Correcting MCO Information

This module is for discussing how to correct MCO information on

Patient and Encounters

MCO # 3 – Passport/Amerihealth

6 – Coventry7 – Kentucky Spirit

8 – Wellcare9 - Humana

Medicaid Payor Codes 2 – KY Medicaid22 – HANDS23 – Passport24 – Amerihealth26 – Coventry27 – KY Spirit28 – Wellcare29 - Humana

We will cover 3 different scenarios.

• Claim billed to KY Medicaid but should have billed to an MCO

• Claim billed to MCO but should have billed KY Medicaid

• Claim billed to MCO but denied• Claim billed to the wrong MCO

We will cover 4 Scenarios in this power point.

The claim billed to KY Medicaid and should have billed to an MCO, take

the following steps to correct.

Scenario #1

Now Report 578 looks like this

EOB Codes 24 & N30

These codes mean that the claim should have been billed to a Managed Care Organization

On Patient Registration, set the visit date to the date the patient

was originally seen.

Set your Reason for Visit.

Set the Medicaid MCO and the MCO Member #

Ask for a PEF and Registration Label. DO NOT check ‘Additional Pef?’.

DO NOT print the labels. You may hand write the corrections on the CH-5 with the effective date and

initial and date

For GUI users, here is the path to get to the NERI screen.

Call up the patient’s NERI screen

Select the encounters and put the MCO# in the Par# field and transmit.

For GUI users, here is the path to get to the PERI screen.

If you call up the PERI, it will now reflect that the MCO has been added to the encounter.

The CPOD will not be necessary for this

scenario.

After the corrections have been made and the MCO # has been added via the NERI screen, the PEF will automatically bill off to

the correct MCO at the next billing.

Check the appropriate invoice register report the following week

to verify services billed.

Adjust off the A/R Invoice that was set up for KY Medicaid

It is your agency’s decision on when to adjust off the invoice

that was set up for KY Medicaid. DPH recommends

adjusting after next invoice register is created.

The claim billed to an MCO and should have billed to KY Medicaid.

Scenario #2

Now your MCO report will look like this.

Call up the patient’s NERI screen

Select the encounters and remove the MCO# in the Par# field and transmit.

After the MCO # has been removed via the NERI screen, the

PEF will automatically bill off to KY Medicaid at the next billing.

You will not need to CPOD this claim. It

should bill off automatically.

Adjust off the Invoice that was set up for Managed Care at your

agency’s discretion.

The claim billed to the correct MCO but denied.

Scenario #3

Example of denied claim

If denial was due to registration errors, make

the appropriate corrections on

registration screen.

Pull up the encounter, make correction if needed, and re-transmit.

On the encounter history screen, the PC field is the payor code. Since the payor code is 26, we

know that it billed or will bill to Coventry.

For GUI users, here is the path to get to the PARI screen.

PARI Inquiry – Payor codes & MCO #

For GUI users, here is the path to get to the CPOD screen.

When requesting the CPOD screen, make sure you enter the correct PEF# and the payor code you are wanting to rebill. In the example

below, we are rebilling PEF#19581689 and those services that went to payor code 26.

The CPOD screen will only pull the services that went to payor code 26. Information on the screen

can be added, edited or removed.

Make sure you enter the correct A/R invoice number. If the services are paid, this is the invoice

that the money will be posted.

After you make changes and enter the A/R Invoice #, transmit. These services will bill on the

next billing cycle.

If you still type commands in the old way, the CPOD will be executed as shown below. If no

services are pulled, verify your payor code on the PEF.

For claims rebilling to Passport, they can’t be rebilled electronically.

You will need to change the Print HCFA? Flag to Y.

The claim billed to the wrong MCO.

Scenario #4

On Patient Registration, set the visit date to the date the patient

was originally seen.

Set your Reason for Visit.

Correct the MCO# and verify the MCO Member # is correct.

Ask for a PEF and Registration Label. DO NOT check ‘Additional Pef?’.

DO NOT print the labels. You may hand write the corrections on the CH-5 with the effective date and

initial and date

Call up the patient’s NERI screen

Put an X next to the claim to correct, enter the correct MCO# and transmit.

To pull up the CPOD, click on Billing, Rebilling, Medicaid, and then PEF History.

When requesting the CPOD screen, make sure you enter the correct PEF# and the payor code you are wanting to rebill. In the example

below, we are rebilling PEF#19581689 and those services that went to payor code 26.

The CPOD screen will only pull the services that went to payor code 26. Information on the screen

can be added, edited or removed.

Make sure you enter the correct A/R invoice number. If the services are paid, this is the invoice

that the money will be posted.

After you make changes and enter the A/R Invoice #, transmit. These services will bill on the

next billing cycle.

If you still type commands in the old way, the CPOD will be executed as shown below.

For claims rebilling to Passport, they can’t be rebilled electronically.

You will need to change the Print HCFA? Flag to Y.

Any Questions????