CONNECTICUT DSS EVV CLAIMS RESUBMISSION TRAINING

Transcription

1 CONNECTICUT DSS EVV CLAIMS RESUBMISSION TRAINING March 2017

2 TOPICS 1. Filing Deadlines 2. File Rollback Process 3. Claim Resubmission Process Voiding Claim via HPE portal Voiding Claim via Sandata system 4. Resubmission Scenarios Slide 2

3 Filing Deadlines The claim submission deadline is typically Thursday, 7:00 PM. Filing submission information is available on the HPE portal. It s important that providers understand that because of the implementation of EVV, their expectations of the claims submittal process will change. The use of EVV requires that providers be aware of the time when submitting claims. Claims submitted via the Santrax system must pass through HPE s translator before claims are processed. Depending on the day and/or time, a provider s claims may be behind several large files, such as those submitted by a clearing house. Slide 3

4 Filing Deadlines As a result, claims may no longer be immediately available for review on the DSS portal after their submittal through Santrax. It may take several hours for providers to see claims submitted via Santrax in the providers secure web portal. Providers should submit their claims well before the claims deadline to ensure that the claims are being received and processed by HPE. This is especially important when claims are recouped from HPE and rolled back and resubmitted via the Sandata system due to claim detail adjustments or denials on paid claims. Slide 4

5 File Rollback Process When there is a structural issue with the file resulting in the entire Claim File not successfully transmitting. HPE sends Sandata a 999 notification indicating a rejection. Sandata researches the issue and contacts the provider agency to advise on the needed correction. Common file failure issues: Physician is identified as a clinic rather than an individual Client missing diagnosis when required Visit missing HCPCS codes Slide 5

6 File Rollback Process 1. Hover your mouse over the Billing module and select History from the drop-down menu Slide 6

7 File Rollback Process 2. Click the plus [+] sign next to the billing folder to open the folder (expand the payer folder if necessary). 3. Click on the date of the export file to be rolled back. 4. Select the Rollback option in the upper-right corner. Slide 7

8 File Rollback Process 5. Click Yes to the pop-up asking you to confirm the roll back of the export. 6. Click OK to the pop-up indicating the number of invoices rolled back. All visits in the file will return to a Billable status. Address the issues which caused the 999 failure. Slide 8

9 File Rollback Process 7. Hover over the Billing module and click Export. 8. Use the filters to locate the invoices set to 05-Billable. 9. Select the Payor and click Export. 10. Click OK to the pop-up confirming creation of the file. Slide 9

10 CLAIM RESUBMISSION PROCESS VOIDING A CLAIM VIA THE HPE PORTAL

11 Process via HPE Portal The claim resubmission process reviewed in this section should be followed when the claim is voided via the HPE portal for one of the following reasons: Claim was paid but information in the claim needs to be changed. Partial payment was received for a claim but claim needs to be edited to receive full payment. Slide 11

12 Process via HPE Portal After the claim has been voided on the Portal 1. Hover your mouse over the Billing module and select Invoices from the drop-down list. Slide 12

13 Process via HPE Portal 2. Use the applicable filters to locate the invoice. 3. Double-click on the invoice line to open the invoice details. Slide 13

14 Process via HPE Portal 4. Set the status of the invoice to Cancelled. 5. Click Save. All visits attached to the cancelled invoice will go back to a status of Confirmed, allowing the visit(s) to be corrected and re-billed. Slide 14

15 Scenario 1 Provider performed 5 units daily of service code 1021Z on DOS from 1/1/17-1/7/17. The PA on the DSS portal is for 4 units daily for DOS 1/1/17-1/7/17, resulting in a PA with a total 28 units. Provider bills and is reimbursed for 4 units daily, for a total of 28 units. After the claim is submitted and paid the Access Agency voids the original PA and uploads a new PA for a total of 35 units, 5 units daily for DOS 1/1/17-1/7/17. Provider wants to void original claim and submit claim for all units performed. Action Required: Void the claim on the HPE Portal. Cancel the invoice in the Sandata system. Adjust the visits to reflect the correct units and rebill the visits. Slide 15

16 Scenario 2 PA is for 2 units SN per week from 1/22/17-1/28/17. Provider schedules 2 SN on 1/22/17 and 1/26/17. 1 SN visit is performed on 1/22/17 On 1/24/17 the client requires an emergency visit. The provider requests and receives a 1x only SN verbal authorization for DOS 1/24/17 from the access agency. A third visit in that week is conducted on 1/26/17. At the time of claims creation, the PA on the DSS portal is for 2 units SN and there is not a 1x only. The provider bills 1/22/17 and 1/24/17 but does not bill 1/26/17. The third visit on 1/26/17 is placed on bill hold. Slide 16

17 Scenario 2 - continued The PA is updated on 2/7/17 and a 1x only SN U2 PA is added to the DSS portal for DOS 1/24/17. Provider would like to void entire claim and bill 1/22/17 and 1/26/17 together, and bill the 1/24/17 visit to the U2 PA. Action required: Void the claim on the HPE Portal. Cancel the invoice in the Sandata system. Review the 1x emergency visit to ensure it contains the correct U2 event code. Rebill the visits. Slide 17

18 Scenario 3 1 unit OT is scheduled and performed on 2/1/17 and 2/8/17. Prior authorization is for 10 OT per week from 1/1/17-2/28/17. Provider has a physician signature for OT on 1/29/17-2/4/17 but the physician refuses to sign for visits performed after 2/5/17 because the client was discharged from his care. A claim was submitted and paid for the 2 OT visits for DOS 2/1/17 and 2/8/17 in error. Slide 18

19 Scenario 3 - continued After claim submittal the provider realizes that the signed PA does not cover the visit performed on 2/8/17 and needs to recoup the 2/8/17 visit and hold it until another physician can be found to sign the orders. Action required: Void the claim on the HPE Portal. Cancel the invoice in the Sandata system. Place the confirmed visit for 2/8/17 on HOLD so it is not picked up for billing again. Rebill for the 2/1/17 visit. Once a physician signature is available to cover the 2/8/17 visit, the status can be changed back to confirmed and rebilled. Slide 19

20 Scenario 4 Client received 1 unit SN per week from 1/1/17-1/28/17 for a total of 4 units SN. PA on the DSS portal was for 4 units SN from 1/1/17-1/28/17. After claim was submitted and paid, Access Agency voided PA and did not replace PA on DSS portal. Action Required: Provider does not need to void claim. HPE will void/reprocess claim and claim will deny. Once the PA is reinstated, the provider needs to resubmit the claim in the Sandata system. * Note: If the auth is not reinstated, the claim will deny. Once the PA is reinstated, the only way to resubmit is via the Sandata system using the rollback and resubmit process. Slide 20

21 Scenario 5 Provider perform 5 units daily of service code 1021Z on DOS 1/1/17-1/7/17. PA on DSS portal is for 35 units for DOS 1/1/17-1/7/17. Provider bills and is reimbursed for all services performed. After the claim is submitted and paid the Access Agency voids the original PA and uploads a new PA for a total of 28 units, 4 units daily for DOS 1/1/17-1/7/17. Action Required: Provider does not need to void claim. HPE will void/reprocess claim and pay up to the 28 units billed, denying the remaining visits. Slide 21

22 Scenario 6 Caregiver provides 1 hour (4 units) Companion in AM, 1 hour (4 units) Companion in PM. Visit in am is confirmed, visit in pm is not. Visit in AM is invoiced, billed and paid. In order to be paid for the second hour, the claim must be recouped, then both visits need to be confirmed and invoiced together to create claim detail with 8 units of Companion. Action required: Void the claim on the HPE Portal. Cancel the invoice in the Sandata system. Review the PM visit; confirm the visit if appropriate or cancel the visit if no service was provided. Rebill the visit (if the PM visit was cancelled) or visits (if the PM visit was confirmed). * Tip: During Billing Review, clear OK To Bill/Not OK To Bill filters to identify any unconfirmed split shift visits. Slide 22

23 CLAIM RESUBMISSION PROCESS VOIDING A CLAIM IN SANDATA

24 Process via Sandata The claim resubmission process reviewed in this section should be followed when the claim is voided in the Sandata system for one of the following reasons: Claim was paid but information in the claim needs to be changed. Partial payment was received for a claim but claim needs to be edited to receive full payment. Slide 24

25 Process via Sandata 1. Hover your mouse over the Billing module and select Invoices from the drop-down list. Slide 25

26 Process via Sandata 2. Use the applicable filters to locate the invoice. 3. Double-click on the invoice line to open the invoice details. Slide 26

27 Process via Sandata 4. Set the invoice status to 11-Resubmit. 5. Check the Void box to mark the invoice voided. 6. Click the Attached Items tab and enter the ICN on a line item. If there are multiple items, it only needs to be entered on one line. 7. Click Save at the bottom of the invoice screen. Slide 27

28 Process via Sandata Slide 28

29 Process via Sandata 8. Hover over the Billing menu and select Export from the drop-down list. Slide 29

30 Process 9. Use the filters to locate the invoice that was voided and set to a status of 11 Resubmit. Slide 30

31 Process 10. Select the Payor in the filters of the Billing Export screen and click Export. 11. Click OK to confirm the export. Slide 31

32 Process 12. After exporting the voided invoice, the recommended best practice is to wait for the take back to appear on the HPE Portal before cancelling the invoice in the Sandata. All visits attached to the cancelled invoice go back to a status of Confirmed, allowing the visit(s) to be corrected and rebilled. Slide 32

33 Scenario 1 Provider performed 5 units daily of service code 1021Z on DOS from 1/1/17-1/7/17. The PA on the DSS portal is for 4 units daily for DOS 1/1/17-1/7/17, resulting in a PA with a total 28 units. Provider bills and is reimbursed for 4 units daily, for a total of 28 units. After the claim is submitted and paid the Access Agency voids the original PA and uploads a new PA for a total of 35 units, 5 units daily for DOS 1/1/17-1/7/17. Provider wants to void original claim and submit claim for all units performed. Action Required: Void and cancel the invoice. Adjust the visits to reflect the correct units and rebill the visits. Slide 33

34 Scenario 2 PA is for 2 units SN per week from 1/22/17-1/28/17. Provider schedules 2 SN on 1/22/17 and 1/26/17. 1 SN visit is performed on 1/22/17 On 1/24/17 the client requires an emergency visit. The provider requests and receives a 1x only SN verbal authorization for DOS 1/24/17 from the access agency. A third visit in that week is conducted on 1/26/17. At the time of claims creation, the PA on the DSS portal is for 2 units SN and there is not a 1x only. The provider bills 1/22/17 and 1/24/17 but does not bill 1/26/17. The third visit on 1/26/17 is placed on bill hold. Slide 34

35 Scenario 2 - continued The PA is updated on 2/7/17 and a 1x only SN U2 PA is added to the DSS portal for DOS 1/24/17. Provider would like to void entire claim and bill 1/22/17 and 1/26/17 together, and bill the 1/24/17 visit to the U2 PA. Action required: Void and cancel the invoice. Review the 1x emergency visit to ensure it contains the correct U2 event code. Rebill the visits. Slide 35

36 Scenario 3 1 unit OT is scheduled and performed on 2/1/17 and 2/8/17. Prior authorization is for 10 OT per week from 1/1/17-2/28/17. Provider has a physician signature for OT on 1/29/17-2/4/17 but the physician refuses to sign for visits performed after 2/5/17 because the client was discharged from his care. A claim was submitted and paid for the 2 OT visits for DOS 2/1/17 and 2/8/17 in error. Slide 36

37 Scenario 3 - continued After claim submittal the provider realizes that the signed PA does not cover the visit performed on 2/8/17 and needs to recoup the 2/8/17 visit and hold it until another physician can be found to sign the orders. Action required: Void and cancel the invoice. Place the confirmed visit for 2/8/17 on HOLD so it is not picked up for billing again. Rebill for the 2/1/17 visit. Once a physician signature is available to cover the 2/8/17 visit, the status can be changed back to confirmed and rebilled. Slide 37

38 Scenario 4 Client received 1 unit SN per week from 1/1/17-1/28/17 for a total of 4 units SN. PA on the DSS portal was for 4 units SN from 1/1/17-1/28/17. After claim was submitted and paid, Access Agency voided PA and did not replace PA on DSS portal. Action Required: Provider does not need to void claim. HPE will void/reprocess claim and claim will deny. Once the PA is reinstated, the provider needs to resubmit the claim in the Sandata system. * Note: If the auth is not reinstated, the claim will deny. Once the PA is reinstated, the only way to resubmit is via the Sandata system using the rollback and resubmit process. Slide 38

39 Scenario 5 Provider perform 5 units daily of service code 1021Z on DOS 1/1/17-1/7/17. PA on DSS portal is for 35 units for DOS 1/1/17-1/7/17. Provider bills and is reimbursed for all services performed. After the claim is submitted and paid the Access Agency voids the original PA and uploads a new PA for a total of 28 units, 4 units daily for DOS 1/1/17-1/7/17. Action Required: Provider does not need to void claim. HPE will void/reprocess claim and pay up to the 28 units billed, denying the remaining visits. Slide 39

40 Scenario 6 Caregiver provides 1 hour (4 units) Companion in AM, 1 hour (4 units) Companion in PM. Visit in am is confirmed, visit in pm is not. Visit in AM is invoiced, billed and paid. In order to be paid for the second hour, the claim must be recouped, then both visits need to be confirmed and invoiced together to create claim detail with 8 units of Companion. Action required: Void and cancel the invoice. Review the PM visit; confirm the visit if appropriate or cancel the visit if no service was provided. Rebill the visit (if the PM visit was cancelled) or visits (if the PM visit was confirmed). * Tip: During Billing Review, clear OK To Bill/Not OK To Bill filters to identify any unconfirmed split shift visits. Slide 40

41 Questions Slide 41

42 THANK YOU FOR YOUR TIME! Slide 42