Commonwealth of Kentucky KY Medicaid KyHealth Net Institutional Companion Guide

Transcription

1 Commonwealth of Kentucky KY Medicaid KyHealth Net Institutional Companion Guide Version 3.7 September 2, 2014

2 Revision History Document Version Date Name Comments /27/2010 EDI Created /14/2010 Marilyn Surratt Revised per Marilyn s requests /03/2010 Marilyn Surratt Revised per Marilyn s requests /9/2010 Martha Senn Revised per Martha s request /18/2010 Stayce Towles Martha Senn 1.5 8/24/2010 Martha Senn Ron Chandler 1.6 9/2/2010 Stayce Towles Martha Senn Ron Chandler 1.7 9/7/2010 Stayce Towles Martha Senn Ron Chandler /4/2010 Stayce Towles Martha Senn Ron Chandler Revised Revised. Removed PHI from images, added numbers to some and modified field tables. Revised per Stayce and Martha s. Revised per Stayce and Martha s. DMS approved on 10/4/ /06/2011 Ann Murray Global corrections and changes /09/2011 Brenda Orberson Ann Murray /14/2013 Martha Senn Keri Hicks Updated screen shots. CO Updated Member Eligibility Verification screen and the Managed Care 5 year History screen. CO Inserted Adjusted Primary Care Attestation screens /14/2013 Keri Hicks Finalized Tech Writer Updates. DMS Approved 02/14/ /26/2013 Martha Senn Removal of Adjusted Primary Care Attestation screens.

3 Document Version Date Name Comments /04/2013 Keri Hicks Finalized Tech Writer Updates. DMS Approved 02/14/ /20/2013 Martha Senn CO Lockin, comment If member has MCO eligibility /1/2013 Martha Senn Finalized: DMS approved 7/1/ /3/2013 Martha Senn CO Supplemental claim inquiry for Primary Care and Rural Health Providers 2.6 7/8/2013 Martha Senn Finalized: DMS approved 7/8/ /24/2013 Martha Senn New eligibility screens with ACA changes /29/2013 Martha Senn Updates for ADO /12/2013 Jamie Redmon Updates for EFT /30/2013 Jamie Redmon Updates for PE and Eligibility Group /08/2014 Jamie Redmon Replacing screen shots for Eligibility Group 3.2 2/25/2014 Jamie Redmon Replacing all instances of ICD-9 with ICD per CO /19/2014 Jamie Redmon Updates to PE screen per CO /29/2014 Martha Senn DMS approved Also removed verify provider box section as it is outdated /4/2014 Martha Senn Updates to PA screen shots and Claim billing codes 3.6 8/18/2014 Martha Senn Update Billing Codes screen with Diagnosis screen shot /20/2014 Martha Senn DMS approved 3.7 8/28/2014 Martha Senn CO and Provider Status Information screen shots 3.7 9/2/2014 Martha Senn DMS approved

4 Commonwealth of Kentucky - MMIS Table of Contents 1 Introduction What it is MEUPS? How do I use this system? What is a Provider Administrator? What is a Billing Agent? What is a PIN Number? How to obtain a PIN number: Using the PIN to Create a New Account Signing into KyHealth Choices Sign into KyHealth Choices Accessing User Applications How to Change the Password: examples of password reminder and account change notification Viewing Agent Roles Add an Agent or New Employee No Address Found: Create Username Manage Agent Roles Accessing KY Health Net Functionality Member Information Member Card Issuance Member Eligibility Verification Searching for a Member View Pharmacy Claim History Presumptive Eligibility Presumptive Eligibility Application Screen Printing the Certificate Presumptive Eligibility Certificate Example Patient Liability Spend Down PA Prior Authorization Prior Authorization Check list Radiology Prior Authorization Procedure Code List PA Letters PA Letter List PA Inquiry Provider References Provider Reference Search TPL Carriers Provider References Documentation Annual Disclosure of Ownership - ADO Electronic Funds Transfer - EFT RA Viewer Claims Claim Inquiry Submitting an Institutional Claim Institutional Claim Header DMS Approved: 9/2/2014 Page i

5 Commonwealth of Kentucky - MMIS Billing Code Screens Detail Screen Summary Panels Adjust or Void Claim Screen Medicare crossover Supplemental Claims The Supplemental Claims display of encounter data Provider Status The Provider Status Information Appendix A Forms Billing Instructions DMS Approved: 9/2/2014

6 1 Introduction 1.1 What it is MEUPS? MEUPS is an acronym for the Medicaid Enterprise User Provisioning System. It s a single signon system that allows users to access multiple applications via a single user name and password. What that means to Kentucky Medicaid Providers is that you can manage your own account, and others access to it. You won t see the word MEUPS on your screen, but you may hear someone refer to your MEUPS account. It s the same thing as your KyHealth Choices account. 1.2 How do I use this system? When you log in, you ll see the KyHealth Choices Home Page, and any applications available to you will appear on your menu, including Account Management, Authorization Request, KyHealth Net and EMAX. Link Functions for All Users Functions for Provider Admin Only Functions for Billing Agents Only Account Management Allows you to manage your personal information, change your security question/answer and reset your password. Allows you to view agents with access to your account and add an agent to your account. None. KyHealth Net Allows user to submit claims, PA requests, check eligibility, etc. Functions are limited to those that are applicable to the Provider type. Functions are limited to those authorized by the Provider Administrators. EMAX None Functions are limited to those that are applicable to the Provider type. Functions are limited to those authorized by the Provider Administrators. 1.3 What is a Provider Administrator? A Provider Administrator has control of a Provider s account, and can grant access to Billing Agents. A PIN is required to set up a Provider Administrator account, and only one Provider Administrator account can exist for each Kentucky Medicaid provider number. 1.4 What is a Billing Agent? A Billing Agent is an account-holder who works on behalf of a Provider, but isn t the Provider Administrator. In other words, the Billing Agent may submit claims on behalf of the Provider, but only as long as the Provider Administrator has granted access to the Billing Agent. A single Billing Agent may work on behalf of multiple providers. An individual may set up his or her own Billing Agent account, but may not access claims submission, eligibility, etc. until a Provider Administrator grants access. DMS Approved: 9/2/2014 Page 1

7 1.5 What is a PIN Number? Each Kentucky Medicaid Provider has been issued a Personal Identification Number which can be used to set up an account. This PIN is the key that unlocks the account initially. Instructions for obtaining the PIN are in the next section of this document.creating a New Provider User Account for KYHealthnet The user creating the KY Healthnet account should be the office manager or someone deemed responsible for accessing provider information. A PIN number is required to create a user account. The Electronic Data Interchange (EDI) Helpdesk will assign a PIN number to each KY Medicaid provider ID How to obtain a PIN number: 1. Go to the KY Medicaid Website 2. Click on Electronic Claims. 3. Click on Frequently Asked Questions. 4. Click on the hyperlink at the bottom of the page; last paragraph; first sentence for PIN release form (user instructions included). 5. Complete the attached PIN Release form and return to the EDI Helpdesk along with a copy of a valid driver's license via or fax. Include your phone number and address and someone will contact you with your PIN and website information. a. Fax your PIN Release form to: or b. your form to: ky_edi_helpdesk@hp.com. The HP EDI department will respond within 2 business days via . The PIN release example is below: From: Jane.doe@hp.com Sent: Monday, August 9, :30 AM To: Daisy.Duck@anywhere.com Subject: KY Medicaid PIN release request To create a KY Health Net account user the following information: Provider ID = XXXXXXXXXX PIN # = XXXXXXXXX To create a KYHealth Net account, access To access the user account: The password expires every 30 days. A reminder is sent on the 20th day to update the password. To change your password click on Account Management, Change my password. In the future you can do the following: If the account user password is expired click on 'Forgot my password' button on the sign in page under password to complete a password update. This function only works if a security question is linked to the account. If you have questions contact the EDI Helpdesk at or KY_EDI_Helpdesk@hp.com. DMS Approved: 9/2/2014 Page 2

8 1.5.2 Using the PIN to Create a New Account 1. Enter the provider ID (KY Medicaid provider ID or Group id); and, 2. Enter the PIN number assigned. User Agreement to Terms of Service window will display, 3. Click the Yes, I agree or No, I do not agree button. DMS Approved: 9/2/2014 Page 3

9 4. Enter the data On the Create New Account Form DMS Approved: 9/2/2014 Page 4

10 The Your account was successfully created window will display. DMS Approved: 9/2/2014 Page 5

11 2 Signing into KyHealth Choices 2.1 Sign into KyHealth Choices 1. Access 2. Enter the username and password DMS Approved: 9/2/2014 Page 6

12 2.2 Accessing User Applications 1. Click on Account Management under Application. The Administrator to the provider account can view or add Agents. An agent has limited access to change password or update security questions. DMS Approved: 9/2/2014 Page 7

13 Account Management screen displays. The functionality available is: Account Home My Information View Agent Roles Change Password Add Agent Click and return to home page (Admin and Agent) Allows user to update address, phone number and security question. (Admin and Agent) Allows the provider administrator to view the roles granted to an agent. Allows user to change the current password (Admin and Agent) Allows the provider administrator to add agents. 2. Click on the My Information button the following screen displays. 3. Scroll to the Security Question & Answer section. 4. Select the security question. 5. Enter the answer. 6. Click on Save. DMS Approved: 9/2/2014 Page 8

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15 2.2.1 How to Change the Password: The account password expires every 30 days. A pink banner will display on the Home page showing the days remaining to password expiration beginning with 10. The user will receive an notification from MEUPS prior to the expiration on the 20 th day. 1. Click on the Change Password button; 2. Complete form; 3. Click the Change Password button examples of password reminder and account change notification From: MEUPS Automated Mailer [mailto:meups_donotreply@ .kymmis.com] Sent: Friday, July 16, :30 PM To: Doe, Jane Subject: PASSWORD EXPIRATION REMINDER: 10 days left Sensitivity: Confidential Kentucky user Jane Doe, Your Medicaid system account password will expire in 10 days on Monday, July 26, Please change your password before then to ensure uninterrupted system access. Please contact the EDS helpdesk at KY_EDI_HelpDesk@hp.com or call (800) between 7:00 am - 6:00 pm Monday - Friday EST should you have questions regarding this notification. Medicaid Enterprise Users Provisioning System MO DMS Approved: 9/2/2014 Page 10

16 From: MEUPS Automated Mailer Sent: Wednesday, August 18, :00 PM To: Doe, Jane Subject: ACCOUNT CHANGE NOTIFICATION Sensitivity: Confidential Kentucky user Jane Doe, KyHealth Choices sends you this account change notification for your information. No action on your part is required. The following changes have been made recently against your systems account: Date of Change Aug :30PM Aug :32PM Description Account access has been reinstated Password changed Please contact the EDI helpdesk at or call (800) between 7:00 am - 6:00 pm Monday - Friday EST if you have questions about any of these changes. KyHealth Choices DMS Approved: 9/2/2014 Page 11

17 2.3 Viewing Agent Roles Provider Administrators and Billing Agents have the ability to add agents to an account, giving them access to submit claims, check claim status, check eligibility or perform other functions on behalf of the provider. Clicking View Agent Roles will allow a Provider Administrator or Billing Agent to see the Agents associated with an account. If no Agents have been added, No Agents Found will appear. 2.4 Add an Agent or New Employee. Provider Administrators and Billing Agents have the ability to add agents to an account, giving them access to submit claims, check claim status, check eligibility or perform other functions on behalf of the provider. Clicking Add Agent allows a Provider Administrator or Billing Agent to add an Agent to the account. DMS Approved: 9/2/2014 Page 12

18 2.4.1 No Address Found: Create Username The Provider Administrator or Billing Agent may search for an existing agent by entering the address of the agent and clicking search. If no agent is found, the screen below will appear, allowing the user to create an Agent account and associate that agent with the Provider account. 1. Complete the fields boxed in red below. 2. Click Add & Manage Agent button. DMS Approved: 9/2/2014 Page 13

19 3. The Agent Account Created window appears. 4. User will receive an as shown below. Automated MEUPS Example: 5. When user clicks the link in the (example above), the Terms of Service User Agreement window appears as shown below. DMS Approved: 9/2/2014 Page 14

20 6. User must click I agree in order to proceed. DMS Approved: 9/2/2014 Page 15

21 2.5 Manage Agent Roles After an Agent is associated with a Provider account, permissions or roles must be granted in order for that Agent to act on the Provider s behalf. To add roles for KyHealth Net (claims, eligibility, etc.), follow the instructions below. 1. Click on the KYHealthNet link. DMS Approved: 9/2/2014 Page 16

22 2. Notice section Modify the permissions for KYHealthNet section opens. 3. Roles are granted or removed in this section. 4. Check the roles you wish to grant agent. 5. Click the Save Changes button to save modifications. DMS Approved: 9/2/2014 Page 17

23 The screen returns Successful adding role of DMS Approved: 9/2/2014 Page 18

24 3 Accessing KY Health Net KyHealth Net allows users to access Member eligibility and related functions, submit claims, adjust or void claims, check claim status, check Prior Authorization requests, print Prior Authorization letters, view or download remittance advice statements, and access other valuable information. 1. On the KyHealth Choices Home page, click on the KYHealth Net link. DMS Approved: 9/2/2014 Page 19

25 2. Select/verify the Provider s NPI/Taxonomy in the drop-down box. NOTE: The drop-down only appears if the user is an agent for multiple providers, otherwise, the agent will see only one provider s NPI/taxonomy in the box. DMS Approved: 9/2/2014 Page 20

26 4 Functionality Provider Administrators have access to all applicable functions on KyHealth Net. Billing Agents and Agents have access to only those functions granted them by the Provider Administrator. A Billing Agent or Agent may only perform the functions granted them by a given Provider Administrator, while logged in under that provider s account. For example, if an Agent works on behalf of Dr. Smith and Dr. Jones, but the Agent doesn t have claim submission access for Dr. Jones, the claim submission function will not appear unless the Agent has selected Dr. Smith s NPI/Taxonomy from the drop-down when logging in. KyHealth Net offers the following functions: Menu Selection Member Claims Prior Authorization (PA) Provider References RA Viewer Functions Check eligibility, card issuance, spend down, patient liability, pharmacy history and enroll a Member in Presumptive Eligibility (PE providers only). Check claim status, submit claims, adjust paid claims or void paid claims. Access PA information, download a PA letter or lookup a PA number. Check coverage on a procedure code, lookup commercial insurance carrier information and access other references on the DMS website. View and/or download your Remittance Advice. The hyperlinks on the Home Page also offer quick access to commonly used functions. DMS Approved: 9/2/2014 Page 21

27 5 Member Information 5.1 Member Card Issuance 1. Select Member from the Menu. 2. Choose Card Issuance from the drop-down. DMS Approved: 9/2/2014 Page 22

28 3. Enter the Member ID or SSN# and click the Search button to find the Medicaid card issue date. The card issuance dates include eligibility begin and end dates along with card type. An R in the retroactive column indicates the segment was issued retroactively. DMS Approved: 9/2/2014 Page 23

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30 5.2 Member Eligibility Verification 1. Select Member from the Menu. 2. Choose Eligibility Verification from the drop-down. The following screen will appear. DMS Approved: 9/2/2014 Page 25

31 5.2.1 Searching for a Member 1. Click the arrow to the right in the Select Lookup Type box and select the criteria to be used in the search. When the search criteria is selected, the screen will expand to include fields for dates of service and Service Type. The Service Type will display all 12 of the CORE ACA required service types, the page will automatically default to Health Plan Coverage. The current date will automatically be plugged in the date s fields. The user may change the dates to the desired dates of service. 2. Enter the search criteria. 3. Click search. DMS Approved: 9/2/2014 Page 26

32 The Member Eligibility Verification page will appear. DMS Approved: 9/2/2014 Page 27

33 When the link under Eligibility Group is selected a new window displays the service types: DMS Approved: 9/2/2014 Page 28

34 If the member eligibility has end dated the following message will display: DMS Approved: 9/2/2014 Page 29

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38 5.3 View Pharmacy Claim History 1. Select Member from the Menu. 2. Choose Pharmacy History from the drop-down. DMS Approved: 9/2/2014 Page 33

39 The following screen will appear. 3. Enter the Member s ID and click Search. DMS Approved: 9/2/2014 Page 34

40 The Pharmacy Claims History screen will appear. DMS Approved: 9/2/2014 Page 35

41 6 Presumptive Eligibility This function is only for Presumptive Eligibility providers. 1. Select Member from the Menu. 2. Choose Presumptive Eligibility from the drop-down. DMS Approved: 9/2/2014 Page 36

42 The following screen will appear. 1. Select the applicable provider number from the drop down menu. If you are a provider, only your number will appear. If you are an agent, you will see the providers for whom you bill. 2. Enter the Confirmation Number and click Login. DMS Approved: 9/2/2014 Page 37

43 6.1 Presumptive Eligibility Application Screen DMS Approved: 9/2/2014 Page 38

44 Field-by-field instructions for completing the Presumptive Eligibility Application appear below. Field#/Menu Selection Description Application Information DMS Approved: 9/2/2014 Page 39

45 1 Application Date The current date will appear here. 2 Provider Number 3 DMS Confirmation # Patient Information 4 Patient SSN The provider number selected on the previous screen will appear. The confirmation number issued to the provider by the Presumptive Eligibility unit will appear here. The patient s Social Security number will appear here. 5 Last Name 6 First Name 7 Date of Birth 8 Gender 9 Street Address 10 City 11 State 12 Zip Code 13 County The patient s last name will appear here. The patient s first name will appear here. The patient s date of birth will appear here. The patient s gender will appear here. Enter the patient s street address. The * indicates that this field is required. Enter the patient s city of residence. The * indicates that this field is required. Enter the patient s state of residence. The * indicates that this field is required. Enter the patient s Zip code. The * indicates that this field is required. Select the patient s county of residence from the drop-down menu. DMS Approved: 9/2/2014 Page 40

46 14 Home Phone 15 Work Phone 16 Marital Status 17 Race Mailing Address (if different) 18 Street Address 19 City 20 State 21 Zip Code Family Income The * indicates that this field is required. Enter the patient s home phone number. The * indicates that this field is required. Enter the patient s work phone number. Select the patient s marital status from the drop-down menu. Select the patient s race from the drop-down menu. Enter the patient s mailing street address. Enter the patient s mailing city. Enter the patient s mailing state. Enter the patient s mailing Zip code. 22 Number of Family Members Enter the number of members in the patient s family. The number should include the patient, the baby (or babies) expected and other family members in the household. The * indicates that this field is required. 23 Total Monthly Family Income Enter the dollar amount of the family s total monthly income. The * indicates that this field is required. Additional Information 24 Is patient pregnant? DMS Approved: 9/2/2014 Page 41

47 25 Is patient under 19? If patient is pregnant select yes and enter the due date. If patient is not pregnant select no and continue with the application. If patient is under 19 years old select yes, if patient is 19 years or older select no and continue with the application. 26 Is patient a former foster care child between the ages of 19 and 26? If patient is a former foster care child between 19 and 26 years old select yes. If patient is not a former foster care child between 19 and 26 years old select no and continue with the application. 27 Is patient living with any dependent children under the age of 19? 28 Is patient under 65? If patient has any children under the age of 19 living in their household select yes, if not, select no and continue with the application. If patient is under 65 years old select yes. If patient is not under 65 years old select no. 29 Is patient currently enrolled in Medicare? 30 Submit Information 31 Cancel This question will only display if the user selects yes to Is patient under 65? Clicking the button will submit the Presumptive Eligibility application. Clicking the button will cancel the Presumptive Eligibility application. DMS Approved: 9/2/2014 Page 42

48 6.2 Printing the Certificate A certificate is generated after the PE application is completed and approved. Click the link on the screen to print the certificate for the Member. This certificate serves as the Member s temporary card. DMS Approved: 9/2/2014 Page 43

49 6.2.1 Presumptive Eligibility Certificate Example DMS Approved: 9/2/2014 Page 44

50 7 Patient Liability 1. Select Member from the Menu. 2. Choose Patient Liability from the drop-down. DMS Approved: 9/2/2014 Page 45

51 The following screen will appear. 3. Enter the Member ID or SSN and click the Search button to find the patient liability. 4. Click on the View button to populate the MAP 552. DMS Approved: 9/2/2014 Page 46

52 8 Spend Down 1. Select Member from the Menu. 2. Choose Spend Down from the drop-down. DMS Approved: 9/2/2014 Page 47

53 The following screen will appear. 3. Enter the Member ID or SSN and click the Search button to find the spend down data. DMS Approved: 9/2/2014 Page 48

54 9 PA Prior Authorization 9.1 Prior Authorization Check list 1. Select PA from the Menu. 2. Choose Prior Authorization from the drop-down. DMS Approved: 9/2/2014 Page 49

55 The following dialogue box will appear. 3. Select Open or Save. DMS Approved: 9/2/2014 Page 50

56 An example of the checklist follows: DMS Approved: 9/2/2014 Page 51

57 9.2 Radiology Prior Authorization Procedure Code List 1. Select PA from the Menu. 2. Choose Radiology Prior Auth Proc Code List from the drop-down. A PDF version of the Radiology Prior Authorization Procedure Code List will appear. DMS Approved: 9/2/2014 Page 52

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59 9.3 PA Letters 1. Select PA from the Menu. 2. Choose CareWise Prior Authorization Letter from the drop-down. DMS Approved: 9/2/2014 Page 54

60 The following screen will appear. Searches may be conducted by Provider or by using a specific Member ID. DMS Approved: 9/2/2014 Page 55

61 9.3.1 PA Letter List Select Member letter under letter type. Searches may be conducted by Provider or by using a specific Member ID. DMS Approved: 9/2/2014 Page 56

62 9.4 PA Inquiry 1. Select PA from the Menu. 2. Choose PA Inquiry from the drop-down. DMS Approved: 9/2/2014 Page 57

63 The following screen will appear. A PA search is completed by entering: Transaction ID is the PA number; or Member ID; or SSN; or Name of member; or, Start date is required with all search criteria. DMS Approved: 9/2/2014 Page 58

64 1. Selecting Search returns the Transaction ID. 2. Click to open the PA. 3. Click on the next button to view the Summary page. DMS Approved: 9/2/2014 Page 59

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66 10 Provider References 10.1 Provider Reference Search 1. Select Provider References from the Menu. 2. Choose Reference Search from the drop-down. DMS Approved: 9/2/2014 Page 61

67 The following screen will appear. 3. Enter the procedure code and date of service 4. Select the Eligibility Group and click Search The response will return the Limitation for the date of service. DMS Approved: 9/2/2014 Page 62

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70 10.2 TPL Carriers 1. Select Provider References from the Menu. 2. Choose TPL Carrier from the drop-down. DMS Approved: 9/2/2014 Page 65

71 The following screen will appear. 3. Enter the TPL Carrier name. 4. Click Search. The response will return all carrier information on file. DMS Approved: 9/2/2014 Page 66

72 10.3 Provider References Documentation 1. Select Provider References from the Menu. 2. Choose Documentation from the drop-down. DMS Approved: 9/2/2014 Page 67

73 The following screen will appear. Selected documentation for additional provider resources available at DMS Approved: 9/2/2014 Page 68

74 11 Annual Disclosure of Ownership - ADO The Annual Disclosure of Ownership is now accessible on Kentucky Health Net for providers and designed users to complete removing the need for paper forms. From the Main Page- Users will see the ADO renewal message if their ADO is due within 60 days or if it is past due. Billing Agents will only see the providers who are due for ADO in the list, and ONLY for the providers that have granted the agent access for ADO. DMS Approved: 9/2/2014 Page 69

75 Page 1, Question 1 4 Questions 1 and 2 will be pre-populated with the provider s information. If the user is a billing agent the fields are auto populated with the first provider in the list who has granted the agent access. To switch providers select the drop down option, select the provider then hit the Switch Working Provider button. If the agent selects a provider from the list who has NOT granted them access, the user will be taken back to the home page and a message will appear that You have not been granted KY Health Choices access. If a user tries to change the name or provider number in question 1 or 2 the user WILL be flagged for DMS to review. Questions 3 and 4 will NOT allow a date in the past. DMS Approved: 9/2/2014 Page 70

76 Page 3-Question 6- is pre-populated for the user DMS Approved: 9/2/2014 Page 71

77 Page 4 question 7 DMS Approved: 9/2/2014 Page 72

78 Page 5 DMS Approved: 9/2/2014 Page 73

79 Page 6 question 9 DMS Approved: 9/2/2014 Page 74

80 Page 7 question 10 DMS Approved: 9/2/2014 Page 75

81 Page 8 question 11 DMS Approved: 9/2/2014 Page 76

82 Page 9 Question 12 DMS Approved: 9/2/2014 Page 77

83 Page 10 question 13 DMS Approved: 9/2/2014 Page 78

84 Page 11 Question 14 DMS Approved: 9/2/2014 Page 79

85 Page 12 Question 15 DMS Approved: 9/2/2014 Page 80

86 Page 13 Question 16 - This page is pre-populated for user. DMS Approved: 9/2/2014 Page 81

87 Page 14 Question 17 DMS Approved: 9/2/2014 Page 82

88 Page 15 Questions Question 18 Select either FEIN OR SSN Both options are not allowed: the SSN/FEIN entered must match existing provider information on file or it will flag it for DMS review Question 19 Select the initials option OR the check box option, both are not allowed. DMS Approved: 9/2/2014 Page 83

89 Summary Page DMS Approved: 9/2/2014 Page 84

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91 By completing question 21 the user is creating an electronic signature. Once the Submit button is selected a message of Selecting this button submits ADO Form and creates a legally binding electronic signature, appears. The Submit button is now disabled until the user logs out of KY Health Net and logs back in. Questions 5, 6, 7, 8, 9, 10, 16 and 17 are flagged for validation by Provider Enrollment to review if any matches are found. DMS Approved: 9/2/2014 Page 86

92 12 Electronic Funds Transfer - EFT Click on EFT Link from Main Page DMS Approved: 9/2/2014 Page 87

93 Instructions for the form are located here DMS Approved: 9/2/2014 Page 88

94 Provider Information and Provider Identifiers will be automatically prepopulated with the provider s information. If New Enrollment or Change enrollment is selected as reason for submission, then a copy of a voided check or bank letter is required. DMS Approved: 9/2/2014 Page 89

95 13 RA Viewer 1. Click RA Viewer on the menu. DMS Approved: 9/2/2014 Page 90

96 The following screen will appear. 2. Select the provider NPI/Taxonomy from the Drop-Down menu (if the user works on behalf of multiple providers) 3. Click Search. RA Viewer holds six months of Remittance Advice statements displaying the most current at the top of the screen. Each RA can be viewed or downloaded. DMS Approved: 9/2/2014 Page 91

97 4. Select the applicable Run Date. DMS Approved: 9/2/2014 Page 92

98 14 Claims 14.1 Claim Inquiry 1. Select Claims from the Menu. 2. Choose Claims Inquiry from the drop-down. DMS Approved: 9/2/2014 Page 93

99 3. Select the applicable NPI and Taxonomy if using an agent or billing agent account. Enter Member ID and From Date/Thru Date or Patient Acct # Claim Status Warrant Date ICN Date of Service Unfinished claims Any Status, Paid, Denied and Suspended Warrant Date should read as RA date Enter ICN and remove From Date/Thru Date A search for claim using the dates of service entered or A claim not completed but saved for future submission DMS Approved: 9/2/2014 Page 94

100 14.2 Submitting an Institutional Claim 1. Select Claims from the Menu. 2. Choose Claims Submission (Institutional) from the drop-down. DMS Approved: 9/2/2014 Page 95

101 Institutional Claim Header The claim Header information appears on this screen, divided in two columns. The column on the left is the Billing Information and the section on the right contains the Service Information. Please follow the Provider type Billing Instructions for detailed field-by-field instructions. Appendix A includes a website link for all Medicaid Billing Instructions Institutional Claim Header Screen Descriptions DMS Approved: 9/2/2014 Page 96

102 Field Number/ Menu Selection Definition of Field Description 1 Provider Number 2 Member ID 3 Last Name 4 First Name NPI Number of billing provider (auto-populated) Enter 10 digit Member s KY MEDICAID ID number. Member s last name (auto-populated). Member s first name (auto-populated). 5 Patient Account Number 6 Date of Birth 7 Gender Patient s account number. (Optional) Member s date of birth (auto-populated). Member s gender (auto-populated). 8 Attending Physician Enter Attending physician s NPI number if applicable. 9 Referring Physician 10 Facility Number Enter Referring physician NPI number. This is the KenPac provider, otherwise leave blank Enter Billing NPI number. 11 Other Physician Enter Other treating physician NPI number. 12 Insurance Denied? Indicates a denial from commercial insurance. If yes is selected the claim must be billed paper with the insurance denial. 13 Prior Authorization 14 Claim Type Enter Prior Authorization number or Treatment Authorization Number if applicable Select the appropriate claim type in drop down box. DMS Approved: 9/2/2014 Page 97

103 Field Number/ Menu Selection Definition of Field Description 15 Type of Bill Select the applicable type of bill. 16 From Date Enter the first date of service. 17 Thru Date Enter the through date of service. 18 Covered Days Enter number of days billed on claim. 19 Patient Status Enter Patient s status on through date. 20 Admit Source Select the admission source. 21 Admission Type Select the admission type. 22 Admission Date Enter the patient s date of admission to the facility. 23 Admission Hour Enter the patient s hour of admission. 24 Discharge Time Enter the time of patient s discharge. 25 Co-insurance Days Number of co-insurance days. (Medicare Only) 26 Lifetime Reserve Days Number of lifetime reserve days. (Medicare Only) 27 EPSDT Indicates an EPSDT related service. (if applicable) 28 EPSDT Condition Indicate appropriate condition from drop down. 29 Next Advance to the diagnosis screen. DMS Approved: 9/2/2014 Page 98

104 Field Number/ Menu Selection Definition of Field Description 30 Print Allows user to print this screen Billing Code Screens This portion includes separate screens accessed by clicking the appropriate links: Diagnosis, Procedure, Condition, Value, Occurrence/Span and Payer. Be sure and click the save code button after entering the information on each screen. Field-by-field instructions follow Billing Code Screen Diagnosis 2 1 Feature available with IDC-10 implementation DMS Approved: 9/2/2014 Page 99

105 Present on Admission (POA) Indicator Claim Type Inpatient Claim Inpatient crossover claim/ TOB and Outpatient claims Requirement POA Field is displayed for all but Admitting and Emergency diagnosis code fields POA field is displayed for all diagnosis codes except Admitting and Emergency No POA required. POA Indicator values Blank/space Yes (Y) No (N) Unknown (U Clinically Undetermined (W) *POA Field is not available for Admitting Diagnosis and Emergency Diagnosis Field Number/ Menu Selection Definition of Field Description 1 Sequence Number The sequence number of the diagnosis. This field is auto-populated. 2 ICD Version Feature available with ICD-10 implementation Select the appropriate ICD version 3 Diagnosis (drop down) 4 Diagnosis Code 5 POA 6 Save Code 7 Add Code Select the type of diagnosis (i.e. Principle, Admitting) Enter the appropriate code for the member s diagnosis. (Do not enter Decimal in Diagnosis code) Choose the appropriate POA indicator Saves the diagnosis information on the claim. Must save to continue. DMS Approved: 9/2/2014 Page 100

106 Field Number/ Menu Selection Definition of Field Description 8 Delete Code 9 Next 10 Print Allows the user to add an additional diagnosis code to the claim. Save code after each additional code added. Allows the user to remove a diagnosis code previously entered on the claim. Advance to the next screen Allows user to print this screen DMS Approved: 9/2/2014 Page 101

107 Billing Codes- Procedure 1 2 Feature available with ICD-10 implementation Field Number/ Menu Selection Definition of Field Description 1 Sequence Number The sequence number of the procedure codes. This field is autopopulated. 2 IDC version - Feature available with ICD-10 implementation Select the appropriate ICD version 3 Procedure Code 4 Date 5 Save Code Enter the ICD procedure code. Enter the DOS that the procedure was done. Saves the procedure information on the claim. Must save code to continue. DMS Approved: 9/2/2014 Page 102

108 Field Number/ Menu Selection Definition of Field Description 6 Add Code 7 Delete Code 8 Next 9 Print Allows the user to add an additional procedure code to the claim. Save code after each additional code entered. Allows the user to remove a procedure code previously entered on the claim. Advance to the next screen Allows user to print this screen DMS Approved: 9/2/2014 Page 103

109 Billing Codes Institutional Cause of Injury 1 2 Feature available with ICD-10 implementation Field Number/ Menu Selection Definition of Field Description 1 Sequence Number The sequence number of the procedure codes. This field is autopopulated. 2 IDC version - Feature available with ICD-10 implementation 3 Injury Code Select the appropriate ICD version DMS Approved: 9/2/2014 Page 104

110 Field Number/ Menu Selection Definition of Field Description Enter the appropriate code for the members injury. 4 Present on Admission 5 Save 6 Save Code 7 Add Code 8 Delete Code 9 Next 10 Print Choose the appropriate POA indicator. Saves the Present on Admission code on the claim. Must save to continue. Saves the procedure information on the claim. Must save code to continue. Allows the user to add an additional procedure code to the claim. Save code after each additional code entered. Allows the user to remove a procedure code previously entered on the claim. Advance to the next screen Allows user to print this screen DMS Approved: 9/2/2014 Page 105

111 Billing Codes Condition Field Number/ Menu Selection Definition of Field Description 1 Sequence Number The sequence number of the diagnosis. This field is auto-populated. 2 Condition Code (drop down) 3 Save Code 4 Add Code 5 Delete Code Select the appropriate condition. Home Health agencies will use the first Payer Codes option when a MAP 34 is on file. This option is coded to the HIPAA qualifier of 12 which is the equivalent to the old Y1 indicator. Saves the condition information on the claim. Must save code to continue. Allows the user to add an additional condition code to the claim. Save code after each additional code entered. DMS Approved: 9/2/2014 Page 106

112 Field Number/ Menu Selection Definition of Field Description 6 Next 7 Print Allows the user to remove a condition code previously entered on the claim. Advance to the next screen Allows user to print this screen Billing Codes - Value Field Number/ Menu Selection Definition of Field Description 1 Sequence Number The sequence number of the diagnosis. This field is auto-populated. DMS Approved: 9/2/2014 Page 107

113 Field Number/ Menu Selection Definition of Field Description 2 Value Code (drop down) 3 Amount 4 Save Code 5 Add Code 6 Delete Code 7 Next 8 Print Select the appropriate value code. Enter the corresponding dollar amount. Saves the value code information on the claim. Must save to continue. Allows the user to add an additional value code to the claim. Save code after each additional code entered. Allows the user to remove a value code previously entered on the claim. Advance to the next screen Allows user to print this screen DMS Approved: 9/2/2014 Page 108

114 Billing Codes Occurrence/Span Field Number/ Menu Selection Definition of Field Description 1 Sequence Number The sequence number of the Occurrence. This field is auto-populated. 2 Occurrence/Span Code (drop down) Select the appropriate code. 3 From Enter the corresponding From date. 4 Thru Enter the corresponding Through date. 5 Save Code DMS Approved: 9/2/2014 Page 109

115 Field Number/ Menu Selection Definition of Field Description 6 Add Code 7 Delete Code 8 Next 9 Print Saves the occurrence code information on the claim. Must save code to continue. Allows the user to add an additional occurrence code to the claim. Save code after each additional code entered. Allows the user to remove an occurrence code previously entered on the claim. Advance to the next screen Allows user to print this screen DMS Approved: 9/2/2014 Page 110

116 Billing Codes -Payer Field Number/ Menu Selection Definition of Field Description 1 Sequence Number The sequence number of the Payer. This field is auto-populated. 2 Payer Code (drop down) 3 Prior Payment 4 Estimated Due Select the appropriate code. Medicare, TPL or Medicaid TPL private insurance payment (not Medicaid) (not Medicare) Enter the estimated amount due. 5 Save Code Saves the occurrence code information on the claim. DMS Approved: 9/2/2014 Page 111

117 Field Number/ Menu Selection Definition of Field Description 6 Add Code 7 Delete Code 8 Next 9 Print Allows the user to add an additional occurrence code to the claim. Allows the user to remove an occurrence code previously entered on the claim. Advance to the next screen Allows user to print this screen DMS Approved: 9/2/2014 Page 112

118 Detail Screen Field Number/ Menu Selection Definition of Field Description 1 Item 2 From DOS* 3 To DOS* Line number of the detail. This field is auto-populated. Enter the first date the services were provided. The * indicates that this field is required. DMS Approved: 9/2/2014 Page 113

119 Field Number/ Menu Selection Definition of Field Description 4 Revenue Code 5 HCPCS/Rates 6 Modifiers 7 Units Enter the last date the services were provided. The * indicates that this field is required. Enter the four digit revenue code which identifies the service provided. (the first digit will be a zero) Enter the procedure code which further identifies the service provided. For all out patient claims. Enter the appropriate two-digit modifier(s) which further describes the service performed. Enter number of units. 8 Units of Measurement 9 Charges 10 Co-pay 11 TPL Amount 12 Status Enter units of measurement (i.e. days) Amount charged by the provider. The co-payment deducted from reimbursement. No information should be entered into this field. Enter amount paid by other insurance. Status of claim. 13 Allowed Amount The amount allowed by Kentucky Medicaid (paid claims only). 14 Non Covered Charges 15 Units Allowed Amount of charges not covered by Kentucky Medicaid. Number of units allowed. 16 Paid Amount DMS Approved: 9/2/2014 Page 114

120 Field Number/ Menu Selection Definition of Field Description 17 Add NDC 18 Save Detail 19 Add Detail 20 Delete Detail 21 Next 22 Print Amount paid by Kentucky Medicaid. Enter the 11 digit NDC code. This is currently only used by hospitals for outpatient services. Saves the detail line on the claim Allows user to add an additional detail line Allows user to remove the detail line previously entered Advance to the next screen Allows user to print this screen DMS Approved: 9/2/2014 Page 115

121 Summary Panels The summary screen allows the user to verity the data entered. DMS Approved: 9/2/2014 Page 116

122 Adjust or Void Claim Screen To ADJUST a paid claim: 1. Select Claim Inquiry. 2. Enter Member information and dates of service or enter the claim Internal Control Number. 3. Click the Next button to advance. 4. Correct the information on the claim. 5. Save the updated information. 6. Click the Adjust button. To VOID a paid claim: 1. Select Claim Inquiry. 2. Enter Member information and dates of service or enter the claim Internal Control Number. 3. Click the Next button to advance. 4. Click the VOID button. If the claim does not show an Adjust or Void Claim button, the claim was previously adjusted or voided. DMS Approved: 9/2/2014 Page 117

123 Field Number/ Menu Selection Definition of Field Description 1 Next Will navigate the user through the claim. DMS Approved: 9/2/2014 Page 118

124 Field Number/ Menu Selection Definition of Field Description 2 Adjust 3 Void Claim 4 Print To adjust a paid claim make the correction and click save when a save button is available. To reverse a paid claim click on Void. Allows user to print this screen. DMS Approved: 9/2/2014 Page 119

125 Medicare crossover 1. Follow the regular billing instructions for Institutional claim submission a. Under Claim Type, select either Crossover (inpatient or Long Term Care) or Crossover (Outpatient). 2. Continue with the regular instructions a. Under Medicare Information, enter the following Medicare information from the Medicare EOMB. Date Paid; Amount Paid; and, Amount Allowed. DMS Approved: 9/2/2014 Page 120

126 Field Number/ Menu Selection Definition of Field Description 1 Claim Type Choose the applicable crossover claim type. 2 Date Paid Enter Medicare s paid date. 3 Amount Paid DMS Approved: 9/2/2014 Page 121

127 Field Number/ Menu Selection Definition of Field Description 4 Amount Allowed Enter the Medicare paid amount on the services being billed. Enter Medicare s allowed amount on the services being billed. DMS Approved: 9/2/2014 Page 122

128 Billing Codes Medicare Field Number/ Menu Selection Definition of Field Description 1 Sequence Number The sequence number of the diagnosis. This field is auto-populated. 2 Value Code (drop down) 3 Amount 4 Save Code 5 Add Code Select Coinsurance Payer A or Deductible Payer A from the drop down and enter the corresponding amount in field 3. Enter the corresponding dollar amount. Saves the value code information on the claim. Must save to continue. DMS Approved: 9/2/2014 Page 123

129 Field Number/ Menu Selection Definition of Field Description 6 Delete Code 7 Next 8 Print Allows the user to add an additional value code to the claim. Save code after each additional code entered. Allows the user to remove a value code previously entered on the claim. Advance to the next screen Allows user to print this screen DMS Approved: 9/2/2014 Page 124

130 Field Number/ Menu Selection Definition of Field Description 1 Sequence Number 2 Payer Code The sequence number of the Payer. This field is auto-populated. Select Medicaid. 3 Prior Payment Enter a 0 (numeric 0). 4 Estimated Due 5 Save Code Enter the estimated amount due from Kentucky Medicaid (total of Medicare coinsurance and deductible). Saves the payer information on the claim. DMS Approved: 9/2/2014 Page 125

131 15 Supplemental Claims 15.1 The Supplemental Claims display of encounter data The Supplemental Claims page allows Primary Care Center (provider type 31) and Rural Health Center (provider type 35) providers to view additional supplemental claim data. The page will display the encounter or encounters that generated the supplemental claim along with the MCO Paid Amount, Calculated Medicaid Allowed Amount, and TPL Amount for the encounter(s). Users can click on the ICN of the encounter(s) to view additional information for that encounter. DMS Approved: 9/2/2014 Page 126

132 The new Supplemental Claims panel will allow the provider to click on each encounter ICN and it will pull up the matching encounter in KyHealthNet so that they can see additional data from the encounter. Please note these are the standard KyHealthNET claims panels and nothing has been changed/added to these panels. DMS Approved: 9/2/2014 Page 127

133 DMS Approved: 9/2/2014 Page 128

134 16 Provider Status 16.1 The Provider Status Information The Provider Status Information panel allows a user to view active provider status items from the provider file. Select the provider NPI and Taxonomy combination or the KY Medicaid ID from the dropdown selection to view provider status information covered in this section. Identification panel is the provider s NPI and KY Medicaid provider number Taxonomy panel is the effective and end date of each taxonomy associate to the provider Group Practice panel is each individual provider effective and end dates linked to the group name. (if applicable) DMS Approved: 9/2/2014 Page 129

135 Annual Disclosure (ADO) panel displays the last ADO received by Provider Enrollment Contracts panel displays the current contract effective and end dates Licenses panel displays the provider s license number, state issued, effective date and end date Revalidation panel displays when the revalidation application is due DMS Approved: 9/2/2014 Page 130

136 Location Address panel displays the provider physical, pay to and correspondence addresses DMS Approved: 9/2/2014 Page 131

137 17 Appendix A Forms Web site link for blank PIN Release form: 1. Click on electronic claims 2. Click on frequently asked questions 3. Read What is KYHealthnet 4. Click on link for PIN Release Form Billing Instructions 1. Click on Provider Relations 2. Click on Billing Instructions 3. Click on Provider Type DMS Approved: 9/2/2014 Page 132