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Claims Adjudication DXC-TennCare Operations Manual 11.0 i

DXC-TENNCARE OPERATIONS MANUAL

Claims Adjudication

Contract Reference A.3.5.3.15

Version 11.0

June 20, 2017

DXC Technology

310 Great Circle Road

Nashville, TN 37228

Claims Adjudication DXC-TennCare Operations Manual 11.0 ii

Document Information Page

Required Information Definition Document Title DXC-TennCare Operations Manual SCR/WR Number SCR/WR Description Claims Adjudication Contract Reference A.3.5.3.15 Version Number 11.0 Version Date June 20, 2017 Filename Claims Adjudication Manual.docx Author Owner Shirelle Humphrey Reviewers Review Timelines Initial Customer review:

DXC Response: Confidentiality Statement This document may contain Work Product and/or Contractor Materials as defined in the contract between the State of Tennessee, Department of Finance and Administration, Division of Health Care Finance & Administration (HCFA), Bureau of TennCare and Enterprise Services, LLC, a DXC Technology company. Use and distribution of the contents of this document must comply with the Contract provisions. Template version date 04/21/2011

Claims Adjudication DXC-TennCare Operations Manual 11.0 iii

Amendment History Summary of Change

Version # Modified Date Modified By Section, Page(s) and Text Revised 1.0 1/1/2007 Operations

Team Personnel Original

2.0 6/1/2007 Operations Team Personnel

Revised document

3.0 10/1/2007 Operations Team Personnel

Revised document

3.1 12/15/2009 Kenelm Floyd Added LTC and HCBS processes. Verified guidelines for working edits/audits.

3.2 12/20/2009 Amelia McHenry Transferred into new template. 3.3 12/23/2009 Kenelm Floyd Deleted unneeded screen shots. 3.4 1/14/2010 Amelia McHenry Quality check 4.0 2/2/2010 Glenn Garby Ready to submit 4.1 ¾/2010 Kenelm Floyd Revised document per comment log 4.2 3/9/2010 Vanda Hansard Review formatting 5.0 3/9/2010 Glenn Garby Ready to submit 5.1 5/18/2010 Tobie Harding/

Amelia McHenry Updated Edit 518 and 5508 (LTC section)

5.2 8/20/2010 Tobie Harding/ Amelia McHenry

Updated to new template and updated Edits 203, 269, 292, 295, 461, 526, 626, 2001, 2019, 4021, and 4064 in Section 4.


Added Edit 6000 instructions in front of the current guidelines


Updated Edit 538

5.5 07/01/2011 Tobie Harding Amelia McHenry

Transferred to new template, Updated manual title, updated edits.

5.6 07/12/2011 Amelia McHenry Document checklist review performed 5.7 07/13/2011 Chris Sutton Document peer review performed 5.8 08/02/2011 Tobie Harding/

Amelia McHenry Further updates made.


Final Author review performed


Added Edits 2008, 2062, and 2082


Added Edits 1015, 207, 518, 1031, 661, and 5546


Added Edit 5546


Added Edit 1092


Added LTC Edits 570 and 572, Replaced Edit 5518


Added Edit 636


Added Edits 2100, 2103, and 2113

Claims Adjudication DXC-TennCare Operations Manual 11.0 iv

Version # Modified Date Modified By Section, Page(s) and Text Revised 6.8 03/09/2012 Tobie Harding/

Roy Burkhead Updated Edit 513 FFS and LTC FFS


Updated FFS Edits 5005 and 5008


Updated FFS Edit 519


Updated FFS Edit 5014

6.12 06/11/2012 Tobie Harding Chris Sutton

Updated Edit 518, 570, and 572


Updated Edit 1226


Updated Edit 1226, 1032, and 1092

6.15 09/25/2012 Teri Canady Amelia McHenry

Updated Edit 538 and 1244


Updated Edit 513

7.1 04/26/2013 Paul Spilburg Amelia McHenry

Updated Edit 5005


Updated Edit 5005


Added Edit 224


Updated Edit 648

8.2 04/06/2016 Teri Canady Revised document – removed edits that no longer suspend

8.3 04/07/2016 Rick Bowenwest Document review checklist performed 9.0 04/07/2016 Rick Bowenwest Final author review 9.1 04/26/2016 Dena Thorpe Manual name change and remove Edit 6773 9.2 05/18/2016 Rick Bowenwest Document review checklist performed 10.0 05/18/2017 Rick Bowenwest Final author review 10.1 06/20/2017 Rick Bowenwest Updated DXC Branding scheme 11.0 06/20/2017 Rick Bowenwest Finalized for publishing

Claims Adjudication DXC-TennCare Operations Manual 11.0 v

Table of Contents 1 Introduction ......................................................................................... 1

1.1 Goals and Objectives ........................................................................................ 1

2 Work Flow Procedures ........................................................................... 1

2.1 Overview......................................................................................................... 1 2.2 Paper Claims Processing Steps ........................................................................... 1 2.3 Claim Location and Region Codes ....................................................................... 2 2.4 Claims Processing ............................................................................................ 4 2.5 How to View Claims and Process Edits ................................................................ 5 2.6 Verify Claim and EOB ........................................................................................ 6

3 Claim Types ......................................................................................... 6

4 Fee-For-Service Edits and Audits ............................................................ 7

4.1 Edits 100 – 6000 .............................................................................................. 8 4.1.1 Procedure for Claims Suspended for Manual Pricing Error Code 6000 ..... 73 4.1.2 Manual Pricing ................................................................................ 76 4.1.3 Comparing Modifiers and Dates ......................................................... 83 4.1.4 Manual Pricing Date of Service on and after 07/01/2008 ...................... 85 4.1.5 Procedure for Claims Suspended for Manual Pricing Error Code 6000 Unlisted Procedure on or after 07/01/2008 ........................................................ 89

4.2 Procedure for Claims Suspended for Manual Pricing Error Code 6000 Claims Suspending on and after 07/01/2008 with Span Dates of Service ................................... 96 4.3 Edits 6662-6670 .......................................................................................... 104

5 LTC Fee-For-Service Edits and Audits .................................................. 108

5.1 LTC Fee-For-Service Timely Filing Processes Overview ...................................... 177 5.1.1 Court Ordered Timely Filing Override ............................................... 177 5.1.2 Retro-Active Medicaid Eligibility ....................................................... 178 5.1.3 Medicare Claims not Crossed Over to TennCare................................. 180 5.1.4 Third Party (Other Insurance) ......................................................... 181 5.1.5 Timely submission and timely follow-up of denied claims.................... 181 5.1.6 Repayment of Voided Claims .......................................................... 182

5.2 LTC Fee-For-Service Claims Requiring Third Party Liability (TPL) Edit Override ..... 186

Appendix A: Special Batch/Override Forms ................................................ 193

List of Figures and Diagrams Figure 4.1-1: Edit 100 ........................................................................................................ 8 Figure 4.1-2: Edit 203 ........................................................................................................ 9 Figure 4.1-3: Edit 207 ...................................................................................................... 10 Figure 4.1-4: Edit 239 ...................................................................................................... 11 EDIT 243 12

Claims Adjudication DXC-TennCare Operations Manual 11.0 vi

Message 12 MISSING MEDICARE PAID DATE ........................................................................................... 12 Figure 4.1-5 Edit 243 ...................................................................................................... 12 Figure 4.1-6: Edit 251 ...................................................................................................... 13 Figure 4.1-7: Edit 252 ...................................................................................................... 14 Figure 4.1-8: Edit 400 ...................................................................................................... 15 Figure 4.1-9: Edit 434 ...................................................................................................... 16 Figure 4.1-10: Edit 451 ...................................................................................................... 17 Figure 4.1-11: Edit 461 ...................................................................................................... 18 Figure 4.1-12: Edit 512 ...................................................................................................... 19 Figure 4.1-13: Edit 513 ...................................................................................................... 20 Figure 4.1-14: Edit 518 ...................................................................................................... 21 Figure 4.1-15: Edit 519 ...................................................................................................... 22 Figure 4.1-16: Edit 527 ...................................................................................................... 23 Figure 4.1-17: Edit 538 ...................................................................................................... 24 Figure 4.1-18: Edit 554 ...................................................................................................... 25 Figure 4.1-19: Edit 555 ...................................................................................................... 26 Figure 4.1-20: Edit 556 ...................................................................................................... 27 Figure 4.1-21: Edit 559 ...................................................................................................... 28 Figure 4.1-22: Edit 570 ...................................................................................................... 29 Figure 4.1-23: Edit 589 ...................................................................................................... 30 Figure 4.1-24: Edit 627 ...................................................................................................... 31 Figure 4.1-25: Edit 629 ...................................................................................................... 32 Figure 4.1-26: Edit 630 ...................................................................................................... 33 Figure 4.1-27: Edit 631 ...................................................................................................... 34 Figure 4.1-28: Edit 635 ...................................................................................................... 35 Figure 4.1-29: Edit 648 ...................................................................................................... 36 Figure 4.1-30: Edit 649 ...................................................................................................... 37 Figure 4.1-31: Edit 1004 .................................................................................................... 38 Figure 4.1-32: Edit 1005 .................................................................................................... 39 Figure 4.1-33: Edit 1007 .................................................................................................... 40 Figure 4.1-34: Edit 1017 .................................................................................................... 41 Figure 4.1-35: Edit 1032 .................................................................................................... 42 Figure 4.1.36: Edit 1092 .................................................................................................... 43 Figure 4.1.37: Edit 1244 .................................................................................................... 44 Figure 4.1-38: Edit 2001 .................................................................................................... 45 Figure 4.1-39: Edit 2029 .................................................................................................... 46 Figure 4.1-40: Edit 2080 .................................................................................................... 47 Figure 4.1-41: Edit 2504 .................................................................................................... 48 Figure 4.1-42: Edit 2504 (cont.) .......................................................................................... 49

Claims Adjudication DXC-TennCare Operations Manual 11.0 vii

Figure 4.1-43: Edit 2505 .................................................................................................... 50 Figure 4.1-44: Edit 2505 (cont.) .......................................................................................... 51 Figure 4.1-45 Edit 2505 (cont.) .......................................................................................... 52 Figure 4.1-46: Edit 2507 .................................................................................................... 53 Figure 4.1-47: Edit 4013 .................................................................................................... 54 Figure 4.1-48: Edit 4014 .................................................................................................... 55 Figure 4.1-49: Edit 4027 .................................................................................................... 56 Figure 4.1-50: Edit 4032 .................................................................................................... 57 Figure 4.1-51: Edit 4052 .................................................................................................... 58 Figure 4.1-52: Edit 4053 .................................................................................................... 59 Figure 4.1-53: Edit 4054 .................................................................................................... 60 Figure 4.1-54: Edit 4055 .................................................................................................... 61 Figure 4.1-55: Edit 4230 .................................................................................................... 62 Figure 4.1-56: Edit 4231 .................................................................................................... 63 Figure 4.1-57: Edit 4252 .................................................................................................... 64 Figure 4.1-58: Edit 5005 .................................................................................................... 65 Figure 4.1-59: Edit 5008 .................................................................................................... 66 Figure 4.1-60: Edit 5008 (cont.) .......................................................................................... 67 Figure 4.1-61: Edit 5014 .................................................................................................... 67 Figure 4.1-62: Edit 5508 .................................................................................................... 68 Figure 4.1-63: Edit 5546 .................................................................................................... 69 Figure 4.1-64: Edit 6000 (Effective 7/1/2009) ....................................................................... 70 Figure 4.1-65: Edit 6000 cont. (Effective 7/1/2009) ............................................................... 71 Figure 4.1-66: Edit 6000 (Effective 7/1/2008) ....................................................................... 72 Figure 4.1.1-1: Physician Data Correction – Procedure Code .................................................... 73 Figure 4.1.1-2: HCPCS Procedure Window – Date of Service .................................................... 74 Figure 4.1.1-3: HCPCS Procedure Window – Options>Pricing> Max Fee .................................... 75 Figure 4.1.1-4: Max Fee List ................................................................................................ 76 Figure 4.1.2-1: Physician Data Correction – Options>Xover Data ............................................. 77 Figure 4.1.2-2: Physician Xover Information - Coinsurance ...................................................... 77 Figure 4.1.2-3: Physician Data Correction – Allowed Amt ........................................................ 78 Figure 4.1.2-4: Warning ...................................................................................................... 78 Figure 4.1.2-5: Physician Data Correction – Save Successful ................................................... 79 Figure 4.1.2-6: Max Fee List ................................................................................................ 80 Figure 4.1.2-7: Max Fee Maintenance Window........................................................................ 80 Figure 4.1.2-8: Max Fee Maintenance - File>Audit .................................................................. 81 Figure 4.1.2-9: Audit Trail window ........................................................................................ 81 Figure 4.1.2-10: Audit Trail ............................................................................................... 82 Figure 4.1.2-11: Audit Trail ............................................................................................... 82 Figure 4.1.3-1: Max Fee List ................................................................................................ 83

Claims Adjudication DXC-TennCare Operations Manual 11.0 viii

Figure 4.1.3-2: Detail section of Physician Data Correction window ........................................... 83 Figure 4.1.4-1: Physician Xover Information .......................................................................... 85 Figure 4.1.4-2: Physician Data Correction Window .................................................................. 86 Figure 4.1.4-3: Warning ...................................................................................................... 86 Figure 4.1.4-4: Physician Data Correction Window .................................................................. 87 Figure 4.1.4-5: Physician Data Correction – Save Successful ................................................... 88 Figure 4.1.5-1: Physician Data Correction Window .................................................................. 89 Figure 4.1.5-2: HCPCS Procedure – Options>Pricing>Max Fee ................................................. 90 Figure 4.1.5-3: Max Fee List window ..................................................................................... 91 Figure 4.1.5-4: Physician Data Correction>Options>Xover Data ............................................... 92 Figure 4.1.5-5: Physician Xover Information .......................................................................... 92 Figure 4.1.5-6: Physician Data Correction Window .................................................................. 93 Figure 4.1.5-7: Warning ...................................................................................................... 93 Figure 4.1.5-8: Physician Data Correction Window .................................................................. 94 Figure 4.1.5-9: Physician Data Correction – Save Successful ................................................... 95 Figure 4.2-1: Suspended Physician Claim ........................................................................... 96 Figure 4.2-2: HCPCS Procedure Window – Options>Pricing>Max Fee ..................................... 97 Figure 4.2-3: Max Fee List Window .................................................................................... 98 Figure 4.2-4: Physician Data Correction – Options>Xover Data ............................................. 98 Figure 4.2-5: Physician Xover Information .......................................................................... 99 Figure 4.2-6: Paid Physician Claim Window ......................................................................... 99 Figure 4.2-7: Physician Xover Information Window ............................................................ 100 Figure 4.2-8: Example: Calculating the TennCare Liability................................................... 100 Figure 4.2-9: Medical Liability ......................................................................................... 101 Figure 4.2-10: TennCare Liability ...................................................................................... 101 Figure 4.2-11: Warning .................................................................................................... 102 Figure 4.11-12: Paid Physician Claim Window .................................................................... 102 Figure 4.2-13: Physician Data Correction – Save Successful ................................................. 103 Figure 4.3-1: Edit 6662 .................................................................................................. 104 Figure 4.3-2: Edit 6663 .................................................................................................. 105 Figure 4.3-3: Edit 6664 .................................................................................................. 106 Figure 4.3-4: Edit 6670 .................................................................................................. 107 Figure 5-1: Edit 100 .................................................................................................... 108 Figure 5-2: Edit 207 .................................................................................................... 109 Figure 5-3: Edit 224 .................................................................................................... 110 Figure 5-4: Edit 258 .................................................................................................... 111 Figure 5-5: Edit 272 .................................................................................................... 112 Figure 5-6: Edit 274 .................................................................................................... 113 Figure 5-7: Edit 281 .................................................................................................... 114 Figure 5-8: Edit 434 .................................................................................................... 115

Claims Adjudication DXC-TennCare Operations Manual 11.0 ix

Figure 5-9: Edit 461 .................................................................................................... 116 Figure 5-10: Edit 508 .................................................................................................... 117 Figure 5-11: Edit 513 .................................................................................................... 118 Figure 5-12: Edit 518 .................................................................................................... 119 Figure 5-13: Edit 538 .................................................................................................... 120 Figure 5-14: Edit 559 .................................................................................................... 121 Figure 5-15: Edit 570 .................................................................................................... 122 Figure 5-16: Edit 572 .................................................................................................... 123 Figure 5-17: Edit 661 .................................................................................................... 124 Figure 5-18: Edit 634 .................................................................................................... 126 Figure 5-19: Edit 636 .................................................................................................... 127 Figure 5-20: Edit 1018 .................................................................................................. 128 Figure 5-21: Edit 1019 .................................................................................................. 129 Figure 5-22: Edit 1032 .................................................................................................. 130 Figure 5-23: Edit 1092 .................................................................................................. 131 Figure 5-24: Edit 1226 .................................................................................................. 132 Figure 5-25: Edit 2002 .................................................................................................. 133 Figure 5-26: Edit 2008 .................................................................................................. 134 Figure 5-27: Edit 2029 .................................................................................................. 135 Figure 5-28: Edit 2062 .................................................................................................. 136 Figure 5.29: Edit 2078 .................................................................................................. 137 Figure 5-30: Edit 2080 .................................................................................................. 138 Figure 5-31: Edit 2082 .................................................................................................. 139 Figure 5-32: Edit 2100 .................................................................................................. 140 Figure 5-33: Edit 2103 .................................................................................................. 141 Figure 5-34: Edit 2113 .................................................................................................. 142 Figure 5-35: Edit 4013 .................................................................................................. 143 Figure 5-36: Edit 4014 .................................................................................................. 144 Figure 5-37: Edit 4030 .................................................................................................. 145 Figure 5-38: Edit 4032 .................................................................................................. 146 Figure 5-39: Edit 4034 .................................................................................................. 147 Figure 5-40: Edit 4040 .................................................................................................. 148 Figure 5-41: Edit 4041 .................................................................................................. 149 Figure 5-42: Edit 4045 .................................................................................................. 150 Figure 5-43: Edit 4052 .................................................................................................. 151 Figure 5-44: Edit 4059 .................................................................................................. 152 Figure 5-45: Edit 4200 .................................................................................................. 153 Figure 5-46: Edit 4252 .................................................................................................. 154 Figure 5-47: Edit 5000 .................................................................................................. 155 Figure 5-48: Edit 5011 .................................................................................................. 156

Claims Adjudication DXC-TennCare Operations Manual 11.0 x

Figure 5-49: Claim Errors .............................................................................................. 157 Figure 5-50: Denied UB92 Claim – Options>Related History............................................... 157 Figure 5-51: Related Claim History ................................................................................. 158 Figure 5-52: Paid UB92 Claim ........................................................................................ 158 Figure 5-53: Edit 5005 .................................................................................................. 160 Figure 5-54: Edit 5007 .................................................................................................. 161 Figure 5-55: Edit 5008 .................................................................................................. 162 Figure 5-56: Edit 5508 .................................................................................................. 163 Figure 5-57: Edit 5510 .................................................................................................. 164 Figure 5-58: Edit 5512 .................................................................................................. 165 Figure 5-59: Edit 5513 .................................................................................................. 166 Figure 5-60: Edit 5518 .................................................................................................. 167 Figure 5-61: Edit 5546 .................................................................................................. 168 Figure 5-62: Edit 6662 .................................................................................................. 169 Figure 5-63: Edit 6663 .................................................................................................. 170 Figure 5-64: Edit 6670 .................................................................................................. 171 Figure 5-66: Edit 6775 .................................................................................................. 172 Figure 5-67: Edit 6778 .................................................................................................. 173 Figure 5-68: Edit 6780 .................................................................................................. 174 Figure 5-69: Edit 6783 .................................................................................................. 175 Figure 5-70: Edit 6785 .................................................................................................. 176 Figure 5.1.6-1: Edit 545 .................................................................................................... 183 Figure 5.1.6-2: Edit 556 .................................................................................................... 184 Figure 5.1.6-3: Edit 630 .................................................................................................... 185 Figure 5.2-1: Edit 2504 .................................................................................................. 187 Figure 5.2-2: Edit 2504 (cont.) ........................................................................................ 188 Figure 5.2-3: Edit 2504 (cont.) ........................................................................................ 189 Figure 5.2-4: Edit 2505 .................................................................................................. 190 Figure 5.2-5: Edit 2505 (cont.) ........................................................................................ 191 Figure 5.2-6: Edit 2505 (cont.) ........................................................................................ 192 Figure 5.2-7: Edit 2507 .................................................................................................. 192 Figure A-1: Edit Override Authorization Form ................................................................. 193 Figure A-2: LTC Special Batch Handling ......................................................................... 194 List of Tables Table 2.2: Explanation of ICN Codes ................................................................................ 1 Table 2.3-1: Location Codes .............................................................................................. 2 Table 2.3-2: Region Codes ................................................................................................. 3 Table 3: Claim Types................................................................................................... 6 Table 4.1.3: Informational Modifiers ................................................................................. 84

Claims Adjudication DXC-TennCare Operations Manual 11.0 xi

Table 4.2: Example: Determining Number of Days payable ............................................. 100

DXC Technology / Bureau of TennCare June 20, 2017

Claims Adjudication DXC-TennCare Operations Manual 11.0 1

1 Introduction The State of Tennessee Department of Finance and Administration, Bureau of TennCare is the agency responsible for administering the Tennessee Title XIX programs. The Tennessee Title XIX programs (Medicaid) consist of a health care insurance program for low-income children, parents, pregnant women, a long-term care program for the elderly, and a funding source for services to people with disabilities.

1.1 Goals and Objectives The purpose of this manual is to describe the day-to-day procedures of claims resolution. It is also used in training employees and as a reference tool.

The goals of the Claims Resolution Group are to cooperate and work as a team, remain knowledgeable about processing standards, develop and retain the most outstanding people, to keep the lines of communication open within the unit, as well as with other departments, and to zero out the daily suspense inventory.

The primary objectives of the Claims Resolution Group are to:

1. Correctly adjudicate 90% of clean claims to a disposition outside DXC Technology (DXC) within 30 days.

2. Correctly adjudicate 99% of clean claims to a disposition outside DXC within 90 days of receipt.

3. Correctly adjudicate 100% of clean claims to a disposition outside DXC within 365 days of receipt.

2 Work Flow Procedures 2.1 Overview

During the claims adjudication process, any claims that fail an edit or audit systematically deny, cutback, or suspend. The error disposition has been set on the Error Disposition Table. A suspended claim means that processing is suspended until the error causing the failure is reviewed, corrected, or otherwise resolved.

The process of reviewing, correcting, and resolving claim errors is performed in the Claims Resolution Group. These clerks follow written guidelines when adjudicating claims that fail defined edits or audits.

2.2 Paper Claims Processing Steps 1. Claims are scanned through the Recognition Research Incorporated (RRI) system and the

Internal Control Number (ICN) is assigned.

4. The ICN is RR YY JJJ SSSSSSS.

Table 2.2: Explanation of ICN Codes

Code Description RR Region Code YY 2-digit year indicator JJJ 3-digit Julian date SSSSSSS 7-digit sequence indicator

5. Claim elements are formatted and placed in the database.



6. Claims are edited for simple field presence, format, data compatibility, and balancing.

7. Claims that fail the field edits are suspended or denied.

8. Claims are subjected to provider edits.

9. Claims that fail the provider edits are suspended or denied.

10. Claims are subjected to recipient edits.

11. Claims that fail recipient edits are suspended or denied.

12. Claims are subjected to the Prior Authorization (PA) and Reference edits.

13. Claims that fail the PA and Reference edits are suspended or denied.

14. Claims are priced.

15. Claims that cannot be priced are suspended for manual pricing.

16. Clean claims are checked for duplicate submissions.

17. Claims that fail the dup-check edits are suspended or denied.

18. Clean claims are audited (History and Medical Policy).

19. Claims that fail the audits are suspended or denied.

20. Clean claims are placed in approved to pay status.

21. Claims, provider, recipient, and PA databases are updated with claims information.

2.3 Claim Location and Region Codes Claims that fail an edit or audit are routed to a suspense location. Depending on the edit or audit that caused the failure, a claim is routed to a claim location that identifies the type of edit or audit that failed. Location codes are assigned to specific departments in the TennCare interChange System.

Table 2.3-1: Location Codes

Location Code Description 04 Return to Provider 05 DXC – Keying Verification 10 DXC – Verification 11 Financial Flush Reprocess 12 Resubmission of Denied Claims 13 Resubmission for Edit 1018 20 Information Systems – General 21 DCS 22 Professional Crossover 23 Institutional Crossover 24 Information Systems – Reference 25 Provider Relations 30 Long Term Care (LTC) 31 PAE 32 Adjustments – General 33 Adjustments – Rate Changes 34 LTC/ Skilled Nursing Facility (SNF) Crossover Supervisor 40 Home and Community Based Services (HCBS) – Mental

Retardation (MR) Waivers 41 HCBS – Aged/Disabled (AD) Waivers



Location Code Description 50 Third Party Liability (TPL) – General 51 TPL – LTC 60 Automatic Recycle 63 System Generated-Denied Encounter / Waiting Acceptance 66 System Generated – Denied / Awaiting Financial 70 Conversion – Policy 71 Conversion 72 Conversion – Long Term Care 73 Conversion – Information Systems 74 Conversion – HCBS Waivers 75 Conversion – Third Party Liability 76 Conversion 93 System Generated – Paid Encounter / Waiting Acceptance 97 System Generated – Claim Created 98 System Generated – Paid Claim / Awaiting Financial 99 System Generated – Claim Finalized in Financial

The suspended claims location is determined by region codes or edit and audit failure hierarchy. Adjustments failing any edit or audit are routed to the Adjustments location. Medical policy edit and audit failures are routed to the Medical Policy Unit location. Claims that fail Lock-In and Suspect Provider edits are routed to State Utilization Review System (SURS), and the remaining edit or audit failures are routed to Claims Resolution. In cases of disposition conflicts, the claims are routed to Claims Resolution.

Table 2.3-2: Region Codes

Region Code Description 10 Paper Claims with No Attachments 11 Paper Claims with Attachments 15 Paper Claims with No Provider ID (NOT AVAILABLE) 20 Electronic Claims with No Attachments 21 Electronic Claims with Attachments 22 Encounter – Original (Pharmacy Benefit Manager - PBM) 23 Encounter – Original (Blue Cross/Blue Shield - BCBS) 24 Encounter – Original (Other) 25 Point of Service Claims (NOT AVAILABLE) 26 Point of Service Claims with Attachments (NOT AVAILABLE) 27 Conversion Encounter Original 28 Internet with No Attachments 29 Internet with Attachments 30 Crossover (NOT AVAILABLE) 31 Crossover Skilled Nursing Facility (NOT AVAILABLE) 40 Claims Converted from Legacy Medicaid Management Information

System (MMIS) 45 Adjustments Converted from Legacy MMIS 47 Converted History Only Adjustments 48 Electronic/Internet Adjustments – Voids 49 Recipient Linking Claims 50 Adjustments - Non-Check Related 51 Adjustments – Check Related 52 Mass Adjustments – Non-Check Related 53 Mass Adjustments – Check Related



Region Code Description 54 Mass Adjustments – Void Transactions 55 Mass Adjustment – Provider Rates 56 Adjustments – Void Non-Check Related 58 Adjustments – Processed by DXC SE 59 Point of Service Claims – Reversal Adjustment (NOT AVAILABLE) 60 Encounter – Adjustment-Voids 61 Conversion Encounter – Adjustment-Voids 70 Reprocess – Paper Claims with No Attachments NOT AVAILABLE 71 Reprocess – Paper Claims with Attachments NOT AVAILABLE 72 Reprocess – Electronic Claims with No Attachments NOT AVAILABLE 73 Reprocess – Health Maintenance Organization (HMO) Co-pays NOT

AVAILABLE 74 Reprocess – Electronic/Internet Adjustment NOT AVAILABLE 75 Reprocess – Adjustments – Non-Check Related NOT AVAILABLE 76 Reprocess – Special Projects NOT AVAILABLE 77 Reprocess – Batches Requiring Manual Review NOT AVAILABLE 79 Reprocess – Encounters NOT AVAILABLE 80 Claims Reprocessed by DXC Systems Engineers 90 Special Projects 91 Batches Requiring Manual Review 92 HMO Co-pay 93 HMO SNF Co pays 99 Converted Claim with Duplicate Internal Control Number (ICN)

2.4 Claims Processing The Data Correction window displays suspended claims to clerks in a format similar to the claim form. The edits and audits are also displayed. The window allows clerks to access various reference files necessary to effectively process suspended claims. When processing suspended claims, clerks have the option of applying the following transactions to a claim, depending on the edit or audit failure:

• Add/Change – The clerks have the ability to add or change data in interChange to correct keying errors.

• Force – Some edits and audits may be overridden to force the claim back through the claim engine.

• Deny – Some edits and audits may be denied. When denying an edit, the clerk has the option to generate just the EOB related to the edit or audit failed or to add a more detailed EOB to explain the denial reason.

• Save with Resubmit – The claim may be recycled. This transaction can be applied if the claim failed an edit or audit due to a keying error which has since been corrected.

Suspended claims display all error codes that caused the claim to suspend, at the header level and at the detail level. After the clerk has cleared all applicable error codes the claim is resubmitted to TCMIS and is again subjected to all edits and audits. Overrides applied to any errors are captured to avoid having the claim suspend again for the same errors. These overrides stay with the history of the claim record.



2.5 How to View Claims and Process Edits 1. Log-in to interChange.

22. From the Main production window select Claims.

23. From the claims menu, select Options dropdown menu.

NOTE: Options is found on the gray bar directly under the blue bar.

24. Select Control functions.

25. Select Reassign/QA Review. The Data Correction Claim Assignment and Review window will display.

26. Select the claim type to work from the Claim Type: dropdown menu.

27. Select Suspended from the Status: dropdown menu.

28. Click Search.

29. The Warning-Max Rows Shown! popup window will display, click OK. A list of claims will display on the lower half of the window.

30. To access the Data Correction window, double click any ICN. The <Claim Type> Data Correction window and the <Claim Type> Xover Information window will display.

31. Copy the first ICN from the assigned list.

32. In the <Claim Type> Data Correction window, paste the ICN into the Next ICN field located in the bottom left-hand corner.

33. Click Inquire, and related claim information will display in both the <Claim Type> Data Correction window and the <Claim Type> Xover Information window.

34. In the <Claim Type> Data Correction window, review the disposition of edits displayed in the Error Disp column located in the list box in bottom left hand corner.

a) Process:

i) Deny

ii) Super Suspend

iii) Suspend

b) Information only:

i) Informational

ii) Pay

35. Verify Claim and EOB.

NOTE: Refer to Section 2.6 for information.

36. Double click any edit number in the Error Code column to display a list of the error codes and their descriptions.

NOTE: See Section 4: Edits and Audits for edit processing guidelines.

37. Click on the appropriate Error Disposition in the Error Disp column in order to Force or Deny the edit based on the processing guidelines.

38. Once all edits have been reviewed and updated (if applicable), click Save with Resubmit.

39. Go to the next claim and repeat steps 12-17.



2.6 Verify Claim and EOB 1. To ensure accurate processing of claims, compare Claim and EOB images that have been

submitted. If data element field exists and is filled out in both documents, the information must be identical. Both lists below contain the pertinent fields to be compared.

If information is not identical, the iC claim information needs to be manipulated in order to force denial. Data elements need to be cleared in both the UB92 Payor Information window and UB92 Value Codes window when processing a suspended UB-04 claim. Zero out the Physician Xover Information window when processing a 1500 form. In both instances EOB code 0536 needs to be added. Please refer to HP-TennCare Provider Support Training Claims Session 1 Section 2.6, located on PWB.

NOTE: If there is no EOB, proceed to step 2.

40. Compare the claim image (Claim Form and EOB [if applicable]) to the data that has been entered into interChange. Always verify the following header and detail information:

• Recipient Name

• Social Security Number

• Recipient ID

• Date of Birth

• Dates of Service

• Procedure Code Billed

• Revenue Codes (UB-04)

• Modifiers (only valid for Traditional Medicare claims)

• Provider Billed Amount

• NPI

41. Verify Medicare Xover data fields against data on the EOB:

• Deductible

• Co-Insurance

• Psych Amount (if applicable)

• Medicare Paid Amount

• Medicare Paid Date

NOTE: TennCare billed Amount should total co-insurance, deductible, and psych amount.

3 Claim Types Table 3 displays Claim Type information.

Table 3: Claim Types

Claim Type Description A UB-04 Institutional Crossover Claims B CMS 1500 Crossover Claims C UB-04 Outpatient Crossover Claims D Dental Claims E DME Claims



Claim Type Description G DCS Claims H Home Health Claims I Inpatient Claims J Hospice Claims K Laboratory Claims L Long Term Care Claims M CMS 1500 Claims N Mental Health Claims O Outpatient Claims P Pharmacy Claims Q Compound Drug Claims T Transportation Claims W HCBS Claims

4 Fee-For-Service Edits and Audits Edits and audits monitor and enforce federal and state laws and regulations. Edit and audit types include:

• validation

• relational

• provider

• recipient

• prior authorization

• history

• medical policy

• surveillance

• utilization

The following sections contain information on the edits and audits.



4.1 Edits 100 – 6000

Figure 4.1-1: Edit 100



EDIT 203

Message RECIPIENT I.D. NUMBER MISSING

Claim Type Location Programs Header/Detail Allow

Override Allow Denial

Recycle Day

ALL ALL HEADER Yes Yes 0

Description RECIPIENT I.D. NUMBER MISSING

Criteria

If the Medicaid ID is NULL (not present) or spaces on the claim header, trigger edit 203.

Resolution Guidelines

• Verify that claim and Data Correction screen match. • Verify that there is not a RID (or ss +00) in box 58B (UB) or 1A

(1500 form). • If blank, deny edit 203. • If not, correct and save with resubmit.




EDIT 207

Message Vendor Number Not on File


Override Allow Denial

Recycle Day

All All Header No Yes 30

Description Vendor Number not on file for provider number

Criteria

If a claim's emergency indicator is not Y or N, fail this edit with EOB 0207. A CCF will be systematically generated to the provider. The CCF must be mailed back to EDS within 45 days. If not, the claim will be systematically denied. If the CCF is returned with corrected information, call up the suspended ICN and enter the corrected information in the proper field. If the CCF is returned without any information (corrected or additional), deny the claim with EOB 0207.


• Check to verify claim and Data Correction Screen match

• From the Claim Inquiry window, choose Options/Original Provider Info.

• From the IC Main Menu window, choose Provider Menu, then Search/Maintenance.

• Search for the correct Provider by the submitted NPI found in the Orginial Provider Info window.

• Verify the Tax ID and NPI – equal to Qlf Ent Type 85- from the Orginial Provider Info window for possible eligible locations.

• Select the location that matches both the Tax ID and NPI from the Orginial Provider info.

• On the Provider Service Location number, select option, vendor number. (Must have Edison vendor number)

• Enter the Billing Number and Location in Prov Loc/NPI and Facility Provider.

• Save with Resubmit

If no errors are determined or the correct Provider can’t be verified by the previous steps, send ICN to your lead. After 30 days this edit will recycle and have a finalization edit of 1015. At that time, the claim will deny and cannot be corrected.




EDIT 243

Message MISSING MEDICARE PAID DATE


Override Allow Denial Recycle Day

All, A, B,C 10.20 Header No Yes N/A

Figure 4.1-5 Edit 243

Description Vendor Number not on file for provider number

Criteria • Medicare Paid date is null or blank


• Check to verify claim and Data Correction Screen match • On UB form Check to verify occurrence code 53, if blank or missing,

DENY edit 243. • If not blank update occurrence code box and xover and save with

resubmit • On 1500 form, check to verify EOB for Medicare paid date. If there is

one, update xover and save with resubmit.



215




Figure 4.1.36: Edit 1092



Figure 4.1.37: Edit 1244



Figure 4.1-42: Edit 2504 (cont.)



Figure 4.1-45 Edit 2505 (cont.)



Figure 4.1-64: Edit 6000 (Effective 7/1/2009)



Figure 4.1-65: Edit 6000 cont. (Effective 7/1/2009)



Figure 4.1-66: Edit 6000 (Effective 7/1/2008)



4.1.1 Procedure for Claims Suspended for Manual Pricing Error Code 6000

Figure 4.1.1-1: Physician Data Correction – Procedure Code

1. Double click the procedure code associated with the detail line that has been suspended with an error code 6000. This brings up the HCPCS Procedure window.



Figure 4.1.1-2: HCPCS Procedure Window – Date of Service

42. Confirm that the Date of Service for the claim falls between the effective and end dates in the Restrictions sub-window.



Figure 4.1.1-3: HCPCS Procedure Window – Options>Pricing> Max Fee

43. Click Options > Pricing> Max Fee, to open the Max Fee List window.



Figure 4.1.1-4: Max Fee List

44. From the Max Fee List window, select the rate type for the claim which falls within the effective and end dates in the Max Fee List. The effective Date should be 07/01/2008.

45. Match the Modifiers (A), Effective Date (B), and End Date (C) to the claim detail line associated with the Manual Pricing 6000 error code to get the Allowed Amount (D). For details on this comparison process, refer to Section 4.4.3.

4.1.2 Manual Pricing 1. If there is no amount entry for the time of the claim, you will need to manually price the claim

from the Physician Xover Information window.

a) For services Rendered Prior to 07/01/2008.

b) If there is an amount and it matches or is less than what Medicare has already paid, you have encountered an unexpected result. Please refer to this issue to your management.

c) If there is an amount and it exceeds the Medicare paid amount and the claim is on or after 01/01/2006 prior to 07/01/2008, you will need to check the audit trail to confirm the amount at the time of the claim.

46. Manual Pricing For Services Rendered after 07/01/2008.

47. If a rate is on file, check to see if it the claim has a span date. If a span date is present, follow the span date process if applicable.

The procedure has no price. Manual pricing is required. Services Prior to 07/01/2008.



Figure 4.1.2-1: Physician Data Correction – Options>Xover Data

Usually the Physician Xover Information window is already open at this point. If not, bring it up by going to the menu bar of the Physician Data Correction window and selecting Options > Xover Data.

Figure 4.1.2-2: Physician Xover Information - Coinsurance

Get the Coinsurance amount from Physician Xover Information window for the detail line associated with the Manual Pricing 6000 Error Code. (If there is an amount in the Deductible column, you will need to get supervisory assistance.)



Figure 4.1.2-3: Physician Data Correction – Allowed Amt

In the Physician Data Correction window scroll to the right until the Allowed Amount is showing.

Enter the Coinsurance amount in the line associated with the Manual Pricing 6000 error code, and then press the tab key bringing up the message in Figure 4.2-4.

Figure 4.1.2-4: Warning

Click Yes to close the dialog window.



Figure 4.1.2-5: Physician Data Correction – Save Successful

If you believe the system should pay when it has not, refer it to your management for disposition.

Click Save With Resubmit to save the changes. When the "Save Successful!" message appears, copy the next ICN from the assigned list and proceed with step 12 in Section 2.5.

The allowed amount exceeds the Medicare paid amount and the claim is on or after 01/01/2006. This is probably because congress made some prices changes retroactive. To confirm this you must view the audit trail for the max fee from the Max Fee List window.




Choose Select to display the Max Fee Maintenance window.

Figure 4.1.2-7: Max Fee Maintenance Window



Figure 4.1.2-8: Max Fee Maintenance - File>Audit

On the menu bar, select File > Audit which brings up the Audit Trail window.

Figure 4.1.2-9: Audit Trail window

Choose Show All to show the complete audit trail.



Figure 4.1.2-10: Audit Trail

1. "Action Code” explanations:

o U= Update

o I = Insert.

48. The "System Date" shows that this max fee was inserted on 01/26/2006 and updated on 03/14/2006.

49. Use the scroll bar to see the rest of the audit information.

Figure 4.1.2-11: Audit Trail

50. The effective date has not been changed. It was January 1, 2006 when the max fee was added in January and it was still January 1, 2006 when the max fee changed in March. Do not confuse System Date and Effective Date.

o The System Date is the date when the system was updated.

o The Effective Date (as well as the Date End) relates to whenever the associated max fee is in force.



51. The amount is the same as it was from before the associated change. Since the change in January was an insert, there was no prior amount. In March, when the amount was changed to $754.32, the prior amount was $720.07. If this amount was in force at the time the claim was processed, use it to determine whether the amount already paid is correct or not.

4.1.3 Comparing Modifiers and Dates


Dates of service (Figure 4.4.3-2 #2 and #3) on the line associated with the 6000 error code (Figure 4.4.3-2 #1) must be matched to the pricing in the Max Fee List window. The dates of services should be on or after the effective date of the fee (Figure 4.4.3-1 #A) and on or before the end date of the fee (Figure 4.4.3-1 #C). The modifiers should match (Figure 4.4.3-1 #A to Figure 4.4.3-2 #4) with the exception of "informational" modifiers.

Figure 4.1.3-2: Detail section of Physician Data Correction window

If the modifier on the detail line of the claim (Figure 4.4.3-2 #4) is on the Max Fee list, it can be ignored. Otherwise, it must be matched (Figure 4.4.3-2 #4 to Figure 4.4.3-1 #A). In this case, the modifier 51 appears on the list and is not used to match the detail line to the max fee. The "From Date of Service" (Figure 4.4.3-2 #2) and the "To Date of Service"



(Figure 4.4.3-2 #3) fall between the effective date (Figure 4.4.3-1 #B) and end date (Figure 4.4.3-1 #C) so this is a match. Table 4.1.3: Informational Modifiers

20 AH EJ GV J2 MS QJ TD W5 YA 21 AJ EM GW J3 ND QK TE W6 YC 22 AK EN GX JD NE QM TF W7 YD 23 AL EP GY JE NG QN TG W8 YF 25 AM ER GZ JG NH QO TH W9 YH 27 AN ES H9 JH NI QP TJ WA YK 47 AP ET HA JI NJ QR TK WC YO 50 AQ EY HB JN NN QS TL WD YR 51 AS FB HC JP NP QT TM WE YS 52 AT FP HD JR NR QX TN WF Z1 53 AU G1 HE JW NS RD TP WG Z2 54 AV G2 HF K0 NU RE TQ WI Z3 55 AW G3 HG K1 P1 RG TR WM Z4 56 AX G4 HH K2 P2 RH TT WN Z5 57 AY G5 HI K3 P3 RI TU WR Z6 59 BA G6 HJ K4 P4 RJ TV WS Z7 60 BL G7 HK KA P5 RN TW WV Z8 62 BO G8 HL KB P6 RP U6 X1 Z9 63 BP G9 HM KC PD RR U7 X2 ZN 73 BR GA HN KD PE SA U8 X3 ZP 74 BU GB HO KE PG SB U9 X4 ZR 76 CA GC HP KF PH SC UA X5 ZS 77 CB GD HQ KG PI SD UB X6 ZU 78 CD GE HR KH PJ SE UD X8 ZX 79 CE GF HS KI PL SF UE X9 ZY 91 CF GG HU KJ PN SG UF XA A1 CG GH HV KK PR SH UG XG A2 CR GI HW KL Q1 SI UH XO A3 DD GJ HX KM Q2 SJ UJ XP A4 DE GK HY KN Q3 SK UK XQ A5 DG GL HZ KO Q4 SL UN XV A6 DI GM ID KP Q5 SM UP Y0 A8 DJ GN IE KQ Q6 SN UQ Y1 A9 DN GO IG KR QA SQ UR Y2 AA DR GP IH KS QC SS US Y3 AB ED GQ IJ KX QD ST VP Y4 AC EE GR IN KZ QE SU W1 Y5 AE EG GS IP LO QF SV W2 Y7 AF EH GT IR LR QG SW W3 Y8 AG EI GU J1 LS QH SY W4 Y9



4.1.4 Manual Pricing Date of Service on and after 07/01/2008 Go to the menu bar of the Physician Data Correction window, select Options > Xover Data.

Figure 4.1.4-1: Physician Xover Information

To Manually Price the claims you will need to:

1. Select The Medicare Allowed Amount.

52. Calculate the Medicaid Allowed amount.

Multiplying the Medicare Allowed Amount by .80%

$345.97 × .80% = $276.80

53. Payment = Lesser of Medicaid Allowed Amount – Medicare Paid Amount not to exceed the Coinsurance + Deductible + Psych Amount.

Medicaid Allowed Medicare Paid Paid Allowed $276.80 $345.97 $0.00

Important: If the Medicaid calculated paid allowed is greater than the co-insurance plus deductible, the system shall pay the co-insurance plus deductible up to the Medicaid allowed. The Medicaid payment amount should never exceed the calculated Medicaid allowed amount.

54. Enter the Amount that is determined the Medicaid Liability.



Figure 4.1.4-2: Physician Data Correction Window

55. In the Physician Data Correction window, scroll to the right until the Allowed Amount is showing. Enter the total of the Medicaid Allowed minus Medicare Paid in the Allowed Amount field associated with the line suspended for Manual Pricing 6000 error code, and then press Tab which brings up the warning message in Figure 4.4-4.


56. Click Yes to close the dialog window.




You will need to force a claim with a zero amount to pay zero. If you believe the system should pay when it has not, refer to management for disposition.

57. Click Save With Resubmit to save the changes.




58. When the "Save Successful!" message appears, copy the next ICN from the assigned list and proceed with step 12 in Section 2.5.



4.1.5 Procedure for Claims Suspended for Manual Pricing Error Code 6000 Unlisted Procedure on or after 07/01/2008



a) Confirm that the Date of Service of the claim is on or after 07/01/2008.

b) Confirm that the effective date in the restrictions Window is prior to 07/01/2008.



Figure 4.1.5-2: HCPCS Procedure – Options>Pricing>Max Fee

59. On the menu bar select Options > Pricing > Max Fee, which brings up the Max Fee List window.



Figure 4.1.5-3: Max Fee List window

1. If there is no amount entry for the time of the claim, you will need to manually price the claim from the Physician Xover Information.

60. If there is an amount and it matches or is less than what Medicare has already paid (Figure 4.4.5-5) you have encountered an unexpected result. Please refer to this issue to your management.

61. If there is an amount and it exceeds the Medicare paid amount and the claim is on or after 01/01/2006, you will need to check the audit trail to confirm the amount at the time of the claim.

62. If there is a price and it exceeds the amount and the claim is before 01/01/2006 you will need to get supervisory help.

The procedure has no price. Manual pricing is required.

1. Access the Physician Crossover Data Information by going to the menu bar of the Physician Data Correction window selecting Options > Xover Data.



Figure 4.1.5-4: Physician Data Correction>Options>Xover Data

Figure 4.1.5-5: Physician Xover Information

63. To Manually Price the claims you will need to:

a) Select The Medicare Allowed Amount.

b) Calculate the Medicaid Allowed amount.

64. Payment = Lesser of Medicaid Allowed Amount – Medicare Paid Amount not to exceed the Coinsurance + Deductible + Psych amount.

Medicaid Allowed Medicare Paid Paid Allowed $276.80 $345.97 $0.00

Important: If the Medicaid calculated paid allowed is greater than the co-insurance plus deductible, the system should pay the co-insurance plus deductible up to the Medicaid allowed. The Medicaid payment amount should never exceed the calculated Medicaid allowed amount.





66. In the Physician Data Correction window scroll to the right until the Allowed Amount is showing. Enter the total of the Medicaid Allowed minus Medicare Paid in the Allowed amount field associated with the line suspended for Manual Pricing 6000 error code and then press the tab key bringing up the message in Figure 4.4.6-4.


67. Click Yes to close the dialog window.




68. You will need to force a claim with a zero amount to pay zero. If you believe, the system should pay when it has not. Refer it to your management for disposition.




4.2 Procedure for Claims Suspended for Manual Pricing Error Code 6000 Claims Suspending on and after 07/01/2008 with Span Dates of Service

Figure 4.2-1: Suspended Physician Claim




Figure 4.2-2: HCPCS Procedure Window – Options>Pricing>Max Fee

71. Confirm that the Date of Service begins prior to and ends after 07/01/2008.

72. From the HCPCS Procedure window on the menu bar select Options>Pricing>Max Fee. This brings up the Max Fee List window.



Figure 4.2-3: Max Fee List Window

• If the procedure is an unlisted procedure, the allowed amount entered will reflect zero.

• If it is equal to or less than what Medicare has already paid you have encountered an unexpected result. Please refer to this issue to your management.

• If the amount exceeds the Medicare paid amount and the claim is on or after 01/01/2006, you will need to check the audit trail to confirm the amount at the time of the claim.

• If there is a price and it exceeds the amount and the claim is before 01/01/2006, you will need to get supervisory help.

The procedure has no price. Manual pricing is required.

1. Access the Physician Crossover Data Information by going to the menu bar of the Physician Data Correction window selecting Options > Xover Data.

Figure 4.2-4: Physician Data Correction – Options>Xover Data



Figure 4.2-5: Physician Xover Information

To Manually Price the claims you will need to:

Select the Medicare Allowed Amount.

Figure 4.2-6: Paid Physician Claim Window



73. Determine the span date range.

74. Determine the number of days prior to 07/01/2008 and the Number of Days payable after 07/01/2008.

Table 4.2: Example: Determining Number of Days payable

Months Total Days Prior Total Days After Total Benefit Period 05/22/08-06/30/08 39 07/01/08-08/20/08 51 Total Payable 39 51 90

Calculate the Medicare Allowed Amount per benefit period by identifying the Medicare allowed per benefit period.

Figure 4.2-7: Physician Xover Information Window

75. Determine the Medicaid liability from the Physician Crossover Data per line item services prior to 07/01/2008:

[ ] %2008/01/07 ××÷ spriortobenefitdayitDaysTotalBeneflowedMedicareAl

Figure 4.2-8: Example: Calculating the TennCare Liability

There are five methods to price professional crossover claims. The system will try the following methods in sequence until one of them applies:

• Manual Pricing Method

• Billed Charges Payment Method

• Increased Reimbursement for Primary Care Procedure Payment Method

• 85% Payment Method

• Max Fee Payment Method

76. Determine the Medicaid liability from the Physician Crossover Data per line item services prior to 07/01/2008:



Figure 4.2-9: Medical Liability

77. Add together the TennCare Liability for services rendered prior to 07/01/08 and the TennCare Liability for services rendered after 07/01/08.

Figure 4.2-10: TennCare Liability

Example Above: TennCare Liability pay coinsurance amount for the benefit period. This example followed the 100 percent max fee pricing method.

Important: If the Medicaid calculated paid allowed is greater than the co-insurance plus deductible, the system should pay the co-insurance plus deductible up to the Medicaid allowed. The Medicaid payment amount should never exceed the calculated Medicaid allowed amount.


79. In the Physician Data Correction window scroll to the right until the Allowed Amount is showing. Enter the total of the Medicaid Allowed minus Medicare Paid in the Allowed amount field associated with the line suspended for Manual Pricing 6000 error code and then press the tab key bringing up the message in Figure 4.6-18.



Figure 4.2-11: Warning

Click Yes to close the dialog window.

Figure 4.11-12: Paid Physician Claim Window

80. You will need to force a claim with a zero amount to pay zero. If you believe the system should pay when it has not, refer it to your management for disposition.




Figure 4.2-13: Physician Data Correction – Save Successful




4.3 Edits 6662-6670




5 LTC Fee-For-Service Edits and Audits

Figure 5-1: Edit 100



EDIT 634

In-Patient Part C (HMO Medicare) Crossover Claims for Long Term Care (LTC) Nursing Facilities

Claims will be sorted before distribution to respective areas. The review must include ensuring applicable Form Locaters are populated. Claims with missing required fields will be returned to the provider (RTP) with an approved RTP Notice, describing in detail what is needed to appropriately adjudicate the claim.

Claim is reviewed to validate:

• The provider is an LTC Nursing Facility; determined by type of bill “21X”

• The existence of HMO Medicare as a primary payer*

• All required fields are populated **

All LTC claims containing an HMO Medicare payer are to be special batched to Claim Region 93, where they will suspend for manual review.

*Examples of HMO Medicare plans include, but are not limited to:

• HealthSpring

• Humana

• Blue Advantage

**Required fields include, but are not limited to:

• Occurrence code 53 along with a Medicare paid date

• Value codes indicating as applicable

o 80 – Covered Days

o 81 – Non-Covered Days

o 82 – Co-Insurance Days

o 09 – Co-Insurance Amount

Edit 634 can be overridden utilizing the set of instructions for either claim or adjustment regions.

All Clean Claims must be processed within the set provisions as contractually detailed.

NOTE: Claims will never be forwarded to the Division of Long Term Care for processing. If questions arise, the Mailroom Supervisor will contact the LTC Claims Unit Manager.



Figure 5.29: Edit 2078



Edit 5007

Figure 5-49: Claim Errors

If claim suspends for Edit 5005, the related claim must be checked. Click Options > Related History.

Figure 5-50: Denied UB92 Claim – Options>Related History



Figure 5-51: Related Claim History

Double Click on Related Claim.

NOTE: The Procedure Code is T2033 U2 UN for date span 6/1 – 6/30/07. Units billed are 29.

Figure 5-52: Paid UB92 Claim



Related claim information is Proc Code T2033 U2 UN for date span 6/8 – 6/30/07. Units billed are 29. Since the related claim contains the same unit amount and same procedure code, the suspended claim must be denied.



5.1 LTC Fee-For-Service Timely Filing Processes Overview Claims with dates of service within one year of current date will adjudicate to:

• Paid

• Denied

• Suspend (manual review required)

Claims containing dates of service greater than one year from the “to” date of service and of which no proof of timely filing has been provided in the documentation, or upon research the claim does not meet timely filing guidelines, must be sent through the interChange claims processing system to deny for timely filing edits.

Claims containing dates of service that are greater than one year from the “to” date of service and meet one of the criteria listed within the manual, are eligible for timely filing override.

Validation of a clean claim (claims containing all required fields) will occur both before and during the RRI (imaging of the claim) process. If a claim does not contain all required data, it will be returned to the provider (RTP) as outlined in the Mailroom Manual.

LTC claim types are A, C, L and W and can be identified as follows:

• A – 21X – SNF inpatient cross-over (timely override code error 630/EOB 259)

• C – 22X – SNF outpatient cross-over (timely override code error 630/EOB 259)

• L – 66X – ICF or SNF (timely override code error 545/EOB 268)

• W – 89X – HCBS (timely override code error 545/EOB 268)

There are six types of Timely Filing Override reasons:

1. Court Ordered

83. Retro-Active Medicaid Eligibility

84. Medicare Claims not Crossed Over to TennCare

85. Third Party (Other Insurance)

86. Timely submission and timely follow-up of denied claims

87. Repayment of Voided Claims (List how to ID void/adjustments)

Proof of timely filing includes, but is not limited to:

Fax confirmation sheets, certified mail slips, emails sent to TennCare (or to the AAAD for E/D Waiver claims); all of which contain inquiries about the specific patient’s claim in question and contain dates that are consistent with the period of time in which follow-up is required, can also be used to prove timely filing. All documents utilized to prove timely filing must be part of the attachments to the claim.

5.1.1 Court Ordered Timely Filing Override Court ordered timely filing override occurs ONLY when signed orders from a judge are received with a claim, which must be part of the claim attachment(s). TennCare must override and pay untimely claims whenever legal intervention occurs.

1. Access and view recipient eligibility information:

a) Click Recipient

b) Key in recipient ID



c) Click Select

d) Select Elig on the Recipient Base window

88. Validation of Medicaid eligibility

e) View Recipient Eligibility window, beside “Programs:” click All to ensure Medicaid eligibility (SSI, XIX, or QMB [for Cross-Over claims only]) covers dates of service billed on the claim.

f) If there is no Medicaid eligibility, contact LTC Claims Unit.

g) Check to ensure Patient Liability is on file for the dates of service.

89. To validate patient liability, click on Pat L from the Recipient Base window or select Patient Liab from the Options drop down menu.

90. Verify there is an effective and end date span that covers the dates of service on the claim regardless of the dollar amount, which is not applicable in working the claim.

h) If there is no Patient Liability on file for the dates of service on the claim, contact LTC Claims Unit.

i) Check to ensure *Pre Admission Evaluation (PAE) and **applicable benefit plan is present on the eligibility and level of care windows.

91. To validate a PAE, click on LOC from the Recipient Base window or select LOC from the Options drop down menu.

92. Verify the provider number matches the number on the claim OR, for HCBS claims, that the LOC window reflects either, 0445853 for AD/SW Benefit Plan, 0445973 for MR Benefit Plan, 0445918 for ARLIN Benefit Plan, and W000002 for SDW Benefit Plan AND that the effective and end date span covers the dates of service on the claim.

93. If there is no PAE and corresponding benefit plan on file, contact LTC Claims Unit.

NOTE: A PAE is NOT required to pay cross-over claims. Eligibility for cross-over claims includes XIX, SSI, and/or QMB.

Once the positive verification of Medicaid eligibility, patient liability and PAE is complete, proceed with processing the timely filing suspended edit, per the guidelines listed in the LTC Claims Adjudication manual.

Required documents include:

• Copy of the signed, final Court Order

• The original or a legible copy of the UB04 Claim Form

• All other documents submitted as attachments to the claim

* Applicable Benefit Plans include: SSI, XIX, MR, ARLN, SDW, ICF/MR, ICF, SNF, and AD/SW.

**Applicable benefit plans for Medicaid eligibility include, XIX, and SSI.

5.1.2 Retro-Active Medicaid Eligibility Eligibility determinations which occur retro-actively and are outside of the one year from date of service timeframe are eligible for timely overrides, but only with the appropriate documentation and data listed within the system.

Claims for recipients who meet this qualification must have the appropriate eligibility in the system for Medicaid eligibility, PAE, and Patient Liability. If it is not, it must be updated accordingly. The only exception is to cross-over claims, where a PAE is not required.



Recipient eligibility windows must be researched to validate Medicaid eligibility, Patient Liability, and/or PAE was added or updated within one year of the dates of service listed on the claim. This is accomplished by checking both add and updates dates on each of the applicable windows, as well as the information contained within the audit trail of each applicable window.

1. Access and view recipient eligibility information:

a) Click Recipient

b) Key in recipient ID

c) Click Select

d) Select Elig on the Recipient Base window

94. Validation of Medicaid eligibility

e) View Recipient Eligibility window, ensuring Medicaid eligibility (SSI, XIX, or QMB [for cross-over claims only]) dates are within the dates of service billed on the claim. If the update date is within one year of the date of service AND the audit trail reflects that the update occurred to the effective and/or end date of the corresponding Medicaid eligibility segment and coincides with the dates of service on the claim, an override can be performed.

f) If there is no Medicaid eligibility, contact the LTC Claims Unit.

g) Verify that Patient Liability is on file for the dates of service.

95. To validate patient liability, click on Pat L from the Recipient Base window or select Patient Liab from the Options drop down menu.

96. Verify there is an effective and end date span that covers the dates of service on the claim regardless of the dollar amount, which is not applicable in working the claim.

h) If there is no Patient Liability on file for the dates of service on the claim, contact LTC Claims Unit.

i) Verify that *Pre Admission Evaluation (PAE) and **applicable benefit plan is present on the eligibility and level of care windows.


98. Verify that the provider number matches the number on the claim OR for HCBS claims that the LOC window reflects either, 0445853 for AD/SW Benefit Plan, 0445973 for MR Benefit Plan, 0445918 for ARLIN Benefit Plan and W000002 for SDW Benefit Plan and that the effective and end date span covers the dates of service on the claim.

j) If there is no PAE and corresponding benefit plan on file, contact LTC Claims Unit.

k) Verify that *Pre Admission Evaluation (PAE) and **applicable benefit plan is present on the eligibility and level of care windows.


100. Verify that the provider number matches the number on the claim OR for HCBS claims that the LOC window reflects either, 0445853 for AD/SW Benefit Plan, 0445973 for MR Benefit Plan, 0445918 for ARLIN Benefit Plan and W000002 for SDW Benefit Plan AND that the effective and end date span covers the dates of service on the claim.



101. If there is no PAE and corresponding benefit plan on file, contact LTC Claims Unit.

NOTE: A PAE is NOT required to pay cross-over claims. Eligibility for cross-over claims includes XIX, SSI, and/or QMB.

Once Medicaid eligibility, patient liability and PAE validation is complete, proceed with processing the timely filing suspended edit, per the guidelines listed in the LTC Claims Adjudication Manual. If other edits post, process according to the specific edit resolution guideline.

* Applicable Benefit Plans include:

• SSI

• XIX

• MR

• ARLN

• SDW

• ICF/MR

• ICF

• SNF

• AD/SW

**Applicable benefit plans for Medicaid eligibility include, XIX, and SSI.


• The original or a legible copy of the UB04 claim form.

• All other documents submitted by the provider as attachments to the claim.

5.1.3 Medicare Claims not Crossed Over to TennCare Claims for which Medicare has paid outside of one year from the dates of service and are submitted within six months of Medicare payment date are eligible for timely override. This determination is made by validating that the date on the Medicare EOMB is within six months of the current date.

Access and view image of attachment:

• From the UB92 Data Correction window, select Options > Image Repository. The Siebel Call Center window will display.

• Click on Image Link to view either the claim or the attachment.

• If the EOMB is dated within six months of current date, proceed with processing the timely filing suspended edit.

• If the EOMB is not dated within six months of current date, perform research as described in Section 5 to determine if the claim was initially submitted within six months of the Medicare paid date and that the appropriate follow-up action occurred.

o If not, deny the timely filing edit.

o If so, proceed with processing the timely filing edit.

• If other edits post, process according to the specific edit resolution guideline.




• The original or a legible copy of the UB04 claim form

• Medicare EOMB

• All other documents submitted by the provider

NOTE: A PAE is not required to pay Medicare cross over claims.

5.1.4 Third Party (Other Insurance) If a Third Party did not pay within a year of the “to” date of service, the provider must submit the claim and supporting documentation to TennCare within 60 days of the date on the TPL EOB (Explanation of Benefits).

Access and view image of attachment.

• From the UB92 Data Corrections window, select Options > Image Repository. The Siebel Call Center window will display.

• Click on Image Link to view either the claim or the attachment.

• If the TPL EOB is dated within 60 days of current date, proceed with processing the timely filing suspended edit.

• If the EOB is NOT dated within 60 days of current date, perform research as described in Section 5 to determine if the claim was initially submitted within 60 days of the TPL paid date and that the appropriate follow-up action occurred.


o If so, proceed with processing the timely filing edit.

• If other edits post, process according to the specific edit resolution guideline.


• The original or a legible copy of the UB04 claim form

• A copy of the TPL EOB must be attached to the claim

• All other documents submitted by the provider

5.1.5 Timely submission and timely follow-up of denied claims Claims initially processed within one year of the “to” date of service AND have subsequent claims processed at least every six months thereafter, qualify for timely override.

Access and view the Claim Inquiry window:

• Click Claims

• Click Claims Inquiry

• Enter the provider ID, recipient ID, and dates of service

• Click Search

• All claims submitted for the provider and time period entered, will display.

The purpose of this search is to verify if the claim was processed within one year of the “to” Date of Service (DOS) and that the claim has processed every six months thereafter.

This research is completed by determining claim submissions from both the RA dates and ICN numbers, as well as viewing all claim attachments that may include applicable submission documentation

NOTE: Information regarding acceptable attachments qualify for use in overriding timely filing edits, is located Section 5.1 of this manual.



o If the claim submission initially occurred within one year of the “to” date of service and there has been follow-up action every six months of the current date, OR if the claim attachments (accessing claim attachment instructions are listed below) fill the gap in the required follow-up action, proceed with processing the timely filing suspended edit.

o If the claim was NOT initially submitted within one year of the “to” date of service and/or no follow-up action has occurred every six months of the current date nor contains attachments (accessing claim attachment instructions are listed below) in which would fill the gap in the required follow-up action, DENY the timely filing edit.

o If other edits post, process according to the specific edit resolution guideline.

• Access and view image of attachment:

o From the UB92 Data Corrections window, select Options > Image Repository. The Siebel Call Center window will display.

o Click on Image Link to view either the claim or the attachment.

o If attachments reflect timely follow-up as described in Section 5.1 , proceed with processing the timely filing suspended edit.



• The original or a legible copy of the UB04 claim form.

• All other documents submitted by the provider.

5.1.6 Repayment of Voided Claims The intent of this action is to re-pay previously voided claims. If the claim in question does not exceed 24 months, additional units can be paid.

After two years from the DOS, TennCare cannot pay for additional days and/or units, but can repay units that were originally paid.

NOTE: There are circumstances in which a claim was paid to an incorrect provider, whereas the correct servicing provider is entitled to payment. Proceed with research in the manner described, except for omitting the step that includes the provider ID as part of the search criteria and replace it with either the applicable revenue code or Healthcare Common Procedure Coding System (HCPCS) code. The additional unit/day criterion does not apply in these situations.

• Access and view the Claim Inquiry window:

o Click Claims.

o Click Claims Inquiry.

o Enter the provider ID, recipient ID, and dates of service.

o Click Search.

All claims and/or adjustment/voids submitted for the provider and time period entered, will display. Voids are identified on the claim inquiry window with Claim Regions, 48, 50, 55, 56 and 58, that are in a “Denied” status.

• Validate the original claim has either been voided or that a denied adjustment exists.

o If there is no previous voided claim or denied adjustment AND the claim does not meet any of the other timely filing override reasons, DENY the edit.



o If a previously voided claim or denied adjustment exists and the dates of service are less than 24 months from the “to” date of service, proceed with processing the timely filing suspended edit.

o If the dates of service are greater than 24 month from the “to” date of service on the claim, review the re-submitted claim against the original claim, to ensure additional units/days are not added.

• If no additional units/days were added, proceed with processing the timely filing suspended edit.

• If additional units/days are indicated on the claim, DENY the edit.


• The original or a legible copy of the UB04 Claim form.

• All other documents submitted by the provider.

Figure 5.1.6-1: Edit 545



5.2 LTC Fee-For-Service Claims Requiring Third Party Liability (TPL) Edit Override Claims will be sorted before distribution to respective areas. The review must include ensuring applicable Form Locaters are populated. Claims with missing required fields will be returned to the provider (RTP) with an approved RTP Notice, describing in detail what is needed to appropriately adjudicate the claim.

NOTE: Claims that are outside the timely filing guidelines (dates of service greater than one year of the “to” date of service on the claim), must also be reviewed for timely filing override.

Claim is reviewed to validate:

• The provider is a an LTC Nursing Facility; determined by type of bill “21X”, “22X”, “66X” and “89X”

• The existence of a TPL as a primary payer*

• All required fields are populated **

All LTC claims containing TPL are to be special batched to Claim Region 90, where they will suspend for manual review.

*Examples of TPL plans include, but are not limited to:

• BlueCross/BlueShield

• Cigna

• Aetna

• Association for the Advancement of Retired People (AARP)

**Required fields include, but are not limited to:

• If TPL carrier denies - Occurrence Code 24 – Date Insurance Denied

• If TPL has been terminated - Occurrence Code 25 – Date Benefits Terminated by Primary Payer

• TPL payment amount applied as primary or secondary to Medicare

Edits 2504, 2505, and/or 2507 can be overridden utilizing this set of instructions for either claim or adjustment regions.

All Clean Claims must be processed within the set provisions as contractually detailed.

NOTE: Claims will never be forwarded to the Division of Long Term Care for processing. If questions arise, the Mailroom Supervisor will contact the LTC Claims Unit Manager.



Appendix A: Special Batch/Override Forms NOTE: The following forms are no longer required for overriding timely filing edits, however, they may be included with claims in which DXC staff are working that the Bureau processed prior to the transition.

Figure A-1: Edit Override Authorization Form



Figure A-2: LTC Special Batch Handling

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