Welcome to Magnolia Health’s Billing
Clinic 101!
We thank you for being part of or considering Magnolia’s network of
participating providers, hospitals, and other healthcare professionals.
Our number one priority is the promotion of healthy lifestyles through
preventive healthcare. Magnolia works to accomplish this goal by
partnering with the providers who oversee the healthcare of Magnolia
members
The intent of this presentation is strictly for provider billing guidance and to assist and educate on MH policy in regards to billing. Our responsibility is to render current coding information and advise accordingly. It is always the responsibility of the provider to determine member eligibility and also determine and submit the appropriate codes,
Eligibility verification
Claims
MHP Website
Prior Authorizations
PaySpan
Provider Services
Provider Relations
www.magnoliahealthplan.com
It is highly recommended to verify member eligibility on the date services are
rendered due to changes that occur throughout the month, using one of the
following methods:
Log on to the Medicaid Envision website at:
https://msmedicaid.acs-inc.com/msenvision/
Log on to the secure provider portal at
www.MagnoliaHealthPlan.com
Call our automated member eligibility interactive voice response (IVR)
system at 1-866-912-6285
Call Magnolia Provider Services at 1-866-912-6285
Claims must be filed within
90
days from the Date of Service (DOS)
All requests for reconsideration or adjustment must be received within
45
days from the
date of notification or denial
Providers should include a copy of the Explanation of Payment (EOP) when other insurance
is involved or provide information when billing electronically
Filed on paper via CMS 1500 (
NO HANDWRITTEN OR BLACK AND WHITE COPIES
)
Filed electronically through clearinghouse
Filed directly through website
Filed on paper claim – 1
STtime paper claims, mailed to:
Magnolia Health Plan
Attn: CLAIMS DEPARTMENT
P.O. Box 3090
Farmington, MO 63640-3825
Claims must be completed in accordance with Division of Medicaid billing guidelines
All member and provider information completed
FILE ONLINE AT WWW.MAGNOLIAHEALTHPLAN.COM!
If provider uses EDI software but is not setup with a clearinghouse, they must bill MHP via
paper claims or through our website until the provider has established a relationship with
a clearinghouse listed on our website
Centene EDI Help desk: 1-800-225-2573, ext. 25525 or [email protected]
Acceptance of COB
24/7 Submission
24/7 Status
Claims must be filed within
90
days from the Date of Service (DOS)
Filed on CMS 1500
To assist our mail center in improving the speed and accuracy to complete scanning
please take the following steps:
◦
Remove all staples from pages
◦
Do not fold the forms
◦
Make sure claim information is dark and legible
◦
Please use a 12pt font or larger
◦
Please use the CMS 1500 printed in red (Approved OMB-0938-1197 Form CMS-1500
(02-12)
Red and White claim forms are required as our Optical Character Recognition ORC
scanner system will put the information directly into our system. This speeds up
the process and eliminates potential sources for errors and helps get your claims
processed faster
The National Uniform Claim Committee (NUCC) has approved the conversion to the 02/12 version of the CMS 1500 form. This change is being made to accommodate the additional reporting needs related to the implementation of ICD-10.
Magnolia Health Plan will follow the implementation of this form as recommended by the NUCC. Specifically:
January 6, 2014 – March 31, 2014: Magnolia Health Plan will accept the current version of the CMS 1500 form (version 08/05)
AND will accept the new version of the CMS 1500 form (version 02/12).
April 1, 2014: Magnolia Health Plan will ONLY accept the 02/12 version of the CMS 1500 form.
The above is date of submission sensitive and not date of service sensitive. For example, if a claim has a date of service of March 17, 2014 and is submitted on or after April 1, 2014, the claim must be submitted on the 02/12 version.
Effective January 6, 2014, providers billing CLIA services to Magnolia Health Plan must include a valid and appropriate CLIA number. Invalid or missing CLIA numbers will be considered incomplete and the claim will be rejected.
See MagnoliaHealthPlan.com for full details
EP modifier is attached to the Health Check CPT codes for periodic
and interperiodic screening assessments
25 modifier is attached to a significant, separately identifiable E&M
code by the same physician on the same day of a procedure or other
service. (Modifier 25 uses may require medical records)
50 modifier is for bilateral operative session
51 modifier is for multiple surgeries and required per DOM
administrative code
TH modifier is for maternity services and required per DOM
administrative code
GP modifier is for Physical Therapy
GO modifier is for Occupational Therapy
GN modifier is for Speech Therapy
Rendering Provider’s NPI
is required in Box 24J
(non-shaded) when
billing Magnolia claims
Group or Individual Tax
ID #/SSN is required in
Box 25 when billing
Magnolia claims
Paper claims require a provider
signature in Box 31 when billing
Magnolia claims (Electronic
claim submissions are
automatically signature stamped)
Electronic and Paper claims it is
optional as of 01/03/14 for Box 32
to be completed when billing
Magnolia claims
Billing provider address is required in Box 33
and the Group NPI is required in Box 33a when
billing Magnolia Claims
SUBMIT:
Claims
Provider Complaints
Demographic Updates
VERIFY:
Eligibility
Claim Status
VIEW:
Provider Directory
Important Notifications
Provider Training Schedule
Provider Resources
Claim Editing Software
Provider Newsletter
Member Roster for PCPs
www.MagnoliaHealthPlan.com
www.MagnoliaHealthPlan.com
Provider Demographic Web Enhancement
Effective: November 13, 2013
Effective 11/13/2013, providers will be able to update/change demographic information which appears on the Find A Provider (FAP) by logging on the secure web site. Simply clinking on the “Update Info” tab will take the user to the secure web where they log in to make their changes.
The groups or practitioners may make limited updates to their service location information that displays in FAP. The new Provider demographic web change allows practitioners to sign into the Secure Web site and update:
The changes flow directly into the Magnolia Health Plan system and the corrected data will appear on the web within 24 hours.
Click on “Claims” at
the top of screen.
(Menu option)
Click on “Create a New
Claim”
Click on “CMS 1500”
Professional Claim
In the Patient Info
section, populate the
Patient’s Account
Number, and other
information related to the
patient’s condition by
clicking the appropriate
button.
In the General Info
section, populate the
claim information and
dates. You can Add
Coordination of Benefits
by selecting the button.
Click Service Lines.
In the Service Lines section,
add your service line
information. You can enter
up to 99 service lines.
***Note: When entering
charges for the service
billed, include the decimal
point to ensure the data is
populated accurately.
For example, 99.00 converts
to $99.00.
To add additional service
lines, click the Save/Update
button and then click the
New Service Line button.
When you are ready to
proceed, click Provider
In the Providers section,
populate the information for
the Referring Provider,
Rendering Provider, Billing
Provider, and Service
Facility Location.
***Use the blue Search
button after entering a Tax
ID or NPI for assistance with
your search.
***Required fields are
dependent on the type of
claim submitted:
Professional or Institutional.
Click Attachments.
In the Attachments section
you can Browse and
Attach any documents to
the claim as desired. If you
have no attachments, none
are required.
In the Review section, you
can review the claim once
again before clicking
In the Success section, a
confirmation ID displays for
your records.
Click Submit another to
submit another claim.
Indicator for submitted
applicable claims where a
NDC # is required.
Instructions for entering
where a NDC # is required.
Reconsiderations - Adjustment requests for claims that do not appear to have been processed
correctly the first time such as member DOB, member gender, etc. where plan may have processed in error. Typically, no documentation would be required other than the Claim Dispute Form advising of the nature of the issue.
Corrected Claims - Adjustment requests for claims where a correction needs to be submitted to correct
information originally submitted by a provider on a claim that was originally inaccurate. Again, could require or could not require documentation other than Claim Dispute Form.
Appeals - Adjustment requests for claims that the provider has submitted a reconsideration/corrected
claim or both, and still feels that the denial or payment is incorrect. These would be for non-authorization related denials only. Denials such as HCI/CXT denials where the provider disagrees; payment disputes where the adjustments have been made, but the payments did not change and were upheld, etc.
Medical Appeals - Strictly for Authorization denials where the provider must submit documentation to
show medical necessity and have submitted a reconsideration and/or corrected claim to attempt to obtain claim payment and denials were upheld.
Reconsideration/Corrected Claims/Appeals/Medical
Necessity Address:
Magnolia Health Plan
ATTN: (Appropriate department – RECONSIDERATION,
CORRECTED CLAIM, APPEALS, MEDICAL NECESSITY)
P.O. Box 3090
Farmington, MO 63640-3825
Must reference original claim # on EOP
Must be submitted within 45 days of adjudication
Corrected/Resubmission of claims is a function of EDI as well as via the Web Portal
Paper submission claims must clearly be marked
“RE-SUBMISSION” or
“CORRECTION”
and must include the original claim number or the original EOP must
be included with the resubmission
These claims must be submitted to:
Magnolia Health Plan
Attn: CORRECTED CLAIMS
PO Box 3090
Farmington, MO 63640-3800
Magnolia uses Code Auditing Software to detect, correct and document
coding errors on claims prior to payment
Analyzes CPT, HCPCS, Modifier and Place of Service Codes
Claims billed in a manner that does not adhere to standard coding
conventions will be denied
Detects inaccuracies such as Unbundling, Fragmentation, Up Coding,
Duplication, Invalid Codes and Mutually Exclusive Procedures
Magnolia follows established coding rules published by the following sources
to ensure claims are paid appropriately and consistently:
Mississippi Medicaid Provider Manuals and/or administrative
codes/regulations
Centers for Medicare & Medicaid (CMS) Rules & Guidelines – Inclusive of
National Correct Coding Initiatives (NCCI)
American Medical Association (AMA)/Current Procedural Terminology
(CPT) Billing Standards
Various Specialty Societies including:
•
American College Of Obstetricians & Gynecologists
•
American College of Surgeons
Patient is seen in doctors office/hospital
Claim submitted via EDI or Paper
Claim accepted in Payment System
6 Steps of Prepay Payment Integrity Adjudication 1. Entry Edits 2. Eligibility Verification 3. Provider Verification 4. Authorization Requirements 5. Benefit Eligibility 6. Pricing
Coding Edits Applied
Claim profiled by Payment Integrity
Preliminary Investigation Code/Claim Set to Pay or Deny & Claim
is Repriced
Claim Payment to Physician/Hospital
Duplicate Claims
Provider name, Taxpayer Identification Number (TIN), or National
Practitioner Identification (NPI) number is missing
Member DOB or Name not matching ID card/member record
Code combinations not appropriate for demographic of patient
Not filed timely
No itemized bill provided when required
Authorization numbers not provided
Diagnosis code not to the highest degree of specificity; 4th or 5th digit
when appropriate
Unbundling
For a complete list of common billing errors refer to the
provider manual
Prior Authorization is a request to the Magnolia UM (Utilization
Management) department for approval of services on the prior
authorization list before the service is rendered
All out of network services require an authorization
Services that require authorizations can be found on Magnolia’s
website. www.magnoliahealthplan.com
It is highly recommended to initiate the Authorization process at
least 14 calendar days in advance for non-emergent services
The PCP should contact the UM department via telephone, fax, or
through our website with the appropriate clinical information to
request an authorization
Escalated requests can be requested from the Medical Management
department as needed
List of services requiring authorization may also
be found on www.magnoliahealthplan.com
An authorization is required for MRI-CT SCAN-PET SCANS
National Imaging Associates (NIA) has been selected by MHP to administer the program
The servicing provider (PCP or Specialist) will be responsible for obtaining authorization for the procedures Servicing providers may request authorization and check status of an authorization by:
Accessing www.radmd.com
Utilizing the toll free number 1-800-642-7554
Inpatient and ER procedures will not require authorization
All claims should be submitted to MHP through the normal processes, www.magnoliahealthplan.com,
electronic submission or paper claim submission
Providers can contact Charmaine Gaymon, Provider Relations Manager at 410-953-2615 or via email at
MRI * CT SCAN * PET SCAN
AUTHORIZATION
Magnolia has partnered with PaySpan
Health to offer expanded claim payment services
Electronic Claim Payments (EFT)
Online remittance advices (ERA’s/EOPs)
HIPAA 835 electronic remittance files for
download directly to HIPAA-compliant Practice Management or Patient Accounting System
Register at: www.PaySpanHealth.com
For further information contact 1-877-331-7154, or email
