Railroad Retirement Board Specialty Medicare Administrative Contractor RRB - SMAC

Transcription

1 MACtoberfest

2 Disclaimer The information provided in this presentation was current as of October 23, Any changes or new information superseding the information in this presentation are provided in articles with publication dates after October 23, 2018 posted on our website at: CPT only copyright 2017 American Medical Association. All rights reserved. The Code on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright 2017 American Dental Association (ADA). All rights reserved. 2

3 MACtoberfest Railroad Retirement Board Specialty Medicare Administrative Contractor RRB - SMAC Presented by: Jennifer Johnson RRB SMAC Provider Outreach and Education

4 Agenda Who We Are and What We Do Getting Started with Railroad Medicare Go Paperless - EDI, ERA and EFT Interactive Voice Response Unit (IVR) eservices Provider Internet Portal Claim Payment, Rejections and Denials Medical Review and Documentation Requests Reopenings and Appeals Resources and Contacts Your Questions 4

5 Who We Are & What We Do

6 What is Railroad Medicare? Railroad Retirement Acts of the 1930s First retirement system for nongovernmental workers Provisions created in 1965 to provide the benefits of the Medicare program to railroad employees and their dependents The Railroad Retirement Board (RRB) works with CMS to ensure Railroad beneficiaries receive the same benefits as their SSA Medicare counterparts Palmetto GBA is the RRB s Part B Specialty Medicare Administrative Contractor, RRB SMAC The RRB SMAC is a Part B Medicare Fee-for-Service contractor; we are not a Medicare Advantage plan 6

7 Where do I file claims for Railroad Medicare beneficiaries? Part B claims Part B claims for Railroad Medicare beneficiaries nationwide are processed by the Palmetto GBA RRB SMAC Includes claims for physician and non-physician practitioners, ambulance providers, mobile x-ray providers, independent laboratories, independent diagnostic testing facilities, ambulatory surgical centers, and mass immunizers Includes claims filed on CMS-1500 (02/12) claim forms or equivalent electronic forms only Palmetto GBA Railroad Medicare PO Box Augusta, GA

8 Where do I file claims for Railroad Medicare beneficiaries? DMEPOS Claims Jurisdictional DME MACs process DMEPOS claims for Medicare and Railroad Medicare beneficiaries CMS DMEPOS Jurisdiction List identifies items as either under DME MAC or Local Carrier Jurisdiction File services under Local Carrier Jurisdiction to Palmetto GBA RRB SMAC for Railroad Medicare beneficiaries File services under DME MAC jurisdiction to local DME MAC CMS Durable Medical Equipment (DME) Center 8

9 Where do I file claims for Railroad Medicare beneficiaries? Hospital Facility Claims Skilled Nursing Facility Claims The jurisdictional A/B Medicare Administrative Contractors (A/B MACs) process hospital facility claims and skilled nursing facility claims for both Medicare and Railroad Medicare beneficiaries Home Health Claims Hospice Claims The jurisdictional Home Health and Hospice (HH+H) MACs process home health and hospice claims for both Medicare and Railroad Medicare beneficiaries 9

10 Getting Started with Railroad Medicare

11 How do I start billing Railroad Medicare? Request a Railroad Medicare Provider Transaction Access Number (PTAN) Are you enrolled with your local Medicare Administrative Contractor (MAC)? Must be enrolled with your local Part B MAC before requesting a Railroad Medicare PTAN Railroad Medicare provider file will match your Part B MAC s file Railroad Medicare effective date will be retroactive to match effective date of your Part B MAC enrollment Have you seen a Railroad Medicare patient? Must have a pending claim to submit Do you submit electronic claims or paper claims? 11

12 Submitting Claims to Railroad Medicare: Electronic or Paper? The Administrative Simplification Compliance Act (ASCA) Requires electronic claim submissions (except for certain rare exceptions) for providers to receive Medicare payment Some exceptions include: Small providers that have fewer than 10 full-time equivalent employees Roster billers Dental claims Providers that submit <10 claims per month to all MACs on average during a calendar year Providers required to bill electronically to local Part B MAC will be required to bill electronically to Railroad Medicare 12

13 Enrollment - Paper Submitters Request a Railroad Medicare PTAN Submit original red and white CMS-1500 (02/12) paper claim Make sure NPIs in items 24J and 33a, TIN in item 25, and addresses in items 32 and 33 match your Part B MAC file Allow 30 days for enrollment from the date of receipt Will receive letter with assigned PTAN or letter explaining why enrollment could not be completed Claim will be processed after PTAN is assigned Do not use PTANs on claims 13

14 Enrollment - Electronic Submitters Request a Railroad Medicare PTAN No CMS-855 Form Required Use PTAN Lookup and Request Tool Enter Part B PTAN and other provider identification information Print or save pdf confirmation with reference number of your request Allow 30 days from request for processing Return to tool to retrieve PTAN information 14

15 PTAN Lookup and Request Tool 15

16 PTAN Lookup and Request Tool Tips When requesting a new PTAN: Verify the PTAN/NPI/TIN combination that is on file with your local Part B MAC before using the tool Enter your individual Part B MAC PTAN and individual NPI Do not enter a group PTAN/group NPI combination Railroad Medicare group PTANs will be established as group members are enrolled Newly enrolled? Allow 10 business days from the date your Part B MAC PTAN was assigned prior to requesting a new Railroad Medicare PTAN 16

17 PTAN Lookup and Request Tool Tips When looking up a PTAN: Verify the PTAN/NPI/TIN combination that is on file with your local Part B MAC before using the tool When entering your Part B MAC PTAN and your NPI, make sure to enter a valid PTAN/NPI combination Enter your individual PTAN and individual NPI or Enter your group PTAN and group NPI 17

18 Provider Enrollment Changes: Let Us Know! Notify Railroad Medicare promptly of changes to your Part B MAC provider enrollment, including when a: Provider address changes Provider retires or leaves group Send written notification on provider/practice letterhead with: Railroad Medicare PTAN, NPI and Tax Identification Number Contact information Explanation of change 18

19 Go Paperless - EDI, ERA and EFT with Railroad Medicare

20 Electronic Data Interchange (EDI) Enrollment Complete a Railroad Medicare Electronic Data Interchange (EDI) enrollment packet Railroad Medicare EDI Enrollment Application (1 page) Railroad Medicare EDI Enrollment Agreement (return all 3 pages) Railroad Medicare EDI Provider Authorization Form (1 page) Will receive Tracking Number by Allow 20 business days for processing Check status on Railroad EDI Enrollment Form Status Update Tool Must have Railroad Medicare PTAN before submitting EDI enrollment forms 20

21 EDI Enrollment Guide Module 21

22 EDI Resources 22

23 Electronic Remittance Advice (ERA) Choose the Receive Electronic Remittances option on EDI Application Designate a receiver Not receiving your ERAs? If you designated a clearinghouse/billing service to receive your ERAs, contact them If you designated to receive ERAs directly, contact the EDI Technology Support Center Medicare Remittance Easy Print (MREP) If you have a Receiver ID, download MREP form to install free software View, print, search and save 835 ERAs 23

24 Electronic Funds Transfers (EFT) Direct deposit of Medicare payments Required for all newly enrolled providers and providers making changes to existing enrollment records No EFT forms. RRB SMAC sets up EFT using CMS-588 form information on file with local Part B MAC questions to Railroad Medicare EFT Specialists, including: Assistance establishing EFT Status of EFT requests Verify EFT effective dates Request EFT notification letters Update banking information Send your EFT questions to: RRBEFT.ADMIN@palmettogba.com Include NPI, PTAN and TIN No bank account information needed 24

25 Railroad Medicare s Interactive Voice Response Unit (IVR)

26 Using the IVR is Mandatory in Some Cases Q. Why can't we get claim status, entitlement or deductible information from a customer service representative? A. CMS IOM Publication , Chapter 6, Section 50.1 states: 'Providers shall be required to use the IVR system to access claim status and beneficiary eligibility information CSRs shall refer providers back to the IVR system if they have questions about claims status or eligibility that can be handled by the IVR system.' Interactive Voice Response (IVR) System

27 IVR Resources Interactive Voice Response (IVR) Conversion Tool Interactive Voice Response (IVR) User Guide General Information is available 24 hours a day Specific information, including claim status and eligibility, is available from 7 a.m.-11 p.m. ET, Monday-Friday Call

28 eservices Provider Internet Portal

29 eservices Portal 29

30 eservices Provider Internet Portal 30

31 Why use eservices? Skip the IVR Check claim status Check beneficiary eligibility View and print remittances online (eremits) View financial data Last three checks paid Payment floor status Payments that have been approved but not yet released for payment 31

32 Why use eservices? Save time faxing or mailing forms eforms Submit Redetermination and Reopening Requests Respond to Medical Review Additional Documentation Request (ADR) letters Report and refund overpayments (echeck) and request immediate offsets (eoffset) Submit General Inquiries Upload pdf attachment files Track your forms online 32

33 Why use eservices? Alternative to paper or electronic claim submission Submit eclaims Submit paperless claims directly without a vendor or clearinghouse Attach documentation as pdf files Correct and resubmit rejected eclaims Track eclaim submissions in eservices 33

34 Why use eservices? Receive Greenmail Paperless Notifications edelivery Medical Review ADRs for prepayment reviews Overpayment Demand letters Medicare Redetermination Notices for your appeal requests Responses to General Correspondence inquiries Provider Administrators may select the edelivery option to receive: eletters in eservices inbox notification of new eletters 34

35 How do I register for eservices? Register at Only one provider administrator per EDI enrollment agreement may register The provider administrator can then grant access to additional users and assign additional provider administrators Register each Railroad Medicare PTAN/NPI combination separately 35

36 How do I register for eservices? Information needed to register Railroad Medicare PTAN, NPI, and Tax ID Must match EDI Enrollment Agreement Amount of most recent Railroad Medicare payment received Choose Line of business: RRB SMAC 36

37 Multi-Factor Authentication (MFA) Adds an extra layer of security to your eservices account CMS mandates portal users provide more than one form of verification Must complete one-time registration for Multi- Factor Authentication (MFA) Must receive and enter an MFA verification code each time you log into eservices MFA code lasts for up to 8 hours 37

38 Multi-Factor Authentication Registration Log into your eservices account Access your My Account tab Enter Mobile Phone number and Carrier name (if desired) Standard messaging and text rates may apply 38

39 MFA Verification at Log In Each time you log in you will be required to enter a verification code If you registered a mobile phone number, you will have choice of how to receive your verification code 39

40 MFA Verification Number Delivery Your verification code will be sent by or by text to your mobile phone Retrieve the code and enter it on the verification screen 40

41 MFA Verification Code s Example with verification code Retrieve the code and enter it on the verification screen Make sure your program does not block messages from 41

42 Keeping Your eservices Account Current Sign in often, at least once every 30 days Respond to profile verification requests Update your account profile if your or phone changes Administrators Complete eservice recertification requests for account users Terminate provider users or additional provider administrators who no longer need access 42

43 eservices Resources 43

44 Claim Payment, Rejections and Denials

45 Where can I find the Railroad Medicare Fee Schedules? RRB SMAC payments are based on the CMS fee schedules for your state and locality Verify allowed amounts on fee schedules posted on your local MAC s website or on the CMS website Palmetto GBA Medicare Physician Fee Schedule Tool Medicare Physician Fee Schedules (MPFS) are viewable for all states and downloadable for NC, SC, WV and VA Display MPFS amounts, indicators and indicator descriptions 45

46 Why did my claim reject? RARC MA130 - Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information Additional RARCs or CARCs provide further explanation Must submit a new claim Reopening and Redetermination requests will be dismissed Resources Interactive CMS-1500 (02/12) Form Denial Resolution Tool Frequently Asked Questions (FAQs) Modifier Lookup Tool Articles 46

47 Interactive CMS-1500 (02/12) Form Tool 47

48 Why Did My Claim Deny? Resources Denial Resolution articles Global Surgery Denial Tool National Correct Coding Initiative (NCCI) Tool Modifier Lookup MSP Lookup Tool Frequently Asked Questions (FAQs) Medicare Learning Network Articles 48

49 Articles 49

50 Frequently Asked Questions (FAQs) 50

51 Claims Processing Issues Log (CPIL) List of current system-related claims payment issues Issues reported to CMS and/or Multi- Carrier System (MCS) Check before calling the Provider Contact Center Sign up for Article Update Notification Receive with the new article when revisions are made 51

52 Medical Review and Requests for Documentation

53 Targeted Probe and Educate CMS's Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help 53

54 TPE How Does It Work? If chosen for the program you will receive a letter from the RRB SMAC that introduces the TPE program and requests a response to set up a contact relationship for the purpose of education The MR department will review or your claims and the supporting documentation Our medical reviewer will contact your designated person during the review if easily curable errors are identified. You can also expect a call prior to the conclusion of each TPE round to discuss the review summary If compliant you will not be reviewed again for at least one year on the selected topic If errors are identified, you will be given a 45 day period to make changes and improve before your practice is moved to round two of reviews. TPE may repeat for three rounds When high denial rates continue after three rounds of TPE, RRB SMAC will send the case for further investigation 54

55 Easily Curable TPE Errors Examples of easily curable errors in which a provider could be contacted during the review are: Missing Orders Submission of the wrong date of service Missing provider signatures Illegible documentation Missing pages of documentation 55

56 Why are You Asking for Medical Records? Medical Review (MR) Prepayment Review Additional Documentation Request (ADR) letters are sent to request documentation for a claim prior to payment Respond promptly within 45 days Respond via eservices, esmd, fax or mail MR will complete review of documentation within 30 days of receipt See Medical Review: Additional Documentation Requests (ADRs) article for complete details Sign up for edelivery to receive prepayment ADRs through eservices 56

57 Why are You Asking for Medical Records? Medical Review Postpayment Review Probe letters sent to request documentation for a selection of paid claims Respond promptly within 45 days Respond via eservices, esmd, fax or mail MR will make a review determination and mail results letter to provider within 60 calendar days of receipt Review may result in overpayments See our Understanding the Railroad Medicare Medical Review Program recorded presentation 57

58 Appeals and Reopenings

59 How do I Appeal a Claim Determination? Redeterminations Submit a redetermination request 120 days from the receipt of the initial determination (date of receipt is presumed to be 5 days from date of the notice) Redetermination forms on website and in eservices Submit through eservices, by fax, by mail, or via esmd No MA-130 rejections Allow 60 days for processing Use Railroad Medicare Redetermination Status Tool No duplicate requests 59

60 How Can I Correct My Claim? Reopenings Correct simple clerical errors and omissions: Number of units Procedure code Diagnosis linkage Modifiers Date of service Request by Telephone, through eservices, by fax or by mail Use appropriate Reopenings Request form or eservices eform See Instead of a Written Redetermination: Consider Having Your Claim Reopened article No MA-130 Rejections 60

61 Resources and Contacts

62 Visit MLN articles from the Centers for Medicare & Medicaid Services (CMS) Articles and FAQs by topic Self-Services Tools eservices Online Portal Redetermination Status Tool Quick Reference Guide Modifier Lookup MSP Lookup Reason/Remark Code Lookup 62

63 RRB SMAC Website 63

64 Where Can I Find Phone and Fax Numbers? 64

65 Provider Contact Center Toll-Free Number Call one number for: Provider Customer Service Option 5 Provider Enrollment Option 3 Reopenings Option 4 Electronic Data Interchange (EDI) and eservices Option

66 Railroad Medicare Contacts RAILROAD MEDICARE RESOURCES Railroad Medicare Homepage Provider Contact Center EDI / eservices Telephone Reopenings Provider Enrollment Palmetto GBA Listserv Select Listservs from top tool bar Contact Us By eservices CMS Listserv Medicare.Railroad@PalmettoGBA.co m Under Forms/Tools Interactive Voice Response (IVR) Palmetto GBA Railroad Medicare PO Box Augusta, GA

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68 MACtoberfest Questions?