Frequently Asked Questions s16

FREQUENTLY ASKED QUESTIONS

Provider Network I’ve gone through the credentialing process for the provider but I can’t activate them. Why? How do I add clinicians to a provider? How do I know which site I’m adding numbers, taxonomies, etc. for when the Sites tile disappears? How can I enter bill type specialty for a site when the Create button is grayed out? How can I enter taxonomies for a site when the Create button is grayed out? How do I add a service to a contract? How do we track facility licensure information?

Patient Can I add a patient to state insurance through the Insurance tile or do I have to do an enrollment? If a patient is already enrolled in state insurance, will it automatically show in the Insurance tile? If a patient is enrolled in Medicaid, will it automatically show in the Insurance tile? When a patient is discharged from state insurance, will the system automatically know or will I have to put an end date on their insurance? What is the COB tile for? Do I have to update the COB tile? How do I enter a target pop? How do I end date a target pop? Where can I upload documents for a patient that aren’t necessarily related to a SAR or treatment plan? If one provider does a crisis plan, can other providers see it? Where can I enter notes for a patient that aren’t PIE notes?

Calls & Referrals How can I refer a current patient to a provider if they call? They don’t need to be enrolled, so where do I go? When I’m searching for a provider, once I’ve added selections to the Specialties field, how do I take them off? How do I go back and find a referral after it’s been made? If I enroll a patient in a new call, how do I find that enrollment after I’ve saved the call?

Enrollment Requests What does the enrollment form enroll someone into? Does it enroll them in Medicaid? Why does it ask if the person has Medicaid?

1 AlphaCM, Inc - 10-1-12; revised 1-10-13 FREQUENTLY ASKED QUESTIONS

Do I fill in the Consumer Unique ID? Where do I enter information that used to go on the STR and LCAD? How do I change the date that the state insurance was active? What’s the difference between an enrollment and a client update request? Is there a report E&E should be running daily? What’s the difference between clicking Send Back to Provider and Deny?

Client Update Requests (CUR’s) What’s the difference between an enrollment and a client update request? How do I know what information has been updated? When I approve a client update request, does it automatically make the changes in the system? What’s the difference between clicking Send Back to Provider and Deny?

Care Coordination When I try to right a note, it doesn’t allow me to submit it and says I’m not the case manager. Why?

Authorizations Can multiple services be requested on a Service Authorization Request (SAR)? Can I upload multiple documents to a SAR? Where do I approve a SAR? I’ve approved the service but it looks like the number of units is wrong… I’ve approved the service but the status looks wrong… Do I have to enter daily/weekly/monthly/yearly limits when I’m approving a service? Shouldn’t these limits already be in the system? Do I have to print authorization letters for providers? Do I have to print denial letters for providers? Do I have to print denial letters for consumers? How do I enter SAR appeal information into the system? If I change a service definition in the system, will this affect the authorizations of any services tied to that definition?

Claims Why am I receiving a debugging error when I try to save or submit a CMS 1500?

In what order do the adjudication rules apply when a claim is processed (e.g. is a valid diagnosis checked before age group, etc.)? When would I readjudicate a claim? When would I revert a claim? When would I override a claim line? If I readjudicate a claim with multiple claim lines, some that paid and some that didn’t, what happens? How is a CMS 1500 replaced or reversed? What is a pended claim? Is there a report to identify pended claims? Are pended claims always set to readjudicate automatically when the issue has been resolved? Is there a time limit on pended claims at which point: (a) provider gets notice, or (b) MCO gets notice of action required? Is there a way to measure system performance for how claims are being adjudicated? What do all these numbers mean?! When an 837 is uploaded into AlphaMCS, what response files are generated for the providers? Are the above three files generated regardless of if there are errors in the 837? How do we send 834’s? When a batch is sent to Great Plains (GP), what claims are included? Can we accept an 837 file that contains claims from multiple providers? Does Faciledi do duplicate file checking? Is there or should there be a maximum number of file we accept per day from a single submitter? How soon are the response files available after 837 submission? Will Professional and Institutional claims information be combined in the same 835 file or separate 835 files? How long do files stay in the /out folder on the FTP site? Why aren’t providers seeing 835’s in their Download Q? Is the NPI and the provider tax ID returned in the 835 file and what loop and line? For contracts that we pay 1/12 each month, does the system handle payment like the State does for single stream funding? If we have blended contracts—part that is 1/12 contract and some services that are fee-for-service—how is that managed in Alpha? Does the system separate payment requests by funding source prior to importing to Great Plains? Is a revenue code different than a procedure code? In the UB-04, what do the numbers in the bill type mean? What are DRG codes?

What is a discharge claim and how does it pay? What do the YP820 and YP821 codes mean? What is the COB Allowable field on the CMS 1500?

Grievance Tracking Why can’t I edit a grievance?

Provider Network I’ve gone through the credentialing process for the provider but I can’t activate them. Why? The system is going to check to ensure all PSV’s have been verified and all checklist items have been checked off. If they haven’t been, the provider will not be able to be activated. If you try to do this anyway, the system will tell you this is the issue. If all PSV’s have been verified and checklist items checked off, then you will need to go to the Application tile and click the “Update” button. Next, click on the Determination field and select Approved from the dropdown. Once you’ve saved, an “Activate” button will be viewable. Click on that to activate the provider. See below for a more in- depth explanation:

Once all checklist items have been accepted and all PSV’s have been verified, go to the Application tile again. Click the 3 view and find the application you’ve been working on.

Click the Update button to go back into the application.

Go to the Determination dropdown and select Approved. Click Update and you will be taken back out to the base tile.

IF YOU HAVE ANY OUTSTANDING CHECKLIST ITEMS OR PSV’s, the system won’t allow you to say the application is approved. It will tell you what needs to be completed in order to do this.

Notice the Activate button is now enabled. Click this and the provider will be active in your system.

How do I add clinicians to a provider?

You cannot do this in the Maintain Provider Info module. You must exit the module and go to Clinician Maintenance. There, search for the clinician if they already exist in the system. If they don’t, you can create them. Once they are in the system, search for them and go to the Provider Associated tile. Click “Create” and enter the provider you want them associated with. Once you save, you will be able to see this clinician in the Clinicians tile for that provider on the Maintain Provider Info module. See below for a more in-depth explanation:

Go to Menu, Provider Network, Clinician Maintenance. In the Clinician Base tile, search for the clinician. If they aren’t there, click Create.

If you have to create a clinician, enter the necessary information and click Save, then search for them again. They will now show.

Highlight their name, then maximize the Provider Associated tile and click Create.

Begin entering the provider’s name and the field will autofill with suggestions. Select the correct one, then enter an effective date and click Save.

When you go to the Maintain Provider Info module and search for the provider, you will now see the clinician associated with them.

How do I know which site I’m adding numbers, taxonomies, etc. for when the Sites tile disappears? The site you’re working with will appear at the top of the screen. If you want to change the site, go back to the Site tab and highlight a different site on the Sites tile.

How can I enter bill type specialty for a site when the Create button is grayed out? If you can’t enter a bill type specialty for a site, then there is probably nothing in the Numbers tile. Bill type specialties must be linked to a specific Number.

How can I enter taxonomies for a site when the Create button is grayed out? If you can’t enter taxonomies for a site, then there is probably nothing in the Numbers tile and the Bill Type Specialties tile. Taxonomies must be linked to a Bill Type Specialty, which must be linked to a Number.

How do I add a service to a contract? First select the contract you want to add the service to by highlighting it on the Contracts tile. Next, Go to Contract Details. Here, click the “Add” button, then enter the code you’re searching for in the text field and click “Search”. When you find the service you want to add, and which site you want to add it to, click the “Add to CD” checkbox. See below for a more in-depth explanation:

Go to the main menu and select Provider Network, then Maintain Provider Info. Search for the provider and click on the Contract tab on the left side of the screen. The main Contracts tile will be prominent on your screen. Highlight the contract you want to add services to, then click on the

Contract Details tile to enter the services the provider will be reimbursed. Click Add button, then search for the service.

Click on the checkboxes under the Add to CD column to insert that service into the contract. Fill out the applicable information to the right—only dates are required and they autofill. When you’re done, click Save. Note that every service code associated with the service you entered pulls up (including the service code with various modifiers). If you have multiple sites, the list of service codes will pull up once for each site.

When services are added to the contract, the rates from the Rate Schedule module are automatically loaded. However, you are able to modify these rates by site, place of service, license and service. To do this, click on the Contract Rates tile and enter the correct rates for the services the provider will be doing. Note that each rate must be attached to a site, place of service and degree group ID. When you begin to type in a site, a list will appear that you will be able to choose from. The same is true of the Proc Code and Degree Group ID dropdowns (for Degree Group, start by typing in a “1”).

The Patient Specific Contract tile is used for two reasons:

-You have a service that is being provided to multiple clients at the initialized rate BUT you also have a client/clients who have specialized rates. In this case, you would highlight the applicable line on the Contract Details tile, then go to the Patient Specific Contract tile and click Upate and enter the clients and their special rates.

-You have a service that is only being applied to a single client. In this case, you would make sure to check the Client Specific checkbox. This means the service does not apply to any other patients.

How do we track facility licensure information? This can be tracked through the Credentialing module for providers entering an application. If it’s a new site for an already credentialed provider, it can be entered in the Credentialing module with the application type Ad Hoc. If the licensure information does not need verification and you simply want to have it to reference, you can enter it in the Sites tile in the Site Notes text box. See below for a more in-depth explanation of the credentialing process:

To reach the Credentialing module, go to Provider Network, Credentialing. You will then see the four tabs of the module: Application, Provider, Sites and Clinician.

The first tab you’ll see will be the Application tab.

The Application tile will show you all applications that are currently under credentialing. To enter a new application, hit the Create button.

This will allow you to enter the information for the application that the provider has sent to you.

There are many dates to be filled in—some of which are autofilled for you based on other information you’ve already entered. Below is a brief description of each field:

Application Date: Date you received the initial application. Review Due: When you need to confirm that everything was included in the application packet. This will autofill to be 10 business days after Received Date. Review Completed: Date you actually confirmed the application has been submitted in full. Packet Complete: Check this if the application has been submitted in full. If it hasn’t been, leave unchecked and enter a Resubmission Due. Response Due: When you should inform the provider the packet wasn’t complete. This will autofill to be 5 business days after Review Completed if the Packet Complete checkbox isn’t checked. Packet Returned: Date you actually returned the incomplete packet and mailed the certified letter. Resubmission Due: When the rest of the application packet should be sent in to the MCO. This will autofill to be 10 calendar days after Packet Returned. Packet Resubmitted: When it was actually sent in and you’re able to move forward with credentialing. Discrepancy Noted: Check this if there are any discrepancies between the info provided by the applicant and info obtained from other sources. Notification Sent: When the letter was sent notifying the applicant of the discrepancy. Additional Info Due: When clarifying information about the discrepancy is due from the applicant. This will autofill to be 10 business days after Notification Sent. Additional Info Received: Date the clarifying information is actually received. PSV Complete: When all Primary Source Verifications have been completed. Referral Date: When the file has been referred to the Medical Director/Credentialing Committee for a determination. Determination Date: When the determination was actually made.

Outcome Letter: When the applicant has been informed of the outcome. Signature Date: Date of the signature on the application (by the applicant). Expiration Date: Date the application expires. Recredentialing Date: When the applicant needs to be recredentialed. This will autofill to be three years from the Determination Date but you can overwrite this and put in a different date if you’d like.

When you’ve entered the necessary information, hit . The application will now appear on the Application tile. Also notice that a checklist has been created in the Checklist tile. This will show everything that needs to be done for the provider to be credentialed.

As items on the checklist are completed, you can mark them off by highlighting the item and clicking the 3 view in the upper righthand corner of the tile.

This will cause an Update and a View button to appear. Click on the Update button.

Fill in the necessary information and click Save. If you enter “Accepted” as the status, the checklist item will show as Active on the Checklist tile.

To begin the process of primary source verification, first highlight the application you want to work on.

In this example, the provider Best Behavioral is highlighted. When you move to another tab, you will be entering information for this provider.

Once you’ve found the application you want to work on, click on the Provider tab. In the Providers tile, you’re able to create the provider associated with the application you just enter. To do this, click the Create button.

Fill in the necessary information and click Save. Note that you can’t check the Active checkbox. This will automatically be checked once all PSV’s have been checked, all checklist items have been marked off, and you’ve activated the client.

Next, go to the PSV tile.

In the PSV tile, you’ll be able to document your primary source verifications. To do this, go to the PSV tile and click Create.

Fill out the necessary information. If the PSV is verified, make sure to check the Verfied checkbox and choose the staff person who did this in the dropdown below it.

The Reason field is where you’re able to say why something wasn’t verified. The Credential ID field is you can enter information about the actual credential (e.g. the insurance number if you’re checking malpractice insurance).

When you click Save, the PSV will display in the tile.

Continue to the Site tab and enter any sites the provider has by clicking Create on the Sites tile.

Enter any PSV’s for the sites you’ve entered. Note that the PSV screen is the same in all tabs. When you’re done, go to the Clinician tab and enter any clinicians and corresponding PSV’s.

Once all checklist items have been accepted and all PSV’s have been verified, go to the Application tile again. Click the 3 view and find the application you’ve been working on.

Click the Update button to go back into the application.

Go to the Determination dropdown and select Approved. Click Update and you will be taken back out to the base tile.

IF YOU HAVE ANY OUTSTANDING CHECKLIST ITEMS OR PSV’s, the system won’t allow you to say the application is approved. It will tell you what needs to be completed in order to do this.

Notice the Activate button is now enabled. Click this and the provider will be active in your system.

Patient Can I add a patient to state insurance through the Insurance tile or do I have to do an enrollment? For patients who aren’t currently enrolled, you will need to do an enrollment. This is because the information in the enrollment is then sent up to CDW.

If a patient is already enrolled in state insurance, will it automatically show in the Insurance tile? If their state insurance information is initially uploaded into the AlphaMCS system from the MCO’s former software and it’s still active, or if an enrollment came in for the patient and was approved.

If a patient is enrolled in Medicaid, will it automatically show in the Insurance tile? Yes, all MCO’s receive a global eligibility file (GEF) daily that lets them know who has Medicaid. The system them updates that information in the patient’s Insurance tile. Note: if your MCO is not yet on the waiver, you have to manually check to see if your clients have Medicaid.

When a patient is discharged from state insurance, will the system automatically know or will I have to put an end date on their insurance?

The system will alert you that it has been 60 days since the last DOS on a claim, which means they should be discharged. You will then need to go to the Insurance tile, click on State Insurance and enter an end date.

What is the COB tile for? COB stands for Coordination of Benefits. This tile is for any insurance besides state insurance and Medicaid that the patient may have.

Do I have to update the COB tile? For MCO’s on the waiver, he Global Eligibility File (GEF) comes into the system daily and will update the COB file by indicating if the patient has a COB. If the patient does, it will show on this tile as “Generic” insurance. Note that this is only for Medicaid eligible patients, as this is who the GEF checks for. Note: if your MCO is not yet on the waiver, you have to manually check to see if your clients have COB’s.

How do I enter a target pop? Go to the IPRS Target Pops tile and enter the necessary information. Once you have saved this, the information will be sent to the state in an 834 file. When it’s returned, the other information on the screen will populate.

How do I end date a target pop? Go to the IPRS Target Pops tile and enter an end date. This information will then be sent to the state in an 834 file.

Where can I upload documents for a patient that aren’t necessarily related to a SAR or treatment plan?

The Clinical Docs tile in the Patient module.

If one provider does a crisis plan, can other providers see it? As long as it’s uploaded to the system with the clinical doc type “Crisis Plan”.

Where can I enter notes for a patient that aren’t PIE notes? In the Chart Notes tile.

Calls & Referrals How can I refer a current patient to a provider if they call? They don’t need to be enrolled, so where do I go? Once you’ve search for that patient and selected them, their information will populate in the corresponding fields. A “Referral” button will also appear. Click on this to get to the Slot Scheduler. See below for a more in-depth explanation:

To record a call, click on Create Call. This takes you to the New Call Entry screen, where you’re able to enter basic information about the call and caller, as well as enter any notes you may have.

If you need information from other tiles while you’re completing this section, you can simply maximize that tile or drag the tile into the main area of the screen and drop it.

Click the Search button and to look for a patient by name, ID, social security number or birthday. This will pull up all patients with Medicaid and/or state funding. To select a patient, double click on their row and it will insert their name and ID into the proper field on the Calls screen.

 If a patient currently has state funding, the Enrollment button will become inactive on the Calls screen.

 For clients who have active Medicaid or state insurance, the Referral button will appear. Clicking this button will take the user to the STR form.

When I’m searching for a provider, once I’ve added selections to the Specialties field, how do I take them off? You can click on the Specialties dropdown and uncheck them.

How do I go back and find a referral after it’s been made? Go to Menu, Clinical, Call Center, Referral Search and search for it there.

If I enroll a patient in a new call, how do I find that enrollment after I’ve saved the call? Go to Menu, Clinical, Call Center, Enrollment Requests and search for it there.

Enrollment Requests What does the enrollment form enroll someone into? State insurance.

Does it enroll them in Medicaid? No.

Why does it ask if the person has Medicaid? To report to CDW.

Do I fill in the Consumer Unique ID? No, the system will generate this for the patient as you fill in their information.

Where do I enter information that used to go on the STR and LCAD? Once you’ve entered information into all the fields on the first page that are marked with a red asterisk, you can click the Save button at the bottom. When you do this, the system will ask you if you want to go to the Additional Clinical Information page? Click yes and you are able to enter target pops, diagnoses, etc.

How do I change the date that the state insurance was active? Go to the Patient module, Insurance tab, then find State. Click on the 3 and you can update that effective date. This will not change the date entered on the actual enrollment but it is the date the system will look when claims come in to be paid by state insurance.

What’s the difference between an enrollment and a client update request?

An enrollment enrolls someone in state insurance. The client update is a form by which the provider lets the MCO know that some of the information either entered on the enrollment or by the MCO has changed. This information isn’t changed in the system until MCO staff approves the client update. The information will then automatically change in the Patient module.

Is there a report E&E should be running daily? This depends on the business process of the MCO but many have their E&E team view the Medicaid Loss Report daily. If you have a consumer who is authorized for a service, then the consumer loses their Medicaid but they still have an active auth, their name would populate on this report. E&E’s role in this would be to contact the care manager and inform them that the patient lost their Medicaid but has an active auth. The care manager should then contact the provider to follow up.

What’s the difference between clicking Send Back to Provider and Deny? Send Back to Provider will allow the provider to continue work on the enrollment—it sends it back to them in Saved status. Deny makes it so the enrollment can no longer be worked on. Note that a provider can always enter another enrollment for the same patient.

Client Update Requests (CUR’s) What’s the difference between an enrollment and a client update request? An enrollment enrolls someone in state insurance. The client update is a form by which the provider lets the MCO know that some of the information either entered on the enrollment or by the MCO has changed. This information isn’t changed in the system until MCO staff approves the client update.

How do I know what information has been updated? AlphaCM is working to highlight fields that have been updated so they are easy for MCO staff to recognize. We recommend telling your providers to go to the Comments section to let you know what they have changed.

When I approve a client update request, does it automatically make the changes in the system? Yes, the information will then automatically change in the Patient module.

What’s the difference between clicking Send Back to Provider and Deny? Send Back to Provider will allow the provider to continue work on the client update request—it sends it back to them in Saved status. Deny makes it so the CUR can no longer be worked on. Note that a provider can always enter another CUR for the same patient.

Care Coordination When I try to right a note, it doesn’t allow me to submit it and says I’m not the case manager. Why? This is probably because the system doesn’t recognize the username you logged in with as being associated with a clinician, or because that client isn’t on your caseload.

To create a care coordinator, follow the process below. To edit someone’s information, skip to step 4.

1. Go to Provider Maintenance, Clinician Maintenance in order to first create them as a clinician in the system.

2. Go to the Clinician Base tile and click Create. Enter the necessary information and click Save.

3. In the surrounding tiles, input the rest of the care coordinator’s information, such as their licenses, degrees, etc. When you get to the Provider Associated tile, click the Create button to indicate that this clinician isn’t associated with an external provider but is a care coordinator.

4. Now that the clinician has been identified in the system as a care coordinator, you’re able to attach them to a system user. This means that when the care coordinator logs into the system (they have

25 AlphaCM, Inc - 10-1-12; revised 1-10-13 FREQUENTLY ASKED QUESTIONS already been set up as someone who can use the system) they will be recognized as a clinician and their caseload will be available for them. To do this, go to Care Coordination, Case Load. On the Care Coordinator tile, you should see the new clinician you just entered. Click the Update button next to their name. If you’re editing someone’s information, this is also where you go.

The clinician can enter their four number PIN, the electonric signature they will use to sign their notes, in the PIN field. If their notes need to be reviewed, you can check this checkbox and choose the reviewer below. Finally, you will want to click the Add User button to link a system user with the care coordinator. When you’re done, click Save.

Authorizations Can multiple services be requested on a Service Authorization Request (SAR)? Yes. After you enter the first service, you will see an “Add Row” button. Click on this and new fields will appear in which you will be able to enter another service. You can click on “Add Row” as many times as you want.

Can I upload multiple documents to a SAR? Yes. After you upload the first document, just repeat the process of selecting a document type, then clicking the “Upload File” button.

Where do I approve a SAR? You don’t actually approve a SAR, only the services on the SAR. First make sure the SAR is assigned to you. When you find the SAR, you can see who it’s assigned to by clicking the 3 info view button in the upper right hand of the tile. If you don’t have assignment, click the “Take Assignment” button. Next, you will make sure the correct SAR is still highlighted, then go to the Service tile. Click the 3 button here, then the “Update” button. You’re now able to review the services and pass a decision on it. See below for a more in-depth explanation:

Once you feel you have enough information to approve or deny, go to the Services tile. You will approve or deny a SAR service by service.

Notice that again you have the option of clicking on a number to view more information. Clicking on the highest number will show you the most information, as well as cause the button to appear. Click on this to approve or deny a request.

Here you are able to enter your decisions and choose the appropriate status, as well as enter a justification if you’re denying the service. When you’re done, click the Save button.

Note that the Approved Units field is NOT the total units being approved for the auth. This corresponds with the Units field grayed out above it.

If you choose to deny a service, it will be sent to a peer reviewer, who will either uphold or overturn your decision. You will know what they decide when the SAR appears on your queue again with their instructions on how to proceed.

While peer reviews are mandatory and automatic for denials, you can request that another MCO staff look at the SAR before you even make a decision. To do this, you can choose the status as Peer Review, then click Save. This will send it to the reviewer’s SAR queue.

If you have questions or want to request additional documentation from the provider, click on the SAR Comments History. You can enter comments here that the provider will see, and their response will also show here.

If you’ve approved the service, a button will appear for you to be able to print the authorization letter. If you denied the service, you’ll see a button to print a denial letter. These buttons will be located on the Services tile under the 3 view.

You can also go to the Authorizations module to print an auth letter.

Highlight the correct authorization in Auth Header Base and click the 3 view.

Click the button.

I’ve approved the service but it looks like the number of units is wrong… Make sure when you approve a service, you’re entering the number of units you approve for a certain time period in the Approved Units field. When you click off this field, the system will automatically calculate the Approved Total Number of units (Approved Units x Approved Duration Definition).

I’ve approved the service but the status looks wrong… Make sure you change the status of the service by clicking the appropriate radio button towards the top of the form, above the Approved Units section. Even if you approve the units, you need to change the status.

Do I have to enter daily/weekly/monthly/yearly limits when I’m approving a service? Shouldn’t these limits already be in the system? The limits are already in the system. You would enter limits here if you want different units than what is set up in your benefit plan. To see current limits, go to the Benefit Plans module and look at the Services/Proc Codes tile.

Do I have to print authorization letters for providers? No, you don’t. But if you want to print the letter, you can do this by going to the Authorizations module. Search for the Authorization and when you have it, click on the 3 button to see a “Print” button. Clicking on this will allow to have a hard copy of the authorization letter. See below for a more in-depth explanation:

Click the button.

Do I have to print denial letters for providers? No, you do not. The letter is available electronically for the Provider to print at any time by accessing the denied service and click the 3 button, then click on the “Denial Letter” button. The Provider can also view the decision status electronically on each SAR. See below for a more in-depth explanation:

Click the button.

Do I have to print denial letters for consumers? Yes, you do. To print a denial letter, go to the denied service and click the 3 button, then click on the “Denial Letter” button. The hard copy must be physically sent to the consumer. See below for a more in-depth explanation:

Click the button.

How do I enter SAR appeal information into the system? Search for the SAR and highlight it, then go to the Appeal tab. In the Appeal tile, click Create. You will be able to enter information about the appeal as well as upload corresponding documents.

If I change a service definition in the system, will this affect the authorizations of any services tied to that definition? In most cases, no. The only reason an authorization would be affected is if on the SAR, “All Services” was chosen in the Services dropdown.

Claims Why am I receiving a debugging error when I try to save or submit a CMS 1500? Check to see if all the necessary information has been filled in—when you receive a debugging error, it can be because the information pulled from the patient’s record is incomplete. When you search for the patient on the CMS 1500 and the system autopopulates those gray boxes, if there’s nothing in some of them, this information needs to be filled in on the Patient module. Providers will have to enter a client update request if they want to add this information.

In what order do the adjudication rules apply when a claim is processed? AlphaMCS looks at the patient id, diagnosis code, and date of service in the claim header. The system validates the following 1) the claim is covered by state insurance 2) the patient has been assigned to a target population 3) the target-population-to-diagnosis code relationship exists 4) the claim date of service falls between the effective and end dates of the target population.

When would I readjudicate a claim? An example of when you would readjudicate a claim is if a provider sent it in before UM had a chance to approve the authorization for the service on the claim. After the authorization was approved, you could go in and readjudicate or just have the provider resubmit the claim.

When would I revert a claim? An example of when you would revert a claim would be if a provider called up and said they accidentally entered a claim for the wrong patient. You could revert it to kick it out of the system.

When would I override a claim line? An example of when you would override a claim line would be if you have a verbal agreement with a provider to do an emergency service but nothing has been put in the system yet. Their claim would deny but you could override so that they would get paid.

If I readjudicate a claim with multiple claim lines, some that paid and some that didn’t, what happens? The whole claim would be readjudicated, including claim lines that paid. However, if a claim line paid the first time, it would not pay again.

How is a CMS 1500 replaced or reversed? You’re able to do this in the system by first filtering for the processed claim you would like to replace or reverse. Once you’ve found the claim, click the Copy button.

This will display the claim in an editable format. This is also the process for submitting claims similar to past claims, since all you would have to do is make a few minor changes and hit Submit. In fact, the only difference is that if you want to replace/reverse a claim, you would simply go to #22 and enter the action you’re taking.

After you choose Replacement or Reversal, enter the original claim number in the Original REF. NO field. This will tell the MCO which claim you’re replacing or reversing.

 Replacement: Replacing a claim tells the MCO that the information you sent in the first time was incorrect and that this new claim has the correct info. If it paid the first time, that money will be recouped by the MCO and you will be asking for it again in this claim. If it didn’t pay, you are essentially just resubmitting the claim for MCO approval.

 Reversal: Reversing a claim tells the MCO you entered the wrong info in the original claim and you want them to recoup the money paid, and that you’re not sending any other claim to try to recollect that money.

In the case of a replacement, make any necessary changes. Finally, click Submit.

What is a pended claim? A pended claim is one that is waiting to be adjudicated because there aren’t rates currently in the rate schedule for the service on it.

Is there a report to identify pended claims? It is the Pending and Denied Claims report or you can create one, in the tb_claim_adj_dets table the stat_id=3.

Are pended claims always set to readjudicate automatically when the issue has been resolved? No.

Is there a time limit on pended claims at which point: (a) provider gets notice, or (b) MCO gets notice of action required? No.

Is there a way to measure system performance for how claims are being adjudicated? The Daily Claims Audit Report can you show a percent of the claims processed so you can spot check performance.

What do all these numbers mean?! 837—sent from providers to insurances for payment for services 277—sent in response to the 837, to acknowledge the 837 was received 824—sent in response to the 837, determines if there are errors, gives claim info and messages 999—sent in response to the 837, similar to the 824 but simplified 835—sent in response to the 837, with payment information

834—sent from the MCO to the state with patients’ demographic information and target pops

834 (different)—a batch eligibility file from the state that gives information on who is Medicaid eligible

When an 837 is uploaded into AlphaMCS, what response files are generated for the providers? A 999, an 824 and a 277. The 999 and 824 files will indicate if there are any errors in the 837, and where those errors are. The 277 file is a Claims Acknowledgement file, and is used to let the submitter of the 837 know that the claim has been received.

Are the above three files generated regardless of if there are errors in the 837? Yes, all three files are generated even if there are no errors in the files.

There are two segments to first look at in a 999 file - the IK5 and AK9. These will be part of the last few lines of the file. The IK5 will read "A" if there are no errors with any claims in the file. It will read "E" if there are any errors with claims in the file. The AK9 will read "A" if the file itself is formatted correctly, and is accepted. It will read "R" if the file is not formatted correctly and has been rejected. Please note that it is possible to have the IK5 read "E" and have the AK9 read "A" - this means the file was accepted, but it had at least one claim in it with an error.

Below is an example of the IK5 and AK9 segments from a clean 999 with no errors:

IK5*A~ AK9*A*1*1*1~

And this is an example of a 999 that shows an 837 file as being formatted correctly, but containing errors:

IK5*E*5~ AK9*A*1*1*1~

The 824 file will contain information about each of the claims that were in the file, even if they were all accepted with no problems. The 824 file will also show any error information that may have been generated, and can be used to troubleshoot errors, but I find the 999 much easier to use when troubleshooting.

How do we send 834’s? 834’s are generated by the system every day at 1:45pm and placed in your SFTP out 834 directory. You need to send them to the state.

When a batch is sent to Great Plains (GP), what claims are included? All claims sent up to that point. Claims are processed at every day at 6pm and 11pm and the batch is sent to GP on the designated date at 1:30am, so all processed claims are sent.

Can we accept an 837 file that contains claims from multiple providers? Yes.

Does Faciledi do duplicate file checking? No.

Is there or should there be a maximum number of files we accept per day from a single submitter? No.

How soon are the response files available after 837 submission? The maximum you would have to wait is three minutes.

Will Professional and Institutional claims information be combined in the same 835 file or separate 835 files? Yes. Claims can come in on 837I’s and 837P’s, but they will be sent back in a single 835.

How long do files stay in the /out folder on the FTP site? 6 months minimum after that we will periodically remove the files.

Why aren’t providers seeing 835’s in their Download Q? It’s usually two reasons: 1) In their provider set up, they don’t have the EDI Certified checkbox checked, or 2) They have a clearing house entered, which means the 835’s go to them clearing house.

Is the NPI and the provider tax ID returned in the 835 file and what loop and line? The NPI isn’t. The provider tax ID is, in loop 1000B, in the fourth element of segment N1.

For contracts that we pay 1/12 each month, does the system handle payment like the State does for single stream funding? You must set those services as is_capitated. The claim will process and show paid but will not create an invoice to go to Great Plains to be paid. It will show on the RA as approved and the approved amount will be in the withheld column.

You can also do this in the provider’s contract when adding or updating a service in the Contract Details tile. Just click check the Sub Capitated checkbox.

If we have blended contracts—part that is 1/12 contract and some services that are fee-for-service—how is that managed in Alpha? You mark each service that is part of the 1/12 as is_capitated (see above). Those will be the only ones treated that way.

Does the system separate payment requests by funding source prior to importing to Great Plains? Each service line comes over with the expense account that follows your chart of accounts including the funding source.

Is a revenue code different than a procedure code? These are both validation codes utilized in Hospital Billing (Inpatient, Outpatient and Emergency Department). Revenue codes are used in place of or sometimes in conjunction with CPT codes to better indicate the hospital unit or service that is being billed. An easy example to use here would be to match up CPT code 99282, which is for an emergency room visit of low to moderate severity, and revenue code 0450, which stands for emergency room.

In the UB-04, what do the numbers in the bill type mean? The bill type consists of four numbers: 1st: This is always 0 and is reserved for future use. 2nd: This is for the facility code. 3rd: Also for the facility code.

4th: This is for indicating the claim frequency. If it’s a 1 or a 4, it’s a discharge claim. If it’s a 3, it’s continuing.

What are DRG codes? “Diagnosis Related Group” (DRG) is a patient classification system adopted on the basis of diagnosis consisting of distinct groupings. It is a system that relates the type of patients a hospital treats with the costs incurred by the hospital. DRG are based upon the patient's principal diagnosis, ICD diagnoses, gender, age, sex, treatment procedure, discharge status, and the presence of complications or comorbidities. It is a system used in inpatient and ED discharges as part of the prospective payment system that utilizes a predetermined rate per case or type of discharge. Example: Medicaid is only responsible for paying for someone’s Room and Board when it comes to inpatient care, everything else done in the hospital would be listed under a DRG (x- rays, drugs, etc.). This means that the hospital will document all services done with that patient and bill it to the MCO, but the MCO will only pay DRG services that are marked as “R & B” (Room and Board). For instance, when a hospital bills for a psychiatric inpatient stay, Medicaid pays for the room and board but not all of the ancillary services that go with their stay.

What is a discharge claim and how does it pay? When a claim comes in with a bill type that designates it as a discharge claim, this means that during the date range on the claim, the final day was the day the person actually left the hospital. Medicaid won’t pay for this last day—Medicaid only pays for a patient who occupies a bed across the 12:00am time frame. For a Patient on the day they’re discharged, they’re not crossing the midnight time frame in the bed.

What do the YP820 and YP821 codes mean? YP820 code = Inpatient services for State insurance. State hospitals can only bill Medicaid for children and seniors. If a patient comes in who doesn’t fall into either of those groups, YP820 is the code to use. YP821 code = Inpatient Services for State insurance under a 3-way contract. If the services were performed at a local community hospital that has a 3-way contract with the MCO and the Division of MHDDSAS, then the code is YP821. In this case, the state pays the hospital but authorizations go through the MCO.

What is the COB Allowable field on the CMS 1500? This is where the user can enter the maximum amount the patient’s primary insurance, if different than state insurance, will pay for the indicated service. If this rate is lower than what the MCO reimburses, the MCO will pay less of their own rate. For instance, if a patient has a COB that will pay $50 for a service, they would enter this info here. If the MCO had a contract rate of $60 for that service, the system would then look at that COB Allowable and consider that the maximum to be adjudicated—so

41 AlphaCM, Inc - 10-1-12; revised 1-10-13 FREQUENTLY ASKED QUESTIONS the most the MCO would pay is $50. Note that after the adjudication process, whatever the COB actually paid, which is indicated in the COB Paid Amount field is adjusted off –e.g. the COB paid $20, so if the MCO adjudicated the claim to pay all $50 for the service, the system would then subtract that $20 so the MCO only actually pays $30.

Grievance Tracking Why can’t I edit a grievance? Once a grievance is submitted, it is considered official document and cannot be edited. However, you’re able to take assignment of the grievance and do follow-ups.

42 AlphaCM, Inc - 10-1-12; revised 1-10-13