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VOL. 1, ISSUE 9 | DECEMBER 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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Happy holidays from your
Smoky Claims and E&E teams!
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____ I know who our assigned Smoky claims specialist is, and I have provided our current contact information.
____ Our site and address information is up-to-date and matches in NCTracks and AlphaMCS.
____ Our clinician licensure and provider associations are up to date.
____ ICD-10 diagnosis codes are being used for all claims with dates of service after October 1, 2015.
____ Claims submitted with an authorization are being billed under the authorized service facility location.
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  Denial Spotlight - 5: Claim received outside of billing period
Background: A provider typically has 90 days from the date of service to submit a claim. The claim will deny if not submitted in the applicable time frame. If the claim is secondary (it must be filed to primary insurance first), a provider has 180 days from the date of service to submit the claim with a coordination of benefits (COB) reason and amount. What causes this denial? AlphaMCS adds the number of allowed claims days, plus three (each claims has a three-day grace period to the date of service), and verifies that the value is greater than or equal to the received date.
If the claim is a replacement claim, and the original claim was not denied for being received after the billing period, 90 additional days are allowed for processing.
If both the COB reason and amount are listed in the claim line, the billable period is extended another 90 days to a total of 180.
How do I correct the denial? Write off charges as non-billable. Do not re-bill.
For questions and assistance with timely filing denials, contact your claims specialist directly, call the general claims line at 828-225-2785, ext. 2455, or claims@smokymountaincenter.com.
For denial reconsiderations, please refer to the Claims Denial Reconsideration Request form, located on the Claims page of the Smoky website.
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The 2016 LME/MCO checkwrite schedule is now available. You can find the PDF version on Smoky's Claims/Eligibility & Enrollment page or view it below.
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Denials for "service not authorized"
Denials for "service not authorized" occur when the site selected on the claim does not match the site designated on the authorization. If there is a valid authorization in AlphaMCS at the time of submission and you receive this denial, verify that the site selected on the claim matches the site designated on the authorization.
For 837 submissions, the site is determined by the service facility location NPI and ZIP+4.
For AlphaMCS portal submissions, the site is selected from a drop-down box.
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Denial questions: Claims or eligibility and enrollment?
A variety of questions overlap claims denials and eligibility and enrollment. If a denial relates to a consumer's eligibility, an E&E specialist can help. Some questions you can ask an E&E specialist:
Has the member's Medicaid lapsed?
Why are claims denying for no coverage if NCTracks shows the member has Medicaid?
The member does not have any other insurance, and there is no other coverage showing in NCTracks. Why am I receiving coordination of benefits (COB) denials?
A member is covered by the N.C. Innovations Waiver, but the member's coverage is not in AlphaMCS. What do I do?
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 Claims research for previous fiscal years
Claims specialists can help research any date of service within Smoky's current fiscal year, which runs from July 1 to June 30 and is named for the year in which it ends.
Providers may submit claims research inquiries for previous fiscal years only if requested within 90 days of the final adjudication. This allows providers to inquire about claims that may have been reprocessed by Smoky at a later date.
Example:
Claim date of service was August 1, 2013 (prior FY2014)
Claim was readjudicated on April 5, 2015 (FY2015)
The provider would have until July 4, 2015, to submit an inquiry.
If you are unsure if a claim qualifies to be researched, contact your claims specialist.
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NCTracks updates from the National Plan and Provider Enumeration System
The National Plan and Provider Enumeration System (NPPES) sends a weekly update file to NCTracks with National Provider Identification (NPI) additions and updates. Based on the enumeration date, it may take up to four weeks for the NPI to be linked to NCTracks. If the provider has not used NCTracks to enroll in the North Carolina Medicaid program, NPIs will not be visible or searchable by NCTracks staff.
To determine if the NPI is available, the provider should attempt the enrollment process on the NCTracks website. During the process, the provider may receive an error message that the NPI is invalid. Providers who receive the error message should wait a week to allow the NPI to link to NCTracks.
The original NCTracks provider communication can be viewed on the NCTracks website.
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MCR/Re-enrollment application status when the record results return "N/A"
When completing a Manage Change Request (MCR) or re-enrollment application on the Status and Management page of the NCTracks Provider Portal, review each section before starting. The Record Results under the Manage Change Request section lists the NPIs for which your NCID has access. If a draft MCR or application for an NPI has been saved by an enrollment specialist or former office administrator (OA), you will see "N/A" under the "select" column of the record results.
To continue with submission of the new MCR/re-enrollment application, the previously saved draft must be completed or deleted. OAs should check with all enrollment specialists who have access to the NPI to see if they have a saved draft. Drafts left unattended automatically delete after 90 days.
The original NCTracks provider communication can be viewed on the NCTracks website.
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Helpful contacts
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Department or team
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Point of contact
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Provider Help Line
- General questions/technical assistance
- Requests to add a site or service
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1-866-990-9712
providerinfo@smokymountaincenter.com
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Compliance Hotline (24/7/365)
- Report fraud, waste or abuse
- Report suspicious billing
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1-866-916-4255
legalandcompliance@smokymountaincenter.com
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Claims
- Billing and reimbursement
- RAs, credit memos, service codes
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1-800-893-6246, ext. 2455
claims@smokymountaincenter.com
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Eligibility and Enrollment
- Health plan eligibility and enrollment
- Client updates
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1-800-893-6246, ext. 2355
eande@smokymountaincenter.com
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Credentialing Hotline
- Credentialing and re-credentialing
- Update/change information
- Add new practitioners to agency roster
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1-855-432-9139 credentialingteam@smokymountaincenter.com
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Care Management
- Authorizations and service definitions
- Clinical Practice Guidelines
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1-800-893-6246, ext. 1513 (MH/SA), ext. 1902 (IDD) um@smokymountaincenter.com
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Member Appeals
- Peer-to-peer discussions
- Reconsideration of authorization decisions
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1-800-893-6246, ext. 1400
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Help Desk/Management Info System (MIS)
- Alpha system issues
- Electronic billing (837/835)
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1-800-893-6246, ext. 1500 helpdesk@smokymountaincenter.com
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Access to Services line (24/7/365)
- Help for appointments and referrals
- Link to Mobile Crisis Management
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1-800-849-6127
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Consumer Relations team
- Connect with a Smoky peer or family support specialist with lived MH/IDD/SU experience
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1-888-757-5724
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Customer Services
- Report a compliment, complaint or concern
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1-888-757-5726 grievances@smokymountaincenter.com
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Enrolling new consumers and updating consumer names
New consumer enrollments
The following information is required for setting up a new consumer in AlphaMCS:
1. Full given birth name (there is a separate field for suffixes such as Sr., Jr., III)
2. Maiden name (there is a required field if the client is female; if the consumer has never been married, the given birth name is also the maiden name)
3. Date of birth
4. Social Security number
For consumers with Medicaid, names must be an exact match to the name on the Medicaid card.
AlphaMCS creates a unique consumer ID using:
- The first three letters of the last name (if the consumer is male) or first three letters of the maiden name (if the consumer is female)
- The first letter of the first name
- The consumer's date of birth (mmddyy)
Updating consumer name changes
- A consumer name change cannot be performed in AlphaMCS unless the county Department of Social Services (DSS) has made the name change in NCFast/NCTracks. In some cases, a consumer may give you a name change but has not notified DSS; therefore, the new name is not yet on the Medicaid card.
- The Smoky AlphaMCS Electronic Health Record system must match the information in NCTracks.
- When a child is adopted and the child's name is changed, the new name should be effective on the date the court finalizes the adoption.
- If the consumer does not currently have Medicaid, but previously did, the consumer's information will still be in the NCTracks system.
Encourage your consumers to have any changes in name, insurance or other demographic information updated in NCTracks through their county DSS offices. Always verify the spelling of names from the Medicaid card, driver's license and/or insurance card. Following these guidelines will expedite the process of enrolling and/or updating consumers with Smoky and avoid problems or delays in authorizations, claims and other process activities.
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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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