Claims Management February 2016

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Overview

• Claim Submission

• Remittance Advice (RA)

• Exception Codes

• Exception Resolution

• Claim Status Inquiry

• Additional Information

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Claim Submission

Life of a Claim

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Claims Intake

Claims are submitted using various methods.

• Electronic Claims

‒ Health Enterprise

‒ Practice Management Software

‒ Payerpath

‒ Crossover Claims via Medicare

• Paper Claims

‒ CMS-1500, Professional Health Insurance Claim Form

‒ UB-04 (CMS-1450), Institutional Claim Form

‒ AK-04, Transportation Authorization and Invoice

‒ J430, American Dental Association Dental Claim Form

‒ AK-05, Adjustment/Void Request Form

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Transaction Control Number (TCN)

Once received, all claims are entered into the system, either electronically or

by data entry, and assigned a TCN.

• TCNs are unique to each claim and determined by multiple submission factors

• The format of this number is YYJJJMBBBBDDDDDDT

•YYJJJ - Year and the current Julian calendar date

•M - Media source code

•BBBB - Conduent internal use

•DDDDDD - Conduent internal use

•T - Transaction code

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Julian Date Calendar

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Transaction Control Number

Media Source Codes Transaction Type Codes

1 - Web submitted claims

2 - Electronic crossover claims

3 - EMC claims

4 - System generated claims

8 - Paper Claims

9 - Pharmacy

0 – Original claim

1 – Void

2 – Credit of adjustment

3 – Debit of adjustment

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Claims Processing

After being assigned a TCN, all claims enter the automated adjudication

process.

• Automated Adjudication

• Claims that are automatically processed

• Manual Adjudication

• If the claim has certain attachments, requires specific or specialized justification

to process or is for a diagnosis or procedure that requires review, it will be

suspended from the automated process for manual processing by a claims

representative

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Suspended Claims

Common reasons for suspended claims:

• Review third-party liability and any attached Explanation of Benefits (EOB)

• Review medical justification

• Manual pricing

If all necessary documentation was properly submitted, no action is required by the

provider while a claim is in suspended status unless contacted by DHSS or

Conduent for further documentation

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Claim Resolution

All claims will adjudicate to a final status of paid or denied.

• Paid

‒ All paid claims will be reflected on your RA

‒ There may or may not be EOB exceptions

• Denied

‒ All denied claims will have EOB exceptions listed on your RA

‒ Look through all of the EOB codes, not just the first few, to decide whether or

not to correct and resubmit

‒ Also use to determine if other actions, such as an appeal may be appropriate

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Remittance Advice

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Remittance Advice

A Remittance Advice is a notice of payments and adjustments sent to providers.

• Once a claim has been received and accepted, it is processed and the appropriate

payment is determined

• Informs provider of submitted claims status

• Adjudicated claims (paid and denied): Claims adjudication in health insurance refers to

the determination of an insurer's payment or financial responsibility, after the member's

insurance benefits are applied to a medical claim

• In-process claims

• Adjusted and voided claims RA Claims Status Codes to look

for:

P – Paid

D – Denied

S – Suspended

O – To Be Paid

C – To Be Denied

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Remittance Advice

RAs, especially the EOB exception codes, can help providers correct denied claims and

prevent future ones

Your RA can tell you how to proceed with denied claims:

• Some denied claims may require additional documentation, such as an EOB or medical

justification, for resubmission

• Some denied claims may be corrected and resubmitted, such as correcting your

NPI/taxonomy information or including a service authorization number

• Some denied claims may require providers to take other actions, such as billing TPL or

getting a service authorization, before resubmission

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Electronic RA – 835

• If you are using approved practice management

software, you may receive your RA a little differently

• If you are submitting HIPAA compliant 837 transactions,

you may receive an 835 transaction as a response

• The 835 is the electronic version of the RA

• You might notice some differences:

– Remark codes returned on an 835 will be HIPAA compliant v5010 X12 remark codes rather than the 4-

character Enterprise codes

• These codes can be found in your Technical Report Type 3 (TR3) guides

– Only one transmission is available - providers must indicate if they want to receive the 835 or if it should be

sent to their billing agent

– The appearance of the 835 will vary depending on the provider’s software

Provider Notice: If using practice management

software, it is your (or the billing agent’s)

responsibility to be able to interpret 835 remark

codes. The Provider Inquiry department does

not have that capability.

- TR3 guides are available for purchase from

www.wpc-edi.com.

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RA Sections

RAs are separated into several different sections, each containing very important information

regarding claims processing.

RAs contain:

• Cover Page

• RA Messages

• Adjudicated Claims

• Adjustments

• Voids

• In-Process Claims

• Explanation of Benefits

• Financial Transactions

• Summary

Helpful Tip: Review all

areas of your Remittance

Advice. It will help you

identify any errors, ways to

correct denied claims, and

prevent future issues. It also

contains helpful notes,

reminders, and training

opportunities, as well as

useful accounting information

throughout.

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Cover Page

The cover page identifies the

provider to which the RA applies.

Provider ID Provider Name Provider Address

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RA Messages

Every RA will start off with a message section. Providers and billing agencies should

read these messages each week.

It contains:

– New information

– Changes in billing procedures or program coverage

– Messages from Department of Health and Social Services (DHSS) and Conduent

– Billing procedures/reminders

– Training schedules

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Example RA message page

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Adjudicated Claims

Adjudicated claims are those that have reached final disposition since the

last payment cycle.

• Paid

• Denied

• Explains how claims were adjudicated

• If claim contains errors or is denied, EOB, or exception, codes will be

listed next to the line item or beneath the individual claim

• Any exception code listed in the RA will be in the EOB Description

section at the end of the RA for quick reference

• If there are multiple exception codes, be sure to look at all of them, not

just the first 1 or 2

• Shows payment date of previously paid claims

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Adjustments are used to make minor corrections to paid claims.

Processed adjustments appear in two parts on the RA:

• Credit: Alaska Medical Assistance credits our account by taking back the money

that was paid incorrectly

– Credit TCNs will end in a 2

• Debit: Alaska Medical Assistance takes money out of our account to pay the

claim correctly

– Debit TCNs will end in a 3

Adjustment Claims

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Voided Claims

A processed void request will result in:

• Reversal of the original transaction

‒ Removal of service and payment information from the provider and

member history files

• Refund back to Alaska Medical Assistance for the full claim amount

• Reduction in claims paid year-to-date dollar amount on RA summary

Any claim with a status of P, D, O, or C may be voided. Suspended claims

cannot be voided.

Common Voids on Paid Claims

• Wrong member ID number

• Wrong provider ID number

• Services not rendered

• Voids related to Medicare

crossover claims:

If paid by Medicaid and also

received payment from

Medicare, provider must void

the claim submitted to Medicaid

and re-bill using the crossover

format.

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In-Process Claims

In-process claims are those claims that have not fully adjudicated. They may require

additional processing steps (status S) or are complete but missed the billing cycle

deadline (status O or C).

• Common reasons for claims to suspend:

• To review third-party liability

• To review medical justification

• No action is required by the provider while a claim is in suspended status, unless

contacted by DHSS or Conduent

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Explanation of Benefits (EOB)

The EOB Description is a complete list of exception codes found on the remittance advice,

including a brief description of each code.

For further explanation or assistance you may:

• Look up more in-depth descriptions using Health Enterprise www.medicaidalaska.com

‒ Documentation>Documents & Forms>Exception Code Lookup

• Call Provider Inquiry

‒ Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650 (toll-free),

option 1,1,1

1140 The Through Service Date on Claim Header is Missing or Invalid.

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Financial Transactions

Financial transactions are payment or recoupment transactions: for example,

provider reimbursements or processing a voided claim that was already paid out.

• This section only populates on the RA if there are applicable financial transactions

for the pay cycle

• Financial transactions may appear on consecutive RAs as each part of the

payment or recoupment process takes place

Provider Tip: If you notice this section but the full

transaction doesn’t appear on that particular RA,

look at the RA from the previous week or wait for

the next pay cycle for the rest of the specific

transaction.

This is an example of what a Financial Transaction section would look like if a provider were overpaid as a

result of paid claims that are then voided.

The 1st part shows how the particular

transaction(s) will affect the current pay

cycle.

Negative amount = provider overpayment

The 2nd part contains details of

each transaction affecting the

current pay cycle.

The RA Summary accounts for

financial transactions as a separate

line item that is applied to cycle totals

and applicable balances. Any negative

balance will be deducted from the total

cycle payment. If overall cycle total is

negative, the negative balance will be

carried forward to the next cycle for

recoupment.

The financial transaction(s) would show here

for accounts receivable purposes.

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This is the next week’s RA for the previous example showing the overpaid balance from the voided claims

being applied to the next cycle.

The 1st part again shows how the particular

transaction(s) will affect the current pay cycle.

Postive amount = provider payment reduction

The 2nd part contains details of each

transaction affecting the current pay

cycle.

For example, recoupment of previous

week’s negative balance.

The RA Summary shows how the financial

transactions were applied to cycle totals

and applicable balances.

In this case, a reduction of payment to

account for prior overpayment due to void.

The recoupment shows here as a prior

balance that is deducted from the current cycle

in the full amount.

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Summary Page

Each RA includes a summary of all provider claims data.

• Shows the current cycle and year-to-date total dollars paid to and collected from

the provider

• After each calendar year, Conduent sends each provider a 1099 tax statement

showing total calendar year Alaska Medicaid reimbursements

‒ Information will match year-to-date total paid on last RA issued for calendar

year

‒ Contact Conduent regarding discrepancies

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Exception Codes

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What is an “Exception”?

Some claims have what is called an exception attached to it.

• Exceptions are codes signifying an issue on a submitted claim

• Listed as Explanation of Benefits (EOB) codes

• Generated manually (claims personnel) or automatically (MMIS)

• Composed of four numeric digits

• Appears on your RA in multiple areas

• Used as information to help correct errors or help rebill denied claims

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Hierarchy of Exception Codes

Claims data is reviewed in a “hierarchy”, from most important details to least

important to determine if the claim needs to be suspended, reduced, or

denied.

• For example, member and provider eligibility are reviewed before the rest

of the claim; if either is determined ineligible, the claim is denied before a

full review of the submitted claim is complete

• Review and correct entire claim before trying to resubmit

• A complete list of exception codes identified throughout the RA can be

found in the EOB Description section of the RA (just before Summary)

Header Level EOB

Line Level EOB

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Exception Code Online Inquiry

Exception codes can be looked up online using www.medicaidalaska.com

• Under Documentation, select Documents & Forms

• When the documents and forms page comes up, select

Exception Code Lookup

• Enter the code you want a description for and click Submit

A complete exception listing can be

downloaded by clicking on the

Exception Listing for Providers link.

If you need more information about an

exception code, contact Provider

Inquiry at 907.644.6800, option 1,1 or

800.770.5650 (toll-free), option 1,1,1.

It is important to review all exception codes associated with each claim, being careful to look at details, to determine a

course of action.

• For example, this claim has five exception codes attached to it:

Reading Exception Codes

The code attached tells you that this claim is in a

suspended status for further review

Based off all attached codes, there is an issue with the

Medicare Crossover and the NDC listed on the claim

These errors could be as simple as making a NDC

typographical error and mislabeling timely filing

justification attachments; a complete review of the

claim would help you determine what is actually

happening

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Suspended Claim Codes

A “suspended” claim is one being held for manual review by:

• Conduent

• State of Alaska

No action is required by the provider unless directly contacted.

These are all examples of exception codes that indicate a claim has been suspended for

further review:

1922 – Explanation of Medicare Benefits (EOMB) requires review

4076 – Review for Medical Justification - Professional Claim Types

4427 – The Procedure Code and Modifier submitted on the claim require manual review

6430 – Cost Avoid for no TPL dollars but EOB exists

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Denied Claim Codes

A denial code indicates a denial and reason for the denial.

• Providers should review all denial codes

Some denied claims can be resubmitted after correcting errors:

• may require resubmission with additional documentation

• may need corrected information before resubmission

• may require providers to take other actions, such as billing TPL, before

resubmission

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Denied Claim Codes

These are examples of common denial exception codes:

1030 – Billing provider number missing or invalid

1320 – Member number missing or invalid

1882 – Claim exceed timely filing and no proof of timely filing attached

2006 – The Dates of Service on the claim are after the Member's eligibility end date

2020 – Claim DOS after Member DOD

3005 – Billing provider not actively enrolled on DOS

6512 – Code pairs found to be unbundled in accordance with National Correct Coding Initiative

(NCCI) for Practitioner or ASC

6600 – Exact duplicate

8040 – The Number of Units on the Claim have exceeded the Service Authorization Approved

Number of Units

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Exception Resolution

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Exception Resolution - TPL

Exceptions related to Third-Party Liability (TPL)

• If member has other health benefits that may be responsible for partial or total payment of

a claim, those benefits are primary and must be billed first

• Exceptions:

• Indian Health Services (IHS)

• Services for which a federal TPL waiver has been granted

• Providers will also receive a denial exception code if the explanation of benefits of the TPL

is not attached to the claim

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Exception Resolution - TPL

How can I tell if a member has other coverage?

• Alaska Medical Assistance eligibility coupons and cards

• Resource code / carrier code

• Automatic Voice Recognition System (AVR)

• Look up the member’s eligibility information in Health Enterprise

• Provider Inquiry

• 907.644.6800, option 1,2 or 800.770.5650 (toll-free) option 1,1,2

• You can review the specific carrier codes on http://medicaidalaska.com under

Documentation>Documents & Forms>TPL Carrier Lookup

TPL Carrier Lists can be found on

http://medicaidalaska.com

• Documentation > Documents & Forms

• Select TPL Carrier Lookup

Exception Resolution – TPL Verification

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If the member is covered under another government program, they will have one of the following resource codes listed:

Government Agency

Resource Codes

G/H/J

Medicare

M

Tricare

N

Veterans

Administration

(VA)

N2

Veterans Greater

than 50%

Disabled

P

Alaska Area

Native Health

Services

Y

No Other

Insurance

Exception Resolution – TPL Verification

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Exception Resolution – Member Eligibility

If a denial is received because of member eligibility:

• Verify member eligibility dates

• Member may be eligible for retroactive eligibility to cover date of service

• Member should provide updated information to provider

• Refile claim to Alaska Medicaid after eligibility has been updated

These are examples of possible member eligibility exception codes:

2005 – DOS is prior to Member’s eligibility begin date

2006 – DOS is after Member’s eligibility end date

2008 – Member’s eligibility does not cover entire period between From and

Through DOS

2011 – DOS is after Member’s eligibility end date with attachment

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Exception Resolution – Procedure Code

If a denial is received because procedure code/item not covered for Medicaid:

• Check procedure codes on the claim

‒ Was the most appropriate code reported on the claim?

‒ Are you qualified to provide that service per your specialty?

• Review billing manual or fee schedule for a list of covered services

‒ Is procedure code covered?

• If procedure code is not valid:

‒ Determine correct billing code

‒ Verify validity of new code

• Send in new claim with corrected information

Provider Tip: Make sure you are using

the appropriate fee schedule for the DOS

time period. Billing manuals and fee

schedules can be found on

http://medicaidalaska.com in the

Documents & Forms section

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Exception Resolution – SA

Some denials result from service authorization requirements.

• If proper SA was obtained, was SA number and associated information correct

and recorded on the claim?

‒ If not, rebill claim with correct SA information

• Does procedure code match service that was authorized?

‒ If not, rebill with correct code or have service authorization amended to correct

code

• If SA was not obtained but required, contact appropriate authorizing entity to

obtain SA

Provider Tip: Refer to fee schedules and

billing manuals to determine which

services require a service authorization.

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Exception Resolution – Timely Filing

Some claims deny because they exceed the 12-month timely filing limit.

• All claims must be filed within 12 months of the date services are provided to a

member

• 12-month timely filing limit applies to all claims, including those that must first

be filed for TPL or Medicare crossover

• Claims denied with this type of exception code cannot be corrected and

resubmitted; you may only appeal the decision

• A claim denied for timely filing may be appealed within 180 days from the initial

denial date

Member Retroactive or

Backdated Eligibility

There are times when a

member is granted

retroactive or backdated

eligibility. If this occurs, the

member should forward all

appropriate documentation

to their provider. Providers

have the ability to file claims

for the retroactive timeframe

if this documentation is

attached to the claim. Even

with this documentation,

there is still a time limit to

file, so don’t delay.

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Exception Resolution – Other

Other common exception codes include incidental procedures and medical

justification requirements.

• A procedure is considered incidental when carried out at the same time as

a primary procedure and is clinically integral to the performance of the

primary procedure; these procedures should not be billed separately

‒ Provider will receive a denial but it is possible to appeal with proper

justification

• A procedure code billed might require medical justification/records for

service rendered; fee schedules and billing manuals denote supporting

documentation requirements for procedure codes

‒ Rebill with supporting documentation attached

• Medical records

• Chart notes

• Doctor’s orders

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Exception Resolution – Duplicate Billing

A duplicate billing error occurs when two claims are submitted with some or all of

the same information.

• This can include, but is not limited to:

‒ Dates of service

‒ Charges

‒ Member’s ID

‒ Provider’s billing ID

‒ Procedure codes

• This can happen if:

‒ Two different providers bill for the same/overlapped DOS or same procedure

for the same member

‒ Same provider sends the same claim more than once

‒ Entire bill resubmitted to add/change charges on a previously paid claim

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Exception Resolution – Duplicate Billing

These are examples of possible multi-provider duplicate exception codes:

6610 – Inpatient or Nursing home claim vs. Personal Care Services - duplicate

6604 – Possible Conflict/Different Provider

To resolve this type of error:

• Check your records – rebill with corrected information if necessary

• Contact other provider to address the issue

• If the paid provider billed incorrectly, they must void their claim

• Second provider can bill once the incorrectly paid claim is voided

Provider Tip: If both providers did actually

provide the same service on the same date to

the same member, the provider submitting their

claim first is paid. The other provider will need to

appeal the denial documenting the duplicated

service.

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Exception Resolution – Duplicate Billing

These are examples of multiple submission duplicate exception codes:

6600 – Exact Duplicate

6602 – Possible Duplicate

To resolve this type of error:

• Keep up-to-date records of all claims

• If duplicate services medically necessary, appeal with proper justification

• If you filed electronically and think the duplicate submission might be the result of a glitch,

contact your vendor

• When charges need to be added, deleted or changed, file an adjustment

‒ Do not rebill the whole claim as an original

• If the change involves TPL, be sure to include EOB with your adjustment

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Prevent Duplicate Billing

Many duplicate denials can be prevented.

• Routinely check claim status, especially before trying to re-bill

• When adding charges to a DOS, adjust the already paid claim instead of rebilling

• Be careful of duplicate revenue codes and HCPCS when billing both inpatient and

outpatient claims for the same member and DOS

• If “duplicate” services are medically necessary, be aware appeal may be necessary

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NCCI Exceptions

National Correct Coding Initiative (NCCI) exceptions were developed by CMS to

promote appropriate coding methods and reduce improper coding that could lead to

payment errors.

• Part of the Patient Protection and Affordable Care Act of 2010

• In effect October 1, 2010

• Any NCCI exception on a claim will cause a denial and requires an appeal for

reimbursement; first level NCCI exception denials go to Conduent

• Members cannot be billed for services denied for NCCI exceptions

• For appeals questions and information, contact the Appeals Department at

907.644.6800 option 8 or 800.770.5650 (toll-free), option 1,5

• http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-

and-Systems/National-Correct-Coding-Initiative.html

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NCCI Exceptions

Two types of NCCI exceptions:

• Procedure-to-Procedure (P-P)

– Defines pairs of HCPCS/CPT codes that should not be reported together

• Medically Unlikely Edits (MUE)

– Defines the maximum number of units of service for each HCPCS/CPT code a

provider would report under normal circumstances for a single member on a

single date of service

• Applied to practitioners, ambulatory surgical centers, outpatient services, and

durable medical equipment claims

• Each NCCI exception has a Correspondence Language Example Identification

Number (CLEID) that gives a rationale and is used for all related correspondence

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Claim Status

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Claim Status Inquiry

There are many methods for checking a claim’s status.

• Login to your Health Enterprise account

‒ Under the Claims tab, select Claim Status Inquiry

‒ Enter the search criteria for the claim(s) you are looking for

• Fax a Check Amount and Claim Status Inquiry form to Provider Inquiry at

907.644.8126

‒ Be sure that all included information is legible if handwritten

• Call Provider Inquiry at 907.644.6800, option 1,1 or 800.770.5650 (toll-free),

option 1,1,1

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Claim Status Form

This form can be found on

http://medicaidalaska.com

•Documentation > Documents & Forms >

Forms

•Select Check Amount and Claim Status

Inquiry Form

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Electronic Claim Status Inquiry

• If you are certified to submit a HIPAA compliant 276 inquiry transaction and

receive a 277 response transaction, you may check your claim status

electronically.

• You must successfully test these transactions

• Contact the Conduent Electronic Data Interchange (EDI) Coordinator

‒ 907.644.6800, option 3 or 800.770.5650 (toll-free), option 1, 4

• You must have some form of practice management software that supports these

transactions

‒ Refer to companion guides for electronic transaction information:

http://manuals.medicaidalaska.com/docs/companionguides.htm

‒ Refer to the applicable TR3 for further information: http://www.wpc-edi.com

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Additional Information

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Alaska Medicaid Compliance & Ethics Training

• Compliance & Ethics: Alaska Medicaid 101 is a computer-based training which includes

an interactive video presentation and a supplemental handbook

• This training serves to:

‒ Familiarize providers with the responsibilities and requirements associated with being a

Medicaid provider

‒ Guide providers through the laws and regulations Medicaid providers must follow

• The training is available at http://learn.medicaidalaska.com

‒ Select Provider>Compliance & Ethics

• Alaska Medicaid provides a certificate for completing this training

• Please direct any questions to the Provider Training department at 907.644.6800 or

800.770.5650

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Additional Resources

Alaska Medicaid Health Enterprise website at http://medicaidalaska.com

– Information necessary for successful billing

– Includes provider-specific Medicaid billing manuals and fee schedules

• You may also call:

– Provider Inquiry

• Eligibility only – 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2

• Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650 (toll-

free), option 1,1,1

– EDI Coordinator

• Electronic transaction inquiries – 907.644.6800, option 3 or 800.770.5650 (toll-free),

option 1, 4

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