1. 2018 IHCP Annual Workshop
MDwise Claims
HHW-HIPP0581 (9/18)

2. Agenda
MDwise History
Updates
Contracting
Eligibility
Claim Submission
Disputes
Refunds
Prior Authorization (PA)
Resources
Questions

3. 2007: MDwise selected to provide care through the Healthy Indiana Plan
MDwise History
1994: MDwise founded as Indiana-based nonprofit health care company Central Indiana Managed Care Organization, Inc. (CIMCO), utilizing a delivery system model
2001: CIMCO teamed up with IU Health Plan and formed into MDwise, Inc., serving more than 55,000 Hoosier Healthwise members.
2007: MDwise begins service Care Select (now Hoosier Care Connect) members
2007: MDwise selected to provide care through the Healthy Indiana Plan
2018: MDwise acquired by Michigan-based McLaren Health Care; one of Michigan’s largest integrated health systems
MDwise’s history began back in 1994 when we were founded as CIMCO. From 2001 to 2014, MDwise offered medical coverage to Indiana residents through the Hoosier Healthwise, Hoosier Care Connect, formerly Care Select, HIP and Marketplace programs. Our focus shifted over the last couple of years from all 4 medical programs to just Hoosier Healthwise and HIP. And in 2017, MDwise was purchased by McLaren Health Care, a Michigan-based health system with a significant health plan operation across the state of Michigan.

4. Who Is McLaren Health Care?
Is one of the largest integrated health care systems in Michigan
Owns 15 hospitals, including Barbara Ann Karmanos, nationally renowned for their cancer care and outcomes
Employs over 500 physicians
Trains over 550 residents annually
Has a workforce of over 20,000
Owns McLaren Health Plan, who covers over 265,000 members in Medicaid, commercial, and Medicare Supplemental markets.

5. MDwise – McLaren Synergies
Sharing Best Practices between MDwise and McLaren Health Plan, such as:
Care Management
Opioid Crisis Management
Effectively managing inappropriate ER utilization
Streamlining Prior Authorizations
Pay for Value Physician Incentive programs
Claims adjudication
Results are Demonstrating:
Improvement in health care outcomes for our members
Enhanced access for members
Greater administrative efficiencies, which allow more health care dollars to be spent on the actual delivery of medical care

6. Updates
Effective 1/1/19:
MDwise is restructuring it’s Delivery System model to:
Improve claim payment timeliness and accuracy
Streamline and reduce administrative redundancy for providers
Provide greater access for our members
One standard authorization list
One point of contact for all authorization requests
One claim submission address
Non-Excel Delivery System contracts
Providers not contracted with MDwise Excel must contract to stay in network.
Effective January 1, 2019, MDwise will begin operating as a single network, MDwise Excel. This will show when checking eligibility in the MDwise Portal as well as the state systems. Along with this change, MDwise delivery system contracts will expire December 31, If you are not currently contracted as a MDwise Excel provider and want to be able to see MDwise members, you will need to contract as a MDwise excel provider. Please reach out to your dedicate provider representative to begin this process. Also changing will be out claims processing, our prior authorization process and requirements, and our MDwise portal access. All of these items are covered in this presentation, so lets get started!

7. Contracting
Effective 1/1/19: Providers not contracted with MDwise Excel must contract to stay in network.

8. Provider Relations Forms
Contracting
Provider Relations Forms
Credentialing/Enrollment
MCE Enrollment Form
Enrollment Cover Sheet (until 12/31/18)
Provider Update Form
Disenroll/Re-enroll
Panel Move
Non-Contracted Set-Up Form
Required for non-contracted providers
Contract Inquiry Form
Submit Forms to:
Our final department to review is Provider Relations. Recently the Provider Relations and Quality departments merged. If you are in charge of quality or billing, you will now be working through one representative. Non-contracted provider form is required to verify that the provider is set up correctly in the provider portal.

9. Effective 1/1/19: Eligibility When determining eligibility, verify:
Is the member eligible for services today?
Which Indiana Health Coverage Program plan are they enrolled?
If the member is in Hoosier Healthwise or Healthy Indiana Plan, are they assigned to MDwise?
Who is the member’s Primary Medical Provider (PMP)?
Beginning in January, you will be able to utilize the state website for the members Program and MCE. The assigned network or delivery system will always be MDwise Excel. To verify a PMP, you will use the MDwise provider portal, as you do now.
Provider Healthcare Portal
MDwise Provider Portal
IHCP Program
Delivery System: MDwise Excel
MCE
Assigned PMP History
Assigned PMP

10. Hoosier Healthwise & Healthy Indiana Plan
Claim Submission
Effective 1/1/19:
Claim Submission is date of service driven.
Electronic Submission
Please note: Paper claims must be on red/white form with black ink.
Hoosier Healthwise & Healthy Indiana Plan
MDwise
P.O. Box 1575
Flint, MI 48501
Effective January 1st, we will go to one claim submission address and Payer ID per program, as shown here. Please remember this is date of service driven. Claims with date of service 12/31/18 being submitted after January 1st will still need to be sent to the correct delivery system and program, as shown on the previous page. Again, for this updated claim submission information, go to MDwise.org and click on Provider contact information.
Hoosier Healthwise
Healthy Indiana Plan
Payer ID: 3519M
Payer ID: 3135M

11. Claim Submission Claim Timelines: Claim Submission:
Primary: 90 days from the date of service
Secondary: 90 days from the date of the explanation of benefits (EOB)
Effective 1/1/19, non-contracted providers will have 180 days for claim submission.*
MDwise Adjudication: (clean claims)
Electronic Claims: 21 days
Paper Claims: 30 days
Claim Disputes:
60 days from the date of the explanation of benefits (EOB)
Dispute Response: 30 business days from date of submission
*Reference BT for more information
Claim submission timelines and response times are not changing in the new year. Primary claims are still due 90 days from the date of service, secondary 90 days from the date of the primary EOP. Due to state changes announced in bulletin BT201829, providers who are not contracted with MDwise Excel will have 180 days to file claims.
MDwise will adjudicate all clean claims within 21 days for electronic submission, and 30 days for paper submission.
If you receive a claim denial that you would like to dispute, the dispute is due within 60 days of the date of the EOB. MDwise will respond back within 30 business days with an outcome.
If you would like to inquire about a claim in process, you can do so at any time. A response will be made to you within 30 business days of your submission. We do ask that you allow the full 21 or 30 days adjudication time before submitting an inquiry, to allow adequate time for the claim to be reviewed.
Moving on from claims….

12. Secondary Insurance Submissions
Claim Submission
Secondary Insurance Submissions
When the member has other insurance:
Provider must submit claims to the other insurance carrier prior submitting to MDwise
Submitting a secondary claim to MDwise
Must be submitted within 90 days of the date on the EOB
Claims submitted via paper must include a copy of the EOB
Be sure to verify member eligibility for the date of service
Effective 1/1/19: Secondary claims will be accepted via electronic submission.

13. Claim Submissions CMS 1500 Form MDwise follows National
Uniform Claim Committee
(NUCC) guidelines.
Box 19 should contain
typed notes
Claims system is not able
to pick up other writing
*Box 22: Corrected or
Replacement claims
-*Required
Box 23: Prior Authorization
If you have an authorization
number, please include it.

14. Claim Submission UB-04 Form MDwise follows National
Uniform Billing Committee
(NUBC) guidelines
Box 80: Notes
Box 4: Bill Type
Include correct frequency
for submission and
resubmission

15. Claim Refund Process changing:
Refunds
Effective 9/15/18
Claim Refund Process changing:
Provider Refund Form required along with supporting documentation
Send to:
MDwise, Inc.
P.O. Box
Indianapolis, IN
Refund form can be submitted without a check if you wish your claim to be offset from future payments.

16. Refunds
Requirements:
One TIN/NPI per form and check

17. How do you know if you received a denial or a rejection?
Disputes
How do you know if you received a denial or a rejection?

18. Denied claims will include an EOB with a denial code.
Disputes
Denied claims will include an EOB with a denial code.
Rejected claims are different than denied claims:
Rejected claims are returned to the provider or electronic data interchange (EDI) source without registering in the claim processing system.
Since rejected claims are not registered in the claims processing system, the provider must resubmit the claim within the claims timely filing limit.
Rejected claims do not extend the timely filing limit.
Contracted providers have 90 days from the date of service

19. Claim Dispute Process:
Disputes
Claim Dispute Process:
Provider completes the Claims Dispute Form found at on the For Providers page, under Claim Forms.
Completed form and supporting documents are sent via
Received is routed to a Claims Dispute work queue where a ticket number will be issued and an notification will be sent back immediately.
The Claim Dispute team will review the submitted dispute and work the cases to resolution (uphold or overturn).
An notification will then be sent to the provider, referencing the dispute and ticket number, on the resolution determination.

20. Informal Claim Dispute
Disputes
Informal Claim Dispute
Provider disagrees in writing with how the claim was adjudicated:
Must be commenced within 60 days from the date on the Explanation of Payment (EOP)
MDwise will reach a resolution and notify provider within 30 calendar days.
Formal Claim Dispute
Provider disagrees with 1st level resolution:
Provider has 60 days from the date of the 1st level resolution
MDwise will compose a panel of persons not involved with the 1st level dispute to review the 2nd level dispute.
MDwise will reach a resolution and notify provider within 45 calendar days.
The panel’s decision is MDwise’s final action on the claim.

21. Effective 1/1/19 Prior Authorization One standard authorization list
One point of contact for all authorization requests
Submission timelines and process will not change
Go to MDwise.org for most up-to-date version of PA lists
MDwise.org
For Providers
Forms
Prior Authorization
Effective January 1st, our PA guides will update. There will be one PA list per program. The PA lists will still be housed on the Prior Authorization page. The current 2017 and prior PA lists will remain on this page to allow for review after the new year. Be sure you are reviewing the correct PA guides in the new year.

22. Prior Authorization
You will need two key items when filing a request for Medical Prior Authorization (PA):
Universal Prior Authorization Form
Located on our website
Documentation to support the medical necessity for the service you are requesting to prior authorize:
Lab work
Medical records/physician notes
Test results
Therapy notes
Tips:
Completely fill out the universal PA form including the rendering provider’s NPI and TIN, the requestor’s name along with phone and fax number.
Be sure to note if PA is for a retroactive member.
Please Note: Not completely filling out the universal PA form may delay the prior authorization timeframe.
When submitting a prior authorization, always be sure your form is completely filled out and required documentation in included. IF a form is incomplete or documentation is missing, your request will be returned to you and your review timeframe will start over. Also, if you are requesting a PA for a retro active member, be sure to note this in the notes section of the form.

23. Prior Authorization Turn-Around Time
All emergency inpatient admissions require authorization within 2 business days of the admission.
Urgent prior authorizations can take up to 3 business days
Requests for non-urgent prior authorization will be resolved within 7 calendar days.
It is important to note that resolved could mean a decision to pend for additional information.
If you have not heard response within the time frames above, contact the Prior Authorization Inquiry Team and they will investigate the issue.
PA Inquiry Line
Turn around time for authorizations depends on the urgency of the request. Emergency requests must have a PA requested within 2 business days of the date of service; urgent requests will have an outcome within 3 business days, and a non-urgent request will have a decision made within 7 business days. If you have an inquiry on a current PA, please regerence the PA quick contact guide on our website.

24. Resources 1 2 5 3 4 9
If you have questions on these forms or on the contracting process for MDwise Excel, be sure to contact your dedicated Provider Relations representative for your region, as shown here. 6 8 7

25. Resources Representative Territory Phone Email Paulette Means Region 1
Garrett Walker
Region 2
Michelle Phillips
Region 3, Hospice, Home Health
Jamaal Wade
Region 4
David Hoover
Region 5
Tonya Trout
Region 6
Rebecca Church
Region 7
Sean O’Brien
Region 8
Whitney Burnes
Region 9
Nichole Young
Behavioral Health
(CMHC, OTP, IMD or Residential)
Michelle Phillips, our dedicate Home Health and Hospice rep is now covering region 3 as well. If you are a DME provider, please reach out to the Representative in you respective region. Also, territory reps are now covering ABA providers as well. For behavioral health, Nichole young covers CMHC’s, OTP’s, IMD’s and residential providers. All other BH providers should contact their territory reps.

26. MDwise Provider Tip Sheets
Resources
MDwise Provider Tip Sheets
resources/tip-sheets/
MDwise Provider Manuals
MDwise Provider Relations Territory Map
MDwise Customer Service
IHCP Provider Modules
Indianamedicaid.com

27. Questions