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.