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Provider
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Quick Links: ◊Projected implementation dates Providers access ProviderOne at: https://www.waproviderone.org/ Note: To access ProviderOne your organization must provide you access by completing the steps outlined on our Security page.
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Answers to the following questions are posted below. We hope you find this information useful as you prepare for the transition to ProviderOne. Click on any question to jump to that answer. Click the arrow back button in your browser to return to the top of the page. 1. How long will DSHS stop processing claims while converting to ProviderOne? 2. How will we update claims that have been sent to our clearinghouse with a PIC... 3. How do we bill if we have an old PIC, but no new ProviderOne client ID? 4. What effects will implementation have on adjustments for the previous two years? 5. What effect will the ProviderOne implementation have on claims that are in process at DSHS? 7. Will “take-backs” have the new ProviderOne client ID or the PIC? 8. What is the ProviderOne implementation schedule? 9. What is the time-frame covered for the PIC crosswalk files downloaded for the Pilot? 10. When will DSHS stop issuing PIC numbers? When will patients receive client services ID? 11. When will the Cut-over Schedule be communicated to Providers? 12. Will Psych and Rehab be included in Pilot Testing this summer? 15. How will Pre-authorized by the RSNs prior to the patient obtaining DSHS coverage be entered 16. Will we be able to test Medicare crossover claims before go-live? 17. When will outreach material be available for the new Services Card and will it be translated? 18. Will Medicaid Managed Care Plans accept new Client Services ID numbers? 19. Will the PIC Crosswalk contain Medicaid Managed Care Patients as well? 20. When will the Specs for the Magnetic Card Readers be released? 22. What is DSHS’ Back-out Strategy? Will DSHS be able to revert back to the Legacy MMIS? 23. At go-live, can providers continue to provide the PIC on claims and let DSHS process the PIC? 24. What is the timeline for payment processing after go-live? 1. How long will DSHS stop processing claims while converting to ProviderOne? DSHS will stop accepting electronic claims over the two (2) week period immediately preceding implementation. DSHS refers to this period as the two (2) week claims “freeze.” Paper claims will need to be submitted no later than three (3) weeks before implementation to ensure entry into the system prior to the freeze. During the claims freeze, the goal is to finish processing as many claims as possible in the current MMIS to final resolution. Partially processed claims cannot be transferred to ProviderOne. Any claim that does not reach final resolution during the freeze period will be denied. After implementation, providers will be required to resubmit the denied claim for re-processing in ProviderOne (see response to Question #24). We encourage all providers to eliminate any DSHS claim backlog, as we prepare to implement ProviderOne.
2. How will we update claims that have been sent to our clearinghouse with a PIC, but have not been sent by the clearinghouse to DSHS? We suggest that you coordinate a schedule with any claims processing company or software vendor you use to only send claims with the current Personal Identification Code (PIC) up to the time of the two (2) week claims freeze and to send claims with the new ProviderOne client ID during and after the claims freeze. Verify with your clearinghouse that they can hold all claims with the new ProviderOne client ID until ProviderOne implementation. ProviderOne cannot process the legacy PIC. Any claims submitted to ProviderOne using the legacy PIC, rather than the ProviderOne client ID, will be denied.
3. How do we bill if we have an old PIC, but no new ProviderOne client ID? You will need to update claims to be submitted to ProviderOne with the ProviderOne client ID. To assist providers with this transition, DSHS has developed a web tool that provides a “crosswalk” of the current PIC number to the new ProviderOne client ID. The tool is available now for testing purposes at: https://fortress.wa.gov/dshs/npicaphrsa
The tool prompts providers to enter their current 7-digit Provider Medicaid ID and federal Tax Identification Number. The tool then provides a list of PIC numbers for clients the provider billed between April 2007 and April 2009, along with the corresponding new ProviderOne client ID. This list or crosswalk is downloadable in several formats. The crosswalk will be refreshed and available to providers about a month before ProviderOne is implemented so that providers may update their billing systems with the new ProviderOne client ID. Please note that the current crosswalk is intended for test purposes only at this time. Some of the ProviderOne client ID numbers could change in the final refresh; however, the format and structure of this file will not change.
After implementation, you can access ProviderOne client IDs (nine-numeric digits followed by WA) several ways:
HIPAA single or batch file inquiries in ProviderOne (270/271). It will show on most ProviderOne correspondence to clients in the bottom left corner. 4. What effects will the ProviderOne implementation have on adjustments for the previous two years? With implementation of ProviderOne, ALL claim submissions MUST contain the new ProviderOne client ID, regardless of when the service was rendered. ProviderOne will NOT recognize the legacy system PIC number. Claims using the legacy PIC will be denied. This means that, after ProviderOne implementation, ALL adjustments to previously billed claims and ALL newly submitted claims MUST contain the new ProviderOne client ID regardless of when the service was performed.
5. What effect will the ProviderOne implementation have on claims that are in process at DSHS? See question #1 above. DSHS will attempt to finish processing all claims that are in process during the two (2) week claims freeze immediately before ProviderOne implementation. Any claims that are still in process after two (2) weeks will be denied and must be re-submitted to ProviderOne with the new ProviderOne client ID for processing.
6. Will Medicare crossovers still have the old PIC or will there be other identifying information available? Medicare claims will cross-over from the intermediary with the ProviderOne client ID.
7. Will “take-backs” have the new ProviderOne client ID or the PIC? After ProviderOne is implemented, when DSHS recovers money or performs an adjustment on a claim, it will have the ProviderOne client ID.
8. What is the ProviderOne implementation schedule? Phase 1 of the ProviderOne implementation is December 6, 2009. This will move medical and nursing home claims processing to Provider and replace the Legacy MMIS and the WAMedWeb.
9. What is the time-frame covered for the PIC crosswalk files we downloaded from the website for the Pilot? The PIC crosswalk includes clients claims that providers billed in the last two (2) years, as of April 2009. This crosswalk is for testing purposes only and will be updated prior to go live for production purposes. This final crosswalk will include additional months of client data for claims billed from April 2009 until the date the crosswalk is published (approximately one month before go live).
10. When will DSHS stop issuing PIC numbers? When will patients receive client services ID? In short, DSHS will continue to issue client PIC numbers in the current system until the claims “freeze” period begins (approximately 2 weeks before go live). The claims “freeze” is when claims can no longer be submitted to the current legacy system. New ProviderOne client IDs will be assigned for all existing clients when the final crosswalk is published. Any new clients established after publication of the final crosswalk will have new ProviderOne client IDs assigned in ProviderOne, as part of the final cut-over process in the last two (2) weeks before go live.
The new client IDs not found in the crosswalk (because they were issued after the crosswalk was published) will be available in ProviderOne via standard eligibility inquiry processes (270/271) after ProviderOne go live (see response to Question #3).
11. When will the Cut-over Schedule be communicated to Providers? The cut-over schedule is part of the Implementation Plan that is in the final review cycle. As soon as the Implementation Plan is accepted by DSHS, the cut-over schedule will be communicated to providers. However, please be aware that adjustments may be made to the schedule even after it is published. The critical timeframe to be aware of is the claims “freeze” period during the two (2) weeks prior to go live. During this time, claims will not be accepted in the current system (see response to Question #24 for a more detailed discussion of the cut-over schedule).
12. Will Psych and Rehab be included in Pilot Testing this summer? The scope of the pilot test does not include prior authorizations. It was not feasible to test prior authorizations in parallel with production prior authorizations and to adjudicate both test and production claims accordingly. Should test claims require a prior authorization that was not included in the pre-production conversion, the test claim will deny; however, DSHS has tested the prior authorization process extensively during User Acceptance Testing (UAT).
13. Is the level of benefit detail significantly different using ProviderOne web inquiry vs. a Medicaid Eligibility Vendor or the 270/271 inquiry? The details are the same in the ProviderOne direct data web inquiry and ProviderOne 270/271 inquiry. We cannot comment on the level of detail provided by external MEVs vendors.
14. Will we be able to test Electronic batch inquiry (EEV) transactions with our clearinghouse and Provider One before go-live? If your clearinghouse submits HIPAA batch files (EDI) and passes HIPAA format testing, they have an opportunity to test content. DSHS encourages providers to work with their billing agents and clearinghouses and test prior to implementation.
15. IP Psych admissions are sometimes Pre-authorized by the RSNs, prior to the patient obtaining DSHS coverage. For example, in the case of an ITA admit where the patient has no prior DSHS coverage, how will the patient be entered into the Provider One Pre-auth system? The situation of an unknown client is not unique to psychiatric admissions. ProviderOne includes functionality to address unknown clients, which we refer to as “the Placeholder Client ID number.” This functionality allows DSHS to bypass any edit that would post on an unknown Client ID number. Once the client has been assigned a Client ID, the hospital will need to call the RSN or their designee to update this record with the correct Client ID number.
These instructions are documented in a new ProviderOne Billing Guide. Training on how to complete authorizations for in-patient psychiatric admissions and how to manage them will be provided in the RSN Prior Authorization training DSHS provides about two (2) months before go live.
16. Will we be able to test Medicare crossover claims before go-live? DSHS will be testing Medicare crossover claims with our Medicare Intermediary contractor, later this summer.
17. When will community outreach material be available and will it be translated into several languages? Client outreach regarding changes due to the new Services Card is planned to begin approximately 60 days before go live. Outreach materials will be translated and available in the languages DSHS supports, with some additional languages for small areas of special need.
18. Will Medicaid Managed Care Plans accept new ProviderOne client ID numbers? Yes, all enrollment and payments for managed care clients will be based on the new ProviderOne client ID, which means Managed Care Plans will need to recognize the new client identifier as well.
19. Will DSHS Crosswalk contain Medicaid Managed Care Patients as well? If not, how will we identify these accounts? DSHS is assigning the new ProviderOne client ID to all clients, including those enrolled in Managed Care Plans. The Plans are receiving the client crosswalk as well.
20. When will the Specs for the Magnetic Card Readers be released? The contractor is putting this information together and will make it available at least 90 days before go live.
21. When will DSHS provide training materials and/or training sessions concerning the Prior Authorization process? All training will be available 45 to 60 days before go-live. Primary methods of delivery will be online tutorials, Webinars, and downloadable reference materials.
22. What is DSHS’ Back-out Strategy? Will DSHS be able to revert back to the Legacy MMIS? DSHS’ approach has been to expand testing to mitigate the risk of a catastrophic failure in ProviderOne requiring abandonment of the system and reverting back to the legacy MMIS. Expanded Integration Testing and User Acceptance Testing, and the addition of Pre-Production Testing with providers, are part of this mitigation plan. That being said, a Back-Out/Contingency Plan is being developed that includes a window after go-live where the current vendor will remain under contract in the event of a catastrophic ProviderOne failure. This element of the Back-Out Contingency Plan will have a very short window for triggering due to the impact not only on state staff but also providers.
23. At go-live, can providers continue to provide the PIC on claims and let DSHS process the PIC crosswalk to the new Client ID internally within ProviderOne? It is not feasible for DSHS to “pre-process” or convert claims on behalf of providers or to change the system to accept the old PIC ID. ProviderOne has been designed to utilize a new non-intelligent Client ID as the unique identifier for a client that will not change over time. Claims history is being converted based upon this client ID. The legacy PIC number will not be used in ProviderOne for claims processing purposes. Changing ProviderOne so that providers could continue to use the PIC instead of the new Client-ID would require significant changes for each submission type (paper, DDE, electronic). This includes system changes, Companion Guide Changes, Billing Guide changes, Client Services Card changes as well as changes to all EDI transactions. This would set the project back many months and require financial support that is not available through state or federal sources.
DSHS will continue to communicate the need for providers to submit all claims to ProviderOne using the new client ID. This includes new claims, as well as any claims processed in the legacy MMIS that require adjusting after go-live. A client ID to PIC crosswalk has been made available to providers participating n pre-productions testing and an updated crosswalk will be made available about one month prior to go-live, so that providers may load their systems with the new IDs and bill DSHS using these new IDs after ProviderOne implementation.
24. What is the timeline for payment processing after go-live? When will the last payment be made from the legacy MMIS and the first payment be made from ProviderOne? Based upon the new go-live date of December 6, 2009, the following cut-over and payment schedule has been developed (please note that this is under review and subject to adjustment):
Note: There are eight (8) business days (14 calendar days) between the last Legacy MMIS payment cycle and the first ProviderOne payment cycle. Provider Readiness Email Distribution List
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