DADS released two information letters and one provider letter:
AFC, ALF, CBA, CLASS, DAHS, HDM, Hospice, ICF/ID, NF, PACE, and other providers:
Last year, LTC CMS processed over 15 million claims, which included 423,185 rejected claims and 456,967 denied claims. DADS provided guidelines to deal with the most common errors that delay LTC provider claim processing and payment An excerpt:
Rejected Claims
A rejected claim fails initial system edits, and is returned to the provider for correction without being submitted for processing. The claim is not entered in CMS and no Internal Control Number (ICN) is assigned. The majority of 2011 claim rejections were due to the following reasons, listed below by Explanation of Benefit (EOB) code:
1. EOB F0077 Billing code not submitted or cannot be determined. Claims reject with EOB F0077 because the Healthcare Common Procedure Coding System (HCPCS) code entered on the claim does not match what is on the consumer’s service authorization.
To resolve this issue:
• Check Medicaid Eligibility and Service Authorization Verification (MESAV) to ensure that there is an established Resource Utilization Group (RUG) level, if needed, and a valid service authorization for the entire timeframe billed.
• Check MESAV to ensure that the correct LTC service group, service code, and procedure code are used. Refer to the most recent Long Term Care (LTC) Bill Code Crosswalk located at www.dads.state.tx.us/providers/hipaa/billcodes/.
HSC and TxHmL:
Medicaid program providers can’t pay for items or services furnished, ordered, or prescribed by persons or entities excluded by the U.S. Department of Health and Human Services, Office of Inspector General. DADS requires these providers to review the list of Excluded Individuals/Entities maintained by HHS (http://www.oig.hhs.gov/fraud/exclusions.asp) and HHSC (https://oig.hhsc.state.tx.us/Exclusions/Search.aspx) before hiring an applicant or contractor and at least every month for each employee or contractor. There are several requirements, so be sure to download the letter. (Letter)
ADC, ALF, HCSSA, ICF/ID, and NF:
DADS reminded providers that since June 1, 2007, all applicants, controlling parties, and affiliates have been required to provide their dates of birth on applications for facility and agency licenses and voluntarily provide Social Security numbers, which help DADS conduct criminal history checks. (Letter)
