1. RESEARCH AND RESOLVE Professional Claim Denials HP Provider Relations/June 2014

2. Research and Resolve Institutional Claim DenialsJune 2014 2 Agenda Claim Inquiry on Web interChange ‒ Search by member number and date of service ‒ Understand Claim Status Information, Disposition and EOB (explanation of benefits) description Common claim denials Determine corrective action Helpful Tools Question and Answer

3. Research and Resolve Institutional Claim DenialsJune 2014 3 Objectives Participants will understand: How to research professional claims via Web interChange How to read the denials How to determine the resolution How to take corrective action

4. Claim Inquiry

5. Research and Resolve Institutional Claim DenialsJune 2014 5 Claim Inquiry

6. Research and Resolve Institutional Claim DenialsJune 2014 6 Claim Inquiry National Provider Identifier (NPI) or LPI will automatically populate ‒ For multiple locations – choose appropriate service location Member recipient identification number (RID) From and through date of service of specific claim Search by date of service (DOS) Why not search by internal control number (ICN)? ICN will only give information on one specific claim Review all claim submissions and denial reasons Use paid claim (if applicable) for corrections ‒ Adjust the paid claim or void and start over Note: Documentation submitted with original claim must also be submitted with current claim. This applies to paper and electronic claims.

7. Research and Resolve Institutional Claim DenialsJune 2014 7 Claim Inquiry

8. Research and Resolve Institutional Claim DenialsJune 2014 8 Claim Inquiry

9. Research and Resolve Institutional Claim DenialsJune 2014 9 Claim Inquiry Claim submission information is displayed Choose the appropriate claim to work with i.e. most recent ICN or paid claim Click on the ICN Choose Scroll to the bottom of the claim Adjustment reason codes (ARCS) Health Insurance Portability and Accountability Act of 1996 (HIPAA) required fields – not the reason detail denied REMARKS HIPAA required fields – not the reason detail denied Provide spend down information

10. Research and Resolve Institutional Claim DenialsJune 2014 10 Claim Inquiry CLAIM STATUS INFORMATION Provides detailed information ‒ disposition of each EOB (explanation of benefits) code – LOOK FOR THE “D” ‒ H/D – the header or detail level  which detail line WHY DID THE CLAIM/DETAIL LINE DENY ‒ description

11. Common claim denials

12. Research and Resolve Institutional Claim DenialsJune 2014 12 Common Denials 2017 - Recipient ineligible on date of service – due to enrollment in a Managed Care Entity Resolution: VERIFY MEMBER ELIGIBILITY ‒ Understand the eligibility information Submit claim to the appropriate entity

13. Research and Resolve Institutional Claim DenialsJune 2014 13 Common Denials 2017 - Recipient ineligible on date of service

14. Research and Resolve Institutional Claim DenialsJune 2014 14 Common Denials 1130 – Ordering/Referring provider is not enrolled in the Indiana Health Coverage Programs (IHCP) Resolution: The NPI of the OPR provider must be in Field 17b on the CMS 1500 claim form or entered in the Referring field on Web interChange Verify the OPR NPI is correct. If not, the provider needs to register with the IHCP.

15. Research and Resolve Institutional Claim DenialsJune 2014 15 Common Denials 0558 - Coinsurance and deductible amount missing Claim submitted has no coinsurance and deductible amount indicating that this is not a crossover claim Resolution: Verify claim is a crossover claim ‒ Submit claim with appropriate crossover information ‒ Primary explanation of benefits (EOB) is not required if payment has been made If claim is not crossover ‒ Submit as Medicaid primary ‒ Include supporting EOB documentation if applicable

16. Research and Resolve Institutional Claim DenialsJune 2014 16 Medicare and Replacement Plans

17. Research and Resolve Institutional Claim DenialsJune 2014 17 Medicare and Replacement Plans

18. Research and Resolve Institutional Claim DenialsJune 2014 18 Common Denials Crossover Claim Information Payer ID = REPLACEMENT PLAN OR MEDICARE PAYER ID Payer Name = Wisconsin Physician Services (Traditional Medicare) or Replacement Plan name in the Payer Name Field Medicare Paid Amount = The total amount paid by Medicare for the claim Subscriber Name = Name of policy holder for primary insurance Primary ID = ID number of the primary insurance (Medicare or Replacement Plan) Relationship Code = 18 (self) Claim Filing Code = 16 (Replacement Plan) or MB (Traditional Medicare) Click Save Benefits at the bottom of the screen Click Save and Close at the top of the screen Note:Obtain coordination of benefits (COB) information from the HELP tab, Reference Materials on Web interChange

19. Research and Resolve Institutional Claim DenialsJune 2014 19 Common Denials Information required in Field 22 Coinsurance/Deductible Information Medicare Payment Information

20. Research and Resolve Institutional Claim DenialsJune 2014 20 Common Denials 4189 - Multiple units of same lab not payable without modifiers on same Date of Service Resolution: All NCCI edits must be reviewed by an Administrative Review Specialist Resubmit claim(s) along with Lab Notes and an Administrative Review request to the IHCP Written Correspondence Unit. HP Administrative Review Written Correspondence P.O. Box 7263 Indianapolis, IN 46207-7263

21. Research and Resolve Institutional Claim DenialsJune 2014 21 Common Denials 2057 – Invalid Family Planning Diagnosis/Procedure Code Resolution: Verify your medical or medical crossover claim includes a diagnosis code that is a valid family planning diagnosis Verify a family planning procedure code is included on each detail line of the claim Please refer to BT201303 for the updated list of billable diagnosis codes

22. Research and Resolve Institutional Claim DenialsJune 2014 22 Common Denials 3001 - Dates of service not on PA database The code billed requires PA (prior authorization) for that program, and the date(s) of service indicated on the claim do not fall within the start/stop dates prior authorized for that code Resolution: Confirm PA information through PA Inquiry on Web interChange Verify service requires PA ‒ Fee schedule ‒ IHCP Provider Manual, Chapter 6

23. Research and Resolve Institutional Claim DenialsJune 2014 23 Requesting and service providers can use member ID to check status. All other providers must have the PA number to see authorization status 3001 - Dates of service not on PA database Common Denials

24. Research and Resolve Institutional Claim DenialsJune 2014 24 Common Denials 4021 - Procedure Code vs Program Indicator Procedure code billed is restricted to specific programs for the claim's dates of service The recipient is not eligible for one of the programs indicated Example: Hoosier Healthwise, Package C Resolution: VERIFY ELIGIBILITY Consult fee schedule for program coverage

25. Research and Resolve Institutional Claim DenialsJune 2014 25 Common Denials The Program Coverage Value descriptors are: 1. Traditional Medicaid and Hoosier Healthwise covered. 2. Traditional Medicaid and Hoosier Healthwise covered, with the exception of Package C. 3. Package C covered only. 4. Not covered. 4021 - Procedure Code vs Program Indicator

26. Helpful Tools

27. Research and Resolve Institutional Claim DenialsJune 2014 27 Helpful Tools IHCP website at indianamedicaid.comindianamedicaid.com IHCP Provider Manual Customer Assistance − 1-800-577-1278 Locate area consultant map on: − indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) indianamedicaid.com or − Web interChange > Help > Contact Us Web interChange Written Correspondence − HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN 46207-7263 Avenues of resolution

28. Q&A