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Pennsylvania Health & Wellness

Claims Reimbursement FAQ

Nursing Facility Services

1Proprietary and Confidential

PAHW Has Several Electronic Claim Submission Options

– EDI

– Provider Web Claim Entry

– Provider Web Batch

– Provider Web Wizards

**Electronic claim submissions decrease claims payment

TAT and increase acceptance and accuracy rates**

Proprietary and Confidential 2

How Can I Submit Claims?


EDI Trading Partners

• Paper Submissions must meet the following criteria for proper OCR

processing.

– Original Red & White Form (no photocopies)

– Blue or Black Ink only

– 9 pt font or larger

– Nothing stamped or handwritten on claim

Pennsylvania Health & Wellness

P.O. Box 5070

Farmington, MO 63640


Paper Claims Submission

• Enroll in PA Health & Wellness’ Secure

provider portal to take advantage of one of

multiple direct claim submission options

– Batch upload of 837I, 837P files

– Single claim direct claim entry

– Recurring Claim Wizards for billing monthly

services


Direct Claims Submission

• Recurring Claim Wizards provide a quick and accurate way to bill recurring claims

(weekly, monthly, etc.)

– One time load of facility participants with easy participant list modification

– Quick and easy interface to bill services for multiple participants for the same

services/dates of service

– Electronic transactions decrease processing time and increase payment accuracy


Recurring Claim Wizards


Billing Guidelines

• Admission Date (Form Locator 12): Admission date is not required to match the

Statement Covers Period “From” date, however, an Admission date must be present in

order for claims to be processed for payment. (Blank admission date will deny as it is a

required field for encounters)

• All non-electronic claims, including crossovers and corrected claims, should be submitted

on Red and White UB-04 forms and should be free of handwritten or stamped verbiage

• Corrected claims should reference the original claim number in field 64 of the UB-04 as

outlined in NUCC guidelines

• Appropriate frequency code/resubmission code should be billed in field 4 of the UB-04


Billing Guidelines, cont’d.

• Claims cannot be billed in advance of Date of Service

• Claims must not contain more than 99 service lines

• Primary Payer EOB information can be submitted electronically using the

appropriate 5010 compliant EDI transaction guidelines

– Primary EOB’s are NOT needed when:• Participant is on FFS Medicare

• Participant is on PAHW DSNP Plan (AllWell Medicare Plan)

• Particpants on Hospice residing in Nursing Facility

– Room and Board should be billed by Hospice

– Claims billed by Nursing Facility will deny if Participant is flagged as Hospice• *Further Clarification of Patient Liability Process, Hospice rates, and other details related to

billing Hospice Participants pending from DHW


Billing Guidelines-Revenue

Codes

• 100- Nursing Home Room & Board (MA Days)

• 185 - Bed Hold Days-Hospitalization

– 15 Days per Hospitalization

• 183 - Leave of Absence- Therapeutic Leave

– 30 Days Per Calendar Year


Reimbursement Structure

Billed on Institutional Claim types

• Room & Board Rate – Per Diem Rate

• Therapeutic Leave – Per Diem Rate

• Bed Hold Days - 33% of per diem rate

Billed on Professional Claim Types

• Exceptional DME – Medicaid Fee Schedule Rates

• Daily Vent Management & Supplies- Medicaid Fee Schedule Rates

• Institutional Respite Care 100% of per diem rate

• Transportation

– Non Medical (NFE Participants only) – Per OLTL Waiver Fee Schedule

– Medical (Emergency/Non-Emergency) Transportation-Per Medicaid Fee Schedule


Supplemental Payments

• Disproportionate Share Supplemental Payments

Facilities that received DISH payments during the lookback period of December

2012-June 2016 will be considered for negotiation of an additional add on per diem

amount

• Vent/Trach Supplemental Payments

Facilities that received supplemental Vent/Tracheostomy supplemental

Payments during the lookback period of March 2016-March 2017 will be

considered for negotiation of an additional add on per diem amount for

patients receiving ventilator/tracheostomy care.

*as authorized and billed with revenue code 101

• Appendix 4 Payments

PA Health & Wellness will be Administering Appendix 4 Payments in accordance with

contract requirements to all Nursing Facilities

• PAHW is currently partnering with Trade Associations on Administration Structure

and methodology

Proprietary and Confidential12

Accepted Bill Types

261 Skilled Nursing-Intermediate Care Level II— Admit through discharge claim.

For participant requiring no ongoing care. Provider submits one claim for the entire stay for the particpant. The Date of Admission is the same day as the Statement Covers

Period “From” Date. The Statement Covers Period “To” Date is the Date of Discharge. **Note for admit through discharge claims, the covered days count does NOT include the

period “To” date (date of discharge). e.g. 03/01/2014-03/31/2014 covered days would be = 30.

262 Skilled Nursing-Intermediate Care Level II— Interim, first claim.

For participant receiving initial care, and will likely receive ongoing care. **Note for interim claims, the covered days count includes the period “To” date. e.g. 03/01/2014-

03/31/2014 covered days would be = 31.

263 Skilled Nursing-Intermediate Care Level II— Interim, continuing claim.

For participant requiring ongoing care. This is an interim claim for a continued, ongoing stay. Date of Admission is a date prior to the Statement Covers Period “From” Date.

Statement Covers Period “To” Date is the last date of the period being billed. **Note for interim claims, the covered days count includes the period “To” date. e.g. 03/01/2014-

03/31/2014 covered days would be = 31.

264 Skilled Nursing-Intermediate Care Level II— Interim, last claim.

For participant no longer requiring ongoing care. This bill type should only be used if the participant leaves the facility and no longer requires ongoing care. **Note for interim, last

claim, the covered days count does NOT include the period “To” date (date of discharge). e.g. 03/01/2014-03/31/2014 covered days would be = 30.

For The Bill Type (in Form Locator Field 4):As a reminder, submitting the correct Bill Type allows the appropriate edits to apply. The most frequently used Bill Types are identified below.

• Resident Cost of Care

– PA Health & Wellness’ Claims System is being configured to mirror current cost

of care process between nursing facilities and OLTL.

– Claims should continue to be submitted with all value codes as they were

through FFS

• Third Party Liability

– Medicaid is Always the Payer of last Resort. As such, PA Health & Wellness is

obligated to ensure that all primary payment sources have been exhausted prior

to reimbursement of services that could be covered by other payers.


Resident Cost of Care & TPL

• Medicare Primary Participants-FFS Medicare

– PA Health & Wellness will be executing a COBA agreement with CMS to enable auto-

crossover of Part A & Part B claims

– Claims/Primary EOP’s for Part A & Part B coinsurance/deductibles will not need to be

separately submitted to PA Health & Wellness for reimbursement.

– Nursing Facilities will bill Medicare for the applicable coverage period

– Medicare FFS claims will then automatically cross over to PAHW for payment of any

applicable cost sharing amounts

• Medicare Primary Participants-PA Health & Wellness DSNP (AllWell)Plan

Participant

– Claims/Primary EOP’s for Part A & Part B coinsurance/deductibles will not need to be

separately submitted to PA Health & Wellness for reimbursement for those participants

that are in both the PAHW DSNP & CHC plan.

– PA Health & Wellness’ system will process the applicable Medicare payment and

automatically cross over and pay any applicable cost sharing amounts on the CHC

plan.


Medicare & Third Party Liability

Claim Submission Requirements

• Medicare Primary Participants-DSNP Participant (other MCO plan)

– For Participants Enrolled in another MCO DSNP Plan:• Medicare Part A and Part B covered Services/days-Claims for CHC applicable

coinsurance/deductible amounts must be billed with the DSNP MCO’s Explanation of Payment.

• Claims for only Medicare non covered days (f.k.a. MA Days)-do NOT require a primary EOP

• Third Party Liability

– Participants with coverage other than Medicare:• Primary payer explanation of payment is required for claims processing

• Residents under Penalty Periods

– State will flag residents under penalty periods on the 834 file to ensure claims

are not paid during the participant penalty period. PAHW will withhold payment

according to state guidance during the timeframes indicated on the 834 file.


Medicare & Third Party Liability

Claim Submission Requirements

• Timely Filing

– First Time Claims- 180 days

– Corrected Claims- 365 Days from Date of Payment/Denial

• Submission Frequency

– PAHW Can accommodate either weekly* or monthly submission of MA only

days. (No Covered Medicare or Coinsurance days)

*Note: Weekly claim submissions will require facilities to submit/track patient liability amounts according to an

alternate method (e.g. Monthly Patient Pay amounts should not be submitted on each claim, or those

amounts would be deducted each time)

• Payment Frequency

– Pennsylvania Health & Wellness will generate two check runs weekly


Other Information

• State Guidelines

– 90% Clean claims within 30 Days


– 100% All Claims within 90 Days

• Our Numbers at a glance

– Average Auto-Adjudication Rate All LTSS Markets 87.3%

– Average Claims Payment TAT* All LTSS Markets 8.81 days

*TAT Calculated from Claim Received date to Claim Paid Date (Claims Received April 2016-June 2017)


Claims Processing Standards

• State Guidelines



– 100% All Claims within 90 Days

• Our Numbers at a glance

– Average Auto-Adjudication Rate All LTSS Markets 87.3%

– Average Claims Payment TAT* All LTSS Markets 8.81 days

*TAT Calculated from Claim Received date to Claim Paid Date (Claims Received April 2016-June 2017)


Claims Processing Standards

• Call Provider Services at 1-844-626-6813 or

visit www.pahealthwellness.com:

– Get Set up for Provider Portal

– Schedule Provider Training

– Get information on electronic payments through

PaySpan

– Discuss Claims testing options prior to go-live


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