Saturday, October 18, 2014

Medicare Definition of Clean Claim



A “clean” claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis. Clean claims must be filed in the timely filing period.
The following bullets are some examples of what are considered clean claims:

• Pass all edits (contractor and Common Working File (CWF)) and are processed electronically);

• Not require external development (i.e., are investigated within the claims, medical review, or payment office without the need to contact the provider, the beneficiary, or other outside source) (Note: these claims are not included in CPE scoring).

• Claims not approved for payment by CWF within 7 days of the FI’s original claim submittal for reasons beyond the carrier’s, FI’s or provider’s control (e.g., CWF system/communication difficulties);

• CWF out-of-service area (OSA) claims. These are claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides;
• Claims subject to medical review but complete medical evidence is attached by the provider or forwarded simultaneously with EMC records in accordance with the carrier’s or FI’s instructions;
• Are developed on a postpayment basis; and,
• Have all basic information necessary to adjudicate the claim, and all required supporting documentation

Wednesday, October 8, 2014

License Update Policy - From Molina Healthcare

Health care providers, who under the state plan and/or state statute are required to be licensed in West Virginia (WV) or the state in which they practice, must maintain and ensure that a current license is on file at all times with the West Virginia Bureau for Medical  Services (BMS) Fiscal Agent, Molina.  A provider’s participation in the WV Medicaid program may be terminated if Molina cannot verify the current status of a provider’s license.

Effective October 1, 2009, the Provider License Update Reminder Process is as follows:

***  60 days prior to the license expiration date, an initial reminder letter will be sent to the provider’s correspondence address indicating their current license expiration date.  If an updated license is not received on or before the expiration date, the provider will be placed on pay hold.

***  If a provider fails to submit a copy of their updated license 30 days after the expiration date, Molina will check listings from the licensing boards.  If a provider’s license renewal date can be verified through the board listings, the pay hold will be re-moved.  If Molina cannot verify an effective license renewal date via the board listing, the provider will remain on pay hold.

***  A letter will be sent 30 days after the provider’s license expiration date to providers who have failed to submit their updated license. Molina will not verify license renewal through the licensing boards.  The provider will remain on pay hold until the updated license is sent to Molina.

***  60 days after the license expiration date, Molina will make a telephone call to those providers that have not submitted an updated license. Providers who have failed to send an updated license to Molina will remain on pay hold.

***  90 days after the license expiration date, Molina will determine which providers have not complied and submitted an updated license.  Providers who have not submitted an updated license will receive notification of intent to terminate if the updated license is not received within 30 days.

***  If after 121 days from the initial license expiration date Molina has not received the provider’s updated license, the provider’s claims will be voided from Accounts Payable and the provider will be terminated from West Virginia Medicaid.  A letter will be sent to the provider notifying them of the termination. Instructions on how to resubmit claims for payment for services ren-dered by the provider prior to the expiration date will be included in the letter. All other claims will remain voided and not pay-able.  A listing of voided claims will accompany the letter.

***  Providers may mail or fax a copy of any license renewal information or other credential/ certification updates prior to expira-tion of the current license.  Mailing address:  Molina Provider Enrollment, PO Box 625, Charleston, WV 25322.  Fax: Provid-er Enrollment 304-348-2763.

***  All providers who have mailed or faxed their updated license will continue their Medicaid enrollment without interruption.

Tuesday, September 23, 2014

Billing Medicare - Medicaid patient . Explanation of different Medicaid plan and its coverage

Dual Eligible Beneficiaries

Dual eligible beneficiaries include individuals who receive full Medicaid benefits as well as those who only receive assistance with Medicare premiums or cost sharing. They must meet certain income and resource requirements and be entitled to Medicare Part A and/or Part B and one of the following Medicaid Programs:

• Full Medicaid; or
• Special Need Plans, which include the following four programs:
○ Qualified Medicare Beneficiary (QMB) Program;
○ Specified Low-Income Medicare Beneficiary (SLMB) Program;
○ Qualifying Individual (QI) Program; and
○ Qualified Disabled Working Individual (QDWI) Program.

Dual eligible beneficiaries may choose coverage under FFS Medicare or a MA Plan. Medicare-covered services are paid first by Medicare because Medicaid is always
the payer of last resort. Medicaid may cover the cost of prescription drugs and other care that Medicare does not cover

Full Medicaid

Its coverage either categorically or throught optional coverage groups based on medically need status. Special income levels for institutionalized individuals or home and community based waivers

Medicaid pays for part A and part B premiums and cost sharing for Medicare providers to the extent consistent with Medicaid state plan

QMB Only

Medicaid pays for part A AND Part B premiums, deductibles, coinsurance and copayments for Medicare services furnished by Medicare providers to the extent consisten with Medicaid state plan

SLMB Only
• Medicaid pays for Part B premiums

Prohibited Billing
Under Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, Medicare and Medicaid payments you receive for furnishing services to a QMB are considered payments in full. You may not balance bill QMBs for any Medicare cost sharing (including deductibles, coinsurance, and copayments) for these services. You are subject to sanctions if you bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing).

We could only bill patient if they SLMB plan.

Thursday, September 18, 2014

Exceptions Allowing Extension of Time Limit

Medicare regulations at 42 C.F.R. §424.44(b) allow for the following exceptions to the 1 calendar year time limit for filing fee for service claims:

(1) Administrative error, if failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority (See 70.7.1).

(2) Retroactive Medicare entitlement, where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished. For example, at the time services were furnished the beneficiary was not entitled to Medicare. However, after the timely filing period has expired, the beneficiary subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service (See 70.7.2).

(3) Retroactive Medicare entitlement involving State Medicaid Agencies, where a State Medicaid Agency recoups payment from a provider or supplier 6 months or more after the date the service was furnished to a dually eligible beneficiary. For example, at the time the service was furnished the beneficiary was only entitled to Medicaid and not to Medicare. Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service. The State Medicaid Agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the the timely filing limit has expired

Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization, where a beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups it payment from a provider or supplier 6 months or more after the date the service was furnished

The conditions for meeting each exception, and a description of how filing extensions will be calculated, are described in sections 70.7.1 – 70.7.4.


Where the initial request for an exception to the timely filing limit is made by a provider or supplier, the Medicare contractor has responsibility for determining whether a late claim may be honored based on all pertinent documentation submitted by the provider or supplier, and for the exceptions described in sections 70.7.2 and 70.7.3, based on its review of the relevant information contained in the Common Working File (CWF) database. As explained in sections 70.7.1 – 70.7.4, the contractor will determine if the requirements for a particular exception are met. However, in certain circumstances, the contractor may contact the appropriate CMS regional office (RO) to ascertain whether it wants to participate in the review and decision-making of the specific exception request. In limited circumstances, the RO may conclude that the exception request should go to CMS Central Office for a final determination.

Monday, September 8, 2014

What we can do further if we receive timely filing denial

Filing Claim Where General Time Limit Has Expired


As a general rule, where the contractor receives a late filed claim submitted by a provider or supplier with no explanation attached as to the circumstances surrounding the late filing, the contractor should assume that the provider or supplier accepts responsibility for the late filing.

Where it comes to the attention of a provider or supplier that health services that are or may be covered were furnished to a beneficiary but that the general time limit (defined in §70.1 above) on filing a claim for such services has expired, the provider or supplier should take the following action.

• Where the provider or supplier accepts responsibility for late filing, it should file a no-payment claim. (See Chapter 3 for no-payment bill processing instructions.) Where the provider or supplier believes the beneficiary is responsible for late filing, it should contact the contractor and also file a no-payment claim and include a statement in the remarks field on the claim explaining the circumstances which led to the late filing and giving the reasons for believing that the beneficiary (or other person acting for him/her) is responsible for the late filing. If a paper claim is submitted, such a statement may be attached and, if practicable, may include the statement of the beneficiary as to the beneficiary’s view on these circumstances.

• Where the beneficiary does not agree with the determination that the claim was not filed timely or the determination that he/she is responsible for the late filing, the usual appeal rights are available to the beneficiary. Where the provider or supplier is protesting the denial of payment or the assignment of responsibility, no formal channels of appeal are available. However, the contractor may, at the request of the provider or supplier, informally review its initial determination.

Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download