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SUPPORTS/SERVICE COORDINATION TRAINING – Billing PROMISeTMTopical AreaODP OCDEL/BEISClaim Submission Timeline:The following error status codes (ESCs), also known as edits, set for timely filing:ESC 512: “Claim Past 365 Day Filing Limit Detail” ESC 545: “Claim Past 180 Day Filing Limit Detail” For ODP, when either ESC 512 or ESC 545 set, the claim suspends. A pay or deny determination will be made by ODP based on ODP’s timely filing exception process. See the following communication for more information on this process: Informational Memo # 064-10These edits suspend the claim for OCDEL.Approval of these suspended claims will require additional information submitted to the BEIS office via email to: ra-ocdintervention@.? The email contents must include the following: Provider nameMCI for the childPELICAN-EI systems issue description, Call Number or PCR Number If the claim that set ESC 545 is a resubmission of a previously submitted claim that was billed within the 180-day claim submission time limit, then resubmit the claim and enter the original Internal Control Number (ICN) from the initial claim into the “Original ICN” field. By doing this, the provider will bypass the 180-day timely filing edit and be given a maximum of 365 calendar days from the date of service to correct the claim. Federal regulations allow up to 365 calendar days from the date of service for resubmission of a rejected original claim or claim adjustment.NOTE: A claim that has been cleared through suspended status does not guarantee being approved for payment (“paid status”). After being processed through suspended status, the claim will continue through the other edits in the PROMISeTM system.Billing FrequencySCOs (providers) will be able to bill whenever they want.? Daily, weekly, monthly…..whatever meets their business needs. The program offices have no restrictions for supports/service coordination procedure codes.?EligibilityProviders should validate the consumer’s eligibility in the PROMISeTM Internet prior to billing in order to prevent their claim from denying on an eligibility edit. At the time that a claim is filed, PROMISeTM checks the child’s eligibility for Medical Assistance for the date of service on the claim.DiagnosisODP has 6 valid ICD-09 codes and 5 valid ICD-10 codes. View Informational Memo # 036-15: ODP’s most recent communication addressing ICD-10. ICD-09: 3159ICD-10: R620Billing NoteODP does not require the county code to be populated in the “Billing Note” field on the claim. Enter the County CodeIMPORTANT: County code MUST include CC+ 5 digitsPlace of ServiceThe following are valid place of service codes for procedure codes T1017 and W7210: 11(office), 12(home), & 99 (other-community).12(home/community)Procedure CodesModifiersODP does not use modifiers with W7210 and T1017. The use of a modifier with these procedure codes will cause a claim denial. T1016 Modifiers: U7 TL: Service CoordinationW0016 Modifier: TL: Service Coordination (Pre-plan/Tracking)Billed AmountThe billed amount should be calculated by using the Department established fee multiplied by the number of units. ODP’s current Department established fees are found in the following communication: billed amount should be calculated by using the county established fee multiplied by the number of units. Billing - BundlingAll SC/TSM services rendered to one person in one day must be bundled together on one claim line.? If you discover that you did not submit enough units on the original claim, then you will need to void the original claim and resubmit the claim using the correct units.? Remittance Advice (RA) reportsFor information on how to read a remittance advice (RA), see: Provider Handbooks/Billing Guides FileTraining resource:HCSIS>Learning Management System (LMS):ODP: FM300J Payment File Payment File Curriculum v1.0 2/2/09 Payment File Headings v1.0 10/28/08PELICAN EI IT: Provider Payment File MaterialsProvider Payment File Training PPT 02/07/12Provider Payment File Layout 5/24/10Provider Payment File Layout Excel Template 5/24/10Provider Payment File Sample Data 6/8/1Provider Payment File Training LiveMeeting RecordingError Status Codes and Descriptions: there are various edits that occur between PROMISeTM and HCSIS that may result in the claim being denied. Some of these edits differ between the two program offices.ESCs in the 900 series - Edits that set in the 900 series are related to the ISP. See HCSIS > LMS > ODP: FM100I_County Financial Management > HCSIS/PROMISe Error Resolution Tip Sheet v4.0 10/31/08 for each 900 ESC that may set and resolution recommendations. In addition to the existing edits in the 900 series related to the IFSP, there will be a new edit for BEIS:972: BILLABLE SERVICE NOTE DOES NOT EXIST WITHIN THE SPECIFIED DATESTraining resource:HCSIS>Learning Management System (LMS):HCSIS_EI_FM_Error_Status_Codes_20110804.pdfPrudent Pay/Financial CycleClick on the following to view ODP’s communication related to prudent pay and how it relates to the financial cycle: ID # The “Recipient ID” is equivalent to the consumer’s MAID # and is 10 digits in length. The Recipient ID is not the MCI # which is only 9-digits. The SCO can find the MAID # of the consumer in HCSIS using the following path > Demographics > Medicaid > Medicaid Details > “Medicaid (MA#)”Resubmit claim status When a provider sees “Resubmit” during a claims inquiry, this claim status is actually a status like “paid” and “denied”. A “resubmit” status means the claim was suspended and already “worked” by ODP or BEIS and is waiting to be reprocessed by PROMISeTM. Resubmit is a status, not a required action for the provider to take. Providers should not resubmit the claim when they see this status. If the provider/SCO waits a bit and does another claims inquiry on the claim that showed “resubmit”, the claim will likely be processed and have a different status. Claim Adjustment Billing RuleA claim adjustment to a claim detail line should never include either adding or removing claim detail lines because of the impact caused by the PROMISeTM/HCSIS interface. If a claim adjustment contains a deleted line, then the data from the deleted line will not be sent back to HCSIS which causes the utilized units on the ISP to be out of sync. If a claim has more than one paid claim detail line and only one detail line must be deleted, then the entire claim must be voided and a new claim should be resubmitted for the valid dates of service. PROMISeTM will not allow an adjustment to be submitted that contains an additional claim detail line from the original claim. This action will cause an edit to set and the claim detail line to deny.Voided Claim/Remittance Advice – Claim/Financial ReconciliationVoided claims process immediately through the financial cycle because they are not held for prudent pay. This information is important because if a claim is voided, the credit will be applied immediately and appears on the next remittance advice (RA). If the provider decides to immediately resubmit a voided/now corrected claim the same day they submitted the voided claim, the payment for the resubmitted claim will not show up until released from prudent pay but the credit for the voided claim will be applied immediately and show up on their next RA.Electronic Funds Transfer (EFT), also known as ACHThrough Electronic Funds Transfer (EFT) payments to providers are deposited electronically into the bank account of the provider’s choice. Go to the following DHS website for more information regarding EFT: LMS Resources:ODP: TSM Impacts Training (Fall 2015)PELICAN EI IT: TCM Impacts Training (Fall 2015)For Additional Questions:Questions regarding this release should be directed to: RA-ODPSCOMonitoring@state.pa.us with the subject line stating “SN Decommission”Questions regarding this release should be directed to your EI Advisor or the BEIS email: RA-ocdintervention@ ................
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