Provider IPRS-Waiver

Orientation

Sandhills Center

LME/MCO

Financial Management and Monitoring • The Finance Department manages the financial

resources of the LME/MCO. This includes:

Management of accountability, availability of funds,

claims processing and payment. • The Finance Department is responsible for ensuring

compliance with General Statute 159 (The Local Government Fiscal Control Act) and other general accounting requirements.

• The Finance/Claims Department supports providers through training and through its Claims Specialist Representatives.

Financial Management and Monitoring

Your responsibility as a Contracted

Provider is to:• Verify consumer insurance coverage at the

time of referral, or admission, or each appointment, and on a quarterly basis.

• Determine the consumer’s ability to pay using the Sliding Fee Schedule for all designated Non-Medicaid services based on your agency’s contract requirements.

Financial Management and Monitoring• Bill and report all first and third party payers prior to

submitting claims to SHC.• Report all billing errors to SHC Claims Department.• Manage your agency’s Accounts Receivable.• Submit all documentation which is required for

federal, state, or grant reporting. • Implement Internal Controls to support audits

performed by Sandhills Center.

Financial Management and Monitoring• Network Providers shall maintain detailed records of

the administrative costs and expenses incurred pursuant to their Contract with SHC.

• This includes all relevant information relating to enrollees for the purpose of audit and evaluation by DMA.

• Records shall be maintained and available for review during the entire term of this contract and for a period of five (5) years thereafter.

• If an audit is in progress or audit findings are unresolved, records shall be kept until all issues are resolved.

 

Financial Management and MonitoringSHC’s responsibility to Providers is to:

• Certify funding for all contracts in accordance with G.S. 159. The Finance Department will review and approve all financial commitments made by Sandhills Center.

• Assign and monitor maximum funding for contracts.

• Monitor grant funds.

Financial Management and Monitoring

• Review Financial reports, financial statements and accounting procedures as applicable.

• Monitor retroactive Medicaid eligibility and recovery of funds.

• Issue payment and remittance advice (RA) on paid and denied claims.

• Assist the Quality Management Dept with claims quality audit process.

Financial Management and Monitoring

• Recover funds based on audit findings.• Audit providers for coordination of benefits

(COB).• Manage and pay clean claims within the 48 day

Prompt Pay Guidelines.• Report credible allegations of Fraud and Abuse

State and Federal Non-UCR Invoicing Rules

The following documentation should be submitted with the invoice:

• Personnel schedule to include FTE percent, Name ID number and Position Title

• Worksheet that shows expenses by month and year to date. (Non-UCR Expense Sheet - sample enclosed)

• Certification Statement with authorized provider signature and title. (see worksheet for statement)

Budget J uly Aug. Sept. Oct. Nov. Dec. J an. Feb. March April May J une 2011-12

0.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.000.00

Reimbursement Mileage/Supplies 0.00Taxes/Contributions/Benefits 0.00

0.000.00

Advertising/Interviewing 0.00Employee Record Check 0.00Training, Mtgs/Seminars 0.00Office Rent/Lease 0.00Insurance / Other 0.00Office Utilites/Communication/Building Maint 0.00Supplies, Equip., & Postage 0.00Psychiatrist 0.00Auto Fuel, Reg/Tax, & Maint. 0.00

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Less Paid Claims - Medicaid 0.00

Less UCR Monthly Income 0.00

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Certification:   I certify that the above data is correct and the expenditures shown have been made for the purpose of and in accordance with applicable contract terms and conditions and that appropriate documentation to support these cost and expenditures are available for review and audit.

Authorized Signature and Title:  ________________________________________       Date    _________________________________________

Income

Net Operating Cost

Non-UCR Request

Total Expense

Other Operating Expenses:

Sub-Total of Expense

Non-UCR FY12-13 Expenses Provider Name: Payroll Expenses:

Wages

Provider requirements prior to submitting claims to Sandhills

• Provider Contract has been completed and signed.

• Login and Password has been requested for Provider Connect and Sandhills Direct Data Entry Web Tool if applicable.

• Sharefile account has been set up.• Treatment Authorization Request has been

entered and approved if required.

Share File Account

• Once contract has been approved and signed, providers will receive notification that a Share file account has been set up. Notification will include URL address, User ID, password and provider instructions.

• A submitter ID and our Receiver ID will also be included for 837 files.

How is Share File used

• Providers will use to upload 837 files for processing.

• Electronic files such as 999, 835 and 277 will be uploaded by the MCO for the provider.

IT Department contact: edi@sandhillscenter.org

Claims Submission

• Medicaid ClaimsMedicaid Claims should be submitted to should be submitted to Sandhills Center if the members Medicaid Sandhills Center if the members Medicaid county of eligibility is within our 9 county county of eligibility is within our 9 county catchment area:catchment area:

• Anson, Guilford, Harnett, Hoke, Lee, Anson, Guilford, Harnett, Hoke, Lee, Montgomery Moore, Randolph, RichmondMontgomery Moore, Randolph, Richmond

Private Providers• Claims must be submitted within 90 days

of Date of Service.

• If a claim is denied, providers have an additional 90 days from the date of denial to correct the denial and resubmit.

Hospitals• Claims must be submitted within 180 days

of Date of Service.

• If a claim is denied, the hospital has an additional 180 days from the date of denial to correct the denial and resubmit.

Coordination of Benefits• Providers are responsible for billing

Medicare and Third Party Insurance prior to billing Medicaid.

• Current Medicaid Insurance edits will be used by HP to adjudicate SHC claims.

• If a member has Medicare or Insurance and payment information is not included on the claim, the claim will deny.

Claims Submission Cont.• Checkwrite schedule is located on our

website: www.sandhillscenter.orgFor Providers>Finance/Claims

• Billing can be submitted daily.

• Cutoff for weekly 837 files will be Wednesday at 5:00p.m.

• Direct Data Entry will be 5:00 p.m. Thursday.

Claims Submission Cont.

• Medicaid Claims can be submitted:

• HIPAA standard EDI Transaction Files837 Professional Health Care Claim 837 Institutional Health Care Claim

Companion Guides are located on the SHC Websitewww.sandhillscenter.org

For Provider>Finance/Claims

Claims Submission Cont.• Medicaid Claims can be submitted:

• Sandhills Direct Data Entry Web Tool

User Guide is located on the SHC Websitewww.sandhillscenter.org

For Providers>Finance/Claims

• Paper Claim

Sandhills Direct Data Entry Password

• To request your DDE Web Tool login and password:

Please fill out the Sandhills DDE request form located on our website: www.sandhillscenter.org

Click on For Providers >Finance/Claims

E-mail to billing@sandhillscenter.org

Medicaid Claims Adjudication

• Sandhills has contracted with HP• Claims will adjudicate against all the current

edits used by Medicaid.• Continue to use the same NPI billing logic as

you did with NC Medicaid (HP)• Example:  If you are a CABHA submitting

enhanced services, the CABHA NPI is your billing NPI and the Attending/Rendering is the NPI mapped to the Medicaid Provider Number for that service.

Denials

• Providers 835 and Remittance Advice will include the current HIPAA Adjustment reason codes used by Medicaid.

• A EOB crosswalk can be found on the SHC website:

www.sandhillscenter.org

For Provider>Finance/Claims

Adjustments/Correction

• Adjustments can be handled three ways:

Electronic 837

Sandhills Direct Data Entry Web Tool

Submit “Claim Inquiry Resolution Form” –Form is located on SHC website

www.sandhillscenter.org

For Providers>Finance/claims

General Information-Medicaid

• Providers will no longer require the member to pay a 3.00 copay.

• Provider payment will include 3.00 copay amount.

• System edits are in place to deny if 3rd party missing.

• Providers will be held accountable.• Co-payments, deductibles, payment for missed

appointments or other forms of cost sharing from Medicaid members, are prohibited.

IPRS Claims Submission• Can be submitted:

• Provider Connect Web Portal

User Guide is located on the SHC Websitewww.Sandhillscenter.org

For Providers>Finance/Claims

• HIPAA standard EDI Transaction Files837 Professional Health Care Claim

Companion Guides are located on the SHC Websitewww.sandhillscenter.org

For Provider>Finance/Claims

Provider PaymentMedicaid and IPRS

• Providers will have the option of receiving a paper check or electronic funds transfer.

• An EFT request form is located on our website:

www.sandhillscenter.org

For Providers>Finance/Claims

Keeping CurrentIt is the responsibility of the provider to research and stayabreast of new requirements and laws by utilizing all available resources:

• Monthly Medicaid Bulletins • DMA and DMH Implementation Updates• SHC Communications/ Bulletins • SHC Website• Provider Connect News