ProviderOne System Training
Submit Fee-for-Service Claims - Professional
Frequently Asked Questions (FAQs)
Last Updated 11/23/09
General – Webinars/ProviderOne
Q: Where can I get a copy of these webinar slides?
A: You can obtain a copy of the webinar presentation by going to the webinar table at the following link: http://hrsa.dshs.wa.gov/providerone/ScheduledWebinars.htm Click on the link beneath the description of the webinar.
Q: Is there an e-Learning course for this webinar?
A: Yes. Go to the following link: http://hrsa.dshs.wa.gov/providerone/EProfFFS.htm
Q: If a claim has multiple line items and some are paid, but others denied, will the claim be available to retrieve for resubmission?
A: If there are paid lines on the claim (which indicates a paid claim at header) the provider will need to submit an adjustment.
Q: Does
the 15-minute wait for status apply to both DDE and batch claims?
A: It
depends on the size of the batch claim file. ProviderOne goes through an
adjudication cycle every 15 minutes. It could take
longer for larger files.
Q: Can
you adjust/void, resubmit denied/voided claim if we are using batch claims
submissions 837?
A: Yes.
Q: In
DDE, would we use Client ID expander if we are billing a newborn under mom’s
client ID?
A: You
would use the client ID expander to enter the mom’s information. The client
expander is not where the provider puts information in about the baby being on
the mom’s client ID. Right below the subscriber/client information, there is a
question next to the question mark (?): “Is this claim for a Baby or Mom’s
Client ID?” You either click the YES or NO.
Q: Will
the Drug Identification information be necessary for all drugs, or will the NDC
be sufficient for most charges?
A: DSHS
doesn’t require the information that you can enter under the Drug
Identification portion of DDE – only the NDC number. If the Provider has that
information and clicks this to expand, then they
would have to enter all of the information in the required fields.
Q: I
am concerned with the requirement to add the patient's last name to the claim
during DDE. If a patient marries and wants to update their last name in our
system, we would need to wait until it shows updated within ProviderOne. If our
front office staff leaves the name as it was, it's possible that ProviderOne
will update with the new name before we enter our claim with the maiden name.
Will there be allowance in such instances?
A: You will be able to do an online check of eligibility or get a
HIPAA batch 271 at the time of service. That information returned has the
correct name of the client in the ProviderOne system, and you will be able to
use that as guidance when billing.
Q: Is
the modifier required on all DME claims?
A: Modifiers are required on all type of claims if it is required by
DSHS.
Q: When
is it appropriate to use 'submit HIPAA batch transaction'?
A: When you are submitting a batch directly through the portal. If
you use a clearinghouse, they will submit batches on your behalf.
Q: Can
you bring up previous claims, copy the information, make date changes, etc.,
and submit as a new claim? Also, can you program in default information for
such things as NPI, a diagnosis list, client information with just the input of
client ID?
A: You will need to re-enter the information, as ProviderOne will
not allow you to copy and re-use a previous claim.
Q: If
I void a claim and there is a payment, will DSHS automatically come and take
back the payment?
A: Yes.
This will be reflected on your next payment cycle.
Q: Do
we all have to enter the date of birth and gender each time we get into a
client ID in order to submit a claim?
A: Yes, the client's name, gender, and date of birth are required
on each claim.
Q: Do
we have to re-enter each month or does it stay tied to an ID?
A: The
information won't stay in the claim, and you'll need
to re-enter it into each Direct Data Entry claim. The claim form will be blank
when you open it in the ProviderOne portal.
Q: With
respect to submitting secondary claims, I didn't quite follow the guidance on
submitting backup documentation (EOB from the Primary Carrier). Is there a way to submit that online in this
billing process? Or with Provide One,
will it be sufficient to enter the relevant information regarding the primary
claim? Or would it still be required to
submit the EOB in the mail, and if so, how would you link that with the claim
that was submitted electronically?
A: You
may submit online by attaching a .pdf file, or via
the mail using a cover sheet. More about that will be covered later in this
presentation.
Q: Can
you attach backup documentation to claims that were submitted using the batch
method?
A: Yes.
Information about submitting backup documentation to
claims that were submitted using the batch method will be included in the ProviderOne Billing and Resource Guide,
which will be available 30 days before ProviderOne goes live. The draft is
available now at http://hrsa.dshs.wa.gov/download/ProviderOne_Billing_and_Resource_Guide.html
Q: How many lines will be available for diagnosis codes when ProviderOne goes live?
A: In Direct Data Entry claims, there are fields for 11 Diagnosis Codes for institutional claims (professional claim submission can hold 8 diagnosis codes), but in HIPAA batches, the number is greater.
Q: If a claim is submitted to Gateway, can we void or adjust the claim in ProviderOne if we have the TCN?
A: Yes.
Q: Are you going to talk about submitting a batch?
A: It happens after he finishes going
over how to submit this claim. If you are taking this webinar only to learn
about submitting a batch, I recommend you go to the following link: http://hrsa.dshs.wa.gov/providerone/EProfFFS.htm and click on Submit a Professional Claim
Using the On-line Batch Claims Submission Method. Another resource for you is
the ProviderOne Billing and Resource
Guide (Draft) found at http://hrsa.dshs.wa.gov/download/ProviderOne_Billing_and_Resource_Guide.html
Q: On
the professional claim DDE, what exactly is meant by a Medicare crossover
claim? I had thought a Medicare crossover claim was one where Medicare
electronically forwarded the claim info to DSHS for processing.
A: You are correct in that a Medicare crossover claim is one
where Medicare electronically forwards the claim info to DSHS for processing.
Now and again claims do not cross over. This section has been added to DDE so
providers don't have to submit on paper.
Q: When
adding or updating service line item, is there any way to not get kicked back
to the first section of the form and stay at the line item section instead?
A: No. The system will
automatically send you there.
Q: If
the client has a Medicare crossover claim, do you check yes or no in the “other
ins besides Medicaid”?
A: No;
do not check yes in this field. You will check yes where you are asked if this
is a Medicare crossover claim.
Q: When
viewing the status of a denied claim, will we be able to see the actual denial
code for each line item? Now, we only see if it paid or denied and need to
review the payment remittance for the denial reason.
A: You
will be able to see the denial codes for each line item.
Q: On
submitting a claim, do you hit a service tab somewhere to have ProviderOne show
your red warnings, or does it come up automatically before you submit the
claim?
A: The
warnings come up once you click on submit.
Q: I have never done any type of batch transaction. How do I get started?
A: You
either need to have a programmer that is able to create HIPAA batch
transactions or you have software that is capable of producing HIPAA batch
transactions. Please start with the following fact sheet, “HIPAA Batch Testing
– Getting Started,” at http://hrsa.dshs.wa.gov/providerone/Providers/Fact%20Sheets/P1PR007%20HIPAAtesting.pdf
.
Carefully
read the Companion Guides for each transaction you plan to use as transaction
testing is required before you can submit production batch transactions. There
are Companion Guides for each type of HIPAA transaction available at http://hrsa.dshs.wa.gov/dshshipaa.
If you have questions about testing, please contact hipaa-help@dshs.wa.gov or call 1-800-562-3022 select option 2,4,4. A signed Trading Partner Agreement (TPA) is required. You will find the TPA at http://hrsa.dshs.wa.gov/providerenroll/ . In addition, please be sure to update your provider file, Steps 11-14 of ProviderOne registration, to reflect your intention to submit HIPAA batch transactions.
Q: Why must we use such a large file name for uploaded claims?
A: You don’t have to. The file name used in the demonstration was just an example.
Q: When doing our testing for uploading our claims, this is when we had to use a large file name. So you’re saying this was just for demonstration purposes?
A: That is a question for our HIPAA Help Team: hipaa-help@dshs.wa.gov Please include your organizational NPI and a topic in the subject line of your email.
Q: Do those questions (the pay-to claim, claim for baby, etc.) have to be answered for each claim, including mental health or drug and alcohol services?
A: The questions apply to each claim. Depending upon your answer, other parts of the claim may need to be completed.
Q: Will claims still be accepted by mail? Or will all billing and adjusted claims be done through ProviderOne?
A: You will be able to submit claims and claims adjustments either through ProviderOne or on paper. Submitting claims through ProviderOne will speed up processing for you.
Q: Where do I get these different code numbers, and how do I know what they man and when to use which one?
A: The procedure codes will be the same ones you use when billing Washington Medicaid today. You can find them in your billing instructions, which you can access from the DSHS Provider Publications Web page: http://hrsa.dshs.wa.gov/download/index.htm
Q: Where do the new ProviderOne numbers need to be on the claim?
A: In the
Basic Claim information on the billing provider and subscriber. You can review
this webinar in e-Learning form by going to this Web site: http://hrsa.dshs.wa.gov/providerone/SystemTraining.htm Also, a ProviderOne
Billing and Resource Guide is under development, as well as updated billing
instructions to assist you once ProviderOne is operational. You can view a
draft version of the ProviderOne Billing
and Resource Guide at http://hrsa.dshs.wa.gov/download/ProviderOne_Billing_and_Resource_Guide.html
Q: Is the bar-coded sheet for every claim or for individual claims only?
A: The bar-coded sheet is for paper attachments. When you submit a claim directly into ProviderOne, it does not need a cover sheet.
Q: Are the bar-coded sheets specific or generic?
A: There are several specific bar-coded cover sheets. For more information, you may refer to the draft version of the ProviderOne Billing and Resource Guide at: http://hrsa.dshs.wa.gov/download/ProviderOne_Billing_and_Resource_Guide.html The final version of this guide will be available when ProviderOne goes live. You can submit backup documentation electronically through ProviderOne, or send it with a cover sheet, using paper.
Q: Can I enter the client ID and pull up all claims we have submitted for that single client?
A: You can do a claim inquiry using the Client ID and Start Date and End Date. The span between the start and end dates cannot exceed three months. This should bring up any claims for a particular client over a specific period of time. This information is covered in this webinar and the e-Learning based on it, so you can review it later. Here is the ProviderOne Training Web page for your reference: http://hrsa.dshs.wa.gov/providerone/Provider%20Training.htm
Q: Can the claim be voided after payment has been made?
A: Yes.
Q: If the claim has been paid and then voided, does the adjustment automatically generate from your end?
A: Yes it does.
Q: My organization uses a billing software company and a clearinghouse to submit electronic claims. Do we still need to batch the electronic claims through the internet, although at the end of the day our claims are batched by the claims software and submitted through the clearinghouse?
A: If you
use a clearinghouse to submit your batched claims, you should contact your
clearinghouse about preparing for ProviderOne. You may find out online fact
sheet helpful: http://hrsa.dshs.wa.gov/providerone/Providers/Fact%20Sheets/P1PR007%20HIPAAtesting.pdf
To
help your clearinghouse, we have a Web page devoted to HIPAA batch file
testing: http://hrsa.dshs.wa.gov/providerone/HIPAAtesting.htm
Your
software company may need to work with both you and your clearinghouse to make
sure your claims have the correct new identifiers in the correct data field.
You will find fact sheets about the new identifiers ProviderOne will require
at: http://hrsa.dshs.wa.gov/providerone/Providers/Fact%20Sheets/FactSheets.htm We suggest you work with both the software vendor and clearinghouse.
Q: How long does it actually take to enter the claim? Seems like a very long time.
A: We are opening every field that can be opened during this webinar. You will not need to do this when you actually enter the claim. How long it will take will depend on the claim. For example, if there are multiple lines and the patient has other insurance, this claim will take longer to enter than a single line, no other insurance claim. Once you are familiar with this system, it won’t take long to enter a claim.
Q: Do we need the NDC code for injectables such as Hyalgan or cortisone?
A: This question falls outside the scope of system training. I need to refer you to your Billing Instructions. When ProviderOne goes live, you will be able to click on the hyperlink for Billing Instructions directly through the system. That hyperlink will be in the top right-hand corner of your screen.
Q: We currently are not required to enter any NDC information when billing for injectables. ProviderOne would be the only one requiring that.
A: The NDC is not a required field in ProviderOne, i.e., it is not marked with a red asterisk. You will only be required to enter the NDC if the Billing Instructions require it.
Q: Is this how all claims have to be submitted for DSHS, Molina and CHP?
A: No. ProviderOne claims submissions are for fee-for-service claims only. If you want to submit on paper, you can. Please continue to bill managed care as you do today.
Q: With the new ProviderOne, will I still be able to electronically send my claims in the same manner I currently use?
A: WAMedWeb will be going away. If you submit through a billing agent or clearinghouse, you can continue to submit through them.
Q: If we are COB-ing, how do we attach the primary EOB?
A: You can
send it electronically. We will show you how to do that upon claim submittal.
If you ever want to review this information, remember that there is a recorded
version of this webinar. You can view the recorded version section-by-section,
allowing you to skip over what you do not want to spend time on. You can find
it here: http://hrsa.dshs.wa.gov/providerone/ELearning.htm
Q: For submitted charges, if it is $239.10, would be written 23910?
A: No. You would add the decimal.
Q: How can we get the TCN if we submit electronically through a clearinghouse?
A: Unless your clearinghouse sends you some kind of report with all of the TCSNs, then once you have been advised that your claims have been submitted, you can complete a claim inquiry search using the Client ID and Claim Service Period (to date is optional).
Q: We are a chemical dependency agency and have to bill on a monthly basis. Is there any way to enter services throughout the month and submit the entire claim at the end of the month?
A: At go-live, there will not be a way to do what you’re describing. There is a system enhancement on the horizon to add a template that would allow you to do this.
Q: Can I print a copy of the claim detail I have entered before I submit it through ProviderOne?
A: There is not a way to do this through the system. You can do a “print screen,” however.
Q: Can you still adjust or void a claim by paper, or is it only on the Web site now? Can we still use the blue forms that we used to correct a paid claim?
A: You can still submit adjustments on the blue adjustment form.
Q: Can we resubmit a denied claim using the Web site, even if we submitted the original through our clearinghouse?
A: Yes, you can.
Q: Once we void a claim, will DSHS recoup payment?
A: Yes.
Q: When I want to make a correction to an already-submitted claim that had an error on it, but was already paid, do I use the Claim Adjustment section?
A: Yes. When you want to make changes to a paid claim, you submit an adjustment. You can do these through ProviderOne.
Q: Is
there a standard naming convention? For example: VanWinkle. Would this
recognize Van Winkle?
A: The
system only searches for the first three letters of the last name. They must be
submitted to ProviderOne the same way they were put in to the system by the
Community Service Office (CSO).
Q: What
does TCN stand for?
A: TCN
stands for Transaction Control Number. The TCN is the
number that uniquely identifies the claim in the ProviderOne system.
Q: Where
will the taxonomy number go on paper claims?
A: That information is contained in the DSHS Numbered Memorandum
number 08-59. You can find that memo at this direct link: http://hrsa.dshs.wa.gov/Download/Memos/2008Memos/08-59.pdf
Q: Is
the taxonomy number for Case Manager/Care coordinator used for both MSS and HIV
case management?
A: Your
organization will need to determine which taxonomy to
use. The taxonomy that you bill with needs to correspond to the service you are
billing for. To learn more about taxonomy in general, you can review the slides
from the taxonomy webinar at http://hrsa.dshs.wa.gov/ProviderOne/ScheduledWebinars.htm
or go to the taxonomy fact sheet at http://hrsa.dshs.wa.gov/ProviderOne/Providers/Fact%20Sheets/P1PR009%20taxonomy.doc
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Q: What
happens if you don't have a taxonomy number for your business? We are a
pharmacy.
A: As
a pharmacy, you are already using the ProviderOne POS
and you are correct - pharmacy claims do not include taxonomy. If you have a
DME business, you would use the appropriate taxonomy, and this claims webinar
could be helpful to your preparation for ProviderOne.
Q: How
will we know the referring provider's taxonomy number?
A: You
do not need to include the referring provider's
taxonomy number.
Q: What
if we do not have a referral, such as an ER patient? What if we don’t know the
referring provider’s taxonomy?
A: The
referring provider’s taxonomy is not required.
Q: On
the line item detail, how do I associate specific taxonomy codes with specific
line items?
A: You
would open the Other Claim Info tab and enter that information there. Line
level taxonomy will only be applicable to Professional CMS1500 type claims. For
HIPAA claims, use Loop 2420A and Data Element PRV03. For paper claims, it’s the
top box for the line in form locator 24.J.
Q: Can
information such as NPI and taxonomy numbers be saved in this form or will it
have to be entered for each claim?
A: The
information must be re-entered for each new claim, as
ProviderOne does not allow a claim form to be saved.
Q: Will
there eventually be drop-down boxes for the Provider NPI and taxonomy codes?
A: I
am not aware of plans to do that.
Q: Account
number would be our encounter number?
A: Yes.
Q: Will
I be able to use the same payer ID, or will there be a new one for ProviderOne?
A: You
will need to bill with all of the new ProviderOne identifiers: NPI, taxonomy,
ProviderOne client ID number…
Q: Is there a place to add these new
numbers in the current claim form?
A: Yes. You may want to refer to the ProviderOne Billing and Resource Guide
to see where you place these numbers: http://hrsa.dshs.wa.gov/download/ProviderOne_Billing_and_Resource_Guide.html
Q: Do
we need to use our clinic NPI on the claim for the payer provider number? The
performing NPI is the rendering provider.
A: Yes.
Q: How
do we deal with clients with no ProviderOne ID as they do not have Medicaid
coverage, but are involuntary clients with an ITA?
A: You will go through the RSN to get the client ID for an ITA
client.
Q: 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?
A: 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 and Resource Guide, which will be available approximately 30 days before go-live.
Q: Is the client ID number format changing?
A: Yes. You may want to
go to the following link and read DSHS is
Changing to a New Client Identifier: http://hrsa.dshs.wa.gov/providerone/Providers/Fact%20Sheets/FactSheets.htm
Q: On
the other insurance information, if you bill Medicare for a denial, do you have
put that information into that section?
A: If
you are billing Medicare for denial, a good approach
is to enter the information and upload the attachment. This way if the claim
suspends for review, the information is already in the claim detail and there
will be an attachment for review.
Q: Will
the claim error if a patient is enrolled in a managed care plan on the date of
service?
A: That
depends. If the service is covered by the managed care plan, the claim could
deny. If the service isn’t covered by the managed care plan and DSHS knows
that, then DSHS might pay.
Q: Can
you print the RA?
A: Sure! It is a .pdf file. You can also save it to your computer
files.
Q: If
our clearinghouse is designated to receive our 835 (remittance advice), will we
still be able to see if through ProviderOne in View Payment under the Payment
Summary list?
A: You
will be able to view the .pdf version.
Q: Once
this goes live, we will only be able to view the RA via your Web site, correct?
A: That
is correct.
Q: When
can you start using ProviderOne to submit claims?
A: At
go live.
Q: Is
there a date that the benefit eligibility will be available via ProviderOne?
A: Eligibility information will be available in ProviderOne at go live.
Q: Regarding
the date the information will be available via ProviderOne: I thought it was
going to be available a month before go-live so we could train, etc?
A: We have training available at this link: http://hrsa.dshs.wa.gov/providerone/Provider%20Training.htm It will not be in the live system, though.
Q: Your
FAQs said that the information would be populated a month before go-live. We
are planning on training our staff with the actual portal.
A: I
believe you are thinking about our final
PIC-to-Client ID crosswalk. That will be updated and made available
approximately 1 month before go-live. We are unable to run the actual
ProviderOne system in tandem with the current MMIS, as our funder will only pay
for one system at a time. When ProviderOne goes live, it will be a "hard
cutover."
Q: Do
I have to submit a test claim if I am not using the HIPAA online batch?
A: No,
you do not need to test if you will use DDE claims
through the ProviderOne portal.
Q: Will there be any test sessions
before going live to make sure this will work? Once live, where do I call for
assistance using the site and avoid claims rejections?
A: For the ProviderOne portal, not
testing is planned before go-live at this time. There is a claims tutorial that
will allow you to walk through a sample claim and help you gain confidence: http://hrsa.dshs.wa.gov/ProviderOne/Provider%20Training.htm After go-live, DSHS will offer online
Q&As with common questions, live webinars to assist with questions, and our
call center will be available at the same 800 number we have today.
Q: The
WAMedWeb home page still shows that WAMedWeb goes away 12/6. Will that be updated
to reflect the new tentative go-live date of 1/10?
A: I’m
told this message will be updated to reflect the new tentative go-live date of
1/10.
Q: In
WAMedWeb, I could retrieve a previously submitted claim, clear the line items
and enter new line items and enter new line items for another set of services
allowing me to avoid re-entering the basic client information, etc. Will I be
able to do this with ProviderOne?
A: Unfortunately,
no.