Western Highlands Network

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Western Highlands Network

• Claims Reimbursement Training Seminar

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Training Agenda

• NPI
• Current Events
• Deficit Reduction Act / False Claims Act
• Claim Submissions
• Remittance
• Denial and Resolution
• Technical Assistance
• Information Resources

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NPI

• Overview
• Claim Submission
• DDE
• 837
• CMS-1500
• Provider Registration
• Claim Adjudication
• WH EOB / 835

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National Provider Identification (NPI)

• The Health Insurance Portability and
  Accountability Act (HIPAA) of 1996 requires the
  adoption of a standard unique identifier for
  health care providers. The NPI Final Rule issued
  January 23, 2004 adopted the NPI as this
  standard.

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What is NPI

• The NPI is a 10-digit, intelligence free numeric
  identifier (10 digit number). Intelligence free
  means that the numbers do not carry information
  about health care providers, such as the state in
  which they practice or their provider type or
  specialization.
• The NPI will replace health care provider
  identifiers in use today in HIPAA standard
  transactions. Those numbers include Medicare
  legacy IDs (UPIN, OSCAR, PIN, and National
  Supplier Clearinghouse or NSC).
• The providers NPI will not change and will
  remain with the provider regardless of job or
  location changes.

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Have an NPI does not

• Ensure a provider is licensed or credentialed
• Guarantee payment
• Enroll a provider in a health plan
• Turn a provider into a covered provider
• Require a provider to conduct HIPAA transactions.
  

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Why the NPI

• Simpler electronic transmission of HIPAA standard
  transactions
• Standard unique health identifiers for health
  care providers, health plans, and employers
• More efficient coordination of benefits
  transactions

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Who can apply for the NPI

• All health care providers (e.g., physicians,
  suppliers, hospitals, and others) are eligible
  for NPIs. Health care providers are individuals
  or organizations that render health care.
• All health care providers who are HIPAA-covered
  entities, whether they are individuals (such as
  physicians, nurses, dentists, chiropractors,
  physical therapists, or pharmacists) or
  organizations (such as hospitals, home health
  agencies, clinics, nursing homes, residential
  treatment centers, laboratories, ambulance
  companies, group practices, HMOs, suppliers of
  durable medical equipment, pharmacies, etc.) must
  obtain an NPI to identify themselves in HIPAA
  standard transactions.

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Western Highlands Direct Data Entry

• Optional NPI claims entry available April 20,
  2008 May 14, 2008
• May 15, 2008, WH requires NPI claims entry.
  Claims entered after May 14, 2008 will deny
  without the appropriate NPI data.

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ASC X12N 837 004010X098A1, Health Care Claim
Professional

• Loop 2010AA Billing Provider
• NM108 and NM109 Submit either NPI (typical
  provider) or tax ID number (atypical provider)
• N403 Add 4-digit extension to zip code (do not
  submit dash) MUST match the appropriate
  location of the billing provider
• REF01 Must submit either legacy provider number
  (if provider is atypical), SSN, or EIN

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Attending Provider

• Loop 2310B Attending Provider
• NM108 and NM109 Submit either NPI (typical
  provider) or tax ID number (atypical provider)
• REF is only required if the Attending Provider is
  atypical

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Service Facility Location

• Loop 2310D Service Facility Location
• NM108 and NM109 Submit either NPI (typical
  provider) or tax ID number (atypical provider)
• N403 Add 4-digit extension to zip code (do not
  submit dash) MUST match the appropriate
  location at which the service was provided
• REF is only required if the Service Facility
  Location agency is atypical

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837 Test/Approval

• 837 w/NPI must be tested with WH prior to
  acceptance of claim submission
• Notify Diane Overman, 225-2785 ext. 2173 or via
  e-mail diane_at_westernhighlands.org
• Test for format, content, and HIPAA compliancy
• Provide feedback to resolve discrepancies
• Upon approval you may submit 837

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CMS-1500 (Rendering)

• Typical w/NPI
• Block 24I, ID Qualifier ZZ
• Block 24J (upper), Rendering Provider Taxonomy
• Block 24J, (lower), Rendering Provider NPI
• Atypical w/out NPI
• Block 24I, ID Qualifier 1D
• Block 24J, (upper), Rendering Provider WH
  Provider ID
• Block 24J, (lower), Rendering Provider ltBlankgt

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CMS-1500 (Billing Provider)

• Typical
• Block 33 Billing Provider Info Ph,
  Address, Zip4
• Block 33a NPI
• Block 33b ZZ and Taxonomy
• Atypical
• Block 33a WH Provider ID

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CMS-1500 (Service Facility Location Information)

• Typical
• Block 32 Address to include zip4
• Block 32a NPI
• Block 32b ZZ and Taxonomy
• Atypical
• Block 32 Address to include zip4

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Mapping Solution

• Atypical claim submission validated against NPI
  registration
• If an NPI is submitted WH will crosswalk the NPI
  to legacy according to registration.
• Address zip4

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NPI Registration

• Submit a copy of the DMA NPI Registration
• Or
• Submit the WH NPI Registration
• Both require a copy of NPPES certificate
• WH Communication Bulletin 54, 2/19/2007

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NPI EOB

• 083      Missing or Invalid Attn Prov NPI
• 084      Missing or Invalid Service Location
  NPI
• 085      Missing or Invalid Zip 4
• 086      Missing or Invalid Atypical PIN
• 087      Missing or Invalid Taxonomy Number
• 088      Invalid Combo Loc NPI Zip 4    

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WH EOB / 835

• WH EOB
• Include both legacy and NPI attending
• 835 HIPAA Compliant
• Will not include legacy number

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Current Events

• Timely Filing Limit (TFL), WHN Communication
  Bulletin 67
• Temporarily lifted through April resume May 1,
  2008, DOS July 1, 2007 - present
• State funded claims finalized within 60 days from
  the date of service
• June 2, 2008, 500 pm, end of fiscal year TFL
  (July 1, 2007 April 30, 2008)
• Provisionally Licensed provider H-code
  reimbursement ends June 30, 2008

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MOS Maintenance of Service

• Maintenance of Service
• Therapeutic Foster Care and Targeted Case
  Management
• Maintenance of Service applies to requests for
  authorization where a denial or reduction of
  service has occurred for a concurrent request and
  a valid appeal notice has been received by DHHS
  or OAH/Office of Administrative Hearing.
• Value options will be notified after the request
  for appeal has been received by the Hearing
  office. Value Options will enter the Maintenance
  of Service authorization within (5) five business
  days after the Hearing Office sends confirmation
  that an appeal has been requested.

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MOSMaintenance of Service cont

• The units that are authorized can be viewed in
  Provider Connect, located on ValueOptions
  website at www.valueoptions.com Providers can
  also contact ValueOptions EDI Helpdesk
  (888.247.9311) for instructions on how to use
  Provider Connect.
• No letter or authorization notice will be sent to
  the LME for MOS.
• MOS authorizations seen in Provider Connect will
  appear as a standard authorization. There is no
  distinction to indicate that it is a MOS
  authorization.
• Submit Claims on the WH Claims Resolution Inquiry
  form with the CMS1500 and provider connect screen
  print of the authorization. Mail or fax to WHN
  828.258.1225.

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Deficit Reduction ActFalse Claims Act

• Law
• Policy
• What is a false claim?
• Penalties
• Your Role
• Whistleblower Provision
• How/Who to Report

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Law

• False Claims Act established under section 3729
  through 3733 of title 31, United States Code
• Federal law that prohibits an individual or
  organization who receives money from the federal
  government from submitting a request for payment
  knowing that such request contains false
  information.

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Policy

• Available within the Western Highlands Network
  Standards of Conduct/Ethics policy available to
  providers through the WH website.
• WHN Communication Bulletin 68

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What is a False Claim

• Submitting a claim for services that were not
• Delivered
• Documented
• Different than what was delivered
• Submitting a claims for services paid by a source
  other than the federal government, or paid for by
  the government under a different program (e.g.
  Medicaid instead of Medicare)

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What is a False Claim (cont)

• Submitting a claim for services that were not
  medically necessary
• Submitting a claim for services which is coded as
  more complex than otherwise indicated in the
  patients record, in order to receive higher
  reimbursement

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What is a False Claim (cont)

• The person must knowingly submit a false or
  fraudulent claim.
• This includes actual knowledge, deliberate
  ignorance, or reckless disregard.

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Penalties

• Civil penalties up to 10,000 fine per claim plus
  double or treble damages, (criminal) up to
  25,000 fine and/or 5 years in jail.

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Role

• Your duty to report fraud, waste, and abuse
• Need not be certain the violation has occurred in
  order to report it.
• WH encourages you to seek guidance on any
  question related to potential or actual
  violations of laws and regulations

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Whistleblower Protections

• The False Claims Act provides protection for
  employees who report suspected false claims
  against retaliation

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How/Who to Report

• Report in person, telephone, or writing
• Who to report
• Immediate Supervisor/Program Director
• Compliance Officer
• A toll-free anonymous and confidential method is
  through the National Hotline Services, Inc.,
  Confidential Compliance Hotline
• 1-800-826-6762

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Resources for verifying eligibility

• Basic Medicaid Billing Guide located on DMAs
  website
• http//www.ncdhhs.gov/dma/medbillcaguide.htm
• 1-800-688-6696, menu option 1, for phone inquires
• NC Medicaid Automatic Voice Response (AVR) System
• 1-800-723-4337
• 270/271
• HIPAA Compliant Health Care Eligibility
  Benefit Inquiry and Response Electronic
  Transaction.
  
• Value Added Networks (VANs)
• Interactive eligibility verification that
  providers may contract with Medicaid for access
  to real time consumer eligibility.
  
  The transaction fee is eight cents
  per inquiry.

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Retro-Medicaid Refunds

• When a State funded consumer obtains
  retro-Medicaid
• Submit a refund using the WH Claims Resolution
  Inquiry Form with the WH EOB indicating the
  refunded services
• WH will apply refund to next payment, transaction
  presented on the WH EOB
• WH will initiate a retro-Medicaid refund upon
  notice from DMA eligibility inquiry/verification
  and State funded recoupment

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DDE

• A WH web-based claims entry product
• Complement the 837 and / or offer an electronic
  claims submission method alternative
• Complete/submit a Care Coordination Information
  System (CCIS) - User ID Assignment Request form

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DDE continued

• Individual user ID/Password
• IT requirements
• Internet Explorer 6.0, 98 or newer
• High-speed Internet
• Generates a report of accepted claims
• Immediate claim acceptance feedback
• Direct Data Entry Users Manual

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Exceptions to the Electronic Claim Submissions

• Void Replace
• COB Coordination of Benefits
• CAP MR/DD Waiver Supplies
• First Party Payment

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Claims Resolution Inquiry Form

• Appeals
• Void
• Void Replace
• Time Limit Override
• Third Party COB
• Refunds
• Other
• File the Claims Resolution Inquiry form with a
  new CMS 1500, and a copy of the WH EOB - Invoice

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Claims Resolution Inquiry

• WESTERN HIGHLANDS NETWORK
• CLAIMS RESOLUTION INQUIRY
• MAIL TO
• WESTERN HIGHLANDS NETWORK
• 356 BILTMORE AVENUE
• ASHEVILLE, NC 28801
• Fax To [phone]
• Please Check _____ Appeals ______ Void
  Replace ______ Time Limit Override ______
  Third Party Override
• _____ Refunds _____
  Other ____________________________________________
  _________________
• Include relative Western Highlands EOB
  (Explanation of Benefits) and a CMS-1500
  (08/05)
• Provider Name ___________________________________
  __________________________________________________
  ___
• Consumers Name _______________________________
  _________ Western Highlands ID
  _________________________
• Date of Services From _____/_____/_____ to
  _____/_____/_____ Check Number
  _____________________________
• Procedure Code ________________________________
  __________________________________________________
  _____
• Please Specify Reason for Inquiry Request

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Reimbursement

• WH provides an Explanation of Benefits Invoice
  and 835 Remittance Advice
• EOB and 835s are sent to your agencies mailbox
• Payments are mailed
• State funded prompt payment
• WHN is mandated to review claim / invoice
  submissions within (18) calendar business days
  after receipt and shall
• A) Approve payment
• B) Notify Provider within that time frame if
  claims/invoice are denied or if further
  information is necessary

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Denial and Resolution

• Duplicate Service
• Authorization
• Unit Limitations
• Attending Provider Numbers
• Service Level Numbers

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WH Explanation of Benefits InvoiceCodes

• EOB codes and description table is available at
  the WH Website and at the end of the WH EOB

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WH EOB 064 - Duplicate Service

• A previously submitted claims was paid, typically
  caused by either incorrect AR posting/flag
  setting or event summarization
• AR Posting
• Validate AR payment from previous EOBs
• Summarize
• Summarize claim prior to submission
• To correct submit a Claim Inquiry form void and
  replace transaction

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Authorizations

• 063 - Incorrect Authorization (DDE)
• Authorization presented doesnt support the
  consumer (consumer, provider, procedure code, and
  DOS)
• UA Authorization for these services does not
  exist or incorrect authorization
• OA Claim exceeds the units of service
  authorized
• A valid authorization, but the authorized units
  of service have been applied to previous
  payments, balance is zero.
• PP Partial Payment
• A valid authorization, but the total units billed
  were reduced to the balance of remaining
  authorized units.

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Unit Limitations

• 080 - Less than minimum daily limits
• Occurs when a service requires a daily minimum
  units of service and units billed were less than
  the minimum
• 081 - More than maximum daily limits

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Attending Provider

• 033 - Missing Attending Provider ID
• Claim was billed w/out an attending provider ID
• 034 - Invalid Attending Provider ID
• Adjudication system compares the billed ID to the
  registered ID and service
• Proper attending must coincide with service
  delivery
• Outpatient Behavioral Health services require the
  individual attending provider DMA enrollment
  number
• Enhanced Benefits require the DMA Community
  Intervention number with the relative alpha
  suffix
• Other services require the Western Highlands
  provider number specified in your contract
• 036 - CPT code requires Medicaid ID

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Attending Provider

• Confirm proper number was billed with service.
  Common error is an Enhanced Benefit billed with
  an individual clinicians enrollment or a Western
  Highlands provider ID
• Verify enrollment number from source
• Verify number was registered with WH. If not,
  follow instructions in WHN Communication Bulletin
  12
• Verify ID number billed matches the number
  registered

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Service Level Number

• 045 - EB Not Med Elig Inv Attd Number
• 051 - Invalid or absent service level number
• A service level number consists of the Community
  Intervention Number (Core Number) plus the alpha
  suffix that coincides with the enhanced benefit
  service
• Core Number 83xxxxx
• Service Level Number 83xxxxxA

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Attending Provider Tips to remember

• Enhanced Benefit Services, enter the DMA
  Community Intervention Number with the alpha
  suffix. Example 83xxxxx () Alpha Character
  representing the Enhanced Service.
• Outpatient Behavioral Health (OBH) service, the
  DMA individual clinicians Medicaid enrollment
  number.
• Neither an Enhanced Service nor OBH service,
  enter your agencys Western Highlands provider
  number. Example 36XXX

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Technical Assistance

• E-mail
• billingquestions_at_westernhighlands.org
• Phone
• [phone] ext. 2191
• Western Highlands Website
• http//www.westernhighlands.org/pr_reimbursement.h
  tm

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Additional Information Sources

• CMS
• http//www.cms.hhs.gov/
• NC Division of Medical Assistance
• http//www.dhhs.state.nc.us/dma/NPI.htm
• IPRS website
• http//www.dhhs.state.nc.us/mhddsas/iprsmenu/index
  .htm
• NPPES
• https//nppes.cms.hhs.gov/NPPES/Welcome.do

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Thank you!

• Thank you for attending Western Highlands Claims
  Reimbursement Training Seminar