Proposed Rule Amendments Managed Care Program and Third Party Liability

November 30, 2017

Focus On…  New Mexico Human Services Department (HSD) Is Moving Managed Care Enrollment from OmniCaid (MMIS) to Aspen (HSD’s Public Assistance Eligibility System) – New  Proposed Rule Amendments – Managed Care Program and Third Party Liability  Top 5 Fee-For-Service New Mexico Medicaid Claim Denials  Provider Type & Specialty List  Fee for Service Claim Requirements for Rendering, Referring, Ordering, and Attending Providers  Provider Enrollment Applications Top Errors  Provider Enrollment Online  Revised Adjustment, Reconsideration and Void Request  Reconsideration of EMSA Claims  Provider Enrollment Online  ITU Service Providers Monthly IHS Open Forum Conduent-IHS Northern Navajo Area Training - New  Conduent Contact Information

New Mexico Human Services Department (HSD) Is Moving Managed Care Enrollment from OmniCaid (MMIS) to Aspen (HSD’s Public Assistance Eligibility System) – New The New Mexico Human Services Department (HSD) is moving Managed Care enrollment from OmniCaid (MMIS) to ASPEN (HSD’s public assistance eligibility system) effective December 2017. There will be no change in how eligibility inquiries are made in the New Mexico Medicaid portal, but there could be a delay of up to 48 hours between the time eligibility information is transmitted from ASPEN and is viewable in the Portal. Presumptive Eligibility Determiners (PEDs) will continue to use YESNM-PE to screen for Presumptive Eligibility (PE) and submit applications. However, PE approvals will no longer be entered in the Portal. PE approvals will be entered directly in YESNM-PE.

Medicaid ID Cards: Recipients who are enrolled in Managed Care will receive their Medicaid ID card directly from their assigned MCO. Recipients enrolled in Fee-for-Service (FFS) will receive their Medicaid ID card from HSD through a contracted mail vendor.

Beginning December 4th, 2017, all Medicaid recipients can use the State’s on-line public assistance system, YesNM (www.yes.state.nm.us), to get information on their Medicaid case or change their MCO enrollment. FFS recipients may also use YESNM to request a replacement Medicaid ID card.

MCO switches:  All recipients who wish to select or change the Managed Care Organization (MCO) can make those selections on the Portal from now until December 1st, 2017 or by calling the NM Medicaid Call Center (1-888-997-2583).  Beginning December 4, 2017 and going forward, all Medicaid recipients who wish to select or change their Managed Care Organization (MCO) should make those selections on YESNM or by calling the NM Medicaid Call Center (1-888-997-2583).  MCO change requests cannot be made on YESNM or through the NM Medicaid Call Center on Saturday, December 2 or Sunday, December 3, 2017 due to system upgrades.

PE Determiners and Medicaid providers will continue to utilize the NM Medicaid Portal to check client eligibility. PE Determiners should always check an individual’s eligibility status before completing an application or entering a PE approval on YESNM-PE.

If you need immediate assistance with eligibility inquires or have general questions please contact the NM Medicaid Call Center at 1-888-997-2583.

Proposed Rule Amendments – Managed Care Program and Third Party Liability

The following notice has been made available to the public through the State of New Mexico rule promulgation process, and is included in this newsletter for your information.

The Human Services Department (the Department) Medical Assistance Division (MAD) is proposing amendments to several New Mexico Administrative code (NMAC) rules to become effective February 1, 2018. These amendments are being proposed to align with recently updated Medicaid managed care requirements in federal rules that the Department must implement.

The register, with additional information on submitting comments, and proposed rule language are available on the Department’s website at:

A public hearing to receive testimony on the proposed amendments will be held on November 20, 2017. The Department will accept written and verbal comments through 5 p.m. MST on November 20, 2017. http://www.hsd.state.nm.us/LookingForInformation/registers.aspx and http://www.hsd.state.nm.us/public- notices-proposed-rule-and-waiver-changes-and-opportunities-to-comment.aspx . Top 5 Fee-For-Service New Mexico Medicaid Claim Denials

The following are the top 5 denials for Fee-for-Service (FFS) NM Medicaid claims. Also provided are tips in order to see why the claims denied in that manner.

1.)Client Date Within Centennial (Exception Code 0128)

Tip: Check the client’s eligibility during the date of service within the NM Medicaid Web Portal. This will confirm if the client had or has Centennial coverage during that timeframe.

2.)Service Not Family Planning (Exception Code 0029)

Tip: Check the client’s eligibility during the date of date of service via the NM Medicaid Web Portal. This will confirm the client has Family Planning Services (COE-029) during the timeframe. This denial will post if the procedure(s) billed on that date are not Family Planning related.

3.)Timely Filing Not Met (Exception Code 0820)

Tip: The claim was not billed within the designated timely filing period from either the date of service, the date of the initial denial, or the date of the attached Explanation of Benefits. In circumstances that you feel this denial was generated in error, resubmit an original claim form that consists of red drop-out ink along with a reconsideration request that references the denied TCN.

4.)Client Not Eligible (Exception Code 0143)

Tip: Check the client’s eligibility during the date of service via the NM Medicaid Web Portal. This will confirm if the client was indeed eligible during that timeframe.

5.)Exact Duplicate (Exception Code 1361)

Tip: This denial is posted when the same date of service has already been processed and paid previously. Check your date of service via the Claim Status inquiry on the NM Medicaid Web Portal. There you will see the information (such as the EOB date) for the previous paid claim. If you have any questions related to these denials or other received FFS denials, please contact the Provider Relations department for assistance at 1-800-299-7304, option 6.

Provider Type & Specialty List

There is a new version of the Provider Enrollment Provider Type & Specialty List now available for your reference on the NM Medicaid Web Portal under the Provider Enrollment section. Please use this document to:

 Determine the correct Provider Type & Specialty to request on your application  Include the correct attachments for your Provider Type & Specialty  View the requirements for your Provider Type & Specialty

If you need further assistance using the Provider Type & Specialty List, please contact the Provider Relations department for assistance at [email protected] or 1-800-299-7304, option 6, followed by option 3.

Fee for Service Claim Requirements for Rendering, Referring, Ordering, and Attending Providers

Additional requirements for providers to report rendering, referring, ordering, and attending providers on their claims become effective on October 16, 2017, and January 1, 2018. These requirements must be met in order to meet federal requirements. Failure to properly report the necessary information by the dates required may result in denied claims. Please refer to the appropriate provider supplements as follows:

Hospitals, Outpatient Hospitals, Home Health Agencies, Hospices, Nursing Facilities, ICF/IIDs, and Residential Providers (ARTCs, RTCs, and Group Homes): See Supplement 17-07 at: http://www.hsd.state.nm.us/uploads/files/Providers/New%20Mexico%20Administrative%20Code %20Program%20Rules%20and%20Billing/Supplements%20for%20MAD%20NMAC%20Program %20Rules/Supplement%2017-07%20(3).pdf

Clinical Labs, Diagnostics Labs, Radiology Facilities and Radiation Treatment Centers; Providers of hearing aids and supplies , glasses, IV infusions, medical supplies and medical equipment; Occupational Therapists, Physical Therapists, Speech and Language Therapists and Pathologists, and Rehabilitation Centers: See Supplement 17-08 at: http://www.hsd.state.nm.us/uploads/files/Providers/New%20Mexico %20Administrative%20Code%20Program%20Rules%20and%20Billing/Supplements%20for%20MAD %20NMAC%20Program%20Rules/Supplement%2017-08.pdf

All other providers and practitioners of professional services: See Supplement 17-09 at: http://www.hsd.state.nm.us/uploads/files/Providers/New%20Mexico%20Administrative%20Code %20Program%20Rules%20and%20Billing/Supplements%20for%20MAD%20NMAC%20Program %20Rules/Supplement%2017-09.pdf In each of these supplements, there is an October 16, 2017 deadline that applies to claims received on or after that date. The NPI numbers must be entered on claims as described in the supplements even if the attending, referring, or rendering provider is not enrolled. The January 1, 2018 date is a deadline by which those providers must be enrolled as a provider in the Medicaid or Managed Care programs. For providers of services for which identification and/or enrollment of the attending, referring, ordering, or rendering provider is already required, those requirements remain in place.

Note that these instructions do not change any requirements for pharmacies, Home and Community Based Services Waiver providers, or school providers at this time. Separate instructions will be sent to these providers in the near future.

If you have any questions related to this notice, please contact the Provider Relations department for assistance at 1-800-299-7304, option 6.

Provider Enrollment Applications Top Errors

The New Mexico Medicaid Provider Enrollment team is taking steps to implement more timely and efficient processing so you can become a provider with New Mexico Medicaid. Conduent is working towards reducing the number of Provider Applications that are returned for missing or incorrect information.

Here are our top errors to keep in mind while completing the provider enrollment application.

1.) Expired License or Insurance

Tip: To ensure processing is not delayed, we cannot accept any license or Certificate of Insurance (COI) that will expire within 30 calendar days from the day Conduent receives your application.

2.) Incorrect National Provider Identification Number (NPI)

Note: Applications using a Social Security Number (SSN) need a Type 1 NPI, and applications using a Federal Employer Identification Number (FEIN) need a Type 2 NPI.

Tip: We recommend visiting the National Plan and Provider Enumeration System (NPPES) website to ensure the correct NPI is entered on the application. The NPPES website is listed directly below:

https://npiregistry.cms.hhs.gov/

3.) Incomplete or Missing Information – IRS Letter/W-9 or Approval Letters

Tip: We recommend you refer to the Provider Type and Specialty List before submitting your application in order to review the required attachments for your specific provider type.

4.) Missing Signature or Initials

Tip: Double check that your application has been signed and initialed in all required places before submitting. Paper applications must be signed in blue ink. Photocopied, stamped, or scanned signatures will not be accepted.

To reduce the chance of your application getting returned, consider submitting the application through the NM Medicaid Web Portal. On the web portal, you will be able to refer to the Provider Type and Specialty List while completing the application, and will receive error messages when required fields are not populated to further assist in the process.

Please review the Provider Enrollment Online Application Process article listed in this E-News, to learn more about the online submission process.

Provider Enrollment Online Application Process

NM Medicaid is taking steps to reduce paper application handling in an effort to improve and streamline the provider enrollment process. MAD 335 (Group or Individual Billing Providers) and MAD 312 (Provider Affiliated with a Billing Group) Provider Enrollment Applications can be submitted and resubmitted electronically on the NM Medicaid Web Portal at the link below:

Provider Enrollment Web Application

There are advantages to submitting provider applications electronically:

 Application rejections and resubmissions are minimized  Applications are delivered to Conduent immediately through the portal  Processing occurs expeditiously, improving timeliness of the applications process

Attention MAC users: Safari browser may not be compatible with certain devices when navigating the online enrollment process. Please use other browsers such as Firefox, Internet Explorer etc. to complete the process. Conduent is aware of the issue and is working to resolve the problem.

If you are unable to submit a Provider application using the online enrollment process, please contact the Provider Relations department for assistance at [email protected] or 1-800-299-7304. Revised Adjustment, Reconsideration and Void Request Forms

New Mexico Medicaid has revised Adjustment, Reconsideration and Void Request Forms to better assist providers and reduce the number of returns.

The Adjustment / Void Request Forms have been consolidated into one form. Submission instructions for the revised Adjustment/Void and Reconsideration Request Forms are included in each form.

The forms can be found on the New Mexico Medicaid Web Portal at:

https://nmmedicaid.acs-inc.com/static/ProviderInformation.htm#FormsPubs

After October 1st, 2017, Conduent will no longer accept older versions of Adjustment, Reconsideration or Void Request Forms and will return to provider.

Each Adjustment, Void or Reconsideration request must be submitted with the correct corresponding form. Requests submitted without the correct request form will be returned to the provider.

If you have any questions related to this email blast, please contact the Provider Relations department for assistance at 1-800-299-7304, option 6.

Reconsideration of EMSA Claims

New Mexico Medicaid providers may request a reconsideration of EMSA claim denials within 30 calendar days from the date of notice (see NMAC 8.350.2, Reconsideration of Utilization Review). Reconsideration requests may be sent to Qualis Health TPA via fax (888-562-2755) or mailed to:

Qualis Health TPA Attn: EMSA Reconsideration Requests PO Box 20910 Albuquerque, NM 87154-0910

ITU Service Providers

 Monthly IHS Open Forum

o Second Wednesday of every month; 2:00pm - 3:00pm (MST)

• Conduent - IHS Training: Northern Navajo Area

o Tuesday; December 19, 2017; 1:00pm - 3:00pm . Location: NAO Main Conference Room; St. Michaels, AZ

For more information or questions about IHS matters, please contact the Conduent IHS Provider Field Representative: [email protected].

Conduent Contact Information

Disclosure- The objective of the E News, training, and webinars is to inform and educate. Articles reflect information at current time and may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their content. E News is published monthly and available on the NM Medicaid Web Portal.