mpaa updates 10/31/14. agenda new look of champs msa 14-34 proposed policy 1442 new look of tpl...
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AgendaNew look of CHAMPSMSA 14-34Proposed Policy 1442New look of TPL webpageL-Letter 14-28Top RejectionsAdditional Updates
Defects in the new look of CHAMPSPrint member summary hyperlink does not print all
that is displayed on the screenPrint function in blue ribbonScreen capture tool on your computerChange print setting to landscape
Internet Explorer version 9 users have encountered problems accessing Archived Documents, Adobe setting instructions
When accessing DDE from the favorites function, the billing NPI does not pre-populateUntil corrected, access DDE without using the favorites
feature
MSA 14-34• Inpatient hospital newborn claims dates of discharge on or after
October 1,2014• Admission type
• Newborn Admission type of 4• Origin code of 5 or 6
• Value code 54 reported with birth weight in grams as a whole number• Further clarification being issued to clarify that cesarean and
induction information should be reported on the mother’s claim not on the newborn’s claim
• Condition Code "81": C-sections or inductions performed at less than 39 weeks gestation for medical necessity
• Condition Code "82": C-sections or inductions performed at less than 39 weeks gestation electively
• Condition Code "83": C-sections or inductions performed at 39 weeks gestation or greater
Proposed Policy Project 1442
Diagnosis Related Group (DRG) Grouper Update, DRG Rate Update, Rehabilitation Per Diem Rate Update, Birth Weight Reporting, Prospective Capital, All Patient Refined DRG (APR-DRG) Notification
Proposed Policy 1442Comments on this policy due by November 14, 2014 Effective January 1, 2015, claims for inpatient hospital
discharges using the DRG methodology will be processed using Medicare DRG Grouper Version 32.0
Claims for discharges on or after January 1, 2015 that fail to report the newborn priority (type of) admission or visit and newborn birth weight will be denied Reporting of cesarean sections or inductions related to
gestational age will continue to result in informational editing only
New look of TPL webpage• Save this link to your favorites
www.michigan.gov/reportTPL• MDCH is now receiving monthly files from BCBS
and BCN• Currently files are handled manually, loaded by the
15th of each month• TPL is no longer making many changes to the TPL
coverage file related to BCBS or BCN• If a change, start or term date, has happened within
the last 30-60 days to the BCBS or BCN coverage, MDCH will receive the update in the next monthly file, no need to submit the DCH-0078 form
L-Letter 14-28
Fee-for-Service Healthy Michigan Plan Beneficiaries with Retroactive Health Plan Enrollment Dates
L-Letter 14-28L-Letter was only mailed to affected providersInpatient Hospital claim recoveries total $1,753,817.70Outpatient Hospital claim recoveries total
$1,287,146.45Credited claims appeared on Remittance Advice
October 16,2014Providers should bill claims to health plans within 60
days of the MDCH take-backThe health plan must process these claims for all in-
network and out-of-network providers without prior authorization, even if prior authorization is normally required for the service
Top Denials IPH
CARC 24: Beneficiary enrolled in a managed care planPayer at the time of admission is responsible for the claim
CARC 251/RARC N205: Predictive modeling has reviewed the documentation submittedIPH claims admission/discharge reports are missing
CARC 133/RARC N47: Fifteen day re-admissionAlways check against your own facility prior to contacting provider
supportCARC 16/RARC N253: Attending NPI not active on date of service
Attending NPI must be active and enrolled on the claim header from date of service
Provider verification tool can be used to verify enrollmentCARC 109/RARC N193: Substance abuse
Check diagnosis information on claim
Top Denials OPHCARC A8: Ungroupable DRG/APC
One or more lines on the claim has denied which causes the claim not to be able to be priced by the APC software
CARC 251/RARC N205: Predictive modeling has reviewed the documentation submittedOPH claims missing orders/results
CARC 16/RARC M51: Missing procedure codeCARC 22/RARC N598-: Other insurance is primary
Review eligibility for other payer information prior to submitting claim
Additional UpdatesEffective September 26,2014 MDCH is now processing
OPH claims using the July APC softwareEffective September 26,2014 the attending NPI reported
has to be effective on the Header date of serviceEffective December 12,2014 EZ link will no longer be an
available option to submit claim documentation such as:Consent formsMedical DocumentationPredictive Modeling
After December 12,2014 providers will need to use Document Management Portal (DMP) tips and tutorial to submit claim documentation
Provider Resources• Medicaid Provider Training
• One on One trainings requests• Association requests• Current trainings available
• Provider Support• www.michigan.gov/medicaidproviders • 1-800-292-2550• [email protected]
• Evaluation Form