Includes: Claims Submissions; Paper Form HCFA 1500 or UB04; Direct data entry via LEO or 837 File; System Disaster Recovery; Timeliness of Submissions; Clean Claims; Authorization for Secondary Coverage; Remittance and Payment Schedule; Fee Determination; Family Support Subsidy Program; LifeWays Operating Procedures 03-04.05 Family Support Subsidy Program and 03-04.09 Ability to Pay.
Provider Claim Schedule 11/2019 -- 12/2020
A. Claim Submissions
Note: This section of the Provider Manual will be revised as needed in accordance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
Providers contracting with LifeWays must comply with data/claims submission guidelines specified in this manual and MDHHS.
Claims may be submitted in one of three (3) ways:
How: by fax 517-796-4532, encrypted email or direct data entry into LEO system, or via 837 file transfer.
By when: Outpatient services within 45 days of service date and Inpatient services within 90 days of service date.
1 Paper Form HCFA 1500 or UB04
For non-electronic submissions by institutional providers, a claim should be submitted using the Centers for Medicare and Medicaid Services (CMS) Form UB-04.
The hospital must diligently pursue all available third-party reimbursement for inpatient and psychiatric services provided, prior to submitting claims to LifeWays. For those consumers for whom the provider renders psychiatric services admitted pursuant to the provider contract and who are ineligible for third party reimbursement or insurance benefits due to benefit exhaustion, LifeWays may be billed according to the following provisions:
The Institutional provider must complete these required fields for the claim to be considered clean on the UB-04:
For non- electronic submissions by professional providers, a claim shall be submitted on a CMS Form 1500 claim form.
The Provider must complete these required fields in order for the claim to be considered clean on the HCFA 1500.
2. Direct Data Entry into LEO
Providers can directly enter claims into the LEO system in place of submitting paper claims or 837 files. To get access for this option please submit a LEO user agreement via the LEO help desk.
3. Electronic Claims via 837 File
Electronic claims by professional or institutional providers must be submitted using the ASC X12N 837 format to be considered a clean claim. Providers must submit the claim in compliance with the Federal Health Insurance Portability and Accountability Act (HIPAA) requirements related to electronic health care claims, including applicable implementation guidelines, companion guides, and trading partner agreements.
Disputes need to be submitted to and received by LifeWays within 30 days of EFT/Check issue date
4. System Disaster Recovery
In the event LifeWays Claims Processing System should fail and claims cannot be processed electronically for more than one payment cycle, the following process should take place:
The provider should log all encounters on a spreadsheet or billing form HCFA 1500/UB 04 with minimal information of:
This information will be submitted to the Finance Department via paper copy for processing. When the electronic system is restored it will be the responsibility of each provider to enter the claims so they can be processed electronically. The same 45-day rule for processing dates of service will apply and the cycle will remain 1st through the 15th and 15th through the last date of the month.
If you have trouble submitting claims, please contact the LifeWays Claims Specialist.
5. Timeliness of Submissions
LifeWays’ Finance Department needs to receive Professional claims within the 45 days from date of services and Institutional claims within 90 days from date of service as required in the contract. Claims submitted timely will be processed for payment weekly according to the claims payment schedule below. Claims received after forty-five (45) days of the delivery of the service will need to file an appeal for reconsideration of payment. Clean Claims will be paid within thirty (30) days of submission
Beginning June 16, 2018, claims will be paid weekly for providers set up on Electronic Funds Transfer (EFT) and bi-weekly for providers still receiving a check payment. Claim periods begin on the Friday and end on Thursday (i.e., claim period begins on June 22 and ends on June 28). All claims received by close of business on Fridays, will be processed on the following Monday and paid out via the established payment schedule based on the Provider’s elected method of payment, either EFT or Check.
6. Clean Claims
A “clean” claim is defined as a one that does not require the payer to investigate or develop on a prepayment basis. Clean claims must be filed in the timely filing period. A provider submits a clean claim by providing the required data elements on the standard claims forms. Claims for inpatient and facility programs and services are to be submitted on the UB-04 and claims for individual professional procedures and services are to be submitted on the CMS-1500.
A clean claim meets all the following criteria:
Refer to LifeWays Operating Procedure: 03-04.08 Claims Payment
7 Authorization for Secondary Coverage
At times, the LifeWays administered plan is the secondary payer. The LifeWays Network Provider must follow the same LifeWays review procedures as those described in the primary payer review procedures. The LifeWays Network Providers are required to assist LifeWays in the management of secondary payer cases. LifeWays Network Providers must notify LifeWays of all pertinent employer and insurance information for the LifeWays consumer being treated. By working collectively when these situations surface, a duplication of the authorization and review process can be avoided. Additionally, the provider shall accept payment received under the LifeWays contract as payment in full for the cost of service and shall not bill consumers, consumer families or other third parties directly for services paid by LifeWays unless otherwise allowed in the LifeWays provider contract. LifeWays should only be billed if the consumer has Standard Medicaid as their secondary payer.
LifeWays’ Network Providers are responsible for obtaining authorization from primary coverage payers prior to calling Utilization Management for authorization. Failure to seek appropriate prior authorization from the primary insurance or LifeWays will result in a denied claim. If payment is received from a primary insurance, LifeWays pays the appropriate coinsurance amounts, copayment amounts, and deductibles up to the beneficiary’s financial obligation to pay or the Medicaid allowable amount (less other insurance payments), whichever is less.
An Explanation of Benefits must be received in LifeWays Finance Department prior to payment being issued to verify the billed amount is correct.
8 Fee Determination
It is the Provider’s responsibility to determine and notify the consumer of their monthly Ability to Pay (ATP) assessment prior to rendering services. LifeWays delegates will complete the ATP determination at initial contact. ATPs are effective for one year. Annual renewals are done during the Person-Centered Plan (PCP) process by the Primary Provider. The consumer’s ATP amount is calculated based on the “Public Mental Health System Ability to Pay Schedule."
9 Family Support Subsidy Program
The Family Support Subsidy Program is designed to provide financial help for families who are caring for their children with severe disabilities in the family home.
Refer to LifeWays Operating Procedure: 03-03.05 Family Support Subsidy Program.