HP Provider Relations October 2011 Medical Review Team

Medical Review TeamOctober Agenda – Objectives – Role of the Medical Review Team – MRT Process – Initial Exams and Services – Authorizations for Additional Services – Billing Procedures – Helpful Checklist – Top MRT Claim Denial Reasons – Helpful Tools – Questions

Medical Review TeamOctober Session Objectives At the end of this session, providers will know : – The composition of the Medical Review Team – How the MRT process works – The initial services and what is needed to bill additional services – How to eliminate and resolve claim errors

Understand Medical Review Team Role and Process

Medical Review TeamOctober Role of the Medical Review Team –Medical Review Team (MRT) staff members consist of physicians, registered nurses (RNs), certified medical assistants (CMAs) and consultants –The MRT determines Medicaid eligibility by completing the following functions: Reviewing clinician information to determine whether applicants meet disability criteria Issuing eligibility decisions based on medical evidence that supports documentation stating the applicant has a significant impairment Submitting determination forms to the Division of Family Resources (DFR)

Medical Review TeamOctober Role of the Medical Review Team –The DFR makes initial and continuing eligibility determinations –The MRT determines if applicants have a significant impairment A significant impairment has an expected duration of a minimum of 12 months without significant improvement The condition must substantially impair the applicant’s ability to perform labor or services, or to engage in a useful occupation

Medical Review TeamOctober MRT Process –All Medicaid applicants apply at the Division of Family Resources (DFR), or through the Service Center for all Medicaid programs at –The DFR will set up a telephone interview with the applicant to obtain information from the applicant Social economic Medical information –A letter will be sent to the applicant and the provider requesting medical records and/or an examination from the provider –The provider will send the medical records to the address listed on the Determination of Disability, Medical Information form

Medical Review TeamOctober MRT Process –The applicant’s information is transferred from the DFR to a team of professionals at the Office of Medicaid Policy and Planning (OMPP) –The information is transferred to an electronic format to be reviewed for quality –Each employee at the OMPP is assigned a region and will process all electronic MRT applications for his or her assigned region All standards for state and federal law must be met –A determination will be made based on demographics, such as age, education, work history, and medical background

Medical Review TeamOctober MRT Process –If information is for medical disability, the file will go to the physician on staff at the state; if it is a mental health disability, it will go to the psychiatrist at the state –At this time, the staff at the OMPP will deny, approve, or ask for additional information from the applicant by a written request sent to the applicant –Eligibility information comes directly from the DFR to HP This step eliminates an extra step and minimizes delays in transferring information from the DFR to HP –Once the information is downloaded to IndianaAIM (Indiana’s Medicaid payment processing system), an MRT eligibility segment is created –The provider can now bill the claim

Learn Initial Exams, Services, and Authorizations

Medical Review TeamOctober Initial Exams and Services Valid codes –Most commonly submitted codes: – Reports – Initial Exam SE – Mental Status Exam S9981 – Medical Records –IHCP Provider Manual lists additional covered MRT procedure codes and their respective rates CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Medical Review TeamOctober Authorizations for Additional Services –The MRT must authorize all additional exams or tests –When additional exams or tests are required, the MRT directs the applicant to obtain those services –The MRT provides the applicants with an Additional Information Request form to authorize additional services

Bill MRT Claims

Medical Review TeamOctober Billing Procedures –MRT claims follow the same billing procedures as IHCP claims with a few exceptions –Submit electronic MRT claims using the Health Insurance Portability and Accountability Act (HIPAA) 837P transaction or Web interChange –Providers may also use the paper CMS-1500 claim form –File all claims within one year from the date of service –Mail paper claims to: HP CMS-1500 CLAIMS PO Box 7269 Indianapolis IN

Medical Review TeamOctober Billing Procedures –Claims may be submitted with the letter from the DFR that authorizes services Submission of the DFR letter is optional –MRT claims must use a unique applicant ID that consists of 850 plus the applicant’s Social Security number (850 + Social Security number) If the resident is a Medicaid applicant, the MRT ID number will remain 850 plus the Social Security number Do not use the applicant’s Medicaid ID for MRT claims

Medical Review TeamOctober Billing Procedures –MRT services cannot be submitted on the same claim with services for Medicaid or any other IHCP program –MRT claims are subject to all audits and edits not excluded by MRT program requirements –Financial information is available in the electronic 835 RA transaction –The Remittance Advice is available on Web interChange –The applicant is not responsible for any charges for an MRT claim if the services are requested by the MRT or the caseworker MRT claims are eligible for payment even when the disability application is denied

Check Helpful Checklist

Medical Review TeamOctober Helpful Checklist –Applicants do not have to be enrolled Medicaid applicants to participate in the MRT program –All applicant IDs must begin with “850,” followed by the applicant’s Social Security number –All providers must be enrolled in Indiana Medicaid as well as the MRT program to submit MRT claims –Only approved Healthcare Common Procedure Coding System (HCPCS) codes and modifiers will be accepted on claims Note – If the MRT code contains a modifier, the modifier MUST be submitted on the claim to avoid claim denial.

Medical Review TeamOctober Helpful Checklist –The maximum fee, procedure code, and all modifiers must be billed on the claim –MRT services cannot be combined with a claim for any other Medicaid services –Claims that encounter an edit or an audit for any missing or invalid information will deny –Claims will suspend if there is a valid attachment accompanied with the claim for any applicant that does not have an eligibility segment on file

Deny Top MRT Denial Reasons

Medical Review TeamOctober Top MRT Denial Reasons Edit 2037 – Member not on file for non-IHCP program –Cause Applicant does not have an MRT eligibility segment in the payer processing system –Resolution Ensure the date of service is within the time parameter as indicated in the request letter from the county; allow 30 days from the application date for eligibility segment to be updated Verify that the applicant’s ID begins with “850,” followed by the applicant’s valid Social Security number

Medical Review TeamOctober Top MRT Denial Reasons Edit 2029 – Non-IHCP member ineligible for dates of service –Cause The date of service is not within the MRT eligibility segment dates –Resolution Verify the MRT number submitted on the claim Verify the dates of service submitted on the claim are in line with the dates of service on the request letter from the county Verify the dates on Medical Records charges are the actual date that Medical Records were copied

Find Help Resources Available

Medical Review TeamOctober Helpful Tools Avenues of resolution –IHCP website at indianamedicaid.comindianamedicaid.com –IHCP Provider Manual (Web, CD, or paper) –Customer Assistance (317) in the Indianapolis local area –Written Correspondence P.O. Box 7263 Indianapolis, IN –Provider field consultant View a current territory map and contact information online at indianamedicaid.comindianamedicaid.com

Q&A