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VOL. 1, ISSUE 3 | JUNE 2015
Greetings from Smoky Mountain's Claims Department!
Welcome to the Claims Corner and Eligibility & Enrollment (E&E) Edge from Smoky Mountain LME/MCO. We hope you'll find this monthly bulletin helpful in answering questions about claims and eligibility and enrollment processes. It is our honor to do business with you. For more information, see our Provider Network Bulletin.
SMOKY OPERATIONS AT A GLANCE May 2015 data |
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 Denial Spotlight - 9: Clinician not licensed to provide the service or license has expired 
Background: The clinician who performed the service does not have the required licensure to perform the service.
What causes this denial? AlphaMCS requires information on whether the service is clinician-based, the clinician's license type, effective dates and any associations with other agencies.
How do I correct the denial? Always verify the claim for the rendering National Provider Identification (NPI). If the service is clinician-based, the rendering NPI must belong to an active clinician. Please confirm that the service is allowable for the specific licensure. Please ensure the clinician licensure and provider agency association are up to date (not expired) in AlphaMCS. If licensure or association information needs to be updated, please contact the Smoky credentialing team.
Credentialing team can be reached:
Website: http://www.smokymountaincenter.com/credentialing/default.asp
Email: credentialingteam@smokymountaincenter.com
Phone: 1-855-432-9139 |
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Clarification: Determining site location on 837 electronic claim submission
In Smoky's May bulletin, site-specific authorization denials were discussed. Please note the clarification below on how to specify site location in an 837 electronic claims submission:
Because services or authorizations may be site-specific, it is important to designate the proper site (service facility location) on a submission. Claims that do not correspond to the correct site can be denied.
Version 5010 of HIPAA transaction sets specifies that Service Facility Loop 2310C cannot be used if the site is a subpart (a location owned by the provider). In such cases, the subpart should be listed as the billing provider.
If a provider has site-specific NPI numbers, Loop 2010AA should list the NPI, address, and ZIP+4 of the location where the service was provided, not the primary address information. If site-specific NPI numbers do not exist for a provider's subparts, claims can be submitted using the primary location NPI and the ZIP+4 of the site where the service was provided, given the ZIP+4 for the site matches the information provided to Smoky. No match will be found if the last four digits of the ZIP+4 provided to Smoky do not match those on the claim. In such a case, segment N403 in Loop 2010AA should be the ZIP+4 of the actual service location. |
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'Transforming Care' conference for providers: July 29-30 in Asheville
The event, "Transforming Care Conference: Evidence-based Medicine and the Future of Behavioral Health and Intellectual Developmental Disabilities Care," is designed for mental health professionals, including substance abuse counselors, social workers, psychologists, marriage and family therapists, school counselors, I/DD professionals and anyone else interested in the subject. Early registration is open though July 22 at $125 per person for both days or $75 per person for the second day only.
Practicing evidence-based medicine (EBM) incorporates provider expertise, clinical evidence and the values, culture and needs of the person receiving care. To help build strong and healthy communities all three components of EBM are needed to effectively support people with mental illnesses, substance use disorders and/or intellectual or developmental disabilities.
The aim of the conference is to increase participants' competence in delivering truly patient-centered, collaborative care while implementing evidence-based treatment in a way that improves care and outcomes for individuals and reduces the per capita costs of care.
The conference takes place at MAHEC's Mary C. Nesbitt Biltmore Campus, 121 Hendersonville Road, Asheville, NC 28803. |
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Time sensitive contract/billing changes
Site-specific NPIs
Smoky has encountered numerous denials in its "upstream" billing or NCTracks billing of claims to DHHS when a provider's service site on the claim does not match that in NC Tracks. This primarily occurs where a provider serves consumers at several sites but only has one NPI for multiple sites. Denials in upstream billing put Smoky's revenue stream at risk and require time-consuming work by both Network Providers and Smoky to correct the issue. Accordingly, Smoky is making a policy decision to require all Network Providers to obtain a National Provider Identifier ("NPI") for each billable site at which it provides services to Smoky consumers. This policy is currently scheduled to take effect October 1, 2015, and will be referenced in FY15-16 provider contracts. On or before that date, it is proposed that all Network Providers must obtain site-specific NPIs and comply with taxonomy requirements regarding service and specialty licensure. More information regarding taxonomy specifics and the implementation of site-specific NPI's will be released in July.
Aside from streamlining the claims process, site-specific NPIs would further benefit providers and Smoky by allowing for simpler electronic transmission of HIPAA standard transactions; more efficient coordination of benefits activities; more effective utilization review activities; better insulation from potential cross-indexing; and would offer enhanced tracking for medical records' needs, group practice productivity measures and revenue collection efforts. If you have any questions or need additional information about this decision, please contact Provider Network directly at the contacts listed below.
Quick reference:
Provider Relations Line: 1-866-990-9712
Provider Relations Email: providerinfo@smokymountaincenter.com
Notice to users of clearinghouse Emdeon
Emdeon is a clearinghouse used by providers and other clearinghouses to submit Electronic Data Interchange (EDI) files containing bulk claim transactions, including response files (837I, 837P, 835, 999, etc.) to Smoky for processing and payment of provider claims. Smoky's contract with Emdeon expires on July 13, 2015, and Smoky will not renew this contract after its expiration because of the fees charged to Smoky by Emdeon. We believe that Smoky is entitled to an exemption of the fee as a government entity, but Emdeon has not approved the fee waiver. This means that Smoky will no longer utilize Emdeon's services after July 13, 2015. To facilitate the closeout of your claims processing through Emdeon, we ask that you adhere to the following timeframe:
- If remittance of your claims does not flow back to you through Emdeon, please submit claims no later than the close of business on July 12, 2015.
- If remittance of your claims does flow back to you through Emdeon, please submit your claims no later than the close of business on June 26, 2015.
Smoky provides two methods of submission for providers and other clearinghouses: (1) direct submission to Smoky; and (2) indirect submission via a participating clearinghouse. Going forward, Smoky will continue to accept claims from participating clearinghouses who meet certification requirements. Any provider or clearinghouse not currently submitting EDI files to Smoky and who wish to submit claims directly to Smoky must be certified to do so. The certification process will require execution of a Trading Partner Agreement, and the submitter must successfully pass format and content testing with Smoky. In order to prevent any disruption in your claim submissions and/or payment, it is imperative you contact Smoky's EDI representative to begin the certification process. You can initiate the process by sending an email to edi@smokymountaincenter.com. If you are unsure whether this affects your organization, please forward this communication to the person(s) responsible for your billing. If you have any questions or need additional information about this decision, please contact Provider Network directly at the contacts listed below.
Quick reference:
Provider Relations Line: 1-866-990-9712
Provider Relations Email: providerinfo@smokymountaincenter.com
AlphaMCS user agreement
Smoky is committed to ensuring the privacy and security of sensitive information we maintain, including protected health information. In order to further improve our security efforts, Smoky will be implementing a new AlphaMCS User Agreement with the FY15-16 contract cycle. This agreement will formalize the responsibilities that AlphaMCS users agree to when they complete training and are assigned a login and password. The AlphaMCS system requires a secure login for each individual system user. Sharing logins is not allowed. As part of this effort, Smoky will be completing a review of all AlphaMCS users associated with each agency. Moving forward, Smoky will regularly send providers a list of users and will require providers to verify the accuracy of the user list. The agreement will require providers to identify a security contact at their agency and notify Smoky when staff who have been assigned an AlphaMCS login leave employment so that Smoky can accurately track and disable logins when necessary. Again, these measures are designed to improve our security efforts and further protect the sensitive information we maintain. If you have any questions or need additional information about AlphaMCS or the proposed user agreement, please contact the Management Information Systems (MIS) department directly at the contacts listed below.
Quick reference:
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Updated AlphaMCS claims adjudication sequential process
The claims adjudication sequential process has been updated. The newest version is available on the Smoky Claims website under Links and Resources.
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Smoky Mountain LME/MCO contact list
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Medicaid categories of aid and the 1915(b)(c) Waiver
Although Smoky is responsible for the administration of Medicaid waivers, it is not responsible for all Medicaid categories of aid.
Review the information below to learn more about the covered population and Medicaid categories of aid Smoky is responsible for paying under the 1915(b)(c) Waiver.
General categories of aid:
- Aid to Families with Dependent Children (AFDC)
- Foster Children, ages 3 and older
- Aged, ages 65 and older
- Blind and Disabled, ages 3 to 20
- Blind and Disabled, ages 21 and older
- Innovations, all ages
Specific eligibility codes for each general category of aid:
AFDC (Aid to Families with children, 3 and older): AAFCN, MAFCN, MAFMN, MAFNN, MAFWN, MICNN, MIC1N, MPWNN
FOSTER CHILDREN (ages 3 and older): HSFCY, HSFMN, HSFNN, HSFNY, IASCN, MCINN (new, March 2015)
AGED (ages 65and older): MAABN, MAACY, MAAMN, MAANN, MAAMY, MAAQN, MAAQY, SAACN, SAACY, SAAQN, SAAQY
BLIND & DISABLED (ages 3 to 20 and ages 21 and older): MABBN, MABCY, MABMN, MABNN, MABQN, MABQY, MADBN, MADCY, MADMN, MADNN, MADQN, MADQY, MSBBN, MSBBY, MSBCN, MSBQN, MSBQY, SADCN, SADCY, SADQN, SADQY
INNOVATIONS (all ages): 1915(c) Waiver recipients as identified by an Innovations waiver code (IN) in the States eligibility file.
The eligibility status of Medicaid recipients who qualify for a category of aid covered by the waiver is downloaded into AlphaMCS through the Global Eligibility File (GEF), which is generated by NCTracks and updated daily.
The following Medicaid populations remain Fee for Service and are not covered by MCOs under the 1915 (b)(c) waivers:
- Infants under the age of three, except those who are Innovations eligible
- Qualified Medicare beneficiaries
- Specified low-income beneficiaries
- Children enrolled in the North Carolina Health Choice (NCHC) Health Insurance Program for Children
- Legal and Illegal aliens
- Refugees
- Individuals eligible for the Program of All-inclusive Care for the Elderly
For questions regarding a consumer's eligibility for Medicaid and coverage under Smoky, contact Enrollment and Eligibility at 828-225-2785, ext. 2355.
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Need help?
For claims-related questions, contact your assigned claims specialist via phone or email.
If you do not know your assigned specialist, use the general contacts in this section. |
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