HP Provider Relations

October 2011

Medical Review Team

Medical Review Team October 20112

Agenda

– Objectives

– Role of the Medical Review Team

– MRT Process

– Initial Exams and Services

– Authorizations for Additional Services

– Billing Procedures

– Helpful Checklist

– Top MRT Claim Denial Reasons

– Helpful Tools

– Questions

Medical Review Team October 20113

Session Objectives

At the end of this session, providers will know :

– The composition of the Medical Review Team

– How the MRT process works

– The initial services and what is needed to bill additional services

– How to eliminate and resolve claim errors

Understand Medical Review Team Role and Process

Medical Review Team October 20115

Role of the Medical Review Team

– Medical Review Team (MRT) staff members consist of physicians, registered nurses (RNs), certified medical assistants (CMAs) and consultants

– The MRT determines Medicaid eligibility by completing the following functions:• Reviewing clinician information to determine

whether applicants meet disability criteria

• Issuing eligibility decisions based on medical evidence that supports documentation stating the applicant has a significant impairment

• Submitting determination forms to the Division of Family Resources (DFR)

Medical Review Team October 20116

Role of the Medical Review Team

– The DFR makes initial and continuing eligibility determinations

– The MRT determines if applicants have a significant impairment• A significant impairment has an expected

duration of a minimum of 12 months without significant improvement

• The condition must substantially impair the applicant’s ability to perform labor or services, or to engage in a useful occupation

Medical Review Team October 20117

MRT Process

– All Medicaid applicants apply at the Division of Family Resources (DFR), or through the Service Center for all Medicaid programs at 1-800-403-0864

– The DFR will set up a telephone interview with the applicant to obtain information from the applicant• Social economic

• Medical information

– A letter will be sent to the applicant and the provider requesting medical records and/or an examination from the provider

– The provider will send the medical records to the address listed on the Determination of Disability, Medical Information form

Medical Review Team October 20118

MRT Process

– The applicant’s information is transferred from the DFR to a team of professionals at the Office of Medicaid Policy and Planning (OMPP)

– The information is transferred to an electronic format to be reviewed for quality

– Each employee at the OMPP is assigned a region and will process all electronic MRT applications for his or her assigned region• All standards for state and federal law must be met

– A determination will be made based on demographics, such as age, education, work history, and medical background

Medical Review Team October 20119

MRT Process

– If information is for medical disability, the file will go to the physician on staff at the state; if it is a mental health disability, it will go to the psychiatrist at the state

– At this time, the staff at the OMPP will deny, approve, or ask for additional information from the applicant by a written request sent to the applicant

– Eligibility information comes directly from the DFR to HP• This step eliminates an extra step and minimizes delays in transferring

information from the DFR to HP

– Once the information is downloaded to IndianaAIM (Indiana’s Medicaid payment processing system), an MRT eligibility segment is created

– The provider can now bill the claim

LearnInitial Exams, Services, and Authorizations

Medical Review Team October 201111

Initial Exams and ServicesValid codes

– Most commonly submitted codes:• 99080 – Reports

• 99450 – Initial Exam

• 90801 SE – Mental Status Exam

• S9981 – Medical Records

– IHCP Provider Manual lists additional covered MRT procedure codes and their respective rates

CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Medical Review Team October 201112

Authorizations for Additional Services

– The MRT must authorize all additional exams or tests

– When additional exams or tests are required, the MRT directs the applicant to obtain those services

– The MRT provides the applicants with an Additional Information Request form to authorize additional services

BillMRT Claims

Medical Review Team October 201114

Billing Procedures

– MRT claims follow the same billing procedures as IHCP claims with a few exceptions

– Submit electronic MRT claims using the Health Insurance Portability and Accountability Act (HIPAA) 837P transaction or Web interChange

– Providers may also use the paper CMS-1500 claim form

– File all claims within one year from the date of service

– Mail paper claims to:

HP CMS-1500 CLAIMSPO Box 7269Indianapolis IN 46207-7269

Medical Review Team October 201115

Billing Procedures

– Claims may be submitted with the letter from the DFR that authorizes services• Submission of the DFR letter is optional

– MRT claims must use a unique applicant ID that consists of 850 plus the applicant’s Social Security number 850 999 99 9999 (850 + Social Security number)• If the resident is a Medicaid applicant, the MRT ID number will remain 850

plus the Social Security number

• Do not use the applicant’s Medicaid ID for MRT claims

Medical Review Team October 201116

Billing Procedures

– MRT services cannot be submitted on the same claim with services for Medicaid or any other IHCP program

– MRT claims are subject to all audits and edits not excluded by MRT program requirements

– Financial information is available in the electronic 835 RA transaction

– The Remittance Advice is available on Web interChange

– The applicant is not responsible for any charges for an MRT claim if the services are requested by the MRT or the caseworker• MRT claims are eligible for payment even when the disability application is denied

CheckHelpful Checklist

Medical Review Team October 201118

Helpful Checklist

– Applicants do not have to be enrolled Medicaid applicants to participate in the MRT program

– All applicant IDs must begin with “850,” followed by the applicant’s Social Security number

– All providers must be enrolled in Indiana Medicaid as well as the MRT program to submit MRT claims

– Only approved Healthcare Common Procedure Coding System (HCPCS) codes and modifiers will be accepted on claims

Note – If the MRT code contains a modifier, the modifier MUST be submitted on the claim to avoid claim denial.

Medical Review Team October 201119

Helpful Checklist

– The maximum fee, procedure code, and all modifiers must be billed on the claim

– MRT services cannot be combined with a claim for any other Medicaid services

– Claims that encounter an edit or an audit for any missing or invalid information will deny

– Claims will suspend if there is a valid attachment accompanied with the claim for any applicant that does not have an eligibility segment on file

DenyTop MRT Denial Reasons

Medical Review Team October 201121

Top MRT Denial Reasons

Edit 2037 – Member not on file for non-IHCP program

– Cause

• Applicant does not have an MRT eligibility segment in the payer processing system

– Resolution

• Ensure the date of service is within the time parameter as indicated in the request letter from the county; allow 30 days from the application date for eligibility segment to be updated

• Verify that the applicant’s ID begins with “850,” followed by the applicant’s valid Social Security number

Medical Review Team October 201122

Top MRT Denial Reasons

Edit 2029 – Non-IHCP member ineligible for dates of service

– Cause

• The date of service is not within the MRT eligibility segment dates

– Resolution

• Verify the MRT number submitted on the claim

• Verify the dates of service submitted on the claim are in line with the dates of service on the request letter from the county

• Verify the dates on Medical Records charges are the actual date that Medical Records were copied

Find HelpResources Available

Medical Review Team October 201124

Helpful ToolsAvenues of resolution

– IHCP website at indianamedicaid.com

– IHCP Provider Manual (Web, CD, or paper)

– Customer Assistance• 1-800-577-1278

• (317) 655-3240 in the Indianapolis local area

– Written Correspondence

• P.O. Box 7263

Indianapolis, IN 46207-7263

– Provider field consultant

• View a current territory map and contact information online at indianamedicaid.com

Q&A