TR586Managed Health Services MHS Durable Medical Equipment DME Presentation - PowerPoint PPT Presentation
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TR586Managed Health Services MHS Durable Medical Equipment DME Presentation
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DME authorization decisions by MHS are based on medical necessity. ... Contact Provider Inquiries with the TPL information so that changes can be made to the TPL file ... – PowerPoint PPT presentation
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Title: TR586Managed Health Services MHS Durable Medical Equipment DME Presentation
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Managed Health Services
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Managed Health Services
Who Are We
- MHS Indiana
- Centene Corporation
- Betty Brinn Foundation
- Centene Foundation for Healthcare Quality
3
Managed Health Services
Our Guiding Principles
- Physician Directed
- Nurse Mediated
- Member Empowered
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Managed Health Services
Mishawaka
Indiana Office Locations
Merrillville
Fort Wayne
Muncie
Indianapolis
Indiana counties with MHS membership
MHS Indiana office locations
5
Managed Health Services
Member Empowerment
- Nursewise
- 24/7 toll free nurse advice line
- Bi-lingual staff
- Member Services
- CONNECTIONS Program
- Transportation
- Statewide vendor reached through toll-free number
- Health Education in the Community
- Participation in local health fairs
6
Managed Health Services
Coordinated Care
- Preventive Care
- Disease / Care Management
- OB Programs
- Immunization Initiatives
- Asthma/Diabetes Initiative
- Focused Utilization Management
- Team Concept (Physician, Nurse,
Social Worker, Coordinator) - Work in Partnership with Doctors
7
Managed Health Services
Provider Empowerment
- Physician Committees
- Compensation
- Pharmacy and Therapeutics
- Quality Management
- Provider Driven Programs
- Pharmacy Gold Card Program
- Member Restricted Card Program
- Practicing Physicians in Key MHS Roles
- Access to Key MHS Leadership
8
Managed Health Services
Whats New for 2007
- Behavioral Health Carve-In
- Members Pick-A-Plan
- Pay For Performance
- Member Initiatives
- E Health
- Enhanced Web Portal
9
Managed Health Services
DME Policy
- Before an item can be considered to be durable
medical equipment - It must be able to withstand repeated use
- It must be primarily and customarily used to
serve a medical purpose - It is generally not useful to a person in the
absence of an illness or injury - It is appropriate for use in the home.
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DME Policy
- Items including, but not limited to, the
following are examples of DME - Hospital beds Wheelchairs
- Canes Walkers
- Raised toilet seat Oxygen systems
- Ventilators Nebulizers
- Neuromuscular Stimulators Bone growth
Stimulators - Infusion Pump CPAP/BIPAP
- Phototherapy (Bilirubin) light with photometer
- Wound Vacs
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DME Policy
- DME items with a purchase price below 500.00 do
not require an MHS authorization. - DME items with a purchase price 500.00 or above
require an MHS authorization.
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DME Policy
- All DME items, regardless of purchase price,
must be medically necessary as defined by 405
IAC 5-2-17 Medically reasonable and necessary
service Authority IC 12-8-5 IC 12-15-1-10 IC
12-15-1-15 IC 12-15-21-2.
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DME Policy
- All DME that require an authorization require
that process to be completed prior to dispensing
the items, with the following exceptions - DME item necessary as part of discharge planning
from the hospital - DME item necessary as part of the treatment plan
for an urgent / emergent medical condition - DME item previously authorized by anther MCO as a
component of continuity of care during the 1st 30
days of transition.
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DME Policy
- DME authorization decisions by MHS are based on
medical necessity. - The MHS Prior-Authorization form should accompany
all clinical information submitted as part of the
prior-authorization request. - Authorization duration is based on medical
necessity, anticipated outcomes, compliance with
utilization, benefit limitations, and alternative
treatment options available to meet the medical
need of the member. - Authorization requests to extend an existing
authorization are required to be submitted prior
to the expiration date of the current
authorization - Authorization numbers and units are provided for
approved DME items
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DME Policy
- Prior-authorization for DME items may be
initiated by contacting MHS - Via facsimile 317-684-8096
- Via US mail Managed Health Services
- Attn Medical Management
- 1099 N. Meridian St., Suite 400
- Indianapolis, IN 46204
- Via phone 1-800-464-0991
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Managed Health Services
- CLAIMS
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Provider Inquiry Services
- Call us at 1-800-414-9475 we are ready to help
you - Knowledgeable, friendly staff available 800-500
- Focused commitment to professional service
- Filing limits dependant upon contract status
- Claims address P.O. Box 3002 Farmington, MO
63640 - Dispute appeal processes (60 days from EOP)
- Appeal address P.O. Box 3000 Farmington, MO
63640 - Follow IHCP requirements
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Claims Submission
- May be submitted electronically (preferred) or on
paper CMS 1500 - Providers should check electronic submission
report daily to ensure claims were received by
MHS - Providers may use Clear Claim Connection to check
the status of claims at www.managedhealthservices.
com - Filing timelines
- 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
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Resubmitted Claims
- If you need to resubmit a denied claim, the
claim must be submitted on paper and should be
clearly marked at the top with the word
RESUBMISSION - Attach a Claim Adjustment Form stating the reason
for resubmission and include the EOP (if
applicable) - Resubmitted claims must be received within 60
days of the EOP date
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Adjusted Claims
- If you need to make an adjustment to a paid
claim, you can do so by calling Provider Inquiry
or you may submit on paper with the adjustment
request form. - Attach a Provider Adjustment Form along with
documentation, including EOP (if available)
explaining reason for resubmission - Claim adjustments must be submitted within 60
days of the date of the MHS EOP
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Third Party Liability
- 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
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Third Party Liability
- Claims will deny L6 if TPL is on file with MHS
- What if I dont agree with MHS TPL indication
- Call provider inquiries
- Resubmit claim with EOB attached
- Reminder TPL claims must be submitted within 60
days of the date of the primary insurers EOB
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Third Party Liability
- MHS updates member TPL information through
- A monthly file from EDS
- Phone call from providers
- Receipt of an EOB with claim
- MHS always verifies new TPL
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DME Billing
- DME with a purchase price of less than 500.00
does not require prior authorization - Manually Priced DME
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DME Billing
- Common Denial Codes
- Manual Priced Item needs invoice (BI)
- Missing rendering provider number (MK)
- Other/Third Party Liability (L6)
- Timely filing (29)
- No authorization (A1)
- Provider specialty must match authorization
(denial HS) - Duplicate (18)
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Claim Dispute Resolution
- Request for adjustments and claim inquiries
- Informal claim objection and dispute resolution
- Written
- Within 60 days of EOP
- Formal dispute resolution
- Written
- Follows informal process
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Questions and Answers
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