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VOL. 1, ISSUE 8 | NOVEMBER 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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 October 2015 data |
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 Denial Spotlight - 102: Patient does not have a valid target pop for the diagnosis
Background: The diagnosis on the claim is not valid for the state target population assigned to the consumer. What causes this denial? AlphaMCS reviews the patient identification number, diagnosis code and date of service in the claim header. The system validates the following: - The claim is covered by state insurance;
- The patient has been assigned to a target population;
- The target-population-to-diagnosis code relationship exists; and
- The claim date of service falls between the effective date and end date of the target-population-to-diagnosis code relationship.
How do I correct the denial? Verify the consumer has a valid state target population that corresponds with the diagnosis information on the claim. If no errors exist, do not refile. Contact Smoky for further assistance.
How do the new ICD-10 diagnosis codes affect this denial? North Carolina Department of Health and Human Services (DHHS) has set up a new array of benefit plan (BP)/diagnosis (DX) combinations that are covered for state-funded consumers. Not all of the new ICD-10 diagnosis codes are included in this new DX array. Some ICD-10 codes listed in the crosswalk in NCTracks are not in the State DX Array and thus not covered by Smoky. Additionally, some codes may show as reimbursable on the ICD-9 data website crosswalk; this does not mean they are included in the diagnosis array provided by the State.
Example: If a claim is submitted with a diagnosis code that is not listed on the state's DX array for covered BP plans (target populations), the claim will deny. Claims will also deny if the DX billed is not valid for a consumer's assigned target population.
Note: These denials cannot be overridden for approval by Smoky claims staff. If the diagnosis code submitted on the claim is not included in the DX array or is not compatible with the target pop the consumer has on file, Smoky cannot be reimbursed for the claims when billed to NCTracks.
Helpful links:
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Claims with incorrect ICD diagnosis code format
Recently, a small number of claims with dates of service after September 30, 2015 approved, despite having ICD-9 diagnoses. Any claims that approved incorrectly have been recouped and will show on the November 10, 2015 or subsequent check-write. Providers may file new claims with a correctly formatted ICD-10 diagnosis to correct the error and receive payment.
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Requesting claim status information
A remittance advice (RA) is available to all providers through AlphaMCS for each weekly check-write. The RA details the claims adjudication status, payments made and explanation of benefit (EOB) codes of each claim submitted for the check-write cycle. Providers and third-party billing services are encouraged to utilize the RA to determine denials and payment status. For privacy and security reasons, claims team staff cannot disclose claims status nor discuss claim information without the claim header number. The claim header number is required for privacy and security reasons. To receive an AlphaMCS login and access the RA, please visit the Smoky website.
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Happy Fall from your credentialing team 
The Smoky credentialing team works hard to process credentialing applications in a timely manner. Please read on to learn more about the process and ways to make it more efficient for you and your practitioners.
Credentialing process
Credentialing ensures all providers delivering services to LME/MCO enrollees meet standards for participation in a closed provider network. The process is required by the Division of Medical Assistance (DMA) and the LME/MCO accrediting body.
In addition to processing credentialing applications for Smoky providers, we also process credentialing applications for CenterPoint Human Services and Partners Behavioral Health Management. The information outlined below applies to all credentialing applications processed by Smoky.
| Process | Description | Processing Days | | CIF: Credentialing Initiation form | Submitted by the practitioner to initiate the credentialing process | 7 business days | | CAQH: Council for Affordable Quality Healthcare | CAQH is an online practitioner credentialing application completed by the practitioner and retrieved by Smoky for review | 30 calendar days | | Application review | Smoky's credentialing team reviews each application for completeness and accuracy. Applicants with missing information are notified by email | 15 business days | | Verifications | Standard verifications are conducted on all complete applications (e.g. verification of license with state licensing board) | 30 calendar days | | Credentialing Committee | All complete applications are presented to the applicable LME/MCO's credentialing committee for consideration | Committees meet on a monthly basis |
Helpful hints
We process an average of more than 200 practitioner applications each month. Due to the high volume, the best way to expedite the credentialing process for your practitioners is submitting a completed application. Incomplete applications significantly extend the time-frames noted above. Last quarter, 60% of CIFs and 75% of CAQH applications received were incomplete.
Once credentialed to be a network member, practitioners are responsible for providing the LME/MCO with current information regarding their contact information, employment status, and any changes to their professional or criminal records.
Contact us
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Website
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Final day to register: N.C. Council of Community Programs annual conference and exhibition 
The N.C. Council of Community Programs yearly conference and exhibition in Pinehurst, N.C., is well known throughout the behavioral health and intellectual/developmental disabilities community with around 800 participants each year, but did you know the N.C. Council works hard to ensure relevant content, not just for LME/MCO members, but for the provider community, as well? This year is no different - providers, don't miss this year's conference.
- David Houle, world-renowned futurist, author and speaker will help everyone understand the best way to market and brand your services using the latest technology in a shifting healthcare market.
- Whole-person care - learn how you can work with your LME/MCO or other partners to design and implement a new approach to whole-person care.
- Survival skills for the modern market - get practical business advice and learn how to optimize your operations, focus on patient-centered care and how to tap into new markets beyond Medicaid and more.
- New state and federal Medicaid regulations - N.C. Medicaid healthcare will soon be managed by private companies, CMS is implementing sweeping regulatory managed care rule changes - learn how these changes affect you as a provider.
- Population health management - the shifts our world has seen demand care integration, outcomes and the ability to track your population's progress. Understand the "how to" tools you will need to compete in this market.
- A two-day track will cover the transformations taking place in North Carolina and at the federal level around I/DD services and regulations.
In addition to the great trainings, the N.C. Council's conference is also famous for networking - LME/MCOs and their staff, providers, hospital leaders, DHHS, Division of MH/I/DD/SAS, DMA, legislators, advocates, consumers - over 100 vendors - all in one place.
Today is the last day to register! Please contact Jean via email (jean@nc-council.org) if you have questions or need additional information.
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Correcting Coordination of Benefits (COB) information in the Global Eligibility File
Occasionally, there are errors in how a consumer's secondary insurance is reflected in the Global Eligibility File (GEF) maintained by DHHS and used by Smoky. Because information in the GEF overwrites any changes made by Smoky in the AlphaMCS system, Smoky now follows a new process for providers to submit changes to COB information.
Providers should now submit any COB changes directly to NCTracks using the 2057 Referral form. This is the only process that ensures a COB change will be made permanent both in AlphaMCS and NCTracks. The link to the 2057 Referral form can be found on the DMA website. All forms should to be processed within three business days of submission.
Questions about the form? Contact HMS at 1-866-263-2227, and select option 6.
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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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