New Claims Resubmission and Reconsideration Process

Mayo Clinic Health Solutions has created a new provider claims resubmission and reconsideration process for commercial health plans. This process does not apply to South Country Health Alliance (SCHA), UCare, or other governmental health plans.

To request a review of a post-service claim determination, providers should now submit the Claims Review and Reconsideration form. This form replaces the Claim Recoupment or Adjustment form. Please discard any copies of the old form and begin using the new form. 

To dispute a review and reconsideration decision, providers may file a grievance in writing using the new Grievance Request form. A grievance request will only be accepted after the provider has requested and received a claims review and reconsideration determination.

These forms are available on the Provider Forms page on the Mayo Clinic Health Solutions web site.

The Claims chapter of the Provider Manual has been updated to include information about the new provider claims resubmission and reconsideration process, with guidance to help you determine when it is appropriate to submit the two forms listed above. If you are assisting a member with filing an appeal due to an adverse claim or authorization determination (denial or disapproval), please review Chapter 7 - Appeals in the Provider Manual.

 

Request Medication Prior Authorization Online

As we mentioned in the last issue of eUpdate for Providers, Mayo Clinic Health Solutions is working with CoverMyMeds® to offer online, automated medication prior authorizations. Using this tool streamlines the medication prior authorization process, offering:

  • Faster determinations
  • Reduced phone calls and faxes
  • Authorization for all plans and any medication
  • Secure HIPAA-compliant submissions
  • Live chat support

This electronic solution also fulfills the requirements of a recent Minnesota state mandate: “drug prior authorization requests must be accessible and submitted by health care providers, and accepted by group purchasers (PBMs), electronically through secure electronic transmissions.”

Effective immediately, you are encouraged to start using CoverMyMeds®, to submit medication prior authorization requests to Mayo Clinic Health Solutions.  

  1. Go to www.covermymeds.com and sign in to your account. You will need to register on your first visit.  
  2. Start a prior authorization request, making sure to fill in the “BIN/PCN/RxGroup or Plan or PBM” box with the corresponding information shown on the member’s ID card.
  3. Fill in all the required medical details. When finished, submit the request. 
  4. Your determination will be delivered online via your account on the CoverMyMeds® web site.

 

Authorization Forms Update

The following provider authorization forms have been revised and should be used for commercial lines of business. Please discard any old copies you may have of these forms and start using the new forms. Whenever possible, please access these forms directly from the Provider Forms page at www.MayoClinicHealthSolutions.com to ensure you are using the most current version of a form. 

The individual completing the form should be the individual providing the health care services. Incomplete forms will not be accepted. All provider forms are available to download on the Provider Forms page without needing to log into our secure site at www.MayoClinicHealthSolutions.com.

 

 

Faster Payments and Reduced Paperwork with Electronic Funds Transfer

Using Electronic Funds Transfer (EFT) to receive claims payment offer providers: 

  • Faster payment, without the need to wait for a check to be mailed or deposited.
  • Reduced paperwork.
  • No risk of lost or stolen checks.

The Electronic Funds Transfer (EFT) Authorization form is used to authorize Mayo Clinic Health Solutions to electronically transfer funds directly to your bank account. For more information about signing up for EFT, please refer to the Electronic Funds Transfer section of the Provider Manual. Or, refer to the instructions on the back of the EFT form.

 

 

Educate Patients About Advance Directives

Mayo Clinic Health Solutions contracted providers are required to inform all adult patients about their right to accept or refuse medical treatment, as well as their right to execute an advance directive. 

  • Providers must document in the medical record whether or not an individual has executed an advance directive. 
  • Providers must also inform patients of their right to file a complaint with the Minnesota Department of Health regarding noncompliance with advance directive requirements.
 

 

Government News

Click on Read More to review the latest updates from South Country Health Alliance (SCHA) and UCare. 

 

  • CMS Delays Enforcement of Part D Provider Enrollment Requirements
  • SCHA Provider Two Percent Medicare Sequestration
  • New Hours for UCare's Provider Assistance Center
  • Change in Newborn Billing to UCare
  • Change to UCare's Authorization Requirements for Adult Rehabilitative Mental Health Services

CMS Delays Enforcement of Part D Provider Enrollment Requirements 
In the last eUpdate for Providers newsletter, we reported that the Center for Medicare & Medicaid Services (CMS) is working toward implementing a new rule requiring physicians and other eligible professionals to enroll or opt-out of Medicare in order to prescribe drugs to patients with Part D prescription drug benefits. The rule was to be effective June 1, 2016. 

CMS has now delayed the enforcement of these new requirements. Part D Prescriber Enrollment Requirements will be enforced by CMS effective February 1, 2017. Prescribers who are not currently enrolled in Medicare are advised to submit their Medicare enrollment applications or opt-out affidavits to their Medicare Administrative Contractors before August 1, 2016. For more information about the Part D Prescriber Enrollment Requirements, please visit the CMS web site.

SCHA Provider Two Percent Medicare Sequestration
In 2013, the Centers for Medicare & Medicaid Services (CMS) implemented a two percent reduction (sequestration) in payments made to providers for services rendered to Medicare beneficiaries. At the same time, CMS also reduced the capitation amount paid to South Country Health Alliance (SCHA) and other Medicare Advantage health plans contracting with CMS by two percent, however, SCHA chose not to implement this reduction with our contracted provider network.

It was anticipated that the sequestration would sunset this year but, instead, it has been continued indefinitely. Effective August 15, 2016, SCHA will implement the two percent sequestration and apply the reduction to SCHA's Medicare fee schedule, applicable to all Medicare eligible covered services. SCHA values its partnership with our providers serving SCHA members through the Mayo Clinic Health Solutions contracted provider network and we appreciate your willingness to work with SCHA in this challenging health care environment. Questions should be directed to SCHA Provider Services at 1-800-995-4543.

New Hours for UCare’s Provider Assistance Center

Beginning May 2, 2016, UCare’s Provider Assistance Center (PAC) opens at 8 a.m. instead of 7 a.m., Monday through Friday. UCare made this change to optimize the number of representatives available during the hours when they experience the highest call volume. Please make note of this change for your future service needs. Keep in mind that you can check claim status and member eligibility 24 hours a day on UCare’s provider portal and through the automated system on the PAC phone line at 1-612-676-3300 or 1-888-531-1493 toll-free.

Change in Newborn Billing to UCare
Effective immediately, UCare will no longer assign temporary ID numbers for newborns. Providers will need to wait to bill for these services until they receive the permanent ID number from the county. This change should:

  • Be a similar process to what providers are encountering with other health plans.
  • Eliminate the need to recoup dollars in cases where the baby does not subsequently become a UCare member.

Please note: Notification of the birth event, which includes type of delivery, gender, and weight, will remain the same. Questions regarding this change should be referred to UCare’s Provider Assistance Center at 1-612-676-3300 or 1-888-531-1493 toll-free.

Change to UCare’s Authorization Requirements for Adult Rehabilitative Mental Health Services

Effective for services provided on or after July 1, 2016, UCare is reinstating 2015 authorization requirements to Adult Rehabilitative Mental Health Services (ARMHS). This includes CPT codes H2017, 90822 and H0034. UCare’s 2016 Medicaid Authorization and Notification Requirements Grid has been updated to reflect this change. 

If you have received an approved authorization for ARMHS since Jan. 1, 2016, those authorizations will remain in effect through the end date on the authorization. There is no need to obtain another authorization. If you received “no authorization on file” claim denials for ARMHS services that were rendered prior to July 1, 2016, please submit a Status Adjustment to UCare for reconsideration.

To comply with HIPAA and internal compliance requirements, providers should fax one prior authorization form at a time. When authorization requests are faxed in bulk, it increases the risk of information being lost or inappropriately filed. Please allow up to 14 calendar days to receive a response to an authorization request. 

For more information, review UCare’s Provider Bulletin, or contact their Provider Assistance Center at 1-612-676-3300 or 1-888-531-1493 toll-free.