Deloitte Status

1
Maine Integrated Management Information System
(MIHMS) Provider Forum
MIHMS Phase 1
December 04, 2008
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Table of Contents

• Status / Timeline
• NPI
• Programs in MIHMS
• Provider Re-enrollment

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Timeline

• Today 12/4

• Project Start
• Project Management Initiation
• Requirement Analysis
• Design Development and Implementation
• Design
• Development and Unit Testing
• System Testing
• User Acceptance Testing
• Implementation
• Provider Communications
• PAG/TAG Meetings (monthly), MaineCare Matters (
  Listserv)
• Operational Readiness

Design Final
2/1 Provider Re-enrollment Go Live
8/1 837 Go Live
8/22 Finalization of Operational Readiness Plan
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NPI

• A health plan cannot require an enumerated health
  care provider or subpart to obtain an additional
  NPI
• A health plan is not prohibited from requiring
  their enrolled providers to obtain and use NPIs
• Non-healthcare (A-typical) providers are not
  required to obtain an NPI
• Freestanding Day Habilitation
• Non-Emergency Transportation
• Non-healthcare (A-typical) providers if they have
  obtained an NPI and are authorized to use it for
  billing purposes
• Implementation of the new version of X12
  transactions
• CMS policy is that the NPI data must match OSCAR
• MIHMS will not be using taxonomy or ZIP4 to
  locate a provider record.

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General Rules

• An NPI will only appear on one Health PAS
  provider record, no duplicate NPIs.
• The only value needed to locate a provider record
  for EDI processing is the NPI.
• All Healthcare providers submitting electronic
  transactions must use an NPI.
• All pay-to provider records must have a unique
  NPI or Medicaid ID and Tax ID (SSN or FEIN).
• A provider must be one of the following
• Health care provider with an NPI
• Atypical provider with an NPI
• Atypical provider with a Medicaid Provider ID
• A provider can not use an NPI and a Medicaid
  Provider ID simultaneously
• If a provider chooses to enumerate with one NPI
  for multiple service locations. The NPI will be
  stored on the pay-to provider record and a unique
  service location ID will be assigned for each
  location. The proposed solution for generating a
  service location ID will be to use the NPI of the
  pay-to provider plus suffix. For example,
  NPI-001, NPI-002, etc.

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Group Rules

• If a group has subparts and elected to obtain
  separate NPIs, each provider record will store
  the unique subpart NPI will need to enroll as a
  distinct pay-to entity
• If a group has subparts that did not elect to
  receive their own NPI, the group will be
  configured as the pay-to and provider records
  will be created for the subpart for provider
  directory, reporting, and auditing purposes. The
  subpart records will not contain an NPI
• Service locations will not have pay-to
  affiliations

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Individual Rules

• CMS requires each individual provider to obtain
  an individual NPI
• The individual provider may choose to obtain a
  group NPI
• If the individual provider only has one NPI, the
  provider will be configured as a single provider
  record with a direct pay-to affiliation
• If the individual provider obtained an individual
  and group NPIs, two provider records will be
  created.

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Facility Rules

• If a facility has subparts and did not elect to
  receive their own NPI, the facility will be
  configured as the pay-to and provider records
  will be created for the subpart for the provider
  directory, reporting, and auditing purposes. The
  subpart records will not contain an NPI.
• If a facility has a subpart that is also a
  distinct service location, then the subpart will
  be configured as a service location. A service
  affiliation will be created between the facility
  and the subpart. The NPI will be stored on the
  facility provider record and the subpart record
  will not contain an NPI.

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Atypical Providers

• Non-traditional Medicaid providers (atypical)
  will continue to obtain a health plan ID
  (Medicaid ID) for identification for claims
  payment purposes.
• Within HealthPAS Administrator, there is
  flexibility to define the provider by the
  business rules outlined in DHHS policy.

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Introduction - Programs

• A program consists of benefit plans and rules
  that govern the administration of covered
  services.
• Programs are the central thread that affiliates
  providers to contracts and member eligibility to
  benefit plans.

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Program Overview
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MIHMS Claims Processing

• The system checks to see if the member is
  enrolled and identifies what program the benefit
  should be paid from.
• The system then checks to see if the provider is
  enrolled to provide services under that same
  program.
• If no, the claim will deny. If yes, it will
  continue through the contract and benefit
  adjudication processes.

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MaineCare Program

• This program includes basic Medicaid benefits and
  additional benefits to include
• Home and Community Based waivers
• Non-Categorical/Childless Adults waiver
• HIV waiver
• Nursing facility services
• Residential care facility services

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Primary Care Case Management (PCCM)

• Represents benefits available to members who
  participate in MaineCare PCCM
• Set up as a program to allow for payment of the
  PCCM management fee to providers

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Medical Eye Care

• Represents eye care services provided through
  limited State funding.
• All services provided under this program are
  prior authorized.

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Children with Special Health Needs (CSHN)

• Represents services that are paid using limited
  funding from the CDC.
• All services provided under this program are
  prior authorized.

17
OES Adult Protective and OCFS Child Welfare

• Two separate programs that represent a small set
  of social services paid with limited State
  funding.
• All services are prior authorized.

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Maine Breast Cervical Health (MBHCP)

• Represents a specific set of services that are
  paid using limited funding from the CDC.
• Set up as a program to account for the specific
  services offered and to allow for different rates
  to be paid to providers.
• Providers who wish to participate must be
  approved by MBCHP.

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Medicare Involved

• This program has no impact on provider enrollment
  it allows services to be paid appropriately for
  QMB and other groups of members with Medicare
  coverage.

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Impact on Provider Enrollment

• MIHMS requires assignment of the program, or
  programs, to the provider during enrollment.
• Providers who wish to participate in the PCCM or
  Maine Breast and Cervical Health Program will
  need to indicate this during enrollment. They
  will be required to complete additional screens
  of information.  
• Other programs will be assigned automatically
  based on internal rules and logic - these will be
  transparent to the providers. 

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Provider Enrollment - Welcome
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Provider Re-Enrollment/ Business Information -
Enumeration
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Provider Re-Enrollment/Business Information -
Contact
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Provider Re-Enrollment/Save Application for
Future Access

• Application Automatically Saved after page 2 is
  completed
• Email generated with Case Number, and
  Instructions For Access

• User must enter case number, pay-to providers
  Tax ID, and email address for access to partially
  completed application

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Provider Re-Enrollment/Business Information -
Address
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Provider Re-Enrollment/Business Information -
Address
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Provider Re-Enrollment/Pay To NP Provider Type
Specialty
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Provider Re-Enrollment/Business Information
Claims Submission
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Provider Re-Enrollment Servicing Location
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Provider Re-Enrollment Service Location
Provider Type Specialty
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Provider Re-Enrollment Facility Information
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Provider Re-Enrollment Medicaid Programs
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Provider Re-Enrollment PCCM Programs
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Provider Re-Enrollment Rendering Provider
Summary
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Provider Re-Enrollment Rendering
Provider/Affiliations
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Provider Re-Enrollment Rendering Provider Type
Specialty
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Provider Re-Enrollment PCCM Program
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Provider Re-Enrollment PCCM Program
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Provider Re-Enrollment Ownership/Board
Information
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Provider Re-Enrollment Ownership/Board-Legal
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Provider Re-Enrollment Ownership/Legal
Declaration
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Provider Re-Enrollment - Documents
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Provider Re-Enrollment/Documents - Additional
Terms
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Provider Re-Enrollment/Documents - Additional
Terms
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Provider Re-Enrollment/ Documents - Additional
Terms
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Provider Re-Enrollment/Status Updates

• Emails Automatically Generated when

• User completes first two pages
• Provider application is submitted
• Provider application is approved

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Questions

• QUESTIONS
• Thank You!