LTC Monthly Claims Training –

Assistive Care & Assisted Living Services

Overview

Medicaid is the medical assistance program authorized by Title XIX of the Social Security Act, 42U.S.C. §1396 et seq., and regulations thereunder, as administered in the State of

Florida by the Agency for Healthcare Administration under s. 409.901 et seq., F.S. It is the state and federal system of health insurance that provides health coverage for eligible children, seniors, disabled adults and pregnant women. The 2011 Florida Legislature passed House Bill 7107 (creating part IV of Chapter 409, F.S.) to establish the Florida Medicaid program as a statewide, integrated managed care

program for all covered services, including long-term care services. This program is referred to as statewide Medicaid managed care (SMMC) and includes two programs: one for medical assistance (MMA) and one for long-term care (LTC). Molina Healthcare will work with different providers to offer quality health care services and to ensure enrollees have access to covered services as needed. Medicaid

recipients who qualify and become enrolled in the Florida Managed Medical Assistance Program will receive all health care services with the exception of long term care.

Statewide Medicaid Managed Care:

Key Components

STATEWIDE MEDICAID MANAGED CARE

PROGRAM

MANAGED MEDICAL ASSISTANCE PROGRAM

LONG-TERM CARE PROGRAM

MMA Plan Awards

MMA Continuity of Care

No disruption of care for MMA members

Providers should continue to provide care during the transition period – 60 days after

the implementation date

Providers should bill claims to the health plan to which the MMA member is assigned

Molina (and other MMA plans) will cover the continued course of treatment without

authorization and without regard to participation status during the transition period

For non-participating providers, Molina will pay claims at the rate previously paid by

the enrollee’s prior health plan for the first 30 days

Care may continue after the transition period with prior authorization

Region Implementation

Date

Transition Period

End Date

7 8/1/2014 9/30/2014

9 8/1/2014 9/30/2014

11 7/1/2014 8/31/2014

*Timeframes not applicable to LTC members

Expanded Benefits

Unlimited PCP Visits (non-pregnant adults) Home Health Care (non-pregnant adults) – 1 visit per day

Physician Home Visits – 4 per month, per specialty

Prenatal/Perinatal Visits – 12 visits for low risk/ 16 visits for high risk pregnancy

Outpatient Services – Mammograms & OB ultrasounds are excluded from accruing

toward the Medicaid Outpatient Services Limitations

OTC - $25 per household per month

Adult Dental Services

Waived Copayments

Vision Services

Hearing Services - $500 every 3 years for an inner-ear hearing aid

Newborn Circumcision - upon request during initial hospitalization

Adult Pneumonia Vaccine – 1 per lifetime

Adult Influenza – 1 per year

Adult Shingles Vaccine – 1 per lifetime

Post Discharge Meals – 3 per day for 7 days

Pet Therapy & Art Therapy

Medically Related Lodging and Food

Covered Services

Managed care plans will be required to provide services at a level

equivalent to the Medicaid state plan. The Medicaid Covered

Services are outlined in the State’s Medicaid Coverage and

Limitation Handbooks.

The Handbooks are located on the Agency’s Fiscal website.

Medicaid Coverage & Limitation Handbooks –

http://portal.flmmis.com/FLPublic/Provider_ProviderSupport/Provider_

ProviderSupport_ProviderHandbooks/tabId/42/Default.aspx

Providers may submit claims to Molina in the following

ways:

•On paper, using a current version CMS-1500 form, to:

Molina Healthcare PO Box 22812

Long Beach, CA 90801

•Electronically, via a clearinghouse, Payer ID #51062 •Visit www.molinahealthcare.com for additional information

about EDI submission

•Electronically, via the Molina Web Portal

Submitting Claims

F.S. 641.3155 requires that providers submit all claims within six (6)

months of the date of service. Network providers must make every

effort to submit claims for payment in a timely manner, and within the

statutory requirement.

If Molina Healthcare of Florida is not the primary payer under

coordination of benefits (COB), providers must submit claims for

payment to Molina Healthcare of Florida within ninety (90) days after

the final determination by the primary payer.

Except as otherwise provided by law or provided by government

sponsored program requirements, any claims that are not submitted to

Molina Healthcare of Florida within these timelines will not be eligible for

payment, and provider thereby waives any right to payment.

Timely Filing

Providers are encouraged to enroll in Electronic Funds

Transfer (EFT) in order to receive payments quicker.

Molina Healthcare’s EFT provider is ProviderNet.

To enroll, visit https://providernet.alegeus.com

Step-by step registration instructions are included in your

training materials.

Direct Deposit of Funds

Billing Using a CMS 1500 Form

Resident Information is entered in Fields 1 - 11

Only Fields 1 – 6 are required

All other fields are optional

Billing Using a CMS 1500 Form

Resident’s authorization for ALF or AFCH to bill and

release information is entered in Fields 12 -13

Both fields are required

Enter “Signature on File” and the date in Field 12

Enter “Signature on File” in Field 13

SIGNATURE ON FILE SIGNATURE ON FILE 12/15/2013

Billing Using a CMS 1500 Form

Diagnosis Code is entered in Field 21

This is a required field

Enter number 9 in the ICD Ind. for ICD 9.

Enter 780.99 in position A (new CMS1500 Form version 02/12

effective for submission dates starting on 4/1/2014)

Enter letter A in 24E to “point” the charges to the diagnosis

780.99 is an unspecified code which will enable your claim to process

9 780.99

A 03 01 14 03 31 14 13 T1020 00 500 31

Charge details are entered in Fields 24A – 24J

The dates of service are entered in Field 24A.

For LTC Members, Molina allows beginning of the month billing for Assisted Living Services. If billing

at the beginning of the month, for the entire month, the Dates of Service FROM and TO must be the same.

ASSISTED LIVING SERVICES:

Billing Using a CMS 1500 Form – Dates of Service – Assisted Living

03 01 14 03 01 14 T2030 A 500 00 31

Billing Using a CMS 1500 Form – Dates Of Service – Assistive Care

Assistive Care Service cannot be billed in advance. The Dates of Service FROM and TO cannot be future dates or overlap . Assistive Care Services can be billed Daily, Weekly, or Monthly.

Daily:

hlhlhl

*Weekly:

Monthly:

*Please Note Dates in Weekly Example DO NOT overlap*

13 T1020 03 01 14 03 01 14 A 500 00 1

03 01 14 03 07 14

03 08

14

03 14 14

13

13

T1020

T1020

A

A

500

500

00

00

7

7

03 01

14

03 31 14 13 T1020 A 500 00 31

Billing Using a CMS 1500 Form

The billing code is entered in Field 24D

Assistive Care Services

Assisted Living Services

T1020

T2030

Billing Using a CMS 1500 Form –

HCPC Situational Grid

MEMBER’S

LINE OF

BUSINESS

PROVIDER

TYPE

HCPC TO

BILL

BILLING

FREQUENCY

WHO PAYS

MMA Only Assisted Living

Facility

T1020 Daily, Weekly,

Monthly but not

in advance

MMA Plan

MMA Only Adult Family

Care Home

T1020 Daily, Weekly,

Monthly but not

in advance

MMA Plan

MMA/LTC

(Comprehensive)

Assisted Living

Facility

T2030 Beginning OR

End of Month

LTC Plan

MMA/LTC

(Comprehensive)

Adult Family

Care Home

T1020 Daily, Weekly,

Monthly but not

in advance

LTC Plan

The Place of Service for ALF is 13

The Place of Service for AFCH is 99

The billed charges for all days in the date span are

entered in 24F

i.e. $500 per month

Remember the A in the Diagnosis Pointer

Billing Using a CMS 1500 Form

99 A 31 T1020 03 01 14 03 31 14 500 00

The number of days the resident is in the ALF or AFCH

is entered in Field 24G

30 units = 30 day month

31 units = 31 day month

Members who were placed in the facility in the middle of

the month are billed using the number of days the member

resides at the ALF or AFCH in the billing month.

Member moves in to the facility on 12/16/2013. Units = 16 (12/16/2013 –

12/31/2013)

Billing Using a CMS 1500 Form

03 01 14 03 31 14 13 T1020 A 500 00 31

The Tax ID is entered in Field 25

Yes is checked in Field 27

Total charges are entered in Field 28 and 30

The signature of the representative completing the claim is

entered in Field 31

The ALF or AFCH Name, Address, & Phone Number are entered

in Field 33

The NPI # (if facility has one) is entered in Field 33A

Billing Using a CMS 1500 Form

Web Portal Tools

•Verify effective dates

•Verify patient demographics

Member Eligibility

• Check claim status

• Submit claims Claims

• Check status of an authorization

• Request authorization Authorizations

Billing Using the Molina Web Portal

Select Create Professional Claim from the Claims drop-

down menu.

Billing Using the Molina Web Portal

- MEMBER

Eligibility Check

Enter the following:

Member ID #

Last Name

First Name

DOB

Date of Service

The portal will fill in

the Patient Information

section

Billing Using the Molina Web Portal

- MEMBER

Other Insurance & Patient Conditions

Other Insurance – Yes

or No (If Applicable)

Patient Conditions -

This section is not

required. Leave this

section BLANK

Billing Using the Molina Web Portal

- MEMBER

Enter the following:

Patient Account Number =

(your internal acct number)

Member Authorized

Assignment of Benefit = Yes

Provider Assignment Code =

Assigned

Release of Information = Yes

Choose NEXT (bottom left

corner)

Verify Required Information

Billing Using the Molina Web Portal

- PROVIDER

Billing Provider Information

Enter the following:

Billing Provider Information is

completed automatically

Rendering Provider is

completed automatically

Facility Information = Service

Location.

Select Facility Name from

“SELECT A SERVICE LOCATION”

drop-down.

Billing Using the Molina Web Portal

- PROVIDER

Diagnosis Code & Claim Line Details

Enter the following:

Dx No. 1 = 780.99

Service From Date = 1st day

of the date span

Service to Date = Last day

of the date span (*Refer to

DOS Slide for further

information on Date Entries*)

Place of Service = 13 or 99

Procedure Code = T1020 for

ACS or T2030 for ALS

Diagnosis Code Ref = 1

Charges = Billed charges for

all units

Unit of Measurement = UN-

Unit

Quantity = Days in Month or

Days in Facility

Leave all other sections

blank

Choose NEXT (bottom left

corner)

Billing Using the Molina Web Portal

- SUMMARY

Submit Claim

Review all of your entries

and:

Choose SUBMIT (bottom

right corner

Provider Handbook

Molina Healthcare of Florida’s Provider Handbook is written specifically to

address the requirements of delivering healthcare services to Molina

Healthcare members, including your responsibilities as a participating provider.

Providers may request printed copies of the Provider Handbook, at no cost, by

contacting Provider Services at (866) 472-4585, or view the handbook on our

website, at:

Medicaid Provider Manual

http://www.molinahealthcare.com/providers/fl/medicaid/manual/Pages/

medical.aspx

Balance Billing

Participating providers shall accept Molina Healthcare’s payments as payment

in full for covered services. Providers may not balance bill the Member for any

covered benefit, except for applicable copayments and deductibles, if any.

As a Molina Healthcare of Florida participating provider, your office is

responsible for verifying eligibility and obtaining approval for those services that

require authorization. In the event of a denial of payment, providers shall look

solely to Molina Healthcare for compensation for services rendered.

.

Questions