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VOL. 1, ISSUE 6 | SEPTEMBER 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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 August 2015 data |
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Denial spotlight - 93: Invalid DCN (Document Control Number)
 Background: The invalid DCN code is used for replacement and reversion of claims.
What causes this denial? This denial occurs when the reference number entered for the replacement/reversion of a claim does not match the claim header for the claim you are trying to replace/revert.
Note: The reference number used for the replacement/reversion of claims is not the same as the MyMCS claim number.
How do I correct this?
The claim must be resubmitted with the correct claim header identification as the reference number. The claim header can be found on the remittance advice (RA), or by searching the Claims Dump File for the claim you want to replace/revert.
CMS1500 Instructions
| 1. | Go to Box 22 and click 'Replacement or Revert'. Enter the claim header identification of the claim you want to replace/revert as the reference number. | | 2. | Make any necessary changes. | | 3. | Click 'Submit' to resubmit the claim. |
UB04 Instructions
| 1. | Go to Box 4 (Bill Type) and replace the fourth digit with a '7' for replacement, or with an '8' for a revert. | | 2. | Go to Box 64A and enter the claim header of the claim you want to replace/revert as the reference number. |
837 Instructions
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To replace:
| In Loop 2300, Claim segment/5th element (CLM05-03), 7 (code for resubmission) should be submitted along with a REF segment with 'F7' as reference code identifier and the claim number found on the RA as the reference number. | | To revert: | In Loop 2300, Claim segment/5th element (CLM05-03), 8 (code for revert) should be submitted along with a REF segment with 'F8' as the reference code identifier and the claim number found on the RA as the reference number. |
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Format testing for ICD-10
 If your organization is interested in participating in Smoky's ICD-10 testing and you have not already done so, please send an email request to ICD10@smokymountaincenter.com. Use "Interest in Testing" as the subject line and include the following information in the body:
* Provider name
* AlphaMCS ID
* Claims system and/or clearinghouse
* Contact information (name, phone, email address) for the person representing your organization
Smoky will contact you to proceed with testing. Your organization will then follow the steps outlined below.
- Create an 837 claims file that contains representative ICD-10 and ICD-9 codes. Please limit the number of claims in your file to a maximum of 12.
- Claims should use October 1, 2014 as the presumed implementation date for ICD-10. It should be expected that claims filed with an ICD-9 diagnosis after this date will deny. (Please note: October 1, 2014, is not the actual ICD-10 implementation date but is the operational date in the AlphaMCS test system.)
- Email the encrypted file to ICD10@smokymountaincenter.com. For HIPAA security purposes, the email must be encrypted.
- Send a password to access the file in a separate email to ICD10@smokymountaincenter.com
- On receipt of your file, you will receive an email acknowledgement. Please allow a minimum of five business days for processing time.
- Smoky will send confirmation after the file has been processed and format testing results are available. Format testing verifies that the data filed conforms to the expected data requirements. Providers should expect a pass or fail result based on whether the claims filed conform to coding requirements. The format testing will not actually process the claim to either a denial or approval and payment.
For general questions regarding ICD-10, please consult the Smoky website.
Thank you for your consideration and assistance in testing for ICD-10 readiness.
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Important reminder: ICD qualifiers
ICD-10 goes into effect October 1, 2015. At that time, providers must begin including ICD qualifiers on 837 submissions. These qualifiers specify which diagnosis codes (ICD-9 or ICD-10) are on the actual claim. The ICD qualifier must be used when you use both ICD-9 and ICD-10 claims on an 837 file. Failing to use these qualifiers may result in a denial.
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Clarification: Refund check process 
Providers occasionally receive overpayment on a service, need to correct the billing of a service that has previously been paid after a self-audit or receive payment that cannot be posted.
Before sending a refund check to Smoky for any of these transactions, we urge providers to submit a void or replacement claim. This results in a more efficient process for both the provider and Smoky, ensuring the appropriate claims have been identified in the refund process.
When a provider submits a void claim and/or replacement claim, the AlphaMCS system will identify the initial and final payments and will handle both transactions in a timely process. The remittance advice (RA) or 835 file will supply details of both voided and paid claims. Any recoupment amounts are applied to other claims payments; therefore, a refund check is not necessary.
If you feel you have an exceptional case or questions about how to submit a replacement or void claim, please contact your claims specialist or call the general claims line at 828-586-5501, ext. 2455.
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Medicare and third party liability bypass list expansion
Smoky has recently updated its Medicare and third party liability (TPL) bypass list to include additional procedure codes. The codes on this list are exempt from the usual third party liability requirements. For example, if a consumer has Medicare or third party (commercial) insurance, the provider may file claims directly to Smoky. Smoky and the AlphaMCS system will process the claims as the primary payer. The newly-added procedure codes are those for which an equivalent is not generally found in Medicare or commercial insurance benefit plans. Providers who continue to use the Provider Portal to enter these claims will no longer need to enter the primary insurance information. Providers may also file these claims using an 837 EDI file. All procedure codes on the Medicare and third party bypass list are listed below. H0038HQU4
| Peer Supports - group
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| B4154BO
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Ent Form Special Met Needs, Excl Inherit Dis
| H0038U4
| Peer Supports - individual
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| B4155BO
| Ent Form Incomplete/Modular
| H0043U4
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Community Transition - MH
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| B4157BO
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Ent Form Special Met Needs, Incl Inherit Dis
| H2029
| Task
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| B4103BO
| Enteral Formula - Pediatric
| H2036
| Medically Supervised Detox/ Crisis Stabilization
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| B4149BO
| Enteral Formula - Mfg Blend Natural Foods
| T2038U4
| DI Community Transition - IDD
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| B4158BO
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Ent Form Complete - Pediatric
| T2038
| Community Transition
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| B4159BO
| Ent Form Complete Soy-based - Pediatric
| B4100BO
| Food thickener
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| B4160BO
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Ent Form Caloric Dense - Pediatric
| B4150BO
| Enteral Formula
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| B4161BO
| Ent Form Hydrolyzed Proteins - Pediatric
| B4152BO
| Ent Form Caloric Dense
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| B4162BO
| Ent Form Special Metabolic - Pediatric
| B4153BO
| Ent Form Hydrolyzed Proteins
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Recredentialing in NCTracks
Smoky submits provider claims through NCTracks to receive reimbursement from the State. To ensure these claims are not denied, providers must maintain current information in their provider profile(s) in NCTracks.
NCTracks sent a communication detailing the recredentialing process on August 24, 2015, an excerpt of which is included below. To view the communication in its entirety, please visit the NCTracks website.
NCTracks Recredentialing Notices - Update
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"The Centers for Medicare and Medicaid Services requires that all Medicaid providers are recredentialed. The N.C. Division of Medical Assistance (DMA) is reviewing the status of enrolled providers to ensure compliance.
This announcement regarding recredentialing is not the official notice to providers. The recredentialing notice is a letter sent to providers via US Postal Service mail and posted to the Message Center Inbox on the secure NCTracks Provider Portal. The notice is mailed and posted when recredentialing is due. Due dates for recredentialing are specific to each provider. All providers will not receive recredentialing notices at the same time. (This is not a new process).
It is crucial that all providers who receive a notice promptly respond and begin the recredentialing process. All Medicaid providers are required to recredential as part of the NCDHHS Provider Administrative Participation Agreement. Recredentialing is not optional. If the recredentialing is not completed, your provider record may be subject to termination.
Providers who have received a notice, but have not started the recredentialing process, should not wait for a second notice."
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Generic Assessment Payment (GAP) target population
The Generic Assessment Payment (GAP) benefit plan offers a way to reimburse providers for single services or assessment events provided to individuals who do not meet eligibility requirements for Medicaid services or any other benefit plans (as determined by the provider).
Criteria for GAP target population eligibility:
- Consumer needs services for a current mental health, substance use or intellectual/developmental disability (I/DD) issue or symptom, AND
- Provider has determined consumer is not eligible for any other MH, SU or I/DD benefit plan, AND
- Consumer has been determined not to be eligible for Medicaid services.
Coverage and limitations of the GAP target population benefit plan:
- Up to two periodic service events (assessments) within the fiscal year, after which eligibility for enrollment in another benefit plan category would be required.
- Eligibility is limited to a maximum of 60 days.
- Concurrency with other benefit plans is not allowed.
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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). 