Electronic
media claim submission is an alternate method of submitting claims to
Molina Medicaid Solutions. With
electronic media, a provider or third party contractor (billing agency) sends
Medicaid claims to Molina on a computer encoded magnetic tape, diskette or via
telecommunications.
The
electronic media claim produced by the provider or billing agency is a
magnetic picture of the Medicaid invoice. This picture is reformatted by Molina to generate computer readable
records of the submitted claims. Molina
then adjudicates the claim in the Claims Processing Subsystem along with
hard-copy claims submitted by other providers.
Each
claim undergoes the editing common to all claims, e.g., verification of dates
and balancing. Each type of claim
has unique edits consistent with the requirements outlined in the provider
manuals. All claims received via
electronic media must satisfy the criteria listed in the manual for that type
of claim.
Twelve
claim types are currently being submitted to the Claims Processing Subsystem
of Medicaid via electronic media: Pharmacy, Hospital Outpatient, Hospital
Inpatient, Physician/Professional, EPSDT, Dental EPSDT, Home Health,
Non-Ambulance and Emergency Transportation, Adult Dental, HCFA 1500 – DME
and Rehabilitation.
Other
claim types may be added in the future.
Advantages
of Electronic Claims Submission
Electronic
media claims submission has the following advantages over hard-copy billing:
·
INCREASED
CASH FLOW
·
IMPROVED
CLAIM CONTROL
·
DECREASE
IN TIME FOR RECEIPT OF PAYMENT
·
AUTOMATION
OF RECEIVABLES INFORMATION
·
IMPROVED
CLAIM REPORTING BY OBSERVATION OF ERRORS
·
REDUCTION
OF ERROR THROUGH PRE-EDITING CLAIMS INFORMATION
A
hard-copy claim goes through many clerical channels before it is entered into
the computer for payment. This is a very time-consuming process. In the case of a pended claim, the time between receipt of
the original invoice and payment can increase by weeks.
Electronic
media claims submission significantly
reduces the time for payment, because claims with errors are automatically
denied and immediately returned to the provider for corrections.
Also,
since electronic media claims have been pre-edited for errors, they have
a much higher payment ratio.
Error
reduction in claims submission is another advantage. Lack of education in recording valid and viable claim information is
the main reason for claim errors. The
provider submitting claims via electronic media is placed in a learning
situation. By correcting the
errors that cause a claim to be rejected, the provider can modify the method
of relating claim information so that similar errors do not recur.
Overview of Provider EMC Enrollment
Enrollment
as an EMC submitter is achieved through the completion of the DHH/Molina
approval process and the successful testing of provider claims of a particular
claim type. The Molina EMC
Coordinator is available to assist in answering questions, but basically,
enrollment and participation proceed through the following steps:
1.
Upon request from an approved Medicaid
provider, provider group or billing agency representing providers, Molina will
provide application and approval forms for completion by the submitter. When completed, these forms must be submitted to the Molina Provider
Enrollment Unit.
2.
During
the authorization process, the prospective provider can call the EMC Department
to receive EMC specifications that contain the data and format requirements for
creating EMC claims. Using these
specifications, the potential submitter develops and tests application software
to create EMC claims.
3.
When the submitter is ready to submit a file of
test claims, the test claims should be submitted to the Molina EMC Coordinator,
whose name and address appears in the back of this booklet, using the submitter
number: 4509999. The test
submission is run through LMMIS programs that validate the data and formats. Reports produced from this testing are reviewed by Molina.
The test results are verified and the submitter is contacted to review
any problems with the submission. If
necessary, additional test claims will be submitted until an acceptable test run
is completed. This test submitter number (4509999) should be used for submission of
test claims only!
4.
When all forms have been received and
approved by the Provider Enrollment Unit, and the EMC Department has verified
the test claims, the submitter will be notified that EMC claims may be
submitted.
The EMC Billing
Process
Once
a provider becomes an approved EMC submitter, the billing process will be as
follows:
1.
After a Medicaid recipient has been
rendered a medical service by a provider, the submitter pre-edits the claim data
for errors. If the claim fails
pre-editing, the data are corrected and pre-edited again.
If the claim passes the submitter's pre-edits, a live submission file is
generated. The submitter completes a Submission Certification Form,
signs and mails the form and submits the claims to Molina for processing.
2.
Upon receipt of the submission, the Molina
EMC Department logs the submission and verifies it for completeness. If the submission is not complete, the log is rejected and the submitter
is notified about the reject reason(s) via electronic message or telephone call.
3.
If the certification form is complete, the
EMC Department enters the submitted claims into a preprocessor production run.
The preprocessor generates a claims data file and one report.
The Claims Transmittal Summary report, which lists whether a provider's
batch of claims has been accepted or rejected, is generated for each submission.
If a provider’s claims are rejected, the provider number, dollar amount
and number of claims is listed on the report.
The Remittance Process
A
Remittance Report is produced for each claims file submitted.
It lists the total records processed, the number of claims denied and
paid, the total amounts denied and paid and the number of providers whose claims
were processed. This report is
mailed to the providers. Telecommunication
submitters also receive the report.
Machine
Readable Remittance Information
The
tape formats used are based upon the same layouts for machine readable input
claims. The output can be used by
the submitter for posting outstanding Medicaid claims to an accounts receivable
system through automated means. This
eliminates the costly and time-consuming process of manually posting Medicaid
receivables by the provider. For
submitters who submit claims via tape, return remittance tapes are available. Electronic remittances are also available for any provider submitting
claims (whether the submission is electronic format or hardcopy) for a nominal
fee. If interested, contact the EMC
coordinator. If a provider is using a billing agent, he/she should contact
the billing agent to see if they are receiving an electronic remittance from the
Molina EMC Department.
Policies
Affecting EMC Submissions and Submitters
The
following policies are in addition to those outlined in the provider manuals for
the individual claim types and in no way supersede those publications.
1.
The required edits, minimum submission
standards, Letter of Certification requirements and data/keying specifications
as outlined in the electronic media specification manuals must be fulfilled and
maintained by all providers and billing agencies submitting claims
electronically.
2.
At any time, an authorized representative
of the Louisiana Medicaid Program, Auditor General, U.S. Department of Health
and Human Services, General Accounting Office, or Inspector General can request
supportive documentation to ensure that all requirements are met, e.g. program
listings, dumps, flow charts, file descriptions and accounting procedures. These regulatory agencies may also request actual information used to
bill Louisiana Medicaid claims via electronic media, e.g. provider files,
recipient files, reference files, pricing files, whether maintained on physical
media, such as a computer listing or stored on automated media. All information thus obtained will be held in strictest confidence.
3.
The individual provider is ultimately
responsible for accuracy and valid reporting of all Medicaid claims submitted
for payment. A provider utilizing
the services of a billing agency must ensure through legal contract (a copy of
which must be made available to the authorized agents of Louisiana Medicaid upon
request) responsibility of an agency to report claim information as directed by
the provider in compliance with all policies of the state. It is the responsibility of a billing agency to ensure that each provider
has an original Medicaid Provider/Billing Agency Agreement and an original
Medicaid Limited Power of Attorney form on file with BHSF/Molina.
Both the individual provider and the billing agency are required to
maintain a record of all Medicaid claims submitted for payment.
4.
All information supplied by BHSF/Molina or
collected internally within the computing and accounting systems of a provider
or billing agency, e.g. master files, provider files, recipient files, reference
files, statistical data, is considered confidential and may only
be used in the accurate accounting of claims containing or referencing
that information. Any
redistribution or dissemination of that information for any purpose other than
the accurate accounting of Medicaid claims is considered an illegal use of
confidential information.
5.
At any time, BHSF/Molina can return,
reject or disallow any claim, group of claims or submission received on
electronic media pending correction or explanation.
6.
No claim received on electronic media can
have a date of service more than 365 days before the date of submission.
7.
A provider or billing agency must contact
BHSF/Molina before initial entry (test submission) of electronic claims, whether
the submission is the first for the submitter or a new claim type for a
submitter billing other claim types. This ensures that all editing is performed and that the
submission is acceptable.
8.
A submitter of electronic media, whether
an individual provider encoding claims using an in-house system or a billing
agency encoding claims for a number of providers, must have received
authorization via a signed Provider's Election To Employ Electronic Media
Submission of Claims For Processing form from BHSF/Molina for the type of claims
submitted.
8a.
A billing agency must have an
original Medicaid Electronic Media Claims Limited Power of Attorney form for
each provider included in a submission on file with BHSF/Molina. If a submission is received from a billing agency without the applicable
forms on file, the claims for the unauthorized provider will not be processed.
9.
A provider can utilize the services of
only one billing agency per type of Medicaid claims during any calendar month
service period.
10.
BHSF/Molina reserves the right to review
the processing of Medicaid claims. This
consists of an onsite validation of edit requirements through utilization of
BHSF/Molina test invoices with embedded errors.
11.
A billing agency which applies prices to
Medicaid claims must have on file a Medicaid pricing schedule for each provider. This schedule must be authorized in writing by each provider and be
available upon demand. The schedule
is not required for those Medicaid claims that are pre-priced on the individual
source document by the provider.
12.
Each reel of tape, diskette or
telecommunicated file submitted for processing must be accompanied by a
Submission Certification form signed by an authorized representative for each
provider whose claims are billed using electronic media. Providers submitting by telecommunications must submit this certification
within 48 hours.
How
to Become an EMC Submitter
1.
Apply for a submitter ID or make
application for services through a billing agency. An application is included in the back of this booklet. Providers submitting claims through a billing agency must also complete
the Limited Power of Attorney form also included in this booklet. These forms should be submitted to:
Molina
- Provider Enrollment
P.O. Box 80159
Baton Rouge, LA 70898-0159
(225) 216-6370 (phone)
2.
Purchase computer equipment and software or sign a service contract with
a billing agency.
a) IBM-compatible
microcomputers running MS-DOS are usually acceptable. UNIX or XENIX systems may send telecommunicated files or else produce a DOS-formatted diskette.
b) A
list of vendors who have available Medicaid computer products (hardware or
software) is included in this booklet. These
vendors are not associated with or sanctioned by the Louisiana Medicaid Program
or Molina in any way.
3.
Request an EMC specifications manual and
use it to prepare a test submission.
a) The
test claims file should include valid Medicaid claims, and the claims selected
should represent a variety of claim types to exercise the data entry options of your software. They are to be submitted using the submitter number of 4509999.
b)
Test diskettes and tapes should be clearly marked "TEST" on the
media label. The label must also
include the name and phone number
of a contact person to whom the test results should be reported. Telecom submitters must include the word "TEST" and the
name and phone number of a contact person in the submission recap file.
c) DO NOT SEND LIVE
CLAIMS AS TEST DATA expecting to be paid.
If possible, submit old claims (already paid, no known errors) to validate the system. Continue
to bill LIVE claims under your old medium number until you receive approval to
bill under the
new medium.
d)
An EMC specifications manual may be obtained by contacting:
Molina EMC Dept.
(225) 216-6303
4.
Submit the test claims submission to Molina and await the results of the
test.
a) Diskettes and tapes should
be sent to:
Molina/Louisiana
Medicaid
Attn: EMC Department
P.O. Box 3396
Baton Rouge, LA 70821
5.
Prepare for regular production submissions.
a) Production
diskettes and tapes must include completed certification forms signed by the
provider or facility administrator. Completed
certification for telecommunicated files must be mailed to Molina within 48
hours of submission.
b) All tapes
and diskettes must be properly packed to prevent damage in shipping.