CLTS Waivers Third Party Administration (TPA) Claims Implementation Overview

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CLTS Waivers Third Party Administration (TPA)
Claims Implementation Overview

• Bureau of Long-Term Support
• Division of Long Term Care
• Wisconsin Department of Health Services
• May 12th, 2011

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Third Party Administrator (TPA) Claims
Processing for Childrens Long-Term Support
(CLTS) Waivers

• DHS is pursuing key initiatives that result in
• Administrative operations cost savings
• Efficiencies consistencies
• Use of common Information Technology (IT) systems
• Outsourcing certain business functions to allow
  Medicaid Home and Community-Based Service (HCBS)
  Waiver programs to focus on core program
  responsibilities
• Claims processing - a major business function
  that provides this opportunity
• Centers for Medicare Medicaid Services (CMS)
  requires MMIS (Medicaid Management Information
  System) compliant claims and reporting system for
  all Medicaid funding -- including funding through
  HCBS Waivers

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Third Party Administrator (TPA) Claims Process

• Current claims process of
• Using Human Services Reporting System (HSRS) to
  track childs enrollment and claims per enrollee,
• Funding county claims through Community Aids
  Reporting System (CARS), and
• Annual reconciliation process
• Does not comply with federal claims data
  collection and reporting requirements
• Renewal of Wisconsins CLTS Waivers and receipt
  of federal matching funds depends on meeting CMS
  requirements for standardized, statewide claims
  handling and data collection

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Third Party Administrator (TPA) Claims Process

• CWAs will remain responsible for
• Establishing agreements with qualified providers
• Ensuring providers are included on Medicaid
  Waiver Provider Registry, with signed Provider
  Agreements
• Conducting caregiver background checks
• Developing individualized service plans (ISPs)
• Authorizing provider services

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Third Party Administrator Vendor

• DHS issued the TPA requirements specified in
  Request for Proposal (RFP)
• Contracted with vendor that demonstrated
  sufficient statewide and timely implementation
  capacity -- Wisconsin Physicians Service (WPS)

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Third Party Administration Pilot

• DHS selected 5 County Waiver Agencies to
  participate in TPA Pilot Phase Dane, La Crosse,
  Milwaukee, Shawano, Waushara
• DHS worked with pilot CWAs and WPS to define
  business rules for centralized claims processing
• WPS began processing TPA claims for the pilot
  CWAs effective September 1, 2010
• TPA pilot period ended December 31, 2010
• DHS reviewed lessons learned from pilot
  experience, and in process of refining TPA
  policies and procedures prior to statewide
  roll-out

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Qualified Provider Data

• Current Waiver Provider Registry data inadequate
  for WPS claims payment (WPS also issues 1099s to
  providers receiving claim payments)
• BLTS requested additional provider data, W-9
  forms for pilot CWA providers
• Created provider file based on WPS data
  requirements, including
• Providers business name
• Providers billing and servicing address
• Taxpayer Identification Number (TIN)
• Tax exempt status
• Provider license number and expiration date (if
  applicable)
• Service specialty information
• National Provider Identifier (NPI) (if providing
  medical services)
• Contracted CWA information
• Will be collecting data from non-pilot CWA
  providers soon
• BLTS reviewing IT needs for long-term solution

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Child Enrollment Data

• DHS CLTS Waivers Database updated to gather
  necessary child data for WPS enrollment file,
  including
• Name (first, last, suffix)
• Date of Birth
• Gender
• Enrollment by program and CWA (participant cannot
  receive benefits from more than 1 CWA in the same
  day)
• Master Client Identifier (MCI)
• Address
• Enrollment date (retroactive enrollments allowed)
• Enrollment termination date
• BLTS issues weekly enrollment file to WPS

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Service Codes

• CWAs will no longer use SPC codes when
  authorizing services
• CWAs and providers must use National
  Procedure/Revenue codes
• BITS created SPC/National Code Crosswalk for TPA
  pilot implementation
• BLTS Code Sub-Committee created, reviewing and
  determining code needs

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Encounter ReportingData Warehouse

• DHS has launched IT project to retire HSRS
• TPA claims process will retire LTS module for
  CLTS Waivers
• WPS collects and sends provider claims data to
  DHS at the Encounter level
• TPA claims payment data stored in DHS Data
  Warehouse, 15th of month following payment
• Both DHS and CWA will have ability to extract
  data from Data Warehouse
• DHS creating reports (e.g., L300), but CWAs will
  also be able to create ad hoc reports, based on
  current needs

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COMPARISON OF PROCESSES
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CLTS Statewide Rollout Keys to Success

• CWA's creating an accurate authorization file
• Authorization Management (Understanding the
  authorization process and applying the proper
  rules)
• CWA's sending a Test authorization file 3 - 4
  weeks before "Live" date
• CWAs sending first Production authorization file
  before "Live" date
• CWA's sending Authorization notices with all
  necessary data elements to their providers
• Providers submitting claims to WPS correctly and
  timely
• CWA's asking questions...

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WPS TPA Claims Processing Flow
Provider receives Service Authorization
Notification from CWA
Provider performs authorized Waiver service
Provider submits claim to other insurance,
Medicare, or Medicaid, if applicable
Provider submits claim to WPS
Participant approved for Waiver Service
CWA authorizes approved Waiver Service
WPS receives Authorization File from CWA
WPS processes claim with corresponding Service
Authorization
WPS sends Payment and/or Provider Remittance
Advice to Provider
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WPS Provider Claims Forms

• Provider may submit claims to WPS in the
  following user-friendly formats
• Electronic filing
• Excel spreadsheet
• Paper claim form
• HCFA (CMS 1500)
• UB04 (CMS 1450)
• CLTS Waivers Claim Form
• WPS issues checks every Monday and Wednesday

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What is a Service Authorization File?

• A standardized file that the County Waiver Agency
  submits to the TPA. This file may contain many
  separate service authorizations.
• The file may contain authorizations for multiple
  services, multiple providers, and multiple waiver
  participants.
• The file is uploaded by the CWA into the WPS
  secured file transfer website called MOVEit.
• WPS uses the information on your authorization
  file to match to the information on a providers
  claim for reimbursement. When the information
  matches, WPS is able to pay claims.

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What is a Service Authorization Notification to
the Provider?

• Each provider will receive a Service
  Authorization Notification from the County Waiver
  Agency authorizing services and supplies.
• The Service Authorization Notification sent to
  providers gives them the information they need to
  include on their claim in order to be reimbursed.
• WPS has held a number of Provider Training
  Seminars throughout the state.

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Third Party Administration Statewide
Implementation

• Statewide TPA claims implementation will be
  phased in
• April 1, 2011 Lutheran Social Services St.
  Francis Childrens Center
• July 1, 2011 Southeastern Region
• August 1, 2011 Southern Region
• September 1, 2011 Northeastern Region
• October 1, 2011 Western Region
• November 1, 2011 Northern Region

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TPA Implementation Roll-out Sessions

• BLTS staff are working with Area Administrators
  to schedule roll-out planning sessions
• CWA staff
• Contracted providers

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TPA Questions?

• Questions regarding the TPA claims
  implementation?
• Contact
• Sue Larsen
• Childrens Services Section Lead
• Phone [phone]
• Email Susan.Larsen_at_dhs.wisconsin.gov