top medicaid mco denials: ilhpco - hospice

TOP MEDICAID MCO DENIALS: ILHPCO - Hospice HFS Workgroup

Meeting Date 6/29/20

ISSUE MCO RESPONSE/STATUS Issue 4: Descriptor Scenario/explanation: Inconsistent prior authorization requirements for hospice service intensity add-on (SIA) visits i.e.) Health plan requires authorization for hospice SIA visits while other MCOs do not. Denial Reason: CO-197 “Precertification/ authorization /notification/ pre-treatment absent.”S MCO(s): HCSC Illinois Provider(s): Seasons Hospice Claim Examples: 1913700CJT00– 04/01/19-04/26/19 – Billed revenue code 0651 for hospice routine home care, billed 0551/G0299 for hospice SIA visits on 4/22, 4/23, 4/25, 4/26. 0651 paid and 0551/G0299 SIA visits denied for no authorization. 19150000EX00– 02/01/19-02/06/19 – Billed revenue code 0651 for hospice routine home care, billed 0551/G0299 and 0561/G0155 for hospice SIA visits on 2/4. 0651 paid and 0551/G0299 and 0561/G0155 SIA visits denied for no authorization.

8/12/19 - Confirmed no separate requirement for SIA auth. This is included in Routine. They will review, communicate back to their staff nothing additional needed and if denials occur, they will override and adjust. Be on the lookout for a notice on their website. 9/10/19 - No auth is required. System has been updated. If any provider has ongoing issues, we should readdress with examples. 9/26/19 - Issue requirement is confirmed; however, claims are still not paid 10/7/19 - Claims will be processed by 11/1/19 10/21/19 - BCBS is on track for 11/1/19 11/4/19 – Sent for adjustment will have an update by November 15th 12/10/19 – Per Seasons: ICN 1913700CJT00 Paid in full. ICN 19150000EX00 has not been paid 12/10/19- BCBS States they show both are resolved – Seasons to confirm.

Association: Top Medicaid MCO Denials Meeting Date

Provider sending Claim Examples: Seasons Hospice JDate Claim Examples Sent: 8/5/19

01/09/20 – We have not received payment for ICN 19150000EX00 as of today. Balance due is still SIA visit on 02/04/19 11 units totaling $118.63. 1/13/20- BCBS is sending back for adjustment this week, hospice to confirm if ICN 19150000EX00 is still open. 1/30/20 - Not Resolved – Payment has not been received and per Availity, claim is not being reprocessed. 2/10/20 – Claims adjusted no auth needed as of 2/7/20 3/04/20 - Per Availity, claim reprocessed on 2/17/20 ICN 19150000EX01 but still denied the SIA visit code 12h: Payment denied/reduced for absence of precert/auth 3/9/20- BCBS will review the SIA non-payment, Seasons confirmed claim status on Availity & still showing denied as of 3/9. 3/13/20 – Denial sent to Jimmy 3/27/20 – Denial sent to Ben Pierce & Kim Johnson Thurmon 4/20/20 – as of 4/16/20, Jimmy is working with Kate Howard, Seasons Hospice. Pending updates. 5/7/20 – Per Jimmy: there was a pricing defect sent for review and adjustment of the claims below with an ETA of 5/23/2020. 5/18/20 – MCO Meeting Update: Pending resolution for 5/23/20


6/3/20: Pending resolution on hospice end still. As of today, no corrected payment received. Reached out to Jimmy 6/3 to inform him its still outstanding.

Issue 10: Authorization denials received even when authorization number is included on claim. Scenario/explanation: Authorization is obtained, and the authorization number is included on the claim to the health plan. Claim is denied for authorization regardless. Denial Code & Reason: CO-197 / Precertification/authorization/notification/pre-treatment absent. MCO(s): Next Level Provider(s): Seasons Hospice Claim Examples: ICN S220IEE00433: Billed rev code 0656 DOS 7/17 – 7/18/19 and rev code 0657/ 99223 DOS 7/18/19. Auth # OP1674709959 listed on claim but still denied CO-197 ICN S158IEE00012: Billed rev code 0651 DOS 4/12 – 4/25/19, rev code 0656 DOS 4/26 – 4/27/19, rev code 0657/99222 DOS 4/26/19, rev code 0657/99232 DOS 4/27/19, rev code 0551/G0299 DOS 4/22/19. Auth# OP1574064311 listed on claim but still denied CO-197 Provider sending Claim Examples: Seasons Hospice

9/10/19 - Next level has identified that auths are not transferring to the claim system. A report is being built to validate prior to claim processing. They will have an answer by next meeting. 10/7/19 - Next Level adjusted claim twice but it still denied. Claim passed first level edits in their system but is now hitting a second level of edits causing inappropriate denial. Next Level needs to do more investigation and will have an update at the 10/21/19 meeting. 10/21/19 - Next Level is still reviewing this issue, they will have an update by next meeting. Possible settlement. 11/4/19 – Next Level’s clinical team approved, auth update in process. Findings no evidence of authorization. Will conduct provider education. 12/10/19 – Per Seasons, we have not been contacted by anyone at Next Level re: provider education. Please provide an update. ICN S220IEE00433 authorization letter dated 07/19/19 states “The services is approved. The authorization number for this request is OP1674709959. Authorization has been issued for hospice code T2045 (7 days) to be provided or performed by Seasons Hospice. This authorization is valid from 07/17/19 to 07/24/19 for hospice code T2045.” We billed Rev Code 0656 per HFS guidelines and were denied. Rev Code 0657 was also billed and does not require


Date Claim Examples Sent: 08/30/19

auth. Claim had auth # OP1674709959 listed. ICN S158IEE00012 authorization letter dated 04/17/19 states “The service is approved. The authorization number for this request is OP1574064311. Authorization has been issued for hospice services code T2042 (90 days) and code T2046 (90 days) to be provided or performed by Seasons Hospice. This authorization is valid from 04/12/2019 to 07/12/2019 for hospice services code T2042 and code T2046.” Patient’s level of care changed on 04/26/19 from Routine to GIP. Authorization letter dated 05/01/19 states “The services is approved. The authorization number for this request is OP1574064311. Authorization has been issued for hospice services code T2045 (7 days) to be provided or performed by Seasons Hospice. This authorization is valid from 04/26/19 to 05/03/19 for hospice services code T2045.” We billed Rev 0651 DOS 04/12/19 – 04/25/19, Rev 0656 04/26/19 – 04/27/19 per HFS guidelines and were denied. Rev Code 0657 and 0551/G0299 (SIA Visit) were also billed and do not require auth. Claim had auth# OP1574064311 listed. 12/10/19 – Not reviewed at meeting, pending MCO response 1/9/20 – No Hospice updates – we have not heard from Next Level. 1/13/20- Payment should be issued on 1/17/20 – Hospice to confirm 1/30/20- Not Resolved – Received a partial payment, not payment in full ICN S220IEE00433 – Rev code 0656 was paid in full, but physician visit 99223 was denied CO-197


ICN S257IEE00286 (Formerly ICN S158IEE00012 Rev 0651, 0656, 0658 were paid in full, but SIA visit Rev 0551/G0299 04/22/19 and physician visits Rev 0657/99222 04/26/19 and Rev 0657/99232 04/27/19 denied CO-A1/N448 “This drug/service/supply is not included in the fee schedule or contracted/legislated fee arrangement.” 2/10/20 -Connect to settle with Next Level 3/04/20 - Mark Smith, email: Began review last week, will have more information later in the week 3/9/20- part of possible settlement 4/7/20- Next Level provided feedback on handful of claims. Seasons is reviewing for possible auth. Settlement still in process. 4/20/20 – settlement in process, new email chain will be started 5/7/20 –Per Hospice: Authorization backup requested was provided on 4/17/20. Mark Smith acknowledged receipt. Emailed 5/7/20 for updates on settlement status. 5/18/20 – MCO Meeting Update: 2018 claim review complete, pending breakdown from MCO of payments. 2019 claim review next. 6/3/20: Next Level approved a small portion of 2018 claims and has started review of 2019 claims. Call set up for 6/4/20 between NL and Seasons. 2018 is not complete.


6/4/20: Hospice is preparing another spreadsheet of claims for their claims manager, Octavia, to review. Next Level completed their own data dump of our claims and reviewed however it did not match the Seasons aging. Mark is working on a timeline on how long UM will take to review all of our documentation and fix auth issues.

Issue 12: Descriptor Scenario/explanation: Claims were being denied for missing information. However, the information was on the claims. Denial Code & Reason: No value codes, no authorization number, No CBSA, no units MCO(s): Meridian Health Plan Provider(s): Joliet Area Community Hospice Claim Examples Meridian – 125455452 – 09/21-09/22/2018 – no value code and no authorization number. Info present on claim. Meridian – 121224598 – 12/01-12/03/2018 – no value code and missing/invalid units Info present on claim. Meridian – 126979971 12/01-12/03/2018 missing Value Code and auth. Info present on claim. Meridian – 120210825 – 11/14-11/30/2018 – missing CBSA code and auth. Info present on claim. Meridian – 127079022 11/14-11/30/2018 missing Value Code and auth. Info present on claim. Provider sending Claim Examples: Joliet Area Community Hospice Date Claim Examples Sent: 8/28/2019]

9/10/19 - Claims are in review, the reps will reach out to hospice directly with update. This will be completed by 9/23. Hospice to inform us if this is completed and issue will be closed. 9/20/2019 - Update from Hospice: We received an email from Stephen Craig on 9/10/2019. He stated that he has given these claim issues to the Utilization Management Team and the Care Coordination Team. He stated he stressed the importance of a thorough review and he would get back to us as soon as he heard from them. As of 9/20 we have not received a response from Stephen and the claims remain unpaid 10/7/19 - Provider Rep in contact with Joliet Hospice, Meridian will report next meeting on 10/21/19. Joliet Hospice please confirm. 10/14/19- Pending Joliet Hospice confirmation 10/21/19 - Meridian sent Joliet Hospice information on billing errors on claims related to the CBSA code. Joliet Hospice to confirm. 10/28/19 – All claims remain unresolved. Provider rep contacted Joliet Hospice after 10/7 meeting stating that all claims would be reprocessed and given new claim numbers. We have not received


new claim numbers or update on status since. 11/4/19 – Meridian & Joliet Hospice have a meeting scheduled on 11/6/19 on billing education. CBSA issue, Joliet needed to adjust claim and rebill. 11/14/19 – Joliet Hospice still working with Steven Craig, will let us know by Dec 2nd if progress. 11/22/19 – Claims remain unpaid 1/6/20 – Not reviewed at meeting, pending MCO response Joliet to confirm balances outstanding still Claim examples: 125455452 RA dated 3/10/19, denied for no value code or CBSA code. Codes present on claim. Several attempts made to resolve with Meridian. Per Stephen Craig's request on 11/7, I sent him this issue on a spreadsheet. No response received. 121224598 / 126979971 RA dated 03/4/19, denied for no value code or CBSA code. Codes were present on claim. Several attempts made to resolve with Meridian. Per Stephen Craig's request on 11/7, I sent him this issue on a spreadsheet. No response received. 120210825- paid 127079022- paid 1/13/20- Per MCO… Rebilling of claims was required and claims


were reprocessed- Hospice to confirm 1/28/19 - Per Hospice: The comment from the MCO on 1/13/20 says that the claims needed to be rebilled and were reprocessed - hospice to confirm. We did not hear from Meridian that this was the action taken on the claims. We have had no communications from Meridian. I checked the portal today and do not see any new claims processing for these patients for these dates of service. I also called Meridian, and per representative Carmen L., there are no new claims processing for these patients. 2/10/20- Joliet Hospice will receive spreadsheet by 2/11/20, please confirm you received. 3/04/20 - Joliet has not received the spreadsheet as of yet 3/9/20 – As of 3/2, MCO shows this is closed. They reached out to provide to request update by 3/13. Joliet please confirm if this issue is still open. 3/17/20 - emailed hospice for follow up 3/20/20 - Per Hospice, we have not had any resolution on these last two claims. Is it possible to get a call set up between hospice & someone from this team on the MCO side? It appears there is a disconnect on status of this item. Hospice narrative, “3/9 notes says they reached out to the hospice to request an update by 3/13. That is not really true. On 3/4 I sent another request to Stephen Craig asking for an update on these


claims (plus some others) and he did not respond. On 3/13 I sent another email to him. He finally responded to that one stating that he is no longer our rep, that I should contact Rachel Maher. On 3/13 I sent the claims issues to Rachel. Rachel did email back on 3/13, only to say said she reached out to Tracye Young at Joliet about some state complaint issues and did not hear back. I told Rachel I knew nothing about that, but if she would call me, I would try to help her. I have not heard back from Rachael about my issues or the complaint issue she mentioned. There are no current replacement claims in the portal for the two claim examples listed. I have had no communication from Meridian as to what we should do to get these claims paid. Last November Stephen Craig asked me to send them to him on a spread sheet. I have asked for updates or direction and have received nothing." 4/20/20 – Rachel now working with Mary @ Hospice. MCO pending response from Mary. 5/18/20 – MCO Meeting Update: 3 claims in question, 2 of the 3 are in review for timely override the 3rd claim was just rebilled on 5/4 and is currently under review. 6/4/20: Hospice update: The last 3 Meridian claims are still unpaid. However, Rachel is great, and I just received an email giving me instruction on re-billing one of the claims. Hopefully it will be resolved soon.

Issue 18: Descriptor Scenario/explanation: VITAS has made several attempts in having claims processed based on HFS guidelines. Next level

9/10/19 - Next level reached out to Vitas today (9/10/19) regarding issues. They will likely request the MEDI backup on these PCF issues.


made us aware of new system and the problems with the claims processing system. VITAS escalated file and we continue to say claims paid correctly. Last couple of months we were advised that they have had new staff and claims are pending review Denial Code & Reason: 193 Original payment decision is being maintained. MCO(s): Next Level Provider(s): VITAS Healthcare Claim Examples: R365IEE00714, S030IEE00473 S091IEE01075 Provider sending Claim Examples: VITAS Date Claim Examples Sent: 8/27/19

Next level has built a 2nd review before the file goes out. 9/24/19 - Per Vitas, still pending payment 10/7/09 - Per Next Level they met with Vitas on 9/18/19 and they will be possibly proposing a settlement. Target completion is 10/30/19. Vitas please keep us posted. 10/14/19 - Pending resolution from Vitas/Next Level 10/21/19 – This the same issues as Seasons (Issue 10), pending retro fix, current system is fixed. Possible settlement, will know more next meeting. 11/4/19 – On 9/18/19 Next Level & Vitas met, on 10/31/19 Vitas submitted a file to Next Level. Goal is to have resolved by end of month, will update at next meeting. Findings included no authorization or PCF, they will request proof by case, possible settlement depending on results. 1/6/20 – Not reviewed at 12/10 meeting, pending MCO response VITAS to confirm balances outstanding still 1/7/20 – Vitas status update R365IEE00714 Paid S030IEE00473- Balance is still outstanding S091IEE01075 -paid 1/13/20- Next Level will have an update by next meeting


2/10/20- Possible settlement need to contact Next Level- Mark Smith- [email protected] & Jessica Pickens- [email protected] 3/2/20 – Per Vitas, the outstanding AR was emailed on 2/14/20 to Mark & Jessica 3/9/20 – part of possible settlement 4/7/20 - pending results of file sent on 2/14/20 4/20/20 – Next Level sent auth findings back to VITAS – pending response from VITAS. 4/20/20 - VITAS submitted findings to Next Level. 5/18/20 – MCO Meeting Update: 2018 claim review complete, pending breakdown from MCO of payments. 2019 claim review next. 6/2/20 – 2018 claims paid, pending results of 2019

Issue 41: Claims denied for authorization when valid auth on claim and matches services authorized Scenario/explanation: Claims denied in error for authorization when authorization number is on claim and matches services billed Denial Code & Reason: HF: DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED

11/4/19 – MCO Still reviewing to find root cause, currently there is a manual review on these claims. Will have more information at the next meeting. 12/10/19 – Not reviewed at meeting, pending MCO response 1/9/20 – No updates from Next Level – balances still outstanding. 1/13/20- Payment should be issued on 1/17/20 – Seasons to

mailto:[email protected]

mailto:[email protected]


MCO(s: Next Level Provider(s): Seasons Hospice Claim Examples: ICN S220IEE00433 DENIED 10/10/19 Rev 656 HF: DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED, Rev 99223 HF, Np: DENY:SERVICES NOT ON THE FEE SCHEDULE ARE NOT SEPERATLY REIMBURSABLE. Authorization # OP1674709959 on claim and approved in portal ICN S115IEE00162 DENIED 06/27/19 ALL LINES DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED. Authorization # OP1541849417 on claim and approved in portal ICN R309IEE00881 DENIED 11/15/18 Hf: DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED . ICN R337IE500460 DENIED 02/28/19 Hf: DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED, ZW: AFTER REVIEW, PREV DECISION UPHELD, SEE PROV HANDBOOK FOR APPEAL PROCESS We have the hardcopy authorization approval letter - OP1365308837 on claim and matches letter. Not listed in portal ICN S225IEE00825 DENIED 10/03/19 REV 656 DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED. MD VISITS: DENY:SERVICES NOT ON THE FEE SCHEDULE ARE NOT SEPERATLY REIMBURSABLE. Authorization # OP1628186678 on claim and approved in

confirm? 1/30/20: Not Resolved – No payments received for ICN S115IEE00162, R309IEE00881, S225IEE00825. Correction – please remove the first ICN S220IEE00433 – it was included in Issue # 10 and I duplicated by listing it here again. (Sorry) 2/10/20- Possible settlement 3/04/20 - Mark Smith, email: Began review last week, will have more information later in the week 3/9/20 – Part of possible settlement 4/7/20- Next Level provided feedback on handful of claims. Seasons is reviewing for possible auth. Settlement still in process. 4/20/20 – pending settlement 5/7/20 –Per Hospice: Authorization backup requested was provided on 4/17/20. Mark Smith acknowledged receipt. Emailed 5/7/20 for updates on settlement status. 5/18/20 – MCO Meeting Update: 2018 claim review complete, pending breakdown from MCO of payments. 2019 claim review next. 6/3/20 - Next Level approved a small portion of 2018 claims and has started review of 2019 claims. Call set up for 6/4/20 between NL and


portal Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 10/17/19

Seasons. 2018 is not complete yet. 6/4/20: Hospice is preparing another spreadsheet of claims for their claims manager, Octavia, to review. Next Level completed their own data dump of our claims and reviewed however it did not match the Seasons aging. Mark is working on a timeline on how long UM will take to review all of our documentation and fix auth issues.

Issue 42: Descriptor Scenario/explanation: Room and Board claims are denying for patient not on PCF when hospice election is on file with HFS. Disputes have been denied stating previous decision upheld. Attempts to call provider center and escalate to provider rep have been unsuccessful. Payer is not cooperating with resolving. Denial Code & Reason: Hf: “MBR NOT CURRENTLY ON PT CREDIT FILE – WILL RECONSIDER ONCE ON FILE” MCO(s): Next Level Provider(s): Seasons Hospice Claim Examples: Claim ICN’s NL181421E03038, S015IEE00434, R242IEE00331, R191IEE00397: Hospice election is on file with HFS per eligibility, but patient has never appeared on our hospice LTC Patient Credit Report from HFS, so how do these get resolved?

11/4/19 – MCO Still reviewing to find root cause, currently there is a manual review on these claims. Will have more information at the next meeting. 12/10/19 – Not reviewed at meeting, pending MCO response 1/9/20 – No updates from Next Level – balances still outstanding 1/13/20- Payment should be issued on 1/17/20 – Seasons to confirm 1/20/20- Not Resolved – No payments received. 2/10/20- Possible settlement 3/04/20 - Mark Smith, email: Began review last week, will have more information later in the week 3/9/20 – Part of possible settlement 4/7/20- Next Level provided feedback on handful of claims. Seasons is reviewing for possible auth. Settlement still in process.


Claim ICN’s R278IEE00234, R338IEE00331, R341IEE00220, S008IEE00308, S049IEE00261: Hospice election is on file with HFS per eligibility and patient is on our hospice LTC Patient Credit Report Run Dates 12/8/18 and 1/4/19, so why are claims denied? Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 10/17/19

4/20/20 – pending settlement 5/7/20 –Per Hospice: Authorization backup requested was provided on 4/17/20. Mark Smith acknowledged receipt. Emailed 5/7/20 for updates on settlement status. 5/18/20 – MCO Meeting Update: 2018 claim review complete, pending breakdown from MCO of payments. 2019 claim review next. 6/3/20 - Next Level approved a small portion of 2018 claims and has started review of 2019 claims. Call set up for 6/4/20 between Next Level and Seasons. 2018 is not complete yet. 6/4/20: Hospice is preparing another spreadsheet of claims for their claims manager, Octavia, to review. Next Level completed their own data dump of our claims and reviewed however it did not match the Seasons aging. Mark is working on a timeline on how long UM will take to review all of our documentation and fix auth issues.

Issue 43: Room and Board claim denied for Medicare EOB Scenario/explanation: Room and Board claim incorrectly denied for Medicare EOB. Why is this denial occurring? Denial Code & Reason: “PLEASE RESUBMIT WITH THE PRIMARY MEDICARE EXPLANATION OF BENEFITS” MCO(s): Next Level Provider(s): Seasons Hospice

11/4/19 – MCO Still reviewing to find root cause, currently there is a manual review on these claims. Will have more information at the next meeting. 12/10/19 – Not reviewed at meeting, pending MCO response 1/9/20 – No updates from Next Level – balances still outstanding 1/13/20- Payment should be issued on 1/17/20 – Seasons to confirm


Claim Examples: S220IEE00477 Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 10/17/19

1/20/20- Not Resolved – No payments received. 2/10/20- Possible settlement 3/04/20 - Mark Smith, email: Began review last week, will have more information later in the week 3/9/20 – Part of possible settlement 4/7/20- Next Level provided feedback on handful of claims. Seasons is reviewing for possible auth. Settlement still in process. 4/20/20 – pending settlement 5/7/20 –Per Hospice: Authorization backup requested was provided on 4/17/20. Mark Smith acknowledged receipt. Emailed 5/7/20 for updates on settlement status. 5/18/20 – MCO Meeting Update: 2018 claim review complete, pending breakdown from MCO of payments. 2019 claim review next. 6/3/20 - Next Level approved a small portion of 2018 claims and has started review of 2019 claims. Call set up for 6/4/20 between NL and Seasons. 2018 is not complete yet. 6/4/20: Hospice is preparing another spreadsheet of claims for their claims manager, Octavia, to review. Next Level completed their own data dump of our claims and reviewed however it did not match the Seasons aging. Mark is working on a timeline on how long UM will take to review all of our documentation and fix auth issues.


Issue 44: Room and Board claim denied as non-covered in error Scenario/explanation: Room and Board claim denied as non-covered in error by health plan. Denial Code & Reason: 96: Non-Covered Charges MCO(s): Next Level Provider(s): Seasons Hospice Claim Examples: 181901E00494 – Room and Board denied as non-covered. Call ref# I-12059123 w/ Demeca, rep states claim denied for requested information not provided but could not tell us what information was being requested. Call ref# I-13203207 w/ Tiffany, rep states payer received requested Hospice NOE paperwork, but claim was not reprocessed and she would resubmit for processing. Call w/ Terry D., rep states claim was not reprocessed due to having a new vendor who processes claims – would not reprocess. Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 10/17/19

11/4/19 – MCO Still reviewing to find root cause, currently there is a manual review on these claims. Will have more information at the next meeting. 12/10/19 – Not reviewed at meeting, pending MCO response 1/9/20 – No updates from Next Level – balances still outstanding 1/13/20- Payment should be issued on 1/17/20 – Seasons to confirm 1/20/20- Not Resolved – No payments received. 2/10/20- Possible Settlement 3/04/20 - Mark Smith, email: Began review last week, will have more information later in the week . 3/9/20 – Part of possible settlement 4/7/20- Next Level provided feedback on handful of claims. Seasons is reviewing for possible auth. Settlement still in process. 4/20/20 – pending settlement 5/7/20 –Per Hospice: Authorization backup requested was provided on 4/17/20. Mark Smith acknowledged receipt. Emailed 5/7/20 for updates on settlement status.


5/18/20 – MCO Meeting Update: 2018 claim review complete, pending breakdown from MCO of payments. 2019 claim review next. 6/3/20 - Next Level approved a small portion of 2018 claims and has started review of 2019 claims. Call set up for 6/4/20 between NL and Seasons. 2018 is not complete yet. 6/4/20: Hospice is preparing another spreadsheet of claims for their claims manager, Octavia, to review. Next Level completed their own data dump of our claims and reviewed however it did not match the Seasons aging. Mark is working on a timeline on how long UM will take to review all of our documentation and fix auth issues.

Issue 45: UM Department misprocessing authorization requests (partial approvals, inappropriate denials) Scenario/explanation: General Inpatient authorization requests are being partially approved even when documentation supporting services is submitted. Authorizations also incorrectly denying for documentation (CTI) not being received even when it was submitted with initial request. UM Department will not reconsider even when proof is provided that CTI was in original request. Denial Code & Reason: DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED MCO(s): Next Level Provider(s): Seasons Hospice

11/4/19 – MCO Still reviewing to find root cause, currently there is a manual review on these claims. Will have more information at the next meeting. 12/10/19 – Not reviewed at meeting, pending MCO response 1/9/20 – No updates from Next Level – balances still outstanding 1/13/20- Payment should be issued on 1/17/20 – Seasons to confirm 1/20/20- Not Resolved – No payments received. 2/10/20- Possible settlement 3/04/20 - Mark Smith, email: Began review last week, will have more information later in the week


Claim Examples: ICN S003IEE00261 PARTIAL PAY 08/08/19. DENIED DOS 08/17/18 REV 656, DOS 08/19/18 REV 656, 08/20/18 REV 656 WITH CODE DZ: DENY: SERVICE HAS EXCEEDED THE AUTHORIZED LIMIT. ALSO DENIED DOS 08/30/18 REV 551 CODE hf: DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED. Authorization # OP1273705155 on claim and approved in portal for DOS 08/01/18 - 08/09/18 REV 651, 08/10/18 - 08/17/18 REV 656 (BUT ONLY FOR 7 UNITS - NOT 8), 08/18/18 - 08/26/18 REV 656 (ONLY 1 UNIT APPROVED, BUT LETTER SAYS AUTH IS VALID 08/19 TO 08/26/18). Authorization # OP1343580083 on claim and approved in portal for DOS 08/21/18 - 08/30/18 REV 651. Need assistance determining why all GIP units were not authorized and why SIA visit is denying for authorization. ICN S155IEE00136 08/29/19 PAID 658, DENIED 656 & 651 DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED. Authorization for hospice services GIP and Routine denied for missing doctor's certification, but the CTI was provided in the original request for authorization. Patient is still on our service and no hospice services have been approved. Need assistance ICN S158IEE00019 10/03/19 PAID 658, DENIED 656, 657 & 651 DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED. Authorization for hospice services GIP and Routine denied for missing doctor's certification, but the CTI was provided in the original request for authorization. Patient is still on our service and no hospice services have been approved. Need assistance

3/9/20 – Part of possible settlement 4/7/20- Next Level provided feedback on handful of claims. Seasons is reviewing for possible auth. Settlement still in process. 4/20/20 – pending settlement 5/7/20 –Per Hospice: Authorization backup requested was provided on 4/17/20. Mark Smith acknowledged receipt. Emailed 5/7/20 for updates on settlement status. 5/18/20 – MCO Meeting Update: 2018 claim review complete, pending breakdown from MCO of payments. 2019 claim review next. 6/3/20 - Next Level approved a small portion of 2018 claims and has started review of 2019 claims. Call set up for 6/4/20 between NL and Seasons. 2018 is not complete yet. 6/4/20: Hospice is preparing another spreadsheet of claims for their claims manager, Octavia, to review. Next Level completed their own data dump of our claims and reviewed however it did not match the Seasons aging. Mark is working on a timeline on how long UM will take to review all of our documentation and fix auth issues.


ICN S187IEE00160 10/03/19 PAID 658, DENIED 651 DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED. Authorization for hospice services GIP and Routine denied for missing doctor's certification, but the CTI was provided in the original request for authorization. Patient is still on our service and no hospice services have been approved. Need assistance ICN S067IEE00215 DENIED 03/14/19 Hf: DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED. UM department denied authorization due to CTI not received and subsequent peer to peer review not completed, but CTI was received and should have been processed. Need assistance. ICN S173IEE00182 DENIED 07/03/19 ALL LINES DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED. AUTH# OP1601630829 FOR ROUTINE DOS 05/12 - 05/20 AND OP1715933543 FOR GIP DOS 05/21 - 05/28...AUTH IS STILL PENDING FOR DOS 05/29-06/04. Payer is denying GIP authorization beyond initial 7 days without sufficient explanation. "Per Next Level Health guidelines, a maximum of 7 days can be authorized initially for hospice General Inpatient and up to 5 days may be approved with ongoing concurrent review for additional days requested." Supporting documentation has been submitted but not approved? Why? ICN S187IEE00163 DENIED 07/06/19 ALL LINES DENY: NO AUTHORIZATION ON FILE THAT MATCHES SERVICES(S) BILLED. Payer is denying GIP authorization beyond initial 7 days without sufficient explanation. "Per Next Level Health guidelines, a maximum of 7 days can be authorized initially


for hospice General Inpatient and up to 5 days may be approved with ongoing concurrent review for additional days requested." Supporting documentation has been submitted but not approved? Why? Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 10/17/19 Issue 59: Two Tiered Hospice Rates Scenario/explanation: This is a general topic to discuss process and expectations of HFS & MCO plans. Do HFS and/or the MCOs track the number of routine hospice dates a patient has? CMS guideline states that hospices are paid at a higher rate for the first 60 days of care. If a patient has previous hospice benefits, or changes from HCS to MCO, or MCO to MCO, are there any means of tracking the number of days? How do providers ensure they are not being over paid? Hospices risk over payment if there is no tracking in place. Do each MCO/HFS start over with new benefit periods & new 60 day count? Denial code and reason: no denials received at this time MCO(s): current discussion for all MCOs Providers: current discussion for all hospice providers Claim Examples: no current examples, we can bring to January meeting if needed.

12/10/19 – Not reviewed at meeting, pending MCO response 1/13/20- No one currently has a process to track days across plans, including HFS. HFS is looking into this one as well. Plans that reconcile history of hospice days (spanning hospices) BCBS Plans with no process in place currently: Next Level- they will pay the lower rate Molina- Currently no, they are working on a way to track, depending on dollars possible pay back (they pay the higher rate). Will have an answer next mtg Meridian Illinicare County Care Humana ABH


2/6/20 - see attached grid for MCO Breakdown 2/10/20- Will circle back by next meeting on the 60 day break between hospice discharge/admis 3/3/20 - HFS has provided update regarding hospice gaps. The health plans were provided with the HFS fee for service approach and were asked to be prepared to answer on Monday how they handle gaps (per Lauren Tomko) 3/9/20 – MCOs are all tracking tiered rates, however, do not have functionality to track gaps between other MCO plans If you have specific examples or claims with credits, please reach out to MCO directly regarding balances MCOs to provide update if they are on track to put a process in place to track gaps 4/20/20 – Most MCOs can track multi-hospice, but not multi-MCO. Illinicare can track other MCO and will provide their workflow to see if it helps other MCOs Question – if hospices see balances on these claims, how should they resolve credits/short payments? 5/18/20 – MCO Meeting Update: If Hospice sees balances on claims, they should….

• Next Level: Send refund check with explanation & backup of overpayment

• IlliniCare: Send refund check with explanation & backup of overpayment


• Aetna Better Health: Send refund check with explanation & backup of overpayment

• Meridian: Send refund check with explanation & backup of overpayment

• BC IL: Send refund check with explanation & backup of overpayment

• Molina: Reviewing & will provide update on next call • County Care: at this time, they advise providers to keep

overpayment 6/5/20: Pending update from Molina & County Care for issue to be closed.

Issue 67: Descriptor Scenario/explanation: Claims denying for hospice service intensity add-on (SIA) visits i.e.). Denials stating due to no preauth completed for SIA visits. Denial Code & Reason: CO-197 “Precertification/ authorization /notification/ pre-treatment absent.” MCO(s): lIlinicare Health Plan Provider(s): Northern Illinois Hospice Claim Examples: Claim # S282ILE16597– 09/27/19-09/30/19 – Billed revenue code 0651 for hospice routine home care, billed G0299 for hospice SIA visits on 09/28/19 & 09/30/19. 0651 paid and

4/20/20 – MCO shows claims were returned for adjustment & will have paid date for next call. Hospice to confirm if any payment is processed. 5/18/20: MCO Meeting Update: Date of Death was not on claim, please review claim submission as this was denied accurately. MCO to respond to Northern Illinois Hospice directly with results 6/5/20 – Hospice confirmed still pending payment


G0299 SIA visits denied for no authorization. Provider sending Claim Examples: Northern Illinois Hospice Date Claim Examples Sent: 03/13/20 Issue 69: Descriptor Scenario/explanation: Claims denying for hospice service intensity add-on (SIA) visits i.e.). Denials stating due to no preauth completed for SIA visits. Denial Code & Reason: A1: “Deny: No authorization on file that matches service.” MCO(s): lIlinicare Health Plan Provider(s): Northern Illinois Hospice Claim Examples: Claim # T037ILE10803– 01/01/20-01/19/20 – Billed revenue code 0651 for hospice routine home care, billed G0155/G0299 for hospice SIA visits on 01/17/20 & 01/18/20. 0651 paid and G0299 SIA visits denied for no authorization. Provider sending Claim Examples: Northern Illinois Hospice Date Claim Examples Sent: 03/13/20

4/20/20 – MCO shows claims were returned for adjustment & will have paid date for next call. Hospice to confirm if any payment is processed. 5/18/20: MCO Meeting Update: Returned for adjustment and should be processed on next check run. 6/8/20: Per Hospice, SIA paid, but still haven’t paid for CC.

Issue 72: Incorrect Room and Board Pricing Resulting in 4/20/20 – Hospice & IlliniCare are working on resolution during


Overpayment to Provider Scenario/explanation: Incorrect rates and/or 5% reduction not applied when processing room and board claims Denial Code & Reason: CO-45 MCO(s): Illinicare Provider(s): Seasons Hospice Claim Examples: R307ILE06322, R214ILE04059, S008ILE16137, S186ILE09853, S281ILE11706, R024IL504659, R093IL509489, R317ILE16374, R101IL509254, R080IL509477, R162ILE08122, S156ILE15055, R360ILE08047, Q237ILE07803, Q265ILE09349, Q279ILE09519, Q346ILE03744, R075ILE09791, R075ILE09785, R214ILE04058, R347ILE14658, R347ILE14588, R317ILE16263, R080IL507170, S249ILE14344, S290ILE04684, T060IL514580, R092IL506564, R317IL513204, S065ILE16243, S252ILE18752, R332ILE12107, R341ILE03114, Q192ILE11063, R341ILE03206, Q269ILE10599, S218ILE17424, R310ILE13510, S007ILE09091, R026ILE05357, S157ILE15455, S189ILE15575, R211ILE09538, S273IL505674, R171ILE15739, R220IL605026, Q311ILE00235, Q346ILE03743, R101IL505563, R157IL511076, R096ILE08127, S007ILE09200, R324ILE11537, R033IL507189, R307ILE06458, S233ILE15664, Q098ILE03137, S280ILE11504 Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected. Providers are all encouraged to work with MCO Rep for any systematic issues. 6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response


Issue 73: Incorrect Room and Board Pricing Resulting in Underpayment to Provider Scenario/explanation: Incorrect rates and/or other miscalculations applied when processing room and board claims Denial Code & Reason: CO-45 MCO(s): Illinicare Provider(s): Seasons Hospice Claim Examples: S310ILE05693, S280IL506033, S175IL519712, R093IL509478, R340IL511567, S094ILE14980, S218ILE17437, S084ILE06556, R282IL617532, R257ILE11262, S249IL817239, S277ILE15310, S161ILE16491, S233ILE15599, S241ILE09810, R218ILE01704, S157ILE15454, R110IL511536, S008ILE15927, S172ILE19982, S037ILE23232, Q182ILE02002, Q196ILE01829, Q182ILE01755, S015ILE01536, Q203ILE02834, R008ILE09894, S047ILE00445, S101ILE10561, R345ILE11798, S212ILE07148, S280ILE11477 Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

4/20/20 – Hospice & IlliniCare are working on resolution during separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected. Providers are all encouraged to work with MCO Rep for any systematic issues 6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response

Issue 74: Patient Liability not deducted from room and board claim resulting in overpayment to provider

4/20/20 – Hospice & IlliniCare are working on resolution during separate call


Scenario/explanation: Payment received includes patient liability that should have been deducted and was present on PCF at time of claims processing Denial Code & Reason: CO-45 MCO(s): Illinicare Provider(s): Seasons Hospice Claim Examples: S340ILE15404, S065ILE16200, R078ILE06876, R128ILE09606, R178ILE16790, S218ILE17426, R065ILE10101, Q067ILE04312, S325ILE12353, R157ILE14006, S218ILE17423, S218ILE17537, S179ILE15000, R107ILE10016, S249ILE14614 Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected. Providers are all encouraged to work with MCO Rep for any systematic issues 6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response

Issue 75: Patient Liability deducted from both NH claim and Hospice claim in error Scenario/explanation: Patient admitted to hospice mid-month and patient liability was deducted from both room and board claims in error Denial Code & Reason: CO-45 MCO(s): Illinicare

4/20/20 – Hospice & IlliniCare are working on resolution during separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by


Provider(s): Seasons Hospice Claim Examples: S299IL505168 PL 1141 was already deducted from NH claim on ICN S213MCE13726 NPI 1003308677 Arista Healthcare LLC. PL should not have been deducted from hospice claim Q273ILE02576 PL 1420 was already deducted from NH claim on ICN Q259ILE03012 NPI 1467426676 Meadowbrook Manor Lagrange. PL should not have been deducted from hospice claim T060IL515238 PL 1355.83 was already deducted from NH claim leaving only 225.17 to be deducted from hospice claim. Full PL 1581 was deducted in error Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

6/15/20. Pricing was a system error that has now been corrected. Providers are all encouraged to work with MCO Rep for any systematic issues 6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response

Issue 76: Patient Liability deducted from both NH claim and Hospice claim in error Scenario/explanation: Patient admitted to hospice mid-month and patient liability was deducted from both room and board claims in error Denial Code & Reason: CO-45 MCO(s): Illinicare Provider(s): Seasons Hospice

4/20/20 – Hospice & IlliniCare are working on resolution during separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected.


Claim Examples: S299IL505168 PL 1141 was already deducted from NH claim on ICN S213MCE13726 NPI 1003308677 Arista Healthcare LLC. PL should not have been deducted from hospice claim Q273ILE02576 PL 1420 was already deducted from NH claim on ICN Q259ILE03012 NPI 1467426676 Meadowbrook Manor Lagrange. PL should not have been deducted from hospice claim T060IL515238 PL 1355.83 was already deducted from NH claim leaving only 225.17 to be deducted from hospice claim. Full PL 1581 was deducted in error Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

Providers are all encouraged to work with MCO Rep for any systematic issues 6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response

Issue 77: Room and Board claim denied in error for not on Patient Credit File Scenario/explanation: Room and Board Denied COA1/MA54 "Physician certification or election consent for hospice care not received timely." NOE was on file with HFS and we had authorization. Denied in error Denial Code & Reason: COA1/MA54 MCO(s): Illinicare Provider(s): Seasons Hospice

4/20/20 – Hospice & IlliniCare are working on resolution during separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected. Providers are all encouraged to work with MCO Rep for any


Claim Examples: S248IL517164, S281IL504037, S290ILE04743, S028ILE15274, S028ILE15501, S094ILE14964, S126ILE17841, S218ILE17450, S280ILE15299, S330IL515343 Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

systematic issues 6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response

Issue 78: Claim recouped in error for missing value codes when value codes were present on claim Scenario/explanation: COA1/M49 missing value code, but value codes 61 and 80 were included on our claim Denial Code & Reason: COA1/M49 MCO(s): Illinicare Provider(s): Seasons Hospice Claim Examples: R220IL606620 Recouped in error for COA1/M49 missing value code, but value codes 61 and 80 were included on our claim. Provider rep did not respond to inquiry or have claim reprocessed R219IL611786 Denied in error for COA1/M49 missing value code, but value codes 61 and 80 were included on our claim. Provider rep did not respond to inquiry or have claim



reprocessed R219IL611788 Denied in error for COA1/M49 missing value code, but value codes 61 and 80 were included on our claim. Provider rep did not respond to inquiry or have claim reprocessed Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20


Issue 79: Room and Board corrected claim denied in error Scenario/explanation: Claim billing errors were corrected and 817 submitted within timely filing but denied in error Denial Code & Reason: CO95/N627 MCO(s): Illinicare Provider(s): Seasons Hospice Claim Examples: T038IL505484 Denied CO95/N627 "Service not payable per managed care contract" in error. Corrected claim submitted within timely and should have been paid Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20


Issue 80: Claims denied in error for authorization when authorization number was on claim or UM department misprocessed authorization request Scenario/explanation: Claim billing errors were corrected and 817 submitted within timely filing but denied in error Denial Code & Reason: CO197 MCO(s): Illinicare Provider(s): Seasons Hospice

4/20/20 – Hospice & IlliniCare are working on resolution during separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected.


Claim Examples: R363IL504635 DOS 9/1-9/15 denied CO15- Authorization but we had authorization OP1113096081 S115ILE11554 Denied DOS 03/17/19 – 03/31/19 CO197 on 05/08/19. UM department mishandled our auth request which had to be corrected. Corrected claim submitted 09/05/19 (within timely filing) to add second authorization number and was denied untimely in error on ICN S248IL517161. Corrected claim was submitted within 6 months of LDOS and within 6 months of denial EOB. S340ILE15422 0658 Denied in error CO197. Auth # OP1579931778 was on claim and per approval letter service dates 10/15/19 – 12/13/19 approved for 60 days S161ILE16485 Denied for CO197 in error due to UM department misprocessing auth request. Auth request sent 04/04/19 was for rev code 0655 DOS 04/02/19 – 04/06/19, but UM approved rev 0656 for these dates in error. Not corrected until 01/16/20 and resubmission denied untimely as a result. S047ILE01073 RB dates of service 01/01/19-01/12/19 denied CO15/Authorization. The November recertification requests were faxed on 11/13/18 and not processed. We followed up and re-faxed the request on 12/05/18 and not processed. We followed up on 01/18/19 and were told by Latrice P. that request would not be processed. UM department did not process auth request causing 1/1-1/12 to deny in error S233ILE15591 Denied CO197 Authorization in error. Auth# OP1685267360 on claim and per auth letter rev 0651 services

Providers are all encouraged to work with MCO Rep for any systematic issues 6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response


dates 07/24/19 – 07/31/19 approved for 8 units S281ILE11765 Denied CO197 Authorization in error. Auth# OP1685267360 on claim and per auth letter rev 0651 services dates 08/01/19 – 08/31/19 approved for 31 units R200ILE09562 GIP dates of service 06/16/18-06/22/18 denied CO15/Authorization in error. Auth # OP1285716161 effective 06/15/18-09/12/18, 90 units approved decision date 06/22/18. Please reprocess correctly. R341ILE02940 GIP dates of service 11/03/18-11/04/18 denied CO15/Authorization in error. Auth # OP1408558015 effective 10/27/18 – 11/04/18, 9 units approved decision date 11/02/18. Illinicare paid 5 units for the October claim, leaving 4 approved units for the November claim. Also, Wrong GIP rate paid: Paid 769.87/day. Should be 784.90/day. S176IL515777 Denied for no authorization. Auth request was faxed 02/11/19 but no authorization on file. Escalated to UM to reprocess and auth finally granted 12/31/19 Auth# OP1856601885. Please reprocess due to UM dept error S311ILE11256 Denied CO197 for all DOS but claim has auth# OP1577132873 valid 07/01/19 – 07/11/19. Please reprocess these dates for payment Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20 Issue 81: Missing/incomplete/invalid "from" date of service Scenario/explanation: Claims denying inappropriately for “From” date of service, but claim is billed correctly.

4/20/20 – Hospice & IlliniCare are working on resolution during separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed


Denial Code & Reason: CO16/M52 MCO(s): Illinicare Provider(s): Seasons Hospice Claim Examples: S084ILE02651, T066ILE04539, T053ILE02349, T011ILE04676, S040ILE01956, T078IL508079, S357ILE11588, S040ILE01560, R277ILE14807, S267ILE12011, R171ILE15754 Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected. Providers are all encouraged to work with MCO Rep for any systematic issues 6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response

Issue 82: Pricing errors on hospice claims Scenario/explanation: Incorrect rates being paid on hospice levels of care Denial Code & Reason: CO45 MCO(s): Illinicare Provider(s): Seasons Hospice Claim Examples: S310ILE05711 Rate 193.35/Day x 31 Days x 95% - PL of 0 + Routine 31 Days @ 200.17 = Expected payment of 11899.43. Payment received = 11380.86. Routine DOS 10/19 - 10/31/19

4/20/20 – Hospice & IlliniCare are working on resolution during separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected. Providers are all encouraged to work with MCO Rep for any systematic issues 6/3/20 – Pending 2017 claims project number from Karina. Call


paid at 61+ rate in error S339ILE21347 Rate 193.35/Day x 30 Days x 95% - PL of 0 + Routine 25 Days @ 200.17 + Routine 5 Days @ 158.20 = Expected payment of 11305.73. Payment received = 10969.97. Routine DOS 11/18-11/25/19 paid at 61+ rate in error S060ILE13920 Wrong GIP rate paid: Paid 174.21/day. Should be 784.90/day S311ILE11314 Routine should be paid at 0-60 rate of 203.71 but was paid at 160.28 in error S311ILE11329 Routine should be paid at 0-60 rate of 203.71 but was paid at 160.28 in error for DOS 06/01/19 - 06/11/19 Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

scheduled for 6/4 to review Illinicare rebuttal response

Issue 83: Routine claim denied in error Scenario/explanation: Incorrect rates being paid on hospice levels of care Denial Code & Reason: CO198/N362 MCO(s): Illinicare Provider(s): Seasons Hospice Claim Examples: T066ILE04823 DOS 02/29/20 Denied CO198/N362 "Number of days or units exceeds acceptable maximum" in error.

4/20/20 – Hospice & IlliniCare are working on resolution during separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected. Providers are all encouraged to work with MCO Rep for any systematic issues


Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response

Issue 84: SIA Visits denied in error Scenario/explanation: SIA Visits do not require authorization but were denied for this reason. Denial Code & Reason: CO197 MCO(s): Illinicare Provider(s): Seasons Hospice Claim Examples: S212ILE07149 SIA Visits denied CO197 in error - SIA does not require authorization Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20


Issue 85: Claims recouped in error during overpayment recovery projects Scenario/explanation: Incorrect recoupments for various reasons listed below. Denial Code & Reason: Multiple MCO(s): Illinicare

4/20/20 – Hospice & IlliniCare are working on resolution during separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call.


Provider(s): Seasons Hospice Claim Examples: R256IL609192 R&B claim originally denied for Hospice NOE in error. Claim was reprocessed and paid on ICN R065ILE10103 but then recouped. Subsequent denials for timely filing. Our NOE was on file and claim submitted within timely filing. Please reprocess correctly. R157ILE13991 Recouped in error stating "claim paid amount greater than billed amount." Billed amount was 5612.55 and paid amount 4472.00. Rate 181.05/Day x 31 Days x 95% - PL of 1174.80 = Expected payment of 4157.12. Payment received after recoupment = 502.06 S056ILE15384 Recouped in error CO95/N627 "Service not payable per managed care contract" Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

5/18/20: MCO Meeting Update: MCO is working directly with Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected. Providers are all encouraged to work with MCO Rep for any systematic issues 6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response

Issue 86: Payer recouped payment when refund had already been issued via check to payer Scenario/explanation: Duplicate overpayment recovery Denial Code & Reason: N/A MCO(s): Illinicare Provider(s): Seasons Hospice

4/20/20 – Hospice & IlliniCare are working on resolution during separate call 5/7/20 – Call completed with Illinicare on 4/27/20. Seasons submitted response spreadsheet 5/1/20. Karina Benitez confirmed receipt 5/4/20 and stated would forward to claims team for review. Pending response and scheduling of next follow up call. 5/18/20: MCO Meeting Update: MCO is working directly with


Claim Examples: Q126ILE02402 was recouped due to payment duplicated payment made for Q112ILE00748 but we refunded payment for ICN Q112ILE00748 on check # 3400008528 in the amount of 3801.60. Please repay 3002.11 Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20

Hospice on resolution. The project is expected to be completed by 6/15/20. Pricing was a system error that has now been corrected. Providers are all encouraged to work with MCO Rep for any systematic issues 6/3/20 – Pending 2017 claims project number from Karina. Call scheduled for 6/4 to review Illinicare rebuttal response

Issue 87: Duplicate payments received by payer Scenario/explanation: Duplicate payments made by payer – unknown reason Denial Code & Reason: N/A MCO(s): Illinicare Provider(s): Seasons Hospice Claim Examples: Q126ILE07817 paid $536.82 then received another payment on ICN Q133ILE09999 S172ILE10846 Payment duplicates previous payment made on ICN S127ILE15352 S172ILE10863 Payment duplicates previous payment made on ICN S163ILE13025



Provider sending Claim Examples: Seasons Hospice Date Claim Examples Sent: 03/27/20 Issue 89: Global Hospice Issue Scenario/explanation: Illinicare is not accepting MEDI to prove PCF issues. All MCO are following suit. Denial Code & Reason: N/A MCO(s):IlliniCare/ All Provider(s): All Claim Examples: Available if needed Provider sending Claim Examples: Date Claim Examples Sent:

4/20/20 – HFS will discuss internally on how they will handle delays 5/18/20 – MCO Meeting Update: ILHPCO will work with IAMHP and HFS regarding this global issue to discuss options that hospice providers have. 6/5/20 – Carrie reached out to IAMHP and HFS to start discussion on how hospice can provide proof and work with timing issues related to the PCF.

Issue 90: Descriptor Scenario/explanation: Claim denies for having no authorization on file. For DOS on or after 1/27/2020, no auth is necessary for hospice R&B claims. Denial Code & Reason: A1: Claim denied for no authorization on file. MCO(s): Illinicare Health Provider(s): Joliet Area Community Hospice Claim Examples Claim T101ILE10217, T108ILE05684, T108ILE05726, T108ILE05712, T071ILE11493, T101ILE10204, T071ILE11447,

5/18/20 – MCO Meeting Update: Under review – will have update by next meeting.


T101ILE10212, T101ILE10191 Provider sending Claim Examples: Joliet Area Community Hospice Date Claim Examples Sent: 4/27/2020 Issue 91: Descriptor Scenario/explanation: Claims being rejected due to a date of birth issue listed with HFS. HFS corrected the patient DOB and Vitas resubmitted the claims to Meridian and the claims were denied for timely. On 3/5/20 Meridian received approval to waive timely filing and they will have the claims reprocessed. After 03/05/20 no communication has been received from Meridian, claims have not been processed and claims are pending payment. Denial Code & Reason: Invalid DOB, Timely filing MCO(s): Meridian Health Plan Provider(s): Vitas Healthcare Claim Examples: 146696426, 146696442, 146696422, 146696412, 146696418, 146696434, 146696430 and 146696403 Provider sending Claim Examples: Vitas Healthcare Date Claim Examples Sent: 12/06/2019

5/18/20 – MCO Meeting Update: All claims were initially denied for Timely Filing. Hospice, are the examples provided your initial claim submission? Or the resubmission after DOB was corrected? 6/2/20 - Denials were from initial claims submission, however email sent on 05/19/20 to Idette McCrary where timely filing was approved to be waived.


Issue 92: Descriptor • Scenario/explanation: County Care is holding payments again.

Payments have been pending for more than 60 days. We reflect a large volume in balances with no denial or payment Data. Based on communications with County Care we they are holding payments. We have identified Date of Service ranging from October 2019 to current.

• Denial Code & Reason: No denials are dropping due to the holding of payments

• MCO(s): County Care • Provider(s): VITAS Healthcare • Claim Examples: VITAS has submitted claim within the required

filing limit but county care is not processing claims or denials due to funding issues. We are pending the response of claims submitted more than 60 days

• Provider sending Claim Examples: VITAS Date Claim Examples Sent: 5/7/2020

5/18/20 – MCO Meeting Update: Claims were released for payment on 5/6 – Please confirm? 6/2/20 – Per Hospice, We still have a large dollar amount in outstanding receivables for County Care after receiving a small amount. County Care has not release the rest of payments nor denials.

Issue 93: Descriptor • Scenario/explanation: Claims are denied with RARC: M52:

missing/incomplete/invalid “from” date(s) of service. But the date spans match the units billed

• Denial Code & Reason: RARC: M52: missing/incomplete/invalid “from” date(s) of service.

• MCO(s): Illinicare • Provider(s): VITAS Healthcare • Claim Examples: T015ILE14147 • R337ILE15341 • R082ILE01763

5/18/20 – MCO Meeting Update: Claims set to pay Wednesday May 20th. This was also part of the IlliniCare global pricing issue. Hospice to confirm payment was received. 6/2/20 – Hospice is still pending payment

Association: Top Medicaid MCO Denials Meeting Date • T073ILE11593 • T073ILE11739 • T073ILE11683

• Claims are being recouped stating a corrected claim was submitted.

No additional payment has been made • Provider sending Claim Examples: VITAS Date Claim Examples Sent: 10/8/2020

Closed Items since 6/1/20 – for a complete list of closed Agenda items, please reach out to Kelly Schnetzer, [email protected].

Issue 32: Descriptor Scenario/explanation: Payer has recouped dollars without a refund request letter or any acknowledgment and are stating we are now in a recurring negative balance. The negative balance report does not reconcile and when escalated to payer they stated back in July they would look into this and have not provided any other response since after many follow up attempts. Denial Code & Reason: Recoupment of Payments MCO(s): Aetna Better Health of IL Provider(s): VITAS Healthcare

10/7/19 - One claim was already repaid. Remaining two claims were denied as duplicate in error. Aetna will repay claims by 10/21/19. 10/21/19 – Vitas billing error, Aetna reached out to Alexis to resolve. Vitas please confirm. 11/4/19 – Vitas please confirm you resolved the billing error??? 11/5/19-VITAS aware of billing error but VITAS escalated issue is unable to reconcile negative balance report for claims in question 1/6/20 – Not reviewed at 12/10 meeting, pending MCO response VITAS to confirm balances outstanding still


Claim Examples: 16128C129702R2, 16100C271540R3, 17125C144953R2 Provider sending Claim Examples: VITAS Healthcare Date Claim Examples Sent: 9/24/19

1/7/20 – Balances remain unpaid, Vitas is in communication with Aetna Rep. 1/13/20- 2 billed in error, Vitas needed to rebill – hospice to confirm 1/30/20- Vitas billing claims per request – pending results 2/10/20- Reached out to Alexius to correct billing error, need to resubmit, do you have the email from Aetna? 3/2/20 – Per Vitas, they emailed Madiha on 3/2/20 to schedule time to discuss for Wednesday March 4th. 3/9/20 – Per MCO, they show this is resolved & provider was asked to resubmit. Vitas, please confirm. 4/8/20 – Per Hospice, claims were resubmitted to Aetna per their request pending adjudication. 4/20/20 – Aetna not on call – will update for next meeting 5/7/20: Claims were rebilled to Aetna - pending response 5/18/20 – MCO Meeting Update: Received 2 claims, they are in process to pay by 5/26 6/8/20 – Per Hospice, issue closed, claims paid

Issue 68: Descriptor Scenario/explanation: Claims denying for hospice service intensity add-on (SIA)

4/20/20 – MCO shows claims were returned for adjustment & will have paid date for next call. Hospice to confirm if any payment is processed.


visits i.e.). Denials stating due to no preauth completed for SIA visits. Denial Code & Reason: CO-197 “Precertification/ authorization /notification/ pre-treatment absent.” MCO(s): lIlinicare Health Plan Provider(s): Northern Illinois Hospice Claim Examples: Claim # S280ILE11499– 09/04/19-09/07/19 – Billed revenue code 0651 for hospice routine home care, billed G0155/G0299 for hospice SIA visits on 09/04/19 & 09/05/19. 0651 paid and G0299 SIA visits denied for no authorization. Provider sending Claim Examples: Northern Illinois Hospice Date Claim Examples Sent: 03/13/20

5/18/20: MCO Meeting Update: Returned for adjustment and should be processed on next check run. 6/8/20: Per Hospice, Issue closed.

top medicaid mco denials: ilhpco - hospice

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