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Magellan: Virginia’s Behavioral
Health Services Administrator
Electronic
Claim Submission
Overview of Claims
Submission
and Tracking
Requirements, Electronic Billing
Options and Provider Website Features
November 5, 2013
Today’s Agenda
• Welcome! (Ajah Mills, Field Network Director, VA BHSA)
• Claims Submission Requirements (Tracey Alfaro, Sr. Network Manager,
Implementations)
• Electronic Claim Submission Options and Tracking – (Aimee Thatcher, Sr.
Systems Analyst and Teresa O’Connor, Lead Systems Analyst)
• Magellan Provider Website – Demo on Claims Courier, Provider Website
Features and more (Melissa Siesener, Reference Systems Analyst)
• Wrap-up – Contact Information and Q & A (Tracey Alfaro)
2
Claims Submission Requirements
Beginning with dates of service on or after December 1, 2013
Claims Submission Procedures
• Beginning with dates of service on or after December 1, 2013, you will need
to submit your claims for rendered DMAS behavioral health fee-for-service
and Medicaid/FAMIS Managed Care plan services to Magellan.
– For dates of service prior to December 1, submit claims to DMAS per your
usual process.
• We strongly encourage all providers to submit claims to Magellan
electronically using one of our three EDI Options: Direct Submit,
Clearinghouse, or Claims Courier on our provider website.
• For more information, visit the Getting Paid/Electronic Transactions
section on the Magellan provider website at
www.MagellanHealth.com/provider.
• Submit all paper claims to:
Magellan Behavioral Health
P.O. Box 1099
Maryland Heights, MO 63043
– For electronic claims, please indicate P.O. Box 1099
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Claims Tips
• Claims with CPT or HCPCS procedure codes should be submitted
electronically on a 837P (Professional) file or paper claim form CMS-1500.
• Claims with Revenue codes should be submitted electronically on a 837I
(Institutional) file or paper claim form UB-04.
• Hints for claim completion:
– Give complete information on the member (name, address, DOB).
– Give complete provider information (TIN/SSN, “servicing” provider name and
address, “billing” provider name and address, National Provider Identifier
[NPI] number for both the “servicing” and “billing” provider). Atypical
providers use your Atypical Provider Identifier (API).
– Attach the primary carrier’s Explanation of Benefits (EOB), if applicable.
– Include all HIPAA-compliant diagnosis codes.
– Include the appropriate billing modifier (where applicable).
– Submit claims prior to the timely filing deadline.
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Claims Tips (continued)
Top reasons for claim rejection/denials:
• Missing or invalid CPT/HCPCS/Revenue code
• Missing or invalid diagnosis code
• Missing or inaccurate place of service code
• Missing or invalid NPI (for “servicing” provider and “billing” provider) or API
• Claims submitted past the timely filing deadline
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Timely Filing
• The initial submission of all claims for covered services provided to
members must be received by Magellan within 365 days of the date of
service.
– If Magellan does not receive a claim within these timeframes, the claim will be
denied for payment.
• Please refer to the DMAS Provider Manual, Chapter 5 – Billing instructions
regarding Timely Filing and Denied Claims
– The Medical Assistance Program regulations require the prompt submission of
all claims. Virginia Medicaid is mandated by federal regulations [42 CFR §
447.45(d)] to require the initial submission of all claims within 12 months
from the date of service. Providers are encouraged to submit billings within
30 days from the last date of service or discharge.
– Denied claims must be submitted and processed on or before thirteen
months from date of the initial denied claim where the initial claim was filed
within the 12 months limit to be considered for payment by Magellan.
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Claim Denials and Corrected Claims
• Claim denials will either be sent on the provider paper remittance or the Electronic
Remittance Advice (ERA), whichever the provider receives. Providers who sign up for
Electronic Funds Transfer (EFT) will be able to view paper remittances on the
Magellan Provider Website after secure login “Check Claim Status/EOB Search”.
– Electronic submissions are the preferred method for claims submission, payment and
remittance advice.
• If there is a need for a corrective change to a paid claim, the corrective claim should
be sent as an adjusted claim and the original claim will be adjusted, not voided.
– Please note: Only claims that were originally paid and have changes should be sent as
corrected.
• An originally denied claim should just be submitted as a new claim, even if there are
changes.
• Corrected claims can be submitted electronically by selecting the appropriate
“corrected claim field” (please consult Magellan’s EDI companion guide).
• For paper submissions, please write “corrected claim” on the top of the claim form
and note the Medicaid Resubmission code and original reference # in box 22 on
CMS-1500.
– Highlighting the changes will ensure Magellan understands the changes being made.
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Dual-Eligible Members and Coordination of
Benefits
• Claims for dual-eligibles should be submitted to Medicare for
reimbursement, for services covered by Medicare. The claims will crossover
to DMAS for processing for the Medicaid portion as currently being done.
Magellan will not receive the dual-eligible claims.
• Claims for services provided to members who have another primary
insurance carrier must be submitted to the primary insurer first in order to
obtain an Explanation of Benefits (EOB). Magellan will not make payments
if the full obligations of the primary insurer are not met.
– There are some service codes that will be TPL exempt (further
clarification will be provided).
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Claims Review
• Upon receipt of a claim, Magellan reviews the documentation and makes a
payment determination.
• As a result of this determination, a remittance advice, known as an
Explanation of Payment (EOP) or Explanation of Benefits (EOB) is sent to
you.
• The EOP/EOB includes details of payment or the denial.
• It is important that you review all EOP/EOBs promptly.
• You can review your EOB online after sign-in with your secure log-in to
www.MagellanHealth.com/provider. Select “Check Claims Status” and
select the EOB Search tab.
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Eligibility Verification
• Authorization for service is based on eligibility at the time of the treatment
request and does not guarantee payment.
• Providers are responsible for verifying a member’s eligibility for coverage:
– Prior to the first appointment,
– Throughout the course of treatment, and
– Prior to submitting claims.
• Providers may check member eligibility beginning on 12/1/13 by:
– Using the Magellan provider website; after secure login, go to “Check
Member Eligibility.”
– Call Magellan at 1-800-424-4046 and speak to customer service
representative.
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National Provider Identifier (NPI) Numbers
• The National Provider Identifier (NPI) is a 10-digit identifier required on all
HIPAA standard electronic transactions.
– There are specific fields on the paper claim forms and electronic file that you
should indicate the “rendering provider NPI” and “pay to provider NPI.”
– For Atypical providers, you would use your Atypical Provider Identifier (API).
• An NPI does not replace a provider’s TIN; the TIN/SSN continues to be
required on all claims – paper and electronic.
– Note: this is a change from the current billing process with DMAS
• The NPI is for identification purposes, while the TIN/SSN is for tax purposes.
• Important: claims that do not include a TIN/SSN will be rejected.
• You can find more information on NPI on the Magellan provider website at
www.MagellanHealth.com/provider; go to the “Getting Paid” section under
“Electronic Transactions.”
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National Provider Identifier (NPI) Numbers (continued)
• For organizations, please bill the organization as the rendering and pay to
NPI (this excludes inpatient facilities who bill on UB-04 and requires
attending physician).
• For groups, please bill the individual as the rendering NPI and the group as
the pay to NPI.
• For Atypical providers, you would use your Atypical Provider Identifier (API).
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Frequently Asked Questions
• Please review the Claims section in the Frequently Asked Questions (FAQ)
document posted on the Magellan of Virginia website
www.MagellanofVirginia.com and go to the “For Providers” section.
– We are continually updating this FAQ document with answers to all
questions we receive from providers regarding the implementation.
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Electronic Claim Submission Options
And Tracking
What’s in it for Providers?
• Improved Efficiency
– No paper claims. No envelopes. No stamps.
– Prompt confirmation of receipt or incomplete claim.
• Faster Reimbursement – cut out the mailman.
• Improved Quality
– Up-front electronic review ensures higher percentage of clean claims.
– Magellan staff do not re-key information from paper claim, eliminating
human error.
– Secure process with encryption keys, passwords, etc.
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1. Claims Clearinghouses
• Act as a middleman between the
provider and Magellan, and can
transform non-HIPAA compliant to
X12N005010 compliant 837.
contracted Clearinghouses to submit
your EDI transactions.
• Note that there may be charges from
the clearinghouses (check directly with
• Magellan accepts 837 Professional and
the clearinghouse).
837 Institutional transactions from the
following contracted Clearinghouses:
• It is critical that the proper Payer ID is
– PayerPath (Allscripts)
used so claims are sent to Magellan:
–
–
–
–
–
–
–
Capario
Availity
Emdeon Business Services
RelayHealth
Gateway EDI
Office Ally
IGI Healthcare
• If you are currently working with a
different Clearinghouse, you may
continue to use your Clearinghouse. You
will need to have your Clearinghouse
work with 1 of the 8 Magellan
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– The following payer unique Payer
IDs are required for all
clearinghouses:
• 837P and 837I: 01260
– The following unique Payer IDs are
for Emdeon only:
• 837I: 12X27
2. Direct Submit
• Primarily for high-volume claim
submitters, but there is no minimum
number necessary for submission.
• Tests X12N 5010 HIPAA-compliant 837 files
to be sent directly to Magellan.
• Magellan offers providers the
EDI Direct Submit testing application, which is an electronic claims tool available on
an EDI-dedicated website at www.edi.MagellanProvider.com.
• EDI Assistance Hot Line: 1-800-450-7281 ext. 75890, and email:
EDISupport@MagellanHealth.com.
• Direct Submit streamlines the process by eliminating the middleman.
• No charge to the provider from Magellan to use Direct Submit.
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Magellan Transactions
• ASC X12N/005010X223A2 Health Care Claim Institutional 837
• ASC X12N/005010X222A1 Health Care Claim Professional 837
• ASC X12N/005010X279A1 Health Care Eligibility Benefit Inquiry and Response 270/271
• ASC X12N/005010X217E2 Health Care Services Review – Request for Review and Response
278
• ASC X12N/005010X212E1 Health Care Claim Status Request and Response 276/277
• ASC X12C/005010X231A1 Implementation Acknowledgement for Health Care Insurance 999
• ASCX12N/005010X214 Health Care Claim Acknowledgment 277CA
• ASC X12N/005010X221A1 Health Care Claim Payment/Advice 835
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Edits
Magellan uses EDIFECS Xengine for editing.
There are four levels of Magellan edits:
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1.
The TA1 Response – Shows the envelope information and format of the file was
accepted or rejected.
2.
The 999 Response – Verifies the HIPAA edits.
3.
Companion Guide Edits – The Magellan specific required edits. Only rejected
claims will be reported back on a 277.
4.
The Host Claims Edits – These are claim edits for Eligibility and provider
information. All claims sent to Magellan’s host system will receive a status of
accepted or rejected on a 277. A provider will receive 277 transaction report to
inform them which claims were accepted or rejected.
Capacities and Limits
• Unlimited amount of files with unique control numbers.
• Magellan requests submitters to limit files to 5000 claims per file.
• HIPAA X12 5010 standard limits the maximum number of claim lines per claim to 99
for the 837I transaction and 50 claim lines per claim for the 837P transaction.
EDI Support Contact
• EDI Assistance Hot Line: 1-800-450-7281 ext. 75890
• EDISupport@MagellanHealth.com
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Testing Center Capabilities
• The Submit EDI Claims application on the provider website is available to Magellan
providers and trading partners. It allows providers to send ANSI X12N 5010 HIPAA
transaction files directly to Magellan and receive ANSI X12N 5010 responses from
Magellan without the use of a clearinghouse.
• The software from EDIFECS, Inc. of Bellevue, WA, allows providers to self-enroll by
creating a unique user ID and password, download EDI guideline documentation,
upload ANSI X12N 5010 test files, and obtain immediate feedback regarding the
results of the validation test.
• This tool allows providers the opportunity to independently validate their EDI test
files (837 X12N 5010 Professional and 837 X12N 5010 Institutional) for HIPAA
compliance rules and codes.
• Files sent to Magellan will be validated, and when production certification is
granted, the user will be permitted to submit production claims files and receive
responses.
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Testing Center Capabilities (continued)
• This web-based testing application is easy to follow and consists of a six step
process.
• You will be assigned an IT analyst to guide you through the process and address any
questions.
• Our providers typically take about 3 to 4 weeks to complete the process, so allow
ample time to complete your independent testing so that you can enjoy the
benefits of claims direct submission.
– We strongly encourage all providers who would like to use Direct Submit to
begin the process now to be ready to submit EDI files directly to Magellan
beginning on December 1.
• The following slides walk through the screenshots you will see as you move through
the process.
• Go to www.edi.MagellanProvider.com to start the process.
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Magellan EDI Testing Center
Welcome Page
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Task 1 - Download Companion Guide & FAQs
25
Task 2 - Complete the EDI Survey
26
Task 3 – Magellan Internal Review of Survey
27
Task 4 - Upload and Validate 1st EDI Test File
28
Task 5 - Upload and Validate 2nd EDI Test File
29
Task 6 - Are You Ready for Production Status?
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CONGRATULATIONS!!
• Once you have completed the six-step process, you’ll be ready to exchange
production-ready EDI files with Magellan.
• If you have any questions about the process, please contact
EDISupport@MagellanHealth.com or 1-800-450-7281 ext. 75890.
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3. Claims Courier
• Claims Courier (Submit a Claim Online) is a
web-based data entry application for
providers submitting professional claims on
a claim-at-a-time basis.
– This application is not for institutional
claim submissions.
• Accessible after sign-in on Magellan’s
provider website:
www.MagellanHealth.com/provider.
• Claims Courier streamlines the claims
process by eliminating the middleman.
• No charge to the provider from Magellan
to use this application.
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Electronic Remittance Advice (ERA)
• Electronic Remittance Advice means receiving remittance data in an
electronic form, such as the HIPAA X12.835.
• You have two options to sign up for ERA or 835:
– Work with an EDI analyst during Direct Submit set-up/testing phase to
request.
– Completing the ERA Registration Form and sending it to the
Clearinghouse with which you chose to contract.
• Please fax the completed form to one of the clearinghouses. (Note, for
Availity, you must register online at www.availity.com.)
• In order to receive electronic claims remittance, you must have a W-9 and a
National Provider Identifier (or Atypical Provider Identifier) on file with
Magellan, and be the owner of the Taxpayer Identification Number (TIN)
under which claims are paid.
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Electronic Funds Transfer (EFT)
• Providers can take advantage of Magellan’s online feature -- Electronic
Funds Transfer (EFT) -- for claims payments. You can request to have certain
claims payments directly deposited to your business bank account.
• EFT is quicker than the standard process of mailing and cashing or
depositing a check, leaving you more time to devote to your practice.
• EFT is available to organizations, group practices and individual providers
who own the Taxpayer Identification Number (TIN) linked to the submitted
claim.
– Individual providers within an organization or group practice are not
able to receive EFT claims payment.
34
Registering for EFT
• To register for EFT, simply complete and submit the registration form.
• To access the EFT registration form:
– Enter your username and password in the Sign-in box at
www.MagellanHealth.com/provider.
– From your MyPractice page, click Display/Edit Practice Information.
– Click Electronic Funds Transfer.
– Click Add to enter your information.
– Click Save to submit your EFT registration.
– Upon clicking, you will see a confirmation page that you can print for your
records.
– If you do not have a provider website login yet, please request via email at
VAProviderQuestions@magellanhealth.com an EFT registration form to
complete and fax to Magellan
• After registering for EFT, Magellan will conduct a transmission test with
your bank to make sure payments are transferred properly. During this
time, you will continue to receive paper checks via U.S. mail.
35
Using EFT
• Once you begin to receive EFT payments, you will no longer receive an
Explanation of Payment (EOP) or Explanation of Benefits (EOB) by U.S. mail
for those benefit plans that allow EFT.
• EOP or EOB information can be accessed and printed through the Check
Claim Status application on your MyPractice page of the Magellan provider
website.
• You must use Check Claim Status on the Magellan provider website, or
review your Electronic Remittance Advice (ERA) online through your
clearinghouse, in order to obtain the processing result for EFT paid claims.
• Should a claim be denied, no payment will be due and there will be no EFT
transaction. You will need to check you EOP or EOB online via the Magellan
provider website at www.MagellanHealth.com/provider.
36
Claims Courier and Provider Website Features
Demonstration
Magellan Provider Website
Claims Features and more
Magellan Provider Sign-In
39
Checking Claims Status on MagellanHealth.com/provider
• Sign in on Magellan provider Web site: www.MagellanHealth.com/provider.
• Select “Check Claims Status” from menu.
• Capabilities to search for claims by member or subscriber name, date of
service, etc.
• Can view claim details such as check number, date and
payment method.
• If claim is denied, reason code and description are provided.
• Contact instructions available if provider has questions.
• View EOB online through the “Check Claims Status” EOB search tab.
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My Claims – Check Claims Status
41
My Claims – View EOB through Check Claims Status
42
View EOB (continued)
43
View EOB (continued)
44
View EOB (continued)
45
My Claims – View Claims Submitted Online
46
My Claims - View Claim Details
47
View Authorizations
48
Check Member Eligibility
49
Magellan Provider Website – Online Training
On Magellan’s provider website: www.MagellanHealth.com/provider.
• Go to the “Education” section at top-menu and select “Online Training.”
Website User Guides
• Authorizations/Eligibility
• Claims
• Electronic Transactions
Demos of Online Tools
• Authorizations/Eligibility
• Claims
• Electronic Transactions
50
Magellan Provider Website – Getting Paid
• Go to the “Getting Paid” section at top-menu.
• In this section, you will find information and resources on:
– Preparing Claims
– CPT Code Changes
– DSM-5/ICD-10
– HIPAA
– Electronic Transactions
– Paper Claim Forms
51
Magellan Provider Website – News & Publications
• Go to the “News & Publications” section at top-menu and select “Stateand Plan-Specific Information.”
• Then select the “Virginia BHSA” under Plan-Specific Information.
• This will take you to the Virginia BHSA Provider Handbook Supplement and
Appendices.
– The supplement and appendices are currently in review and will be
posted soon.
52
Wrap-up
Closing Information
Magellan Provider Website
Provider Sign In (Secure Provider Information)
54
Provider Website Login Set-Up Process
How to Login the Provider Website
Once you receive your executed contract, the cover
letter will give you instructions on how to sign in on
the Magellan provider website for the first time.
Log on to www.MagellanHealth.com/provider
• Enter your User Name and Temporary Password in
the Sign In Box
• User Name = Magellan MIS #
• Password = ????
For new providers who are still in the
credentialing/contracting process with Magellan and
do not have an executed contract, Magellan is in
process of setting up website logins for providers.
Once you sign in, follow the online instructions to
create a new password
• A Magellan Network representative will be
contacting you to provide you with your Username
and temporary password.
You will need to assign someone as the administrator
(it can be yourself if you are a solo practitioner)
• If you do not hear from us in the next couple weeks,
please send an email to
VAProviderQuestions@magellanhealth.com to inquire
about your website login.
Administrative rights allow you to create a login, set
an initial password and specify system rights tailored
for each member of your practice
For existing providers, please use your same website
login information. We may have to link additional
service locations to your existing login.
You may wish to grant access to these online tools to
other staff members as you deem appropriate – an
office manager, billing clerk, clinical staff, etc.
Contact Information
• General Provider Credentialing, Contract and General Billing Inquiries – Virginia
BHSA Network Department at 1-800-424-4536 or
VAProviderQuestions@magellanhealth.com.
– Ajah Mills, Field Network Director, AMills@magellanhealth.com
– Danyelle Dutton, Area Contract Manager – DDDutton@magellanhealth.com
– Renee Chichester, Field Network Coordinator, PRChichester@magellanhealth.com
– Timothy Louk, Field Network Coordinator, TLouk@magellanhealth.com
– Kelly Norton, Field Network Coordinator, KNorton@magellanhealth.com
– Blair Swanson, Field Network Coordinator, BSwanson@magellanhealth.com
– Niquetra Temple, Field Network Coordinator, NTemple@magellanhealth.com
– Shakara Wilkins, Field Network Coordinator, SWilkins@magellanhealth.com
• Claims Denial Inquiries – Magellan of Virginia Call Center at 1-800-424-4046 and
select the prompt for “Claims Inquiry” to speak to the Claims Customer Service
department (prompt will not be activated until 12/1).
– This claims customer service line only assists with inquiries regarding claims
that have been submitted and denied.
55
Contact Information (continued)
• EDI Support and Inquiries – EDI Support Line at
EDISupport@MagellanHealth.com and 1-800-450-7281 ext. 75890.
• Magellan Provider Website Support – If you have trouble logging in to your
secure account or you need technical assistance, go to the FAQs page at the
top of www.MagellanHealth.com/provider and select the option that best
meets your needs.
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Q&A
• We are here to help you!
– Questions
– Comments
– Feedback
– Concerns
• Please visit the Magellan of Virginia website at
www.MagellanofVirginia.com and go to the “For Providers” section.
– We have a Frequently Asked Questions (FAQ) document posted and
continually updated with answers to all questions we receive from
providers regarding the implementation.
– Recordings of the webinar sessions and the PowerPoint presentation
will be posted here as well.
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Confidential Information
This presentation may include material non-public information about Magellan Health Services, Inc. (“Magellan” or the
“Company”). By receipt of this presentation each recipient acknowledges that it is aware that the United States securities laws
prohibit any person or entity in possession of material non-public information about a company or its affiliates from purchasing or
selling securities of such company or from the communication of such information to any other person under circumstance in
which it is reasonably foreseeable that such person may purchase or sell such securities with the benefit of such information.
The information presented in this presentation is confidential and expected to be used for the sole purpose of considering the
purchase of Magellan’s services. By receipt of this presentation, each recipient agrees that the information contained herein will
be kept confidential. The attached material shall not be photocopied, reproduced, distributed to or disclosed to others at any time
without the prior written consent of the Company.