KanCare All MCO Training - Spring 2021 - KMAP
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KanCare All MCO Training Spring 2021
Welcome, Introductions &
Agenda
• Welcome
• Introductions
– Aetna Better Health of Kansas
– Sunflower Health Plan
– United HealthCare
• Agenda for the day
– Session 1 – KanCare 101
– Session 2 –
• Denials and Helpful Hints
• Policy Updates
2
Who is Assigned to a
MCO?
• The majority of Medicaid beneficiaries will be assigned to one of the
3 KanCare Managed Care Organizations (MCO)
• Examples of populations excluded:
– Qualified Medicare Beneficiary (QMB) only members
– Low Income Beneficiary (LMB) only members
– Emergency Care for Immigrants (SOBRA) members
– Tuberculosis (TB) Only members
– MediKan members
Claims for members in these categories will be submitted to
Kansas Medical Assistance Program (KMAP) for processing.
Note: If a member has retro-eligibility which exceeds 90 days,
there may be months where the member does not have an MCO
assignment. Claims for those months would be billed to KMAP.
3
Member Eligibility and
MCO Assignment?
• Options
– KMAP Website
– MCO Websites
– EDI transactions (270/271 transactions)
– KMAP Automated Voice Response System (AVRS)
– KMAP Provider Services Call Center
– MCO Provider Services Call Center
• Important items to look for:
– Which MCO is the member assigned to?
– Is the member in the lock - in program?
– Does the member have other insurance?
• It is important providers check the MCO specific website for member
Third Party Liability (TPL)/Coordination of Benefit (COB) information
– Does the member have a spenddown amount, client obligation
or patient liability?
4
MCO Provider Services All 3 MCO’s have self service tools on their Websites, Provider Services Call Centers, and Provider Relations staff to assist you with any question regarding how a claim was processed. When reaching out for assistance please make sure you have the following information: • The MCO claim number • The members Medicaid ID # • The date of service on the claim • Total billed charges • The Tax ID # or NPI for the provider • Provider Contact Information If working with one of our call centers or Provider Relations staff, please make sure you note in your file the name of the person you spoke with and the date and time of the call. 5
Eligibility Verification
Eligibility verification can be
accessed from the Provider
page. The Eligibility tab
appears on the menu bar at
the top of the page and the
Eligibility Verification link is
found below the provider
information.
6
Eligibility Verification
Continued
Beneficiary eligibility can be
searched in three different ways.
1. Beneficiary ID
2. SSN and/or Date of Birth
3. Name and Date of Birth
7
Waiver Member and Third-
Party Liability Example
8
Nursing Facility Member
9
Unmet Spenddown
Amount Example
10Locked-in Member
11Member Third Party Liability
Information
Aetna
Providers may obtain member TPL/COB information by calling
Member Services Department at 855-221-5656, (TTY: 711) or
online via our secure provider portal
Log into Aetna Better Health of Kansas secure provider portal
aetnabetterhealth.com/kansas
• Member’s policy start and stop date,
• COB Primary payer information and other payer details are
available
12Member Third Party Liability
Information
Sunflower
• Log into Sunflower Secure Provider Portal and click on the Eligibility
tab
• Enter Medicaid Member ID and Date of Birth
• Click the Green box “Check Eligibility”
• On the left click the Coordination of Benefits tab for COB details
Providers may also call Customer Service Center at 1-877-644-4623
13Member Third Party Liability
Information
United HealthCare
Providers may obtain the following member TPL/COB
information online using LINK eligibility function via
UHCprovider.com
– Member’s policy start and stop date, COB Primary payer
information and other payer details are available
Provider’s other options is to contact our Provider Services Call
Center 1-877-542-9235 to obtain TPL/COB information for a
member.
14Member Third Party Liability
Information
If provider is aware of TPL
changes for the member.
Please fill out the form on
the KMAP website and
submit by mail, faxing or
email, to the KMAP TPL
department.
https://www.kmap-state-
ks.us/Documents/Content/
Forms/TPL_provider.pdf
15How to Verify Coverage of
a Service or Supply?
MCOs provide the same benefits required
under KMAP. There are several ways to
determine if a service is a covered benefit:
• KMAP Website
– Procedure code look up tool
– Fee schedules
– KMAP Provider Manuals
• MCO Provider Manuals, Administration Guides, or Quick
Reference guides
• MCO Provider Services Call Center
1
6KMAP Reference Codes
The KMAP Reference
Codes page has links to
search by procedure,
NDC, and diagnosis
codes. There are
additional reference
links to fee schedules,
tables, and pricing.
17Reference Codes Continued
Procedure code search
18Reference Codes
Continued
Once a HCPCS code link is clicked, a box (similar to the one
below) will open automatically with information on that
particular procedure code.
19Reference Codes
Continued
NDC Search
Once a NDC code link is clicked, a box will open
automatically with information on that particular NDC.
20Reference Codes
Continued
Diagnosis Search
Once a diagnosis code link is clicked, a box will open automatically with
information on that particular diagnosis as shown above.
21Coding Modifiers
The Coding Modifiers Table is located in the Helpful Information section of
the Provider page. Historical and current versions are available. Click the
link and the Coding Modifier Table document will open.
22How to Determine if a Service
Requires Prior Authorization?
Each MCO determines which services and supplies require
a prior authorization (PA) for their members. Each MCO will
have a unique list of services requiring a PA. A provider can
validate whether services require a PA by using the
following:
• MCO Website
• MCO Provider Services Call Center
• MCO Provider Manuals or Admin guides
Retro-Eligibility and Prior Authorization
• Each MCO has a process in place for providers to follow
when the member was not eligible at the time of the
service, preventing a provider from obtaining a PA
23How to Determine if a Service
Requires Prior Authorization?
Aetna
Online:
• Go to aetnabetterhealth.com/kansas
o Select for Providers / Resources / Prior Authorization
o Click on the online prior authorization search tool
o Enter up to 6 CPT or HCPCS codes
Phone:
• Call the Aetna Better Health of KS PA request line 1-855-221-5656
o Provide the PA representative with the code/codes
o PA representative will review the PA requirements
24How to Determine if a Service
Requires Prior Authorization?
Sunflower
• Online Prior Authorization Prescreen tool
o Answer a few questions about the service being rendered.
o Enter CPT code to validate authorization requirement
▪ No: No Pre-authorization required for all providers.
▪ Yes: Pre-authorization required for all providers.
▪ Maybe: Pre-authorization is required for non-participating providers only
• Prior authorization should be requested 14 calendar days prior to the scheduled
service delivery date or as soon as the need for service is identified including
weekdays, weekends and holidays.
• Authorization requests may be submitted by fax, phone or secure web portal and
should include all necessary clinical information. Urgent requests for prior
authorization should be called in as soon as the need is identified.
• #1 reason for denied prior authorization = not including clinical details
25How to Determine if a Service
Requires Prior Authorization?
United HealthCare
Online:
• Go to UHCprovider.com
• Select Prior Authorization and Notification
• Click Determine if Notification or Prior Authorization is Required
for a Patient and Service.
• Go to Prior Authorization and Notification Tool
• Log in using your OPTUM ID or email address
• Select Prior Authorization and Notification tile
• Check if a prior authorization is required
Phone:
• Call the UHC Provider Services line
• Provide the agent with the code in question
• Request information in regards to PA requirements for this codes
26How Do I Request a PA?
Aetna
Medical - requests can be submitted by secure web portal, phone or fax
and should include the necessary clinical information.
• Phone: 855-221-5656
• Fax: PA form can be found on the website:
aetnabetterhealth.com/kansas
• Toll Free Fax Number: 855-225-4102
• Local Toll Fax Number: 860-975-3251
• Secure Provider Portal
Radiology Services (CT, MRI) are authorized by contacting
• EviCore 1-888-693-3211
Vision and Dental Services are authorized by contacting
• Skygen 1-855-918-2258
27How do I request a PA?
Sunflower
• Authorization requests may be submitted by secure web portal, phone or
fax and should include all necessary clinical information.
• Using the fax forms located in the Provider Resources section of the
Sunflower website, providers may fax requests to:
- Inpatient, Outpatient, and Home Services 1-888-453-4316
- PT/ST/OT Services: 1-888-453-4316
– Concurrent Review – Clinical: 1-877-213-7732
– Admissions/Face Sheet/Census: 1-866-965-5433
– Behavioral Health Services: 1-844-824-7705
• For HCBS Authorization concerns please call 1-877-644-4623 ext. 44329
• High Tech Imaging Services (CT, MRI) are authorized by National Imaging
28
Associates at www.radmd.comHow do I request a PA?
UHC
Providers have 2 options for requesting a PA with UHC:
Online:
• UHCprovider.com
• Select Prior Authorization and Notification
• Click Determine if Notification or Prior Authorization is Required
for a Patient and Service.
• Go to Prior Authorization and Notification Tool
• Log in using your OPTUM ID or email address
• Select Prior Authorization and Notification tile
• Select Create a New Notification or Prior Authorization Request
• Use of this option allows a provider to submit and track a PA request through
every step of the process. (excludes HCBS services)
Phone:
• Providers can contact the UHC PA department at 1-866-604-3267 to initiate a
Prior Auth
*Please note faxing is no longer an option for prior authorization
29Claims Timely Filing
Each MCO is allowed to set timely filing requirements as part of
each individual contract with providers. Review individual
provider contracts for timely filing requirements.
• New day claims
– Generally, the timely filing requirement for new day claims is 180 days*
from the date of service
• Corrected claims
– The timely filing requirement for Aetna and UHC is 365 days* from the
date of service. For Sunflower, timely filing is 365 days from the
explanation of payment (EOP).
• Claims impacted by Retro-eligibility
– Timely filing requirements begin on the date the member was deemed
eligible by the state. A provider has 180 days* from the date the
member was determined eligible by the State to file their initial claim
*Providers must check their individual contract for each MCO for
provider specific timely filing requirements.
30Date Span/Future Date
billing - DME
Dispensing/Prescribing Requirements
The claim date of service will be considered the actual dispensing
date of the item(s) with the following exceptions:
• The claim date of service for custom-made DME P&O will be the
date the item is ordered rather than the date it is dispensed.
• If Medicaid is not the primary payer, the date of service should
reflect the rules of the primary payer.
For DME supplies with monthly limitations or span dates and that are
provided on an ongoing routine basis, the claim may be billed using
the date the beneficiary will begin using the item(s). This allows
providers delivery or mailing time. Providers are expected to follow
all limitations for the individual supply. If billing for more than one
date of service, the full date range must be on the claim.
31Member Billing
A member can only be billed in the following situations:
• Spenddown, client obligation, and patient liability
• Non-Covered services
• A member can be billed for non-covered services only when the member
has been notified in advance and in writing that the service is non-covered
and they will be responsible for payment. To ensure the beneficiary is
aware of his or her responsibility, the provider has the option of obtaining a
signed Advanced Beneficiary Notice (ABN) from the beneficiary prior to
providing services. A verbal notice is not acceptable. Posting the ABN in
the office is not acceptable.
• Member did not present their KanCare/Medicaid card at the time of service.
Although providers are never required to accept a member’s
KanCare/Medicaid card after services have been provided. We strongly
encourage providers accept the Medicaid card if the claim is still within the
provider’s timely filing limit.
– Provider should not accept the Medicaid card if the claim is outside their timely filing
period. If you bill a claim in this situation and receive the timely filing denial, it
becomes a contractual provider write-off
32Medicare Cross-Over Claims
• When a member has Medicare Primary, a secondary payer or
Medicare supplemental plan and KanCare
– Medicare will send the cross-over claims to both the secondary payer and
the KanCare MCO at the same time
– If the secondary payer is not listed on the member file on the KMAP eligibility
site and/or the MCO system, it is likely the claim will not process as expected
resulting in an overpayment. If this occurs, submit a corrected claim with the
secondary EOB attached
• There are providers who are required to bill on a UB-04 form
for Medicare and a CMS 1500 form for Medicaid. Electronic
cross-over claims will never be successful in those situations.
The provider will need to submit those secondary claims to the
KanCare MCO directly, with the EOB attached, on the required
claim form.
33How Secondary Claims are
Priced (Coordination of Benefits)
All 3 KanCare MCOs are required to follow the same pricing logic when
pricing and paying claims as the secondary payor.
➢ Medicare
• Look at Medicare allowed amount in comparison to Medicaid allowed amount and
the lessor of the two amounts becomes the allowed amount for the claim.
• Once allowed amount is determined, Medicare payment is deducted and the MCO
will pay any difference between the allowed amount and the Medicare paid amount
up to the patient responsibility
Medicare when Part A is exhausted and Medicare Part B is paying
• This would only apply to inpatient claims
• The allowed amount is calculated (no comparison with Medicare allowed amount)
and then the Medicare B payment is deducted from the allowed amount and the
MCO would pay the remaining balance
34How Secondary Claims are
Priced (Coordination of Benefits)
All 3 KanCare MCOs are required to follow the same pricing logic when
pricing and paying claims as the secondary payer. (cont.)
➢ Commercial payers
• The MCO reviews Commercial payers EOB, determines the allowed amount for
the claim and then compare to the Medicaid allowed amount. The lessor of the
two amounts becomes the allowed amount for the claim.
• Once the allowed amount is determined, Commercial payment is deducted and the
MCO will pay any difference between the allowed amount and the Commercial
paid amount up to the patient responsibility
➢ RHCs/FQHCs/Indian Health Centers
• These providers are always paid up to the state determined encounter rate so that
amount is always the allowed amount for the claim
• MCOs are required to deduct the primary carrier payment from the state set
encounter rate and then pay the remaining balance
35Corrected Claim Timeline
A corrected claim would be needed if the provider determines there was
an error on the original claim either by their internal review or based on
how the MCO processed their claim. The following items must be
included on the corrected claim or it will be denied as a duplicate claim:
– Indicate 7 as the 3rd digit of the Type of bill on a UB-04 or as the frequency code on a
CMS 1500
– Include the MCO claim number being corrected in the appropriate field on the claim.
– Submit the corrected claim within 365 days from the date of service for Aetna and
UHC. For Sunflower, timely filing is 365 days from the explanation of payment (EOP).
Although it is recommended these be submitted as quickly as possible.
*If you are submitting a corrected claim the outcome of the claim of the claim is the
same, please reach out to the customer service of the MCO, to confirm the correction
36Claim Reconsideration -
Timeline
Claim reconsiderations can be submitted by a provider when they believe a claim was
processed incorrectly by one of the MCOs. This is the most efficient way to have
claims reviewed, and possibly reprocessed, by an MCO. Although each MCO process
may vary slightly the general guidance is the same.
Reconsiderations must be submitted within 120 (+3 days for mailing) calendar days of
the claim adjudication date on the Providers Remittance Advice (PRA) or Explanation
of Payment (EOP).
— Submit the reconsideration to the MCO making note of the specific error made on the
claim
— Explain what the correct outcome should be on the claim
— Provide any documentation or additional supporting information for the desired
outcome for the claim
— Provide all data elements required on the MCO form or electronic reconsideration
request
— Reconsideration is not required to file an Appeal.
37ABH Claim Reconsideration
process
Providers may submit reconsideration requests the following
ways:
Providers may submit reconsideration requests by contacting the Provider
Experience department at 1-855-221-5656 or for the hearing-impaired Relay
711. Providers may also submit a written reconsideration to:
Aetna Better Health of Kansas Attn: Reconsideration
PO Box 81040
5801 Postal Road
Cleveland, OH 44181
Fax: 1-833-857-7050
Email: KSAppealandGrievance@AETNA.comSunflower Claim Reconsideration
process
Reconsiderations can be submitted by calling,
online or in writing.
Online: On the provider portal at provider.sunflowerhealthplan.com select
the claim and on the claim detail screen select the reconsideration button to
complete your reconsideration submission.
Phone: Call Customer Service 1-877-644-4623
In writing: Mail to the address listed in EOP or letter the providers receive.UHC Claim Reconsideration
process
Providers have 3 options for submitting a reconsideration:
• Online – Providers can submit online reconsiderations online using Link
reconsideration function via UHCprovider.com
• Phone – Providers can call our Provider Services Call Center at 1-
877-542-9235
• Mail – Providers can submit a UHC Reconsideration form and submit via
mail. Reconsideration forms are located at UHCprovider.com under the claims
payment section. Mail reconsiderations to:
UnitedHealthcare
P.O. Box 5270
Kingston NY 12401
40Appeal Timelines
If a provider disagrees with an MCO action or a reconsideration
determination the next step would be to initiate the formal appeal
process
▪ Providers must submit an appeal within 60 calendar days, plus 3
calendar days for mailing, from the date of the negative action
▪ All provider appeals must be submitted in writing
▪ The written request must specifically indicate an appeal is being
requested
▪ Providers will receive a written acknowledgment of the appeal within 10
calendar days of the appeal receipt, unless the appeal is resolved prior
to this timeframe
▪ The MCO must resolve 98% of all appeals within 30 calendar days and
100% of all appeals within 60 calendar days
▪ The provider will receive a written notice from the MCO indicating the
outcome of the appeal
▪ Process on How to Submit an Appeal will be discussed specific MCO
session
41ABH Appeals Process
Appeals should be sent to :
Aetna Better Health of Kansas
Attn: Appeals
P.O. Box 81040
Cleveland, OH 44181
Fax: 1-833-857-7050Sunflower Appeals Process
Appeals can be submitted online or in writing:
Online: On the provider portal at provider.sunflowerhealthplan.com
select the claim and on the claim detail screen select the appeal button to
complete your appeal submission*.
In writing: Mail to the address listed in EOP or letter the providers
receive*.
*Both submissions require the submission of the appeal form located on our provider
website sunflowerhealthplan.com under provider resources.
43UHC Appeals Process
Appeals can be submitted online via UHCprovider.com or in writing, In
person and mailed to UHC at the following address:
Online: If submitting via uhcprovider.com, in the comment section it is
required to indicate this is an appeal.
In Person:
United Healthcare Community Plan of Kansas
State Fair Hearing
Mail Route: KS015-M400
6860 West 115th Street
Overland Park, KS 66211
Mail:
UnitedHealthcare
Attention: Formal Grievances and Claim Appeals
PO Box 31364
Salt Lake City, UT 84131-0364
If the request does not specifically indicate an appeal is being requested, it will process
as a reconsideration.
44External Independent Third
Party Review (EITPR)
KMAP MCO General Bulletin 19178
• Effective with denials of authorizations for new services or denials of reimbursement
issued on or after January 01, 2020
• Optional review of appeal decision
– Providers must complete the MCO internal appeal process prior to submission of
a request for EITPR. External review information will be added to notices of
appeal resolution after January 01, 2020.
• EITPR will only review the same documentation submitted for the MCO internal
appeal, along with the medical necessity criteria applied, if applicable.
• If providers wish to submit additional documentation, State Fair Hearing process will
need to be used.
• Providers have 63 calendar days from the date of MCO internal appeal resolution to
file a request for EITPR.
– Must be submitted in writing to the Health Plan and will be acknowledged in
writing by the Health Plan.External Independent Third
Party Review (EITPR)
• EITPR has 30 calendar days to complete review and provide decision to Health Plan
and appellant.
– If EITPR overturns the Health Plan decision, the MCO will be responsible for the
cost of the EITPR review.
– If EITPR upholds Health Plan decision, the appellant will be responsible for the
cost of the EITPR review.
• If an appellant disagrees with the outcome of the EITPR, they can file a State Fair
Hearing.
– SFH requests must be submitted within 33 calendar days of the EITPR
determination.How Do I File for a State
Fair Hearing?
All providers have the right to request an administrative fair hearing, also known as a state
fair hearing, following receipt of the negative outcome of their claims appeal or clinical appeal
• State Fair Hearing requests can be submitted through various means:
In writing:
Office of Administrative Hearings
1020 S. Kansas Avenue
Topeka, KS 66612-1327
Electronically via Office of Administrative Hearings fax:
1-785-296-4848
or In Person: (During business hours 8 am – 5 pm CST)
United Healthcare Sunflower Health Plan Aetna Better Health of Kansas
Community Plan of Kansas
State Fair Hearing
Mail Route: KS015-M400
6860 West 115th Street
Overland Park, KS 66211
47How Do I File for a State
Fair Hearing?
• The request must specifically request a fair hearing.
The request should describe the decision appealed
and the specific reasons for the appeal.
• The request must be received by that office within
120 (+3 days for mailing) calendar days of the date
of the negative action.
Provider must complete the MCO appeals
process prior to filing for a state fair hearing
48Questions?
49
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