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Financial Services

Claims

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. Updated 1/9/18

Provider Claim Schedule 2019  (Added 11/19/18)

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:

  1. Paper Form (HCFA 1500/UB 04)
  2. Direct Data entry into LEO
  3. Electronically via 837 File Transfer

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:

  1. For each public or Medicaid consumer day of care at the agreed upon rate as specified in the provider contract.
  2. For professional psychiatric procedures delivered which are listed in the provider contract at the approved rate.
  3. The provider will produce evidence that a Medicaid application was completed and submitted when a consumer has no insurance and meets financial eligibility standards.
  4. The authorization number issued by LifeWays Access must be listed on each claim.
  5. An explanation of benefits or any other official report received from primary insurances indicating the amount covered by insurances and LifeWays’ liability.
  6. Clean claims will be paid within thirty days (30) of submission.
  7. Inpatient claims received after ninety (90) days of the delivery of the service will need to file an appeal to the claims department for reconsideration.
  8. All claims must list the authorization number assigned to the episode by LifeWays.

The Institutional provider must complete these required fields for the claim to be considered clean on the UB-04:

  • Provider’s name, address and telephone number (field 1);
  • Patient control number (field 3a);
  • Type of bill code (field 4);
  • Provider’s federal tax ID number (field 5);
  • Statement period (beginning and ending date of claim period) (field 6);
  • Patient’s name (field 8);
  • Patient’s address (field 9);
  • Patient’s date of birth (field 10);
  • Patient’s gender (field 11);
  • Date of admission (field 12), required for inpatient and home health;
  • Admission hour (field 13);
  • Type of admission (e.g. emergency, urgent, elective, newborn) (field 14), required for inpatient;
  • Source of admission code (field 15);
  • Patient-status-at-discharge code (field 17);
  • Value code and amounts (fields 39-41);
  • Revenue code (field 42);
  • Revenue/service description (field 43);
  • HCPCS/Rates (current CPT or HCPCS codes are required) (field 44);
  • Service date (field 45), (required for each date of facility-based non-inpatient services or itemization in a separate attachment is required);
  • Units of service (field 46);
  • Total charge (field 47);
  • HMO or preferred provider carrier name (field 50);
  • Main NPI number (field 56);
  • Subscriber’s name (field 58);
  • Patient’s relationship to subscriber (field 59);
  • Insured’s unique ID (field 60);
  • Diagnosis qualifier (field 66);
  • Principal diagnosis code (ICD-10 codes are required effective 10/1/15) (field 67);
  • Admit diagnosis (field 69);
  • Provider name and identifiers (field 76-79).

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.

  • Subscriber’s/patient’s plan ID number (field 1a);
  • Patient’s name (field 2);
  • Patient’s date of birth and gender (field 3);
  • Subscriber’s name (field 4);
  • Patient’s address (street or P.O. Box, city, zip) (field 5);
  • Patient’s relationship to subscriber (field 6);
  • Subscriber’s address (street or P.O. Box, City, Zip Code) (field 7);
  • Whether patient’s condition is related to employment, auto accident, or other accident (field 10);
  • Subscriber’s policy number (field 11);
  • Subscriber’s birth date and gender (field 11a);
  • Disclosure of any other health benefit plans (field 11d);
  • Patient’s or authorized person’s signature or notation that the signature is on file with the physician or provider (field 12);
  • Subscriber’s or authorized person’s signature or notation that the signature is on file with the physician or provider (field 13)
  • Name of Referring Provider or Other Source (field 17);
  • Referring Provider NPI Number (field 17b);
  • Diagnosis codes or nature of illness or injury (current ICD-10 codes are required effective 10/1/15) (field 21);
  • Date(s) of service (field 24A);
  • Place of service codes (field 24B);
  • Procedure/modifier code (current CPT or HCPCS codes are required) (field 24D);
  • Diagnosis code (ICD-10 codes are required effective 10/1/15) by specific service (field 24E);
  • Charge for each listed service (field 24F);
  • Number of days or units (field 24G);
  • Rendering provider NPI (field 24J);
  • Physician’s or provider’s federal taxpayer ID number (field 25);
  • Total charge (field 28);
  • Signature of physician or provider that rendered service, including indication of professional license (e.g., MD, LCSW, etc.) or notation that the signature is on file with the HMO or preferred provider carrier (field 31);
  • Name and address of facility where services rendered (if other than home or office) (field 32);
  • The service facility Type 1 NPI (if different from main or billing NPI) (field 32a);
  • Physician’s or provider’s billing name and address (field 33); and
  • Main or billing Type 1 NPI number (field 33a).

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 (1) 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:

  1. Consumer ID
  2. Consumers initials
  3. Date of service
  4. CPT/Service code
  5. Units of service
  6. Charge amount
  7. Authorization number related to the service
  8. Total amount due

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

2018

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. Below is schedule for claims and payments beginning June 16, 2018.

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:

  1. The service(s) that constitute the claim has/have been authorized.
  2. The service(s) has/have been provided and properly documented according to the guidelines listed in this manual.
  3. The service(s) must be reimbursable as defined by MDHHS and the master contract between LifeWays and the provider.
  4. The service(s) is/are submitted to LifeWays without errors, all required data elements associated with the specific claim are present and in standardized format.
  5. The claim(s) has/have been received by LifeWays within the time specified in the contract.
  6. Ability to pay fee assessment is complete, Insurance is verified and all supporting financial documentation is in place. (i.e., pay stubs and insurance card copies)
  7. All data elements requiredas specified in this provider manual, are complete for the consumers.
  8. Medical record documentation supports medical necessity and service description criteria.
  9. Provider has verified the consumer’s Medicaid eligibility at the time the service and any third-party insurances have been properly billed prior to billing LifeWays for reimbursement.

LifeWays Operating Procedure:  03-04.08 Clean Claims

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."

  • All Ability to Pay information should be entered into LEO within 48 hours of receipt.
  • Consumers who are covered by Medicaid/Healthy Michigan will automatically have a $0.00 Ability to Pay. Financial Determinations need to be updated if/when a consumer changes income as well as insurance.
  • Consumers who are eligible for MI Child, or is a child in Foster Care do not have to complete the Employment/Income section. These consumers will automatically have $0.00 ATP.
  • The performance of the functions discussed in this procedure must comply with the Health Insurance Portability and Accountability Act (HIPAA).
  • Ability to Pay will be recalculated when the financial situation of the person responsible to pay the bill changes.

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.

10 Attachments

  1. Paper Form HCFA 1500
  2. Reporting Requirements, PIHP/CMHSP Reporting Cost Per Code and Code Chart (Effective 10/1/17; last revision 05/16/2018
        (PIHP/CMHSP Encounter Reporting HCPCS and Revenue Codes)
  3. LifeWays Operating Procedure 03-03.05 Family Support Subsidy Program
  4. LifeWays Operating Procedure: 03-04.08 Claims Payment
  5. LifeWays Operating Procedure: 03-04.09 Ability to Pay