wyoming medicaid provider information and resources wyoming medicaid provider workshops summer 2015...
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Wyoming Medicaid Provider Information and Resources
Wyoming Medicaid Provider Workshops
Summer 2015
Presenter: Kilee Thompson, Field Representative
Provider Manuals
Located on the Wyoming Medicaid Websiteo http://wymedicaid.acs-inc.como Select Providero Select Provider Manuals and Bulletins (Left Hand Navigation Bar)o Select appropriate provider typeo Open provider manual listed for your provider type
Provider Manual Updateso Many changes are being made to the Provider Manuals to update
and improve the informationo Please look for these changes in the next couple months.
April 19, 20232
Chapter 1: General Information & 2: Getting Help when You Need It
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Chapter 3: Provider Responsibilities
• Enrollment
• Accepting Medicaid Clients
• Medical Necessity
• Medicaid Payment is Payment in Full
• Out-of-State Service Limitations
• Medicare Covered Services
• Usual and Customary Charges
• Record Keeping, Retention, and Access
• Tamper Resistance Rx Pads
April 19, 20234
Chapter 4: Utilization Review
• Utilization Review
• Complaint Referral
• Release of Medical Records
• Client Lock-In
• Fraud and Abuse
• Provider Responsibilities
• Referral of Suspected Fraud and Abuse
• Sanctions
• Adverse Actions
April 19, 20235
Chapter 5: Client Eligibility
• What is Medicaid?
• Who is Eligible?
• Maternal and Family Health (MFH)
• Eligibility Determination
• Client Identification Cards
• Other Types of Eligibility Identification
• Clients without Cards
• Freedom of Choice
• Verification of Client Eligibility
• Verification Options
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Chapter 6: Common Billing Information
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Chapter 7: Third Party Liability
• Definition of a Third Party Payer
• When Clients Have Third Party Liability (TPL)
• Identifying Other Sources of Coverage
• Exceptions to Billing Third Party Payers First
• Preventive Pediatric Care
• Prenatal Care
• Health Insurance Policies Held by Absent Parents
• 100% Federally Funded Programs
• Legal Liability Has Not Been Established
• Billing Third Party Payers
• Previous Attempts to Bill Services Letter
• Coordination of Benefits
• Questions about TPL
• Third Party Resources Information Sheet
April 19, 20238
Chapter 8: Electronic Data Interchange• What is Electronic Data Interchange (EDI)
• Benefits
• Standard HIPAA Transaction Formats
• Sending and Receiving Transactions
• EDI Services
• Web Portal
• WINASAP
• Additional Information Sources
• Scheduled Web Portal Downtime
April 19, 20239
Chapter 9: Wyoming Specific HIPAA 5010 Electronic Specifications• Wyoming Specific HIPAA 5010 Electronic Specifications
• Transaction Definitions
• Transmission Methods and Procedures
• Acknowledgement and Error Reports
• Testing
• 270/271 Eligibility Request and Response
• 276/277 Claim Request and Response
• 278 Request for Review and Response
• 835 Claim Payment/Advice
• 837 Professional Claims Transactions
• 837 Institutional Claims Transactions
• 837 Dental Claims Transactions
April 19, 202310
Chapter 10: CMS-1500 Covered Services
April 19, 202311
Chapters 10+: Institutional Covered Services
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Provider Reenrollment
• The Affordable Care Act (ACA) is requiring that all Medicaid providers are screened and re-enrolled at least every five (5) years.
• This includes both Pay-To Providers, and Treating Providers.
• Most providers can re-enroll by visiting the Wyoming Medicaid website at http://wymedicaid.acs-inc.com and selecting the “Provider” tab. Then select the “Provider Enrollment” link on the left hand navigation bar.
• Additional information about the reenrollment process can be found at the same website under the “CMS Reenrollment” link
• If you unsure about whether you have completed the reenrollment process, please contact provider relations at 800.251.1268 options 1, 5, and then 0 to speak to a representative who will be able to tell you the last date that an enrollment was completed.
Must be completed by December 31, 2015
April 19, 202313
835 Vs. Remittance Advice (RA)
835 Electronic Remittance Advice•X12N 835 Claim Payment/Remittance Advice
•Used to autopost claim payments
•Nonproprietary Explanation of Benefits
• Standard pre-set explanations
•Can be retrieved through a clearinghouse, a direct connection, or downloaded from the Provider Web Portal
Remittance Advice•Claims are grouped by disposition: Paid, Denied, Pended, and Adjusted
•The above groups are alphabetized by client last name.
•Proprietary Explanation of Benefits• Wyoming Medicaid specific
explanations
•Can be retrieved through the Wyoming Medicaid Provider Web Portal
April 19, 202314
Electronic Claims Mandate
All providers submitting claims containing diagnosis codes to Wyoming Medicaid will be required to follow this mandate
Exceptions: o Providers submitting 25 claims or less in a calendar year
o Adjustments do not count towards the 25 claims
o Providers which do not submit claims with ICD-9 or 10 diagnosis codes
To get started:o If you already bill electronically through the Provider Web Portal, WINASAP or a
clearinghouse which submits your claims electronically, no further action is required.o If you have not yet started billing electronically, please review chapter 8 and 9 of either
provider manual and complete an EDI Applicationo To use the Provider Web Portal to bill, please utilize the Provider Tutorials listed on the
website and contact EDI Services at 800.672.4959 Option 3 with any questions you may have.
Effective July 1, 2015
April 19, 202315
Electronic Claims Mandate
Another feature available on the Provider Web Portal is the ability to submit electronic attachments for your claims or you can submit your attachments by paper by completing the Attachment Cover Sheet
Requesting an exemptiono Must submit request in writingo Request must include
Provider name, NPI, Contact name, and phone number The calendar year which to be exempt and reason for the exemption The approximate future date you will be ready to submit claims electronically Detailed explanation of the reason for exemption
Effective July 1, 2015
April 19, 202316
Provider Contacts
It is important for all providers, both treating and pay-to providers, to maintain current and accurate contact information. Why it is important to update provider contact information.
o To receive up-to-date policy informationo To know when to renew your licenseo Any other communication which needs to occur between Wyoming Medicaid and providers
To update your provider contact information, please do the following:o Fax in a written correspondence on office letter with your requesto Please include:
NPI/Provider number Provider contact information which needs updated
• Physical, correspondence, or financial address, provider phone or fax number, or email addresses on file
Date this change will go into effecto Pay-to Providers can also update their contact information by logging into the Provider Web Portal
and going to “Update Provider Demographics”o Email addresses on file can also be updated by speaking to a representative at
Provider Relations by calling 800.251.1268 options 1, 5, and then 0.
April 19, 202317
Resources
April 19, 202318
Resources
IVR 1.800.251.1268o 24 hours a day / 7 days per weeko NPI is required
IVR Functionalityo Verify client eligibility
Client ID or client SSN and date of service is required Benefit plan
• Covered services• Limitations
Cap Limits Lock-in TPL / Medicare Buy-in
o Verify claim statuso Verify Paymento Opt out to agent
April 19, 202319
Resources
Provider Relations 1.800.251.1268 (Option 1,5,0)o 9-5 MST Monday - Fridayo Bulletin / Manual inquiries o Cap limitso Claim inquirieso Claim submission problemso Client eligibilityo Questions on completing formso Payment inquirieso Timely filing inquirieso Billing issues regarding PAo Verifying validity of procedure codeso Claim void / adjustment inquiries
Fax Numbero 307.772.8405
April 19, 202320
Resources EDI Services 1.800.672.4959 (Option 3)
o 9-5 MST Monday – Fridayo EDI Enrollment Formo Trading Partner Agreemento WINASAP Software & Technical Support for WINASAP o Technical Support for Vendors, Billing Agents, and Clearinghouseso Provider Web Portal Registrationo Technical Support for Provider Web Portal & Password Resets
Medical Policy 1.800.251.1268 (Option 1,1,4,3)o 9-5 MST Monday – Fridayo Prior Authorizations (PAs) Requests for:
o Out-of-State Home Healtho Surgeries requiring Paso Hospice Services: Limited to Clients Residing in a Nursing Home
o Status of a Pending PAo How to Complete a PA Requesto Office Visit, PT, and OT Cap Limit Waiver Requests
April 19, 202321
Questions?
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