A: Claims adjudication and payment cycles will be the same in ProviderOne as they are today. Checks, EFTs, and RAs will be sent every Monday for claims in final paid status by the previous Tuesday.

Q: Has the system changed at all in terms of how Series Claims are processed?

A: Assuming that a “Series Claim” is the submission of multiple paper claims to accommodate a single claim that has more than the maximum allowed lines on one claim form, ProviderOne will consider this as one claim. The current system considers these as multiple claims.

Q: 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?

A: 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-week claims freeze and to send claims with the new ProviderOne client ID number 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.

Q: What effects will the ProviderOne implementation have on adjustments for the previous two years?

A: 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.

Q: What effect will the ProviderOne implementation have on claims that are in process at DSHS?

A: DSHS will attempt to finish processing all claims that are in process during the two-week claims freeze immediately before ProviderOne implementation. Any claims still in process after that will be denied and must be resubmitted to ProviderOne with the new ProviderOne client ID for processing.

Q: Will “take-backs” have the new ProviderOne client ID or the PIC?

A: After ProviderOne is implemented, when DSHS recovers money or performs an adjustment on a claim, it will have the ProviderOne client ID.

Q: How will we update claims that have left us but have not been sent by our billing agent or clearinghouse at cutover?

A: We suggest 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-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.

Q: How are we going to bill ITA claims? We usually bill with “Q” tie breaker.

A: I’ve checked with technical experts on psych and rehab authorizations in ProviderOne.

The Q number will no longer be used for psychiatric inpatient admissions. The hospital should contact the appropriate RSN according to the processes for auth by that RSN. The hospital will receive an actual reference/authorization number that is to be used for that admission and if the admit is an ITA, a client ID number issued by HRSA over the next few business days.

However, if the client is not an ITA admit, and the client has filed for eligibility or this is a PM&R admission where the client has applied for eligibility, the hospital will receive an actual reference/authorization number, with no client ID, but the patient name. Under this circumstance, it is the responsibility of the hospital to confirm when the eligibility determination has been made and a real client ID established in order to support the preparation of the claim for billing. When the client ID has been assigned, the hospital needs to notify the RSN or the HRSA PM&R program manager and ask them to update the prior authorization record with this assigned client ID number. Then the claim will match the prior authorization record to support claims adjudication.

For your planning purposes, provider training in Prior Authorization status checking will be included in Client Eligibility Webinars that will be offered beginning in late October 2009.

Q: When ProviderOne comes up, will all functionality for electronically submitting back-up be available?

A: Yes. ProviderOne will allow you to submit backup electronically at go-live. For direct instructions, you may refer to page 33 in the Professional Claims chapter of the ProviderOne System User Manual: http://hrsa.dshs.wa.gov/providerOne/documentation/Provider%20System%20User%20Manual/O.Submitting%20a%20Professioanl%20Claim.pdf.

Q: Are you set up to accept dental claims that are billed with the ADA format?

A: Yes. DSHS accepts dental claims in the ADA format now, and will continue to do so after ProviderOne goes live.

Q: Currently, DSHS contractors/vendors are supposed to register with ACS in order to submit claims online. Will ACS transfer this registration file to ProviderOne so that our contractors/vendors do not have to register again with ProviderOne?

A: Agreements that providers have now with ACS will no longer be valid (and cannot be transferred) after ProviderOne goes live. But they won’t be needed, either. In ProviderOne, when a provider submits claims via the ProviderOne portal (direct data entry), they will not need to have a Trading Partner Agreement (TPA). Only if the provider is submitting HPAA batch transactions will they need a TPA.

Providers can get training before go-live, so they will know how to enter their claims. Here is our training Web site: http://hrsa.dshs.wa.gov/ProviderOne/Provider%20Training.htm.

Provider training will be scheduled during October and November. The providers you support can be notified directly by e-mail if they want to sign up for the listserv: http://listserv.wa.gov/archives/providerone_provider_readiness.html.

Medicare Crossovers

Q: How are Medicare Crossovers (tapes) handled?

A: DSHS is testing with GHI, the Medicare intermediary in the month of September. Medicare Crossover claims must have taxonomy on the claim. Medicare will pass the taxonomy on the claim to ProviderOne.

Q: Will Medicare crossovers still have the old PIC or will there be other identifying information available?

A: Medicare claims will crossover from the intermediary with the ProviderOne client ID.

Q: What are Medicare’s requirements around taxonomy related to Part B claims (not inpatient)?

A: Medicare does not require taxonomy codes be submitted in order to adjudicate claims, but will accept the taxonomy code, if submitted. However, taxonomy codes that are submitted must be valid against the taxonomy code set published at http://www.wpc-edi.com/codes/taxonomy. Claims submitted with invalid taxonomy codes will be rejected.