hp provider relations october 2010 claim adjustment process

HP Provider RelationsOctober 2010

Claim Adjustment

Process

Claim Adjustment Process October 20102

Agenda

– Session Objectives

– Types of Adjustments

– Adjustment Considerations

– Live Demonstration

– Attachments Process

– Paper Adjustment Process

– Timely Filing Limitations

– Where to Submit Adjustment Requests

– Administrative Review and Appeal

– Helpful Tools

– Questions


Objectives

Following this session, providers will be able to:

– Understand the different types of paid claim adjustments

– Determine when to file a paid claim adjustment

– Complete claim adjustments online

– Understand the impact of the filing limit on adjustments and replacements

DefineTypes of adjustments


Types of Adjustments

– Check-related adjustments

– Noncheck-related adjustments

– Retroactive rate adjustments

– Mass adjustments

– Voids and Replacements

– Reprocessing (Region 80)

Each managed care organization (MCO) may establish and communicate its own criteria for claim adjustments


Check-related Adjustments

– Provider sends a check in the amount of the excess payment with the adjustment form and appropriate documentation if an overpayment has been made

– Also referred to as a refund, can be for a partial payment or the entire payment on a claim

– First two digits of the internal control number (ICN) (region code) are 51


Noncheck-related Adjustments

– Initiated by the provider due to an underpayment or an overpayment

– Does not include a refund check from the provider

– Types of noncheck-related adjustments:

• Underpayment adjustment – the adjustment was requested because the provider was underpaid

• Partial payment adjustment – the adjustment was requested because the provider was overpaid; overpayment amount is deducted from future claim payments through an accounts receivable offset

• Full claim adjustment – the adjustment was requested because the provider was overpaid on the entire claim; the entire claim is recouped

– First two digits of the ICN (region code) are 50


Retroactive Rate Adjustments

– The rate-setting contractor for long-term care facilities initiates retroactive rate adjustments

– Retroactive rate adjustments are a result of minimum data set (MDS) field audits

– Claims paid for the dates of service affected are reprocessed, and can result in increased or decreased payments



Mass Adjustments

– The Office of Medicaid Policy and Planning (OMPP), HP, or Affiliated Computer Services (ACS) can initiate a mass adjustment

– Mass adjustment requests are applied to change a large number of paid claims at one time

– Mass adjustments can apply to many providers or just one provider

– Mass adjustments can be used when a system problem caused claims to be paid incorrectly, or when a rate for a procedure code changed retroactively



Replacement Features

– Replacement is a change to an original claim, whether performed on the same day, same week, or post financial

– Replacement is a Health Insurance Portability and Accountability Act (HIPAA) term for an adjustment



– An electronically submitted replacement claim can be performed for a previously submitted electronic or paper claim

– Only noncheck-related replacements are accepted electronically

– Check-related replacements (adjustments) continue to be submitted on paper



– If a provider replaces a claim and the original claim has been through a financial cycle (has appeared on a Remittance Advice), the first two digits of the replacement claim ICN are one of the following:

• 61 – Provider-initiated replacement containing attachments and/or claim notes

• 62 – Provider-initiated replacement with no attachments and/or claim notes


Web interChange Replacement Feature


Void Feature

– Void is a HIPAA term for adjustment

– Void is the cancellation of an entire claim whether the original claim was sent the same day, same week, or post financial

– Void requests can be submitted electronically using the 837 transaction or Web interChange

– Void requests submitted electronically can be for a previously submitted electronic claim or paper claim

– Voids cannot be performed on a claim in a denied status

– A void can be performed on a claim in a paid or suspended status


Void Feature

– If the void of a claim occurs the same day or week that the original claim was submitted, a new ICN is not created• The same ICN assigned to the claim applies to the void

• The original claim denies with edit 0120 – Claim denied due to an electronic void request

– If the original claim being voided is a historical claim, a new ICN is created• The new ICN starts with 63

– Check-related voids (adjustments) continue to be submitted on paper


Adjustment Considerations

– Adjustments cannot be performed for the following scenarios:• Change member name

• Change member ID (RID)

• Change billing provider number/National Provider Identifier (NPI)

– Providers should submit a new claim to correct these types of errors

– A paper adjustment cannot be performed on a claim in a denied status

Limitations


Adjustment Considerations

– Providers are encouraged to perform all adjustment activities via Web interChange

– Avoid submitting paper adjustments when possible

– Do not submit duplicate paper adjustment requests

Web interChange versus paper

Live DemoReplace this claim


Replacement Feature

– Filing limit rules apply for replacement requests

– The system compares the date of service to the date of the current activity to make sure that a year has not passed

– Web interChange will not display a Replace This Claim button on claims more than one year from the claim’s Remittance Advice (RA) date

– These replacements must be submitted on paper

– If the date of service on the claim is greater than one year from the date of the replacement request, proof of timely filing is required to avoid a full recoupment of the paid amount

– The filing limit does not apply to crossover claims or check-related adjustments

Filing limits for replacements

DescribeAttachment process


Reimbursement Methodology

Following are the steps to mail paper attachments for electronic claims and adjustments submitted via Web interChange:

–On the Claim Submission screen, click the Attachments button


Attachment Process

– Complete the Attachment Information screen


Attachment Process

– Create an attachment control number (ACN)

• The ACN can be numbers, letters, or a combination of letters and numbers and can be up to 30 characters in length

• Each paper attachment submitted must include a unique ACN

• If an attachment has more than one page, the ACN must be written on each page of the document

– Select the Report Type Code – Indicates the type of attachment being sent to HP

– Transmission code – Indicates the type of delivery method used for documentation transmission

• “BM” (By Mail) is the only acceptable value for this field

– Once completed, click Save and Close


Attachment Process

– The provider must send an IHCP Claims Attachment Cover Sheet for each set of attachments associated with a specific claim.• A copy of the IHCP Claim Attachment Cover Sheet can be found on the IHCP

provider Web site at www.provider.indianamedicaid.com under the Forms link under the heading “Claim Forms (Non-Pharmacy)”

– The provider must complete the following information on the IHCP Claims Attachment Cover Sheet:• Billing provider service location address

• Billing NPI and ZIP Code + 4

• Date(s) of service on the claim

• Member identification number (IHCP RID number)

• ACN

• Number of pages associated with each attachment (do not count the cover sheet in the page count)

http://provider.indianamedicaid.com/


Attachment Process

– Paper attachments for electronic claims/adjustments must be mailed to the IHCP at the following address:

HP Claims AttachmentsP.O. Box 7259Indianapolis, IN 46207

– The HP Claims Support Unit will review each Claims Attachment Cover Sheet for completeness and accuracy of the number of ACNs to the number of attachments

– If errors are found, the cover sheet and attachments are returned to the provider for correction and resubmission

– If the attachment is not received within 45 days of claim submission, the claim will automatically deny


Attachment Process

– Explanation of benefit for denied detail lines (Medicare or commercial carriers)

– Invoices

– Sterilization/hysterectomy consent forms

– Past filing limit documentation

– Consultation reports

– Periodontal chart

– Operative report

Claim attachment example


Paper Adjustment Process

Always submit claim adjustments via paper when:

– Submitting a check-related adjustment

– The date you are requesting the adjustment is more than one year from the most recent RA date

• Past filing documentation must be submitted with the adjustment request

– Provider discovers the IHCP overpaid on at least one detail line and the one-year filing limit has passed

• Providers may submit an adjustment on the overpaid detail line without causing a recoupment of the entire claim

When to submit a paper adjustment


Adjustment Forms

– Types of paper adjustment forms

• CMS-1500, Dental, Crossover Part B Paid Claim Adjustment Request

• UB-04 Inpatient/Outpatient Crossover Adjustment Request

• Pharmacy Paid Claim Adjustment Request

– All relevant information on the form must be completed, or the form will be returned

– Attach copies of the Medicare and/or Third Party Liability (TPL) remittance notices, if necessary


CMS-1500, Dental, Crossover Part BPaid Claim


UB-04 and Inpatient/Outpatient Crossover Adjustment Request


Adjustment Form RTP

Paper adjustments are returned to the provider unprocessed for the following types of requests:

–Claim in denied status

–No primary insurance explanation of benefits (EOB) for TPL adjustments

–Requests to override benefit limitations

–Nonspecific narratives

–No approved prior authorization on file

Return to provider


Timely Filing Limitations

– The HP Adjustment Unit must receive nonpharmacy paid claim adjustment requests within one year of the last processing action

– When a service is allowed by Medicare, a crossover claim is not subject to the one-year filing limit

– Medicare-denied services are not considered crossover services, and therefore are not exempt from the one-year filing limitation

– Providers may obtain a waiver of the one-year filing limit for adjustment requests by providing past filing documentation with the request



– Commonly accepted documentation to waive filing limit

• Dated paper RAs with bills, dated claim forms, dated letters to and from insurers or the insured

• Dated EOBs from the primary insurer

• A print-screen of the Web interChange Claim Inquiry screen, showing all the times the claim had been filed

• Written Inquiry responses, Indiana Prior Review and Authorization Request Decision Forms, dated letters and e-mails to and from the county Division of Family Resources (DFR) offices, HP field consultants, and the member

Past filing documentation



HP may waive the filing limit due when the following can be documented:

– HP, state, or county error or action has delayed payment

– The provider has made reasonable and continuous attempts to resolve a claim problem

– The provider has made reasonable and continuous attempts to bill and collect from a TPL, before billing the IHCP

– A member has been enrolled in the IHCP retroactively

– A provider has been enrolled in the IHCP retroactively

Waiving the filing limit



Follow the guidance below to submit past filing documentation with electronic claims:

–Click the Attachments button and follow the Attachment process to mail the past filing documentation

–Place supporting documentation in chronological order behind the Attachment Cover Sheet

–Address any gaps in filing limit documentation

Electronic claims



– Submit legible and signed (if necessary) paper claims – photocopies are acceptable

– Attach supporting documentation as needed (example: Sterilization Consent Form)

– Place past filing documentation in chronological order behind the adjustment form• Each claim must have its own past filing documentation

– Address any gaps in filing limit documentation

– Use correct address; there is no separate address for filing limit adjustments

Note: Do not send claims to the Written Correspondence address

Paper claims



– HP is required to process 90 percent of noncheck-related adjustments within 30 days

– HP is required to process 100 percent of noncheck-related adjustments within 45 days

– Providers should contact HP Customer Service if an adjustment does not appear on an RA within 45 days of submission, plus mail time

Processing time


Where to Submit Adjustment Requests

– Forward noncheck-related and underpayment adjustment requests to:

HP AdjustmentsP.O. Box 7265Indianapolis, IN 46207-7265

– Forward check-related adjustments to:

HP RefundsP.O. Box 2303, Dept. 130Indianapolis, IN 46206-2303

–Return uncashed IHCP checks to:

HP Finance Unit950 N. Meridian, Suite 1150Indianapolis, IN 46204-4288


Where to Submit Adjustment Requests

– Send refunds for Community Alternatives to Psychiatric Residential Treatment Facilities (CA-PRTF) claims to:

HP/CA-PRTF RefundsP.O. Box 7247Indianapolis, IN 46207

– Send Money Follows the Person (MFP) refunds to:

HP/MFP RefundsP.O. Box 7194Indianapolis, IN 46207


Administrative Review and Appeal

– An administrative review may be requested when a provider disagrees with the way a payment was determined or a claim was denied

– Before requesting an administrative review, providers must exhaust routine measures to obtain the desired payment, including:

• Correct billing and resubmit claim

• Claim adjustment−When requesting an adjustment for a paid claim, include documentation

explaining the reason the provider disagrees with the IHCP payment

• Inquiry to HP Written Correspondence

Note: The above steps are not considered to be an appeal of a claim



– A formal administrative review must be filed within seven days of notification of claim payment or denial from HP

– Send administrative review requests to the following address:

Administrative ReviewHP Written CorrespondenceP.O. Box 7263Indianapolis, IN 46207-7263

– Providers receive a response within 90 days of the request



– A formal appeal may be requested after the administrative review process has been exhausted

– Appeal requests must be made within 15 days of receipt of the final administrative review decision, to the following address:

Attn: IHCP Provider Claim AppealsFSSA Office of General Counsel402 W. Washington Street, Room W451, MS27Indianapolis, IN 46204

Refer to the IHCP Provider Manual, Chapter 10, Section 6 for more information

Find HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP Web site at www.indianamedicaid.com

– IHCP Provider Manual (Web, CD-ROM, or paper)

– Customer Assistance• Local (317) 655-3240

• All others 1-800-577-1278

– Written Correspondence• HP Provider Written Correspondence

P. O. Box 7263Indianapolis, IN 46207-7263

– Provider field consultant

• View a current territory map and contact information online at http://provider.indianamedicaid.com/contact-us/provider-relations-field-consultants.aspx

http://www.indianamedicaid.com/

http://provider.indianamedicaid.com/contact-us/provider-relations-field-consultants.aspx

http://provider.indianamedicaid.com/contact-us/provider-relations-field-consultants.aspx

hp provider relations october 2010 claim adjustment process

Documents

underpayment adjustment

adjustment form

adjustmentclaim adjustment

entire claim

original claim

future claim payments

timemass adjustments

providermass adjustments