Standard Operating Procedure Handling Payor Denials - Integration Customers

Agenda Introduction Problem Solving and Solutions Additional Information Quiz

Purpose The purpose of this SOP is provide education on how to determine the reason for reimbursement denials due to EVV Validation errors and the steps to correct those errors.

Scope This SOP is applicable to customers in Texas participating in the EVV Mandate.

General Requirements The following requirements must be met. The user must have access to view, add, and/or edit information in the Clients/Staff/Call Mgr/Reports sections of the VinCENT system. If a user does not have access, they would need to contact their Agency System Administrator.

Agenda Introduction Problem Solving and Solutions Additional Information Quiz

Verifying Correct Payor Information Accessing the Client Search Screen Selecting the Client Selecting the Payor Payor Effective Dates Payor Authorization Payor Priority Status

Verifying Correct Payor Information Accessing the Client Search Screen To verify that the correct payor information is applied to the client file, first the user will need to click on the Clients icon in the upper left hand corner of the VinCENT system.

Verifying Correct Payor Information Selecting the Client Select the client in question by clicking on their name.

Verifying Correct Payor Information Selecting the Payor The user can view all payors that are assigned to the client on the left side of the client folder. To verify the payor information is correct, click on the payor that you wish to view.

Verifying Correct Payor Information Selecting the Payor

Verifying Correct Payor Information Selecting the Payor

Verifying Correct Payor Information Payor Effective Dates The user can verify that the effective dates for that payor are correct. If they are incorrect, the user will need to contact their primary software to ensure that the correct effective dates get sent over through the integration process. **Please Note: The VinCENT system is designed to determine which payor to assign to each schedule based on the Effective Dates first. If there are multiple payors with overlapping effective dates, the system will then look at authorizations that are active for the service and date of the schedule. If effective dates overlap and there are active authorizations for more than 1 payor, the system will finally look at the Priority level of the payor to determine which payor should be applied to that schedule.

Verifying Correct Payor Information Payor Authorization The user can then verify that there is an active authorization entered for the service and dates in question by viewing the authorization information. If there is no active authorization, the user would then contact their primary software to ensure that the authorization information is sent over through the integration process.

Verifying Correct Payor Information Payor Priority Status Finally, the user can verify that the correct Priority Status is selected for that payor by clicking on the blue Edit Payor icon. If the Priority Status of the payor is incorrect, the user would need to contact their primary software to ensure that the correct priority status for the payor is being sent through the integration process.

Verifying Correct Payor Information Payor Priority Status

Verifying Eligibility Information Click on the Clients Icon Select the Client Click on Eligibility

Verifying Eligibility Information Click on the Clients Icon To verify that the client has eligibility information populated on their folder, first, the user would click on the Clients Icon in the upper left hand corner of the VinCENT system.

Verifying Eligibility Information Select the Client The user would then click on the client's name to open the client folder.

Verifying Eligibility Information Click on Eligibility Finally, the user would click on Eligibility on the left hand side of the client folder.

Verifying Eligibility Information Click on Eligibility The client's Eligibility information will be populated. **Please Note: If Eligibility information does not populate, the user would need to check the client's MCD ID and Date of Birth for accuracy and then make the appropriate updates in their primary software. The information can then be sent into the VinCENT system through the integration process. If Eligibility information does not match the payor that is on the client file, the user would again verify the MCD ID and Date of Birth and may need to reach out to the payor directly for further clarification.

Verifying Correct Service Codes and Updating Schedules Some denials are caused by incorrect service codes being applied to the client's schedules in the VinCENT system.

Verifying Correct Service Codes and Updating Schedules Client Authorization Paperwork Service Code Crosswalk Click on Call Mgr Icon Add Client Filter Add Date Range Adding Payor Column Updating Schedules Viewing Service Codes Applied Correcting Service Codes

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Client Authorization Paperwork The user would need to refer to the client's authorization paperwork in order to locate the information needed to determine the appropriate service code in the VinCENT system. This is based on the Service Group/Service Code for DADS clients or HCPCS Code and Modifiers for TMHP and MCO clients.

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Service Code Crosswalk The MEDsys Service Code Crosswalk is a tool that is offered to determine the appropriate service code for the client's schedules.

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Click on Call Mgr Icon To view the service codes that are currently applied to the schedules in question, first the user would click on the Call Mgr Icon in the upper left hand corner of the VinCENT system.

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Add Client Filter The user can add a filter for the client to view only that client's schedules. To do that, click the green Add + icon by filters in the upper left hand corner of the call manager screen and select the client from the Client dropdown menu.

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Add Client Filter

Verifying Correct Service Codes and Updating Schedules Add Date Range The user would then select the appropriate date range for the dates in question at the top of the call manager screen. To do that, click on the first date box at the top and select the appropriate begin date. Then click inside of the second date box and select the appropriate end date. The date can be selected from the calendar that opens upon clicking inside of the date boxes or it can be manually typed in.

Verifying Correct Service Codes and Updating Schedules Add Date Range

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Adding Payor Column The user can add a column to view the payor that is assigned to each schedule. To add the payor column, the user would click on the Add Columns icon in the upper left hand corner and scroll down to check the box marked Payor.

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Adding Payor Column

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Adding Payor Column

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Updating Schedules The user can perform an update to the schedules to ensure that all correct payor information has been applied to the appropriate schedules. To perform an update, click on the Circle with Checkmark icon in the upper right hand corner of the Call Manager screen.

The user can click OK to close this window. Verifying Correct Service Codes and Updating Schedules Updating Schedules After the update has been completed, a pop up window will open letting the user know that the schedules have been updated successfully. The user can click OK to close this window.

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Viewing Service Codes Applied The user can view the service codes that have been applied to the schedules in the Service column of the Call Manager screen.

Verifying Correct Service Codes and Updating Schedules Verifying Correct Service Codes and Updating Schedules Correcting Service Codes If it is determined that the service is listed incorrectly in the VinCENT system, the user would need to follow up with their primary software to make sure that the information is mapped correctly from their system into the VinCENT system.

Transmission Reports There are 2 reports available in the system that assist with determining which information was transmitted to the payors and which information was withheld.

Transmission Reports Transmissions Reports Defined Click the Reports Icon Click Reference Select the Report Add the Appropriate Filters Generate the Report Viewing the Report

Transmission Reports Transmissions Reports Defined The Transmissions report will show the user which schedules were submitted to the payor. If the schedules in question that were denied appear on this report, the invoice may have been submitted prior to the Last Upload date to the payor. The user would print this report and contact the payor directly to determine the next steps for reimbursement.

Transmission Reports Transmissions Reports Defined The Transmissions (Unsent) report will show the user which schedules were withheld from transmission to the payor. The reason why it was not transmitted will appear highlighted on the report. If the HCPCS and/or modifiers are highlighted, that could be an indication of an incorrect service applied to the schedules. Once the issues have been resolved, those schedules will be transmitted to the payor on the next daily transmission.

Transmission Reports Click the Reports Icon To access the reports, click on the Reports icon in the upper left hand corner of the VinCENT system.

Transmission Reports Click Reference The Reports screen will open. The user would then click on the category of "Reference" on the left hand side.

Transmission Reports Select the Report The user can then select which report it is that they wish to view by clicking on the name of that report.

Transmission Reports Add the Appropriate Filters Filters can be applied to the report so that it will only populate data that the user wishes to see. To add a filter, the user can click each of the drop down menus to select the specific filter option. A date range can also be added at the bottom of the filter options.

Transmission Reports Generate the Report The user would then click on the blue Generate Report icon to view/print that report.

Transmission Reports Viewing the Report The report will open.

Helpful Hints and FAQ When are Transmissions sent? What information gets sent in the Transmissions? HCPCS, Modifiers, Service Groups/Codes Company Numbers

Helpful Hints and FAQ When are Transmissions sent? Transmissions are sent to the payors on a daily basis. This includes any updates that are made to Confirmed status schedules as well.

Helpful Hints and FAQ What information gets sent in the Transmissions? The information that gets sent for the schedules in the daily transmissions includes: Client Name MCD ID SDA Service Group Service Code HCPCS Modifiers The Service Group, Service Code, HCPCS, and Modifiers are determined by the service code that is applied to the schedules.

Helpful Hints and FAQ HCPCS, Modifiers, Service Groups/Codes If a service code is listed incorrectly on the client's schedules, that schedule will appear on the Transmissions (Unsent) report and those fields will be highlighted requiring attention. If the service codes are incorrect, the user would need to reach out to their primary software to ensure that everything is mapped correctly so that they appear in the VinCENT system with the correct service.

Helpful Hints and FAQ Company Numbers Another potential reason for denial could be that we have missing or incorrect information that was provided to us for the agency. This information includes NPI and API/TPI numbers. These are required fields in the database. If you find that some or all of that information is missing from the top of your Transmissions (Unsent) report, please have the agency system administrator contact MEDsys directly so that we can update your account accordingly.

Agenda Introduction Problem Solving and Solutions Additional Information Quiz

Direct questions about this document to: Agency System Administrator Contact Information Direct questions about this document to: Agency System Administrator

Agenda Introduction Problem Solving and Solutions Additional Information Quiz

Which report will provide information on schedules that were not transmitted to the payor? A. Transmissions B. Transmissions (Unsent) C. Transmissions Withheld D. Company Numbers Checklist The correct answer is B.

Which data gets sent to the payor through the transmissions? A. Client Name, MCD ID, SDA, Service Group/Code/HCPCS/Modifiers B. Client Name, Service Code, MCD ID C. Client Name and MCD ID Only D. Client Name and Social Security Number The correct answer is A.

How often are the transmissions sent to the payors? A. Once the Schedule is Updated B. Monthly C. Weekly D. Daily The correct answer is D.

Once the schedule has been transmitted to the payor, it will not be resent. A. True B. False The correct answer is B.