Grayzone Service Criteria Summary

Medicare CrossOver Claims

The Department of Health and Mental Hygiene's Medicaid Program will be taking over the processing and payment of electronic and paper claims for individuals who received specialty mental health services and are covered by both Medicaid and Medicare (Medicare crossover claims).

The transition over to Medicaid will be based on the Medicare payment date, not the service date. Medicaid will process and pay claims that have a Medicare payment date of June 30, 2003, or later.

Electronic Claims

There is no change in the submission process of electronic claims for providers; however, providers now will receive payment checks from Medicaid rather than Maryland Health Partners (MAPS-MD). Providers can expect to begin receiving payments from Medicaid according to the timeframes described below.

Medicare Intermediary: CareFirst

All electronic claims (Medicare Part A and Part B outpatient only) transferred prior to June 30, 2003, by the Medicare Intermediary, CareFirst, will reflect a Medicare payment date of June 29th or earlier. Claims transferred on June 30, 2003, will reflect a Medicare payment date of July 1, 2003. Medicaid, therefore, will begin processing and paying electronic claims received from CareFirst on June 30, 2003.

Medicare Carrier: Trailblazers

Medicare Part B claims transferred electronically on July 7, 2003, by the Medicare Carrier, Trailblazers, will reflect a Medicare payment date of June 30, 2003. Medicaid, therefore, will begin processing and paying electronic claims received from Trailblazers on July 7, 2003.

Paper Claims

Medicaid also will be sending payment checks to providers for paper claims. The paper claim submission process for providers will be changing as well. Providers will need to begin submitting their paper claims to Medicaid based on the Medicare payment date. Claims that have been paid by Medicare on or after June 30, 2003, will need to be submitted to Medicaid with a copy of the Explanation of Medicare Benefits. Providers should continue to send claims with Medicare payment dates prior to June 30, 2003 to MAPS-MD.

Please use the following addresses when submitting your claims.

Claims submitted to MAPS-MD with Medicare payment dates on or after June 30, 2003, will be denied by MAPS-MD and will not be forwarded to Medicaid. Likewise, Medicaid will deny claims it receives with Medicare payment dates prior to June 30, 2003, and will not forward them to MAPS-MD.

Should you have any questions, please call Medicaid's Provider Relations Unit at 410-767-5503.

Communicating with MAPS-MD

Please help us to help you better. We have noticed an increase in calls to various persons throughout the organization for the same problem or issue. When several of us are trying to respond to the same issue, our ability to help everybody diminishes. So as a reminder, please use the resource best able to assist you. The two main units for dealing with provider and consumer issues and problems are Provider Relations and Customer Service. The Customer Service phone number is 1-800-888-1965. Please use the following information as a guide for calling:

Provider Relations

• Provider applications
• Provider information updates
• Electronic billing
• Chronic or special provider problems
  

Customer Service

• Claims payment
• Authorizations
• Retractions
• Check status
• Appeals process
• All other issues

Our policy is to respond to every call within a 24-hour period. You can help us by always having your provider number and phone number available, and providing such information if you leave a voice mail on one of our phones.

If research is required, it may take longer to receive the answer you need. Please ask the representative how long it will take for a response and allow the representative to opportunity to complete the job before calling again. If you are dissatisfied in any way, please contact the representative's supervisor.

Other matters are best handled through the mail. For example:

If you wish to submit paper claims, you should send them to P.O. Box 3000, Columbia, MD 21046. We frequently get deliveries of claims to our offices, but you will get faster, more efficient service if they are mailed to the P.O. Box. There are some exceptions to this for claims that require special handling, but these should be the exception only.

Obviously, we prefer to receive electronic claims and encourage that form of submission.

If you need to file an appeal, you should send it in writing to PO Box 3190, Columbia, MD 21045-7190.

Provider Survey

A provider survey relating to the Maryland Public Mental Health System will be sent out to active providers in July. The survey asks questions relating to satisfaction with the services provided by the Mental Hygiene Administration (MHA), Core Service Agencies (CSA's), and Maryland Health Partners (MAPS-MD). We encourage all providers receiving the survey to complete it and provide us with the feedback necessary to improve our services. Thank you.

Provider Application Process

The process for registering to be a provider with the Maryland Public Mental Health System involves both the State of Maryland and Maryland Health Partners.

1. Call Provider Enrollment at 410-767-5340 to obtain a Medical Assistance Provider Number.
2. After you have received an MA Provider Number, call Provider Relations at 410-953-1837 to obtain a Provider Application. We do not send out applications prior to your receiving an MA Provider Number.
3. This application requires the completion of a set of data elements and copies of your professional license, professional liability insurance cover sheet, and appropriate drug registrations if you are an M.D. Provider Relations staff reviews this information and appropriate entries are made to the computer systems and databases to allow claims to process for your services. This process takes approximately 5-7 working days to complete. The effective date of the MA Provider Number is used by MAPS-MD, so claims may be submitted retroactively back to that date.
   

Provider Training Sessions

Provider training sessions are in process throughout the State. There is still time to attend one of the later June sessions as shown below:

• June 26 Charles County Dept. of Social Services, La Plata
• June 30 Eastern Shore Hospital Center, Cambridge

Go to the Training Section of www.mdhp.com for the Application Form, Agenda, and Driving Instructions.

Fax Authorization Program

If you are not enrolled in the fax authorization program and would like to be, please send an email to info@gzmd.com.

We have also started using the numbers in this fax program for getting out "Provider Alerts" on issues of concern that need to be disseminated quickly and in between the Bulletins. So please sign up so that we can contact you more easily. If your fax number changes or is no longer in use, please email the address above so that appropriate changes can be made to our systems. Thank you.

Authorizations

Authorizations continue to be a major source of denials for providers. Please bear in mind that claims are processed using computers, and every single edit has to be met before a claim will adjudicate for payment. Frequent causes of claims denying for NX (No authorization) include:

Claim and Authorization have a different MA number-Please request your authorization with a specific MA number and match the MA number on the paper authorization you receive against your request. If the numbers do not match, please call to have the authorization number changed or your claim will deny for NX No authorization for services on record.

The number of services billed may not exceed the number of services authorized. Please monitor closely the number of services being billed or you may receive a denial for 09 -Visit maximum for this benefit has been met.

Date(s) of Service-Each date must match the authorization date or range of dates. If there is not an exact match, the claim will deny for NX. We frequently see dates of service that exceed the authorization by a day or two. The entire date range on a claim must be valid or all dates will deny for NX.

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