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Star Date 2010. Captain’s LogStar Date 2010. Captain’s Log

• Short – Doyle Medi-Cal Phase 2Short – Doyle Medi-Cal Phase 2– We have entered the new realmWe have entered the new realm

•What did not comply with Federal HIPPA What did not comply with Federal HIPPA StandardsStandards– DMC Billing then Phase 1DMC Billing then Phase 1

•Collaborative Effort betweenCollaborative Effort between– ADP - DMH - DHCSADP - DMH - DHCS

System OverviewSystem Overview

•File SubmissionFile Submission

• ITWSITWS

•DHCS SD/MC Phase 2DHCS SD/MC Phase 2

•ADP’s roleADP’s role

•State Controllers OfficeState Controllers Office

•837P / 997 / 835837P / 997 / 835

Claim Submission and AdjudicationClaim Submission and Adjudication

Claim Submission and Adjudication Process

DH

CS

SD

MC

AD

PC

ou

nty

or

Dir

ect

Pro

vid

er

START1. Prepare claim

file and documentation

2a. Submit zip-compressed claim

file (837P)

via ITWS

3. Perform HIPAA validations and

produce 997

2b. Submit Claim Submission Certification

To Claims Payment

via ITWS

8. Generate 835 for denied claims, 277U for approved

claims

Receive status via 997, 277U, and/or

835

4. Identify claims requiring additional

review

2c/d. Submit documentation for delay reasons and manual overrides

5. Verify documentation

supporting overrides and/or

delay

6. Release claims for processing

7. Adjudicate claims

9. Report status of adjudicated claims

to ADP

10. Receive status of adjudicated

claims

Submit claim file and documentation

To Claims Payment

Claim PaymentClaim Payment

Claim Payment Process

DH

CS

SD

MC

SC

OC

ount

y or

D

irect

Pro

vide

rA

DP From Claim

Submission, Step 11

1. Process claims for payments and

recoveries

2. Record non-payable approved

claims on suspense

3. Generate payment requests for payable claims

5. Process payment and

recovery requests

6. Transmit payment schedule

to State Controller’s Office

7. Generate warrants for scheduled payments

8. Deliver warrants to payees

Receive payments END

9. Transmit payment

information to ADP

11. Generate 835s

Receive 835s

10. Deliver payment,

recovery, deferral information to

DHCS

4.Generate recovery request

for claims requiring recovery

From Claims Submission,

Step 2b

SDMC Phase 2 Claims Payment SDMC Phase 2 Claims Payment ProcessProcess

SM

AR

T

DHCS

StateController

sOffice

ITW

S

AD

P T

rad

ing

Part

ners 837

Warrants

835

997

276277

SD

/MC

P2 S

yste

m

ClaimPayment

File

ClaimSummary

File

ADP

Claims File SubmissionClaims File Submission

• Claims are submitted by ADP Trading Partners Claims are submitted by ADP Trading Partners via ITWSvia ITWS

• ITWS tracks and validates file submissionsITWS tracks and validates file submissions– Ensures zip and file name are the same Ensures zip and file name are the same – Ensures that no duplicate file names have been usedEnsures that no duplicate file names have been used

ITW

S

ADP Trading Partner

s

837

Initial DHCS ProcessingInitial DHCS Processing

• ITWS sends the 837 file to DHCS for processingITWS sends the 837 file to DHCS for processing• DHCS performs SNIP validation on the file using DHCS performs SNIP validation on the file using

Edifecs softwareEdifecs software• Once validation is complete a 997 Once validation is complete a 997

acknowledgement is returned to ITWSacknowledgement is returned to ITWS– In some circumstances a 997 is not returned In some circumstances a 997 is not returned

• The 997 indicates if the file was accepted or The 997 indicates if the file was accepted or rejected by DHCSrejected by DHCS

ITW

S

837 DHCS

997 SD/MC P2

DHCS AdjudicationDHCS Adjudication

• Once validation is complete, accepted claims files are adjudicated• All applicable business rules are applied• Eligibility is verified at the beneficiary level via a MEDS interface• Based on the collective results of all business rules, claims are

approved or denied for payment• The amount of payment is calculated for all approved claims• All available reasons for denial are identified • Denied claims are sent for immediate 835 processing• Approved claims are sent to ADP’s SMART system for processing

of payment

ClaimsAdjudication

ADP SMART

System

DHCS

De

nia

ls

Accounting and SCO Accounting and SCO InterfaceInterface

• ADP processes approved claims for payment by SCO• Appropriate approvals are secured• Warrant requests are forwarded to SCO for payment• Warrants are paid to counties and direct providers• Warrant information is returned to ADP

ADP Trading Partner

s

ADP State

ControllersOffice

Warrants

The Payment PieceThe Payment Piece

• ADP’s SMART sends warrant information to DHCS• DHCS 835 processes all available claim

information at the time the process runs– This may include both approved and denied

claims on the same file• 835 transaction file is sent to ITWS for posting

ClaimsAdjudication

ADP SMART System

DHCS

De

nia

ls

835Processing

AD

P T

rad

ing

P

art

ner

s

835IT

WS

ITWS

ADP SMARTSystem

Approvals

837P at DHCS

DENIALS

SCO

Why doesn’t my 835 match my 837?Why doesn’t my 835 match my 837?

837P

835

835

835

TRADING PARTNER

What happened to my What happened to my claim??claim??

What does an EDI file look What does an EDI file look likelike

Can you read an 837P?Can you read an 837P?ISA*00* *00* *30*956000927 ISA*00* *00* *30*956000927 *ZZ*SDMCPHASETWOADP*100114*0928*U*00401*000001401*0*T*:*ZZ*SDMCPHASETWOADP*100114*0928*U*00401*000001401*0*T*:GS*HC*956000927*SDMCPHASETWOADP*20100114*0928*1401*X*004010X09GS*HC*956000927*SDMCPHASETWOADP*20100114*0928*1401*X*004010X098A18A1ST*837*1401ST*837*1401BHT*0019*00*711347*20100114*0928*CHBHT*0019*00*711347*20100114*0928*CHREF*87*004010X098A1REF*87*004010X098A1NM1*41*2*LOS ANGELES COUNTY*****46*956000927NM1*41*2*LOS ANGELES COUNTY*****46*956000927PER*IC*RICHARD LUGO*TE*6262994547PER*IC*RICHARD LUGO*TE*6262994547NM1*40*2*ADP*****46*SDMCPHASETWOADPNM1*40*2*ADP*****46*SDMCPHASETWOADPHL*1**20*1HL*1**20*1NM1*85*2*ALCOHOL AND DRUG PROGRAM*****XX*1700090834NM1*85*2*ALCOHOL AND DRUG PROGRAM*****XX*1700090834N3*1000 SOUTH FREMONT AVEN3*1000 SOUTH FREMONT AVEN4*ALHAMBRA*CA*91803N4*ALHAMBRA*CA*91803REF*EI*956000927REF*EI*956000927HL*2*1*22*0HL*2*1*22*0SBR*P*18*******MCSBR*P*18*******MCNM1*IL*1*SUTTER*RAYMOND****MI*30011296MNM1*IL*1*SUTTER*RAYMOND****MI*30011296MN3*ELM STN3*ELM STN4*WILMINGTON*CA*90638N4*WILMINGTON*CA*90638DMG*D8*19441007*MDMG*D8*19441007*MNM1*PR*2*ADP*****PI*20NM1*PR*2*ADP*****PI*20CLM*A675020001*11.34***57::1*Y*A*Y*Y*BCLM*A675020001*11.34***57::1*Y*A*Y*Y*B………………………………………………………………....SE*73*1401SE*73*1401GE*1*1401GE*1*1401IEA*1*000001401IEA*1*000001401

ISA*00* *00* *ZZ*SDMCPHASETWOADP*30*956000927 ISA*00* *00* *ZZ*SDMCPHASETWOADP*30*956000927 *100114*1906*U*00401*000003725*0*T*:*100114*1906*U*00401*000003725*0*T*:GS*HP*SDMCPHASETWOADP*956000927*20100114*190658*1*X*004010X091A1GS*HP*SDMCPHASETWOADP*956000927*20100114*190658*1*X*004010X091A1ST*835*1401ST*835*1401BPR*I*11.34*C*CHK************20100114BPR*I*11.34*C*CHK************20100114TRN*1*90000290*1680290013*ADPTRN*1*90000290*1680290013*ADPREF*EV*956000927REF*EV*956000927DTM*405*20100114DTM*405*20100114N1*PR*20N1*PR*20N3*1700 K StreetN3*1700 K StreetN4*Sacramento*CA*95811N4*Sacramento*CA*95811N1*PE*ALCOHOL AND DRUG PROGRAM*XX*1700090834N1*PE*ALCOHOL AND DRUG PROGRAM*XX*1700090834REF*TJ*956000927REF*TJ*956000927LX*1LX*1CLP*A675020002*2*11.34*11.34**MC*2120057*57*1CLP*A675020002*2*11.34*11.34**MC*2120057*57*1NM1*QC*1*TIMELESS*AMANDA****HN*30011437MNM1*QC*1*TIMELESS*AMANDA****HN*30011437MNM1*74*1*TIMELESS*AMANDA****C*956000927,39,30011437M,50,N,01142010-NM1*74*1*TIMELESS*AMANDA****C*956000927,39,30011437M,50,N,01142010-ADP-19-837P-01142010-001.datADP-19-837P-01142010-001.datDTM*050*20100114DTM*050*20100114SVC*HC:H0020:HG*11.34*11.34**1.00SVC*HC:H0020:HG*11.34*11.34**1.00DTM*472*20091201DTM*472*20091201REF*6R*20002REF*6R*20002AMT*ZK*6.98AMT*ZK*6.98AMT*ZL*4.36AMT*ZL*4.36AMT*B6*11.34AMT*B6*11.34SE*22*1401SE*22*1401GE*1*1GE*1*1IEA*1*000003725IEA*1*000003725

ISA*00* *00* ISA*00* *00* *ZZ*SDMCPHASETWOADP*30*956000927 *ZZ*SDMCPHASETWOADP*30*956000927 *100114*1752*U*00401*000003723*0*T*:*100114*1752*U*00401*000003723*0*T*:GS*FA*SDMCPHASETWOADP*956000927*20100114*17GS*FA*SDMCPHASETWOADP*956000927*20100114*1752*1*X*004010X098A152*1*X*004010X098A1ST*997*0001ST*997*0001AK1*HC*1401AK1*HC*1401AK2*837*1401AK2*837*1401AK5*AAK5*AAK9*A*1*1*1AK9*A*1*1*1SE*6*0001SE*6*0001GE*1*1GE*1*1IEA*1*000003723IEA*1*000003723

997 file coming back to TP997 file coming back to TP

HL*2*1*22*0HL*2*1*22*0SBR*P*18**MEDICAL ADP DRUG C/O DEPARTMENT OF ALCOHOL AND SBR*P*18**MEDICAL ADP DRUG C/O DEPARTMENT OF ALCOHOL AND DRUG PROGRAM*****MCDRUG PROGRAM*****MCNM1*IL*1*ANDERSON*SXF-WARPITA*DIANE***MI*92409591MNM1*IL*1*ANDERSON*SXF-WARPITA*DIANE***MI*92409591MN3*1625 CAPITOL AVEN3*1625 CAPITOL AVEN4*SACRAMENTO*CA*95814N4*SACRAMENTO*CA*95814DMG*D8*19960820*MDMG*D8*19960820*MNM1*PR*2*ADP*****PINM1*PR*2*ADP*****PIN3*1700 "K" STREETN3*1700 "K" STREETN4*SACRAMENTO*CA*95814N4*SACRAMENTO*CA*95814CLM*1111TRAIN*65.61***55::1*Y*A*Y*Y*BCLM*1111TRAIN*65.61***55::1*Y*A*Y*Y*BREF*EA*36435REF*EA*36435HI*BK:30440HI*BK:30440NM1*82*1*BENNETT*ANDRIA****XX*1760672273NM1*82*1*BENNETT*ANDRIA****XX*1760672273NM1*FA*2*PLAINS MEDICAL SYSTEMS INC*****XX*2001234014NM1*FA*2*PLAINS MEDICAL SYSTEMS INC*****XX*2001234014N3*1133 COLOMA WAY #CN3*1133 COLOMA WAY #CN4*ROSEVILLE*CA*95661N4*ROSEVILLE*CA*95661LX*1LX*1SV1*HC:H0004*65.61*UN*1***1SV1*HC:H0004*65.61*UN*1***1DTP*472*D8*20091001DTP*472*D8*20091001REF*6R*067031332735-1REF*6R*067031332735-1

Loop and Claim informationLoop and Claim information

Are we even speaking the Are we even speaking the same language?same language?• Programs are intuitive and Easy to usePrograms are intuitive and Easy to use

• The Companion GuideThe Companion Guide

• The Companion Guide AppendixThe Companion Guide Appendix

• ADP FAQsADP FAQs

• Vendor Interface documentationVendor Interface documentation

• County procedures, records and systemsCounty procedures, records and systems

New DefinitionsNew Definitions• Bridge Resubmission and ResubmitBridge Resubmission and Resubmit

• Adjudicated - Approved or DeniedAdjudicated - Approved or Denied

• ACN ACN

• PCCNPCCN

• ReplacementReplacement

• VoidVoid

• Delay Reason CodeDelay Reason Code

• Claim Submitter IDClaim Submitter ID

Bridge ResubmissionBridge Resubmission

•A bridge resubmission is a resubmission in Phase 2 of a claim that was denied in Phase 1.

•Files are differentiated by the filename which contains BR in it.

•Trading Partner must submit the BR form to their analyst.

Resubmit – Phase 2Resubmit – Phase 2

•There is no such thing as a resubmit in Phase 2.

•Trading Partners must use a replacement or void claim to make changes to originals.

Adjudicated – Adjudicated – Approved or DeniedApproved or Denied

• If a claim is approved, the amount approved will be on an 835.

• If a claim is denied, there will be an adjustment reason code on the 835 (page 20 of CG appendix) which describes the reason for the adjustment. – Claims can be completely denied or partially

denied depending on the circumstances.

Attachment Control Number Attachment Control Number ACNACN

• Attachment Control Number (page 55 of 837 CG)

• This is the number in PWK06 in the 837 that references the paperwork being sent in to ADP.

• FMAB analysts use this number to match the

claim with paperwork being sent in for Manual Override and certain Delay Reason Codes.

Payer Claim Control Number Payer Claim Control Number PCCNPCCN

• Payer Claim Control Number (page Payer Claim Control Number (page 27 of 835 CG): 27 of 835 CG):

• Unique identifier on the 835 in CLP07 Unique identifier on the 835 in CLP07 that is generated by DHCS. that is generated by DHCS.

• This number must be used to identify This number must be used to identify prior claims in a void or replacement prior claims in a void or replacement claim. claim.

ReplacementReplacement

•A replacement claim will have a 7 in CLM05-03 (page 49 of 837 CG). The PCCN of the original claim must be put in REF02 (page 58 of 837 CG).

•A replacement claim essentially voids out the original claim and replaces it with the new replacement claim.

VOIDVOID• A void claim will have a 8 in CLM05-03

(page 49 of 837 CG). The PCCN of the original claim must be put in REF02 (page 58 of 837 CG).

• Void claim voids out the original. – This is a final action and a voided claim cannot

be replaced.

• There are several examples of void and replacement claims in the CG Appendix.

Delay Reason Code, DRCDelay Reason Code, DRC

•Delay Reason Code (page 15 of CG Appendix):

•Codes that will bypass late claim edits based on specific circumstances.

•DRC’s 4 and 11 require ADP’s approval prior to being used.

•DCR 8 certified and submitted by TP

• Must include a user generated ACN

Claim Submitter IDClaim Submitter ID

• Unique number generated by the Unique number generated by the county for each claim to track from county for each claim to track from creation to payment (page 49 of creation to payment (page 49 of 837P CG)837P CG)

• Echoed back on 835 for payment and Echoed back on 835 for payment and denialsdenials

• CLM01 on 837P ties to CLP01 on the CLM01 on 837P ties to CLP01 on the 835835

New Drug Medi-Cal FormsNew Drug Medi-Cal Forms

• Bridge Resubmission – Bridge Resubmission – Phase 1 denied onlyPhase 1 denied only

• DMC Claims Adjustments ADP 5035cDMC Claims Adjustments ADP 5035c

• Good Cause Certification - ADP 6065 A/BGood Cause Certification - ADP 6065 A/B

• Multiple Billing Overide – ADP 7700Multiple Billing Overide – ADP 7700• Claim Submission Claim Submission – – Cnty Contracted ADP 100186Cnty Contracted ADP 100186

• Claim Submission Claim Submission – – Cnty Operated ADP 100187Cnty Operated ADP 100187

Getting help from DHCSGetting help from DHCShttps://mhhitws.cahwnet.gov/systems/sdmc/docs/public/short_doyle_-_medi-

cal_phase_ii.asp

Getting Help from ADPGetting Help from ADP

Training EvaluationTraining Evaluation

•Please complete form

–Yes we do read the information–Yes it does matter what you say–Additional Question Sheets

– Jeffrey Trapnell– jtrapnell@adp.ca.gov 916-323-1819