CW-TCM HEALTHCARE CLAIMING

Transcription

1 CW-TCM HEALTHCARE CLAIMING This document walks you through the generation of Child Welfare-Targeted Case Management (CW-TCM) claims that can be submitted from SSIS to MMIS for payment, possible proofing messages and related reports. HELPFUL RESOURCES SSIS Claiming Helpful Hints and Proofing Messages is a document in the Fiscal Mentor Manual on the SSIS Fiscal Mentor Program web page. This document includes: Overview flow chart of how the claiming process flows through the different steps. Hints for each Healthcare Claim Category. For CW-TCM the hint is: TEFRA Override Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) option provides MA eligibility to some disabled children who live with their families. TEFRA covers the same services provided by MA. Eligibility is determined based on a child's qualifying disability, determined by SMRT (State Medical Review Team), regardless of parental income and assets. Parents may, however, be assessed a parental fee for services based on income. Enter TEFRA override dates to indicate that CW-TCM should be claimed for a TEFRA child. Listing of Proofing Messages for each claim category that includes a possible solution to the proofing message. Fiscal Reports and Descriptions is a link to the Fiscal Reports and Descriptions document found in the Reporting Chapter of the Fiscal Mentor Manual. This document lists all the Fiscal-related reports in SSIS a description, all the options for navigating to the report, what the report might be used for as well as a report example. CW-TCM CLAIMING REQUIREMENTS CW-TCM is claiming done for Time Records that meet the CW-TCM criteria set by policy staff that include the following: Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 1 of 36

2 ELIGIBLE STAFF ACTVITY TIME RECORDS Services 104 Child Protection Investigation 107 Child Welfare Assessment 108 Family Assessment Response 109 Concurrent Planning Assessment 192 Family Assessment Case Management 193 General Case Management 492 Child General Case Management 592 Child (<21) DD Non-Waiver Case Management Activities Client contact Collateral Contact CW-TCM eligible contact 60+ mi from cnty. border Contact Status Completed Contact Method Face to face Phone (Phone is only valid if Activity is CW-TCM eligible contact 60+ mi from cnty. border) Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 2 of 36

3 SUPPLEMENTAL HEALTHCARE ELIGIBILITY A Supplemental Healthcare Eligibility Record must exist for the claim category of CW-TCM with an effective date on or before the Service Dates of the CW-TCM claim. CW-TCM Supplemental Healthcare Eligibility Entry Screen From the Supplemental Eligibility folder we see Mary CWTCM has a CW-TCM Supplemental Eligibility record beginning 01/01/2008. If none exists for the timeframe needed from Action menu select New CW-TCM Eligibility. 1. Enter a date if the child was determined: At risk of placement or is in placement At risk of maltreatment or is experiencing maltreatment In need of protection or services 2. Enter text of the CW-TCM Finding. 3. CW-TCM Effective Date the Start Date is determined by the earliest date both a CW- TCM Assessment date and Service Plan Date are in effect. 4. Select from the drop down the Service Plan Type that includes the details of CW-TCM services being provided. Select the Service Plan Date for that plan. 5. If the child is on TEFRA enter a Start Date to override TEFRA to indicate the child will receive CW-TCM services. NOTE: The parents, based on their income, may be charged a parental fee for this service. 6. Always select a WG so to see the Primary Worker name on reports. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 3 of 36

4 7. Latest Annual Review is display only. These fields display information entered on the Annual Review Date tab of the CW-TCM Supplemental Healthcare Eligibility record. 8. Click Save. Creating a New CW-TCM Supplemental Eligibility Record If the Billable Contact Date is more than one year after the CW-TCM Effective "Start Date", an associated Annual Review Record Must exist and the Billable Contact Date must be within one year of the Annual Review Date. From Action menu select New CW-TCM Review Date. 1. Enter the date the Annual review of the CW-TCM plan was completed. 2. Select the Service plan type that includes details of the CW-TCM services to be provided as a result of the review. 3. Enter the selected Service plan date. 4. Click Save. MMIS RECIPIENT INFORMATION Must be MA Eligible Major Program MA Eligible MA Federally-Paid Medical Assistance MNCare Eligible LL MinnesotaCare Citizen Kids/PWS Eligibility Status must be Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 4 of 36

5 Active Closed Billable Contact Date must be within the Eligibility Start Date and Eligibility End Date CLIENT INFORMATION Client age is determined as of the first day of the month in which the service was provided. Client age must be less than 21 DIAGNOSIS CODE A billable diagnosis code is required to submit a claim. The default Diagnosis of Z60.9 is included on the claim. ADDITIONAL RULES Maximum of one CW-TCM claim can be submitted per month per client. All eligible Time Records in a month are linked to the claim. A separate claim is created for each CW-TCM eligible client listed in the Regarding section of the Time Record. For a month in which both a Phone and Face to face contact occur, the Face to face contact is claimed even though it may occur after the Phone contact. A telephone claim is create for a month in which only a Phone contact occurred. A Face to face contact must occur at least once every three months. This edit ignores Face to face claims that are Denied or To be denied. The first claimable contact must be Face to face. If a TEFRA Eligibility record exists any time during the month of service, the current CW- TCM Supplemental Healthcare Eligibility record must have a TEFRA Override in effect for the month of service. CLAIM RECORD The healthcare claim includes: HCPCS/Modifiers Contact Method = Face to face T2023 U3 CW-TCM, face-to-face Contact Method = Phone T2023 U3 U4 CW-TCM, telephone Units = 1 Amount = Staff-provided Rate for the HCPCS/Modifiers First Service Date = Billable Contact Date Last Service Date = Billable Contact Date Diagnosis Code = Z60.9 Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 5 of 36

6 ADDITIONAL EDITS NOT IN SSIS Eligibility Using the CW-TCM Supplemental Healthcare Eligibility screen, the worker must record the basis for providing CW-TCM. The worker must record the date and type of service plan that specifies CW-TCM related services. When reviewing the continuing need for CW-TCM services, the worker must record the type of plan and plan date that specifies the continued CW-TCM services. Worker Eligibility To trigger a claim, the worker on the Time Record must be qualified to claim CW-TCM as defined in statute. The county must create a CW-TCM Qualifications record for each worker qualified to claim CW-TCM. County Practice Worker must ensure that the role of each "relevant" collateral is documented in the case record. If the service plan used to establish CW-TCM eligibility is for the entire family, the worker must ensure that it specifically identifies the services to be provided to each child who will receive CW-TCM. Contacts must be documented in the case record, either electronically or written, and must be easily identifiable in an audit. The following must be included in the documentation: Location of contact (home, office, school) Type of contact (Face to face, phone) Identification of the client Name of the contact Kind of service provided (BRASS Service) Date of contact In addition, a description of the service provided must be document in the case record. Claims for clients in a MA Funded Facility are limited to one claim in the last 30 days in the facility. The 30 day allowed claims period starts over each time a client is admitted to the MA Funded Facility. A maximum of two CW-TCM claims for a client in a MA Funded Facility is allowed in a calendar year. MISC. NOTES A CW-TCM telephone contact is only claimable for MN recipients place outside the county of financial responsibility in an excluded time facility or through the Interstate Compact and the placement is more than 60 miles beyond the county border. CW-TCM may be provided concurrently with an investigation of child maltreatment CW-TCM expenses are included as a part of a person's spenddown for MA eligibility. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 6 of 36

7 Place of Service on the claim is converted from the SSIS Location. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 7 of 36

8 CREATING A CW-TCM CLAIM BATCH 1. Select Claim Batch Search in the task panel. 2. Search to see if a draft batch exists. Based on your claims processes, enter as much or as little search criteria to determine if another batch exists for the time period you are working with. 3. To create a new healthcare claim batch click the Action menu and select New Claim Batch. Creating a New Claim Batch 4. The batch entry screen displays. Select CW-TCM as the Claim category. CW-TCM is for Time only and the system defaults a Claim batch #. A batch may be created for one month or multiple months. Claims can be submitted for up to one year from the date of service. This edit is enforced by MMIS. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 8 of 36

9 CW-TCM Claim Batch The Batch owner defaults to the user creating the batch. Only the owner of a batch or a user who has the function of Manage Claims assigned to their Role in Admin can change the Batch owner. 5. Enter a Description for your batch. Description is optional but consider having a standard naming convention in your agency. 6. The batch is in Draft Status because it has not yet been submitted it to MMIS for payment. This field is not editable. The Batch status updates as you move through the different steps of the claims processing. 7. Once the batch has been generated the Generated date and time displays. The most recent date and time the batch was generated displays. 8. Submitted date and time displays once the batch has been submitted to MMIS. 9. Claims total displays a total dollar amount of all the claims in this batch. 10. # of claims displays the number of claims in this batch. 11. The Generate button is enabled and the batch can be regenerated at any time prior to submitting the batch. Always Generate one last time prior to submitting a batch to be sure everything is current and accurate. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 9 of 36

10 CW-TCM CLAIM TAB Double-click a batch to open it full screen to see more information without scrolling. Clicking the Claims tab of the batch provides the detail of the individual claims within the batch. Selecting a claim in the grid displays the details of the claim below. Note all the information related to the requirements that are included as a part of the claim. Claims tab of a CW-TCM Claim batch Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 10 of 36

11 CW-TCM TIME PROOFING The next tab of the batch is the Time Proofing tab. The top portion of the tab displays the different categories of proofing messages. The default selections are shown below. Review as many or as few categories at one time. Perhaps one person looks at a section of messages and someone else the remaining. Again, an agency decision. You do not need to be the Batch owner to view Time Proofing. Time Proofing Tab However you do your proofing, at some point before submitting, you will want to look at all the proofing messages for the batch to make sure you have not missed something. Click Search to see the proofing messages for this batch. Results display in the grid. Records listed are potentially claimable but not all the claiming requirements have been met. Search can be done multiple times. Searching again removes corrected records. Fixing one message may produce another. For example, selecting a client who does not have a PMI# proofing message. Once that client is cleared and they now have a PMI # re-search could produce a message that the client has no Supplemental Healthcare Eligibility. This is referred to as error hierarchy. Keep in mind that taking care of one proofing message does not always guarantee that a claim will generate. More work may need to be done. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 11 of 36

12 Time Proofing Time Record Category The first proofing category on the Time Proofing tab is Time Record. Listed below are all the messages related to time records. No Staff Qualification No Staff-provided Rate for the HCPCS/Modifiers County of Service not in the region First claimable contact must be Face to face Face to Face contact required every 3 months 2003 No CW-TCM Staff Qualifications for the worker on the activity date Message 2003 displays when a Qualification has not been entered for a staff person and reads No Staff Qualifications for the worker on the activity date. The staff person from the Time Record is listed in the proofing message and is very helpful so you know who you need to contact without navigating to another place to see that. Clicking on a proofing message generally takes you to where the record may be fixed. However, for this message Staff Qualifications are in the Admin application that is a separate executable so it cannot take you there from proofing. You will need to have Admin access in order to see or change this information. In Admin: Search for the staff person. From the Qualifications tab view what has been entered along with the Start and End dates. If a Staff Qualification needs to be entered or there was an end date create a record from the Action menu and selecting New Qualification. If there is already a record but it has an end date you do not want to overwrite the existing record. You will lose history and invalidate past claims. A new record should be created. It is not necessary to close Admin and Worker to apply the updates in Worker. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 12 of 36

13 New Staff Qualification 2004 No Staff-provided Rate for the HCPCS/Modifiers on the activity date Message No Staff-provided Rate for the HCPCS/Modifiers on the activity date displays when no staff-provided rate has been entered for the HCPCS/Modifiers that are trying to claim. Staff-provided rates are entered in SSIS Admin. Clicking on the message will not take you directly there. The Admin application is a separate executable so it cannot take you there from proofing. Within Admin select Tools/Programs and Services. Click on the HCPCS/Modifiers folder. The grid displays all the available codes. Selected the HCPCS/Modifiers missing a rate. For example, T2023 U3 CW-TCM, face-to-face. The details below show more information about the HCPCS/Modifiers. For T2023 U3 the unit type is Month and this code became active 1/1/2004 and has no end date. Note this is for time and not for payments. Also, there are times when additional billing information is added for detail. The first tab, Claimable Services, displays the Claimable services under this HCPCS/Modifiers and are determined by policy. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 13 of 36

14 Claimable Services Tab The second tab of the HCPCS/Modifiers information window is the Staff-provided Rates tab and is where agency rates are entered. Do not just enter the maximum billable amount. Enter the rate that it actually costs your agency to provide the service. Staff Provided Rates tab Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 14 of 36

15 Do not overwrite existing data. If a new record is needed select the Action menu and New Staff-provided Rate. If there is an existing record without an end date you must edit that record and add an end date before a new record can be added. Save your record when you are finished. It is not necessary to exit Admin or Worker to see the change County of Service not in the region Message # County of Service not in the region. In regions, SWHHS, DVHHS, MnPrairie or F/M the county of service for the client must be a county in the region. County of Service is edited on the Workgroup setup screen. Cnce corrected any Time Records must be deleted and re-entered in order for the change to be reflected on the Time Record. If there are many Time Records, contact the SSIS Help Desk. In general, there are not many. Contact/Activity Entry Screen Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 15 of 36

16 2203 First claimable contact must be Face to face Message First Claimable contact must be Face to Face displays when the first claimable contact Method is Phone. For all the TCM claim categories the first claimable Time Record must be Face to face. This message displays when a Phone contact exists where no prior Face to face contacts has been submitted during the Supplemental Healthcare Eligibility Span. Clicking on the message in proofing displays the Time Record in question. Follow agency practice for who should edit the record. There are times reading the Note section will help identify if this really was a Phone contact or selected in error. If changes are made to the Time Record be sure to save your changes. Best practice is to generate the batch before doing proofing to reduce the number of Phone proofing messages that display. Contact/Activity Entry Screen Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 16 of 36

17 2204 Face to face contact required at least once every 3 months Message Face to Face contact is required at least once every 3 months displays when two consecutive monthly phone contacts have been made without a face to face contact. Clicking on the proofing message displays the Time Record. Check if changes are needed. In a month where both a Phone and Face to face contact occur the Face to face contact is always billed first to be sure as many months of Face to face are billed that can be. In the instance where the previous two claims were phone, another claim for a phone contact cannot be submitted. Contact/Activity Entry Screen Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 17 of 36

18 Time Proofing Attempted Contact Category The next Time Proofing category is Attempted Contact. There is only one message. Attempted Contact is not claimable 2202 Contact Status (Attempted) is not claimable Message 2202 Contact Status Attempted is not claimable. The Status of the contact must be Completed in order to claim. Clicking on the proofing message navigates to the Time Record. Claims generation looks at the Status of the contact. If Attempted is selected the record is not claimable. Reading the Notes can also give you an idea if it was completed. The contact Status must be Completed to claim. Follow your agency policy for editing records. Best practice is to generate your batches first to reduce the number of "Attempted" messages that display and picks up the claimable Face to face contacts. If a claim is generated for a Completed contact and Time Records for this same client in this month for CW-TCM that were Attempted records will not display in proofing. Contact/Activity Entry Screen Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 18 of 36

19 Time Proofing Client Age Category The next proofing category is Client Age. One message is available. Client must be Under Age as the first of the month for the service date must be under 21. Message 2205 Age as of the first of the month for the service date must be under 21. The client must be under 21 years of age as of the first of the month of the contact to generate a claim. Clicking on the proofing message displays the Client demographics screen. Claims generation looks at the Date of birth for the client and the corresponding Age as of the first of the month of the contact. If the client is over 21 the record is not claimable. Client Demographics Screen Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 19 of 36

20 Time Proofing Duplicate Claim Category Next in the list of proofing categories is Client Age. One message applies to this category. Claim would be a duplicate 2017 One or more claims already exist during the service dates Message 2017 One or more claims already exist during the service dates. Only one CW-TCM claim can be submitted per month per client. Clicking on the proofing message displays a grid listing all the claims with the same service dates. Clicking on the record in the grid displays the submitted claim below. As the long message states, only one claim can be submitted for a HCPCS/Modifiers for a given date range. The existing claims would need to be Voided and Resubmitted in order for this time record to be included in the claim. Claims history Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 20 of 36

21 Time Proofing MA Eligibility Category Client must be MA Eligible to claim Invalid Major Program No MMIS Eligibility Information 2010 No Eligibility Span exists for the service dates Message 2010 No Eligibility Span exists for the service dates. Clicking on the message navigates to the Eligibility Spans folder for the client. In the example, the program eligibility began on March 1, 2007 and no claims will be generated before that date. In order for a claim to generate the Status must be Active or Closed for the date of the time record. Eligibility Spans Folder Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 21 of 36

22 2011 The Major Program is not valid for CW-TCM Message 2011 The Major Program is not valid for CW-TCM. Clicking on the Invalid Major Program message navigates to the Eligibility Spans folder for the client. Here the Major Program for the client is IM. Although the Status is currently Closed the client was Active based on the Begin Date and End Dates for the date of service. However, Major Program IM is not eligible, and a claim is not generated. Note for CW-TCM the Major Program must be MA Federally-Paid Medical Assistance or LL MinnesotaCare Citizen Kids/PWS. Eligibility Spans Folder Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 22 of 36

23 2021 The client has no Healthcare Eligibility from MMIS Message 2021 The client has no Healthcare Eligibility from MMIS. The client must have Healthcare Eligibility from MMIS in SSIS to verify eligibility. No eligibility information has been received from MMIS as a part of the nightly load to SSIS. Since MMIS eligibility does not exist, clicking on the proofing message navigataes to the Time Record. If the date of the time record is correct check with your MMIS staff to see if the person was eligible. If not, the time record cannot be claimed. Contact/Activity Entry Screen Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 23 of 36

24 Time Proofing Supplemental Eligibility Category Next in the list of proofing messages is the Supplemental Eligibility category which has three messages. No Supplemental Eligibility Annual Review needed No TEFRA override 2015 No CW-TCM Supplemental Eligibility Exists for the service dates Message 2015 No CW-TCM Supplemental Eligibility Exists for the service dates. A CW-TCM Supplemental Eligibility record must exist in order to claim. Clicking on the proofing messages displays the Supplemental Healthcare Eligibility folder. The grid displays a Supplemental Healthcare Eligibility record that ended August 1, Enter a new Supplemental Eligibility click on the Action menu and select New CW-TCM Eligibility. CW-TCM Supplemental Eligibility Entry Screen The CW-TCM Supplemental Eligibility Entry screen displays. 1. Enter a date if the child was determined: At risk of placement or is in placement At risk of maltreatment or is experiencing maltreatment In need of protection or services 2. Enter text of the CW-TCM Finding. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 24 of 36

25 3. CW-TCM Effective Date the Start Date is determined by the earliest date both a CW- TCM Assessment date and Service Plan Date are in effect. 4. Select from the drop down the Service Plan Type that includes the details of CW-TCM services being provided. Select the Service Plan Date for that plan. 5. If the child is on TEFRA enter a Start Date to override TEFRA to indicate the child will receive CW-TCM services. NOTE: The parents, based on their income, may be charged a parental fee for this service. 6. Always select a WG to see the Primary Worker name on reports. 7. Latest Annual Review is display only. These fields display information entered on the Annual Review Date tab of the CW-TCM Supplemental Healthcare Eligibility record. 8. Click Save. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 25 of 36

26 Time Proofing Client Category We move through the list to the Client Category which has two proofing messages. Missing PMI# Estimated DOB 1018 No PMI # Message 1018 No PMI #. The client must have a valid PMI # in order to claim. Clicking on the No PMI # message navigates to the Client node. In the example the PMI # is blank. The PMI # for a client displays when a client has been cleared. The PMI # is the link between SSIS and MMIS for the eligibility information. If a client is known to have a PMI but it does not display here, change something on this screen to send them back to your clearing log again. Be sure to change that information back before clearing them. You cannot manually add a PMI, it must be done through the clearing process. If you are not the person who does the clearing in your agency speak to that person about your agency process to reclear the client to include the PMI #. Client Demographics Screen Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 26 of 36

27 107 Est. date of birth Message 107 Estimated date of birth. The client must have an actual DOB in order to claim. Clicking on the Estimated DOB message navigates to the client node. The client has an estimated DOB, and not an actual DOB. If an actual DOB is known, enter it for the client. Until you have an actual DOB claims will not generate for the client. Once the actual DOB has been entered, follow your agency process for clearing clients to include the PMI and MMIS Eligibility information for the client in SSIS. Client Demographics Screen Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 27 of 36

28 Time Proofing Do Not Claim Category Next in the list is the Do Not Claim category. There is one message in this category. Client marked Do Not Claim 2008 A Do Not Claim Determination is in effect on the service dates Message 2008 A Do Not Claim Determination is in effect on the service dates. Clicking on message 2008 navigates to the Do Not Claim record in effect for the date of the time record. Review the dates of the record to be sure this remains accurate. Make changes as needed; be sure to save your changes. If the dates are accurate the Time Record cannot be claimed. Do Not Claim Supplemental Eligibility Screen Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 28 of 36

29 Time Proofing Staff Not Qualified Category The Staff Not Qualified Category has one message. Staff Claim Qualifications, Qualified = No 2018 Qualified = No on the CW-TCM Staff Qualifications for the worker on the activity date Message "Qualified" = "No" on the CW-TCM Staff Qualifications for the worker on the activity date. Clicking on message 2018 navigates to the Time Record. Staff Qualifications are entered in the SSIS Admin application. Proofing cannot take you directly to the Admin application. The proofing message lists the worker on the time record. The staff name for this record is Earl Unqualified. Review the dates of the time record to be sure they are accurate. If the Time Record looks correct go to the Admin application and look at the Staff Qualifications entered for the worker. In order to do this, you must have SSIS Admin rights. Contact/Activity Screen Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 29 of 36

30 Staff Qualifications Entry In the example, the worker name is Earl Unqualified. 1. Within the User Search of SSIS Admin enter the first and/or last name of the staff person you re looking for and click Search. 2. Select the staff person in the grid. 3. Click on the Qualifications tab. We can see that a Staff Qualification has been entered stating this user is not qualified to claim for CW-TCM beginning May 31, 2007 through September 16, If this remains true, do nothing and the time record cannot be claimed. 4. Create a new CW-TCM Staff Qualification selecting Yes for Qualified and the date they became qualified. If the record does not have an end date and is now qualified enter an end date that they were not qualified and then create the new CW-TCM Qualification. 5. Click the Action menu and select New Qualification. 6. The options for Type are Healthcare claiming and Child safety/permanency professional. We are working with Healthcare claiming so that would be the appropriate selection. 7. Enter Yes/No if they are qualified. 8. Select the claim category for which they are qualified. In this example, select CW-TCM. Enter the Start Date and End Date if there is one. 9. Save your record when finished. Remember, do not want to just change this record unless it was incorrect. You want that history of when they were not qualified as well as when they became qualified. SSIS does not edit to be sure a staff person is qualified. Verification is a manual process done outside of SSIS and documented here. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 30 of 36

31 Time Proofing Exclusions Category The last proofing category is Exclusions and has one message. Exclusions Exist Time Records 2051 An Exclusion for Healthcare Claiming exists Message 2051 An Exclusion for Healthcare Claiming exists displays when an Exclusion has been entered for a time record so a claim is never generated. Clicking on the proofing message navigates to the time record. Clicking on the Exclusion tab displays the entered Exclusion and details. One or more exclusions can be entered for each time record. To enter additional exclusion click the Action menu and select New exclusion Healthcare claiming. Edit the existing record if errors were made. The date the record was created, the reason the record is being excluded and any additional comments displays. It is helpful for future reference to enter additional details as to why you do not want to claim for this record. Exclusions Tab of a Time Record Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 31 of 36

32 Submitting the batch Once satisfied with cleaning up your proofing messages the batch can be submitted to MMIS for payment. Always remember to generate your batch one last time before submitting to pull in anything from proofing that has been corrected. To submit the batch, click the Action menu and select Submit. CW-TCM Claims Batch Tab Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 32 of 36

33 Updates to the Submitted Batch Once submitted the Batch status updates to Submitted. The Submitted date updates to the date and time the batch was submitted. Both of these fields are system generated and cannot be changed. CW-TCM Claims Batch Tab The Claims tab of the submitted batch displays the claims within the batch and the Claims Status of each of the claims within this batch also display the status of Submitted. CW-TCM Batch Claims Tab Overnight processing by MMIS and the interface between MMIS and SSIS will update the Claim status to To be paid or To be denied. MMIS processes Remittance Advices every two weeks. At that time the Claim Status will update to Paid, Partially Paid or Denied. Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 33 of 36

34 Paid units display in the Allowed Units column and the dollar amount displays in the Paid Amount column. Research any Partially Paid or Denied claims to determine if further action is needed. If additional payment is being sought for a Partially Paid claim Void and Resubmit the Open claim. To return paid money to MMIS and resubmit a replacement claim by generating a new CW-TCM claim once the Void claim has been processed by MMIS. If the claim was Denied, make the necessary corrections and Resubmit the Open claim. CW-TCM Reports In addition to the general Healthcare Claim Reports that cover all claim categories there are two reports specific to CW-TCM. The CW-TCM Eligibility Report and the CW-TCM Eligibility Review Report. These reports are available from: Tools>General Reports> Healthcare Eligibility Searches/Logs>Healthcare Claiming>Healthcare Eligibility Reporting (Treeview) Healthcare Claiming> Healthcare Eligibility Reporting Healthcare Eligibility Reporting Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 34 of 36

35 CW-TCM Eligibility Report Use this report for a listing of all CW-TCM Supplemental Healthcare Eligibility entered. Review Supplemental Healthcare Eligibility dates and TEFRA Override dates as needed. Add WG Open and Close Dates to this report to determine if Supplemental Healthcare Eligibility is still in effect. On the Setup tab of the report, enter the desired date parameters. Filter the report for the desired detail by using the Report on options of Department, Unit, Worker or All. The following is an example of the report results. Current Primary Worker is determined by the Workgroup selected on the CW-TCM Supplemental Eligibility record. If no Workgroup is selected the record displays under Current Primary Worker: (blank). CW-TCM Eligibility Report Example Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 35 of 36

36 CW-TCM Eligibility Review Report Use this report to monitor CW-TCM eligibility that is due for review or past due. The report lists the date of the last Annual review as well as the due date of the next review during the date range selected. CW-TCM must be reviewed annually in order to claim. Add WG Open and Close Dates to this report to determine if Supplemental Healthcare Eligibility is still in effect. On the Setup tab of the report, enter the desired date parameters. Filter the report for the desired detail by using the Report on options of Department, Unit, Worker or All. The following is an example of the report results. Current Primary Worker is determined by the Workgroup selected on the CW-TCM Supplemental Eligibility record. If no Workgroup is selected the record displays under Current Primary Worker: (blank). CW-TCM Eligibility Review Report Example Fiscal Mentor Manual Claiming Chapter: CW-TCM Healthcare Claiming Page 36 of 36