Medicaid The Basics Part II Q & A
Date: Thursday, March 25, 2010
Starting time: 1:12 PM
Q:I attempted to find out who our provider rep was accessing TMHP, providers,
Regionalsupport for Region1 but could not see where to find my rep. what did I do
wrong?
A:I am going to take you through the navigation on TMHP.com. I will showyou how to find your area rep
Q: Does an LPC need to obtain prior authorizationor precertification before the1st appointment with a client?
A:Please refer to section 30 of the Texas Medicaid Provider Procedure Manual (TMPPM) a total of 30 visits are allowedper year for a traditional client regardless if there are different providers. It is a total of 30. We do suggest at 20 visits to submit an authorization request.
Q: I will refer to the section 30 after the webinar for sure, however I would like to know where I find the current number of visits the client has and if my claims will be accepted.
A:You can call our Contact center – 1-800-925-9126. However currently there is not a way foryou to do this through TexMedConnect. This part can be tricky because you might notknow if the client is seeing another provider for behavior health services.
Q: How are we as providers to know how many units the client has left out of the
30?
A: That is a good question. You can call our contact center to requestthe number of visits to date. Keep in mind thenumber that will be provided is whatwe have been billed for and have those claims in our system.
Q:We have called to request that information, but the representative would notprovide that information as to how many units had been used.
A: The process is to make contact with the Contact center for thisinformation. I apologize you might have been mislead or misunderstood by the rep,to my knowledge our representatives can provide this information.
Q: Thank you for your concern regarding these matters of checking on units. If werun into this issue again where the representative will not provide the informationwould it be best to request that we talk with a supervisor?
A: If you run into that issue again you should escalate and request tospeak to a Supervisor.
Q:For hospital discharges can the ambulance company request for the prior authorization number (PAN) on line?
A: The guidelines for prior authorization on line are available at Select provider electronic submission guide. It states Ambulance canbe requested online short tern 1-60 days or 180 days.
Q: In filling out a prior authorization forphysical and occupational therapy underfrequency it only allows week or month. What should be checked if the script isfor 3 times a week for 4 weeks?
A:The form will allow you to include frequency per week. What form are you using?
Q: The online form thru the website.
A: Are you a CCP provider viewing the online prior auth manual it doesindicate you can file out a patient services form for CCP only. The guide is available onour website.
Q: Yes, we are a CCP provider.
A: At the bottom of each prior authorization there is a free M text box. You can place comments specific to weekly frequency.
Q: Where do I find the paper prior authorization forms for physical and occupational therapy and the fax number?
A: Appendix B has these forms in the TMPPM or you can access all our forms online on the right hand side - search for Medicaid forms.
Q: Isit required that allMedicaid patients require prior authorization forphysical and occupational therapy?
A: CCP guidelines require prior authorization
Q:If we did not specify that in our request, can we amend this anywhere?
A: The only way to make request changes would be if you are extending therequest. Unfortunately, you will need to provide the modifications to the request viafax.
Q:Is there a way we can obtain a list of dr’s provider identifier #'s? I know itasks for that on the form but many physicians' fail to write it in.
A: The referring provider should provide you with the NPI and TPI number tosubmit on the request. We do not publish a listof provider numbers, the onlineprovider look up tool does give the provide NPI#.
Q:When asking for a provider identifier can it be a Unique Physician Identification Number (UPIN) or does it have to be theTexas Provider Identifier (TPI) or National Provider Identifier (NPI)?
A:We do not accept upin #’s so it will need to be TPI or NPI #’s.
Q:How do you establish clientnumber?
A:The client number is their Medicaid Identification number.
Q:I was prompted with needing a random 5 digit code issued by TMHP prior to beingable to enroll for TexMedConnect- it said it could only be mailed, is this correct?
A:This is correct if you are requesting a Provider Identifier Number (PIN). Unless you have a recent Internal Control Number (24 digit internal control number) is the claim number you receive onyour remittance and status report by using an lCN you can, have the password emailed to you. Does this help?
Q: We fax our precerts to Medicaid. In particular PCCM auths are taking longerthan 72 hours for us to get a response back. Currently it is more like 5-6 daysbefore we get a response. Why and is the online precerting faster?
A:Online is a great tool because you can tack the request. We were notaware there is an issue with the timeline exceeding the 72 hour turnaround. Is this a consistent issue for you? If so please reach out to your rep so we can get your information.
Q:What happens when you submit a fax for a prior authorization number (PAN) and then research the status of iton line and there is nothing found and we call and ask as well and there is nothingfound what happens then?
A:If it is a service you can initiate and request online then resubmitvia online. If not you will need to resubmit the fax/request.
Q:If a pan was not obtained is there any way to apply for one after?
A: Prior authorizations require the services have an auth before theservices are rendered. Refer to the participants guide page 3 if a provider fails to obtainthe PA the service will be denied.
Q: Why do some patients with Medicare primary and Medicaid secondary do not have QMBor MQMB? We see this from time to time
A: This is based on their eligibility criteria. For more detailedinformation about MQMB vs. QMB please join our Beyond the Basics webinar scheduled for March 30th.
Q: Why is the "appeal claim" box not available on all claims?
A:It could be the claim has not been dispositioned or cannot be appealed through this venue.
Q:If we do Electronic Funds Transfer (EFT), will we receive confirmation that the checks were received in ouraccountand will they notate which NPI they being paid under?
A:if you choose to enroll in EFTit will take a couple of weeks for you tostart receiving payment through this venue. The Remittance Status (R & S) report will show the EFT transaction number. Please read page 40 ofthe participants guide and this should answer your questions.
Q: Does Medicaid allow retroprecert or authorization for services rendered?
A: If the client is retroactive then yes you would be allowed to requestthe precert or prior auth however the key is to make the request is submitted before the claim issubmitted. Once a claim is submitted the claims will remain denied.
Q: Do we need to submit an additional document on an appeal or can it just bewritten on the R&S report? Can a Family Planning claim be appealed electronically?
A: The requirement is that you state that you need an adjustment. Be realspecific on the R&S report. Additional documentation is not required. Are youreferring to a specific title of Family Planning? Refer to section 20.5.4.2 of the Texas Medicaid Provider Procedures Manual, it does state you can appeal family planningclaims electronically.
Q: No we are funded under Title V, XX, and XIX.
A: It’s my understanding you can appeal electronically. The Department of State Health Servicesproviderprocedure manual is a great resource forthis information.
Q: From Medicaid Basics Part 1- Discrimination: If reimbursement for J7302 is less than what theagency pays for the device, are we allowed to discontinue this birth control method for Medicaid patients only?
A: No, you cannot discriminate what is available to Medicaid patients. Ifyou have it for private pay then it must be available to Medicaid patients.
Q: Does TMHP accept electronic signatures for TP1, TP2 and Title 19's
A:On a claim form the signature has to be signed or say Signature on file.The Title 19 has to have the physicians hand written signature on it.
Q: DTPITP2's would not be accepted?
A:What do you mean TPI1 &TP2? We need your TP1 on a paper claim form butit does not replace the signature.
Q: TPl &TP2 wouldn't be accepted with electronic signatures either?
A: TPI to me means your provider number andit does not replace the signature.
On forms that TMHP needs a signature it means a handwritten signature
Q:Request for Initial Outpatient Therapy (arm TP-1) ~ Request for Extension ofOutpatient Therapy (Form TP-2). These forms need to be signed by the MD In order to obtain prior authorization? Would TMHP accept these forms with a electronic signature?
A: No.
Q: lf submitting a prior auth online, do we still complete the TP-l or TP-2 form and have the PCP sign it?
A: Yes, you have to keep it on file for if at any time you are asked for it.
Q:I thought secondary claims had to be filed paper witha copy of the primary payer's explanation of benefits (EOB) ... is that true?
A: Yes, if you have one with other insurance you must send in the EOB fromthe other insurance with your paper claim. There are some that you can file on TexMedConnect. There are fields tobe able to file the other insurance information. Medicare if they do not crossoverhave to be filed by paper.
Q:Then when would you need to enter informationon other insurance when filing a claimonline?
A: When you have filed to other insurances first then filing to Medicaid youwould need to enter the information from the other insurance.
Q:Can claims where Blue Cross/Blue Shield is primary be filed on TexMedConnect without sending acopy of the EOB?
A:Yes, put in the other insurance information on TexMedConnect.
Q:This is a question that may be addressedwhen we get to appeals ... but when I amappealing a claim on TexMedConnect where one line paid but another did not, do I delete the line that paid so it does not cause problems and appear as a duplicate?
A:We will answer this later in the presentation. However, do not delete any lines. Just correct the line you want to appeal and submit.
Q:I missed the last few minutes ...I apologize. Can a paper appeal include a corrected HCFA or just the Remittance &Status (R & S)and any supporting documentation?
A: TMHP now just wants the R&S with the explanation on the R&S as to what needs to be changed or appealed & attach supporting documentation. No claim form is needed.
Q:What are the different situations where we can contact the Third Party Resource (TPR) department versusthe patient having to update the termination of other insurance with their caseworker?
A:When you have documentation from the TPR. You can call TMHP with that information. If the client just says they do not have the other insurance (OI), they have to make sure they call the OI get it terminated if that is the case.
Q: Afterupdating TPR with other insurance information, do we need to resubmit the claim or does that happen automatically (Assuming that OI has terminated)?
A:After the information has been up dated you will have to appeal your claim. TMHP does not do that automatically.
Q:So for example, the patient is shown to have Blue Cross as primary and we areable to obtain proof of termination from them. We can then call TPR and providethat information and have our claim processed as primary?
A:After the informationis updated, you can file your claim &Medicaidwill pay as primary if that OI has been terminated.
Q:How long does it take for the records to be updated and will a timely denial beoverturned based on this information?
A: It can take up to 10 daysfor the information to be updated. After that you can appeal your claim and your claim will be reprocessed.
Q:What section of the provider’s manual is the complete list of exceptions found?
A: This information is found in the Texas Provider Procedures manual chapter 4page 15.
Q: Please, can you resend the link for Medicaid HMO payers, being thatwe must be able to accept all Medicaid clients?
A: On the TMHP.com web site under Providers there is a link for you to find these HMOs.
Q: Page 47 indicates that TMHP does not handle foster care and that these complaintshave to be addressed through Superior Health. Does this mean that they havedifferent forms for prior authorization, claims, etc than what is being covered in this training?
A:Superior uses the same claim forms that TMHP uses. They also use thesame prior auth forms. They may have a different ways to ask for the prior auth. You would need to ask them their procedures.
Q:We are a pediatric group. If a patient has other health insurance and we bill traditional Medicaid for THSteps first we will not get a denial for other coverage primary?
A: No, for THSteps you do not have to file other insurance first and your claim will not be denied.
Q:May we appeal online if we file our claims on paper?
A:Yes, if they do not require attachments.
Q: Is the fee schedule online the same as thepaper version?
A:What paper version? There is no longer a paper version. Use the online version.