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Medicaid Management Information Systems

Maine Integrated Health Management Solution

Health PAS Online: Certification User Guide


Date of Publication: 05/07/2014

Document Number: UM00039

Version: 1.0


Revision History

Version

Date

Author

Action/Summary of Changes

Status

0.1

03/13/2014

Darcy Casey

Creation per CR 22633

Draft

0.2

03/19/2014

Darcy Casey

Removed/blurred all training member information per State rejection dated 3/14/2014

Draft

0.3

04/29/2014

Darcy Casey

Updates per State comment log v0.2 dated 4/20/2014

Draft

1.0

05/07/2014

Darcy Casey,

Ryan Albrecht



Finalization per State acceptance email dated 05/06/2014

Final

Usage Information

Documents published herein are furnished “As Is.” There are no expressed or implied warranties. The content of this document herein is subject to change without notice.



HIPAA Notice

This Maine Health PAS Online Portal is for the use of authorized users only. Users of the Maine Health PAS Online Portal may have access to protected and personally identifiable health data. As such, the Maine Health PAS Online Portal and its data are subject to the privacy and security regulations within the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA).

By accessing the Maine Health PAS Online Portal, all users agree to protect the privacy and security of the data contained within as required by law. Access to information on this site is only allowed for necessary business reasons, and is restricted to those persons with a valid user name and password.

Table of Contents



Maine Integrated Health Management Solution 1

Health PAS Online: Certification User Guide 1

Revision History i

Table of Contents i

List of Figures i

List of Tables ii

1. Introduction 1

2. System Requirements 1

3. Preparation for Certification Submission Process 1

4. Trading Partner 1

5. Navigating to Certification Submission 2

6. Submit Certification 5

7. Certification Confirmation 13

8. Add Attachments to Certification 14

9. Certification Cover Sheet 15

10. View Certification Status 17

11. Print Detail 20


List of Figures

Figure 4 1: Trading Partner Sign In 2

Figure 5 2: Form Entry- Certification Submission 2

Figure 5 3: Patient Roster 3

Figure 5 4: Primary Care Roster 4

Figure 5 5: Billing Provider 4

Figure 5 6: Member Search 5

Figure 5 7: Member Search Results 5

Figure 6 8: Certification Detail Screen 6

Figure 6 9: Rendering Provider Search 7

Figure 6 10: Provider Search Results 8

Figure 6 11: Search for Diagnosis Code 9

Figure 6 12: Diagnosis Search 9

Figure 6 13: Diagnosis Search Results 10

Figure 6 14: Diagnosis Description 10

Figure 6 15: Service Code Search 11

Figure 6 16: Service Code Search Window 11

Figure 6 17: Service Code Search Results 12

Figure 6 18: Service Line 12

Figure 6 19: Miscellaneous Information 12

Figure 6 20: Notes 13

Figure 7 21: Certification Confirmation 14

Figure 8 22: Add Attachment 15

Figure 9 23: Certification Cover Sheet 16

Figure 10 24: Form Entry: Certification Status 17

Figure 10 25: Certification Status 18

Figure 10 26: View Certification Detail 19

Figure 10 27: View Attachment Button 20

Figure 10 28: View Attachment 20

Figure 11 29: Print Detail 20

Figure 11 30: Certification Detail 21



List of Tables

Table 1: Certification Information Tab 6

Table 2: Diagnosis Fields 9

Table 3: Field Name and Field Description 10

Table 4: View Certification Detail Functions 19




1.Introduction


MaineCare reviews the medical necessity and validity of some services to be provided to its members through the use of a certification. At present, certifications may be submitted for services performed under Home Health. A certification is similar to a prior authorization (PA), but does not need approval before services are rendered. Instead, certifications are reviewed periodically to verify the services that are provided to members.

The MIHMS Health PAS Online Portal (online portal) provides MaineCare providers with the tools required to submit certifications via the online portal.


2.System Requirements


To successfully use all features of the online portal, ensure that your computer system meets the following minimum requirements:

  1. Reliable online connection

  2. Web browser- the latest version of Microsoft Internet Explorer is recommended. As versions of Internet Explorer become available, it is recommended that these versions are used.

  3. The latest version of Adobe Acrobat Reader

3.Preparation for Certification Submission Process


When completing and submitting a certification via the online portal, the user will need to gather the following information:

  • MaineCare Member ID

  • Member Name

  • Member Date of Birth

  • Member Social Security Number (SSN)

  • Prepare all the necessary documentation you will attach to the certification request you are submitting over the online portal. Paper documents may be scanned for the purposes of attachment.

4.Trading Partner


To access the secure portion of the online portal to submit a certification to MaineCare via Direct Data Entry (DDE), the user must first be registered as a Trading Partner. To log into your Trading Partner Account (TPA):

  1. From the online portal home page, click on the Provider tab at the top of the screen.

  2. On the Provider tab, enter the username and password created during Trading Partner registration into the Trading Partner Sign In. See Figure 4-1: Trading Partner Sign in.

  3. Click the Sign In button.



Figure 4 1: Trading Partner Sign In

Note: If you are not already a registered Trading Partner, click the link to the Trading Partner user Guides for more information at:

https://mainecare.maine.gov/Trading%20Partner%20Guides/Forms/Publication.aspx

5.Navigating to Certification Submission


There are three ways you can submit a certification using the online portal, as shown in Figure 5-1: Form Entry- Certification Submission.

  • Patient Roster. See Section 5.1: Patient Roster or Primary Care Roster for more information.

  • Primary Care Roster. See Section 5.1: Patient Roster or Primary Care Roster for more information.

  • Certification Submission: See Section 5.2: Certification Submission for more information.



Figure 5 2: Form Entry- Certification Submission

5.1Patient Roster or Primary Care Roster


The Patient Roster is created by the provider and contains a list of the members that are patients of the provider. The Primary Care Roster is an automatic list of the members that have been assigned to a primary care provider enrolled in the Primary Care Case Management Program (PCCM). Members from the Primary Care Roster can be added to the Patient Roster List. The user may choose to identify the member for certification submission by using the Patient or Primary Care Roster.

  1. Once you are logged in as a Trading Partner, click on either the Patient Roster or Primary Care Roster link under the Form Entry heading.

  2. The roster screen will display, as shown in Figure 5-2: Patient Roster or Figure 5-3: Primary Care Roster, depending on which roster you have chosen.

  3. Select the Billing Provider from the drop-down menu, if applicable. If there is only one Pay-To provider, this field will be grayed out.

  4. If using the Primary Care Roster, select the PCP from the drop-down menu.

  5. Select the member from the roster list by clicking the radio button, or

  6. Select the first letter of the member’s last name from the alphabetical list. If a letter is grayed out, there are no members assigned that have a last name which starts with that letter. If using the Patient Roster and the member does not appear, the member needs to be added before a submission can be completed. For instructions on adding new members, see the MHP Patient Roster User Guide at the link provided:

https://mainecare.maine.gov/MyHealth%20PAS%20User%20Guides/Forms/Publication%20View.aspx

Note: The user will not be able to add new members to their Primary Care Roster. The Primary Care Roster members are assigned by Member Services.

  1. When the correct member is visible, select the radio button next to the member in the roster list.

  2. Click the Submit Certification button to begin the certification submission process.



Figure 5 3: Patient Roster



Figure 5 4: Primary Care Roster

  1. Go to Section 6: Submit Certification to complete the certification submission.

5.2Certification Submission


To submit a certification via the Certification Submission link under Form Entry, the user must have access to the member’s information and enter the information under the Find Member search to locate the correct member. To begin:

  1. Once logged in as a Trading Partner, click on the Certification Submission link. The online portal will navigate to the Submit Certification- Find Member screen. Verify that the Select Billing Provider information (above the Find Member tab) is correct. If there is more than one billing provider associated with the Trading Partner ID, click the drop-down menu to select the proper billing provider from the pre-determined list. See Figure 5-4: Billing Provider.



Figure 5 5: Billing Provider

  1. Once the billing provider is selected, the member must be identified. To search for a member, at least two of the four available member search criteria fields must be filled with the correct information. The member search fields are:

    • Member ID

    • Name (Last and First)

      • The Last Name and First Name count as one search criterion.

      • On the search screen, enter the last name in the first field provided and the first name in the second field, as shown in Figure 5-5: Member Search.

      • Names must match exactly for the first five letters of the last name and the first three letters of the first name.

Hint: For example, Jane Example-Member could be entered as Examp for the last name and Jan for the first name.

  • Date of Birth (e.g. MM/DD/YYYY)

  • Social Security Number (SSN)- should be entered without any dashes



Figure 5 6: Member Search

  1. Select the Submit button to perform your search.

Note: If no match is found, change your search criteria. For example, use the MaineCare ID and member date of birth. If no match is found, or to start your search over, select the Reset button to clear all the values entered in the Find Member search fields.

  1. The search results are returned under the Find Member Results tab, as shown in Figure 5-6: Member Search Results. The search may return a list of multiple members. Using the member’s criteria, identify the correct member. The member information that will be displayed is:

  • Name

  • Gender

  • Date of Birth

  • Member ID

  1. Select the radio button next to the member name to select the member.

  2. Click the Continue button to begin the certification submission process.



Figure 5 7: Member Search Results

  1. Go to Section 6: Submit Certification to complete the certification submission.

6.Submit Certification


After selecting the member, the online portal will navigate to the Submit Certification- Certification Detail screen as shown in Figure 6-1: Certification Detail Screen. There are seven tabs associated with this screen:

  • Member Information

  • Certification Information

  • Rendering Provider

  • Diagnosis

  • Services

  • Miscellaneous Information

  • Notes

Note: Some of the fields have been pre-populated with the member and provider information based on the member you have selected and the provider entering the certification.

Note: Input fields with a red asterisk (*) are required. An error message will be displayed if these values are left blank.



Figure 6 8: Certification Detail Screen

  1. Complete the Certification Information tab as outlined in Table 1: Certification Information Tab.

Table 1: Certification Information Tab

Field Name

Helpful Information

Certification Type

Required field. Click the drop-down menu and make a selection from a pre-determined list. Note: at this time, the only available selection is Home Health.

Pay-To/Billing Provider

Pre-populated. This field will be system-generated based on the trading partner account submitting the certification.

Requesting Provider

Required field. Click the drop-down menu and make a selection from a pre-determined list. This includes all affiliations associated with the trading partner account submitting the certification. Select the appropriate one.

Requested Length of Stay

Optional field. Some examples for when this field would be used are: Inpatient Hospital stays, Nursing Homes, Boarding Homes and ICF-IID.

Start Date

Required field. When a start date is not entered, the system will default to the current date. The date entered cannot be prior to 04/01/2011.

End Date

Required field. When an end date is not entered, the system will default to 60 days from the start date. The end date cannot extend beyond one (1) year from the start date.

  1. Complete the Rendering Provider section. The Rendering Provider or Group field is required and should reflect the provider that is rendering the service associated with the certification. To enter a value in the Rendering Provider or Group field, select the Search icon as shown in Figure 6-2: Rendering Provider Search.

Note: The system automatically defaults to the provider that is requesting the service.



Figure 6 9: Rendering Provider Search

  1. A provider search screen will populate, as shown in Figure 6-3: Provider Search Results.



Figure 6 10: Provider Search Results

  1. Complete one or more of the provider search fields.

  2. Click the Search button. The search results are returned at the bottom of the screen under the Search Results tab as shown in Figure 6-3: Provider Search Results.

  3. To make a selection, click on the radio button next to the correct rendering provider, as shown in Figure 6-3: Provider Search Results, and select the Continue button. Clicking Cancel closes the Provider Search Screen and returns to the certification screen.

  4. In the Pay-To/Billing Provider field, if the Rendering Provider (RP) is affiliated to more than one Pay-To provider, the correct Pay-To/Billing Provider must be selected from the drop-down menu. See Figure 6-2: Rendering Provider Search.

  5. Select the correct Service Location from the drop-down menu, as shown in Figure 6-2: Rendering Provider Search.

  6. The Diagnosis section must be completed to submit the certification. It is possible for the member to have multiple diagnoses. There are three fields in the diagnosis section; these fields are described in Table 2: Diagnosis Fields. If the user already knows the Diagnosis Code, he or she can type in the code and press tab.

Table 2: Diagnosis Fields

Field Name

Helpful Information

Seq #

The Seq # will increase as each line is added. To add a new line, press the Tab key at the end of the last line and a new line will appear.

Code

This user is responsible for populating the code field.

Description

The description will appear once the code is entered and the tab key is pressed.

Only one primary diagnosis can be entered for each certification. The first line entered is the primary diagnosis and must be closely related to the procedure. Any additional diagnosis entered will be considered a secondary diagnosis.



Note: Always tab through fields on a single line to ensure proper completion.

  1. To search for a Diagnosis Code, click within the code box and then click the Search icon, as shown in Figure 6-4: Search for Diagnosis Code.



Figure 6 11: Search for Diagnosis Code

  1. A new search window will open, as shown in Figure 6-5: Diagnosis Search. To search for a specific code, enter part of its description in the field provided.

  2. Click the Search button to retrieve a list of results.



Figure 6 12: Diagnosis Search

Note: The online portal will match exactly the sequence of characters entered in the search criteria. For example: if nothing is found for “sleep disorder” try using only “sleep”. Conversely, using just the word “disorder” may be too broad and result in a longer list. To start over, click Reset to clear the Description field.

  1. The search will return a list of Code IDs, Descriptions, Effective and Term Dates, and ICD Versions. Click any Code ID link to populate the Code ID to the Diagnosis section, as shown in Figure 6-6: Diagnosis Search Results.



Figure 6 13: Diagnosis Search Results

  1. Once the Code ID is displayed, tab through to auto-populate the description, as shown in Figure 6-7: Diagnosis Description. A new line will be presented if additional codes need to be entered.



Figure 6 14: Diagnosis Description

  1. Complete the Services section. The Services section is used to enter all of the services for which the provider is requesting a certification. As many as 99 service lines can be entered. The fields and links associated with this section are summarized in Table 3: Field Name and Field Description.

NOTE: A user may only request certifications for Home Health codes listed in the MaineCare Benefits Manual, Section 40, Chapter III. When entering in the Service Code in the Services section, choose the appropriate service from the HH procedure codes listed in Chapter III. To access the MaineCare Benefits Manual, follow the link below:

http://www.maine.gov/sos/cec/rules/10/ch101.htm

Table 3: Field Name and Field Description

Field Name

Field Description



Click this icon to delete a service line.

Seq #

Pre-populated. This is a system-generated field used to number each service line added by the user.

To add a new service line, hit tab at the end of the last line and a new line will appear.



Code

This field represents the Current Procedural Terminology (CPT) or Revenue Code for the service. Enter the code in this field if known or use the Search icon link to perform a code search. See step 16 for instructions on searching for a code.

Description

Description of the service code entered for the specified service line.

Modifier(s)

CPT code modifiers provide additional details regarding various services.

Units

Enter the number of times the service will be performed.



  1. To search for a Service Code, click the Search icon, as shown in Figure 6-8: Service Code Search.



Figure 6 15: Service Code Search

  1. A new search window will open, as shown in Figure 6-9: Service Code Search Window. Select the appropriate radio button to search for either a Service Code or a Revenue Code.

  2. Enter any part of the description of the code in the Description field and click on the Search button.



Figure 6 16: Service Code Search Window

Note: The online portal will match exactly the sequence of characters entered in the search criteria. For example: if nothing is found for “sinus surgery” try using only “sinus.” Conversely, using the word “surgery” may be too broad and result in a longer list.

  1. To start over, click the Reset button to clear the Description field.

  2. The search will return a list of Service ID Codes, Descriptions, and Effective and Term Dates as seen in Figure 6-10: Service Code Search Results. Click the Service Code link to return the selected Service Code to the Service Code field.



Figure 6 17: Service Code Search Results

  1. Once the code is selected, the Code will be highlighted in the code field as shown in Figure 6-11: Service Line. Press the tab key to auto-populate the description field, and continue pressing tab to move to the next field to be completed.



Figure 6 18: Service Line

  1. Enter any miscellaneous information about the member into the Miscellaneous Information section, as applicable. See Figure 6-12: Miscellaneous Information. The Accident Information box has three (3) selections:

  • Employment

    • Auto Accident

    • Other Accident

NOTE: The Accident Date is to be filled in if any of the radio buttons are selected. Click Investigation Required, if applicable.



Figure 6 19: Miscellaneous Information

      1. In the Pregnancy Information box, enter in the last menstrual period date and the estimated delivery date, if applicable. Dates must be entered in eight digit (MM/DD/YYYY) format.

      2. The Notes section is used to enter any other comments to further support the certification request. Click in the text box and type in supporting text.

      3. When all the information has been entered, click the Submit button to submit the certification, as shown in Figure 6-13: Notes.

NOTE: Any errors in your application will be indicated at the top of the page in a red font and must be corrected before the certification can be submitted.



Figure 6 20: Notes

7.Certification Confirmation


Upon successful submission of the certification, a certification confirmation screen will display. This screen provides the user with a certification number and a summary of the certification information as shown in Figure 7-1: Certification Confirmation.



Figure 7 21: Certification Confirmation

  1. By using the buttons at the bottom of the screen, the user may print the certification confirmation, add attachments, or print an attachment cover sheet, if necessary. See:

    1. Section 8: Add Attachment to Certification

    2. Section 9: Certification Cover Sheet, and

    3. Section 11: Print Detail

for more information on how to execute these functions.

8.Add Attachments to Certification


Supporting documentation of medical necessity and other required documentation must be attached to the certification request. To add an attachment, follow these steps:

  1. Select the Add Attachment button at the bottom of the confirmation screen, as shown in Figure 7-1: Certification Confirmation.

  2. The Add Attachments screen will open in a new window as shown in Figure 8-1: Add Attachments. Certification information will be pre-populated on the top of the page.

  3. Click the drop-down menu to select the Type of Attachment that will be added. This field defaults to HHSNSSupport.

  4. Select the Browse button to locate the file on your local computer. All supporting document files must be in one of these formats:

    1. GIF

    2. JPEG

    3. MS Excel (.xls)

    4. MS Word (.doc)

    5. PDF

    6. TIFF

  5. Click the Attach button when the selected file to upload is listed in the Browse field.

    1. If the user is unable to upload required attachments, certifications should then be submitted on paper with the appropriate attachment. See Section 9: Certification Cover Sheet for more information.

  6. Each attachment must have a unique file name.

  7. Once the user receives a message that the attachment has been successfully submitted, the user may:

    1. Repeat steps 1 through 6 to attach another document.

    2. Click the Cancel button to return to the Certification Confirmation screen.

Note: Be sure to check that the red message at the top indicates the documentation you attached has been accepted by the system.



Figure 8 22: Add Attachment

9.Certification Cover Sheet


Supporting documentation can be submitted manually if a user is unable to upload electronic copies of attachments. To do this, the user must print a Certification Cover Sheet (which comes pre-populated with the Certification Number). The attachments and cover sheet must be mailed or faxed for processing. To print a certification cover sheet, follow these steps:

  1. Click the Print Attachment Cover Sheet button located at the bottom of the confirmation screen.

  2. A new window will populate with the certification cover sheet, as shown in Figure 9-1. This must be included as part the manual submission of any attachments.

  3. Select the Print button, located at the bottom of the screen and shown in Figure 9-1, to print the certification cover sheet.



Figure 9 23: Certification Cover Sheet

  1. Send this cover sheet, along with any attachments, via fax or mail to:

Mail to:

Prior Authorization Unit

Office of MaineCare Services

11 State House Station

Augusta, ME 04333-0011
Fax #: 1-866-598-3963

10.View Certification Status


To view the status of a certification that has been previously submitted, follow the steps below:

  1. On the left navigation pane, locate the Certification Status link under Form Entry to access the View Certification screen. See Figure 10-1: Form Entry- Certification Status.



Figure 10 24: Form Entry: Certification Status

  1. As shown in Figure 10-2: Certification Status, this screen provides a list of the most current certification requests submitted by a specified billing provider.

  2. The Billing Provider selection reflects data associated with the trading partner logged into the online portal and requesting the certification status.

    1. A different billing provider can be selected from the Billing Provider drop-down menu only if the trading partner has additional provider associations.

  3. The certification list for the specified provider is automatically sorted by the date of service in the order of newest to the oldest.



Figure 10 25: Certification Status

  1. To view the certification detail, click the Certification number next to the appropriate certification. This displays the Certification Details screen as shown in Figure 10-3: View Certification Detail.



Figure 10 26: View Certification Detail

The Certification Detail screen displays the options shown in Table 4.



Table 4: View Certification Detail Functions

Option/Function Listed

Description/Additional Information

Add Attachments

Follow the steps in Section 8: Add Attachments to Certification to add attachments.

Print Attachment Cover Sheet

Follow the steps in Section 9: Certification Cover Sheet to print an attachment cover sheet.

Print Detail

Follow the steps in Section 11: Print Detail to print the certification details.

View Attachments

Follow the steps in section 10.1: View Attachments to view any certification attachments.

Back to Certifications

Click on the Back to Certifications button to navigate back to the View Certification Status page.



  1. The status of all certifications will be CLOSED.

NOTE: even though a certification status is closed, all required documentation needs to be attached to the certification.

10.1View Attachments


If a user needs to review any attachments associated with a certification request, follow the steps below.

  1. Select the View Attachments button from the Certification Detail screen as shown in Figure 10-4: View Attachment Button.



Figure 10 27: View Attachment Button

  1. The View Attachment window will open with an Attachments drop-down menu, as shown in Figure 10-5: View Attachment.



Figure 10 28: View Attachment

  1. Select the drop-down menu to view all attachments and click on the name of the attachment you would like to view.

11.Print Detail


Providers rendering services on a certification may want to print a copy of the certification for their medical records. To print the certification details, follow the steps in Section 10: View Certification Status to navigate to the Certification Details page, then:

  1. Select the Print Detail button from the Certification Detail Screen as shown in Figure 11-1: Print Detail.



Figure 11 29: Print Detail

  1. The Certification Detail screen will populate, as depicted in Figure 11-2: Certification Detail.

  2. Select the Print button at the bottom of the Certification Detail screen to print.



Figure 11 30: Certification Detail


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