group Administration• Administer Groups

Group Maintenance

Group Member Maintenance

View Group Report Review the Group Report every 90 days Compliance is tracked by the OMPP and HP


Administrator FunctionsProvider Profile


Administrator FunctionsProvider Profile – Select View or Edit

The Edit button will only appear when user has "Provider Maintenance" access


Administrator FunctionsProvider Profile – Change of ownership?

Must respond

to ‘CHOW’ question


Administrator FunctionsProvider Profile – Update provider specialty

Select “Specialty”, then “Add New”


Administrator FunctionsProvider Profile – Begin or update electronic funds transfer

Note: EFT deposits begin 18 days after enrollment


Administrator FunctionsProvider Profile – Update rendering provider specialties

Click “Edit”

Rendering additions and terminations cannot be performed online


Administrator FunctionsProvider Profile

– Using Web interChange, providers can also make the following profile updates:• Ownership information

• Changes in members of a board of directors

• Name of office manager or other management personnel

• Ownership in subcontractor entities

• Prequalify as a qualified provider for the Presumptive Eligibility for Pregnant Women program

Describe User Functions


User FunctionsPassword reset

– Users may reset their own password using the “Reset Password” function

– Administrators may reactivate a user who is inactive for lack of use (has not logged on for 90 days)


User FunctionsUser Lists



Features of a User List:

– May create user lists to alleviate keying information manually in specific claim submission fields

– Allows information to be added or deleted as needs change

– Can only be created for fields listed with a drop-down arrow in the claim submission screen

Resolve Researching a Claim


Researching a Claim

Perform the following steps to research the reason for a claim denial

1.Access Claim Inquiry to look up the claim

a) Enter the member identification number (RID) and date of service; OR,

b) Enter the claim internal control number (ICN) only

2.Click Show More Claim Information, then scroll to the bottom of the screen to display the Claim Status Information

3.Look for “D” under the “Disp” column and read the messages that correspond to each detail line


Researching a Claim

Detail Online Adjustments


Online AdjustmentsVoid



– Void is a HIPAA term for an adjustment and refers to the cancellation of an entire claim whether submitted the same day, same week, or post-financial (after the RA is published)

– Void requests can be submitted electronically using the 837 transaction or Web interChange

– Void requests submitted electronically can be for a previously submitted electronic or paper claim

– A voided claim results in the full recoupment of the amount paid on the original claim

– Voids cannot be performed on a claim in a denied status



– A void can be performed on claims in a paid or suspended status

– If the void of a claim occurs the same day or week that the original claim was submitted, a new ICN is not created

• The same ICN assigned to the claim applies to the void

• The original claim denies with edit 0120 – Claim denied due to an electronic void request

– If the original claim being voided is a historical claim, a new claim with a new ICN is created

• The new ICN starts with 63

– Check-related voids (adjustments) continue to be submitted on paper because a paper check must be mailed to HP


Online AdjustmentsVoid and the RA

Pre-Financial Post-Financial

2011275000002 – Paid

User voids the claim

Voided claim denies EOB 0120

2011242001001 – Paid

Today’s date: 10/10/11

6311252001000 – Denied with EOB 0120

RA/835 shows:

Claim shows on the denied page only – same ICN

RA/835 shows:

Mother Claim: 2011242001001 and Daughter Claim: 6311252001000

Both ICNs appear on the adjustment page of the RA


Online AdjustmentsReplacement



– Replacement is a change to an original claim, whether submitted the same day, same week, or post-financial

• Original claim indicates the most recent ICN assigned to that claim

– An electronically submitted replacement claim can be for a previously submitted electronic or paper claim

– Only noncheck-related replacements are accepted electronically

– Check-related replacements continue to be submitted on paper



– If the IHCP receives a replacement claim for an original claim that has been through a financial process (has appeared on an RA), the replacement claim ICN starts with one of the following:

• 61 – Provider-initiated replacement containing attachments and/or claim notes

• 62 – Provider-initiated replacement with no attachments and/or claim notes


Online AdjustmentsFiling limits for voids and replacements

– There is no filing limit for void requests

– One-year filing limit for replacement requests • Web interChange will not display a Replace This Claim button after one year

from the RA date

The system compares the last date of claim activity (RA date) and the date of the current activity to make sure that a year has not passed

These replacements must be submitted on paper with past filing documentation

Do not replace a claim more than one year from the date of service

• The filing limit does not apply to crossover claims

Define Claim Attachments


Claim Attachment Feature


Claim Attachment FeatureAttachment window

– Create the attachment control number (ACN)

• Unique number assigned by provider

• Claim- and document-specific

• Each ACN may only be used one time

– Select the appropriate Report Type Code

• Report Type describes the document being sent

– Transmission Code defaults to “BM” – by mail

• Electronic and emailed attachments are not accepted

– Text Box

• Used for institutional (UB-04) claims only



Created by the provider

Hover over and single-click to display a list of available codes


Claim Attachment Cover Sheet

– Available on IHCP home page, under Forms

– Complete one cover sheet for each claim

– Include provider information

– Provide member ID

– List each ACN pertaining to specific attachment

– Indicate the page count for the attachment (do not count the cover sheet)

– Write “ACN #” and the assigned ACN on each page of documentation corresponding to that number

– Mail cover sheet and supporting documentation to P.O. Box 7259


Claim Attachment Cover Sheet

Do not count the cover sheet

Utilize Claim Notes


Claim Notes


Claim NotesSubmit claim notes to Indiana Medicaid ONLY if the notes relate to these situations:–90 Day Provision

• When a third-party insurance carrier fails to respond within 90 days of the billing date, you can submit the claim to the IHCP for payment consideration. However, to substantiate attempts to bill the third party, the following must be documented:

Date of the filing attempts

The phrase “NO RESPONSE AFTER 90 DAYS”

The member’s identification number (RID)

Your IHCP provider number

–Abortion diagnosis/procedure indicated• In the claim note, the IHCP accepts indication of medical documentation that supports

the need to save the mother’s life or a police report that indicates rape or incest

–Consultation billed 15 days before or after another consultation• In the claim note, you can indicate the medical reason for a second opinion during the

15 days before or after the billed consultation


Claim Notes

Submit claim notes to Indiana Medicaid ONLY if the notes relate to these situations:

–Joint injections (four per month)

• In the claim note, you can document that the injections are performed on different joints (for example, left and right) and indicate the injection sites

–Excessive nursing home visits or more than one per 27 days

• In the claim note, the IHCP accepts documentation supporting the treatment of emergent, urgent, or acute conditions or symptoms with the new diagnosis code

–Pacemaker analysis (two within six months)

• Use the claim note to document the medical reason for the second analysis in the six-month time frame, such as a dysfunctional pacemaker

–Assistant surgeon not payable when cosurgeon is paid

• In the claim note, the IHCP accepts information that documents the medical reason for the assistant surgeon, such as the problem requiring assistance


Claim Notes

Submit claim notes to Indiana Medicaid ONLY if the notes relate to these situations:

–Excessive nursing home visits or more than one per 27 days

• In the claim note, the IHCP accepts documentation supporting the treatment of emergent, urgent, or acute conditions or symptoms with the new diagnosis code.

–Retroactive eligibility

• Use claim notes when billing a claim that is past the filing limit and the member was awarded retroactive eligibility. In the case of retroactive member eligibility, claims must be submitted within one year of the eligibility determination date. Enter information stating, “Member has retroactive eligibility. Please waive timely filing.”

• Refer to BR200819

Explain Crossover and TPL Billing


Crossover Claims


Crossover Claims Submit Medicare crossover claims electronically using Web interChange

Crossover header information

– Click Benefit Information on the Claim Submission screen

– Payer ID = 00630

– Payer Name = Medicare Part B

– Medicare Paid Amount = the total amount paid by Medicare for the claim

– Subscriber Name

– Primary ID = Medicare number w/ alpha

– Relationship Code = 18 (self)

– Gender


Crossover ClaimsCrossover header information

Date of birth

Claim Filing Code = MB

– Click Save Benefits at the bottom of the screen

– Click Save and Close at the top of the screen

• If the Payer ID is a Medicare payer, the Claim Filing Code is MA (Medicare A) or MB (Medicare B)

Note: Obtain COB information, including Payer IDs from the HELP tab, Reference Materials on Web interChange


Crossover ClaimsCoordination of Benefits – header level


Crossover ClaimsCoordination of Benefits – detail level (CMS-1500 claims only)


Crossover Claims Crossover detail information

To report detail information, perform the following:

– Click Detail Benefits Info

– Payer ID = 00630

– TPL/Medicare Paid Amount = Enter the amount paid by Medicare for the highlighted detail line only

– Click Save Payer

– Group Code = Enter PR

– Reason Code = Enter 1 for deductible, 2 for coinsurance, and 122 for psychiatric reduction • Do not report write-off or contractual adjustment/discount amounts

– Amount = Enter the amount of the deductible and/or coinsurance

Note: Claims for Federally Qualified Health Centers (FQHCs) that did not cross over electronically must be billed on a CMS-1500 form with the code T1015 added to the claim


TPL Claims


TPL Claims

– Submit an electronic request to the HP TPL Unit to update a member’s insurance information

– The TPL Unit receives the request, researches, confirms the information, and updates the eligibility screen with corrected information

• Updates are usually made within 20 days

– Confirm that eligibility has been updated by reviewing the Eligibility Inquiry feature


TPL Claims Submit TPL claims electronically using Web interChange

TPL header information

– Click Benefit Information on the Claim Submission screen

– Payer ID = ABCINSURANCE

– Payer Name = ABCINSURANCE

– TPL Paid Amount = the total amount paid by TPL for the entire claim

– Subscriber Name

– Primary ID = TPL ID

– Relationship Code = 18 (self)

– Gender

– Date of birth

– Click Save Benefits at the bottom of the screen

– Click Save and Close at the top of the screen


TPL ClaimsCoordination of Benefits – Header level

Announce Clear Claim Connection


Clear Claim Connection

– To offer the provider community transparency and disclosure of coding rules and editing rationales, the IHCP introduced a Web-based tool, Clear Claim Connection, July 1, 2011

– The Clear Claim Connection tool provides the following benefits:

• Provides the rationale for each edit

• Provides policy and editing logic to improve physician and outpatient hospital coding

• Reduces provider administrative costs associated with claim resubmissions

• Gives providers access to code auditing methodologies 24 hours a day, seven days a week

– Web interChange users must have access to Claim Submission to use Clear Claim Connection



Enter NPI or LPI


Click “Disallow” or “Review” to obtain clinical edit

clarification


Using the Clear Claim Connection Tool

– Select the Clear Claim Connection link under the Code Auditing menu

– Choose appropriate NPI if it is not currently populated• Atypical providers will use the Legacy Provider Identifier (LPI)

– Click the Continue button and click Agree on the Terms and Agreement page to access the Clear Claim Connection

– Enter claim detail information to determine how the claim will process according to the auditing rules set up in ClaimsXten McKesson

– Click Review Claim Audit Results to view the results

– If “Disallowed,” click Disallow to review the Clinical Edit Clarification window to see why the code was disallowed

– Click New Claim to input information for another claim

– Click Current Claim to change the information on the current scenario and continue with claim analysis

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Discuss HP ICD-10 Compliance Project Status


Details

– Professional diagnosis codes will increase to 12 entries per transaction.

– Diagnoses fields will increase from 5 characters to 7.

– ICD-9 procedure fields will increase from 4 characters to 7 alphanumeric characters for ICD-10.

– Diagnosis code pointer (professional claims) will expand from 4 positions to 8 (4, 2-character fields).

– The ICD version qualifier will be required on paper, Web, or EDI claim submissions to indicate the version of ICD codes being used.

– Claims with both ICD-9 and ICD-10 listed will be rejected.

– Date of service (DOS) and date of discharge (DOD) will aid in determining if ICD-9 or ICD-10 is used when billing your claims to the IHCP.


FAQs

– What is the current implementation timeframe?

HP has completed the assessment for the Medicaid Management Information System (MMIS) and is on target for the October 1, 2013, implementation of the ICD-10 Compliance Project.

– Is there going to be a system freeze? If so, when?

Yes, there will be a system freeze. Currently, it is scheduled for September 2013.

– Will there be vendor testing? When?

Yes, there will be vendor testing that will include managed care entities (MCEs). Vendor testing is scheduled to begin January 1, 2013.

– Will providers/vendors be able to use the ICD-9 codes after the October 1, 2013, implementation?

No, you must use ICD-10 codes for DOS or DOD(inpatient) on or after the October 1, 2013, implementation date. There is no grace period.


ICD-10 IHCP Provider Readiness Survey

– The first ICD-10 Provider Readiness Survey is in development.

• A link to the survey will be posted on the Indiana Medicaid Web site Provider page.

– The survey will be available from November 7 to November 14.

– Upcoming Bulletins, Banner Pages, and Newsletters will include information about accessing the survey.

– This survey should be completed by the individual that is instrumental in planning, implementing, and/or managing the transition to ICD-10 in the provider’s business.

– Survey results will help us help you, by tracking your progress and capturing your issues.

Define Prior Authorization


Prior Authorization

– Allows the requesting provider to inquire about all nonpharmacy prior authorizations via the Web

• Applies to PAs submitted via paper, telephone, fax, or Web

– The requesting provider and the named service provider may view a PA without the PA number

– All other providers must have the PA number to view a PA

Prior authorization inquiry


Prior Authorization278 prior authorization inquiry


Prior Authorization

– The following provider types can submit PA requests via Web interChange:

• Chiropractor

• Dentist

• Doctor of medicine

• Doctor of osteopathy

• Home Health Agency (authorized agent)

• Hospice

• Hospitals

• Optometrist

• Podiatrist

• Psychologist endorsed as a health service practitioner in psychology (HSPP)

• Transportation providers

278 prior authorization submission


Prior Authorization

– Must be given access by the administrator to submit PAs

– Medical necessity documentation must be submitted within 30 calendars days of the request

– To send required documentation for PA requests submitted via Web interChange, print the Prior Authorization System Update Request Form

• The form is available under the Forms link at indianamedicaid.com

• Include the PA number – the PA number alerts Care Management Entity staff that the documentation is related to a PA that has already been submitted and is in an Evaluation or Suspended status

Decision letters:

– The system sends a decision letter for PAs submitted via Web interChange, the same way it does for paper PA requests


http://www.indianamedicaid.com/


Prior Authorization

– Fax the Prior Authorization System Update Request Form and supporting documentation to ADVANTAGE Health Solutions for:• Traditional Medicaid Fee-for-Service and ADVANTAGE Care Select:

FAX: 1-800-689-2759

– Fax the Prior Authorization System Update Request Form and supporting documentation to MDwise Care Select:

• FAX: 1-877-822-7186



Prior Authorization278 prior authorization submission


Prior Authorization

– Verify eligibility to determine where to send the PA request• ADVANTAGE Health Solutions – FFS

Prior Authorization DepartmentP.O. Box 40789Indianapolis, IN 462401-800-269-5720 Fax: 1-800-689-2759

• ADVANTAGE Health Solutions – Care SelectPrior Authorization DepartmentP.O. Box 80068Indianapolis, IN 462801-866-440-2449 Fax: 1-800-689-2759

• MDwise – Care SelectPrior Authorization DepartmentP.O. Box 44214Indianapolis, IN 46244-02141-800-356-1204 Fax: 1-877-822-7186

Prior authorization by telephone, fax, or mail

Find Help Resources Available


Helpful ToolsAvenues of resolution

– IHCP Web site at indianamedicaid.com

– EDI Solutions Service Desk–1-877-877-5182– (317) 488-5160 (local)

– Customer Assistance• Local (317) 655-3240• All others 1-800-577-1278

– Written Correspondence• HP Provider Written Correspondence

P. O. Box 7263Indianapolis, IN 46207-7263

– Provider field consultant

• View a current territory map and contact information online at indianamedicaid.com

http://provider.indianamedicaid.com/

http://provider.indianamedicaid.com/

hp provider relations october 2011 web interchange advanced functions

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