- THCA

Volume XXXI, Number 5
May 2016

TMHP to Implement Enhancements to LTC Claims Management System

Earlier this year the Texas Medicaid & Healthcare Partnership (TMHP) announced that, in an effort to reduce the number of claim denials and rejections and align the TMHP’s claims systems with those of the managed care organizations (MCOs), TMHP was planning significant enhancements to the Long Term Care (LTC) Claims Management System. Just as a reminder to everyone, these system changes went into effect on April 29, 2016. TMHP has offered to providers some general guidance regarding the new system enhancements:

Previously providers may have received Warning Messages related to some claims; however, TMHP continued to forward those claims to the MCO’s for payment. Effective April 29, 2016 when providers receive an Error Message, the claim will not be accepted or sent to the MCO for payment until the provider corrects the data.
- Providers will need to review their Claim Response Files, correct any errors and resubmit the claim for it to be accepted by TMHP and/or sent to the MCO for payment.
Additional editing will be done on claims, to ensure providers are using valid provider NPI, Provider Name, diagnosis codes and Tax IDs.
Valid External Cause Diagnosis, when required, must be entered, a validation has been added and if this validation fails, claim submissions will not be accepted.
Claims submitted with dates of service (DOS) spanning both fee-for-service and managed care segments will reject. Providers must submit separate claims for fee-for-service DOS and managed care DOS.
Should a resident’s RUG level change the provider must bill on separate lines with the appropriate dates. e.g. should the RUG level change three times within the billing submission that resident would appear on three separate lines with the three different RUG’s and appropriate dates for each.
- For billing new claims: Separate Claim details (lines) should be billed for different RUG level within the Service Period.
- If the RUG value is retroactively changed for the “complete” period of the originally paid claim detail DOS then the MCOs will automatically adjust the Paid claims to change the RUG level.
- If the RUG value is retroactively changed such that the RUG value is changed “within” the original paid claim detail DOS then MCOs will notify Providers about rebilling these claims. Providers should rebill these claim details by separately billing the claim details for different RUG levels. MCOs cannot automatically reprocess these claims to split the claim details for different RUG levels. MCOs will ensure that Providers are notified about these claims and Provider are allowed to rebill in this scenario (not failing the duplicate claims edit).
- (For FFS Claims TMHP automatically splits the claim detail in this scenario as a part of retroactive claim adjustment process)
If a third-party vendor is used for claims submission, it is the responsibility of the provider to notify those vendors about the upcoming changes to the Claims Management System so that software updates can be made if needed.

When these enhancements are implemented, the following changes will be reflected in the claim submission process for both TexMedConnect and the Electronic Data Interchange (EDI):

TexMedConnect

A valid External Cause Diagnosis, when required, must be entered in the third position of the diagnosis table located on the Claim tab. The message “No Match Found” will be displayed if an External Cause Diagnosis is entered as a Principal Diagnosis or Admit Diagnosis on Institutional claims. Additionally, the message “No Match Found” will be displayed when a non-External Cause Diagnosis is entered in the External Cause Diagnosis field (Third Position) on Institutional claims. A validation has been added and if this validation fails, claim submissions will not be accepted.
Claims with Other Insurance submissions will have a validation added to allow entry of either the Employer Name or Group Number. For claim submissions to be accepted, both options cannot be entered. The Employer Name field will be disabled if there are characters in the Group Number field; and The Group Number field will be disabled if there are characters in the Employer Name field.
Tax ID will auto populate based on the value contained in the Provider File (Billing National Provider Identifier [NPI]).
When updating the Billing NPI for a new claim, draft claim, or claim template, the ID Qualifier will automatically default to Tax ID and Other Information will display the associated Tax ID. Previously entered information in these fields will be lost.
The Attending Provider field on the Provider tab will be checked to ensure a valid NPI is entered using the standard Luhn algorithm (a checksum formula) to check for errors. If this validation fails, claim submissions will not be accepted. If the NPI submitted is not valid, the following message will display: “NPI failed digit check and is not valid. Please check the NPI and enter a valid NPI number.”
Claims submitted with dates of service (DOS) spanning both fee-for-service and managed care segments will reject. Providers must submit separate claims for fee-for-service DOS and managed care DOS.

Electronic Data Interchange (EDI)

837I, 837P, and 837D claims will require all NPIs to pass the standard Luhn algorithm (a checksum formula) to prevent errors.
837I claims will require Attending Provider Name.
837I claims will require dates of service to be equal to, or within, the statement begin and end dates.
837I claims will not allow a value in both the Other Insurance Group Number and Employer Name to be present on the claim.
837I claims will require Principal Diagnosis.
837I Inpatient Admission claims will require Admitting Diagnosis.
837I Inpatient Admission claims will require Admission Date/Hour.
837I Inpatient Final claims will require Discharge Hour.
Claims submitted with dates of service (DOS) spanning both fee-for-service and managed care segments will reject. Providers must submit separate claims for fee-for-service DOS and managed care DOS.

For more information, call the LTC Help Desk at 1-800-626-4117, Option 1.

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If you have any questions about the THCA Commitment to Care Initiative or would like to share your facilities successes please contact Gloria Bean-Williams by email or call (512) 458-1257.