1. Standard Operating Procedure
Handling Payor Denials - Integration Customers

2. Agenda
Introduction
Problem Solving and Solutions
Additional Information
Quiz

3. 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.

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

5. 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.

6. Agenda
Introduction
Problem Solving and Solutions
Additional Information
Quiz

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

8. 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.

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

10. 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.

11. Verifying Correct Payor Information Selecting the Payor

12. Verifying Correct Payor Information Selecting the Payor

13. 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.

14. 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.

15. 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.

16. Verifying Correct Payor Information Payor Priority Status

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

18. 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.

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

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

21. 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.

22. 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.

23. 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

24. 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.

25. 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.

26. 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.

27. 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.

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

29. 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.

30. Verifying Correct Service Codes and Updating Schedules Add Date Range

31. 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.

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

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

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

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

40. 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.

41. 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.

42. 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.

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

44. 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.

45. 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.

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

47. Transmission Reports Viewing the Report
The report will open.

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

49. 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.

50. 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.

51. 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.

52. 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.

53. Agenda
Introduction
Problem Solving and Solutions
Additional Information
Quiz

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

55. Agenda
Introduction
Problem Solving and Solutions
Additional Information
Quiz

56. 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.

57. 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.

58. 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.

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