Commonwealth Coordinated Care (CCC) Update

Claims Processing Concerns

Over the past few weeks, significant claims processing issues among the three Medicare/Medicaid Plans (MMPs) have come to light, with substantial receivables adding up for nursing facilities.  We requested accounts receivables information from the field and 103 facilities responded, representing nearly $12.2 million in accounts receivable outstanding through 12/31 for CCC Medicaid residents alone.  We had alerted the Department of Medical Assistance Services (DMAS), who was unaware of the issues as most of the claims had rejected and where therefore not yet “in process” to show up on reports from the MMPs to DMAS.  In response, DMAS initiated meetings with the MMPs to work through the issues at hand.

The following is the current status of the claims processing errors for each of the three MMPs.  We will continue to monitor the situation, but in order to do so, we need feedback from the field as to whether the receivables are clearing according to the specified actions of the MMPs.

Anthem:  Anthem has determined that the main claims processing issue is related to system changes made to support RUGs-based payments beginning for dates of service on or after November 1.  Specifically, Anthem has stated that “Anthem, Inc. and its trading partners cannot currently accept claims with retired Health Insurance Prospective Payment System (HIPPS) codes. This includes many of the RUG III Version 34 codes used to bill custodial nursing claims pursuant to Medicaid guidelines.”  Anthem is working on a system fix and has stated that they expect the fix to be completed by February 23rd.   

In regards to the rejected claims that resulted, Anthem stated that “Our IT staff has swept the clearinghouses data to identify the rejected claims for dates of service 11/1/2014 to present.  They were able to recover rejected claims and are manually processing those claims.  We have also asked providers to fax their claims to us [1-855-626-6483] which we will "bounce" against the recovered claims files to ensure we have captured all claims.  We also know some providers decided to hold claims rather than submit the claims and have the claims reject so it is important that they fax those claims to us so we capture those as quickly as possible as well.”  Anthem has clarified that they intend to process the backlog of rejected claims by February 23rd as well.

Humana:  Humana has indicated that Humana/ILS is not seeing a large backlog of claims denying or in pend status.  They have had issues arise regarding:

  • Providers not submitting RUG codes, Assessment Indicator Codes, and/or ARD dates per submission guidelines
  • Rates for some providers not having been configured correctly (in these cases they indicate they resolved within a few days of a provider raising the issue)

They also indicate that there are some re-route related issues (between ILS and Humana) they are currently running down which have created some provider confusion and in a few cases resulted in double payments, but they are not seeing systemic issues with issuing timely RUG payments to these providers or the nursing facility population as a whole.

Finally, Humana identified, through its internal review process, 955 claims from participating providers that processed January 4th – 17th, 2015 were denied for no authorization.  These skilled claims do require an authorization but in good faith are being re-adjudicated by the end of last week (February 6th) for payment to providers.  Humana will launch an educational effort to the nursing facilities on the authorization process.  

At Humana’s request, VHCA provided accounts receivable data from those facilities responding to our request so that Humana staff could research for further claims processing issues and outreach to providers to clear up any pending claims.  We will continue to dialogue with Humana to the extent additional issues are uncovered in this process.

Virginia Premier:  Premier’s biggest issue was an edit for timely filing that was applied in error.  This issue arose in system changes made to apply RUGs-based billing, and caused a significant number of claims to fall into “pend queues”.  Premier states that the system has been fixed, but a backlog of claims remains.  To deal with the backlog, they have established a targeted team of claims adjusters focused solely on nursing facility claims.  Their goal is to remediate the backlog by the end of February.   Premier stated that there is no issue currently with electronic or paper claims coming in, nor do providers need to resubmit claims that are in the backlog.

Premier also indicated that they had discovered a “minor” issue with some claims processing through with a payment of $0 – they have not yet identified the reason for this, but they are currently researching.  Further, Premier is concerned that providers are not seeking the reauthorization for Medicaid custodial care at the six month mark, and that the lack of authorization will cause claims to deny.  Virginia Premier intends to issue some guidance reminding providers of this.

CCC Authorization Issues for Medicare Parts A & B

For some time now, we have been attempting to reconcile issues associated with service authorization by the MMPs for Medicare services under CCC (both Parts A & B).  Specifically, we have articulated disagreement over level of care authorized (skilled v. Part B plus Medicaid) and concerns with the timeliness of authorizations (both Parts A & B).  

In order to move forward in the discussion of Medicare authorization concerns under CCC, DMAS is interested in seeing actual examples where we believe such issues exist.  Because the examples will contain personal health information (PHI), VHCA, due to HIPAA, cannot serve as the go-between.  As such, DMAS would like you to send the information directly to Sarah Broughton at via the encrypted e-mail solution utilized by DMAS.  If you do not yet have an account established with DMAS for the encrypted e-mail, send a normal email to Sarah (without any PHI) to request an account.  She will reply with an encrypted e-mail that will walk you through the process of establishing an account.  If you could let VHCA know separately, without PHI (email to, that you have submitted an example (or examples), and of what authorization issue(s), that would be useful for monitoring/follow-up purposes.