Get documents about "Sample of Authorization Letter to Claim Something
Description
Sample of Authorization Letter to Claim Something document sample
Document Sample
DD Waiver Billing
ACS, Inc.
Presented by:
Sara walk & Shanna Alles
ACS Field Representatives
October 3rd & 4th, 2005
Table of Contents
ACS Phone Numbers-------------------------- 4
Billing Steps-------------------------------------- 5
Prior Authorization Letter---------------------- 6
Problems/Questions----------------------------- 7
Important Questions---------------------------- 8
Place of Service Codes------------------------ 9
Remittance Advice ----------------------------- 10
Void/Adjustments------------------------------- 17
Timely Filing ------------------------------------ 22
Other Ways ACS Can Help-------------------- 23
Other Frequently Asked Questions ---------- 24
2
Abbreviations:
What they stand for
ACS- Affiliated Computer Services
DDD- Developmental Disabilities Division
AVR- Automated Voice Response
WINASAP 2003- Windows Accelerated Submission & Processing 2003
RA- Remittance Advice
EOB- Explanation of Benefits
TCN- Transaction Control Number
ISC- Individually-Selected Service Coordinator
3
ACS Phone Numbers
Provider Relations – 1-800-251-1268
(or in Cheyenne) 772-8401
AVR – (Check eligibility using your
provider number and client ID.)
1-800-251-1270
(or in Cheyenne) 772-8403
Fax – 1-307-772-8405
Web Site!
wyequalitycare.acs-inc.com
4
Billing Steps
ISC (case manager) writes the Individualized Plan of Care
Plan of Care sent to DDD to be reviewed, have corrections requested, and
signed off by authorized individual
Pre-approval is returned to ISC for distribution to providers
ACS receives plan of care from DDD
ACS assigns prior authorization number
ACS sends provider prior authorization number
Provider performs services
Provider bills claim to ACS electronically
Provider receives remittance advice and check or direct deposit
Provider needs to adjust paid claim through ACS if needed
5
Prior Authorization Letter
WYOMING DEPARTMENT OF HEALTH
MEDICAID MANAGEMENT INFORMATION SYSTEM
PRIOR AUTHORIZATION NOTICE
***PRIOR AUTHORIZATION APPROVAL DOES NOT GUARANTEE ELIGIBILITY***
PA-NUMBER: 2000000000 01/09/05
DD PROVIDER RECIP: JOE BROWN
DD WAIVER SERVICES RECIP ID: 0600000000
123 MAIN STREET
CHEYENNE WY 82001
THE AUTHORIZATION FOR MEDICAID SERVICES REQUESTED FOR
JOE BROWN HAS BEEN APPROVED OR DENIED AS FOLLOWS:
01/01/05-01/31/05 T2022- KIDS CASE MANAGEMENT * APPROVED
02/01/05-02/28/05 T1005- KIDS RESPITE CARE * APPROVED
COMMENT:
6
Problems/Questions
When to call AVR: When to call ACS:
Client eligibility Problems with WINASAP
Check/payment status CD or downloading
WINASAP from internet
When to call ISC Case Claims inquiry and
eligibility
Manager:
Problems with plan of care Check/payment status
Problems with client Adjustments/voids
eligibility Didn’t receive PA letter
7
Checklist Prior to Submitting Claims
Did you enter the correct provider
number?
Does the client identification number
match what is on the PA letter?
Did you enter the correct PA number?
Are you using the correct place of
service code? (See the following slide
for place of service codes)
Did you enter the correct amount of
units?
8
Where Were the Services Performed?
(Place of Service Codes)
Patient’s Home -------------------------12
Other or combination------------------ 99
9
Sample Remittance Advice (RA)
REMITTANCE ADVICE
TO: DD PROVIDER R.A. NO.: 0574205 DATE PAID: 06/13/05 PROVIDER NUMBER: 100000000 PAGE: 1
TRANS-CONTROL-NUMBER BILLED MCARE COPAY OTHER DEDUCT- COINS MCAID WRITE TREATING
LI SVC-DATE PROC/MODS UNITS AMT. PAID AMT. INS. IBLE AMT. PAID OFF PROVIDER S PLAN
* * * CLAIM TYPE: HCBS WAIVER * * * CLAIM STATUS: PAID
ORIGINAL CLAIMS:
*ANDERSON ANDY RECIP ID: 0600123456 PATIENT ACCT #:1
3-00000-00-012-0000-00 80.00 0.00 0.00 0.00 0.00 0.00 80.00 0.00
01 08/25/05 T2013 4 80.00 0.00 0.00 0.00 0.00 0.00 80.00 0.00 100000000 P DDCW
*BRADY BOBBY RECIP ID: 0600111222 PATIENT ACCT #: 2
3-00000-00-011-0000-00 100.00 0.00 0.00 0.00 0.00 0.00 100.00 0.00
01 09/01/05 T2013 5 100.00 0.00 0.00 0.00 0.00 0.00 100.00 0.00 100000000 P DDCW
*COOPER CHARLIE RECIP ID: 0600222555 PATIENT ACCT #: 3
3-00000-00-010-0000-00 40.00 0.00 0.00 0.00 0.00 0.00 40.00 0.00
01 09/01/05 T2013 5 40.00 0.00 0.00 0.00 0.00 0.00 40.00 0.00 100000000 P DDCW
* * * CLAIM TYPE: HCBS WAIVER * * * CLAIM STATUS: DENIED
ORIGINAL CLAIMS:
*SMITH SUZIE RECIP ID: 06005551111 PATIENT ACCT #: 4
3-00000-00-009-0000-00 100.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
01 09/01/05 T2013 5 100.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 100000000 K DDCW
LINE EOB(S): 270 900
10
Sample Remittance Advice (RA) Continued…
REMITTANCE ADVICE
TO: DD PROVIDER R.A. NO.: 0574205 DATE PAID: 06/13/05 PROVIDER NUMBER: 10000000 PAGE: 16
TRANS-CONTROL-NUMBER BILLED MCARE COPAY OTHER DEDUCT- COINS MCAID WRITE TREATING
LINE SVC-DATE PROC/MODS UNITS AMT. PAID AMT. INS. IBLE AMT. PAID OFF PROVIDER S PLA N
*********************************************************************************************************************
* * * CLAIM TYPE: HCBS WAIVER * * * CLAIM STATUS: IN PROCESS
ORIGINAL CLAIMS:
*SMITH SAMMY RECIP ID: 0644444444 PATIENT ACCT #: 5
3-00000-00-008-0000-00 1817.29 0.00 0.00 0.00 0.00 0.00 0.00 0.00
01 05/01/05 T2016 23 1592.29 0.00 0.00 0.00 0.00 0.00 0.00 0.00 100000000 P DDCW
02 05/01/05 T2018 5 180.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 100000000 P DDCW
03 05/01/05 T1002 3 45.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 100000 000 P DDCW
LINE EOB(S): 900 000
REMITTANCE T O T A L S
PAID ORIGINAL CLAIMS: NUMBER OF CLAIMS 87 --------- 289,961.29 289,961.29
PAID ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 --------- 0.00 0.00
DENIED ORIGINAL CLAIMS: NUMBER OF CLAIMS 1 --------- 1,955.52 0.00
DENIED ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 --------- 0.00 0.00
PENDED CLAIMS (IN PROCESS): NUMBER OF CLAIMS 1 --------- 1,967.29 0.00
AMOUNT OF CHECK: ------------------------------------------------------------ 289,961.29
---- THE FOLLOWING IS A DESCRIPTION OF THE EXPLANATION OF BENEFIT (EOB) CODES THAT APPEAR ABOVE: COUNT:
270 RECIPIENT IS INELIGIBLE ON THE DATE OF SERVICE. 3
900 THE CLAIM IS IN SUSPENSE. DO NOT RESUBMIT THE CLAIM. 4
11
Common Denial Reasons
Denial- This is an exact duplicate of a previously paid claim.
Action- Refer to TCN reported on RA as previously paid claim/TCN.
Denial- The procedure code requires a prior authorization number and the
procedure code on the claim does not match the procedure code on the PA.
Action- Make sure the correct prior authorization number with the correct
procedure code is on your claim. Resubmit the claim with the correct prior
authorization number.
Denial- The client number is not on file.
Action- Resubmit the claim with the correct client number.
12
Common Denial Reasons
Denial- Dates or names on claim do not match the dates or names on the prior
authorization.
Action- Make sure the correct prior authorization number for the correct client
and dates is on the claim. Resubmit the claim with the correct prior
authorization number.
Denial- Prior Authorization has been used.
Action- Make sure the correct prior authorization number is on the claim.
Refer back to previous RA’s where claims have paid under this prior
authorization number.
Denial- The prior authorization is not on the prior authorization file.
Action- Make sure the correct prior authorization number is on the claim.
Resubmit the claim with the correct prior authorization number.
13
What to do if a Claim Denies
Don’t panic!
Look at the EOB code listed at the bottom of your RA
Fix the problems you are able to correct
Resubmit the claim
Do not adjust a denied claim
If all else fails, call ACS!
14
What to do if a Claim is
“In Process”
Don’t panic!
Do NOT resubmit the claim, only resubmit
denied claims
Do NOT adjust the claim
Wait for a future Remittance Advice (Be
patient - this can take up to 30 days!)
Remember…an “In Process” claim is not
guaranteed to deny
15
Common Reasons Claims Are
“In Process”
Client is not eligible
Possible duplicate claim
PA / procedure code conflict
PA / client conflict
PA / provider number conflict
PA / claim service dates conflict
16
What to do if a Claim Pays
Incorrectly - Adjustments
Do NOT resubmit the claim
Check PA for errors
Fill out a Void / Adjustment Request Form
Contact ACS
17
Sample Void / Adjustment Request Form
VOID/ADJUSTMENT REQUEST FORM
If your claim was DENIED, DO NOT use this form.
Please resubmit your claim.
SECTION A: CHECK BOX 1) OR 2)
1) CLAIM ADJUSTMENT: Attach 2) CANCELLATION OF THE ENTIRE
claim copy with corrections made in REMITTANCE ADVICE. Every claim on
red ink. the Remittance Advice must be incorrect.
DO NOT USE HIGHLIGHTER. This option should only be used in rare
instances.
Complete Section B and C.
Attach RA and warrant.
If attaching a check, the check should be
payable to Office of Medicaid. Skip to Section C.
SECTION B
TO FACILITATE CLAIM ADJUSTMENT PROCESSING, PLEASE COMPLETE THE FOLLOWING:
1. 17-DIGIT TCN: (OR) 14-DIGIT PDCS TCN:
3-03000-00-020-0001-00
2. 9-DIGIT PAY-TO-PROVIDER: 3. PROVIDER NAME:
1111111-11 DD Provider
OR 7-DIGIT NABP NUMBER
4. 10-DIGIT CLIENT NUMBER:
0600000000
5. REASON FOR ADJUSTMENT OR VOID:
Procedure Code T1015 billed at 16 units on original claim. Need to adjust this claim and reprocess so tha t 18 units
can be paid.
SECTION C: SIGNATURE AND DATE REQUIRED
PROVIDER SIGNATURE: DD Provider DATE: January 21, 2005
RETURN ALL REQUESTS TO:
ACS, INC.
P.O. BOX 667
CHEYENNE, WY 82003-0667
REMARKS/STATUS: (FOR ACS, INC. USE ONLY)
CASH CONTROL NUMBER:
ADJUSTED BY: DATE:
18
Possible Reasons to Void or Adjust
a Claim…
Claim paid for incorrect client
Claim paid for incorrect amount of units
Claim paid for incorrect month
Claim paid for incorrect procedure code
Provider has over billed for the month
19
Checklist Prior to Submitting
Adjustments
Did you mark box 1 (Section A)?
Did you enter the correct TCN?
Is your reason for the adjustment or void (Section
B, Field 5) accurate, legible and understandable?
Did you sign the adjustment?
Did you attach a copy of your RA to the back?
Did you keep a copy for your records?
Please do not send a check
Keep providing services!
20
How to Read an Adjustment on an RA
REMITTANCE ADVICE
TO: DD PROVIDER R.A. NO.: 0624284 DATE PAID: 01/15/05 PROVIDER NUMBER: 100000001 PAGE
TRANS-CONTROL-NUMBER BILLED MCARE COPAY OTHER DEDUCT- COINS MCAID WRITE TREATING
LINE SVC-DATE PROC/MODS UNITS AMT. PAID AMT. INS. IBLE AMT. PAID OFF PROVIDER S PLAN
* * * CLAIM TYPE: HCBS WAIVER * * * CLAIM STATUS: PAID
ADJUSTMENT CLAIMS:
ADJ-R: 20 TCN-TO-CREDIT: 3-05150-00-040-0000-58 NET 0.00 0.00 4898.43
*JOHNSON JAMES RECIP ID: 0600333444 PATIENT ACCT #: 055
0-05200-22-456-1010-00 22000.00- 0.00 0.00 0.00 0.00 0.00 261.26- 21738.74
01 01/05/05 T1015 80- 11000.00- 0.00 0.00 0.00 0.00 0.00 130.63- 10869.37-100000001 M DDCW
02 01/18/05 T1015 80- 11000.00- 0.00 0.00 0.00 0.00 0.00 130.63- 10869.37-100000001 M DDCW
*JOHNSON JAMES RECIP ID: 0600333444 PATIENT ACCT #: 055
0-05200-22-456-2010-00 22000.00 0.00 0.00 0.00 0.00 0.00 5355.63 16644.37
01 01/05/05 T1015 80 11000.00 0.00 0.00 0.00 0.00 0.00 5225.00 5775.00 100000001 M DDCW
02 01/18/05 T1015 80 11000.00 0.00 0.00 0.00 0.00 0.00 130.63 10869.37 100000001 M DDCW
ADJ-R: 20 TCN-TO-CREDIT: 3-05040-00-030-0000-55 NET 0.00 0.00 5094.37
REMITTANCE T O T A L S
PAID ORIGINAL CLAIMS: NUMBER OF CLAIMS 88 --------- 491,364.85 491,364.85
PAID ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 5 --------- 8,206.02 8,206.02
DENIED ORIGINAL CLAIMS: NUMBER OF CLAIMS 0 --------- 0.00 0.00
DENIED ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 --------- 0.00 0.00
PENDED CLAIMS (IN PROCESS): NUMBER OF CLAIMS 0 --------- 0.00 0.00
AMOUNT OF CHECK: ------------------------------------------------------------ 499,570.87
---- THE FOLLOWING IS A DESCRIPTION OF THE ADJUSTMENT REASONS THAT APPEAR ABOVE: COUNT:
21
What to Do If There is a
Problem With a PA…
Refer to your copy of the PA
letter. Is something not
matching your claim?
Contact your ISC Case
Manager if PA needs
amended.
If you need a copy of your PA
letter, or a PA number contact
ACS.
22
Timely Filing Requirements
12 months from last date of service for a
claim to be submitted and paid
6 months from paid date for an adjustment
of underpaid claim to be submitted and
paid
Adjustment requests for overpayments are
accepted indefinitely
23
Other Ways ACS Can Help
Client eligibility
Provider training
Written correspondence
Check status of claim
Don’t know who to ask? We can direct
you.
24
Other Frequently Asked Questions
How long should I keep my records?
You need to keep your records on file
for 6 years from the end of the fiscal
year.
When do I have to re-enroll?
If your tax ID changes, if you move
out of state, or you haven’t billed in
over 2 years. You will need to re-
enroll through DDD. When any of
these circumstances occur, please
contact DDD.
25
THE END
26
Related docs
Other docs by gvj12004
Sample of Cape Internal Assessment State of Readiness NSC 2010 Presentation to the
Views: 1573 | Downloads: 0
