1. October 2010 HP Annual Workshop
MDwise – CMS 1500(08-05) Quick Tips to avoid Claim denial A guide for claim adjudication
October 2010
HP Annual Workshop
APP0043 (09/10

2. Purpose for today’s presentation
Claim adjudication for Managed Care Medicaid- MDwise
Top claims denials and rejected submissions
You received a denial… now what ?
How to file a claim dispute and appeal
Quick tips for claims adjudication (including prior authorization)

3. Who is MDwise?
MDwise is a local, not-for-profit company serving Hoosier Healthwise, Care Select and Healthy Indiana Plan (HIP) members. We have been giving the best possible health care to our neighbors since In fact, we only take care of families living in Indiana. Our services are provided to more than 280,000 members in partnership with over 1,400 primary medical providers.

4. General claims processing overview for MDwise
In the MDwise plan, claims processing is delegated to the MDwise delivery systems.
Example: If a provider renders service for a MDwise Wishard member, the provider would submit their claim to MDwise Wishard. If the same provider rendered services to a Methodist member, the provider would submit claim to MDwise Methodist.
If uncertain of the members delivery system, the provider may access this information on HP’s Web interChange at

5. Claims Filing Limit
In-Network Providers have a filing limit that ranges from 90 to 180 days, depending on their contract with the Delivery System.
Claims filing limit for 2011 will change to 90 days for all MCEs.
Out-of-Network Providers have 365 days from the date of service to file a claim.
It is the responsibility of ALL providers to check eligibility at the time of each visit.

6. MDwise Delivery Systems
Hoosier Alliance
Methodist
ProHealth
Select Health
St. Catherine
St. Francis
Saint Margaret Mercy
St. Vincent
Total Health
Wishard

7. General claims processing overview for MDwise
…when a members RID number is entered, along with the NPI, you will see:
The IHCP program the member is enrolled in.
The plan (MCE)
MDwise, what delivery system they are assigned to.
Assigned PMP

8. Eligibility Screen

9. General claims processing overview for MDwise
Contractually, all in-network providers are required to submit claims within 180 days of date of service, unless the claims involves third party liability.
Providers are encourage to submit claims electronically for faster claim adjudication.
Note: MDwise behavioral health providers are required to submit claims within 90 days of date of service.

10. MDwise overview- Enrollment screen snapshot

11. Third Party Liability
MDwise is always the payer of last resort (Medicaid)
MDwise contracts with Health Management Solutions (HMS) to work with coordination of benefit issues.
MDwise does not have a 90 day rule, providers should work with delivery system on a case by case basis.
Hoosier Healthwise

12. General claims overview
Out of network providers
Send paper or electronic claims to the appropriate MDwise delivery system.
Submit claims within 365 days of date of service

13. Top Claims denials for MDwise

14. Top claims denials Duplicate claim
Claim/Service lacks information which is needed for adjudication
Coverage not in effect at the time the service was provided
Payment denied/reduced for absence of, or exceeded, precertification/authorization
Non-covered charges
The referring/prescribing/rendering provider is not eligible to refer/prescribe/order/perform the service
Past the timely filing limit
Payment adjusted due to member having primary insurance payer/coordination of benefits
Charges exceed fee schedule or maximum allowable amount
Diagnosis code is non-covered or invalid

15. Sample electronic claim submission

16. EDI format- 837 Professional
ST*837*987654~
BHT*0019*00*X2FF1* *1230*CH~
REF*87*004010X098A1~
NM1*41*2*ANDERSON MEDICAL GROUP*****46*P123~
PER*IC*ALICE WILSON*TE* ~
NM1*40*2*IHCP*****46*IHCP~
HL*1**20*1~
NM1*85*2*ANDERSON MEDICAL GROUP*****XX* ~
N3*4000 E MELROSE STREET~
N4*INDIANAPOLIS*IN*46204~
REF*24* ~

17. EDI Format cont CLM*755555M*126***11::1*Y*A*Y*Y*C*AA:::IN~
DTP*484*D8* ~
DTP*435*D8* ~
DTP*439*D8* ~
DTP*096*D8* ~
PWK*AS*BM***AC*86576~
AMT*F5*35~
REF*9F*12~
REF*EA*D234345~
HI*BK:V723*BF:4660~
NM1*DN*1*WILSON*JOEL****34* ~
PRV*RF*ZZ*363LP0200X~
REF*1D* D~
LX*1~
SV1*HC:99396*110*UN*1***1:2*1~
DTP*472*RD8* ~
REF*6R*24210~
NM1*82*2*ANDERSON*MARTIN****XX* ~
PRV*PE*ZZ*207RI0001X~
LX*2~
SV1*HC:99000*16*UN*1**1:2*1~

18. Top rejected claims
Rejected claims are different than denied claims, which are registered in the claims processing system but do not meet requirements for payment under MDwise guideline. Example of rejected claims:
DX code not present
Valid authorization number
Current ICD-9*
If there is a 4th or 5th digit, the more general digit code may not be used
Date of Illness or last menstrual period
Federal Tax ID
Provider NPI
RID number
All claims must be legible

19. Pre-Claims Submission/Check List (CMS 1500)
It is necessary to confirm all of the items on the check list prior
to rendering services and submitting a claim.
Is the member eligible for services today?
What IHCP Plan is the member enrolled in ? ( Hoosier Healthwise [Anthem, MDwise, MHS] , Care Select, Traditional, Presumptive Eligibility)*
Is the member enrolled in the Healthy Indiana Plan?
Who is their Primary Medical Provider (PMP)?
Does the member have primary health insurance other than Medicaid or HIP?
Hoosier Healthwise

20. So your claim has denied… now what?

21. So your claim has denied… now what?
Claims Inquiry
In and out of network providers need to contact the MDwise Delivery System to inquire about a claims denial.
MDwise Delivery Systems are required to respond within 30 calendar days of inquiry to the provider with the decision of the inquiry.
Appeals/Dispute-Must be in writing & include the following
*Providers have 60 calendar days to file an appeal and must include the following documentation:
Appeal form, remittance advice and a copy of the claim
If a delivery system fails to make a determination or the Provider disagrees with the determination, the provider should forward their appeal to:
MDwise Corporate at
P. O. Box
Indianapolis, IN
Attention: Grievance Coordinator

22. Electronic rejections
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 corrected claim within the claims timely filing limit.

23. Quick tips for claims for adjudication
Quick tips to avoid denied claims
CMS 1500 (08-05)
Audience participation

24. Quick Tips – audience participation
Example :
MDwise St. Vincent patient is referred to a specialist for outpatient surgery (hysterectomy). Surgery was rendered at Methodist Hospital. Provider submits outpatient claim for $3, and receives denial.
What are the missing elements that caused the claim to deny? (Hint: 2 necessary elements)
Team captains will have 60 seconds to enter data element (s) on sample CMS form) 21-24

25. Example 1

26. Example 1 answer

27. Quick tip CMS 08-05 Example 2:
Outpatient setting (community mental health center)
Patient presents for manic depression and medicine therapy before meds are filled.
Patients sees therapist and psychiatrist on the same day.
( How is this claim submitted for claims adjudication) Hint: member has already had 22 visits with a contracted provider.
( team captains will have 60 seconds to enter data elements on sample CMS form) 21-24

28. Example 2

29. Example 2 answer

30. Quick tips CMS 08-05
Example 3.
Patient presents for a sick visit for low back pain and after chart review is found to need an annual exam and immunizations
How is this claim submitted for adjudication
Team captains will have 60 seconds to enter data elements on sample CMS form) 21-24

31. Quick tip CMS Example 3

32. Example 3 Answer

33. Example 4
Patient is Package B and presents for family planning services ( post delivery).
How is this claim submitted for adjudication?
team captains will have 60 seconds to enter data elements on sample CMS form) 21-24

34. Example 4

35. Example 4 Answer

36. Example 5.
Dr. Good submits claim to MDwise Hoosier Alliance for primary care services rendered to patient “I don’t feel so good” and submits charges from his group A location. Group A location receives a denial. Why did the claim deny?

37. Quick Tip Denial… Example 5

38. Quick Tip Denial… Example 5 claims form completion answer
hint* All of the coding elements on the claim are correct.
Why did the claim deny?

39. Example 6
NCCI edit
Patient is sent to the lab for DX XXXXX. Labs submits claim two details same procedure codes. Second detail denied as dup. Why did this detail deny?

40. Example 6

41. Example 6 answer

42. Tie Breaker
Name all 10 MDwise Delivery systems

43. Tie Breaker answer Hoosier Alliance Methodist ProHealth Select Health
St. Catherine
St. Francis
Saint Margaret Mercy
St. Vincent
Total Health
Wishard

44. Quick Tips to avoid claims denial or rejections
Submit claims and corrected claims timely.
Inquire or dispute claims within contractual time line.
Check with medical mangement or online for services that require PA.
Follow correct coding guidelines for claims submission.
Check member eligibility at the time of service.
Verify payer id information before claims are submitted electronically.
Providers must report NPI to IHCP.

45. Quick tips tools for claims submission
Inside of folders:
Prior authorization forms
Quick contact sheets
Provider Tool Kit
Program information
CMS link
CDC link
Well Child First Poster

46. Thank you from the staff at MDwise and our Delivery Systems