A number of updates were presented by Unisys during the June Provider Workshops. For your convenience, additional information is included in this edition of the WESGRAM Online.
ClaimCheck
One of the most critical updates, and one that may strongly impact your practice, is the addition of the ClaimCheck auditing solution for claims. As of July 1, 2007, this automated claims auditing system was fully integrated within the Unisys claims processing system and provides a bundling/unbundling solution. In order for claims to be paid correctly, all required modifiers must now be used. For drug claims (J codes) you will now need to list the NDC number and the amount used.
The ClaimCheck clinical auditing system utilizes consistent auditing criteria to ensure that current standard coding principles are applied. The software more fully automates the claim review process; eliminating costly overpayments and post audit reviews.
As of 7/1/2007, the clinical auditing will include 90 days of historical auditing. The pre/post operative auditing will not include any dates of service prior to 7/1/2007. At this time, the clinical auditing will only apply to services submitted on a CMS 1500 claim form or services submitted via 837 transactions.
The medical criteria used for ClaimCheck includes the American Medical Association guidelines (CPT 4), CMS guidelines (HCPCS), and Medicare CCI (Correct Coding Initiative) standards.
Some examples of claim errors, in addition to unbundling/rebundling of services, that ClaimCheck will audit include billings for incidental services, mutually exclusive services, age conflict services, and gender conflict services.
Physicians who question a clinical audit denial may contact Unisys Provider Relations (304-348-3360 or 888-483-0793) and submit documentation for review of the claims in question.
Timely Filing Policy
The timely filing for WV Medicaid claims is one year. The year is counted from the "from date" on a CMS 1500 form to the receipt date of the claim. Claims that are over one year old must have been billed and received within the one year filing limit.
Claims that are over one year old must be submitted to the Provider Relations Unit with a copy of the remittance advice that proves the claim was received prior to the one year deadline date. Service dates for claims over two years old are not eligible for reimbursement.
If you are submitting a reversal or replacement claim that is over one year old, it must be billed on paper with a copy of the original remittance advice. There must be no additional services billed on the replacement claim. If additional services that were not originally billed appear on the claim and the dates of service are over one year old, the claim will be denied for timely filing.
The timely filing date for Medicare primary claims is one year from the EOMB date. Unisys reports that there are no Medicare primary claims in backlog.
When a Medicaid patient has a backdated Medicaid card, the member (patient) must provide a copy of the card or letter of eligibility (LOE) to the physician. Physicians then have one year from the date the eligibility was backdated in order to file the claim. The claim must be sent with a copy of the card/LOE to the Unisys Provider Relations Department in order to verify that the card was truly backdated. Once verified, the timely filing will be waived and the claim will be submitted for processing. Claims should be sent to the following address:
Unisys Provider Relations
P.O Box 2902,
Charleston, WV 25327-2002
Billing Instructions When Another Insurance is Primary
All primary insurance billing requirements must be followed prior to billing Medicaid. If a physician is not enrolled in the primary insurance plan, he/she must inform the patient that he/she should either see a physician in their primary plan network or be responsible for payment of the services if they choose not to use a physician in their plan network. Under no circumstances should the primary insurance and Medicaid be billed at the same time. The primary insurance must always be billed first.
If the primary insurance pays on or approves a service, the physician does not have to obtain a PA (prior authorization) from West Virginia Medical Institute (WVMI). If the primary insurance denies the claim, the service must be billed on paper with a copy of the EOB attached. The EOB must show all fields on the EOB, including denial reasons and remark codes.
Unlike Medicare, all primary insurance claims are subject to the Medicaid timely filing regulations of 12 months from the date of service, not 12 months from the date of the EOB.
It is very important for physicians to understand that once Medicaid has been billed, the physician must accept the Medicaid payment as payment in full and cannot bill the patient for any remaining balance. If, on the other hand, the physician is not a participating Medicaid provider, you may bill the patient, but you may not bill the patient if you have billed Medicaid. Per Medicaid policy, if you bill Medicaid, you have agreed to accept assignment.
In all situations, whether it is commercial insurance or payment received from a settlement, if Medicaid has been billed, then the Medicaid payment must be accepted as payment in full.
Additional billing information may be found on the Unisys website www.wvmmis.com welcome screen under "provider manuals".
Mountain Health Choices
Mountain Health Choices refers to the New Medicaid for West Virginia. This new program is focused on the AFDC-related population. It is in the first phase of development and is now being tested in Lincoln, Clay and Upshur Counties. When the program is rolled out statewide, it will encompass approximately 63% of the Medicaid population.
The goal of the new Medicaid program is to create a partnership of Medicaid, its members, and the medical home. It is a very patient-centered program with pro-active personalized care which uses teams providing continuity of care for members. The plan hopes to achieve long term program growth by promoting prevention and wellness. It also provides shared accountability and encourages integration of technology in physicians' offices which serve as medical homes.
Mountain Health Choices began with the establishment of a medical home for each Medicaid member. The program is responsive to physicians and members and changes are made when necessary.
For the Phase-I roll out of the program in the three county area, the Medicaid system triggers enrollment dates for member inclusion by the member's re-determination date, the rate code (for the AFDC-related population) and the geographical location. Members are offered a choice of a Basic or Enhanced Benefit Package and are also asked to sign a member agreement which states that they will work with their medical home physician to improve his/her healthcare.
The Mountain Health Choices program plans to continue to expand until it reaches all 55 counties. The initial acceptance has been slow but it is anticipated that membership will continue to increase.
If you need additional information about the Mountain Health Choices program, you may contact Shannon Riley at the Bureau for Medical Services, (304) 558-1700, or via email shannonriley@wvdhhr.org.
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