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Provider and Trading Partner Frequently Asked Questions (WEB)

Provider and Trading Partner Frequently Asked Questions

 

The following table contains Frequently Asked Questions that relate to the Maine Integrated Health Management Solution (MIHMS).  Click on the topic to view the answer.

The MyHealth PAS (MHP) User Guides that are referenced in this FAQ are located on the Provider Tab.  To access them, go to Provider Manuals > MyHealth PAS User Guides, from the left menu.  Many other instructions, guides, manuals, or documents can also be found using the Provider Quick Reference (PQR).  From the Provider Tab main page, scroll down to Provider Quick Reference under Welcome to MIHMS.  Most common questions may be answered and details obtained from these two resources.

 

 

Billing Codes

·          How do I correctly bill for bundled or unbundled services?

Claims

·          What is the difference between a service location and a place of service?

·          Who is considered a Billing Provider?

·          Can the Billing Provider address be a PO Box or Lock Box?

·          Is there a cancel button to stop a claim that was just submitted by Direct Data Entry (DDE)?

·          Is there a limit of how many Coordination of Benefits (COB) entries can be made with DDE?

·          How can I add Coordination of Benefits (COB) information after I have adjudicated a claim using Direct Data Entry (DDE)?

·          Can I see the edit for a denied claim using the portal?

·          What is Ambulatory Payment Classifications/ Diagnosis Related Groups (APC/DRG)?

·          How long will a claim remain in PEND status?

·          Why did my claim pay zero dollars ($0)?

Electronic Funds Transfer

·          How do I sign up for Electronic Funds Transfer (also called Direct Deposit)?

Eligibility                                                                                                                                 

·          How can I see the primary insurance for a member when checking eligibility using the portal?

·          How can I see if a member has a classification when checking eligibility on the portal?

HIPAA Transactions

·          What are the types of HIPAA-compliant claims?

Prior Authorization

·          How do I know if my Prior Authorization (PA) has been approved on the portal?

·          How do I change/update a Prior Authorization (PA)?

Referral

·          How can I see if a referral has been processed on the portal?

Remittance Advice

·          How can I find my Remittance Advice (RA) on the portal?

Trading Partner

·          How does a billing agent associate all provider Pay-To National Provider Identifiers (NPIs)?

·          When registering as a Trading Partner, what do you mean when you ask for a PIN?

 

 

Billing Codes

 

How do I correctly bill for bundled or unbundled services?

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment of claims.  NCCI edits prevent improper payment when incorrect code combinations are reported.

For more information, go to the NCCI Edits webpage of the CMS website.

 

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Claims

 

What is the difference between a service location and a place of service?

Place of Service (POS) is a required field in a health care claim.  The National POS code set is defined and maintained by the Centers for Medicare and Medicaid Services (CMS).  It includes such codes as 01 Pharmacy, 03 School, 11 Office, 12 Home, and so on.  Service location is a term used by MIHMS to identify the physical address from which services are administered.  Service locations are assigned three digit codes in MIHMS that may be required on the MaineCare claim form.  Please refer to MaineCare’s billing instructions for more information.

 

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Who is considered a Billing Provider?

In ANSI 5010 format, the use of the “Billing Provider” field has been clarified.  The billing provider must be a provider of health care services and can no longer be a billing service or clearinghouse.  The “Billing Provider” field can no longer state the information of a billing service or clearinghouse.  Information must be that of a health care service provider.

 

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Can the Billing Provider address be a PO Box or Lock Box?

The billing provider address must be a physical street address and can no longer be a PO Box or lock box.  In ANSI 5010 format, there is a Pay-To address in addition to the physical address if the provider prefers to send payments to another location.  This Pay-To address can be a PO Box or lock Box.  The 5010 Pay-To address is different from the 4010 Pay-To address.  The 5010 Pay-To address has the same name as the physical address provided.  The Pay-To address no longer refers to a different person or organization.

 

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Is there a cancel button to stop a claim that was just submitted by Direct Data Entry (DDE)?

No, there is no cancel button, but the claim can be reversed.  Each time you push the “submit” button, you are submitting the claim.  Pushing the “submit” button more than once in a 24-hour period will cause duplicate claims to be submitted.  Refer to the MyHealthPAS Claim Submission and Claims Status User Guide.

 

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Is there a limit of how many Coordination of Benefits (COB) entries can be made with DDE?

No, there is no limit to how many COB entries can be made with DDE.

 

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How can I add Coordination of Benefits (COB) information after I have adjudicated a claim using Direct Data Entry (DDE)?

A claim cannot be edited if it is in a “paid,” “denied,” “wait pay” or “wait deny” status.  You can edit the claim if it is in “open,” “adjudicated,” “deny,” “pay” or “pend.”  Refer to the MyHealthPAS Claim Submission and Claims Status User Guide.

 

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Can I see the edit for a denied claim using the portal?

Yes, the edits are located at the end of the claim status inquiry screen, under “Claim Edits.”  MIHMS claims edits are cross-walked to the HIPAA compliant codes found in the Common Adjustment Reason Codes and Remittance Advice Remark Codes (CARC & RARC) document under “Supplemental Billing Instructions.”

 

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What is Ambulatory Payment Classification/ Diagnosis Related Groups (APC/DRG)?

Ambulatory Payment Classification (APC) Groups are the Outpatient Prospective Payment System (OPPS) for hospital pricing of outpatient hospital services.  For more information about OPPS, go to the Hospital OPPS webpage on the CMS website.

Diagnosis-Related Groups (DRG) cover all items and services provided to the hospital inpatient except for professional services.  For more information about DRG, go to the Acute Inpatient Prospective Payment System webpage of the CMS website.

 

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How long will a claim remain in PEND status?

Ninety percent of claims will be paid within 30 days.  Ninety-nine percent will be paid within 90 days.  For more information, refer to the Claims Statuses throughout Claims Cycles document found in Supplemental Billing Information, under Billing Instructions on the portal.

 

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Why did my claim pay zero dollars ($0)?

There are several reasons why a claim will pay at zero.  Sometimes claims pay appropriately at zero and sometimes they pay inappropriately at zero.

The following are examples of a claim paying at zero inappropriately:

·          If a provider bills Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPC) codes that are not covered by MaineCare, the claim will pay inappropriately at zero.  Instead, the claim should have denied.

·          If a provider bills with a valid and active CPT or HCPC code that is not reimbursable by the provider’s type and specialty, the code will pay inappropriately at zero.  Instead, the claim should have denied.

 

The following are examples of a claim paying at zero appropriately:

·          Hospital outpatient claims that are reimbursed via Ambulatory Payment Classifications (APC) methodology have claim lines that pay zero appropriately due to bundling.

·          When billing MaineCare secondary after commercial insurance, MaineCare will pay at zero if the primary payment is greater than what MaineCare would have allowed.

·          MaineCare does not reimburse hospitals for coinsurance or deductibles when the member has only full MaineCare coverage.  The hospital claim will pay zero, and hospitals log this information as “bad debt” so they can collect a portion of this from the federal government at the end of the year.

 

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Electronic Funds Transfer

 

How do I sign up for Electronic Funds Transfer (also called Direct Deposit)?

The instructions and link to the form needed to sign up for Electronic Funds Transfer (EFT) are available on Provider Home Page, under Provider Documents.

If you have questions about EFT, contact the MaineCare Provider Services at 1-866-690-5585, option 1.

 

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Eligibility

 

How can I see the primary insurance for a member when checking eligibility using the portal?

You must first login as a Trading Partner to view the secure provider page.  Go to “Form Entry” under the left navigational pane.  Next, select “Eligibility Verification” and then “Eligibility Inquiry.”  Primary insurance is listed under the other insurance tab.  You may select the “Print Receipt” option at the bottom of the page for a printable version.  Refer to the MyHealthPAS Eligibility Verification User Guide.

 

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How can I see if a member has a classification when checking eligibility on the portal?

You must first login as a Trading Partner to view the secure provider page.  After you login as a Trading Partner, go to “Form Entry” under the left navigational pane.  Next, select “Eligibility Verification” and then “Eligibility Inquiry.”  The classification will display beneath the financial eligibility segment.  Refer to the MyHealthPAS Eligibility Verification User Guide.

 

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HIPAA Transactions

 

What are the types of HIPAA-compliant claims?

You can submit claims in several ways:

1.         Electronic ANSI ASC X12 837 files

There are three versions of the 837: the Institutional (comparable to the UB-04 paper claim), the Professional (comparable to the Centers for Medicare and Medicaid Services- CMS 1500 paper claim), and the Dental (comparable to the American Dental Association - ADA paper claim).  For more information, see the MyHealthPAS File Exchange User Guide.

 

2.         Direct Data Entry on the HealthPAS Online Portal.  See MHP User Guides for:

Professional

Institutional

Dental

 

3.         Paper Claims

Please refer to the MyHealthPAS User Guides for more information.

 

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Prior Authorization

 

How do I know if my Prior Authorization (PA) has been approved on the portal?

A service is not approved unless both the “Disposition” (under Authorization Details) and the “Services” line are in an “Approved” state.  Services under an “Approved” service line should not be provided prior to receiving a “Disposition” of “AP-Approved” or “AD-Approved with Denied Lines.”  Refer to the MyHealthPAS Prior Authorization User Guide.

 

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How do I change/update a Prior Authorization (PA)?

·          When mailing or faxing - The PA Supporting Document or Updates Cover Sheet is found on the Provider Home Page, under “Provider Forms” >”Authorizations and Referrals”.  Complete the form and attach it on top of the supporting documentation.  By mail: Prior Authorization Unit, Office of MaineCare Services, 11 State House Station, Augusta, ME  04330.  By fax: 1-866-598-3963.

·          When using Direct Data Entry (DDE)- Attachments can be added to existing authorizations previously submitted by following these steps:

Step 1:  Select the “Add Attachments” button at the bottom of the confirmation screen.  The Add Attachments screen will open in a new window.  Authorization information is pre-populated on the top of the page.

Step 2:  Click the drop down menu to select the type of attachment that will be added.  This defaults to PA Support.

Step 3: Select the “Browse” button to locate the file on your local computer.  The valid file formats are: GIF, JPEG, MS Excel (.xls), MS Word (.doc), PDF, and TIFF.

Step 4:  Click the “Attach” button when the selected file is listed in the “Browse” field.

 

Note: Be sure to check that the red message at the top indicates the documentation you attached has been accepted by the system.

For more information, see the MyHealthPAS Prior Authorization User Guide.

 

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Referral

 

How can I see if a referral has been processed on the portal?

The referral status is shown as “closed” when it has been processed.  For more information, see the MyHealthPAS Referral User Guide.

 

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Remittance Advice

 

How can I find my Remittance Advice (RA) on the portal?

You must have a Trading Partner Agreement to view the PDF RA on the portal.  It is found under “Reports” on the secure Trading Partner tab of the portal.  Refer to the MyHealthPAS File Exchange User Guide.

 

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Trading Partner

 

How does a billing agent associate all provider Pay-To National Provider Identifiers (NPIs)?

If you are a provider with several Pay-To NPIs, you will not enroll as a billing agent.  You will apply for a billing provider Trading Partner ID using one of your Pay-To NPIs.  Once that Trading Partner (TP) registration is approved, you will be able to add all of your other Pay-To NPIs to that TP registration.

If you are a billing agent, you will apply for a TP registration using the Tax ID, NPI or Atypical Provider Identifier (API) and the Enrollment Case Number (ECN) of one of your associated providers.  Once the TP registration is approved, you will be able to add all of your other providers to that TP registration.  The providers you bill for must supply you with their ECN as an indication that they authorize you to act on their behalf.

If you do not have the ECN, you will not be able to associate that provider to your account.  Contact the provider for their ECN.  If you are a new billing agent and do not have an ECN, you will not be able to initiate a TP agreement.

 

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When registering as a Trading Partner, what do you mean when you ask for a PIN?

A PIN is the Enrollment Case Number (ECN) assigned to the provider during your enrollment in MIHMS.  If you are a billing agent, you must obtain the PIN from the provider you represent.

 

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