Maine MECMS Project

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Maine MECMS Project
Phase 1 Provider Enrollment

• Maine Integrated Health Management Solution
  (MIHMS)
• November 13, 2008
• MIHMS Provider Group

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Phase 1 - Objectives

• Provider re-enrollment/enrollment with National
  Provider Identification (NPI)
• Capability to submit 837 transactions

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Timeline

• Today 11/13

• 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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Provider enrollment/re-enrollment - Options
Enroll at Tax ID level
Enroll at NPI level
Use existing process

• Re-enrollment / enrollment will be done with NPI
  at Tax ID level
• Pros
• This option will allow all providers tied to one
  Tax ID to enroll together
• Cons
• Provider application will be very large and
  complex for organizations with multiple IDs
• Future maintenance is going to be complicated
• Minimal re-use of information at the
  organization level because limited amount of
  information is captured.
• COMPLEX AND NON-MAINTAINABLE

• Re-enrollment / enrollment will be done at NPI
  level
• Pros
• The processing in new system happens at NPI level
  as a result it will keep, processing, provider
  information and communication in sync.
• System will capture the data as enumerated by
  providers.
• Reduced effort to re-enroll providers
• Easy maintenance
• Cons
• This is a change in approach from the current
  process resulting in increased effort in
  communication and training.
• RECOMMENDED APPROACH

• Re-enrollment / enrollment will be done with NPI
  using the same billing provider model as we have
  today.
• Pros
• Providers and staff are aware of the processes
  and its limitations as result no major effort
  required for communication and training
• Cons
• Not consistent with NPI and how it is enumerated
• Designed for MeCMS data model
• Every billing and servicing provider needs to be
  issued an ID and relationships need to be built.
  This will result in massive effort from
  Providers and staff .
• INFLEXIBLE AND LABOR INTENSIVE

NPI level enrollment/re-enrollment is recommended
because Health PASs capability of NPI based
processing and timing of re-enrollment puts us in
an ideal situation.
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Provider File Maintenance

• Providers should continue to keep provider file
  data up-to-date and complete in both MeCMS and
  MIHMS until implementation of the new system
• Data captured during provider re-enrollment to
  MIHMS is NOT sent to MeCMS
• MIHMS
• Enrollment in MIHMS is only to prepare for the
  new system
• Enrollment begins in February 2009
• After enrollment a provider may go online, view
  all profile information in MIHMS and submit
  updates to this information
• Provider may also submit update requests on paper
• Prior to go-live of MIHMS in 2/2010 providers are
  encouraged to view profile information and ensure
  it is up to date before go live
• MeCMS
• Provider should continue to submit updates to
  MeCMS to ensure that claims maybe processed
  correctly
• Updates to MeCMS must continue to be submitted on
  paper
• Until the implementation of MIHMS in 2/2010
  providers should continue to submit claims and
  other transactions using the provider data in
  MeCMS.

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Provider Maintenance

• Provider file configuration in MIHMS is different
  than in MeCMS making automatic data
  synchronization difficult. It is critical that
  each change is applied correctly and does not
  impact claims processing and payments.
• Example 1 Provider adds a new specialty to
  MIHMS. As provider specialties in MeCMS and MIHMS
  are sometimes different, adding this specialty to
  MeCMS could result in incorrect provider data.
• Example 2 Provider logs on to the Online portal
  and submit an update to the mailing address
  Provider in MIHMS has one NPI but the same
  provider in MeCMS has three billing IDs. Which
  billing ID is updated with the new address?.

NPI 1
Billing Provider C
Mailing Address Billing Provider A
Mailing Address
Mailing Address Billing Provider B
Mailing Address Billing Provider C
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Claims Submission
Overview MeCMS does not accept 837 HIPAA claims,
nor is there DDE (Direct Data Entry)
functionality. The new MMIS must offer 837 data
submission processes and tools that are HIPAA
compliant, easy to use/access, cost-effective for
small providers, etc. One step toward gaining
HIPAA compliance is the use of the portal to
submit 837 claims. 837 Data Submission
Options 1.) Batch submission and DDE 2.) DDE only

• Recommendation Option 2
• For providers who do not have the means for
  creating numerous, complex files, this option
  allows them to still submit claims electronically
• Providers will not need to spend extra
  effort/cost to modify 837 file format to meet
  MeCMSs limitations
• Minimal changes to DDE screens when Phase 2 goes
  live as opposed to significant changes to revert
  837 file format back

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MIHMS Re-Enrollment Overview

• Current MaineCare Providers Begin to Re-enroll
  February 2009
• Facilitated enrollment for provider community
• Provider Training Sessions beginning in January
  2009 (schedule to follow)
• Staff support
• On-line tutorials
• Enrollment based on NPI/API (National Provider
  ID/Atypical Provider ID)
• Prepares for MIHMS claims submission in 2010 (No
  NPIs for MeCMS claims)
• One Pay-To NPI/API One Enrollment Application
• Multiple Pay-To NPIs/APIs Multiple Enrollment
  Applications
• Each Enrollment Application can define multiple
  service locations
• Multiple Service Providers may be affiliated with
  multiple service locations
• On-Line Enrollment Available
• Phased-In Approach
• Invitations to enroll one month prior
• One month timeline to enroll
• Allows time to ensure all providers enrolled on
  time

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Benefits of Re-Enrollment

• Ensures accurate provider data in new system
• Result Accurate claims processing upon full
  implementation
• Provider Opportunity to become familiar with
  Portal
• Prior to full implementation
• Conforms to HIPAA standards
• Provides access to Direct Data Entry (DDE) claims
  submission

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Benefits of On-Line Re-Enrollment

• Intuitive process - EASY to use
• On-line tutorials available
• Mouse hover-over help
• Pop-up guidance
• Drop-down menus
• Auto-population from previous entries
• Automatic interface/download from NPI
• Interfaces/Downloads from DEA, CLIA, Some
  Licensing Boards
• Easy association of servicing providers to many
  locations/NPIs
• Multiple forms available at a click
• Only see fields that apply to your type of
  application
• User Guides On-Line
• Companion Guides On-Line
• Quicker to complete
• Quicker to process automated workflow reduces
  manual processing

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Recommended Phased-In Process

• Examples of Considerations in Developing Phase-In
  Process
• Program stability (i.e. programs requiring little
  maintenance)
• Program size
• Location and number of locations
• Number of billing and servicing providers
• Potential impact of local codes
• Pending policy changes
• Potential program interdependencies
• Paper versus EMC submitters
• Potential for early Direct Data Entry (DDE) of
  claims
• Providers stated preference to enroll all
  locations and provider types at once

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Draft Enrollment Implementation Process
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First Cycle
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Second Cycle
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Third Cycle
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Fourth Cycle
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MIHMS Maintenance
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Atypical Services

• Services that are generally not considered to be
  healthcare
• May or may not be determined to be healthcare by
  individual State Medicaid programs
• If healthcare, must use NPI in electronic
  transactions
• If non-healthcare, is not required to use an NPI
  may be assigned an API Atypical Provider ID
• Healthcare provider submitting claims for
  atypical services will use their NPI for
  electronic transactions

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Atypical Services
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Atypical Services
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Atypical Services
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Atypical Providers

• Most Atypical Services are Provided by Healthcare
  Providers using NPIs
• Atypical Services being provided by Atypical
  Providers Include
• Free-Standing Day Habilitation Programs
• Section 24
• Transportation Providers
• Section 113
• APIs will be issued as needed

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Atypical Providers Using NPIs

• Atypical Providers may obtain NPIs
• Some have already done so based on their legal
  counsel
• MIHMS will accept atypical claims from providers
  using NPIs

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MIHMS Overview Provider Type / Specialty

• Carrie Miller
• Configuration Manager
• Unisys

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MECMS Provider Enrollment

• Providers bill using Provider ID Number
• Enrollment is based on Provider Type, Specialty
  and Sub-Specialty

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MIHMS Provider Enrollment

• National Provider Identifier (NPI) is required
  for all health care providers (typical providers)
• Payment will be made based on your NPI
• You will receive one check per NPI
• MaineCare will assign a 10 digit alpha numeric
  provider number for providers that do not provide
  medical services (atypical)
• Atypical providers will be identified prior to
  re-enrollment

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MECMS to MIHMS

• Crosswalk from MeCMS to MIHMS is based on
• Provider Type
• Provider Specialty
• There is no Sub-specialty in HealthPAS
• Provider Contract
• In MIHMS the Provider is paid based on the
  reimbursement methodology in each Section of
  MaineCare policy.

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Example of Change

• Targeted Case Management is a Provider Type in
  MeCMS
• MIHMS will require the provider to enroll as
  ex. Mental Health Clinic with a contract attached
  for Targeted Case Management Services

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Hospital Crosswalk
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Private Non-Medical Institution Mapping (PNMI)
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Private Non-Medical Institutions (Cont.)
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Intermediate Care Facility/Mental Retardation
(ICF-MR)
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• Questions?

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Thank You