© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

Georgia Medicaid Health Fair Hospital Presentation Presented by: Janey Griffin (HP Enterprise Services) Georgia Medicaid Health Fair Hospital Presentation Presented by: Janey Griffin (HP Enterprise Services)

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Agenda Objectives Overview Topics for Discussion Interactive Voice Response System (IVRS) Session Review Closing, Questions and Answers 3

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Objective The information presented will enable providers to: Understand claims processing Be informed of updates addressed in the agenda Use the information provided for timely claims reimbursement 4

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Overview The Hospital Program provides: Reimbursement for medical services rendered in an inpatient or outpatient hospital setting. Covered services for eligible members that are primarily for treatment indicated in the management of acute illness, injury, or impairment, or for maternity care. 5

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Topics for Discussion CAH Facilities Transfer from Facility to Facility Contractual Agreement Timely Filing Policy Moving Paperless IVRS Overview Closing 6

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Critical Access Hospital (CAH) A Critical Access Hospital is identified as: A facility that is located in a rural area or be treated as rural under a special provision that allows qualified hospital providers in urban areas to be treated as rural Furnish 24-hour emergency care services 7 days a week. Maintain no more than 25 inpatient beds that may also be used for swing bed services. 7

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Critical Access Hospital (CAH) CAH facilities are identified by Type of Bill 851 for outpatient crossover claims only. All other type of claims are to be billed as noted in the Policy and Procedure Manual for straight Medicaid claims. CAH facilities submit their emergency room claims separately from the Inpatient admission claims due to the CMS guidelines. Medicaid will process these claims according to Medicare guidelines. 8

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Critical Access Hospital (CAH) At this time, CAH facilities are exempt for the Present on Admission (POA) Indicator requirement and Hospital-Acquired Conditions (HAC) payment. Patient Status 66 should be used when a patient is Discharged/Transfer to a Critical Access Hospital 9

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Transfer from Facility to Facility If a patient is transferred from one hospital for admission to a second hospital for medically appropriate cause and the claims for both hospitals fall into the same DRG, both hospitals will be eligible for payment. Each hospital’s payment will be the lesser of the DRG rate or a rate calculated by the CCR methodology. 10

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Transfer from Facility to Facility If a patient is transferred from one hospital for admission to a second hospital for medically appropriate cause and the claims for both hospitals fall into different DRGs, each hospital’s payment will be the amount that a non-transfer claim would be paid. All transfers are subject to either precertification or retrospective review. 11

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Transfer from Facility to Facility If there is not a Contractual Agreement from both facilities, for transfers back to the originating hospital, the originating facility receiving the back-transfer for lower level of care is eligible to receive reimbursement for both confinements. To ensure accurate claim processing, the originating facility must request an adjustment to the precertification date span. 12

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Transfer from Facility to Facility The originating facility must also adjust any previously paid claim for the initial hospitalization. Combine and resubmit as a single claim for both date spans. The dates of service spent in the alternate facility are reflected as leave of absence days. 13

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Contractual Agreement When covered services are not available or provided in the hospital where the member is an inpatient or outpatient, the services must be furnished by another enrolled hospital through a contractual agreement. The original hospital where the member is an inpatient or outpatient must bill the Medicaid program for the shared services or procedures along with the other charges incurred during that course of treatment or inpatient confinement. 14

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Contractual Agreement The original hospital is responsible for reimbursement to the shared service facility. These claims should not be billed with Revenue Code 180 for Leave of Absence Days. Medicaid program should only be billed by the original hospital for all of the charges incurred. 15

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Timely Filing Hospital providers must follow the established billing and timely filing protocols, in accordance with Appendix O and Part 1 of Policies and Procedures Medicaid and Peach Care for Kids. Provider has 6 months from the date of service for the initial submission. Provider has 6 months form the date of retro eligibility. Provider has 3 months from the date of a denied claim to correct and resubmit. 16

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Timely Filing Provider has 3 months from the date of payment to request an adjustment to a paid claim. Provider has 3 months from the date of payment to submit a claim for outlier reimbursement. Provider has 12 months from the date of service if the provider is an out of state provider to submit the initial claim. Provider has 12 months from a TPL or crossover claim payment to submit the claim to Medicaid for secondary and/or crossover reimbursement. 17

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Timely Filing Provider has 30 days from the date of the date of a denied claim to submit the initial appeal on the DMA 520 and/or DMA 520 A. Provider has 30 days from the date of an appeal if it is upheld. HPES has up to 30 business days to process claims within the GAMMIS system. HPES has up to 30 business days to respond back to appeal on the DMA 520. This information can be found in Part 1 Policy and Procedure Manual 18

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Policy The Policies and Procedures Hospital Services Policy Manual is located at We encourage providers to review the manual quarterly (January 1, April 1, July 1, and October 1). In addition, we encourage providers to review the Provider Notices and Provider Messages weekly for policy updates Medicaid Services. 19

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Provider Message 10/24/2014 Outpatient Claims for NCCI Mass Reprocessing 10/17/2014 Registration for the DMA 520 and DMA 520A Online Submission 10/14/2014 Register Now for the Submission of Institutional Claims Electronically Webinar 20

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Provider Message 09/11/2014 Online Submission of Crossover Claims for Medicare Advantage Plans 09/11/2014 Changes for Radiology and Cardiology Services (not limited to MRI’s, CT’s and similar procedures) 09/08/2014 Revenue Code 21

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Moving Paperless Any claims submitted on paper after May 1, 2015, will be returned to the provider with a letter stating the claims must be submitted electronically. Beginning December 1, 2014, DCH will require that all Inpatient Part B Only Claims must be submitted through the Georgia Medicaid Management Information System (GAMMIS –

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Moving Paperless Listed below are the type of claims that are now required to be submitted electronically and/or over the web portal. DMA 520 Medicare and Medicare Advantage Claims Professional Claims Institutional Claims Inpatient Part B only Claims 23

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. IVRS Overview Option 1Member Eligibility Option 2Claims Status Option 3Payment Information Option 4Provider Enrollment Option 5Prior Authorization and Georgia Better Healthcare member referrals Option 6Web Portal password reset, Pharmacy Benefits, the Nurse Aide Registry or Nurse Aide Training program, PeachCare for Kids, ® EDI submission, or electronic claim submission, or a system overview. 24

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Provider Service Contact Center PSCC assists providers with inquiries regarding claims status, eligibility coverage, prior authorization, remittance advice, demographic changes and other Medicaid questions. They are available: Monday – Friday (excluding state holidays) 7 a.m. – 7 p.m. Eastern Time Providers can also use the “Contact Us” link on GAMMISAMMIS 25

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. 1. Select a Type of Inquiry item. 2. Select a Contact Method. 3. Click submit.    Contact Us Public Area

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Provider Relations Field Service Representatives (FSR) Territory 1 – N. Georgia – Graham Gerritz Territory 2 – Fulton – Shay Daniels Territory 3 – NE Georgia – Stanfinie Clayton Territory 4 – NW Georgia – Danny Williams Territory 5 – SE Metro – Anita Maddox Territory 6 – Middle Georgia – Sabine Fortune Territory 7 – Augusta – Sharonna Strong Territory 8 – SW Georgia – Jill McCrary Territory 9 – SE Georgia – Veronica Meng Territory 10 – South Georgia – Donna Hurst Hendley State Wide – Hospital Rep – Janey Griffin 27

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Session Review You should now: Be able to understand claims processing Be knowledgeable about updates addressed in the agenda Be able to use the information for timely claims reimbursement 28

© 2014 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Closing Questions & Answers 29