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VOL. 1, ISSUE 5 | AUGUST 2015
Greetings from Smoky Mountain's Claims Team!
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.
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 July 2015 data |
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Denial Spotlight - 11: Another concurrent service has been approved or waiting to be processed
Background: A claim is denied for this reason when the service being billed is not compatible with a previously billed service that is processing or approved. This denial ensures adherence to the National Correct Coding Initiative (NCCI) standards for compatible codes.
What causes this denial? AlphaMCS looks for claim lines for a particular consumer that have been adjudicated as approved. AlphaMCS will deny a claim if two procedures are performed by the same provider on the same date of service, as defined in the non-concurrent procedure code definition.
How do I correct the denial? The provider should confirm the service previously sent is correct and if not, send a reversal or replacement claim.
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Medical Detoxification services provided on a medical floor
As stated in Department of Health and Human Services Joint Communication Bulletin #J103 on October 31, 2014, LME/MCOs are required to authorize and pay for Medical Detoxification services when provided for a Medicaid-eligible consumer and when the criteria for medical necessity are met (as described in Clinical Coverage Policy 8B).
Smoky Mountain LME/MCO (Smoky) utilizes the same Service Authorization Request (SAR) process in the review and authorization of Medical Detoxification services as it does for Inpatient Psychiatric Treatment. Medical Detoxification services are required to be delivered in a hospital facility. The hospital providing the service does not have to have a contract with Smoky in order to submit claims as described below.
Medical Detoxification on a medical floor is authorized separately from Inpatient Psychiatric Treatment and follows the same unmanaged benefit of up to three days without requiring authorization for service. Concurrent review and SAR processes are the same as with Inpatient Psychiatric Treatment services. The authorization for Medical Detoxification services on a medical floor will be driven by the specific authorization requested in the SAR, and claims for either private beds (Revenue Code 0116) or semi-private beds (Revenue Code 0126) will be billed accordingly. Smoky has a single rate for Medical Detoxification services on a medical floor.
Medical Detoxification services on a medical floor is intended to set the stage for ongoing recovery. Psychiatric Treatment management, comprehensive discharge planning and referral to appropriate aftercare should reduce the risk of recidivism and avoidable hospital re-admissions. Medical Detoxification services on a medical floor is distinguished from the treatment of Delirium Tremens (DTs) in an Intensive Care Unit or a medical bed, when the consumer may be too medically ill to be engaged in recovery planning during the majority of the hospitalization.
Please note that the Division of Medical Assistance (DMA) Mixed Services Payment Protocol, Appendix T, "delirium tremens (DTs), is not a covered benefit under the LME/MCO Prepaid Inpatient Health Plan (PIHP), but is to be billed to DMA fee-for-service Medicaid when provided in an inpatient medical bed. Delirium tremens is a complication of chronic alcoholism associated with poor nutritional status. It is characterized by "a major physiological and metabolic disruption, and can be accompanied by delirium, agitation, tremors, elevated temperature and seizures."
For assistance in getting established to provide Medical Detoxification on a medical floor, please contact Smoky's Provider Network department at providerinfo@smokymountaincenter.com or 1-866-990-9712.
For assistance in initiating a care management review, including potential authorizations for services retroactive to December 1, 2014, please contact Laura Woodrup, MH/SU Care Management Manager, at laura.woodrup@smokymountaincenter.com or 828-586-5501 ext. 5152.
For assistance with claims related to the delivery of Medical Detoxification services, please contact your assigned claims specialist or Tracey Driver, Claims Specialist Lead at 828-586-5501 ext. 1197.
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Time is running out! Are you ready for ICD-10?
Register for an upcoming training to prepare for the transition to ICD-10. ICD-10 codes are longer and more complicated than ICD-9 codes. The crosswalk of the ICD-9 code set to ICD-10 is also complex.
This training will prepare staff responsible for diagnosing, coding or submitting claims. Specialized sessions are available for both clinical staff and financial and claims staff.
What will I learn?
- How to describe format changes between ICD-9 and ICD-10
- How to recognize challenges of cross walking DSM-5 and ICD-9 to ICD-10
- How to understand software system changes to accommodate ICD-10
- How to select testing strategies to ensure claim systems are ready for ICD-10
- How to use ICD-10 resources like the CMS general equivalence mappings (GEMS), the ICD-10 crosswalks in the DSM-5 manual and several ICD-10 websites
Registration is required. To register online, choose from the sessions below...
August 26, 2015
Foothills Higher Education Center
Room HEC163
2128 S. Sterling Street
Morganton, NC | 9:00 a.m. to 12:00 p.m.
1:00 to 4:00 p.m.
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See the flyer to learn more. Questions? Call 828-225-2785 or email us at ICD10@smokymountaincenter.com.
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ICD-10 Training provided by NCTracks extended through September 
The NCTracks team has added September dates for ICD-10 training.
An excerpt from the announcement is below. Read the entire bulletin and register for a training on the NCTracks website.
Two of the three instructor-led ICD-10 provider training courses scheduled for August are full, so registration has been opened for September. The same course is being offered on multiple dates in August and September. This course will be taught via WebEx and can be attended remotely from any location with a telephone, computer and internet connection. The WebEx will be limited to 115 participants.
| Thursday, | September 3 | 9:00 a.m. | to | 9:45 a.m. | | Tuesday, | September 8 | 3:00 p.m. | to | 3:45 p.m. | | Friday, | September 18 | 10:00 a.m. | to | 10:45 a.m. | | Monday, | September 21 | 3:00 p.m. | to | 3:45 p.m. |
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Claims status and using the claims dump file
The AlphaMCS claims dump file is a useful source of provider-specific information. As a repository of claims adjudication detail, the file is a resource for finding the status of claims. Please review the information about your claims dump file prior to contacting Smoky staff for assistance. Smoky claims staff will no longer take inquiries about claim status. Please ensure you can view and use this file.
The portal claims dump is in the Download Q of the AlphaMCS Provider Portal. It contains information including all claims adjudication detail and other existing files for consumers enrolled and authorizations collected over the previous six months. For step-by-step instructions, read the AlphaCM Portal Claims Dump guide.
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Helpful provider links and contacts for NCTracks
The NCTracks call center remains the single best source for registering concerns and requesting help. You can reach them at 1-800-688-6696.
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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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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). 