Beginning April 15, 2013 Emdeon will be moving to a single payer ID format for medical claim submission for the Kentucky Spirit Health Plan. While Emdeon will crosswalk the old payer ID (68067), please ensure that you are making the change to use the NEW payer ID (68069) to assure your claims submittals are processed in a timely manner; Emdeon will only crosswalk the old payer IDs for a 90-day period (July 15th). After that time claims will be rejected for an invalid payer ID number.

There is an upcoming P & T meeting on Friday, May 31 from 2:30 PM to 4:30 PM at Kentucky Spirit Health Plan. Please check in with the 5th floor receptionist when you arrive.

For more information, please visit our Pharmacy & Therapeutics Committee page.

This notification is to provide reminders to help reduce mailing/routing errors when submitting claims for reimbursement.

• Please do not include medical records at original claim (first-claim) submission.
• Allow 30 days for claims processing before submitting a duplicate claim
• A Claim Dispute must be submitted in writing and:
• Include sufficient identifying information which includes, at a minimum, the patient name
  and patient ID number, date of service, total charges, and provider name
• Include a detailed description of the reason for the request.
• For Emergency Dept (ED) claims reconsideration, include medical records and other clinical rationale (i.e., presenting symptoms, patient age, date, and time of arrival) that support overturning the ED triage rate.

To dispute the decision made providers should complete the Claim Dispute Form (located under “Forms” at www.kentuckyspirithealth.com.)

Mail All Requests for Claim Dispute to:
Kentucky Spirit Health Plan
Attn: Claim Disputes
P. O. Box 3000
Farmington, MO 63640‐3800
Healthy Regards,

Kentucky Spirit Health Plan

In order to receive the Medicaid rate increase for primary care services provided from January 1, 2013, through December 31, 2014, physicians must request the reimbursement by self-attesting that they are an eligible provider. Physicians can begin applying for the payment adjustment on March 1, 2013, through the KYHealthNet portal on Kentucky Medicaid’s website, www.chfs.ky.gov/dms/kyhealth.htm. In order to register, applying physicians MUST have a current KyHealthNet account with an active login and password.

To receive the enhanced rates retroactive to January 1, 2013, physicians must self-attest by March 31, 2013. For self-attestations submitted April 1, 2013, or later, the effective date of the enhanced payment will be the first of the following calendar month.

Kentucky Medicaid has also provided the 2013 Primary Care Physician Rate Adjustment FAQ.

This Clinical Policy has been developed by appropriately experienced and licensed health care professionals based on a thorough review and consideration of generally accepted standards of medical practice, peer-reviewed medical literature, government agency/program approval status, and other indicia of medical necessity.

The purpose of this Clinical Policy is to provide a guide to medical necessity. Benefit determinations should be based in all cases on the applicable contract provisions governing plan benefits (“Benefit Plan Contract”) and applicable state and federal requirements, as well as applicable plan-level administrative policies and procedures. To the extent there are any conflicts between this Clinical Policy and the Benefit Plan Contract provisions, the Benefit Plan Contract provisions will control.

Clinical policies are intended to be reflective of current scientific research and clinical thinking. This Clinical Policy is not intended to dictate to providers how to practice medicine, nor does it constitute a contract or guarantee regarding results. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members.

Description:

• KY.PPA.02 addresses quantity and dose limits related to Glucose Test Strips. This policy and its restrictions are applicable as revisions to prior policies specifically related to glucose test strips.
   
• CRITERIA: Preferred PDL agents must be used first line. True Test and True Track Monitors are preferred monitors and True Test and True Track test strips are preferred test strips. Original new prescriptions for quantities greater than 200 test strips will require prior authorization. All refills for quantities greater than 100 test strips will require prior authorization.

This notification is to provide reminders to help reduce mailing/routing errors when submitting claims for reimbursement.

• Please do not include medical records at original claim (first-claim) submission.
• Allow 30 days for claims processing before submitting a duplicate claim
• Prior to submitting a Claim Dispute, providers must first submit a “Request for
  Reconsideration.” A request for reconsideration must be submitted in writing and:
  • Include sufficient identifying information which includes, at a minimum, the patient name
    and patient ID number, date of service, total charges, and provider name
  • Include a detailed description of the reason for the request.
  • For Emergency Dept (ED) claims reconsideration, include medical records and other clinical rationale
    (i.e., presenting symptoms, patient age, date, and time of arrival) that support overturning the ED triage rate.
  • Mail All Requests for Claims Reconsideration to:
    Kentucky Spirit Health Plan
    Attention: Claims Department
    P.O. BOX 4001
    Farmington, MO 63640-4401

To dispute the decision made during the request for reconsideration process, providers should complete the Claim Dispute Form (located under “Forms” at www.kentuckyspirithealth.com.)

• Mail All Requests for Claim Dispute to:
  Kentucky Spirit Health Plan
  Attn: Claim Disputes
  P. O. Box 3000
  Farmington, MO 63640‐3800

Please contact Provider Services at 866-643-3153 if you have questions or if you need additional information regarding the claim review process.

Healthy Regards,

Kentucky Spirit Health Plan

Over two months ago DMS notified Providers that they reassigned newborns among the three
MCOs to correct for instances of inappropriate assignment from 11-1-11 through 4-30-12.
Between the three MCOs there were 1,321 newborns reassigned. KSHP’s eligibility system has
been updated with the newborn reactively added and removed from eligibility.
The following actions will occur to rectify:

• Reassigning newborns as received from DMS to the correct MCO as of the newborn’s
  original effective date
• Recouping capitation payments from the previously assigned MCO and sending to the
  appropriate MCO
• MCO recouping claim payments from the affected providers on newborns reassigned to
  another MCO
• MCO will be responsible for paying all eligible & properly authorized expenses on
  newborns recently assigned

The following actions will be required of Hospitals and Physicians in order to receive payment
for eligible services due to this switch of MCOs.

• Provider must notify KSHP of the delivery and should contact UM department via
  telephone, fax or through our website with appropriate supporting clinical information
  to request the authorization.
  • Provider will need to communicate the extenuating circumstances to plan at
    time of authorization requests. In this instance, it is based on DMS
    notification of Newborn Assignment to MCO correction. Deadline for
    reporting these services to be considered for retro authorization is January 31,
    2013.
  • Service beyond 48 hours for vaginal delivery or 96 hours for a cesarean will
    require concurrent review.
  • All NICU admissions and/or reimbursements require authorization regardless of
    length of time infant is in NICU or Special Care Nursery level of care.
  • All services provided by a non-participating provider require authorization.

Providers should also be aware that the requests will be reviewed per KSHP policy and resulting
approvals/denials will be based on our policies. Reimbursement rates will be based on KSHP
reimbursement rates and not previously assigned MCOs. For questions please contact Provider
Services at Kentucky Spirit at 1-866-643-3153.

Kentucky Spirit Health Team

Download DMS Newborn Reassignment to Correct MCO (PDF)

HEDIS Quick Reference Guide – Pediatric (PDF)

HEDIS Quick Reference Guide – Women (PDF)

Kentucky Spirit Health Plan’s (KSHPs) commitment to delivering exceptional service to our providers and members at the lowest cost remains at the forefront of our mission. This effort includes strong performance in our turnaround time and accuracy of claims processing. Since our inception, KSHP has worked hard to ensure our capabilities support this level of performance. However, black and white UB-04 or HCFA-1500 forms copied/downloaded or handwritten red forms presents a challenge when processing these claims through Optical Character Recognition (OCR) technology such that the timeliness, accuracy and efficiency of these claims is jeopardized. In addition, eliminating the acceptance of handwritten red forms will reduce the risk of misinterpretation of submitted data.

As a result, KSHP will be changing our policy as it relates to the acceptance of black and white or handwritten red forms to align with the Centers of Medicare and Medicaid Services (CMS). Therefore, effective April 1, 2013, any UB-04 and HCFA-1500 forms received that do not meet the CMS printing requirements will be rejected back to the provider or facility upon receipt. You are highly encouraged to submit your forms electronically via our Web Portal www.kentuckyspirithealth.com.

The printing requirements are outlined in the Medicare Claims Processing Manual Chapter 26 – Completing and Processing Form CMS-1500 Data Set (Pub.100-04) of which the CMS regulation is described below:

• The only acceptable claim forms are those printed in Flint OCR Red, J6983, (or exact match) ink. Although a copy of the CMS-1500 form can be downloaded, copies of the form cannot be used for submission of claims, since your copy may not accurately replicate the scale and OCR color of the form. The majority of paper claims sent to carriers and DMERCs are scanned using Optical Character Recognition (OCR) technology. This scanning technology allows for the data contents contained on the form to be read while the actual form fields, headings, and lines remain invisible to the scanner. Photocopies cannot be scanned and therefore are not accepted by all carriers and DMERCs.
• The National Uniform Billing Committee (NUBC) is responsible for the design of the form, and award of the contract for printing of the form. CMS does not supply the form to providers for claim submission. Blank copies of the form may also be available through office supply stores in your geographic area. Although a copy of that form can be downloaded, copies of the form should not be downloaded for submission of claims, since your copy may not accurately replicate colors included in the form. These colors are needed to enable automated reading of information on the form.

Sincerely,

Kentucky Spirit Health Plan