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Greetings from Smoky Mountain's Claims Department!

WELCOME to the Claims Corner and Eligibility and Enrollment (E&E) Edge from Smoky Mountain LME/MCO! We hope you'll find this monthly bulletin helpful in answering questions about Smoky claims and eligibility and enrollment processes. It is our honor to do business with you.

 

For complete, up-to-date provider information, also see our Provider Network Bulletin.
 
  
NEED ASSISTANCE?
  
For claims-related questions, email Claims@Smokymountaincenter.com
 or call your claims specialist
at 828-225-2785, ext. 2455.
  
For questions about this bulletin, email

ClaimsCorner@smokymountaincenter.com.

  
  
QUICK LINKS
   
 

AlphaMCScodesAttention providers: Lapsed diagnosis codes in AlphaMCS

 
Smoky has identified a system issue in claims processing that is causing claims to deny incorrectly. We determined the AlphaMCS system has lapsed several valid diagnosis codes beginning February 27, 2015.
 
Claims that received the following denial codes may have denied incorrectly: 23 (Invalid Diagnosis/Age Combination), 24 (Invalid PC/DX Combination) or 102 (Consumer does not have a valid target population for the diagnosis submitted).
 
Smoky and AlphaMCS are taking action to research and fully identify affected diagnosis codes and claims. Providers do not need to refile claims at this time. Additional information on the resolution will be provided once AlphaMCS and the MCO's have reviewed the logic and impact of this particular issue. Please contact your claims specialist with any questions or concerns. 
AssociatelevelAssociate-level licensed providers: Direct enrollment 

 

Effective July 1, 2015, associate-level licensed providers of Medicaid outpatient behavioral health services must directly enroll with Medicaid and apply with and enroll through the LME/MCOs with which they want to contract.

 

Read more on the DMA website. For information on enrolling with any or all of the Western Regionalization Partnership LME/MCOs, see our credentialing webpage.

PRTFsNew claims requirements for Psychiatric Residential Treatment Facilities (PRTFs)

  

Effective July 1, 2015, all institutional (UB04/837i) claims for Psychiatric Residential Treatment Facility (PRTF) services must include the name and National Provider Identifier (NPI) of the beneficiary's attending psychiatrist and billing provider for reimbursement. 
  
Learn more from the DMA website. Additionally, clinical coverage policies are posted on this DMA webpage.

NCTRACKSInformation to know: NCTracks and third-party insurance forms

  

To request changes to

third-party insurance in NCTracks, please use the Online Submission for Health Insurance Information Referrals on the N.C. DMA website.

 

Scroll down to third-party insurance forms, click to expand and select "Online Submission for Health Insurance Information Referrals."
ICD10ICD-10 deadline coming in fall

The deadline to comply with ICD-10 is October 1, 2015. If you provide Medicaid services, ICD-10 code sets must be used in transactions when the service date is on or after the October deadline. All health plans, clearinghouses and providers using electronic transactions must transition to the ICD-10 code sets on the compliance date, not before. 

For more details, visit the Smoky website and select ICD-10 Resources and Implementation from the index drop-down menu. We will continue to issue regular communications about the implementation of ICD-10 -- Stay tuned! 

 

     

DENIAL SPOTLIGHT

Denialspotlight7: Client has other covered insurance (COB)

 
Background
Federal and state regulations require Smoky to be the payer of last resort. Providers must collect all first and third-party funds prior to submitting claims to Smoky for reimbursement.
 

Third-party payers are any other funding sources that can be billed to pay for services provided. This can include worker's compensation, disability insurance or other health insurance coverage. Third-party payers, including Medicare and private health insurance carriers, must process the claim before Smoky does.

On claims filed with Smoky, providers must report any payments or denial reasons from third-party payers. Claims submitted without third-party information will be denied.

What causes this denial?
 When a consumer has a Coordination of Benefits (COB) on record in AlphaMCS, this covers the date of service, but the claim is not submitted to Smoky as a secondary claim. If applicable, a secondary claim includes other first and third-party paid amounts and Explanation of Benefits (EOB) denial reasons.

How do I correct the denial?
Providers must ensure that a consumer's primary insurance has been billed and is documented on the claim being submitted. Secondary claims can be billed up to 180 days from the date of service.
 
Claims that fall outside of this period will deny for "5-Claim received after billable period." If this denial is due to delays from other insurance processing, it's possible to submit a request for denial reconsideration.
  
Please visit the Smoky webpage for claims and eligibility and enrollment for Claims Denial Reconsideration Request Forms, under Forms and Templates.

unmanagedvisitsBehavioral health unmanaged visits to restart on state fiscal year, not calendar year

 

 

Effective July 1, 2015, limits on unmanaged visits to behavioral health providers will begin resetting according to the state fiscal year (July 1 through June 30), rather than the calendar year. This applies to NCTracks and providers filing claims directly into NCTracks. Read more on the N.C. Division of Medical Assistance website.

 

Smoky and AlphaMCS will also adopt the July 1 annual restart on outpatient behavioral health managed services. At Smoky, most behavioral health services under the Medicaid Benefit Plans are unmanaged. The exceptions are psychological testing codes in the CPT code range 96101 to 96118. Under Smoky's state benefit plan, behavioral health outpatient services, including individual and family services and psychological testing codes, are managed for fee-for-service providers. However, they are not managed for sub-capitated providers.

 
   

  

BenefitplanProvider review: Benefit plan (target pop)


Benefit plans (target pops) listed below in red are auto-populated** by AlphaMCS. The others are requested by providers via the update module and approved by Smoky's eligibility and enrollment staff.

 

PLEASE NOTE: ** Auto-population is triggered by an approved service authorization request (SAR) or claim for service.

 
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NCSNAPYour easy guide to printing N.C. SNAP forms

 

 Busy day? In a hurry? Smoky makes it easy to print N.C. SNAP forms. Just follow these eight simple steps:

  1. Visit the Smoky website at www.smokymountaincenter.com.
  2. Click on the "Service Providers" tab.
  3. On the left, under "Service Providers Categories," click on "I/DD Service."
  4. Click on "N.C. SNAP."
  5. Visit the N.C. SNAP link.
  6. Scroll to the bottom, and click on "Forms."
  7. Print out the Assessment Profile and Summary Report and Supplement Information Coversheet (black and white copies are allowed).
  8. When complete, e-mail both forms to tammy.harwood@smokymountaincenter.com or scan the forms into AlphaMCS.
Smoky Mountain LME/MCO manages publicly funded services for mental health, substance use and intellectual or developmental disabilities in the North Carolina counties of Alexander, Alleghany, Ashe, Avery, Buncombe, Caldwell, Cherokee, Clay, Graham, Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mitchell, Polk, Rutherford, Swain, Transylvania, Watauga, Wilkes and Yancey. For help with services, call 1-800-849-6127, 24 hours a day (TTY: Relay NC at 711). Visit us at www.smokymountaincenter.com.