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9/30/2019Rosters When agencies are credentialed at the facility level,we are reliant on provider rosters to ensure MCOssystems are up-to-date. MCOs have established a common roster template forall providers to use in order to streamline processes. Allow approximately 30-45 days for roster updates tobe processed prior to submitting claims to avoid denialsand re-work. Updated rosters should be sent to MCOs on a regularbasis. Failure to send timely roster updates may resultin incorrect payments and/or denials.Reporting Provider Changes/UpdatesProviders must give notice at least 60 days in advance of any providerchanges such as: Group and/or Individual NPI Provider Terms Provider Adds/Updates Billing and/or Pay to addresses Clinic locations (where services are Tax ID Changesrendered)Please submit rosters and any other changes/updates mCoordinated CareContracting@CoordinatedCareHealth.comMolina edHealthcareCommunity PlanWAIMC@Optum.com16

9/30/2019What You Need to Know About NPIsThere is a two-step process related to NPIs:1.2.Obtain NPIs for individual providers All providers (all levels, including unlicensed providers) that providedirect, encounterable care to members must obtain an NPI number toreport as the servicing/rendering provider on claims. Exceptions are identified in IMC SERI and HCA NPI Q&A about NPIs - whereHCA and MCOs are allowing a provider to use the billing providerinformation in the rendering provider fields. If the provider's situation isnot identified as an exception, they should assume the actual renderingprovider needs an NPI and needs it registered with HCA. (Exceptionexample: Freestanding E&T billed with Billing Provider NPI.)Enroll individual providers NPIs with HCA to obtain an HCA ProviderOneID number. More detail on this process on the next slide.HCA ProviderOne ID - RequiredBHAs must ensure that all individual providers have an HCAProviderOne IDOREnroll as a ‘non-billing‘ provider (if he/she does not wish toserve fee for service Medicaid clients) but each provider musthave an active NPI number with the HCA to bill independently. 42 CFR 438.602(b) requires all BHA providersto be enrolled by 1/1/2019. Both Organizations (Type 1) and Individuals (Type 2) NPI’sneed to be registered.17

9/30/2019HCA ProviderOne ID - Required Requirements and Instructions on enrollment are available on HCA’s Lack of compliance with this HCA requirement can IMPACTclaims payment, please ensure you are properly registeredand obtain the ProviderOne ID!35Access to Care andAppointment Standards18

9/30/2019Access to Care Standards DSHS Access to Care Standards implemented by DBHR(utilized by BHOs) will be eliminated January 1, 2020. MCOs will utilize medical necessity criteria rather thanthe DBHR Access to Care Standards. MCOs will nowoversee all Medicaid-covered behavioral healthbenefits, regardless of diagnosis. MCOs will continue to utilize industry standard medicalnecessity decision making guidelines, based onevidence based practices, for determining levels ofservices.Appointment StandardsMCO appointment standards comply with the Health Care Authority (HCA) andthe National Committee for Quality Assurance (NCQA) requirements.Providers must also adhere to these standards.Type of CareAppointment StandardPreventive Care AppointmentSecond OpinionsNon-Urgent, Symptomatic CareUrgent CareEmergency CareAfter-Hours CareCare Transitions – PCP VisitWithin 30 calendar days of requestWithin 30 calendar days of requestWithin 10 calendar days of requestWithin 24 hours24 hours/7 daysAvailable by phone 24 hours/seven daysTransitional healthcare services by a Primary CareProvider, within 7 calendar days of discharge frominpatient or institutional care for physical or behavioralhealth disorders or discharge from a substance usedisorder treatment programTransitional healthcare services by a home care MentalHealth Professional or other Behavioral HealthProfessional within 7 calendar days of discharge frominpatient or institutional care for physical or behavioralhealth care, if ordered by the Enrollee’s Primary CareProvider or as part of the discharge plan.Care Transitions – Home Care19

9/30/2019Behavioral Health AppointmentStandardsMCO appointment standards comply with the Health Care Authority (HCA) andthe National Committee for Quality Assurance (NCQA) requirements.must also adhere to these standards.Type of CareAppointment StandardNon-life threateningWithin 6 hoursUrgent careWithin 24 hoursRoutine care – initial visitThe earlier of 10 business days or 14calendar daysRoutine care – follow-up visitsWithin 30 daysEligibility and ID Cards20

9/30/2019Eligibility Eligibility should be verified before every service.HCA updates eligibility daily, therefore retrospectiveor mid-month changes can exist. Methods to confirm eligibility: EachMCO Portals HCAProviderOne: https://www.waproviderone.org/ HCAEligibility oviders/manual verifyclienteligibility.pdf AI/AN members may opt into managed careEligibility Example - AmerigroupMember is eligible for Amerigroup Integrated Managed Care effective 1/1/2018.21

9/30/2019Eligibility Example - MolinaMember is eligible for Molina Healthcare Integrated Managed Care effective 8/1/2018.Eligibility Example - BHOMember is eligible for Great Rivers BHO effect 2/1/2018, AMG FCS Housing effect8/1/2018 and AMG Apple Health effect 11/1/2017.22

9/30/2019Eligibility Example - UnitedHealthcareMember is eligible for UHC Fully Integrated Managed Care effective 1/1/2019Member is eligible for UHC Behavioral Health Service Only effective 1/1/2019Eligibility Example - IneligibleMember is ineligible.23

9/30/2019Amerigroup ID CardsIMCBHSOCoordinated Care ID CardsIMCBHSOAHFC24

9/30/2019Molina Healthcare ID CardsBHSOIMCUnitedHealthcare ID CardsIMCBHSO25

9/30/2019Spenddown Individuals Spenddown is the amount of medical expenses for which anindividual is responsible, similar to an insurance deductible. Once spenddown is met, the individual will receive a letterdescribing their eligibility. MCOs do not have visibility as to whether an individual’sspenddown has been met. It is only once met, that they areassigned to an MCO. ProviderOne Eligibilty: https://www.waproviderone.org/Incarcerated Individuals HCA will “suspend” Medicaid coverage for individuals duringincarceration. Suspended coverage means the individual is eligible forMedicaid, but all claims payment and managed careassignment is suspended while the individual is in custody The benefit to suspended (as opposed to terminated)coverage is that individuals are quickly re-enrolled with theirMCO upon release. MCOs have developed processes to create “honor” or“presumptive” authorizations for incarcerated members toassist them in accessing services immediately upon releasefrom the correctional facility.26

9/30/2019Websites, Portals andDirectoriesMCO Website ContentClinical andPayment PoliciesClinical PracticeGuidelinesFrequently UsedFormsHEDIS GuidesPreferred Drug ListProvider ManualsProviderNewsletters andAnnouncementsProvider Portal LinkProvider Trainingand ResourceMaterialsVerify Prior Authrequirements27

9/30/2019MCO Website Links for ProvidersMCOWebsite oordinated lina dicaid/Pages/home.aspxUnitedHealthcareCommunity Planwww.uhcprovider.com/communityplanProvider Portal ContentAuthorization statusand submissionCase managementreferralsCheck membereligibility andbenefitsClaim audit toolClaim submissionand statusClaim correctionand resubmissionMember rostersMember care gapsSecure transactionsUpdate practiceinformation28

9/30/2019MCO Portal Links for ProvidersMCOPortal eb/public.elegant.login?source MBUCoordinated Carewww.coordinatedcarehealth.com/login.htmlMolina HealthcareUnitedHealthcareCommunity PlanAccess Molina WebPortal via OneHealthPort.If new to OneHealthPort, register ml?rfid UHCCPProvider Directory Links ublic.elegant.login?source MBU Coordinated om/ Molina com/ UnitedHealthcare Community rreferral-directory.html29

9/30/2019Claims and BillingClaim vs EncounterProviders are required to submit a claim or encounter foreach service that is rendered to an MCO enrolleeregardless of the provider’s reimbursement arrangement.ClaimEncounterDefinitionA bill for services for onemember received for aspecific date or date rangeA claim processed and paid at 0because the provider is pre-paidfor services per the terms oftheir contractPaymentMethod Paid Fee for Service (FFS)based on negotiatedcontract rate w/ MCO. Typically, each coveredservice provided to themember is individuallypaid based on an allowedamount. Individual services are notpaid Provider is paid a capitatedamount for pre-definedservices as outlined in anindividual contract30

9/30/2019Claim/Encounter SubmissionSubmissionMethodFirst Time ClaimsCorrected ClaimElectronic DataInterchange (EDI)837 transactionSubmit through clearinghouseSubmit through clearinghouse withappropriate frequency codeMCO’s PortalReference to MCO websiteCorrected claims are submitted byclicking on the original claim, makingcorrections and submittingMailing in a PaperClaim CMS-1500 for professional claims UB-04 for institutional claims All claim forms must meet CMSprinting requirements and beprinted in Flint OCR Red, J6983,ink No handwritten claim forms orphotocopies will be accepted Institutional Claims (UB): Must bebilled with corrected type of bill(XX7) in field 4, original claimnumber in field 64 and appropriatefrequency code. Professional Claims (HCFA): Mustbe billed with original claim numberin field 22 along with the appropriatefrequency code.*Preferred methodClearinghousesDefinitionA trading partner securely transmitting claims (837file) electronically from the provider to the MCO.Benefits Submits multiple claims to specifiedpayer Provides Electronic Remittance Advice(ERA) for automatic updates forpayments and adjustments by MCO Meets HIPAA compliance standards Stand-alone entity Scrubs claims for errors prior tosubmission to MCO to improve accuracy The most common Electronic DataInformation (EDI) transmissions areknown as, files: 837, 277, 999 and 835. Allows providers to manage claim statusin one place31

9/30/2019Clearinghouse Data FlowProvider ged CareOrganizationPlease refer to the Claims/Encounter Process handoutfor additional information.Clean/Non-Clean Claim Definitions Clean Claim – A clean claim is a claim that can beprocessed without obtaining additionalinformation from the provider of the service, orfrom a third party. A clean claim contains all therequired data elements on the claim form (seeeach MCO’s billing guide for claim formrequirements). Non-Clean Claim – Non-clean (dirty) claimsinclude, but are not limited to, those that arerejected for missing data elements, submitted onincorrect forms, contain incorrect data (e.g.wrong member ID, invalid CPT/ICD code, etc.).32

9/30/2019Timely FilingThe amount of time you have to file a clean claim isdependent on your specific contract terms with eachMCO. Please refer to your contract and make note ofyour timely filing deadlines. Timely filing is determined by the number of days betweenwhen the MCO receives a clean claim from you and thedate of service. Claims that are not received within the requiredtimeframes will be denied and will not be paid unlessthere are extenuating circumstances (these are rare). You must check the member’s eligibility on each date ofservice to make sure you are timely billing the correctpayer or MCO. Members can move around betweenmanaged care plans. Contracted providers have 24 months from date of EOP toappeal a claim decision.Rejected vs Denied ClaimsWhat’s the Difference?RejectedDoes not enter theadjudication systemdue to missing orincorrect information.DeniedGoes through theadjudication processbut is denied forpayment.When billing electronically, your clearinghouse can send you reportsof rejected claims (you may need to request this). You must workthis report regularly to resolve the issues and resubmit claims.When sending in a paper claim, if it is rejected, it will return to youwith a letter explaining the reason for the rejection.A claim that rejects and does not enter the MCO’s claimspayment system to be assigned a claim number is not a cleanclaim and does not count towards timely filing calculations.33

9/30/2019Most Common Rejection ReasonsMissing or invalid required data elements or fields on claim form Member date of birthMember ID numberProvider taxonomy codeNPI numberService date spanCLIA number for lab claimsUnreadable claim form Ink too faded Typing is not fully within the fields, Ink bleeds into other fields Font is too smalli.e. misalignedIncorrect claim form usedPhotocopy of claim formHand-written claim formClaim/Encounter SubmissionMCOPayer ID(s)Contact Number AddressAmerigroupAvaility:26375Availity:(877) 334-8446Coordinated Care68069(877) 644-4613Molina Healthcare Claims:38336Encounter:43174UnitedHealthcare Electronic:Community Plan87726ERA:04567Washington ClaimsAmerigroup Washington Inc.PO Box 61010Virginia Beach, VA 23466-1010Claim Processing DepartmentPO Box 4030Farmington MO 63640-4197(866) 409-2935Molina Healthcare ofWashingtonEDI.claims@Molina P.O Box 22612Healthcare.com Long Beach, CA 90801(866) 556-8166UnitedHealthcarePO Box 31365FaxSalt Lake City UT 84131-0365(855) 312-1470Please refer to MCO Provider Manuals for additionalinformation on Claims/Encounters.34

9/30/2019Balance Billing Providers must accept payment by MCOs as payment in full. Balance billing is not permitted unless the provider and memberfully complete and sign an HCA 13-879 form--Agreement to Payfor Healthcare Services. additional information, refer to: WAC182-502-0160, 42 CFR 447.15, and HCA Memo #10-25. Services must be rendered within 90 days from signing the HCA13-879 form, otherwise a new form must be completed andsigned. The HCA 13-879 form must be translated into the member’sprimary language if he or she has limited English proficiency, andif necessary, an interpreter must be provided for the member. Ifan interpreter is used to complete and sign the form, theinterpreter’s signature must also be obtained. All other requirements for the HCA 13-879 form apply, as outlinedin.Electronic Funds Transfer andElectronic Remittance AdviceBenefits of registering for Electronic Fund Transfer and/or ElectronicRemittance Advice: Receive payments through direct deposit to bank accountMore timely and secure paymentsReceive notification upon paymentDownload an 835 file or other available reports to use for auto-postingHistorical EOP search by various methods (i.e. claim number, membername)Create custom reportsProviders must register and complete the process for these administrativeservices.35

9/30/2019Electronic Funds Transfer and ElectronicRemittance AdviceMCOWebsiteContact NumberEmailTo register, please use this information for assistance:EFT help: efthelp@enrollhub.caqh.orgAmerigroupEFT:(844) px?ReturnUrl /bpas/default.aspx/%22(800) 454-3730ERA: www.Availity.comCoordinated alth.comMolina Healthcarehttps://providernet.admini(877) tion@emdeon.comUnitedHealthcareCommunity (877) /a(877) 331-7154For ERA, submit email /ticket: vioral Health Supplemental DataThis is the non-encounter data that was created in 2016 to replace and combine theTARGET and CIS non-encounter data. The data is needed by HCA in order to meet SAMHSAblock grant reporting requirements. The data has also been referred to as “nativetransactions.”Changes effective January 1, 2020: Healthcare Authority has released an updated Behavioral Health SupplementalTransaction Data Guide. The guide along with a list of changes from the older versions isavailable on HCA website: resources All licensed and certified BHAs contracted with the MCOs/BH-ASOs are required tocollect this data starting January 1, 2020. MCOs and BH-ASOs must begin submitting data to HCA no later than April 1, 2020 forWashington to be compliant with the SAMHSA CAP. Currently, MCOs are determining a method to collect this data from providers. Our goal isto implement systems/processes that are as similar as possible to minimize the burdenon providers. In the meantime, providers should use the final HCA guide to beginenhancing their own systems in order to be ready to collect such data.36

9/30/2019HCA IMC Service EncounterReporting Instructions (SERI)In order to receive federal match for Medicaid services, the Health CareAuthority is required under CFR438.818 to ensure that all encounter datacomplies with HIPAA security and privacy standards. CFR also requires thatproviders accurately prepare claims using applicable coding rules andguidelines. HCA must also guarantee that encounter data is validated foraccuracy and completeness; and changes in the IMC SERI guide will ensurethat all encounter data is HIPAA and regulatory compliant.The most current SERI Guide and interim guidance issued by HCA betweenSERI Guide updates can be reporting-instructions-seriEvidence-Based Practice CodesWhat are Evidence-Based Practice (EBP) codes and how are they used?EBP codes are specially designated identif

Facility credentialing applications vary by EACH MCO. All MCOs utilize ProviderSource (OneHealthPort) and/or CAQH as primary credentialing vendors for individual provider credentialing. Credentialing materials and inquiries may be submitted to each MCO, as follows: MCO Email Amerigroup