Managed Health Services

National Provider Identifier

• MHS needs to obtain NPI numbers prior to January 2008. Please submit directly to MHS for entry into our claims payment system.

• Submit NPI via MHS Web site at www.managedhealthservices.com or via fax (866) 912-0326. This must be submitted even if you have already submitted to the State of Indiana or EDS.

National Provider Identifier

MHS will process with NPI only, effective January 1, 2008, unless OMPP requires a later date.

CURRENTLY:• If you have reported your NPI to MHS and it is on file, you may bill with NPI only on both

the CMS-1500 (field 24J – top half) and the UB-04 (field 56), claims will process with NPI only.

• If your NPI is not on file and claims are submitted with NPI only, the claims will reject.

• You may continue to use your Indiana Medicaid Number until January 2008. An informational edit will be sent requesting you to report your NPI.

MHS Web site

www.managedhealthservices.com

• Enhanced Web site– On-line Registration– On-line Prior Authorizations– Provider Directory Search Functionality– Enhanced Claim Detail– Code Auditing Software Tool– Printable, Current Forms and Manual

MHS Web site

Upcoming Enhancements

• Direct claim submission – 4th Quarter 2007• Claim resubmission – 1st Quarter 2008• Claims Xtend – 4th Quarter 2007• 835 Transactions – 4th Quarter 2007

Managed Health Services

CLAIMS

CMS 1500 Billing

Provider Inquiry Services

Call us at 1-877-647-4848. We are ready to help you!

Knowledgeable, friendly staff available 8:00am–6:00pm ESTFocused commitment to professional serviceClaims address P.O. Box 3002 Farmington, MO 63640Dispute & appeal processes (60 days from receipt of EOP)Appeal address P.O. Box 3000 Farmington, MO 63640Filing limits dependant upon contract statusFollow IHCP requirements

Claims Submission

• Submit electronically (preferred) for fastest response.• Providers should check electronic submission report daily to ensure claims

were received by MHS.• Filing timelines

– 120 days from DOS for Participating ProvidersExceptions: Newborn, Third Party Liability, and Eligibility delays (filing limit 365 days)

– 365 days from DOS for Non Participating Providers

Billing MHS with Ease

Helpful suggestions to prevent delay in payment are provided so thatMHS can provide speedy payment.

Beginning November 1st, MHS will no longer be accepting old claim forms.

Verify other insurance (TPL). Medicaid is the payer of last resort. MHS does require a copy of the primary EOP.

Check eligibility at each visit prior to submitting claims to ensure that you are billing the correct carrier, as members may change MCOs often.

Billing MHS with Ease

Please allow at least 30 to 45 days for claim adjustments to be made.

PA requirements changed April 1, 2007. Please ensure that your staff is familiar, as retroactive authorizations are not provided.

Utilization of our Web site will allow for the quickest service available.

MHS will generate a Provider Watch Bulletin of helpful tips and Plan updates to billing office locations for all par providers on a quarterly basis. All providers can review this bulletin on the MHS Web site at www.managedhealthservices.com

Resubmitted Claims

• If you need to resubmit a denied claim, the claim must be submitted on paper and should be clearly marked at the top with the word “RESUBMISSION.”

• Attach a MHS Claim Adjustment Form stating the reason for resubmission and include the EOP (if applicable).

• Resubmitted claims should be mailed to the address listed on the claim adjustment form and must be received within 60 days of the EOP date.

Adjusted Claims

• If you need to make an adjustment to a paid claim, you can do so by calling Provider Inquiry, or you may submit on paper with the adjustment request form.

• Attach a MHS Provider Adjustment Form along with documentation, including EOP (if available) explaining reason for resubmission

• Claim adjustments requests must be submitted within 60 days of the date of the EOP

Claim Dispute Resolution

PROVIDERS HAVE 60 CALENDAR DAYS FROM THE DATE OF PROVIDERS HAVE 60 CALENDAR DAYS FROM THE DATE OF RECEIPT OF THE EOP TO FILE AN OFFICIAL DISPUTE OR APPEAL RECEIPT OF THE EOP TO FILE AN OFFICIAL DISPUTE OR APPEAL WITH MHSWITH MHS

Verbal Inquiries can be made by calling MHS Provider Inquiries at 1-877-647-4848, option 3.

*Note: A verbal inquiry is notnot considered a dispute or appeal and does not stop the 60 calendar days from the date of receipt of the EOP to file a dispute or appeal.

Third Party Liability

• MHS updates member TPL information through:– A monthly file from EDS– Phone call from providers– Receipt of an EOB with claim

• MHS always verifies new TPL

Third Party Liability

• If a member has TPL on file but no longer has other coverage or the member has other coverage but the information is not on file take the following steps:

– Contact Provider Inquiries with the TPL information so that changes can be made to the TPL file

– Send an update notification to EDS via the WebInterchange

Third Party Liability

• Claims will deny L6 if TPL is on file with MHS.

• What if I don’t agree with MHS’ TPL indication?– Call provider inquiries– Resubmit paper claim with EOB attached

• Reminder: TPL claims must be submitted within 60 days of the date of the primary insurer’s EOB.

Pregnancy Coverage

Package B: Pregnancy Coverage

• Hoosier Healthwise Members receiving pregnancy coverage (Package B) are eligible for Pregnancy Related coverage only. MHS strictly adheres to IHCP Coverage guidelines.

• Use a diagnostic code that relates to pregnancy, the complications of pregnancy, or, when applicable, check emergency on the claim form when billing for covered services.

Pregnancy Coverage

Ultrasound Services

• According to Chapter 8 of the Indiana Health Coverage Manual, only medically necessary pregnancy ultrasounds are considered coveredservices; “routine” echograph and sonograph services are not covered. When billing, please be sure to use a diagnoses that appropriately indicates the reason for the ultrasound.

• If pregnancy ultrasounds are medically necessary, MHS will allow for two ultrasounds without Prior Authorization in accordance with industry standards.

HPV Vaccine

Human Papilloma Virus (HPV) Vaccine• IHCP now provides reimbursement for the HPV. The coverage is retroactive to

January 1, 2007. All claims rendered in 2007 should be billed directly to EDS for reimbursement regardless of which MCO the member is covered under. This administration fee is carved out for RBMC members until December 31, 2007.

• Please do not submit claims for procedure code 90649 to MHS for MHS members in 2007.

• MHS claims processing system will deny 90649 if they are submitted for 2007 service dates.

DME BILLING

• DME with a purchase price of less than $500.00 does not require prior authorization.

• Manually Priced DME – must be submitted with invoice.

• DME authorization requested by treating PMP or specialist.

Pain Management

• If the physician is an Anesthesiologist, an auth will always be needed for office visits.

• If the physician is an Anesthesiologist, an auth will always be needed for pain management injections in all locations.

• If the physician is anything other than an Anesthesiologist, an auth will be needed for pain management injections in all locations.

New Software

Claims Xtend software replacing code edit

MHS will begin utilizing a new code editing software. The software will continue to ensure that MHS is processing claims in compliance with accepted industry coding standards.

It will replace our current Code Edit system.

The current Web-based code audit reference tool will remain the same and is located at www.managedhealthservices.com. This tool helps explain how MHS evaluates different code combinations.

Referrals and Prior Authorization

• Referrals and Prior Authorization

Referrals and Prior Authorization

Prior Authorization

REFERRALA referral is a request (verbal, written, or telephonic communication) by a PMP Specialty care services.

PRIOR AUTHORIZATIONPrior Authorization is an approval from MHS to provide services designated as needing approval prior to treatment and/or payment.

Prior Authorization

ALL Referrals to Contracted Specialists for Office Visitsrequire communication between the PMP and the Specialist.

Prior Authorization

ALL Referrals to Non-Contracted Specialists and/or for Procedures that Require Authorization Must be Obtained by Contacting MHS.

• Telephonic Process 1-877-647-4848 or Fax to 317-684-8096

• Call must be placed at least two business days prior to date of service. A PA number will be given at the time of the call unless clinicaA PA number will be given at the time of the call unless clinical l information is required.information is required.

Prior Authorization

When should the PMP get the authorization orreferral from MHS?• When referring to a non contracted specialist for an office visit• When referring a patient directly for a procedure that requires an

authorization even if the PMP is not performing

Prior Authorization

When should the Specialist get the authorizationfrom MHS?• For any procedure or test that requires an authorization that the specialist

decides in needed after the patient has been seen during an office visit.

PA for Labs and X-Rays

• Labs and X-Rays do not require PA (or referral) when performed at a contracted facility.

• Labs and X-Rays preformed at a non-contracted facility do not need prior authorizations when performed as stand alone services.

Self Referral Services

• Podiatrist• Chiropractic • Family Planning• Routine Vision Care• Routine Dental Care• Mental health by Type and Specialty• HIV/AIDS Case Management• Diabetes Self Management• Individualized Education Plan (IEP) for Schools

Questions and Answers