Healthchoice Medicaid HMO Timely filing limit and claim submission address

BILLING INFORMATION

Providers must bill on the CMS-1500. Claims can be submitted in any quantity and at any time within the filing limitation.

Filing Statutes: Claims must be received within 12 months of the date of service. The following statutes are in addition to the initial claim submission.

12 months from the date of the IMA-81 (Notice of Retro-eligibility)

120 days from the date of the Medicare EOB

60 days from the date of Third Party Liability EOB

60 days from the date of Maryland Medicaid Remittance Advice

The Program will not accept computer-generated reports from the provider’s office as proof of timely filing. The only documentation that will be accepted is a remittance advice, Medicare/Third-party EOB, IMA-81 (letter of retro-eligibility) and/or a returned date stamped claim from the Program.

Paper Claims Submission: Once a claim has been received, it may take 30 business days to process your claim. Invoices are processed on a weekly basis. Payments are issued weekly and mailed to provider’s pay-to address. All claims should be mailed to the following address:

Claims Processing

Department of Health and Mental Hygiene

P.O Box 1935

Baltimore, MD 21203

Electronic Claims Submission: Providers must submit claims in the ANSI ASC X12N 837P format, version 5010A. A signed Submitter Identification Form and Trading Partner Agreement must be submitted, as well as testing before transmitting such claims.

what is self referral and what are the covered service under self referral?

Self-Referral Services

Self-referral services are defined in the HealthChoice regulations as “health care services for which under specified circumstances the MCO is required to pay without any requirement of referral or authorization by the primary care provider (PCP) or MCO when the enrollee accesses the services through a provider other than the enrollee’s PCP.”

The following services must be reimbursed by the MCO without a referral:

Child With Pre-Existing Medical Condition - Medical Services

Child In State-Supervised Care - Initial Medical Exam

 Emergency Services Family Planning Services

HIV/AIDS Annual Diagnostic and Evaluation Service Visit

Newborn’s Initial Medical Examination In A Hospital

Pregnancy-Related Services Initiated Prior To MCO Enrollment

Renal Dialysis Services Provided In A Medicare Certified Facility

School-Based Health Center Services Substance Abuse Assessment

For additional information regarding the above self-referral services contact the Division of Outreach Care and Coordination at 410-767-6750/6859.

Medicaid HMO non covered service list

MCO Excluded Services

(Fee-For-Service)

The MCO’s are responsible for providing all Medicaid covered services excluding the following, which are paid fee-for-service by Medicaid:

Abortion Services – MCO’s are responsible for related services performed as part of a medical evaluation prior to the actual abortion.

 Aids Drug Therapies - Limited to Protease Inhibitors, Non-nucleoside Reverse Transcriptase Inhibitors and viral load testing.

Healthy Start Case Management Services

IEP/IFSP - Individual Education Plan (IEP) or Individual Family Services Plan (IFSP). Medically necessary services that are documented on the IEP or IFSP when delivered in schools or by Children’s Medical Services community based providers.

Medical Day Care Services

Nursing Home/Long Term Care Facility Services - After the first 30 consecutive days of care.

Personal Care Services

Rare & Expensive Case Management Services (REM) - Recipients are eligible based on one of the diagnoses listed in COMAR 10.09.69. Recipients receive all State Plan Medicaid services on a fee-for-service basis.

Provider not participated with Medicaid MCO - Would he get reimbursement?

Payments to Managed Care Organizations

Recipients are linked by their MCO to a primary care physician or clinic. All MCO-enrolled recipients are provided an identification card by their respective MCO. As a result, recipients must obtain all services except services excluded (see page 4 for a list of excluded services) through their MCO. The recipient’s primary care physician or clinic will give referrals for specialty care.

If you are not part of an MCO and a recipient identified by EVS as an MCO recipient seeks services from you for which an MCO is responsible, you may contact that MCO to determine if it will approve payment for rendered services. Otherwise, the MCO has no obligation to reimburse you except in the case of providing routine family planning services, or in some instances reimbursement for pregnancy related services.

NOTE: If the recipient-required services are emergency services, you may provide the appropriate services and expect to be reimbursed by the MCO upon billing the MCO directly. If you provide non-emergency services without MCO authorization, Medical Assistance will not reimburse you.

Managed Medical Assistance (MMA) Program

Managed Medical Assistance (MMA) Program - Mandatory Recipients Only: For those who are required to enroll in a plan. 

1.    What if my current plan will not participate in the MMA program? 

If your current plan will not participate in the MMA program, you must pick a different plan. The plan you pick must cover your services with your current providers for up to 60 days while you move to new providers in the plan’s network. You may want to pick the plan that has most of the doctors and service providers that are important to you. 

2.    What if I do not choose an MMA plan? 

If you do not choose an MMA plan in time, the State will choose one for you. Your packet includes the name of the MMA plan that would be chosen for you and the MMA plan’s start date. Also keep in mind that you will have 90 days to change your MMA plan from the date your enrollment in the plan begins. After 90 days, you may only change your plan during Open Enrollment or with a State-approved reason. Open Enrollment is a period of time, once a year, that allows you to change plans without a State-approved good cause reason. 

3.    If I am enrolled in a Long-term Care plan do I need to enroll in an MMA plan, too? 

Yes. If you or your family member are enrolled in a Long-term Care plan, you will need to choose an MMA plan for medical services covered by Medicaid. 

Managed Medical Assistance (MMA) Program FAQs

1.    What if I want to change plans?

If you have been approved for Medicaid, you may change your plan during the first 90 days of your enrollment. After the 90 days you will only be able to change your plan during your open enrollment period or with a State-approved good cause reason. 

2.    What is open enrollment? 

Open Enrollment is the 60-day period each year when you can change plans without state approval. Open Enrollment occurs yearly on the anniversary date of your first enrollment into the plan. 

3.    What is the no change period? 

The no change period is the time period between the end of your initial first 90 days of enrollment and your 60-day annual open enrollment period. No change period also exists between your 60-day open enrollment periods going forward. Please refer to the below chart for reference. You will receive reminder letters assisting you with these time periods.

4.  What is "good cause"?

This is a State-approved reason to change plans during the no change period. 

5.    What happens to my plan if I relocate or my address changes? 

If your address changes, you may need to select another plan if your region has changed. You may need to contact the Department of Children and Families (DCF) at 1-866-762-2237 or the Social Security Administration (SSA) at 1-800-772-1213 to report a change in address. 

6.    Will enrolling into the MMA program cancel my Medicare? 

No, the MMA program will not cancel your Medicare. You are allowed to be enrolled in this program and Medicare at the same time because they cover different services. 

7.    Will my current providers, including doctors, hospital, mental health or transportation to covered services, be available in the new program? 

Each plan must cover all of the Medicaid services listed in the Program Information page of this website. However, each plan will have its own network of providers, which may include your current providers and or facilities. When you receive your enrollment packet, review the list of services provided by each plan. You may want to pick the plan that has most of the doctors and service providers that are important to you. 

8.    What if no Managed Medical Assistance (MMA) plans include all of my current providers? 

The plan you pick will be required to cover your services with your current providers for up to 60 days while you move to new providers in your new plan’s network. You may want to pick the plan that has most of the doctors and services that are important to you. 

Medicare HMO denied the claim as covered by hospice

Claims From Medicare Advantage Organizations

Federal regulations require that Medicare fee-for-service contractors maintain payment responsibility for managed care enrollees who elect hospice. These regulations are found that Medicare Fee for Service retains payment responsibility for all hospice and non-hospice related claims beginning on the date of the hospice election.

A - Covered Services

While a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee-for-service contractor of CMS. These claims are subject to the usual Medicare rules of payment, but only for the following services:

1. Hospice services covered under the Medicare hospice benefit if billed by a Medicare hospice;

2. Services of the enrollee’s attending physician if the physician is not employed by or under contract to the enrollee’s hospice;

Basic billing question on Medicaid Managed care

MANAGED CARE

How do we find out which network provider to call?

If you check eligibility through the web portal, look for this information in the Managed Care section of the recipient’s eligibility screen. You will find the name, type and phone number of the HMO, PSN or other managed care plan.

Is the network provider the one who is going to give us the authorization for the services?

No, you would get the authorization from the Health Plan. The only time you will get authorization from a provider is for a person managed under MediPass.

Referring to Slide 50: If recipients don’t have managed care, will it be blank or will it state FL Medicaid? If the recipient does not have managed care, the Web Portal screen will show ***No rows found***.

A patient will come in with a Medicare managed plan yet also show us a Medicaid card. The Medicaid eligibility will show full Medicaid benefits but does not show the Medicare Advantage plan yet we do call and verify eligibility with the Medicare HMO. Does Medicaid pay as a secondary in this case?

Medicaid is not currently paying crossover claims for beneficiaries in Medicare HMOs (Part C plans), but there are changes in the works that may take place as soon as the end of the year. Please watch for any upcoming provider alerts on this subject. You may also contact your Local Medicaid Area Office for questions on this topic. You can find a list of the Medicaid Area Offices and contact information on the Medicaid fiscal agent’s Web Portal at: http://mymedicaid-florida.com/

Medical billing - Blue Medicare HMO referral process

Effective January 1, 2011, Health Options, Inc. (HOI) is instituting a change in the member referral process for all Medicare Advantage (BlueMedicare® HMO and BlueMedicare® Group HMO) members.

 PCP refers a member to a participating specialist. Participating specialist refers a member to another participating specialist.·Notification of a member referral is required when: 

Note: Authorizations are required for all referrals to nonparticipating physicians and providers.

Exempt Covered Services

The following covered services are exempt from the referral requirement: Emergency services Certain specialists including chiropractors, dermatologists and podiatrists Flu shots Laboratory services at a participating Quest laboratory within the member’s service area with a valid prescription Mammograms

The physician or authorized participating specialist is responsible for obtaining any required referral and prior authorization approvals for all services including facility, outpatient, ancillary and professional services. The physician or provider must also verify that the authorization is appropriate, approved and complete before rendering services.

Medical Records System

Medical Records System

HMO providers must maintain a medical records system that is consistent with professional standards and that: 

Permits prompt retrieval of information and provides legible and timely information, accurately documented, and readily available to members and/or appropriate or authorized health care practitioners.

Protects the confidentiality of patient records. There are occasions when Health Options may request to review and/or obtain copies of medical records from physicians to review quality of care, medical necessity, appropriateness of service, and/or clarification of treatment. The member’s enrollment application includes an authorization for the release of information that allows Health Options to obtain the medical records of the member and/or eligible spouse and dependents

Records in the medical record a summary of significant surgical procedures, past and current diagnoses or problems, allergies, and untoward reactions to drugs and current medications.

Identifies the patient by name, identification number, date of birth, and sex.

 

Initial Health Assessment process in HMO

Initial Health Assessment

As a Medicare Advantage Organization, BCBSF must make a reasonable effort to complete an initial health assessment for each BlueMedicare HMO, BlueMedicare PPO and BlueMedicare PFFS member within 90 days of enrollment to identify members with potential serious and/or complex medical conditions. BCBSF will notify the member’s in-network primary physician if:

* The member refuses the assessment.

* The member is placed in the high-risk category and the member consents to the release of the results.