Commonwealth Coordinated Care (CCC) Claims Processing Issues Update

The Managed Care Ad Hoc Committee has continued to work with the Department of Medical Assistance Services (DMAS) and the Medicare/Medicaid Plans (MMPs) to address claims processing errors and delays under CCC.  As we have reported in several CCC updates in the past few weeks, there were significant claims processing errors and delays under CCC stemming from the switch to RUGs-based billing for dates of service on and after November 1, 2014.  The MMPs all identified claims processing system issues that caused various degrees of processing issues for the MMPs.  In the research that has ensued, the parties have also identified submission errors by providers that were contributing to the overall errors and delays.

The three MMPs have been working with select individual facilities in an attempt to research where the processing errors originate in order to help fix all aspects of the submission process, from provider submission, through clearinghouses, to MMPs (or business partners), to payment.  Eventually, the hope is to articulate any broad provider submission issues to the membership as a whole as an educational resource, and to identify and fix any submission/processing issues at the MMPs.  

All three MMPs have reported significant progress in addressing Medicaid accounts receivables in excess of 30 days.  Therefore, if you are experiencing processing errors or delayed payment under CCC and you are not seeing any movement in resolution of those claims, we suggest you proactively contact the MMPs to request a meeting to research the issues you are experiencing.  It is likely that they will request a sample of claims at issue, so that they can investigate where in their systems the claims run into trouble.  As we reported two weeks ago, all three MMPs have stated that they are currently capable of receiving and processing claims, electronic or otherwise, so there is no need to hold claims if you have been doing so while the issues are being investigated.  

The MMPs have identified the following individuals as points of contact for these claims processing concerns:

VA Premier

First Inquiry:  Call the Claims Customer Service line: (855) 338-6467, Option 3, and ask for either Evelyn McClendon or Jennifer Blankenship

Escalation (if first inquiry not timely): 

Anthem

Humana

PR Claim Contacts:  Facilities are assigned to PR reps by region.  If they do not have a PR Rep established already, they should contact Valerie (info below).  Please copy email communication to the VA duals inbox at VA_Duals_inbox@humana.com.