VOL. 1, ISSUE 13 | APRIL 2016
 
Welcome to the Claims Corner and Eligibility & Enrollment (E&E) Edge from Smoky Mountain 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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NEED ASSISTANCE?
  For claims-related questions, email 
 or call 828-225-2785, ext. 2455.
  
For enrollment and eligibility questions, email eande@smokymountaincenter.com
or call 828-225-2785, ext. 2355.
  
QUICK LINKS
                      NC Council of Community Programs Training Calendar
EDIElectronic data interchange site determination changes

Correctly reporting address and provider information on 837 files

In March, Smoky implemented claims edits in AlphaMCS to verify the correct submission of site information on 837 electronic claims files. Providers must appropriately identify the enrolled site location responsible for the service billed as the Billing Provider in accordance with national regulations for electronic healthcare claims. 
 
Provider agencies that deliver services from multiple credentialed locations are required to identify the agency's specific site information on the claim, including 9-digit code and associated National Provider Identifier (NPI) for the location where the service was based and/or delivered. Providers must ensure that information on the 837 claim file is presented in the appropriate data fields in compliance with ANSI ASC X12N 837 version 5010 standard requirements described below.
 
On 837 electronic claim files, the provider's facility or site location information is reported as the Billing Provider data (837 Loop 2010AA). Alpha MCS edits will ignore information presented as the Service Facility in 837 Loop 2310C when determining the location credentialed and/or authorized to provide the service.
 
Please Note: 
The 837 Service Facility Location Loop 2310C is reserved for reporting ONLY when services were provided at a health care facility that is NOT owned by the billing provider (for example, an independent practitioner or a group practice billing services for a patient located at a hospital or skilled nursing facility).
 
The provider's billing or administrative office address should NOT be reported in the Billing Provider Loop unless it is the same address where the service was rendered or based.
 
Correctly Reporting Billing Provider Data on the 837 file

To avoid denials on valid services, the following elements must be correctly reported in the 837 file Billing Provider Loop 2010AA to successfully identify a valid enrolled provider location:
 
Billing Provider NPI number, reported in the 837 file's Billing Provider Loop 2010AA, segment NM109, MUST match the NPI registered with Smoky and recorded in Alpha MCS system as associated with the provider agency's specific site location; credentialed and/or authorized to perform the service where it was rendered. Many services are authorized to a specific physical address.
 
Billing Provider's Location Address is identified by the 9-digit ZIP code (ZIP+4) reported in 837 Loop 2010AA, segment N403. The ZIP+4 on the claim must be associated with the NPI submitted for the Billing Provider and match the physical address on file for the provider location responsible for services billed. It is important that the provider's NPI numbers and associated addresses are correctly recorded in both the AlphaMCS system and the State's NCTracks system.
 
Questions? 
Contact the claims team at claims@smokymountaincenter.com or 828-225-2785, ext. 2455.
Please see the ANSI ASC X12N 837 version 5010 standards regarding correct use of the Billing Provider and Service Facility Location Loops cited below:

Loop 2010 AA - BILLING PROVIDER NAME LOOP - SUBPARTS
When the Billing Provider is an organization health care provider, the NPI of the organization health care provider or its subpart is reported in Segment NM109. When an organization health care provider has determined a need to enumerate subparts, it is required that a subpart's NPI be reported as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration and MUST be the same identifier sent to any trading partner.

Loop 2310C - SERVICE FACILITY LOCATION NAME
When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.
 
GuidanceGuidelines for patient monthly liability corrections
 
Providers are instructed to follow the below guidelines to correct patient monthly liability (PML) amounts on submitted claims.
 
In the event that errors were made in reporting PML on a claim:
  • Same as any other correction: 90 days allowed from date of adjudication for replacement claim.
  • If outside the 90-day adjustment filing period, the provider should complete the Provider Self-Audit process (if corrected PML amount would result in funds owed to Smoky) or file a Claims Denial Reconsideration Request (if corrected PML amount would result in funds owed to provider).
In the event that the PML amount was added or changed in NCTracks:
  • A replacement claim can be submitted 90 days from the update date if NCTracks made a retroactive alteration of the PML amount. Provider must submit proof of update date.
  • A replacement claim can be submitted 90 days from the insert date if NCTracks was late in inserting the Medicaid coverage layer with PML amount. Provider must submit proof of insert date.
  • If outside the 90-day adjustment filing period, the provider should complete the Provider Self-Audit process (if corrected PML amount would result in funds owed to Smoky) or file a Claims Denial Reconsideration Request (if corrected PML amount would result in funds owed to provider).
Please visit our website for all forms for self-audit and denial reconsideration.
LabfeeLab fee schedule change
 
MEMORANDUM
 
To:           Smoky Mountain Providers

From:      Smoky Mountain Finance Department

Re:           Notification of DMA Laboratory Fee Schedule Changes

Date:       April 1, 2016
 
The North Carolina Division of Medical Assistance (N.C. DMA) has announced a change in Laboratory Fee services. This update of rates will go into effect May 1, 2016. Please note the inclusion of a rate on the laboratory fee schedule does not guarantee that a service is covered. Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice Clinical Coverage Policies on the DMA website.
 
If you have questions, email provider.info@smokymountaincenter.com.
 
Thank you for your consideration and attention. 
 
 
  
AMTCLNew Transition to Community Living (AMTCL) state benefit plan
 
The AMTCL benefit and Tenancy Support Team (TST) service went into effect November 1, 2015. To pull down the new Transition to Community Living Initiative (TCLI) Mental Health Services allocation, the TST service must be utilized in conjunction with the AMTCL Benefit Plan. All individuals eligible for AMTCL must be assigned to the AMTCL Benefit Plan in NCTracks prior to submission of TST claims. 
 
From the N.C. DMA:
 
The AMTCL benefit plan consists of adults, ages 18 and over, who have been identified as participating in the N.C.-U.S. DOJ Settlement Agreement. Without the covered treatments and support, these individuals could experience impaired functioning that would compromise their ability to transition to or remain housed in the community and put them at risk for remaining in or admission to an institutional setting.

Participation in the settlement agreement is evidenced by:
  1. Having a verified diagnosis of serious mental illness (SMI) or serious and persistent mental illness (SPMI)
    AND
  2. Living in an adult care home (ACH)
    OR
  3. Receiving treatment in a state hospital, and upon discharge will have unsafe or unstable housing
    OR
  4. At risk of living in an ACH
Individuals covered by this plan can and may include individuals approved for a housing slot and/or participating in a Supported Employment program that meets fidelity to an evidence-based model.
 
Individuals who meet eligibility for AMTCL also meet eligibility for Adult with Mental Illness (AMI) and must be enrolled to pay for services necessary to sustain supportive community living while participating in TCL. Individuals may also be eligible for other benefit plans, but would be considered secondary.

The AMTCL benefit plan can be used concurrently with the following target populations:
Adult with Mental Illness (AMI) 
Adult Substance Use Treatment Engagement and Recovery (ASTER) 
Adult Substance Use Injecting Drug User/Communicable Disease (ASCDR) 
Adult Substance Use Women (ASWOM) 
Adult Developmental Disability (ADSN)

Joint Bulletin #J167 provides a complete service definition for tenancy support, as well as criteria for utilizing the AMTCL benefit plan.  
needhelpNeed help?
For claims-related questions, contact your assigned claims specialist via phone or email. If you do not know your assigned specialist, use these general contacts.
contactsFor general claims information

 

Send an email to us at: claims@smokymountaincenter.com or call 828-225-2785, ext. 2455.
For enrollment and eligibility

 

Send an email to us at: eande@smokymountaincenter.com or call 828-225-2785, ext. 2355. 

Smoky Mountain 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).