Day Limits

The State of Maryland has enacted legislation that imposes day limits on inpatient stays according to DRG.  This legislation is effective January 1, 2004.  These limits are applicable to acute care hospitals located in Maryland and the District of Columbia.

For the public mental health sector, the mental health DRG’s include those in the following table.  Other DRG’s may be billed as determined by specific circumstances.

Please follow these preliminary guidelines in billing inpatient days under these new regulations.  These may be subject to change if and when additional guidance is received.

• Enter the appropriate DRG in Box 11- DRG Code.
• Block 6 – Do not include the date of discharge (current instructions)
• Block 7 – Covered days should not exceed the day limit for the DRG billed or the claim will deny.
• Blocks 7 & 8 (covered and non-covered days) should equal the number of days in Block 6 – the statement covered period. (current instructions)
• Block 46 – The service units for the Room and Board Revenue Code should include all covered and non-covered days.
• Blocks 47 & 48  - Allocate the charges for the covered and non-covered days between the two blocks as appropriate.
• Ancillaries on the non-covered days should be reported as non-covered services.

HIPAA

As of the printing date of this bulletin, the public mental health system is still operating under a contingency plan.  Therefore, you may continue to submit claims electronically under the old formats and use the existing codes until formal notification from the Mental Health Administration.  We anticipate that the new codes will be published soon, and you will have at least 30 days from date of publication to change your billing systems.

Retroactive Authorizations

The following clarification regarding retroactive authorizations has been issued by the Mental Hygiene Administration, with an effective date of January 1, 2004:

The Maryland Legislature included the following language in its Joint Chairmen’s Report dated April 2003:

 [T]he Mental Hygiene Administration may not waive

 payment regulations in effect April 1, 2003, except

 as specifically authorized in legislation.

COMAR 10.70.02 provides that MHA shall preauthorize non-emergency care and conduct utilization review.

Current MHA policy permits a lifting of the preauthorization edit if a community provider seeks a retrospective review within 30 days of the service being provided.  Effective January 1, 2004, the MHA will no longer permit retrospective review for the purpose of obtaining authorization for non-emergency services or services that are continuation or renewals.   All non-emergency services must be pre-authorized.

A one-time claim for assessment for eligibility for PRP services, does not require pre-authorization.   

If a consumer receives retroactive Medicaid eligibility, and MHA/MAPS-MD has not paid for the services under the fee for service system or under a grant,  MHA/MAPS-MD will conduct a retrospective review for medical necessity. However, pre-authorization for services will be required for all services provided after the provider has received notice of the retroactive eligibility.  Retrospective reviews will still be permitted for emergency care.

MAPS-MD may not waive this requirement.  Denials should be appealed through the appeal process.   Only if it can be proven that the failure to obtain the reauthorization was not due to any action by the provider, will MHA consider granting an authorization retroactively.

Claims Update

Ordering Laboratory Services

Laboratories have noted a large volume of non-billable claims because some providers are not supplying the Maryland Medicaid Individual Practitioner Identification Number (IPIN) or identifying the individual ordering the laboratory services.  Identification of the group practice, clinic or facility is not sufficient for the laboratory services to be paid.

Please assist the laboratories you are using by providing the required information.  All parties need to be able to submit a clean claim so they can be paid for their services.  The laboratories are dependent upon your assistance in this matter, so please review your ordering practices to assure that you are entering all required information on the laboratories’ forms.

Program Integrity

As a condition of your participation in the Medicaid program, it is your responsibility to identify and return all overpayments.  In addition, you have an affirmative responsibility to monitor the process surrounding the submission of claims to ensure that the claims submitted accurately reflect the services provided. 

When problems are detected, they must be reported immediately to both Maryland Health Partners and the Mental Hygiene Administration.  Corrective steps must b taken to ensure that the problems are not repeated.

Some providers have developed Compliance programs to assure that claims are being submitted accurately to the various payers.  We suggest that you consider establishing such a program, particularly if you have experienced numerous retractions or overpayment situations in the past.  To set up such a program, you should contact your accountant/auditor or the Compliance Officer at the Mental Hygiene Administration for further information or assistance.

Overpayments

MAPS-MD cannot accept partial refunds on an overpayment.  The entire amount of the overpayment must be refunded.  It is preferable if you notify us of the overpayment, identifying the claims in question, and MAPS-MD will retract.  If you prefer, you may send a refund check.  This requirement applies to retraction notices, negative balance reports and those overpayments identified by you.

If you identify the overpayment, ideally we would like the name of the member, control number (which is our claim number), and dates of service involved.  All of this information is on the EOP, which you should attach to your letter together with your letter requesting a retraction or enclosing a refund check.

Electronic Claims Submission

MAPS-MD currently accepts electronic claims from three different clearinghouses:  Payerpath, ProxyMed and WebMD.  At this point in time, ProxyMed and Payerpath are HIPAA compliant and WebMD is still working to become HIPAA compliant.  You may find information about these clearinghouses on our website at http://www.apshealthcare.com/ if you click the link entitled “Submitting EDI Transactions” prior to logging into the site.  Scroll down the page until you come to the box with the column headed “Additional Information.”  You will find the clearinghouse contact information and their different states of readiness.

Please note that the costs of submitting electronic claims may change for your organization.  We will continue to pay the transaction costs for electronic submitters using one of the three vendors above.  We will only pay the transaction costs from the clearinghouse to APS healthcare, our parent company.   If the clearinghouse has any other types of transaction costs, i.e., from your organization to the clearinghouse, these will be your responsibility.  Any individual installation or set-up costs will continue to be your responsibility.  We will not be offering HIPAA compatible software.

MAPS-MD, through our parent company APS healthcare, offers a data entry application that will allow you to submit professional claims (HCFA-1500’s) under the secure login at http://www.apshealthcare.com/.  This application is now available.  The application does not allow for electronic data downloads.   To avail yourself of the data entry application, your organization will need to sign and return the agreement we mailed previously in order to obtain a log on to the website.  If you have not done so, please return your agreement or call Provider Relations for the forms.  If you have already received a log-on for the website, you will need to obtain a second log on for the data entry application.  You may do this by clicking on the “Contact Us” block on the log on screen.

Check Distribution by Comptroller

The scheduled date for the Maryland Comptroller to begin sending out checks has been delayed until December 2003.  We will publish the instructions for enrolling for electronic funds transfer in a future Issues Bulletin after the transition has successfully occurred.

Customer Service Call Overload

Our Customer Service unit is getting many calls every day questioning when claims will be processed and paid.  Many of the claims have already been paid or they are still awaiting adjudication in the Claims Department.   These calls place an excessive burden on our staff and jeopardize our ability to maintain service levels for other important questions.

Our general policy is that Customer Service will provide a claims update after 30 days of the claim’s receipt at MAPS-MD.   Once a claim has paid, you should allow an additional week for the check to be printed, placed in an envelope, and transmitted to your office via the U.S. Postal Service. These timeframes translate to our requesting that you allow approximately 40 days from when the claim leaves your office before you place a claims inquiry call.

You can help us serve all providers better if you research the claim’s status yourself on http://www.apshealthcare.com/.  This methodology is more efficient for both of us.  You can research any number of claims and we will be able to address other types of provider needs more quickly if the number of claims status calls is reduced.  If you have not yet signed up for access to the Claims Inquiry and Gray Zone Eligibility functions, please call Provider Relations at 410-953-1836 and get the necessary paperwork completed.

On-Line Claims, Eligibility and Authorization Inquiry

Please submit your agreements to use the http://www.apshealthcare.com/ website.  The website will allow you to access claims inquiry for MA and gray zone consumers and eligibility inquiry for gray zone consumers. 

The website http://www.gzmd.com/ will no longer provide the gray zone eligibility information on or about January 1, 2004 as the above website is the replacement.  Please call Provider Relations at MAPS-MD if you have any questions.

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