AADD submitted a letter to Department of Health Care Services requesting a resolution plan for the following issues:
MMIS Conversion Issues experienced by Waiver and PCA Providers since 10/01/13
CLAIM SUBMITTAL and DENIAL CODES
Claims are denied for lack of a rendering provider NPI and rendering provider ID, for services such as respite and chore which do not require a rendering provider NPI.
Payment rates do NOT always match the new rates as of July 1, 2013—nor did the rates match any previous rate for that provider agency. This is especially prevalent in PCA services.
Claim types for recipients which had previously processed without issue in the old system (meals, for example) are going into suspended status, then being released the following week.
New Waiver Service categories (for example, Group Day Habilitation, Group Supported Employment, Pre Employment Services) which became effective July 1, 2013 and would not pay in the old MMIS system, were not resolved in the Health Enterprise release.
New EOB denial codes not previously seen that are incongruent with data. For example, hourly respite amounts which are denied for “exceeding daily respite amount” which do not exceed the daily respite amount.
Claims are being denied for timely filing, although the date of service is clearly within one year of filing.
Acuity Add-ons (TG modifiers) are being denied as duplicate services in error.
Providers are experiencing an excessively high rate of denials (25%-95%) of weekly claims submitted, including for agencies with prior denial rate of 2%-3% of weekly claims submitted.
PAYMENT PROCESSING TIMELINES AND REMITTANCE ADVICES
Claims submitted prior to the Thursday deadline are being processed 1-2 days after the deadline
AVRS payment information is not available until Monday (compared to Wednesday following the Tuesday deadline in the old EVS system)
835 file formats are not consistently available to download to apply your payments electronically. Some providers still do not have and 835 folder set up by Xerox. 835 files do not contain the Remittance Advice Number, or the Medical Record Number (invoice number) from the originating billing system. No training guide appears to be available for the new formats.
Remittance Advices are only available in paper or .pdf format which requires additional paper and printing time and cost to providers, as well as extensive manual payment application. They are missing the Medical Record Number (invoice) captured in the old MMIS system which allows identification of the original invoice when applying payments.
EFT Payments which were previously slated to be available on the Tuesday following the Thursday deadline, are not available in provider bank accounts until Fridays (3-4 days later)
Advances are due to start being recovered from this week’s cycle (10/25/13) over 6 payments but paid claims may not be sufficient to recover these amounts, and allow sufficient cashflow for providers to meet regular expenses such as payroll.
ELIGIBILITY AND PRIOR AUTHORIZATION VERIFICATION
Prior Authorization has not transferred from the old EVS system to allow access via phone, and there is no current means of identifying how many units remain unbilled on a Service Authorization
New Service Authorizations have a different format which was not previously published for testing. The 10-character format starting with an alpha-character requires reconfiguration of billing software.
Senior and Disability Services report that they do not have access to generate new Service Authorizations for Plans of Care approved, or to make corrections to Service Auths containing errors
Web access only allows viewing of eligibility status, but not claim status or service authorizations for recipients