“Working to protect, preserve, and promote the health and safety of the people of
Michigan by listening, communicating, and educating our providers, in order to
effectively resolve issues and enable providers to find solutions within our
industry. We are committed to establish customer trust and value by providing
a quality experience the first time, every time.”
-Provider Relations
Agenda
Welcome!
Policy Updates
Spend Down
Top 10 Denials
New Document Management Portal (DMP)
Policy Highlights
New 2014 Policy Changes. Find all Proposed Policy and final Policy on website at
www.michigan.gov/medicaidproviders and selecting “Policy and Forms”.
Proposed Policy open for Public Comment for 30 days.
MSA 13-35 & MSA 14-03
Modified Adjusted Gross Income
Effective 10/01/13.
Eligibility determination through DHS for Medicaid is based on Modified Adjusted Gross Income (MAGI) methodology.
The MAGI method will be used to determine eligibility for all Temporary Assistance for Needy Families (TANF) related Medicaid categories; it excludes SSI-related categories (Aged, Blind, or Disabled).
The MAGI methodology was implemented October 1, 2013, and became effective for Medicaid eligibility cases on and after
January 1, 2014.
MSA 13-17
Ordering/Referring and Attending Provider Requirements
Effective 7/1/2013.
Outlined in MSA 12-55: claims for services rendered as a result of an order or referral must contain the name and individual
National Provider Identifier (NPI) of the practitioner who ordered or referred the items or services.
All practitioners who order/refer/attend services for Michigan Medicaid beneficiaries must be enrolled/registered in the Michigan Medicaid program.
Informational edits were added 7/01/13. These edits changed to DENY as of 10/01/2013.
MSA- 14-11
Healthy Michigan Plan
The Healthy Michigan Plan is a new category of eligibility
authorized under the Patient Protection and Affordable Care Act and Michigan Public Act 107 of 2013 that began April 1, 2014. The Healthy Michigan Plan ensures beneficiary access to quality
health care, encourages utilization of high-value services, and promotes adoption of healthy behaviors.
The purpose of the bulletin is to inform providers of this new eligibility category and to provide information regarding the services available to Healthy Michigan Plan beneficiaries.
Current enrolled providers are automatically active providers for the Healthy Michigan Plan.
Spend Down
Some individuals are ineligible for MA because
their countable income (after all applicable
disregards) exceeds the applicable MA standard.
However, they may become eligible for MA by
"spending down" their excess income for eligible
medical expenses.
An individual that is over-income for MA, but who
is otherwise eligible, may qualify for MA if
allowable medical expenses exceed their spend
down "deductible."
Spend Down
(continued)
Beneficiaries who exceed the income
requirement must use their medical costs in order
to have their monthly income at or below the
allowable income limits for the month.
The spend down/deductible amount is usually the
amount of a beneficiary’s income limit that is
OVER threshold.
Factors or amounts may vary county to county.
The exact formula is determined by the DHS
county where the beneficiary resides.
Spend Down Highlights
Spend Down renews each month.
Spend Down dollar amount may change monthly.
Determining Factors:
Income.
Employment.
Address.
Others in household.
Spend Down - Expenses
Samples of Expenses: Care from: hospitals, doctors, nurses, clinics, dentists, podiatrists and chiropractors.
Most medicines.
Medical supplies and equipment.
Transportation to and from medical care.
Personal care services provided in an AFC home or home for the aged.
Beneficiaries may not use costs already paid by other insurances.
Beneficiaries may report older unpaid bills and new medical costs within their “deductible report” which is submitted to the DHS worker.
Spend Down – Old Bills
The expense was incurred one month prior to themonth being tested;
The expense is/was still unpaid; and
Liability for the expense still exists (existed);
A third party resource is not expected to pay the expense; and
The expense was not previously used to establish MA income eligibility.
Spend Down - Submitting
Spend Down – Documentation
(continued)
Unpaid Bills Paid receipts Other statements Superbills Statements must include:
Date of service (DOS).
Amount owed or paid.
County Specialist Process
Beneficiary submits application to DHS for Medicaid coverage.
DHS specialist establishes coverage.
DHS worker sends a letter titled “Deductible Notice” to the beneficiary. This notice is also titled “NOTICE OF CASE ACTION” (DHS-1605 ).
This notice includes the deductible amount and hearing rights.
Spend Down Process
MSA-Pub. 617 is a brochure sent to beneficiariesoutlining the spend down/deductible guidelines and process.
It is a beneficiary’s responsibility to submit required documents to the DHS caseworker.
Some counties have a central location for document submission.
Spend Down Process
(continued)
The local DHS worker reviews the medical bills
incurred and determines if the amount of beneficiary liability is met and the first date of Medicaid eligibility.
Not all submitted documentation may be included.
The DHS worker will chronologically organize dates of service.
Bills for services rendered prior to the effective date of Medicaid eligibility are the beneficiary's responsibility.
When a beneficiary submits bills that do not “pay” for the service(s), it is the responsibility of the beneficiary to make arrangements with the provider for payment.
Spend Down Process
For the first date of eligibility, the DHS worker sends letters to providers whose services are:
Entirely the beneficiary's responsibility.
Partly the beneficiary's responsibility and partly Medicaid's responsibility.
A letter is also sent to the beneficiary indicating which services are the beneficiary’s responsibility for that first date of Medicaid eligibility.
Dual Coverage
Beneficiary may have a MSP (Medicare Savings Plan) in addition to Spend Down.
Benefit Plan assignment will be QMB until the Spend Down is met.
For any Medicare non-covered service, please provide the beneficiary with proof of the incurred medical expense so this documentation can be
provided to DHS as part of satisfying Spend Down. (QMB only pays Medicare Deductible/Co-insurance)
Billing Beneficiaries
General Information for Providers Chapter Section 11
Non-billable Highlights
When a provider accepts a Medicaid beneficiary as a patient, the beneficiary cannot be billed for:
Medicaid-covered services.
Providers must inform the beneficiary before the service is provided if Medicaid does not cover the service.
Medicaid-covered services for which the provider has been denied payment because of:
Improper billing,
Failure to obtain prior authorization (PA), and/or
Over filing limit (retro eligibility MSA-1038) . Missed appointments.
Copying of medical records for the purpose of supplying them to another health care provider.
Billable Highlights
Copayment, PPA.
The provider has been notified by DHS that the
beneficiary has an obligation to pay for part or all
of a service because services were applied to the
beneficiary's Medicaid deductible amount.
Medicaid does not cover the service.
If the beneficiary requests a service not covered by Medicaid, the provider may charge the beneficiary for the service if the beneficiary is told prior to rendering the service that it is not covered by Medicaid. If the
beneficiary is not informed of Medicaid non-coverage until after the services have been rendered, the provider cannot bill the beneficiary.
Billable Highlights
(continued)
Patient refuses Medicare Part A or B.
Provider chooses not to accept the beneficiary as a Medicaid beneficiary and the beneficiary had prior knowledge of the situation.
It is recommended that providers obtain the
beneficiary's written acknowledgement of
payment responsibility prior to rendering any
non-authorized or non-covered service the beneficiary
elects to receive.
Spend Down
A beneficiary is responsible for payment of
expenses incurred to meet the deductible
amount.
Payment does not have to be made before
Medicaid eligibility is approved. Providers may
bill a beneficiary for services rendered after a
claim rejects for lack of Medicaid eligibility.
Partial deductible met.
Reduce amount of providers charges by the
Spend Down amounts in Form Locator 24F.
Retro Eligibility
May be several days through 3 months. DHS may apply old bills to the past three months or may prospectively apply them to the next several months,
depending on the DOS and the date the bill was presented to the DHS worker.
It is the provider's choice to bill Medicaid if the beneficiary has paid the provider for services rendered. MDCH
encourages the provider to return the amount the beneficiary paid and bill Medicaid for the service.
If the provider decides to bill Medicaid, the provider must return all money the beneficiary paid over and above the amount identified as the beneficiary's responsibility on the Medicaid deductible letter.*
Health Plan Website
Health Plan Website
Displays the Spend Down amount in the eligibility
response within the MI Health Plan Benefits
page.
The information is yesterday’s information as the
Top 10 Denials
CARC 18 RARC N30 – Duplicates
Utilize Claim Limit List.
CARC 16
Review associated Remark Codes (RARC).
CARC B5 RARC N10 – Exceed Limit
Utilize Claim Limit List.
CARC 208 RARC N286 - NPI Not matched
Referring, attending or ordering NPI not enrolled or missing on the claim.
Top 10 Denials
(continued)
CARC 24 RARC N130- Enrolled in Health Plan
MA-MC click on CHAMPS ID hyperlink.
CARC 31 N130 – Patient not Eligible
Verify eligibility for date of service (DOS).
CARC 22 RARC N36 –Other Insurance on File
Medicaid is the payer of last resort.
CARC 9 RARC N129 – Diagnosis Inconsistent with Age
Document Management Portal
Phase 1
What is DMP?
The Document Management Portal (DMP) provides
a browser-based interface to perform various tasks
pertaining to submission of documents to Michigan
Medicaid.
In Phase 1 implementation, DMP was integrated
within CHAMPS.
Users are able to access DMP functionality directly
through CHAMPS interface only.
DMP is authenticated via the State’s Single Sign-On
By directly accessing the DMP, providers are able
to submit Medicaid documents that may or may not
be related to claims.
Users accessing the DMP will be able to:
Submit supporting documentation.
Submit documentation for authorization and
approval.
Send and receive messages pertaining to
submitted documents.
View documents and associated correspondence
history.
What is DMP?
(continued)
Directly upload documents.
Create cover sheets and fax documents.
Search existing uploaded documents.
View document notifications within CHAMPS.
Have messaging capabilities.
Receive notification when documents are approved.
What is DMP?
(continued)
Phase I
Access Points
CHAMPS Provider Portal
CHAMPS Direct Data Entry
DMP will launch in a new window when “Upload/View Documents” is selected. Tabs at the top of the page are used to navigate features within DMP.
When DMP is launched, NPI is prepopulated. Any documents loaded in the past will be shown at the bottom. Search for documents by entering data in the search fields. If no date is entered then the last 100 documents based on upload date will display.
While searching by TCN, the Header TCN must be entered (must end in 000). All search filters MUST match documents in history or search will not yield any results.
In the above example searched by “Beneficiary ID”, multiple NPI’s were loaded for these documents.
Search results will be listed at the bottom of the screen in sortable fields. Click on the “Document Title” hyperlink to open the document.
Click the “View Message” Icon to view messages associated with the document. Click the “Send Message” Icon to send a message regarding the document.
To search by “Status”, select from the following status indicators: Approved, Hold, Rejected, or currently in Review/Process.
To search the status of a Consent, filter by “Beneficiary ID” and drop-box menu option of “Consents” within “Document Type” .
Select “Document Upload” from top menu bar.
Guidelines for uploading documents are highlighted.
Enter required information that is marked with an asterisk (*). Documents may be shared across different NPI’s.
The example above shows 5 documents selected to upload.
Filter options can be changed within each line.
“Document Type” and “Document Title” can be utilized to search uploaded documents.
Once the document is uploaded under a TCN, it will automatically be attached to the TCN and Beneficiary ID will populate within the screen.
Upload Document
(continued)
Only TCNs listed within CHAMPS as IN PROCESS or SUSPENDED are eligible to attach a document within DMP.
A document may still be uploaded to the beneficiary ID if there is not an IN PROCESS or SUSPENDED TCN.
To connect an electronic claim with documentation submitted through the DMP, for a unknown TCN, the following notation must be included in the Claim Note:
Documents sent via DMP
Once information is completed, select “BROWSE”.
A file upload box will launch and allow the selection of the location where the file is stored. Select the file . The FILENAME box will prepopulate. Once file is selected, select “OPEN”. and “SUBMIT”.
Once document is submitted, the DMP screen will flash. Upload Successful pop up will display.
Upload is complete. Click OK.
CHAMPS
Once the necessary information is entered via direct data entry (DDE), click “Submit Claim” which will launch a pop-up window.
The pop up window will contain a new link that states “Upload Document”. Select the “Upload Document” hyperlink to launch the DMP portal.
The DMP will launch in a separate window and information from the claim will be prepopulated. Changes and adding messages in an option.
Documents can be updated to a TCN if IN PROCESS or SUSPENDED.
CHAMPS
From “CLAIMS” menu, select “Manage
Claims”
Select, “Adjust/Void Claim Provider”
Enter the header TCN to be
Add any and all necessary changes to the claim. Select “SAVE”.
Selecting "Save” creates a new TCN. The TCN change is displayed at the top of the page. Please Note the NEW TCN. You must select “SAVE for DMP” to attach to the correct TCN.
Select the “Upload/View” documents button to add a document. The DMP will launch in a separate window.
Information from the claim in CHAMPS will be prepopulated in DMP . Verify the information is correct, and fill in remaining areas.
A new FAX cover sheet must be created for each submitted document.
Re-using the same fax cover sheet will result in the document being attached to an incorrect beneficiary and/or claim and the possibility of your claim(s) being rejected.
An Online Fax Cover Sheet will launch in a new window.
A NEW cover sheet for each
documentation submission to DMP is required.
A barcode is created and used to store the PHI on the previous
screen.
Print out FAX cover and attach to documents.
Send Fax to appropriate number listed on the cover sheet.
Add note to claim:
Documents sent via DMP
(Loop 2300 NTE segment ) Allow 1 business day for document to be attached.
Messaging
DMP has messaging capability.
Messages will be attached to the document in
which they were submitted.
An e-mail notification is sent when a new message
arrives in the DMP message box.
The email notification will be sent to the email
address that is attached to your single sign on (SSO) login.
Please add our email address to your address book to avoid the email defaulting to SPAM or JUNK mail.
Select the “Messages” tab at the top of the DMP Portal.
Messages that are sent to a SSO login ID will be stored in this area. To view a message, select the Message indicator icon.
If there is a new message in your box, DMP will generate a generic email to the email address attached to your Single Sign On (SSO).
Message notations can be reviewed.
Once in the message, there is an option to “Reply” to sender and “View” the document associated with the message.
Selecting “Ok” returns to the Messages Screen. There is a 250 Character limit.
New icons display in CHAMPS if there are documents or messages attached to the TCN .
The “note” icon displays if documents are attached to the TCN.
The “envelope” icon displays if there are messages related to the TCN.
