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CLAIMS MANUAL FISCAL YEAR 2019-20

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TABLE OF CONTENTS

INTRODUCTION 3 ELECTRONIC CLAIM SUBMISSION (ECS) AGREEMENT 3 TRADING PARTNER AGREEMENT (TPA) 3 CLAIM SUBMISSION GUIDELINES 4 ALPHAMCS CLAIMS PROCESSING 5 SUBMITTING COB INFORMATION ON CMS1500 5 SUBMISSION VIA AN 837 5 RETRIEVAL OF 835 6 TRANSACTIONAL UPLOAD AND DOWNLOAD QUEUE 6 REMITTANCE ADVICE (RA) REPORTS 9 VERIFYING AGENCY DETAILS 13 IMPORTANT CONTACTS 14 IMPORTANT RESOURCES 15 FREQUENTLY ASKED QUESTIONS 15 APPENDIX A: Manually Entering a Claim/Claim Search (AlphaMCS University) http://www.alphacm.net/mcsuniversity/documents/finance/fin_Manually%20Entering%20a%20Claim.pdf

APPENDIX B: Claims Denials Guide (AlphaMCS University) http://www.alphacm.net/mcsuniversity/documents/general/AlphaMCS_Version_2_Denials_Guide.pdf

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Introduction Welcome to fiscal year 2019-2020. This document will provide you with basic information regarding the claims process at Alliance Behavioral Healthcare. It will be posted on our website www.alliancebhc.org under: Provider>Finance and Claims Resources. This document is intended to supplement other claims guidance and instructional material found on the DMA, DMH, NCTracks, Alliance, and AlphaUniversity webpages. Providers are encouraged to follow the Alliance Provider Newsletter on a weekly basis for notification of claims processing changes throughout the year. We hope that this manual allows you to clearly understand the billing requirements for Alliance Behavioral Healthcare as well as give you insight to the billing process and available resources. AlphaMCS will be used for processing State and Medicaid service claims filed through Alliance Behavioral Healthcare. NCHealthchoice claims should be billed through NCTracks. Claims questions and needs can also be reviewed and discussed directly with a provider’s assigned Claims Research Analyst by phone, by email, or in-person (by appointment). Please remember that when communicating via email, providers should adhere to HIPAA/Confidentiality best practices. Please note that the prompt pay guidelines state that the LME-MCO has 18 days to approve a claim and 30 days to pay after approval-- allowing a total of 48 days for processing payments. Providers are encouraged to consider this in their revenue cycle design and to plan accordingly. Providers may contact their assigned Claims Research Analyst at any time with questions, concerns, requests for training or technical assistance. Providers may also contact a Claims Supervisor for assistance. Should these contacts not meet the provider’s needs, the provider may also contact the Claims Director or our CFO. Contact information is included at the end of this document.

Electronic Claim Submission (ECS) Agreement Alliance Behavioral Healthcare requires an attestation for claims submitted through the provider portal. We have created an Electronic Claims Submission (ECS) agreement for this purpose. All providers must sign this agreement. The original agreement will be maintained at Alliance Behavioral Healthcare. The agreement needs to be signed only once for the fiscal year. It will be in effect for the entire fiscal year or until the provider makes changes to addresses, contacts, etc. Additionally, the Alliance Notice of Change form must be completed and submitted to the Contracts Department when any change occurs. *Please note that the ECS Agreement will be sent with your contract. Please sign and return it with your contract. If you do not receive an agreement or misplace it, please obtain it from our website www.alliancebhc.org We cannot release a check to your agency unless we have this agreement on file. Trading Partner Agreement (TPA) The Trading Partner Agreement (TPA) will be used for submission of 837s. Providers will receive a TPA with their contract. The TPA can be used for both State and Medicaid claims. The agreement needs to be signed only once for the fiscal year. It will be in effect for the entire fiscal year or until the provider makes changes to addresses, contacts, etc. Additionally, the Alliance Notice of Change form must be completed and submitted to the Contracts Department when any change occurs. Please note that this agreement will be sent with your contract. Please sign and return it with your contract. If you do not receive an agreement or misplace it, please obtain it from our website www.alliancebhc.org We cannot release a check to your agency unless we have this agreement on file.

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Claim Submission Guidelines for FY19-20 The claim submission deadlines for Medicaid and State contracts are different. Both timelines are stated in the respective contracts and are also listed below: State or Locally Funded Services - Original and/or replacement claims must be submitted within sixty (60) days of the date of service. - When a replacement claim is received, the original claim will be recouped and the replacement claim will be

processed. If the replacement claim denies when processed, the original claim payment will not be reissued. - If a claim cannot be submitted by the above deadlines due to an authorization delay or AlphaMCS system correction

or update, the claim must be submitted within ten (10) business days of receipt of authorization or AlphaMCS system correction or update.

- Rate changes will be communicated in the provider newsletter and will be posted on our website unless it is provider-specific, which will be communicated via email.

********Please remember that it is imperative to our State funding that claims be submitted on time. Your submission of claims has a direct impact on how soon we draw down our funds. If we do not draw down our State funds, the state will reduce our funding which could impact your agency************ Medicaid Services - Original claims must be submitted within ninety (90) days from the date of service. - Replacement claims can be submitted within ninety (90) days of the original submission date. The original claim will

be recouped and replacement claim will be processed. If the replacement claim denies, the original payment will be reissued.

- If a claim cannot be submitted by the above deadlines due to an authorization delay or AlphaMCS system correction or update, the claim must be submitted within ten (10) business days of receipt of authorization or AlphaMCS system correction or update.

- Coordination of Benefits - Effective 01/01/16, the Provider must submit a secondary claim within 180 days of the date of service to be within

the timely filing deadline. The primary EOB must be uploaded to the patient portal at time of claim submission. - Retro Medicaid/Authorization

Should Medicaid be activated after services are rendered, the provider must submit a claim within ninety (90) days of the retroactive Medicaid being activated for unmanaged services. For managed services (requiring an authorization), the provider must submit the claim within ninety (90) days from the authorization for managed services.

Taxonomy - Beginning 8/1/17, claims must include valid Billing Taxonomy and valid Rendering Taxonomy numbers. The

NPI/Taxonomy on the claim must match the information in the provider’s AlphaMCS setup as well as the information in the provider’s NCTracks profile. Claims Research Analysts can assist providers with identifying which NPI/Taxonomy combinations are active for use with claims.

- Electronic Claim files with missing taxonomy information (blank fields) may be rejected and not processed in AlphaMCS.

AlphaMCS Claims Processing AlphaMCS has a web-based provider portal that allows providers to submit claims to the LME/MCO. Claims can be submitted via a CMS 1500/UB04 or via an 837P/I. The daily cutoff for nightly adjudication is 5pm. The claims are

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adjudicated nightly. For claims submitted via CMS1500/UB04, the claims status is updated in the provider portal (download queue) the next business day. The Remittance Advice is available the following week (see Checkwrite Schedule). Claims submitted via 837s will have adjudication information on the 835s which will be available according to the standardized checkwrite schedule. The Claim Research Analysts review the claims processed on a daily basis to ensure claims are approving correctly, to review denials for possible system errors, and to review any claims that pended for manual review. The reviews are performed to ensure that claims are processed efficiently so that payment can be made timely. Alliance requires all Network providers to either submit claims through the AlphaMCS Portal or to file claims electronically through an 837. All paper claims submitted to Alliance by Network providers will be returned unprocessed to the provider. The instructions below will cover how to submit a claim via the CMS 1500 or UB04 as well as the process for 837 testing and submission.

Manually Entering a Claim into AlphaMCS Portal See attached Appendix A- “Manually Entering a Claim/Claim Search”

Submitting Secondary Claims Submission of secondary claims will require that the related EOBs are uploaded into AlphaMCS. Providers should upload the EOBs at the time of claim submission. When keying secondary claims you must enter the information needed from the primary EOB as highlighted below. “COB amount” refers to the value paid by primary insurer and “COB Allowable Amount” refers to the value the primary insurance allows for the service billed. You must also include a “COB Reason” in order for the claim to be recognized as a secondary claim.

COB PAYMENT AMOUNT For approved Secondary claims, Alliance will either: 1. Pay the difference up to the Medicaid amount, or 2. Not pay any additional amount if primary pays more than Medicaid allowed amount.

Submission of Claims via an 837 Providers, including hospital facilities, have the option of submitting claims through a HIPAA compliant 837. To learn more about 837s, please go to our website http://www.alliancebhc.org/providers/finance-and-claims-forms to access our 837 Companion Guides. Providers may also call 919-651-8500 option 2 for more information on the 837 process. Once an agency is EDI Certified, a secure FTP login and password will be assigned. 837s may be submitted using this method or by uploading the file through the provider portal using the instructions below.

1. Using the menu, choose Transactional Upload Q

2. Click on “Upload file”.

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3. Choose the file to upload. 4. Click Save.

Please note that “EDI Certified” must be checked under you provider information in order for the 837s to be uploaded to Alliance. If you have submitted your claims and are not seeing them in your system please email claims@alliancebhc.org with a contact phone number so assistance can be given.

Retrieval of 835 Agencies submitting 837s will be able to retrieve 835s on checkwrite dates. The 835s can be retrieved using the agency assigned secure FTP or via the provider portal using the instructions below.

1. Using the menu, choose Download Q.

2. Files will be listed. The user may select the applicable file and click on download.

TRANSACTIONAL UPLOAD & DOWNLOAD Q Transactional Upload: The instructions below will assist you with uploading an 837 file. If your agency does not upload files via 837, proceed to the Download Que instructions. The Transactional Upload Q module allows you to upload files, such as 837 files which contain the claims you want the MCO to process, into their system.

Click the Upload File button, choose the file from your local computer and click the Save button. The Download Q module allows you to download files your MCO has waiting for you.

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Exporting from the Download Queue To export from the Download Q, click on the checkbox to the left of the document you want to download, then click the Download button. *To see the claims that you have billed, select the option that says: current_claims (not current_client).

Note: The MCO that the file is from is listed in the file name right before the ‘.txt’. If you are contracted with multiple MCO’s you will receive the same file (in this case, the client dump) daily from each MCO. When you click the Download button, it will may ask you if you want to leave the page or not. Click Leave this Page.

After the file has been downloaded, it will either show at the bottom of your screen or a pop-up will display asking if you want to open or save it. Click Open. If it asks what you want to open it in, choose Excel. If you’re not given the option, you can open the file in it’s .txt version. When it’s open, go to File on the menu bar and choose Save As.

Files that will be available are:

- Response files – 999’s, 824’s and 277’s - 835’s - Current Client Dumps (Current_Client_) – runs

daily. This shows all clients for which the provider has submitted claims, has an authorization, has an enrollment, has an appointment, has a SAR, has a client update request, or is marked as the clinical home.

- Current Auth Dumps (Current_Auths_) – runs daily. This shows info for authorizations that have not ended within the last 90 days.

- Current Claims Dumps (Current_Claims_) – runs daily. This shows all claims inserted within the last year.

If 835’s aren’t showing on your Download Q, check your Provider Details module. On the Base tab, if your company doesn’t have Certified for EDI checked OR if it is checked but there’s a clearing house chosen, you will not receive 835’s from the system.

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You’ll want to resave the file name by taking out the .txt and putting in .xls instead. When you’re done, click Save. Don’t worry about the Save as type dropdown.

Go to where you saved the file and open it. Click on the A column,

then go to your Menu Bar and click Data.

Next, click the Text to Columns button.

There will now be a series of pop-ups. Select Delimited from the screen and click Next. In the following screen, uncheck Tab and check Other. Then enter a solid vertical line in the text box. This line can be found on your keyboard just above the Enter key. Click Shift and this key to enter the line into this text box, then click Next.

On the next screen, select General, then click Finish. You will now see the report in a more easy to read format.

Remittance Advice (RA) Reports If claims are manually entered into the AlphaMCS Portal, the provider will need to access the Remittance Advice Report for posting information.

Make sure to save the file somewhere you’ll remember, like My Documents

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RA Reports will be available following every checkwrite date. Providers can select RAs by date range according to check date or claim processing date.

1. Using the menu, choose RA reports.

2. The user can search by a specific check number, check date or claim processing date. The RA will appear in the box below for the user to retrieve.

How to read your RA: The RA is grouped by four adjudication decisions: Approved claims, Denied claims, Sub-Capitated claims and Recoupments (Credit Memos). From within each adjudication group, there are sub-groups broken down by funding source (State or Medicaid). From within the funding source grouping, it is then sub-grouped by consumer. Lastly, within the consumer grouping, claims are in order by date of service-- with subtotals under each grouping. RA Outlined: Grouping is visualized as below 1) Paid Claims

a) State Claims i) Consumer

(1) Date of Service b) Medicaid Claims

i) Consumer (1) Date of Service

2) Denied Claims a) State Claims

i) Consumer (1) Date of Service

b) Medicaid Claims i) Consumer

(1) Date of Service 3) Sub-Capitated Claims

a) State Claims i) Consumer

(1) Date of Service b) Medicaid Claims

i) Consumer (1) Date of Service

4) Recoupments (Credit Memos) a) State Claims

i) Consumer (1) Date of Service

b) Medicaid Claims i) Consumer

(1) Date of Service

RA Break Down (TOP)

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Header Information: The RA header displays core MCO and payment information such as contact information, check number, check amount claims type and processing dates.

Claim Field Labels: at the top of every page, there is a frozen pane that identifies what each data element on the claim represents. It will look as below:

Paid Claims (TOP): Below is an example of a paid claim. Notice how all three claims came in on the same claim header, but broken down per claim line. Since adjudication is at the claim line level, then this claim is viewed as 3 separate claims on the RA.

In the above example, you’ll notice that 6 units were billed per day. Although each claim line was approved, you’ll notice that the paid amount was adjusted due to claimed amount is higher than the contract amount. Billed Amount ($417.00) - (6 units * contract rate of $31.41) = Adjusted amount $228.54 to pay $188.46. Under the reason codes, 2 meaning the claim was approved after adjusting paid amount to equal the contract rate (indicated using the number one). Since the funding sources are grouped, you’ll have a subtotal for State Claims and a sub total for Medicaid claims.

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Denied Claims (TOP): Denied claims are also grouped together as well as broken out by funding source with it’s own sub total. On the claim line that denied, the denial code is also listed. Reason codes are defined at the end of the RA to assist in working denials. In this example the denial reason is 25 which is for “Invalid POS & Service Combo.”

Shown below is the sub total of denied claims for State services which is listed earlier in this sample RA. This will show you the numbers to get the total amount above in gray:

Sub Capitated Claims (TOP): sub capitated claims are listed in the next section of the RA. This will look very much like Fee for Service claims except a dollar amount will be indicated in the subcap field as listed below:

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**Note: Do not let the denied amount confuse you. This is basically stating that the FFS paid amount is “denied” because the provider is already being paid for the service and the encounter claim submitted was approved at the contracted rate. Claim was adjusted to the contracted rate. (Contract rate * 4 = $78.68. ) Recoupments (Credit Memos) (TOP): the last grouping of claims are where recoupments and credit memos are identified. Each line will display the claim where a recoupment or CM was applied as well as identify the source claim from where the CM came from:

The highlighted verbage explains exactly what happened: “The payment for Clm_adj_ID A was used to reconcile a CM created for the recoupment of Clm_adj_ID B which was originally paid by a previous CM. This transaction satisfied 79.24 of the 79.24 CM.” Reason Code Key (TOP): towards the end of the RA immediately under the grand totals for the RA, is a reason code key that assists in identifying why a claim denied. The listed denial reasons are not all of the MCS denial reasons, but a list of denial reasons on the RA you are looking at. So the below list of denial reason are currently on this sample RA:

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Field Descriptions (TOP): at the very end of the RA, field descriptions are listed to assist in navigating and reconciling the RA.

How to verify EDI Certification Under the main menu, choose Provider Details. Click on the number 3 to expand the view. Please see the “Certified for EDI” box. If it is checked, your agency is EDI certified and we can process any 837 files that are sent from your agency. If you have completed testing for 837s and you do not see that your EDI Certified box is checked, please call 919-651-8500 and choose option 2 – IT/837 support. Any claims submitted via an 837 will not be processed if the EDI Certified box is not checked. Please limit your first 837 file to no more than 5 to 10 claims.

Verifying Your Agency Details It is critical to verify the details of your agency prior to submission of claims to ensure correct processing. The following instructions review tabs and tiles that are critical in your claims processing. Other tabs/tiles not show but in the Provider Portal are for reference only.

Base Provider Tab From the main menu, choose Provider Details. Click on the number 3 to expand the view. Verify the tax ID, the Medicaid Provider Number (MPN) and the NPI number. The MPN and NPI number listed are what will be considered the “main” numbers for your agency. If you would like us to consider another number as the “main” number, please email us at providernetwork@alliancebhc.org or you may call 919-651-8500 and choose option 4 – Provider Network.

Site Tab On the second tab, the multiple sites for the agency are listed. For this provider, there is a site called “Billing” and a site called “Durham Service”. Your agency may have sites that contain the license name or the street name. Click on the number 3 to expand the view. Verify the address and NPI number for each site. A site can have multiple NPI numbers. This can be considered the “main” NPI number for this site. Note: That when you click on the different sites, the header information will change according to the site name. Here are two views.

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Site Mapping Tab It is important for the agency to verify the MPN and NPI number associated with each site. As you click on the site, that site information will carry over to the Site Mapping tab. The example below shows we are on the Billing site, as verified by the header information, and the MPN is 3402585410 and the NPI is 1234567891.

Contract Tab This is a critical tab in that it will show what services are in your contract, down to the exact procedure code, and at what location they can be provided. The first tile will let the provider know what contracts are in place. In this case, the provider has a state funded contract and a Medicaid contract that both started 7/1/2012.

As the user clicks on the different contracts, note how the information in the other tiles change. To verify the procedure codes, click on a contract and drag the Contract Details tile into the main screen. Note: That this provider can bill for only 5 different procedure codes. What is even more important to note is that they can ONLY be provided at the Billing site. There are no services linked to the Durham Service site. It is important that your agency verify each procedure code to each site. Your billing will not process if you bill a service that is not linked to the right site on this tile.

Important Contacts Alliance Help Desk (919) 651-8500

Option 1 – Claims (Business Operations) for assistance with completion of CMS1500 or UB04, Download Q, viewing Remittance Advices, or assistance with denied claims.

Option 2 - IT/Log in Issues – for assistance with new Alpha portal logins or password resets. Also responsible for the 837 testing and EDI certifications.

Option 3 – Clinical Operations – for assistance with SARS, Client Updates or Client Enrollments.

Option 4 – Provider Network – for assistance with NPI mapping, sites and contract issues.

CLAIMS TEAM: Avery Piercy 919-651-8696 Ashley Jones 919-651-8741 Barbara Morrison 919-651-8865 Belinda Davis 919-651-8876 Chelsea Reid 919-651-8955 Christopher Corley 919-651-8629 Christy Mercer 919-651-8610 Karen Currey 919-651-8620 Todd Penree 919-651-8621

Claims Supervisors: EDI Specialist: Tina Everett (919) 651-8817 Hugh Greene (919) 651-8898 Marilyn Madison (919) 651-8450 Senior Analysts: Amy Stewart (919) 651-8609 Claims Director: Regina Davis (919) 651-8617 Lisa Sullivan (919) 651-8581

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Important Resources A variety of resources have been added to the Alliance website to assist providers with claims processing. The resources can be found under Providers>Finance and Claims Resources.

Frequently Asked Questions and Answers

1) Who do I contact if I need a log in for the Alpha Portal or if I need my password reset? Please call 919-651-8500 and choose option 2 IT/log in issues.

2) I can’t see my Alpha screens very well. The best resolution is 1360x765 screen resolution. If that is not an option try holding down the Ctrl button on the left bottom part of your keyboard and rolling the ball on your mouse if using Internet Explorer. If that doesn’t work, please contact your IT department for additional help.

3) My agency would like to submit 837s. How do I do that? There is a companion guide located on our website at http://www.alliancebhc.org/providers/finance-and-claims-forms. It will provide detailed information on how to proceed with the test process.

4) Who do I contact if any of my NPI numbers are not correct? Email providernetwork@alliancebhc.org or you can contact the help desk at 919-651-8500 option 4 5) Who do I need to contact if I need to update a site address for my agency?

Prior to move, complete a Notice of Change form and send via email to: providernetwork@alliancebhc.org 6) How do I add a practitioner?

Complete a Notice of Change form and send via email to: providernetwork@alliancebhc.org 7) Should I use the UB04 or the CMS 1500?

For all IPRS services billed you will only use the CMS-1500. For Medicaid claims, professional services must be billed on a CMS-1500. Services such as ICF, inpatient, and ED claims are billed on a UB04.

8) How do I see if an authorization is in the system? Navigate in Alpha: Menu>Authorizations>Filter>Patient Search>Enter the consumers last name, first name and date of birth>Highlight the consumer’s name>Click on the Auth Service Tile>Expand the tile by clicking the 3 in the right had corner>The start date (effective date) and the end date are displayed

9) How do I update a diagnosis for a consumer and who do I contact if I am having trouble with this? Your clinical staff will need to do a client update in ALPHA. If you are unsure about how to enter it, please contact Tasha Jennings at tjennings@alliancebhc.org.

10) What place of service should I select? Should I leave it as Pharmacy?

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Each service should be billed where the intervention was performed. Mostly commonly used is the office or home. For more information about place of service exceptions, see the “Alliance POS Mapping” located on our website under Finance and Claims Resources.

11) Where can I find Alliance rates, checkwrite schedule, ECS agreement, Trading partner agreement and Vendor profile form? Under http://www.alliancebhc.org/providers/finance-and-claims-forms

12) What time is the daily cutoff? Cutoff for claims to be processed is every Tuesday at 5:00 pm. Claims will adjudicate every evening and the status of most claims will be available to view the next day. *Please note: processing time can be impacted by AlphaMCS updates. If the system is updating, claims may not process until the update is complete (sometimes not until the next day).

13) How do I request claims research? What if I have a question about specific claims? Utilize the standard Claims Research spreadsheet as a tool to communicate with your assigned Claims Research Analyst. Complete the spreadsheet, email it to your assigned Claims Research Analyst, and you will receive a prompt response.