2018 IHCP Annual Workshop MDwise Claims Providing health

2018 IHCP Annual Workshop MDwise Claims Providing health coverage to Indiana families since 1994 HHW-HIPP 0581 (9/18)

Agenda • • • MDwise History Updates Contracting Eligibility Claim Submission Disputes Refunds Prior Authorization (PA) Resources Questions 2

MDwise History • 1994: MDwise founded as Indiana-based nonprofit health care company Central Indiana Managed Care Organization, Inc. (CIMCO), utilizing a delivery system model • 2001: CIMCO teamed up with IU Health Plan and formed into MDwise, Inc. , serving more than 55, 000 Hoosier Healthwise members. • 2007: MDwise begins service Care Select (now Hoosier Care Connect) members • 2007: MDwise selected to provide care through the Healthy Indiana Plan • 2018: MDwise acquired by Michigan-based Mc. Laren Health Care; one of Michigan’s largest integrated health systems 3

Who Is Mc. Laren Health Care? Mc. Laren Health Care: • Is one of the largest integrated health care systems in Michigan • Owns 15 hospitals, including Barbara Ann Karmanos, nationally renowned for their cancer care and outcomes • Employs over 500 physicians • Trains over 550 residents annually • Has a workforce of over 20, 000 • Owns Mc. Laren Health Plan, who covers over 265, 000 members in Medicaid, commercial, and Medicare Supplemental markets. 4

MDwise – Mc. Laren Synergies • Sharing Best Practices between MDwise and Mc. Laren Health Plan, such as: – – – Care Management Opioid Crisis Management Effectively managing inappropriate ER utilization Streamlining Prior Authorizations Pay for Value Physician Incentive programs Claims adjudication • Results are Demonstrating: • Improvement in health care outcomes for our members • Enhanced access for members • Greater administrative efficiencies, which allow more health care dollars to be spent on the actual delivery of medical care 5

Updates Effective 1/1/19: • MDwise is restructuring it’s Delivery System model to: – Improve claim payment timeliness and accuracy – Streamline and reduce administrative redundancy for providers – Provide greater access for our members • One standard authorization list • One point of contact for all authorization requests • One claim submission address • Non-Excel Delivery System contracts – Providers not contracted with MDwise Excel must contract to stay in network. 6

Contracting Effective 1/1/19: Providers not contracted with MDwise Excel must contract to stay in network. 7

Contracting Provider Relations Forms • http: //www. MDwise. org/for-providers/forms/provider-enrollment • Credentialing/Enrollment – MCE Enrollment Form – Enrollment Cover Sheet (until 12/31/18) – Provider Update Form • Disenroll/Re-enroll • Panel Move • Non-Contracted Set-Up Form – Required for non-contracted providers • Contract Inquiry Form Submit Forms to: • prenrollment@mdwise. org 8

Eligibility Effective 1/1/19: When determining eligibility, verify: • Is the member eligible for services today? • Which Indiana Health Coverage Program plan are they enrolled? • If the member is in Hoosier Healthwise or Healthy Indiana Plan, are they assigned to MDwise? • Who is the member’s Provider (PMP)? Provider Healthcare Portal. Primary Medical MDwise Provider Portal • IHCP Program • Delivery System: MDwise Excel • MCE • Assigned PMP History • Assigned PMP • Delivery System: MDwise Excel 9

Claim Submission Effective 1/1/19: • Claim Submission is date of service driven. Hoosier Healthwise & Healthy Indiana Plan MDwise P. O. Box 1575 Flint, MI 48501 • Electronic Submission Hoosier Healthwise Healthy Indiana Plan Payer ID: 3519 M Payer ID: 3135 M Please note: Paper claims must be on red/white form with black ink. 10

Claim Submission Claim Timelines: • Claim Submission: – Primary: 90 days from the date of service – Secondary: 90 days from the date of the explanation of benefits (EOB) – Effective 1/1/19, non-contracted providers will have 180 days for claim submission. * • MDwise Adjudication: (clean claims) – Electronic Claims: 21 days – Paper Claims: 30 days • Claim Disputes: – 60 days from the date of the explanation of benefits (EOB) – Dispute Response: 30 business days from date of submission *Reference BT 201829 for more information 11

Claim Submission Secondary Insurance Submissions • When the member has other insurance: – Provider must submit claims to the other insurance carrier prior submitting to MDwise – Submitting a secondary claim to MDwise – Must be submitted within 90 days of the date on the EOB – Claims submitted via paper must include a copy of the EOB • Be sure to verify member eligibility for the date of service • Effective 1/1/19: Secondary claims will be accepted via electronic submission. 12

Claim Submissions CMS 1500 Form MDwise follows National Uniform Claim Committee (NUCC) guidelines. • Box 19 should contain typed notes – Claims system is not able to pick up other writing • *Box 22: Corrected or Replacement claims -*Required • Box 23: Prior Authorization – If you have an authorization number, please include it. 13

Claim Submission UB-04 Form MDwise follows National Uniform Billing Committee (NUBC) guidelines • Box 80: Notes • Box 4: Bill Type – Include correct frequency for submission and resubmission 14

Refunds Effective 9/15/18 Claim Refund Process changing: • Provider Refund Form required along with supporting documentation • Send to: MDwise, Inc. P. O. Box 441423 Indianapolis, IN 46244 -1423 • Refund form can be submitted without a check if you wish your claim to be offset from future payments. • https: //www. mdwise. org/for-providers/forms/claims 15

Refunds Requirements: • One TIN/NPI per form and check 16

Disputes How do you know if you received a denial or a rejection? 17

Disputes • Denied claims will include an EOB with a denial code. • Rejected claims are different than denied claims: – Rejected claims are returned to the provider or electronic data interchange (EDI) source without registering in the claim processing system. – Since rejected claims are not registered in the claims processing system, the provider must resubmit the claim within the claims timely filing limit. • Rejected claims do not extend the timely filing limit. – Contracted providers have 90 days from the date of service 18

Disputes Claim Dispute Process: 1. Provider completes the Claims Dispute Form found at www. mdwise. org on the For Providers page, under Claim Forms. 2. Completed form and supporting documents are sent via email: – cdticket@mdwise. org 3. Received email is routed to a Claims Dispute work queue where a ticket number will be issued an email notification will be sent back immediately. 4. The Claim Dispute team will review the submitted dispute and work the cases to resolution (uphold or overturn). 5. An email notification will then be sent to the provider, referencing the dispute and ticket number, on the resolution determination. 19

Disputes Informal Claim Dispute • Provider disagrees in writing with how the claim was adjudicated: – Must be commenced within 60 days from the date on the Explanation of Payment (EOP) – MDwise will reach a resolution and notify provider within 30 calendar days. Formal Claim Dispute • Provider disagrees with 1 st level resolution: – Provider has 60 days from the date of the 1 st level resolution – MDwise will compose a panel of persons not involved with the 1 st level dispute to review the 2 nd level dispute. – MDwise will reach a resolution and notify provider within 45 calendar days. 20 – The panel’s decision is MDwise’s final action on the claim.

Prior Authorization Effective 1/1/19 • One standard authorization list • One point of contact for all authorization requests • Submission timelines and process will not change • Go to MDwise. org for most up-to-date version of PA lists MDwise. org For Providers Forms Prior Authorization 21

Prior Authorization You will need two key items when filing a request for Medical Prior Authorization (PA): 1. Universal Prior Authorization Form • Located on our website 2. Documentation to support the medical necessity for the service you are requesting to prior authorize: • • Lab work Medical records/physician notes Test results Therapy notes Tips: • Completely fill out the universal PA form including the rendering provider’s NPI and TIN, the requestor’s name along with phone and fax number. • Be sure to note if PA is for a retroactive member. Please Note: Not completely filling out the universal PA form may delay the prior authorization timeframe. 22

Prior Authorization Turn-Around Time • All emergency inpatient admissions require authorization within 2 business days of the admission. • Urgent prior authorizations can take up to 3 business days • Requests for non-urgent prior authorization will be resolved within 7 calendar days. – It is important to note that resolved could mean a decision to pend for additional information. • If you have not heard response within the time frames above, contact the Prior Authorization Inquiry Team and they will investigate the issue. • PA Inquiry Line – 1 -888 -961 -3100 23

Resources 1 2 5 3 6 4 9 8 7 24

Resources Representative Territory Phone Email Paulette Means Region 1 317 -822 -7490 pmeans@mdwise. org Garrett Walker Region 2 317 -983 -6088 gwalker@mdwise. org Michelle Phillips Region 3, Hospice, Home Health 317 -983 -7819 mphillips@mdwise. org Jamaal Wade Region 4 317 -822 -7276 jwade@mdwise. org David Hoover Region 5 317 -983 -7823 dhoover@mdwise. org Tonya Trout Region 6 317 -308 -7329 ttrout@mdwise. org Rebecca Church Region 7 317 -308 -7371 rchurch@mdwise. org Sean O’Brien Region 8 317 -308 -7344 sobrien@mdwise. org Whitney Burnes Region 9 317 -308 -7345 wburnes@mdwise. org Nichole Young Behavioral Health 317 -822 -7509 nyoung@mdwise. org (CMHC, OTP, IMD or Residential) 25

Resources MDwise Provider Tip Sheets • http: //www. mdwise. org/for-providers/tools-and-resources/additionalresources/tip-sheets/ MDwise Provider Manuals • http: //www. mdwise. org/for-providers/manual-and-overview/ MDwise Provider Relations Territory Map • http: //www. mdwise. org/for-providers/contact-information/ MDwise Customer Service • 1. 800. 356. 1204 IHCP Provider Modules • Indianamedicaid. com 26

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