Billing Codes

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

·          Where can I find a list of bundled codes?

·          Where do I find the correct modifiers used with certain Current Procedural Terminology (CPT) codes?

Claims

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

·          Can I bill multiple days for a service on the same claim line?

·          Who is considered a billing provider?

·          Can the billing provider address be a PO Box or lock box?

·          Is there a cancel button to immediately stop a claim that was 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) after I have adjudicated a claim using Direct Data Entry (DDE)?

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

·          Can I reverse a denied claim? If not, why does it seem to work?

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

·          How long will a claim remain in PEND Status?

·          How do I request I reverse or adjust an electronic claim?

·          How do I reverse a paper claim? Can I adjust the paper claim?

·          When the edit states UM is required, what does that mean?

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

Electronic Funds Transfer

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

Eligibility

·          How far back does the Health PAS Online Portal display a member’s eligibility information?

·          Why can’t I use the Health PAS Online Portal to see if the member is on a spenddown using the Health PAS Online Portal?

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

·          When I verify coverage using the Health PAS Online and see “State only PA”, how do I access the Prior Authorization (PA)?

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

Enrollment

·          How do I term or affiliate a rendering provider from our group?

Pathways Prior Authorizations (PA)

·          I need to request a Pathways Prior Authorization (PA) for a service that must be performed right away. Is there a special process I must follow?

·          How do I change the servicing provider when entering a Pathways Prior Authorization (PA) request on the Health PAS Online Portal?

·          How can I fix a Pathways Prior Authorization (PA) if done incorrectly on the Health PAS Online Portal?

·          How do I select the group for a Computed Tomography (CT) or Positron Emission Tomography (PET) scan instead of entering just the Current Procedural Terminology (CPT) code?

·          Why do I need to fax a PA request form if I enter it online and it was auto-approved?

HIPAA Transactions

·          What are the types of HIPAA-compliant claims?

Prior Authorization

·          I need to request a Prior Authorization (PA) for a service that must be performed right away. Is there a special process I must follow?

·          How can I fix a Prior Authorization (PA) if done incorrectly on the Health PAS Online Portal?

·          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?

·          How do I add new users to our Trading Partner Account?

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 CMS NCCI Edits webpage.

Where can I find a list of bundled codes?

MaineCare does not post lists of bundled codes. Bundled codes are based on National Correct Coding Initiative (NCCI) rules which are developed by the Centers for Medicare and Medicaid Services (CMS). This initiative was developed to promote correct coding methodologies and accurate payment. For further information on NCCI edits, you can refer to the CMS NCCI Edits webpage.

Where do I find the correct modifiers used with certain Current Procedural Terminology (CPT) codes?

MaineCare does not post a list of modifiers used with CPT codes. Providers can reference CPT code books for a list of modifiers that may be acceptable to be used with certain codes. The best option is to work with certified coders who can assist with determining which modifiers are used on MaineCare claims.

Claims

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

A Place of Service (POS) is a required field on 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.

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.

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 than the physical address.

Is there a cancel button to immediately stop a claim that was 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.

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.

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.

Can I see the Edit for the denied claim on 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.”

What is the 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.

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.

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.

Can I reverse a denied claim? If not, why does it seem to work?

Currently, the Health PAS Online Portal does not have a mechanism in place to prevent a user from reversing a denied claim. Only paid claims should be reversed because denied claims that are reversed are likely to continue denying when re-submitted.

How do I request I reverse or adjust an electronic claim?

Instructions for reversing or adjusting an electronic claim can be found in the Billing Instructions folder. Select The guide for the type of claim being adjusted or reversed. If you think an error was made when the claim was processed, please contact MaineCare Provider Services at 1-866-690-5585 for assistance.

How do I reverse a paper claim? Can I adjust a paper claim?

Instructions for reversing a paper claim are available in the Billing Instructions folder. Select the instructions for the type of claim you are submitting because the process is based on the claim type. You cannot adjust a paper claim.

When the edit states UM is required, what does that mean?

UM stands for Utilization Management. This indicates that a prior authorization is required for the service you are billing.

Electronic Funds Transfer

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

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.

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.

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. 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 below the financial eligibility segment. Refer to the MyHealthPAS Eligibility Verification User Guide.

How far back does the Health PAS Online Portal display a member’s eligibility information?

With a recent system upgrade, you can look back two years at a member’s eligibility information.

Why can’t I use the Health PAS Online Portal to see if the member is on a spenddown using the Health PAS Online Portal?

Spenddowns are not visible on the eligibility screens of the portal due to the complexity of reporting it correctly. There are many variable involved in calculating spenddowns that are based on income, and the claims applied to the deductible change quickly. MaineCare is unable to accurately display spenddown amounts in real time on the portal.

When I verify coverage using the Health PAS Online and see “State only PA,” how do I access the Prior Authorization (PA)?

State Only PA coverage requires that the member contact a case manager at DHHS and gain authorization for treatment prior to the service being rendered. If approved, DHHS will outreach the provider with the prior authorization number.

Enrollment

How do I term or affiliate a rendering provider from our group?

Instructions on how to perform these enrollment functions can be found in the Enrollment Guides folder.

Pathways Prior Authorizations (PA)

I need to request a Pathways Prior Authorization (PA) for a service that must be performed right away. Is there a special process I must follow?

Life or death situations can be marked as “urgent.” A Pathways Radiology PA can be marked as urgent when the service will be performed within 24 hours. If the member cannot wait the 24 hour period, they can be seen at the emergency department. Otherwise, please submit the PA using the normal process and ensure it is marked as “urgent.”

How do I change the servicing provider when entering a Pathways Prior Authorization (PA) request on the Health PAS Online Portal?

Instructions on how to request a Pathways PA can be found in the MyHealth PAS User Guides under the Pathways PA Request Guide.

How can I fix a Pathways Prior Authorization (PA) if done incorrectly on the Health PAS Online Portal?

A correction to a Pathways Radiology PA can be requested by submitting a new Pathways PA Request Form. A correction to all other PAs can be requested by submitting a “Prior Authorization Supporting Documents or Updates Cover Sheet.” Both forms are available in the Authorization and Referrals folder.

How do I select the group for a Computed Tomography (CT) or Positron Emission Tomography (PET) scan instead of entering just the Current Procedural Terminology (CPT) code?

If you need guidance on how to select the group for a CT or PET scan, please see the instructions on how to request a Pathways PA in the MyHealth PAS User Guides under the Pathways PA Request Guide.

Why do I need to fax a PA request form if I enter it online and was auto-approved?

Providers must always provide supporting documentation. This supporting documentation can either be uploaded electronically or faxed in with a “Prior Authorization Supporting Documents or Updates Cover Sheet”. This is described in the PA User Guide in the MyHealth PAS User Guides.

HIPAA Transactions

What are the types of HIPPA-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.

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.

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.

I need to request a Prior Authorization (PA) for a service that must be performed right away. Is there a special process I must follow?

Emergency services do not require PA. All other requests must be submitted using the appropriate process. All PAs marked as “urgent” will be processed following MaineCare guidelines.

How can I fix a Prior Authorization (PA) if done incorrectly on the Health PAS online Portal?

A correction to most PAs can be requested by submitting a “Prior Authorization Supporting Documents or Updates Cover Sheet.” A correction to a Pathways Radiology PA can be requested by submitting a new Pathways PA Request Form. Both forms are available in the Authorization and Referrals folder.

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 but this does not mean the request has been approved. For more information, see the MyHealthPAS Referral User Guide.

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.

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.

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 you during your enrollment in MIHMS. If you are a billing agent, you must obtain the PIN from the provider you represent.

How do I add new users to our Trading Partner Account?

New users can be added to a Trading Partner Account by anyone who has administrator permissions. The administrator signs into his/her account and selects the “Manage Users” link under “Account Maintenance.” From this link, the administrator can enter the new user’s identifying information and send him or her a user invitation email with information about creating a user name and password. Additional assistance can be obtained by calling EDI Helpdesk at 1-866-690-5585 option 3.

Additional information for Trading Partner maintenance can be found in the Trading Partner Guides.