Title: CLTS Waivers Third Party Administration (TPA) Claims Implementation Overview
1CLTS Waivers Third Party Administration (TPA)
Claims Implementation Overview
- Bureau of Long-Term Support
- Division of Long Term Care
- Wisconsin Department of Health Services
- May 12th, 2011
2Third Party Administrator (TPA) Claims
Processing for Childrens Long-Term Support
(CLTS) Waivers
- DHS is pursuing key initiatives that result in
- Administrative operations cost savings
- Efficiencies consistencies
- Use of common Information Technology (IT) systems
- Outsourcing certain business functions to allow
Medicaid Home and Community-Based Service (HCBS)
Waiver programs to focus on core program
responsibilities - Claims processing - a major business function
that provides this opportunity - Centers for Medicare Medicaid Services (CMS)
requires MMIS (Medicaid Management Information
System) compliant claims and reporting system for
all Medicaid funding -- including funding through
HCBS Waivers
3Third Party Administrator (TPA) Claims Process
- Current claims process of
- Using Human Services Reporting System (HSRS) to
track childs enrollment and claims per enrollee, - Funding county claims through Community Aids
Reporting System (CARS), and - Annual reconciliation process
- Does not comply with federal claims data
collection and reporting requirements - Renewal of Wisconsins CLTS Waivers and receipt
of federal matching funds depends on meeting CMS
requirements for standardized, statewide claims
handling and data collection
4Third Party Administrator (TPA) Claims Process
- CWAs will remain responsible for
- Establishing agreements with qualified providers
- Ensuring providers are included on Medicaid
Waiver Provider Registry, with signed Provider
Agreements - Conducting caregiver background checks
- Developing individualized service plans (ISPs)
- Authorizing provider services
5Third Party Administrator Vendor
- DHS issued the TPA requirements specified in
Request for Proposal (RFP) - Contracted with vendor that demonstrated
sufficient statewide and timely implementation
capacity -- Wisconsin Physicians Service (WPS)
6Third Party Administration Pilot
- DHS selected 5 County Waiver Agencies to
participate in TPA Pilot Phase Dane, La Crosse,
Milwaukee, Shawano, Waushara - DHS worked with pilot CWAs and WPS to define
business rules for centralized claims processing - WPS began processing TPA claims for the pilot
CWAs effective September 1, 2010 - TPA pilot period ended December 31, 2010
- DHS reviewed lessons learned from pilot
experience, and in process of refining TPA
policies and procedures prior to statewide
roll-out
7Qualified Provider Data
- Current Waiver Provider Registry data inadequate
for WPS claims payment (WPS also issues 1099s to
providers receiving claim payments) - BLTS requested additional provider data, W-9
forms for pilot CWA providers - Created provider file based on WPS data
requirements, including - Providers business name
- Providers billing and servicing address
- Taxpayer Identification Number (TIN)
- Tax exempt status
- Provider license number and expiration date (if
applicable) - Service specialty information
- National Provider Identifier (NPI) (if providing
medical services) - Contracted CWA information
- Will be collecting data from non-pilot CWA
providers soon - BLTS reviewing IT needs for long-term solution
8Child Enrollment Data
- DHS CLTS Waivers Database updated to gather
necessary child data for WPS enrollment file,
including - Name (first, last, suffix)
- Date of Birth
- Gender
- Enrollment by program and CWA (participant cannot
receive benefits from more than 1 CWA in the same
day) - Master Client Identifier (MCI)
- Address
- Enrollment date (retroactive enrollments allowed)
- Enrollment termination date
- BLTS issues weekly enrollment file to WPS
9Service Codes
- CWAs will no longer use SPC codes when
authorizing services - CWAs and providers must use National
Procedure/Revenue codes - BITS created SPC/National Code Crosswalk for TPA
pilot implementation - BLTS Code Sub-Committee created, reviewing and
determining code needs
10Encounter ReportingData Warehouse
- DHS has launched IT project to retire HSRS
- TPA claims process will retire LTS module for
CLTS Waivers - WPS collects and sends provider claims data to
DHS at the Encounter level - TPA claims payment data stored in DHS Data
Warehouse, 15th of month following payment - Both DHS and CWA will have ability to extract
data from Data Warehouse - DHS creating reports (e.g., L300), but CWAs will
also be able to create ad hoc reports, based on
current needs
11COMPARISON OF PROCESSES
12CLTS Statewide Rollout Keys to Success
- CWA's creating an accurate authorization file
- Authorization Management (Understanding the
authorization process and applying the proper
rules) - CWA's sending a Test authorization file 3 - 4
weeks before "Live" date - CWAs sending first Production authorization file
before "Live" date - CWA's sending Authorization notices with all
necessary data elements to their providers - Providers submitting claims to WPS correctly and
timely - CWA's asking questions...
13WPS TPA Claims Processing Flow
Provider receives Service Authorization
Notification from CWA
Provider performs authorized Waiver service
Provider submits claim to other insurance,
Medicare, or Medicaid, if applicable
Provider submits claim to WPS
Participant approved for Waiver Service
CWA authorizes approved Waiver Service
WPS receives Authorization File from CWA
WPS processes claim with corresponding Service
Authorization
WPS sends Payment and/or Provider Remittance
Advice to Provider
14WPS Provider Claims Forms
- Provider may submit claims to WPS in the
following user-friendly formats - Electronic filing
- Excel spreadsheet
- Paper claim form
- HCFA (CMS 1500)
- UB04 (CMS 1450)
- CLTS Waivers Claim Form
- WPS issues checks every Monday and Wednesday
15What is a Service Authorization File?
- A standardized file that the County Waiver Agency
submits to the TPA. This file may contain many
separate service authorizations. - The file may contain authorizations for multiple
services, multiple providers, and multiple waiver
participants. - The file is uploaded by the CWA into the WPS
secured file transfer website called MOVEit. - WPS uses the information on your authorization
file to match to the information on a providers
claim for reimbursement. When the information
matches, WPS is able to pay claims.
16What is a Service Authorization Notification to
the Provider?
- Each provider will receive a Service
Authorization Notification from the County Waiver
Agency authorizing services and supplies. - The Service Authorization Notification sent to
providers gives them the information they need to
include on their claim in order to be reimbursed. - WPS has held a number of Provider Training
Seminars throughout the state.
17Third Party Administration Statewide
Implementation
- Statewide TPA claims implementation will be
phased in - April 1, 2011 Lutheran Social Services St.
Francis Childrens Center - July 1, 2011 Southeastern Region
- August 1, 2011 Southern Region
- September 1, 2011 Northeastern Region
- October 1, 2011 Western Region
- November 1, 2011 Northern Region
18TPA Implementation Roll-out Sessions
- BLTS staff are working with Area Administrators
to schedule roll-out planning sessions - CWA staff
- Contracted providers
19TPA Questions?
- Questions regarding the TPA claims
implementation? - Contact
- Sue Larsen
- Childrens Services Section Lead
- Phone 608-267-9184
- Email Susan.Larsen_at_dhs.wisconsin.gov