Indiana Claim for Refund by spo10605

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									Claim Adjustment
Process


HP Provider Relations
October 2010
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

2    Claim Adjustment Process   October 2010
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




3   Claim Adjustment Process   October 2010
Define
  Types 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


5    Claim Adjustment Process   October 2010
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




6   Claim Adjustment Process   October 2010
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


7   Claim Adjustment Process   October 2010
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
    – First two digits of the ICN (region
      code) are 55



8    Claim Adjustment Process   October 2010
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
– First two digits of the ICN (region code) are 56




9   Claim Adjustment Process   October 2010
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




10   Claim Adjustment Process   October 2010
Replacement Features

 – 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




11   Claim Adjustment Process   October 2010
Replacement Features

 – 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




12   Claim Adjustment Process   October 2010
Web interChange Replacement Feature




13   Claim Adjustment Process   October 2010
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


14   Claim Adjustment Process   October 2010
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




15   Claim Adjustment Process   October 2010
Adjustment Considerations
Limitations

 – 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




16   Claim Adjustment Process   October 2010
Adjustment Considerations
Web interChange versus paper

 – Providers are encouraged to perform all adjustment activities via
   Web interChange
 – Avoid submitting paper adjustments when possible
 – Do not submit duplicate paper adjustment requests




17   Claim Adjustment Process   October 2010
Live Demo
 Replace this claim
Replacement Feature
Filing limits for replacements

 – 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

19   Claim Adjustment Process   October 2010
Describe
  Attachment 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




21   Claim Adjustment Process   October 2010
Attachment Process
 – Complete the Attachment Information screen




22   Claim Adjustment Process   October 2010
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


23   Claim Adjustment Process   October 2010
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)


24   Claim Adjustment Process   October 2010
Attachment Process
 – Paper attachments for electronic claims/adjustments must be
   mailed to the IHCP at the following address:
      HP Claims Attachments
      P.O. Box 7259
      Indianapolis, 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


25   Claim Adjustment Process   October 2010
Attachment Process
Claim attachment example

 – 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




26   Claim Adjustment Process   October 2010
Paper Adjustment Process
When to submit a paper adjustment

 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




27   Claim Adjustment Process   October 2010
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




28   Claim Adjustment Process      October 2010
CMS-1500, Dental, Crossover Part B
Paid Claim




29   Claim Adjustment Process   October 2010
UB-04 and Inpatient/Outpatient Crossover
Adjustment Request




30   Claim Adjustment Process   October 2010
Adjustment Form RTP
Return to provider

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




31   Claim Adjustment Process   October 2010
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

32   Claim Adjustment Process   October 2010
Timely Filing Limitations
Past filing documentation

 – 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




33   Claim Adjustment Process    October 2010
Timely Filing Limitations
Waiving the filing limit

 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




34   Claim Adjustment Process   October 2010
Timely Filing Limitations
Electronic claims

 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


35   Claim Adjustment Process   October 2010
Timely Filing Limitations
Paper 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

36   Claim Adjustment Process   October 2010
Timely Filing Limitations
Processing time


 – 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




37   Claim Adjustment Process   October 2010
Where to Submit Adjustment Requests
– Forward noncheck-related and
  underpayment adjustment requests to:
     HP Adjustments
     P.O. Box 7265
     Indianapolis, IN 46207-7265

– Forward check-related adjustments to:
     HP Refunds
     P.O. Box 2303, Dept. 130
     Indianapolis, IN 46206-2303

– Return uncashed IHCP checks to:
     HP Finance Unit
     950 N. Meridian, Suite 1150
     Indianapolis, IN 46204-4288
38   Claim Adjustment Process   October 2010
Where to Submit Adjustment Requests

 – Send refunds for Community Alternatives to
   Psychiatric Residential Treatment Facilities
   (CA-PRTF) claims to:
      HP/CA-PRTF Refunds
      P.O. Box 7247
      Indianapolis, IN 46207
 – Send Money Follows the Person (MFP)
   refunds to:
      HP/MFP Refunds
      P.O. Box 7194
      Indianapolis, IN 46207



39   Claim Adjustment Process   October 2010
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
40   Claim Adjustment Process      October 2010
Administrative Review and Appeal
– 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 Review
     HP Written Correspondence
     P.O. Box 7263
     Indianapolis, IN 46207-7263
– Providers receive a response within 90 days of the request




41   Claim Adjustment Process   October 2010
Administrative Review and Appeal
– 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 Appeals
      FSSA Office of General Counsel
      402 W. Washington Street, Room W451, MS27
      Indianapolis, IN 46204


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




42   Claim Adjustment Process   October 2010
Find Help
  Resources Available
Helpful Tools
Avenues 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 7263
          Indianapolis, 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
 44       Claim Adjustment Process   October 2010
Q&A

								
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