Standard Operating Procedure Handling Payor Denials Agenda Handling

Standard Operating Procedure Handling Payor Denials

Agenda è • • • Handling Payor Denials Introduction Problem Solving and Solutions Additional Information Quiz 2

Purpose The purpose of this SOP is provide education on how to determine the reason for reimbursement denials due to EVV Validation errors and the steps to correct those errors. Handling Payor Denials 3

Scope This SOP is applicable to customers in Texas participating in the EVV Mandate. Handling Payor Denials 4

General Requirements The following requirements must be met. The user must have access to view, add, and/or edit information in the Clients/Staff/Call Mgr/Reports sections of the Vin. CENT system. • If a user does not have access, they would need to contact their Agency System Administrator. Handling Payor Denials 5

Agenda • è • • Handling Payor Denials Introduction Problem Solving and Solutions Additional Information Quiz 6

Verifying Correct Payor Information • • • Accessing the Client Search Screen Selecting the Client Selecting the Payor Eligibility Dates Payor Authorization Payor Priority Status Handling Payor Denials 7

Verifying Correct Payor Information Accessing the Client Search Screen To verify that the correct payor information is applied to the client file, first the user will need to click on the Clients icon in the upper left hand corner of the Vin. CENT system. Handling Payor Denials 8

Verifying Correct Payor Information Selecting the Client Select the client in question by clicking on their name. Handling Payor Denials 9

Verifying Correct Payor Information Selecting the Payor The user can view all payors that are assigned to the client on the left side of the client folder. • Handling Payor Denials To verify the payor information is correct, click on the payor that you wish to view. 10

Verifying Correct Payor Information Selecting the Payor Handling Payor Denials 11

Verifying Correct Payor Information Selecting the Payor Handling Payor Denials 12

Verifying Correct Payor Information Payor Eligibility Dates The user can verify that the effective dates for that payor are correct. **Please Note: The Vin. CENT system is designed to determine which payor to assign to each schedule based on the Effective Dates first. If there are multiple payors with overlapping effective dates, the system will then look at authorizations that are active for the service and date of the schedule. If effective dates overlap and there active authorizations for more than 1 payor, the system will finally look at the Priority level of the payor to determine which payor should be applied to that schedule. Handling Payor Denials 13

Verifying Correct Payor Information Payor Eligibility Dates If the effective dates are not populated, the user can click on "Add Dates. " Handling Payor Denials 14

Verifying Correct Payor Information Payor Eligibility Dates The Payor Activity Box will open and the user would select the appropriate payor from the drop dox and click inside each of the effective dates boxes to input the effective dates for that payor. Handling Payor Denials 15

Verifying Correct Payor Information Payor Eligibility Dates The user would then click the Save icon in the upper left hand corner of the Payor Activity Box. Handling Payor Denials 16

Verifying Correct Payor Information Payor Eligibility Dates If the effective dates exist but are incorrect, the user can edit those dates by clicking on the dates. Handling Payor Denials 17

Verifying Correct Payor Information Payor Eligibility Dates The Payor Activity Box will open and the user can click inside each of the effective dates boxes to input the correct effective dates for that payor. Handling Payor Denials 18

Verifying Correct Payor Information Payor Eligibility Dates The user would then click the Save icon in the upper left hand corner of the Payor Activity box. Handling Payor Denials 19

Verifying Correct Payor Information Payor Authorization The user can then verify that there is an active authorization entered for the service and dates in question by viewing the authorization information. Handling Payor Denials 20

Verifying Correct Payor Information Payor Authorization The user can add an authorization by clicking on "Add Authorization. " Handling Payor Denials 21

Verifying Correct Payor Information Payor Authorization Enter Reference Number & Control Number if applicable. Then click on the Save icon. Handling Payor Denials 22

Verifying Correct Payor Information Payor Authorization Click on Add Authorization Detail to bring up Authorization Detail window. Handling Payor Denials 23

Verifying Correct Payor Information Payor Authorization Add the Begin & End dates of the authorization. Choose the correct Service and Activity from the dropdown selections. There will need to be a different authorization for each Service on the authorization. Handling Payor Denials 24

Verifying Correct Payor Information Payor Authorization Utilize the Format Dropdown Selections to select the format of the authorization. Handling Payor Denials 25

Verifying Correct Payor Information Payor Authorization Utilize the Format Dropdown Selections to select how the authorization is limited. Handling Payor Denials 26

Verifying Correct Payor Information Payor Authorization When the By Day Limitation is selected the days of the week appear. • If the authorization also dictates when the schedule must start there is an area to the right for time entry. Handling Payor Denials 27

Verifying Correct Payor Information Payor Authorization When the authorization is limited by Week, Month or Year the Limitation Value will need to be entered. • • Handling Payor Denials The Limitation Value limits the amount entered by the Limitation. For example if the client is authorized for 10 hours a month then a 10 would be entered in the Limitation Value box. The Maximum box will display the amount available and amount used. 28

Verifying Correct Payor Information Payor Authorization When the None Limitation is selected place the total billable time for the Begin and End date in the Maximum box. • Handling Payor Denials Example: if the authorization states the client receives 156 hours a year; no restriction on how or when. The user would place 156 in the Maximum box. 29

Verifying Correct Payor Information Payor Authorization After the authorization is complete select Save on the Authorization Detail and Authorization window. Handling Payor Denials 30

Verifying Correct Payor Information Payor Authorization The Authorization Line Item is now viewable from the Payor screen and can be clicked on at any time to reopen or edit the authorization. Handling Payor Denials 31

Verifying Correct Payor Information Payor Priority Status Finally, the user can verify that the correct Priority Status is selected for that payor by clicking on the blue Edit Payor icon. Handling Payor Denials 32

Verifying Correct Payor Information Payor Priority Status If the priority status of the payor is incorrect, the user can click the Priority drop down menu to select the correct priority. Handling Payor Denials 33

Verifying Correct Payor Information Payor Priority Status The user would then click the Save icon in the upper left hand corner of the Admission Payor box. Handling Payor Denials 34

Verifying Eligibility Information • Click on the Clients Icon • Select the Client • Click on Eligibility Handling Payor Denials 35

Verifying Eligibility Information Click on the Clients Icon To verify that the client has eligibility information populated on their folder, first, the user would click on the Clients Icon in the upper left hand corner of the Vin. CENT system. Handling Payor Denials 36

Verifying Eligibility Information Select the Client The user would then click on the client's name to open the client folder. Handling Payor Denials 37

Verifying Eligibility Information Click on Eligibility Finally, the user would click on Eligibility on the left hand side of the client folder. Handling Payor Denials 38

Verifying Eligibility Information Click on Eligibility The client's Eligibility information will be populated. **Please Note: If Eligibility information does not populate, the user would need to check the client's MCD ID and Date of Birth for accuracy and then make the appropriate updates in the Personal tab of the Client folder. If Eligibility information does not match the payor that is on the client file, the user would again verify the MCD ID and Date of Birth and may need to reach out to the payor directly for further clarification. Handling Payor Denials 39

Verifying Eligibility Information Click on Eligibility If updates need made to the MCD ID or Date of Birth, the user can return to the Personal tab, make the updates in those fields, and then Save Changes in the upper right hand corner of that Personal Tab. Handling Payor Denials 40

Verifying Correct Service Codes and Updating Schedules Some denials are caused by incorrect service codes being applied to the client's schedules in the Vin. CENT system. Handling Payor Denials 41

Verifying Correct Service Codes and Updating Schedules • • • Client Authorization Paperwork Service Code Crosswalk Click on Call Mgr Icon Add Client Filter Add Date Range Adding Payor Column Updating Schedules Viewing Service Codes Applied Correcting Service Codes Handling Payor Denials 42

Verifying Correct Service Codes and Updating Schedules Client Authorization Paperwork The user would need to refer to the client's authorization paperwork in order to locate the information needed to determine the appropriate service code in the Vin. CENT system. • This is based on the Service Group/Service Code for DADS clients or HCPCS Code and Modifiers for TMHP and MCO clients. Handling Payor Denials 43

Verifying Correct Service Codes and Updating Schedules Service Code Crosswalk The MEDsys Service Code Crosswalk is a tool that is offered to determine the appropriate service code for the client's schedules. Handling Payor Denials 44

Verifying Correct Service Codes and Updating Schedules Click on Call Mgr Icon To view the service codes that are currently applied to the schedules in question, first the user would click on the Call Mgr Icon in the upper left hand corner of the Vin. CENT system. Handling Payor Denials 45

Verifying Correct Service Codes and Updating Schedules Add Client Filter The user can add a filter for the client to view only that client's schedules. • To do that, click the green Add + icon by filters in the upper left hand corner of the call manager screen and select the client from the Client dropdown menu. Handling Payor Denials 46

Verifying Correct Service Codes and Updating Schedules Add Client Filter Handling Payor Denials 47

Verifying Correct Service Codes and Updating Schedules Add Date Range The user would then select the appropriate date range for the dates in question at the top of the call manager screen. Handling Payor Denials • To do that, click on the first date box at the top and select the appropriate begin date. • Then click inside of the second date box and select the appropriate end date. • The date can be selected from the calendar that opens upon clicking inside of the date boxes or it can be manually typed in. 48

Verifying Correct Service Codes and Updating Schedules Add Date Range Handling Payor Denials 49

Verifying Correct Service Codes and Updating Schedules Adding Payor Column The user can add a column to view the payor that is assigned to each schedule. • Handling Payor Denials To add the payor column, the user would click on the Add Columns icon in the upper left hand corner and scroll down to check the box marked Payor. 50

Verifying Correct Service Codes and Updating Schedules Adding Payor Column Handling Payor Denials 51

Verifying Correct Service Codes and Updating Schedules Adding Payor Column Handling Payor Denials 52

Verifying Correct Service Codes and Updating Schedules The user can perform an update to the schedules to ensure that all correct payor information has been applied to the appropriate schedules. • Handling Payor Denials To perform an update, click on the Circle with Checkmark icon in the upper right hand corner of the Call Manager screen. 53

Verifying Correct Service Codes and Updating Schedules After the update has been completed, a pop up window will open letting the user know that the schedules have been updated successfully. • The user can click OK to close this window. Handling Payor Denials 54

Verifying Correct Service Codes and Updating Schedules Viewing Service Codes Applied The user can view the service codes that have been applied to the schedules in the Service column of the Call Manager screen. Handling Payor Denials 55

Verifying Correct Service Codes and Updating Schedules Correcting Service Codes If it is determined that the service is listed incorrectly in the Vin. CENT system, the user can update the schedules as needed. • Handling Payor Denials For a single schedule, the user can click on that schedule to open the schedule detail window, select the new service and save. 56

Verifying Correct Service Codes and Updating Schedules Correcting Service Codes For multiple schedules, the user can utilize the Mass Edit tool to update the service listed on those schedules. • • • Handling Payor Denials First, the user would add another filter for the incorrect service that is currently in the system. If all schedules need to be updated to the same service, proceed to the next step. Add a filter by clicking on the green Add + icon by Filters and select the current incorrect service from the Service drop down menu. 57

Verifying Correct Service Codes and Updating Schedules Correcting Service Codes Handling Payor Denials 58

Verifying Correct Service Codes and Updating Schedules Correcting Service Codes Click the Mass Edit (Double Pencil) Icon in the upper right hand corner of the Call Mgr screen. The Mass Edit Schedules box will open. Handling Payor Denials 59

Verifying Correct Service Codes and Updating Schedules Correcting Service Codes Select the new, correct Service from the Service drop down, then click the Save Icon to save those changes. Handling Payor Denials 60

Verifying Correct Service Codes and Updating Schedules Correcting Service Codes A popup will open verifying that you wish to mass edit those schedules. • Make sure to double check the number of schedules listed in that popup window to verify that it is correct. • The user can click OK to proceed with the change. Handling Payor Denials 61

Verifying Correct Service Codes and Updating Schedules Correcting Service Codes If a filter for the incorrect service had previously been applied, the user can remove that filter by hovering over it and clicking the red X that appears. • Handling Payor Denials The user will now be able to view the schedules with the updated service. 62

Transmission Reports There are 2 reports available in the system that assist with determining which information was transmitted to the payors and which information was withheld. Handling Payor Denials 63

Transmission Reports • • Transmissions Reports Defined Click the Reports Icon Click Reference Select the Report Add the Appropriate Filters Generate the Report Viewing the Report Handling Payor Denials 64

Transmission Reports Transmissions Reports Defined The Transmissions report will show the user which schedules were submitted to the payor. • • If the schedules in question that were denied appear on this report, the invoice may have been submitted prior to the Last Upload date to the payor. The user would print this report and contact the payor directly to determine the next steps for reimbursement. Handling Payor Denials 65

Transmission Reports Transmissions Reports Defined The Transmissions (Unsent) report will show the user which schedules were withheld from transmission to the payor. • The reason why it was not transmitted will appear highlighted on the report. • If the HCPCS and/or modifiers are highlighted, that could be an indication of an incorrect service applied to the schedules. • Once the issues have been resolved, those schedules will be transmitted to the payor on the next daily transmission. Handling Payor Denials 66

Transmission Reports Click the Reports Icon To access the reports, click on the Reports icon in the upper left hand corner of the Vin. CENT system. Handling Payor Denials 67

Transmission Reports Click Reference The Reports screen will open. The user would then click on the category of "Reference" on the left hand side. Handling Payor Denials 68

Transmission Reports Select the Report The user can then select which report it is that they wish to view by clicking on the name of that report. Handling Payor Denials 69

Transmission Reports Add the Appropriate Filters can be applied to the report so that it will only populate data that the user wishes to see. Handling Payor Denials • To add a filter, the user can click each of the drop down menus to select the specific filter option. • A date range can also be added at the bottom of the filter options. 70

Transmission Reports Generate the Report The user would then click on the blue Generate Report icon to view/print that report. Handling Payor Denials 71

Transmission Reports Viewing the Report The report will open. Handling Payor Denials 72

Helpful Hints and FAQ • When are Transmissions sent? • What information gets sent in the Transmissions? • HCPCS, Modifiers, Service Groups/Codes • Company Numbers Handling Payor Denials 73

Helpful Hints and FAQ When are Transmissions sent? Transmissions are sent to the payors on a daily basis. • This includes any updates that are made to Confirmed status schedules as well. Handling Payor Denials 74

Helpful Hints and FAQ What information gets sent in the Transmissions? The information that gets sent for the schedules in the daily transmissions includes: • • Client Name MCD ID SDA Service Group Service Code HCPCS Modifiers The Service Group, Service Code, HCPCS, and Modifiers are determined by the service code that is applied to the schedules. Handling Payor Denials 75

Helpful Hints and FAQ HCPCS, Modifiers, Service Groups/Codes If a service code is listed incorrectly on the client's schedules, that schedule will appear on the Transmissions (Unsent) report and those fields will be highlighted requiring attention. • If the service codes are incorrect, the user would need to update the schedules accordingly to reflect the correct service code. Handling Payor Denials 76

Helpful Hints and FAQ Company Numbers Another potential reason for denial could be that we have missing or incorrect information that was provided to us for the agency. • This information includes NPI and API/TPI numbers. • These are required fields in the database. • If you find that some or all of that information is missing from the top of your Transmissions (Unsent) report, please have the agency system administrator contact MEDsys directly so that we can update your account accordingly. Handling Payor Denials 77

Agenda • • è • Handling Payor Denials Introduction Problem Solving and Solutions Additional Information Quiz 78

Contact Information Direct questions about this document to: Agency System Administrator Handling Payor Denials 79

Agenda • • • è Handling Payor Denials Introduction Problem Solving and Solutions Additional Information Quiz 80

Which report will provide information on schedules that were not transmitted to the payor? A. Transmissions B. Transmissions (Unsent) C. Transmissions Withheld D. Company Numbers Checklist The correct answer is B. Handling Payor Denials 81

Which data gets sent to the payor through the transmissions? A. Client Name, MCD ID, SDA, Service Group/Code/HCPCS/Modifiers B. Client Name, Service Code, MCD ID C. Client Name and MCD ID Only D. Client Name and Social Security Number The correct answer is A. Handling Payor Denials 82

How often are the transmissions sent to the payors? A. Once the Schedule is Updated B. Monthly C. Weekly D. Daily The correct answer is D. Handling Payor Denials 83

Once the schedule has been transmitted to the payor, it will not be resent. A. True B. False The correct answer is B. Handling Payor Denials 84