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Medical Review TeamPresented by EDS Provider Field Consultants

2 / October 2007 Medical Review Team

Agenda

• Objectives• Medical Review Team Role• MRT Provider Enrollment• Initial Services• Requirement for Additional Services• Billing Procedures• Transportation Services• Web interChange Overview• Remittance Advice• Top Denial Reasons• Questions


Objectives

At the end of this session, providers will:

• Who the Medical Review Team is comprised of

• Know how to enroll in the MRT program

• Know the initial services and what is needed to bill additional services

• Understand the top denials and how to eliminate and resolve errors


Medical Review Team Role

• Medical Review Team (MRT) members consist of physicians and consultants

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

meet disability criteria

–Establish medical reviews for current Medicaid members

–Issue eligibility decisions based on medical evidence that supports whether the applicant has a significant impairment

–Perform assessment of applicants and submit determination forms to the Division of Family Resources (DFR)


Medical Review Team RoleMember Eligibility

• The DFR makes initial and continuing eligibility determinations

• The MRT determines whether 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


MRT Provider Enrollment

• Existing IHCP enrolled providers will need to complete an update provider enrollment form to add the MRT program

• Non-IHCP providers must complete a Provider Enrollment Application to enroll as an IHCP provider–Applications are available at www.indianamedicaid.com

–Non-IHCP providers must indicate MRT enrollment in the appropriate section of the enrollment application

• Mail completed applications to:EDS Provider Enrollment

P.O. Box 7263

Indianapolis, IN 46207-7263


Initial Exams and ServicesValid Codes

• 99080 – Reports

• 99450 – Initial Exam

• 90801 SE – Mental Status Exam

• S9981 – Medical Records

• IHCP provider bulletin BT200620 lists additional covered MRT procedure codes and their respective rates


Authorizations For Additional Services

• The MRT must authorize all additional exams or tests

• When additional exams or tests are required, the MRT directs the member to obtain those services

• The MRT provides the member with an Additional Information Request form to authorize additional services


Billing Procedures

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

• Submit electronic MRT claims using the electronic 837P transaction , Web interChange or the CMS-1500 claim form–See IHCP provider bulletin BT200703 for claim form

completion instructions

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

• Mail paper claims to:EDS CMS-1500 Claims

P.O. Box 7269



Billing Procedures Cont.

• MRT claims must use a unique member’s 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 member the MRT ID

number will still remain 850 plus the Social Security number

–Do not use the members Medicaid ID for MRT claims



• MRT claims cannot be submitted for payment with a claim for Medicaid or any other IHCP program

• Providers may bill for partial units

• MRT claims must be submitted with a unique member identification number that begins with ‘850’ and the social security number



• 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 applicant is not responsible for any charges for a MRT claim if the services are requested by the MRT or the caseworker–MRT claims are paid even when the

disability application is denied


Transportation Services

• Transportation services for applicants and members are reimbursable in cases of financial hardship when:–No other transportation is available for medically necessary

exams or tests

• A trip is defined as: the act of transporting a member from the initial point of pick-up to the drop-off point at the final destination

• The provider must contact the MRT to obtain approval prior to rendering the service

• Transportation providers are expected to use the shortest and most efficient route to and from the destination


Transportation Services

• The following codes are authorized for MRT transportation services:–T2003 SE – Non-emergency

transportation, encounter, trip

• Reimbursement is $10.00 each way, irrespective of vehicle type

–T2007 SE – Transportation waiting time, air ambulance and non-emergency vehicles, ½ hour increments

• Reimbursement is $4.50 per unit

–A0425 SE – Ground mileage, per statute mile

• Reimbursement is $1.25 per mile


Web interChangeOverview

• Web interChange is a free Web application that allows providers to submit MRT claims, review claims already submitted, and verify eligibility status of the member

• Web interChange is HIPAA-compliant. Member and claim information is protected by Encryption and secure socket layer (SSL) technology


Web interChangeFeatures

• Claim Inquiry – Allows providers to view claims previously submitted –Claims are accessible within two hours of submission

– Providers may search for claims based on the date of service, claim type, member ID, or internal control number (ICN)

• Claim Submission – Allows providers to submit claims electronically to the IHCP

Note: MRT claims are a professional claim type


Web interChangeFeatures

• Check Inquiry – Allows providers to inquire about previously-received payments. Payment inquiries are made based on the check or electronic funds transfer (EFT) number or date range. Providers may click on the displayed check or EFT number to identify the claims paid on that specific check or EFT

• Void – A void is a deletion of a paid claim

• Replacement – A replacement is claim adjustment. The replace this claim function may be used to correct an incorrect payment


Web interChangeHow to Enroll

• To use Web interChange, providers must designate at least one person to be the Web Administrator. The Web Administrator must complete the Administrator Request Form available at https://interchange.indianamedicaid.com and mail it to the address shown on the form

• Direct questions about accessing Web interChange to the EDS Electronic Solutions Helpdesk at (317)488-5160 in the Indianapolis area or 1-877-877-5182, or by e-mail at [email protected]

https://interchange.indianamedicaid.com/

mailto:[email protected]


Remittance Advice

• Providers receive a remittance advice (RA) each week if IndianaAIM has claims in the processing system. The IHCP mails paper RAs to providers each Tuesday. The RA contains the status of each processed claim

• The electronic 835 transaction lists paid and denied claims

• Paper RAs list paid claims, denied claims, claims in process, and adjusted claims

• The paper RA also includes claim correction forms (CCFs)

See Chapter 12 of the IHCP Provider Manual for more information about RAs


Top MRT Denial Reasons

• 2037- Member not on file for NON IHCP program

• 1004 – Rendering provider not eligible to render services on this date of service

• 4021 – Procedure code vs. program indicator

• 513 – Recipient name and number disagree

• 1001 – Billing provider not enrolled at the service location for the program billed


Helpful ToolsAvenues of Resolution

• IHCP Web site at www.indianamedicaid.com

• IHCP Provider Manual (Web, CD-ROM, or paper)

• Customer Assistance–1-800-577-1278, or

–317-655-3240 in the Indianapolis local area

• Written Correspondence–P.O. Box 7263


• Provider Relations Field Consultant

http://www.indianamedicaid.com/


Questions

Presentation by EDS Provider Field ConsultantsEDS950 N. Meridian St., Suite 1150Indianapolis, IN 46204

EDS and the EDS logo are registered trademarks of Electronic Data Systems Corporation. EDS is an equal opportunity employer and values the diversity of its people. © 2005 Electronic Data Systems Corporation. All rights reserved.

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