1. MHS CMS-1500
Prior Authorization
Top Denials
October 22, 2009

2. CLAIM PROCESS

3. Claim Process -Top 10 Denials
Time Limit For Filing Has Expired (EX 29)
Claims must be received within 120 calendar days of the date of service (Contracted Providers)
Exceptions
120 days from DOS for Participating Providers
Exceptions: Newborn, Third Party Liability, and Eligibility delays (filing limit 365 days)
365 days from DOS for Non Participating Providers
Bill Primary Insurer 1st (EX L6)
Verify other insurance (TPL). Medicaid is the payer of last resort
MHS requires a copy of the primary EOP
Timely Filing (EX 29):
Newborns (30 days of life or less) – Claims must be received within 365 days from the date of service. Claim must be filed with the newborns RID #.
TPL - Claims with primary insurance must be received within 365 days of the date of service with a copy of the primary EOB. If primary EOB is received after the 365 days, providers have 60 days from date of primary EOB to file claim to MHS.
Eligibility Delays – Claims involving eligibility retroactively received by MHS must be filed within 365 days from date of service
TPL (L6)
MHS updates member TPL information through:
A monthly file from EDS
Phone call from providers
Receipt of an EOB with claim
Via HMS through active verification on a quarterly basis
If a member has TPL on file but no longer has other coverage or the member has other coverage but the information is not on file take the following steps:
Contact Provider Inquiries with the TPL information so that changes can be made to the TPL file
Send an update notification to EDS via the WebInterchange

4. Claim Process -Top 10 Denials
Coverage Not In Effect When Service Provided (EX 28)
Check eligibility at each visit prior to submitting claims to ensure that you are billing the correct carrier
Non Covered Service For Package B Member (EX BP)
Package B allows for pregnancy related services only
Pregnancy related diagnosis must be on claim for service to be coverage
Package B (BP)
Hoosier Healthwise Members receiving pregnancy coverage (Package B) are eligible for Pregnancy Related coverage only. MHS strictly adheres to IHCP Coverage guidelines.
Use a diagnostic code that relates to pregnancy, the complications of pregnancy, or, when applicable, check emergency on the claim form when billing for covered services.
You should have member sign a waiver if they are Package B & service is not related to pregnancy

5. Claim Process -Top 10 Denials
Code Was Denied By Code Auditing Software (EX 57)
McKessen code audit analysis all claim line items and code combinations by date of service during the auditing/processing of claims
Unbundling
Global
Assistant Surgeon
Claim auditing software tool on assists in explanation on how MHS evaluates different code combinations
The exact reason for denial will not show on the EOP but can be found on web.
Web tool allows providers to enter different code combinations to determine rationale behind determination
These denials cannot be reprocessed by Provider Inquiry representatives. An appeal with supporting documentation must be completed if the provider does not agree with the denial decision.

6. Claim Process -Top 10 Denials
Member Name/Number/Date Of Birth Do Not Match (EX MQ)
Member information on claim must match what is on file with Indiana Medicaid
This Service is Not Covered (EX 46)
Service must be coverable through Indiana Medicaid to be eligible for reimbursement

7. Claim Process -Top 10 Denials
Authorization Not On File (EX A1)
Prior Authorization should occur at least two (2) business days prior to the date of service. Non All elective inpatient/outpatient services must be prior authorized with MHS at least two (2) business days prior to the date of service
All urgent and emergent services must be called to MHS within two (2) business days after service/admit
Failure to prior authorize services will result in claim denials.

8. Claim Process -Top 10 Denials
Claim and Auth Service Provider Not matching (EX HP)
Authorization on file does not match date of service billed
Claim and Auth Provider Specialty Not Matching (EX HS)
Authorization on file does not match provider billing service
HP – Date of service authorized is different than that billed. Providers should contact MHS if date of service differs than that authorized
HS – Authorizations entered are specialty specific. If authorization is entered under 1 specialty type, but different specialty bills, claim will deny. Providers should contact MHS if rendering provider differs from authorized. This includes Nurse Practitioners

9. Claim Process - Billing With Ease
Newborns
Newborn’s RID number is required for payment.
Consent Forms
Need to be attached to the claim form when submitted for claim processing.
NPI, Taxonomy, Tax ID Not on File with MHS Rejections
The system cannot make a one to one match based off of the information provided on the claim.

10. Claim Process – Claim Filing
EDI SUBMISSION
Preferred method of claims submission
Immediate Confirmation of receipt
Faster payment processing
Less expensive than paper submission
MHS Payor ID 39186
It is the responsibility of the provider to review the error reports received from the Clearinghouse
ERF / ERA available
Contact with questions
Paper claims do not require Red/White submission, but should not have handwritting.

11. Claim Process – Claim Filing
On-line through the Managed Health Services website:
Provides immediate confirmation of received claims and acceptance
Paper Claims
Managed Health Services
PO Box 3002
Farmington, MO

12. Claim Process – Resubmission
Clearly mark RESUBMISSION or CORRECTED CLAIM at the top of the claim.
Must attach EOP, documentation, and explanation of the resubmission reason.
May use the Provider Claims Adjustment Request Form.
Providers have 67 calendar days from the date they receive their EOP to file a resubmission.

13. Claim Process – Claim Adjustment
If you need to make an adjustment to a paid claim, you can do so by submitting the adjustment request on paper with the adjustment request form.
Attach a MHS Provider Adjustment Form along with documentation, including EOP (if available) explaining reason for resubmission
Claim adjustments requests must be submitted within 67 days of the date of the MHS EOP

14. Claim Process – Dispute Resolution
PROVIDERS HAVE 67 CALENDAR DAYS FROM THE
DATE OF RECEIPT OF THE EOP TO FILE AN
OFFICIAL DISPUTE OR APPEAL WITH MHS
Verbal inquiries can be made by calling the MHS Provider
Inquiry Line at MHS-4U4U ( ).
A verbal inquiry is not considered a dispute or appeal and does not
stop the 67 calendar days from the date of receipt of the EOP to file
a dispute or appeal

15. Claim Process – Dispute Resolution
INFORMAL CLAIM DISPUTE/OBJECTION
Level One Appeal
1ST step in the appeals process
Should be made in writing by using the Dispute/Objection form
Submit all documentation supporting your objection
Send to MHS within 67 calendar days of receipt of the MHS EOP
A call to Provider Inquiry does not reserve appeal rights

16. Claim Process – Dispute Resolution
FORMAL CLAIM DISPUTE/OBJECTION
Level Two Appeal
(Administrative)
Submit the Formal Claims Dispute (Administrative Appeal) with all supporting documentation to the MHS appeals address:
Managed Health Services
Attn: Appeals
P.O. Box 3000
Farmington, MO
MHS will acknowledge your appeal within 5 business days
Provider will receive notice of determination within 45 calendar days of the receipt of the Appeal

17. Provider Inquiry Services
Call us at We are ready to help you!
Knowledgeable, friendly staff available 8:00-6:00 EST
Focused commitment to professional service
Claims address P.O. Box 3002 Farmington, MO
Dispute & appeal processes (67 days from receipt of EOP)
Appeal address P.O. Box 3000 Farmington, MO
Provider Inquiry Services should be 1st contact when questioning claims issues.
Stress: 67 days to file corrected claim, claim adjustment or appeal.

18. Utilization Management (Prior Authorization)

19. Utilization Management
PRIOR AUTHORIZATION
Prior Authorization is an approval from MHS to provide services designated as needing approval prior to treatment and/or payment.
REFERRAL
A referral is a request (verbal, written, or telephonic communication) by a PMP for specialty care services.

20. Utilization Management
Self Referrals
Podiatrist
Chiropractic
Family Planning
Immunizations
Routine Vision Care
Routine Dental Care
Mental Health by Type and Specialty
HIV/AIDS Case Management
Diabetes Self Management

21. Utilization Management
Prior Authorization (PA) should be initiated through the MHS referral line at MHS-4U4U ( )
The PA process begins at MHS by speaking with the MHS non-clinical referral staff.
Prior Authorizations can also be submitted online via our website at Additional documentation may be required to be sent via fax for approval of authorization.

22. Utilization Management
Services that require a prior authorization regardless of contract status:
All elective hospital admissions two business days prior All urgent and emergent hospital admissions (including NICU) require notice to MHS by the 2nd business day after admission
Transition to hospice
Newborn deliveries by 2nd business day
Rehabilitation facility admissions
Skilled nursing facility admissions
Transition of care
Transplants, including evaluations
Par Providers may request up to two business days after

23. Utilization Management
Services that require a prior authorization regardless of contract status:
Cardiac rehabilitation
Hearing aides and devices
Home care services, including home hospice
In-home infusion therapy
Orthopedic footwear
Orthotics and prosthetics >$250
Respiratory therapy services
Pulmonary rehabilitation

24. Utilization Management
Services that require a prior authorization regardless of contract status:
Abortions (spontaneous only)
Assistant Surgeon
Blepharoplasty
Cholecystectomies
Circumcision (any patient over 30 days old)
Hysteroscopy and Hysterectomy
Therapies, excluding evaluations
Dental Surgery for members >5 y/o &or general anesthesia is requested
Dialysis

25. Utilization Management
Services that require a prior authorization regardless of contract status:
Experimental or investigational treatment/services
Genetic testing or counseling
Home care services
Implantable devices including cochlear implants
Infertility services
Injectable Drugs (greater than $100 per dose
Mammoplasty
Nutritional counseling (non-diabetics only)
Pain Management Programs including epidural, facet and trigger point injections
PET, MRI, MRA and Nuclear Cardiology/SPECT scans
Non Par require CT with angiography

26. Utilization Management
Services that require a prior authorization regardless of contract status:
Scar revision/cosmetic or plastic surgery
Septoplasty/Rhinoplasty
Spider/Varicose veins
Specific DME services (listing on Quick Reference Guide)
This is just quick hits list.. Refer to web for complete lsting.
Non contracted providers require PA for most services. Auth not required for Labs, EEG (rev 740). OB ultrasounds require PA

27. Utilization Management
To initiate the authorization, referral staff will require the following information:
place of service: outpatient, observation or inpatient
service type: elective, emergent or transfer
service date
name of physician performing service
CPT code for proposed services
primary and any secondary diagnosis
contact name and number to obtain clinical information
MHS will
Provide the caller with the name and phone/fax number of the Care Manager (CM) assigned to the case
The CM will correspond with the provider via the provider’s preferred method: phone or fax
The MHS CM will review all available clinical documentation; apply Milliman Care Guidelines, and seek Medical Director input as needed.

28. Utilization Management
Denial of Request and Appeal Process
If MHS denies the requested service:
MHS CM will notify the provider verbally within one business day of the denial, provide the clinical rationale, and explain appeal rights
A formal letter of denial explaining denial rationale and appeals rights will be mailed within the next business day
If denial is based on Milliman Care Guidelines, provider has right to obtain a copy of the guidelines in which denial is based
If member is still receiving services the provider has the right to an expedited appeal which must be requested by the attending physician

29. Utilization Management
Denial of Request and Appeal Process
If MHS denies the requested service:
If the member has already discharged- an appeal must be submitted in writing from the attending physician within 60 days of the denial
The attending physician has the right to a Peer to Peer discussion
Peer to Peer discussions and Expedited Appeals are initiated by calling MHS at MHS-4U4U ( ) and asking for the Appeal Coordinator

30. Utilization Management
MEDICAL NECESSITY GRIEVANCE AND APPEALS
Managed Health Services
Attn: Appeals Coordinator
1099 North Meridian Street, Suite 400
Indianapolis, IN
Determination will be communicated to the provider within 20 business days of receipt

31. MHS - Need To Know

32. MHS – Need to Know Member Services Transportation NurseWise
Healthy Reimbursement Account
Connections
Panel Change Requests

33. MHS – Need to Know Adding a new provider
Provider must have Indiana Medicaid Linked to group before MHS credentialing and set up process can begin.
Contact Provider to obtain Provider Enrollment Form for proper set up and Participation Provider Attestation to link provider to existing contract.
Welcome letter will be issued once set up complete.
Obtain Prior Authorization for all services rendered to MHS prior to confirmation of contracted status. Provider Inquires

34. MHS – Need to Know www.managedhealthservices.com &
1-877-MHS-4U4U ( )

35. Need to Know - MHS Website
Enhanced website – Access for both contracted/non-contracted groups
On-line Registration – Multiple Users
Provider Directory Search Functionality
Enhanced Claim Detail
Direct Claim Submission (Professional Claims only)
Printable EOP
On-line prior authorization guide and submission
Claim Auditing Software Tool
Downloadable Eligibility Listing
Printable, Current Forms and Manual
Highlight features of website including: Online claim submission, PA requests, Printable EOP, Eligibility listing, QI guidelines, Immunization schedules, Medical Record Audit Tool

36. Need to Know - MHS Website
Upcoming Enhancements
Direct claim submission UB04 – 2010
Claim resubmission – 2010
Claims Xtend – 2010

37. Need to Know – Provider Education
MHS generates a Provider Watch Bulletin of helpful tips and Plan updates to billing office locations for all participating providers on a quarterly basis. All providers can review this bulletin on the MHS website at
Remind: Personalized Provider Relations staff (contact information in packet)

38. Questions and Answers