Welcome Nursing Facilities

1. Welcome Nursing Facilities Department of Human Services June 2009

2. Goal To provide you with the tools and resources that are necessary to access and perform many of the features and functions that you need to submit your claims for payment processing.

3. Objectives After completing today’s session, you will: • Have a basic understanding of the replacement MMIS and how it impacts Nursing Facility providers. • Be able to submit Institutional (UB-04) claims on paper, through the provider Web portal, or by submitting through Electronic Data Interchange (EDI). • Be able to perform basic Web portal functions. • Be able to perform claim searches and adjustments by using the Web portal.

4. DHS at a glance

5. DHS structure DHS DirectorBruce Goldberg, MD Addictions and Mental Health (AMH) Administrative Services Division (ASD) Children, Adult and Families Division (CAF) Seniors and People with Disabilities (SPD) Division of Medical Assistance Programs (DMAP) Public Health Division (PHD)

6. Department of Human Services • The Department of Human Services (DHS) mission: • To make it possible for people to lead lives that are independent, healthy and safe. • DHS provides: • Services to more than 1 million Oregonians every year. • More than 300 programs and different services through 170 field offices located throughout the state. • Approximately 85% of our biennial budget flows directly to clients and communities as payments to: • Foster parents • Nursing homes • Healthcare providers and clinics • Local governments, and • Other service providers

7. Seniors and People with Disabilities • SPD provides services to seniors and people with disabilities, including physical and developmental disabilities. • Services are determined by an individual’s financial circumstances and/or personal daily needs. • SPD determines eligibility for state and federal programs.

8. Division of Medical Assistance Programs • Administers state programs that provide medical coverage to low-income Oregonians. • Processes health care claims according to the policies of the State of Oregon’s Medicaid programs. • Issues payment to enrolled Medicaid providers.

9. DMAP programs • DHS Programs administered by DMAP: • Medicaid (OHP) • Children’s Health Insurance Program (CHIP) • Breast and Cervical Cancer Program (BCCP) • Senior Prescription Drug Assistance Program (SPDA) • Disease Case Management Program (DCM)

10. Medicaid Management Information System (MMIS)

11. Medicaid Management Information System • Previous MMIS: • Implemented in 1980. • Designed to handle paper claims and track eligibility. • It was decided that a replacement MMIS was needed due to outdated technology. • It was unable to meet the demands of federal, state and local legislation. • Replacement MMIS: • Implemented in 2008/2009. • Provides real-time client eligibility. • Allows for faster claims processing. • Self-service access via the Internet.

12. MMIS • The replacement MMIS, has a secure Web portal feature that will allow DHS authorized providers access to perform various internet-based self-service functions, such as: • Verify and view current client eligibility. • Submit, track and view claims online. • Submit, track and view prior authorization requests. • Perform Health Services Commission (HSC) prioritized list inquiries.

13. Provider Web portal • The Provider Web portal is free of charge and designed to be accessible 24 hours a day, 7 days a week. • Access to the Web portal requires: • An Internet connection. • Microsoft Internet Explorer 6 or 7, or Firefox 2.0. • Authorization from DHS to access Web portal services. • Your Provider ID and the Personal Identification Number (PIN) issued by DHS.

14. ID and PIN • To access the Provider Web portal for the first time, providers must login using their DHS provider ID and a Personal Identification Number (PIN) sent by DHS. • After the account has been set up, providers will login using their own usernames and passwords; you will no longer need the PIN letter. • If you have not received your PIN or you need to have your PIN reset, contact: DMAP Provider Services 800-336-6016 DMAP.providerservices@state.or.us Team.Provider-ACCESS@state.or.us Monday - Friday, 8:00 a.m. to 5:00 p.m.

15. Eligibility verification

16. Verification of eligibility Providers are responsible to verify eligibility prior to providing services in order to ensure reimbursement of services. Providers are responsible to verify that a person is enrolled in a benefit package that covers the services rendered. Providers assume full financial responsibility in serving a person whose eligibility was not confirmed on the date(s) of service.

17. Resources Two options are available to verify medical eligibility: • Automated Voice Response (AVR): Provides free, phone-based eligibility verification. • MMIS Provider Web portal: Provides free, real-time eligibility verification over the Web.

18. Automated Voice Response (AVR)

19. What is AVR? • The AVR is a computer system that gives: • Client eligibility. • Status of a claim. • Status of a prior authorization. • Recent payment or suspended claim information. • Benefit limits for eye exams and optical services. • Allows providers to complete automated inquiries using a touch-tone telephone. • AVR is available 24 hours a day, 7 days a week.

20. What does AVR provide? • The AVR can tell you the following information: • The client’s Medicaid identification number. • The client’s date of birth. • If a client is eligible on a specific date of service. • Which benefit plan the client is eligible for. • The client’s copayment requirement. • If the service is covered in the client’s benefit plan. • If the client is enrolled in a managed care plan. • If the client has other insurance coverage. • The date of the client’s last vision exam and glasses.

21. Personal Identification Number • To access AVR, providers must use the personal identification number (PIN) sent by DHS. • If you have not received your PIN from DHS or you need to have your PIN reset, contact: DMAP Provider Services 800-336-6016 DMAP.providerservices@state.or.us Team.Provider-ACCESS@state.or.us Monday - Friday, 8:00 a.m. to 5:00 p.m.

23. Web portal eligibility verification

24. Getting started • In the address field of your Internet browser, type https://www.or-medicaid.gov. • The session “times out” after 20 minutes of inactivity. • Any work or changes that have not been submitted will be lost. • If your session expires, you will receive a message.

25. Accessing the Web portal Click here to access the Web portal.

26. Web Portal login • Select “Account”. • Select “Secure Site”. • Enter your “User Name” and “Password”. • Select “Login”.

27. Home page Select “Eligibility” Provider ID: ###### MCD Taxonomy: ########## Zip Code: ##### - #### This is the DHS provider that corresponds with the user name entered on the previous screen.

28. Eligibility verification request • To search for client eligibility use one of three combinations: 1. Client ID and dates of service; 2. Client SSN, birth date and dates of service; 3. Client name, birth date and dates of service. • The Procedure Code field is used to identify service limitations for a specific procedure.

29. Eligibility verification request • Enter one of the 3 combinations as indicated on the previous page and click search. • You can view 13 months of historical eligibility up to today’s date. • The Provider Web portal will not give future eligibility information. All end dates listed in your search results are either the date the client’s coverage ended or the “To DOS” you listed in your request. XX#####X 12/01/2008 12/31/2008

30. Eligibility search results; displays 6 sections XX#####X######### Doe Jane • Client information. • Benefit Plan (formerly benefit package). • TPL (third party liability). • Managed Care. • Lockin. • Service Limitations.

31. Client information section XX#####X ######### Doe Jane • The client information section displays basic information about the client. • ID • SSN • Last dental visit • Branch ID and phone number • Name of client • Medicare Parts A, B or D effective dates

32. Benefit plan section • The client benefit plan section gives information about the client’s benefit plan (formerly benefit package). • The following codes indicate DHS benefit plans. Disregard all other codes; they are for internal use only. Should have all 3 plans NFC - Nursing Home NFG - Nursing Facility Developmental Disability Specialized Services NFS - Nursing Home Short Term BMH - OHP Plus KIT - OHP Standard MED - Qualified Medicare Beneficiary BMM - QMB + OHP with Limited Drug CWM - Citizen/Alien-Waived Emergency Medical (CAWEM) CWX - CAWEM Plus SMHS – Title 19 State Plan Mental Health Services

33. Third party liability (TPL) section Carrier Name Policy Number Policy Holder Coverage Type Effective Date End Date Blue Cross # # # # # # # # Doe, John Major Medical 08/01/2000 11/30/2008 Prime Dental Health # # # # # # Doe, John Dental 08/01/2000 11/30/2008 • Displays specific information about the client’s third-party resources (other insurance).

34. Managed Care section • The Managed Care section displays information about which managed care plan or primary care manager the client is enrolled in. • Plan types are: FCHP - Fully Capitated Health Plan DCO - Dental Care Organization MHO - Mental Health Organization PCO - Physician Care Organization PCM - Primary Care Manager CDO - Chemical Dependency Organization

35. Lockin section Lockin Plan Effective Date End Date Provider Provider Name Provider Phone Pharmacy 08/01/2000 10/31/2007 # # # # # # # # # # NPI My Pharmacy (503) # # # - # # # # # • If the client is required to use a specific pharmacy through the Pharmacy Management Program (PMP), that information will be listed in this section.

36. Service limitation section Service Limitation has been found for Procedure Code 92002, next possible date of service is 12/01/2008 • This section shows the next available date for a specific service that has limitations according to Oregon Administrative Rules. • This would not apply to Nursing Facilities.

37. Open card example • 1. This example shows a “From/To DOS” date range. • 2. Indicates that the client has Medicare Parts A and B coverage. • 3. Indicates the client is in the BMM (Qualified Medicare Beneficiary and OHP with Limited Drug) and NFC (Nursing Home) benefit plans. Ignore SMHS. • “No rows found” indicates the client is not enrolled in a managed care plan during the “From/To DOS” listed in this request. XX#####X XX#####X Doe Jane

38. Managed care example • 1. This example shows a “From/To DOS” date range. • 2. Indicates that the client does not have Medicare coverage. • 3. Indicates the client is in the BMH (OHP Plus) and NFC (Nursing Home) benefit plans. Ignore SMHS. • Indicates the client is enrolled with FCHP, MHO and DCO managed care plans. XX#####X XX#####X Doe Jane

39. Client not eligible example • This example shows a specific “from/to DOS” date range. • Indicates that the client is not eligible for the requested date range.

40. Plan of Care

41. Plan of Care Select “POC” • The POC search screen allows you to look up an approved and active Plan of Care. • There are four ways to search for a Plan of Care. • Enter the From/To date of service and Client ID. • Enter the Client ID only. • Enter the From/To dates of services. • Leave all fields blank. XX#####X

42. POC results • The POC search results returns all active POCs based on the criteria that was entered at the Search screen. • To review the details of the POC, click on the line and the detail information will appear.

43. Detail information • POC information includes: • Service code • Effective dates • Client liability • Used units Revenue Code 100 All inclusive/room and board SPD Resident Stay ######### Nursing Facility XX#####X Jane Doe System price 01/01/2008 04/15/2008 106 $0.00 0 $0.00

44. Claims processing

45. MMIS • The federal government requires DHS to process Medicaid claims through the automated claim processing system which is MMIS. • This system is a combination of people and computers working together to process claims. • This system performs daily edits for presence and validity of data. • DHS staff only reviews claims that MMIS cannot make a payment decision based on the information submitted on the claim and other system related data (i.e.; eligibility).

46. Claims submission • No matter how the claim was submitted (paper, electronically, or through the Web portal), providers will have the capability of viewing the claim. • If billing through the Web portal, the claim will process real-time so you will know the status of the claim as soon as you submit it. • If billing EDI, it is near to real time, in that within 20 minutes or so of MMIS receiving the claims transaction, the status of the claim is available. • Providers can: • View submitted claims for status and accuracy. • Submit new claims. • Correct and resubmit denied claims. • Adjust, void or copy paid claims.

47. Claim processing times • 80% of the department’s claim volume is electronic. • Electronic claims process in real-time and usually adjudicate the week in which they are submitted. • Paper claims may take up to three weeks for processing. • DMAP pays providers on a weekly Friday cycle. • Electronic fund transfers are processed on Wednesdays in the week following the Friday claims cycle. • Less than two percent of claims suspend. Once they suspend, DMAP works them within 14 days.

48. Claims Processing • Paper claims submitted by mail go to the DHS Office of Document Management (ODM) Imaging Unit. • ODM processes hardcopy claims using Optical Character Recognition (OCR) scanning. • Make sure your claim form meets OCR specifications. • Effective August 1, 2009, only red forms will be acceptable. • A Remittance Advice (RA) listing all claims adjudicated is mailed to the provider (with payment if appropriate).

49. Prior to submitting a paper claim • Verify eligibility to assure the client is eligible on the date of service for the services provided. • Bill third-party resources first. • Check the provider number to verify the claim will be submitted for the correct provider.

50. A few tips! • When submitting handwritten claim forms, you must use blue or black ink, never use red ink. • Make sure your hand writing is legible and clearly indicates zero’s (0) versus O’s, five’s (5) versus S’s, and eight’s (8) versus B’s. • If possible, submit no more than twenty-two lines of services per claim form. • Do not use liquid whiteout. • Check your printer alignment.