MACSIS & MITS Medicaid Claims Processing in SFY 2013

Second Planning Group MeetingMarch 7, 2012

Status Update

Focus Group Reports

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Agenda

Welcome & Introductions New Website Focus Group Reports

– New Client Enrollment– Retroactive Medicaid Eligibility & Medicaid Spend Down– Board Access to Data– Medicaid Claims Run Out– Software Requirements for 837P/835 and EDI Standards for TPL

Batch Medicaid Eligibility Verification (270/271) Availability Pharmacy Approach – MH Medications Training Items Other Issues Next Steps

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Go-Live Reality

Today = Wednesday March 7, 2012 Julian Date = 067

Implementation = July 1, 2012 Julian Date = 183

Simple Math: 183 – 067 = 116 days to implement.

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Website

Can get access from the MACSIS Home Page at the Link on the Bottom Right of the Page.

Or directly at:http://mentalhealth.ohio.gov/what-we-do/protect-

and-monitor/macsis/macsis-mits-claims-processing.shtml

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MACSIS Resources

MACSIS Reports

–MACSIS Reports and Files for Boards/Providers 2/29/2012

EDI Transactions

–MACSIS compared to MITS 837 Professional Claim v5010 3/1/2012 DRAFT–MACSIS compared to MITS 835 Health Care Claim/Remittance Advice 3/2/2012

DRAFT

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MITS Resources

EDI Transactions Companion Guides–837P Fee-for-Service Professional Claims–835 Fee-for-Service Health Care Claim Payment/Advice –270 Eligibility, Coverage or Benefit Inquiry–271 Eligibility, Coverage or Benefit Inquiry

Trading Partner Resources–ODJFS Trading Partners Information–ODJFS Authorized Trading Partners – Professional ClaimsTPL change requests–MITS Provider Training Resources - TPL training–Health Insurance FACT Request–Health Insurance FACT Request Instructions–Consumer application and changes to address/eligibility via internetOther–Eligibility Verification Services (EVS) vendors–Medicaid Spend Down Brochure

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MACSIS New Client EnrollmentFocus Group

Enrollments with effective dates prior to July 1, 2012:– No change for either Medicaid or non-Medicaid clients.

Enrollments with effective dates July 1, 2012 and after:– Providers and Boards are not required to enroll

Medicaid clients unless the Board is paying for non-Medicaid services.

– No change for non-Medicaid clients.

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MACSIS New Client EnrollmentFocus Group

Role of the MACSIS Help Desk - July 1, 2012 & after– The Help Desk will no longer be enrolling clients

MACSIS Enrollment in Emergency/Crisis Situations - July 1, 2012 & after

– Need to establish clear guidance on enrollment when residency is being disputed at time of enrollment.

MACSIS Enrollment Non-emergency/Non-crisis Situations - July 1, 2012 & after

– Use current process for resolving residency disputes.

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MACSIS New Client EnrollmentFocus Group

New MACSIS Benefit Rule – Deny Medicaid Claims

– New MACSIS benefit rule will be implemented to deny payment of Medicaid services provided to Medicaid clients with dates of service on and after July 1, 2012.

– A new MACSIS denial reason code will be used and mapped to a HIPAA remark code.

– Denied claims will be returned on MACSIS 835s and providers must bill those services to MITS.

– MACSIS will continue to allow payment for non-Medicaid services to Medicaid and all services to non-Medicaid clients.

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MACSIS New Client EnrollmentFocus Group

New MACSIS Benefit Rule – Deny Medicaid Claims Continued

– The nightly eligibility update process will continue in order to maintain Medicaid eligibility synchronization and to avoid duplicate Medicaid and non-Medicaid payments in MACSIS and MITS.

– Only clients enrolled in MACSIS will be updated through the nightly eligibility update process.

– Medicaid claims with dates of service prior to July 1, 2012 will process as usual until full Medicaid phase out.

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MACSIS New Client EnrollmentFocus Group

New MACSIS Benefit Rule – Deny Medicaid Claims Continued

– The nightly eligibility update process will continue in order to maintain Medicaid eligibility synchronization and to avoid duplicate Medicaid and non-Medicaid payments in MACSIS and MITS.

– Only clients enrolled in MACSIS will be updated through the nightly eligibility update process.

– Medicaid claims with dates of service prior to July 1, 2012 will process as usual until full Medicaid phase out.

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Retroactive Medicaid Eligibility & Medicaid Spend Down Focus Group

Current Process Uses 3 Files– If claim was originally paid as non-Medicaid, the claim is

reversed, the member’s eligibility is updated, the claim is then split and adjudicated as Medicaid.

– If the claim is denied as out of county, once the member’s eligibility is updated, it is split and adjudicated as Medicaid.

– If the claim is denied, once the member’s eligibility is updated, it is split and adjudicated as Medicaid.

– Un-finalized claims do not need reversed, they just need re-adjudicated once the member’s eligibility is updated.

The non-Medicaid payback and the Medicaid payment occur in the same payment cycle and appear in the same 835.

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Retroactive Medicaid Eligibility & Medicaid Spend Down Focus Group

Process July 1, 2012 and After– The same 3 files will be produced.– Dates of Service prior to July 1, 2012 will work the same.– For dates of service July 1, 2012 and after, the board will reverse

the non-Medicaid claim and update the member’s eligibility, but will not split the claim.

– An identified HIPAA adjustment code (141) and adjustment group of CR will appear on the 835 that is associated with the MACSIS adjustment reason code of ADMBR.

– The provider will submit the claim to MITS. This can occur through EDI (837P) or manually through the MITS

portal.

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Retroactive Medicaid Eligibility & Medicaid Spend Down Focus Group

Boards could split and process the claim as denied for informational purposes/communication to the provider, but this is not required.

The non-Medicaid reimbursement will be taken back from the provider.

For retroactive Medicaid claims that are un-finalized, the member’s eligibility is refreshed at the claim header and the claim is re-adjudicated at the detail.

Outlier reports - as is for DOS prior to July 1, 2012 and non-Medicaid for DOS on and after July 1, 2012.

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Retroactive Medicaid Eligibility & Medicaid Spend Down Focus Group

The nightly Medicaid eligibility updates in MACSIS will continue.

Only those clients enrolled in MACSIS will be updated. A provider can check eligibility through EDI (270/271)

transaction set or EVS vendors; manually through the MITS web portal, or through IVR.

Boards can continue to use MACSIS EEI to check eligibility at enrollment

Medicaid eligibility and spend down reporting at the local level does not change.

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Retroactive Medicaid Eligibility & Medicaid Spend Down Focus Group

To the extent non-Medicaid services in MACSIS are also reported to the CDJFS, they may be counted toward the consumer’s spend down amount.

Until a consumer has met their spend down amount, services should be billed through MACSIS if the Board is paying for them.

Once the consumer’s Medicaid eligibility is verified, the Medicaid services must be billed to MITS.

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Medicaid Claims Run Out Focus Group

4 Scenarios to Consider– Individual boards negotiate with one another to

establish efficiencies and pool resources.– Individual boards continue status quo

arrangements.– Individual boards choose to stop performing

claims processing and payment functions.– Transfer claims payment to MITS at a point in the

future regardless of date of service.

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Medicaid Claims Run Out Focus Group

Next Steps– ODADAS and ODMH will continue working with

boards and OACBHA staff based on specific board circumstances.

– ODADAS and ODMH will provide guidance related to:

negative amounts on the 835s and provider paybacks (pre and post SFY 2012 DOS);

the continued use of mCPE; and board financial reporting.

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Board Access to Data Focus Group

Claim Extract – MITS & MACSIS Member Extract – MACSIS

– No Change July 1

Affiliation Extract – MACSIS– No Change July 1

Authorization Extract – MACSIS– No Change July 1

Retroactive Medicaid Extract – MACSIS– No Change July 1

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Board Access to Data Focus Group

MACSIS Claim Extract– No changes July 1 and after with the exception that

Medicaid claims will decrease given extract will only include dates of service prior to July 1.

RA/RJ/ERA will be discontinued July 1, 2012 as previously planned.

The manually reversed Medicaid claims reports will remain in production until all MACSIS Medicaid operations are completed.

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Board Access to Data Focus Group

MITS Claim Extract– MITS fields are mapped to MACSIS claims extract fields. – Only paid and denied claims will be included - not suspended

claims.– Will not contain some fields currently in the MACSIS extract

(company code, plan code, med defs, etc.) because they do not exist in MITS.

– There are 20 new MITS fields that will be available.– Available on a weekly basis for claims submitted that week – it is

not a cumulative extract.– Claim adjustments are included in the week they occur and can be

paired with the original claim.– Concept: MITS claim information may be able to be shared with

boards based on enrolled clients in MACSIS.

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Board Access to Data Focus Group

3 Options for Consideration

– One cumulative MACSIS/MITS claim file.– A cumulative MACSIS file and a cumulative MITS

file.– A cumulative MACSIS file and a weekly MITS file.

Only one option will be implemented across all boards.

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Board Access to Data Focus Group

MITS TPL and Medicare Extracts– Business requirements are cost avoidance and

care coordination. Carrier Coverage date ranges Policy number Insured/policy owner Information identifying the individual Limits, exclusions, copayments Etc.

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Board Access to Data Focus Group

Next Steps– Share MITS claim extract, TPL and Medicare file

layouts.– Work with ODJFS to address consumers with

more than one Medicaid number.– Work with Boards to decide claim extract option.– Develop claim extract distribution methodology.– Assure HIPAA privacy and security compliance.

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Software Requirements for 837P/835 and EDI Standards for TPL Focus Group

The MACSIS and MITS 837P/835 5010 version transaction set is NOT identical or interchangeable in terms of data content.

Initial information on the identified differences was shared and is available on the website along with the MACSIS and MITS companion guides.

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Software Requirements for 837P/835 and EDI Standards for TPL Focus Group

Trading Partner Agreements– Single trading partner agreement can be used for both

MH and AoD as well as other Medicaid lines of business.

– Providers should initiate contact with ODJFS.– Paperwork process will take a minimum of 2 weeks.– Assignment of Trading Partner ID.– Trading Partner ID is required prior to MITS testing.– Trading Partner ID and ODJFS Provider Number are

NOT THE SAME THING.

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Software Requirements for 837P/835 and EDI Standards for TPL Focus Group

EDI Testing– ODJFS certifies by transaction sets:

837/835 270/271 Etc.

– Sequence testing of transactions which are most important: 837P/835 should be initial focus.

– Structural content will be validated.– Submission of an 837P will result in a test 835 response.

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Batch Medicaid Eligibility Verification Options

Trading Partners can use 270/271 transaction set for batch eligibility verification.

Providers can check eligibility on a person-by-person basis using the MITS web portal as well as the IVR phone option.

Vendors also can be used to check eligibility.

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Pharmacy Approach – MH Medications

Goal is to eventually offer physician administered drugs as both a medical benefit and a pharmacy benefit.

– The pharmacy benefit would only be administered by specialty pharmacies meeting specific criteria to assure things such as drug storage safety and integrity and delivery of the drugs directly to the office of the practitioner.

This will not occur for July 1, 2012. Therefore, long-acting injectable medications will be

offered through the medical benefit for the scope of this project and until the change described above occurs.

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Training Items

General Claim Submission Information & Instructions– Date of Service.– MACSIS UCI & MITS Medicaid Number

Software Requirements– 837P/835 & TPL and other requirements

Hold & Review Process– EDI – use PWK segment in 837P to indicate supporting

documentation is coming– MITS Provider Portal – provider uploads documentation

Pharmacy Requirements MACSIS Member Enrollment

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Training Items

Eligibility Verification– MITS Provider Portal– EDI – 270/271 transaction set

Prior Authorization Electronic Fund Transfer Requirements Web Portals Claim Correction Processes

– MITS Provider Portal– EDI – 837P

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Other Issues/Items Discussed

Use UCI when billing MACSIS – Use ONLY Medicaid ID when billing MITS.

Develop reason codes in Diamond mapped to HIPAA compliant codes.

Assure each MH and AoD provider has a valid ODJFS Medicaid Provider Number & NPI.

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Next Steps

Follow through on the items identified in the individual focus groups.– Parallel MACSIS changes Focus Group to be convened

(MACSIS MIS User’s Group)

Develop and disseminate regular, timely communications to the field.

Develop and roll out training.

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Questions?

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