TR586Managed Health Services MHS Durable Medical Equipment DME Presentation

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Managed Health Services
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Managed Health Services
Who Are We

• MHS Indiana
• Centene Corporation
• Betty Brinn Foundation
• Centene Foundation for Healthcare Quality

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Managed Health Services
Our Guiding Principles

• Physician Directed
• Nurse Mediated
• Member Empowered

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Managed Health Services
Mishawaka
Indiana Office Locations

Merrillville
Fort Wayne
Muncie
Indianapolis
Indiana counties with MHS membership
MHS Indiana office locations
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Managed Health Services
Member Empowerment

• Nursewise
• 24/7 toll free nurse advice line
• Bi-lingual staff
• Member Services
• CONNECTIONS Program
• Transportation
• Statewide vendor reached through toll-free number
• Health Education in the Community
• Participation in local health fairs

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Managed Health Services
Coordinated Care

• Preventive Care
• Disease / Care Management
• OB Programs
• Immunization Initiatives
• Asthma/Diabetes Initiative
• Focused Utilization Management
• Team Concept (Physician, Nurse,
  Social Worker, Coordinator)
• Work in Partnership with Doctors

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Managed Health Services
Provider Empowerment

• Physician Committees
• Compensation
• Pharmacy and Therapeutics
• Quality Management
• Provider Driven Programs
• Pharmacy Gold Card Program
• Member Restricted Card Program
• Practicing Physicians in Key MHS Roles
• Access to Key MHS Leadership

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Managed Health Services
Whats New for 2007

• Behavioral Health Carve-In
• Members Pick-A-Plan
• Pay For Performance
• Member Initiatives
• E Health
• Enhanced Web Portal

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Managed Health Services
DME Policy

• Before an item can be considered to be durable
  medical equipment
• It must be able to withstand repeated use
• It must be primarily and customarily used to
  serve a medical purpose
• It is generally not useful to a person in the
  absence of an illness or injury
• It is appropriate for use in the home.

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DME Policy

• Items including, but not limited to, the
  following are examples of DME
• Hospital beds Wheelchairs
• Canes Walkers
• Raised toilet seat Oxygen systems
• Ventilators Nebulizers
• Neuromuscular Stimulators Bone growth
  Stimulators
• Infusion Pump CPAP/BIPAP
• Phototherapy (Bilirubin) light with photometer
• Wound Vacs

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DME Policy

• DME items with a purchase price below 500.00 do
  not require an MHS authorization.
• DME items with a purchase price 500.00 or above
  require an MHS authorization.

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DME Policy

• All DME items, regardless of purchase price,
  must be medically necessary as defined by 405
  IAC 5-2-17 Medically reasonable and necessary
  service Authority IC 12-8-5 IC 12-15-1-10 IC
  12-15-1-15 IC 12-15-21-2.

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DME Policy

• All DME that require an authorization require
  that process to be completed prior to dispensing
  the items, with the following exceptions
• DME item necessary as part of discharge planning
  from the hospital
• DME item necessary as part of the treatment plan
  for an urgent / emergent medical condition
• DME item previously authorized by anther MCO as a
  component of continuity of care during the 1st 30
  days of transition.

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DME Policy

• DME authorization decisions by MHS are based on
  medical necessity.
• The MHS Prior-Authorization form should accompany
  all clinical information submitted as part of the
  prior-authorization request.
• Authorization duration is based on medical
  necessity, anticipated outcomes, compliance with
  utilization, benefit limitations, and alternative
  treatment options available to meet the medical
  need of the member.
• Authorization requests to extend an existing
  authorization are required to be submitted prior
  to the expiration date of the current
  authorization
• Authorization numbers and units are provided for
  approved DME items

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DME Policy

• Prior-authorization for DME items may be
  initiated by contacting MHS
• Via facsimile 317-684-8096
• Via US mail Managed Health Services
• Attn Medical Management
• 1099 N. Meridian St., Suite 400
• Indianapolis, IN 46204
• Via phone [phone]

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Managed Health Services

• CLAIMS

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Provider Inquiry Services

• Call us at 1-800-414-9475 we are ready to help
  you
• Knowledgeable, friendly staff available 800-500
• Focused commitment to professional service
• Filing limits dependant upon contract status
• Claims address P.O. Box 3002 Farmington, MO
  63640
• Dispute appeal processes (60 days from EOP)
• Appeal address P.O. Box 3000 Farmington, MO
  63640
• Follow IHCP requirements

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Claims Submission

• May be submitted electronically (preferred) or on
  paper CMS 1500
• Providers should check electronic submission
  report daily to ensure claims were received by
  MHS
• Providers may use Clear Claim Connection to check
  the status of claims at www.managedhealthservices.
  com
• Filing timelines
• 120 days from DOS for Participating Providers
• Exceptions Newborn, Third Party Liability, and
  Eligibility delays (filing limit 365 days)
• 365 days from DOS for
• Non Participating Providers

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Resubmitted Claims

• If you need to resubmit a denied claim, the
  claim must be submitted on paper and should be
  clearly marked at the top with the word
  RESUBMISSION
• Attach a Claim Adjustment Form stating the reason
  for resubmission and include the EOP (if
  applicable)
• Resubmitted claims must be received within 60
  days of the EOP date

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Adjusted Claims

• If you need to make an adjustment to a paid
  claim, you can do so by calling Provider Inquiry
  or you may submit on paper with the adjustment
  request form.
• Attach a Provider Adjustment Form along with
  documentation, including EOP (if available)
  explaining reason for resubmission
• Claim adjustments must be submitted within 60
  days of the date of the MHS EOP

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Third Party Liability

• If a member has TPL on file but no longer has
  other coverage or the member has other coverage
  but the information is not on file take the
  following steps
• Contact Provider Inquiries with the TPL
  information so that changes can be made to the
  TPL file
• Send an update notification to EDS via the
  WebInterchange

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Third Party Liability

• Claims will deny L6 if TPL is on file with MHS
• What if I dont agree with MHS TPL indication
• Call provider inquiries
• Resubmit claim with EOB attached
• Reminder TPL claims must be submitted within 60
  days of the date of the primary insurers EOB

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Third Party Liability

• MHS updates member TPL information through
• A monthly file from EDS
• Phone call from providers
• Receipt of an EOB with claim
• MHS always verifies new TPL

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DME Billing

• DME with a purchase price of less than 500.00
  does not require prior authorization
• Manually Priced DME

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DME Billing

• Common Denial Codes
• Manual Priced Item needs invoice (BI)
• Missing rendering provider number (MK)
• Other/Third Party Liability (L6)
• Timely filing (29)
• No authorization (A1)
• Provider specialty must match authorization
  (denial HS)
• Duplicate (18)

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Claim Dispute Resolution

• Request for adjustments and claim inquiries
• Informal claim objection and dispute resolution
• Written
• Within 60 days of EOP
• Formal dispute resolution
• Written
• Follows informal process

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Questions and Answers