Wyoming Medicaid Provider Information and Resources Wyoming Medicaid Provider Workshops Summer 2015 Presenter: Kilee Thompson, Field Representative

Provider Manuals  Located on the Wyoming Medicaid Website o o Select Provider o Select Provider Manuals and Bulletins (Left Hand Navigation Bar) o Select appropriate provider type o Open provider manual listed for your provider type  Provider Manual Updates o Many changes are being made to the Provider Manuals to update and improve the information o Please look for these changes in the next couple months. September 7,

Chapter 1: General Information & 2: Getting Help when You Need It  Chapter One o How the Manual is Organized o Updating the Manual o State Agency Responsibilities o Fiscal Agent Responsibilities  Chapter Two o Quick Address and Telephone Reference o Quick Website Reference o How to Call for Help o How to Write for Help o How to Get On-Site Help o How to Get Help Online o Training Seminars o Ordering Forms September 7,

Chapter 3: Provider Responsibilities Enrollment Accepting Medicaid Clients Medical Necessity Medicaid Payment is Payment in Full Out-of-State Service Limitations Medicare Covered Services Usual and Customary Charges Record Keeping, Retention, and Access Tamper Resistance Rx Pads September 7,

Chapter 4: Utilization Review Utilization Review Complaint Referral Release of Medical Records Client Lock-In Fraud and Abuse Provider Responsibilities Referral of Suspected Fraud and Abuse Sanctions Adverse Actions September 7,

Chapter 5: Client Eligibility What is Medicaid? Who is Eligible? Maternal and Family Health (MFH) Eligibility Determination Client Identification Cards Other Types of Eligibility Identification Clients without Cards Freedom of Choice Verification of Client Eligibility Verification Options September 7,

Chapter 6: Common Billing Information Basic Claim Information Authorized Signatures (CMS-1500) Completing the Claim Form Medicare Crossovers Examples of Billing Cap Limits Reimbursement Methodologies Co-Payment Schedule How to Bill for Newborns No Show Appointments Home Health (CMS-1500) Prior Authorization Submitting Attachments for Electronic Claims Sterilization, Hysterectomy, and Abortion Consent Forms The Remittance Advice Resubmitting Verses Adjusting Claims Returning a Medicaid Check Credit Balances Third Party Payments Received after Medicaid’s Payment Timely Filing Important Information Regarding Retroactive Eligibility Decisions Failure to Notify a Provider of Eligibility Billing Tips to Avoid Timely Filing Denials Telehealth (UB-04) September 7,

Chapter 7: Third Party Liability Definition of a Third Party Payer When Clients Have Third Party Liability (TPL) Identifying Other Sources of Coverage Exceptions to Billing Third Party Payers First Preventive Pediatric Care Prenatal Care Health Insurance Policies Held by Absent Parents 100% Federally Funded Programs Legal Liability Has Not Been Established Billing Third Party Payers Previous Attempts to Bill Services Letter Coordination of Benefits Questions about TPL Third Party Resources Information Sheet September 7,

Chapter 8: Electronic Data Interchange What is Electronic Data Interchange (EDI) Benefits Standard HIPAA Transaction Formats Sending and Receiving Transactions EDI Services Web Portal WINASAP Additional Information Sources Scheduled Web Portal Downtime September 7,

Chapter 9: Wyoming Specific HIPAA 5010 Electronic Specifications Wyoming Specific HIPAA 5010 Electronic Specifications Transaction Definitions Transmission Methods and Procedures Acknowledgement and Error Reports Testing 270/271 Eligibility Request and Response 276/277 Claim Request and Response 278 Request for Review and Response 835 Claim Payment/Advice 837 Professional Claims Transactions 837 Institutional Claims Transactions 837 Dental Claims Transactions September 7,

Chapter 10: CMS-1500 Covered Services Claims Review Physician Supervision Definition Coding Importance of Fee Schedules and Provider’s Responsibility Ambulance Services Audiology Services Children’s Mental Health Waiver (CMHW) Community Mental Health and Substance Abuse Treatment Centers Developmental Centers Family Planning Clinics Health Check – EPSDT Interpreter Services Laboratory Services Physician and Nurse Practitioner Services Pregnant By Choice/Family Planning Waiver Therapy Services September 7,

Chapters 10+: Institutional Covered Services Chapter 10: Important Information Chapter 11: Outpatient Services Chapter 12: Critical Access Hospital and General Hospital Inpatient Chapter 13: Comprehensive Outpatient Rehabilitation Facility (CORF) Chapter 14: End Stage Renal Disease (ESRD) Chapter 15: Federally Qualified Health Centers (FQHC) Chapter 16: Home Health Chapter 17: Hospice Chapter 18: Indian Health Services (IHS) Chapter 19: Skilled Nursing Facility and Swing Bed Services Chapter 20: Rural Health Clinics (RHC) Chapter 21: Psychiatric Residential Treatment Facility (PRTF) September 7,

Provider Reenrollment The Affordable Care Act (ACA) is requiring that all Medicaid providers are screened and re-enrolled at least every five (5) years. This includes both Pay-To Providers, and Treating Providers. Most providers can re-enroll by visiting the Wyoming Medicaid website at and selecting the “Provider” tab. Then select the “Provider Enrollment” link on the left hand navigation bar. Additional information about the reenrollment process can be found at the same website under the “CMS Reenrollment” link If you unsure about whether you have completed the reenrollment process, please contact provider relations at options 1, 5, and then 0 to speak to a representative who will be able to tell you the last date that an enrollment was completed. Must be completed by December 31, 2015 September 7,

835 Vs. Remittance Advice (RA) 835 Electronic Remittance Advice X12N 835 Claim Payment/Remittance Advice Used to autopost claim payments Nonproprietary Explanation of Benefits Standard pre-set explanations Can be retrieved through a clearinghouse, a direct connection, or downloaded from the Provider Web Portal Remittance Advice Claims are grouped by disposition: Paid, Denied, Pended, and Adjusted The above groups are alphabetized by client last name. Proprietary Explanation of Benefits Wyoming Medicaid specific explanations Can be retrieved through the Wyoming Medicaid Provider Web Portal September 7,

Electronic Claims Mandate  All providers submitting claims containing diagnosis codes to Wyoming Medicaid will be required to follow this mandate  Exceptions: o Providers submitting 25 claims or less in a calendar year o Adjustments do not count towards the 25 claims o Providers which do not submit claims with ICD-9 or 10 diagnosis codes  To get started: o If you already bill electronically through the Provider Web Portal, WINASAP or a clearinghouse which submits your claims electronically, no further action is required. o If you have not yet started billing electronically, please review chapter 8 and 9 of either provider manual and complete an EDI Application o To use the Provider Web Portal to bill, please utilize the Provider Tutorials listed on the website and contact EDI Services at Option 3 with any questions you may have. Effective July 1, 2015 September 7,

Electronic Claims Mandate  Another feature available on the Provider Web Portal is the ability to submit electronic attachments for your claims or you can submit your attachments by paper by completing the Attachment Cover Sheet  Requesting an exemption o Must submit request in writing o Request must include  Provider name, NPI, Contact name, and phone number  The calendar year which to be exempt and reason for the exemption  The approximate future date you will be ready to submit claims electronically  Detailed explanation of the reason for exemption Effective July 1, 2015 September 7,

Provider Contacts It is important for all providers, both treating and pay-to providers, to maintain current and accurate contact information.  Why it is important to update provider contact information. o To receive up-to-date policy information o To know when to renew your license o Any other communication which needs to occur between Wyoming Medicaid and providers  To update your provider contact information, please do the following: o Fax in a written correspondence on office letter with your request o Please include:  NPI/Provider number  Provider contact information which needs updated Physical, correspondence, or financial address, provider phone or fax number, or addresses on file  Date this change will go into effect o Pay-to Providers can also update their contact information by logging into the Provider Web Portal and going to “Update Provider Demographics” o addresses on file can also be updated by speaking to a representative at Provider Relations by calling options 1, 5, and then 0. September 7,

Resources  Wyoming Medicaid Website – o Provider Manuals and Bulletins  Click on Provider / Provider Manuals and Bulletins / Select Provider Type / CMS-1500 Provider Manual or Institutional Manual o Fee schedule  Click on Provider / Fee Schedules / Accept / Procedure Code Search Page  CMS NCCI Tables  Procedure Code Searches  Dental Fee Schedule  OPPS/APC-Base Fee Schedule o IVR Navigation tips  Helps to direct providers to the appropriate options for each department  Click on Provider / Contact Us / Click here for helpful Provider IVR Navigation Tips o Remittance Advice Retrieval  From the Secure Provider Web Portal o Medicaid and State Healthcare Benefit Plan document  Click on Provider / Provider Manuals and Bulletins / Additional Links September 7,

Resources  IVR o 24 hours a day / 7 days per week o NPI is required  IVR Functionality o Verify client eligibility  Client ID or client SSN and date of service is required  Benefit plan Covered services Limitations  Cap Limits  Lock-in  TPL / Medicare Buy-in o Verify claim status o Verify Payment o Opt out to agent September 7,

Resources  Provider Relations (Option 1,5,0) o 9-5 MST Monday - Friday o Bulletin / Manual inquiries o Cap limits o Claim inquiries o Claim submission problems o Client eligibility o Questions on completing forms o Payment inquiries o Timely filing inquiries o Billing issues regarding PA o Verifying validity of procedure codes o Claim void / adjustment inquiries  Fax Number o September 7,

Resources  EDI Services (Option 3) o 9-5 MST Monday – Friday o EDI Enrollment Form o Trading Partner Agreement o WINASAP Software & Technical Support for WINASAP o Technical Support for Vendors, Billing Agents, and Clearinghouses o Provider Web Portal Registration o Technical Support for Provider Web Portal & Password Resets  Medical Policy (Option 1,1,4,3) o 9-5 MST Monday – Friday o Prior Authorizations (PAs) Requests for: o Out-of-State Home Health o Surgeries requiring Pas o Hospice Services: Limited to Clients Residing in a Nursing Home o Status of a Pending PA o How to Complete a PA Request o Office Visit, PT, and OT Cap Limit Waiver Requests September 7,

Questions? September 7,