MHS UB04

1
MHS UB-04 Prior Authorization Top Denials
October 20, 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

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

5
Claim Process -Top 10 Denials

• Not a MCO Covered Benefit (EX 50)
• Service must be covered by Indiana Medicaid
• Carve Out Services not paid by MHS
• Please Resubmit to Cenpatico For Consideration
  (EX 54)
• Cenpatico (CBH) handles all behavioral health
  claims for MHS members

6
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. All
  non 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

7
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
• Denied By Medical Services (EX EB)
• Authorization related denial

8
Claim Process - Billing With Ease

• NEWBORNS
• No prior authorization or referral is required
  for normal newborn nursery.
• Newborns RID number is required for payment.

9
Claim Process - Billing With Ease

• HOSPITAL STAYS
• Hospital stays under 24 hours are not billable as
  inpatient and must be submitted as outpatient
  services.
• Medical Management will not approve inpatient
  less than 24 hours.
• 72-hour observation may be available for stays
  that may not meet medically necessary inpatient
  admissions.

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 EDI_at_centene.com with questions

11
Claim Process Claim Filing

• Paper Submission
• Managed Health Services
• PO Box 3002
• Farmington, MO 63640-3802

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 1-877-MHS-4U4U (647-4848).
• A verbal inquiry is not considered a dispute or
  appeal and does
• not top the 67 calendar days from the date of
  receipt of the EOP
• to file 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 63640-3800
• 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 1-877-647-4848. We are ready to help
  you!
• Knowledgeable, friendly staff available 800-600
  EST
• Focused commitment to professional service
• Claims address P.O. Box 3002 Farmington, MO
  63640
• Dispute appeal processes (67 days from receipt
  of EOP)
• Appeal address P.O. Box 3000 Farmington, MO
  63640

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

• Prior Authorization (PA) should be initiated
  through the MHS referral line at 1-877-MHS-4U4U
  (647-4848)
• 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 www.managedhealthservices.com.
  Additional documentation may be required to be
  sent via fax for approval of authorization.

21
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

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

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 gt250
• 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 gt5 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

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)

27
Utilization Management

• Hospital Services
• All elective inpatient/outpatient services must
  be prior authorized with MHS at least 2 business
  days prior to the date of service.
• All urgent and emergent services must be called
  to MHS within 2 business days after the admit.
• Failure to prior authorize services will result
  in claim denials.

28
Utilization Management

• TRANSFERS
• MHS requires notification and approval for all
  non-emergent transfers, at a minimum 3 (three)
  business days advance notice.
• MHS requires notification within three (3)
  business days following all emergent transfers.
  Transfers are inclusive of, but not limited to
  the following
• Facility to facility
• Level of care changes

29
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 admitting physician
• CPT code for proposed services
• primary and any secondary diagnosis
• contact name and number to obtain clinical
  information

30
Utilization Management

• The MHS CM will review all available clinical
• documentation apply Milliman Care Guidelines,
  and
• seek Medical Director input as needed.
• PA for Observation Level of Care (up to 72 hours)
  is not required for contracted facilities
• If the provider requests an inpatient level of
  care for a covered/eligible condition/procedure
  and documentation supports an outpatient/observati
  on level of care, the case will be sent for a
  Medical Director review

31
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

32
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 1-877-MHS-4U4U
  (647-4848) and asking for the Appeal Coordinator

33
Utilization Management

• MEDICAL NECESSITY GRIEVANCE AND APPEALS
• Managed Health Services
• Attn Appeals Coordinator
• 1099 North Meridian Street, Suite 400
• Indianapolis, IN 46204
• Determination will be communicated to the
  provider within 20 business days of receipt

34

• MHS - Need To Know

35
MHS Need to Know

• www.managedhealthservices.com
• 1-877-MHS-4U4U (647-4848)

36
Need to Know - MHS Website

• www.managedhealthservices.com
• 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

37
Need to Know - MHS Website

• Upcoming Enhancements
• Direct claim submission UB04 2010
• Claim resubmission 2010
• Claims Xtend 2010

38
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 www.managedhealthse
  rvices.com.

39
Questions and Answers