Innovative Solutions in Healthcare Administration - PartnerSolutions Insights

SmartCareMCO Regional Training for Provider Agencies November 6th, 13th, 16th, 29th2017 Warren, Steubenville, Findlay, and Canton PartnerSolutions.org

What is PartnerSolutions? What we do A department of Stark County Mental Health & Addiction Recovery, PartnerSolutions (formerly Heartland East) operates the administrative services organization for a number of mental health and recovery boards in Ohio. Data Analytics (MACSIS/SmartCareMCO) Health Informatics (NextGen) Homeless Navigation (Stark County Homeless Hotline/HMIS) PartnerSolutions.org A department of StarkMHAR

PartnerSolutions Statistics SFY 2016 Volume 15 counties 67 agencies 22,000 clients served 4,800 claim files received 433,000 claims paid totaling $24 million PartnerSolutions.org A department of StarkMHAR

Streamline Healthcare Solutions The contract for SmartCareMCO, PartnerSolutions MACSIS replacement, was awarded and signed in June 2016 to Streamline Healthcare Solutions, the vendor with the best score/total cost of ownership (value per dollar). Quick Facts Established in 2003 and has 148 employees and 48 customers in 16 states Based in Kalamazoo, Michigan with offices in Chicago and Bangalore, India Maintains two product lines for web-based MCO and EHR software PartnerSolutions.org A department of StarkMHAR

SmartCareMCO Implementation: Fundamental Concepts Mimic Medicaid unless there isn t a compelling reason to do so Mimic MACSIS unless there isn t a compelling reason to do so Make the system work as well and as easily as possible for everyone involved When in doubt, choose the more secure, forward-thinking, and less arduous option that introduces the least amount of change for January 2018 Don t rock the boat in the middle of a fiscal year PartnerSolutions.org A department of StarkMHAR

Strengths of MACSIS Stability and reliability Passed security audits Easy and fast data entry Extremely difficult to create a duplicate client Duplicate claims checking with both Medicaid and other boards was baked into the system and easy Allowed claims to be routed to the appropriate payer based on a client s residency Boards didn t have to pay for it! PartnerSolutions.org A department of StarkMHAR

How MACSIS Handles Claims Portage The file contains claims for Portage, Stark, and Summit County clients. Provider submits a claim file to MACSIS. Stark Summit MACSIS is able to parse out claims to the appropriate board (i.e., payer) based on a client s county of residence at the time of a claim s date of service. For instance, a provider can submit one claim file containing claims for Portage, Stark, and Summit County clients, and MACSIS will route those claims to the appropriate boards. PartnerSolutions.org A department of StarkMHAR

How Other Payer Systems Handle Claims The file contains claims for both Medical Mutual and Aetna clients. Medical Mutual Provider submits a claim file to Medical Mutual. Aetna Modern insurance companies and their software systems don t work like MACSIS if a claim file is submitted to Medical Mutual that is intended for Aetna, Medical Mutual isn t going to send those claims to Aetna for them to be paid. Most MACSIS replacements operate in this same manner. For instance, a claim file submitted to the Summit Board s GOSH system that contained claims intended for the Tuscarawas-Carrol Board s GOSH system wouldn t be able to be routed to the appropriate payer. PartnerSolutions.org A department of StarkMHAR

How SmartCareMCO Handles Claims Portage The file contains claims for Portage, Stark, and Summit County clients. Provider submits a claim file to SmartCareMCO. Stark Summit MACSIS s functionality to parse out claims to the appropriate payer is retained in SmartCareMCO for all PartnerSolutions boards, such as Portage and Stark. However, any claim files intended for non-PartnerSolutions boards (e.g., Summit) will need to be submitted to their respective payers outside of the system. PartnerSolutions.org A department of StarkMHAR

Weaknesses of MACSIS Mandatory lag between EDI and creation of 835s No data integrity checking (race, family size, language, etc.) Inconsistent collection of family size/income/client copayments and poor enforcement of periodic demographics updates Coordination of benefits No definitive policy stance on arbitration of residency disputes and general lack of enforcement of residency rules Poor maintenance of email contact lists PartnerSolutions.org A department of StarkMHAR

Weaknesses of MACSIS (continued) No periodic client disenrollment No fund accounting Difficult to cap contracts Authorization module was never purchased by OhioMHAS No clinical components and poor integration with the Patient Care System used by state psychiatric hospitals PartnerSolutions.org A department of StarkMHAR

What Isnt Changing on 01/01/18 UCI numbers in MACSIS and ClientIDs in SmartCareMCO will be the same for existing non-pseudo clients who have had a claim pay either in MACSIS or MITS from 07/01/16 to the present. If a client s UCI number is 1234567 in MACSIS, and they meet the above criteria, their ClientID in SmartCareMCO will be 1234567 as well. Five-digit MACSIS UPI numbers are used as agencies Submitter IDs in SmartCareMCO. PartnerSolutions reporting will be the same other than for pseudo clients. PartnerSolutions.org A department of StarkMHAR

What Isnt Changing on 01/01/18 (continued) Use of https://www.heartlandeast.org/ to retrieve reports and upload claim files intended for MACSIS Frequency of ERA creation (once per week) Board requirements not otherwise specified in SFY 2018 contracts Out-of-county held claims Back-end eligibility and claims interface with Medicaid/retros PartnerSolutions.org A department of StarkMHAR

What Is Changing on 01/01/18 Unlike MACSIS, provider staff members will have access to SmartCareMCO and be able to use the system to view agency-, claim-, and client-related data. Provider users will upload claim files and download remittance files within the system. These files will no longer have enforced naming conventions. Claims billed with partial units will deny in SmartCareMCO. All hour-based, non-Medicaid reimbursable services will be reduced to 15 minute units. However, there are still a handful of hour-based BH redesign codes. PartnerSolutions.org A department of StarkMHAR

What Is Changing on 01/01/18 (continued) There will be no direct communication between the various MACSIS replacement systems. Multiple enrollment processes and rules for each system No cross-platform master patient index No shared ClientIDs between systems for the same clients Up-to-date residency information across counties is now even more vital for prompt payment. All pseudo clients will have new ClientIDs. Some third modifiers currently in use are being reassigned by ODM. PartnerSolutions.org A department of StarkMHAR

Reassigned Third Modifiers MACSIS Modifier HO HN SmartCareMCO Equivalent 06 03 Board Stark Stark Agency C&A C&A Meaning Trauma-informed Day Treatment Trauma Program Sexually Inappropriate Behavior Remediation Crisis Stabilization Hope Program Outpatient Mobile Response - Youth Medication Assisted Treatment Adult IOP Grace Initiative Adult TASC Services Family & Youth Together LEAD ATP ATP ATP Stark Stark Stark Stark Stark Stark Stark Stark Stark Stark Stark Trumbull Meridian Trumbull Compass Trumbull First Step C&A CIRC CIRC CIRC CIRC CommQuest CommQuest CommQuest TASC TASC TASC HK HN HO TS HG HM HN HK HN HK HG HI HI HI 04 03 06 07 05 02 03 04 03 04 05 08 08 08 PartnerSolutions.org A department of StarkMHAR

Data Migration of Clients Clients with claims in either MACSIS or MITS with dates of service from 07/01/16 to the present will be migrated into SmartCareMCO during the week of 12/18/17. Clients who don t fit this criteria won t be migrated and will acquire a new ClientID if enrolled again in the future. Client data that will be retained in the migration includes: Basic demographics Medicaid/board eligibility Copayment responsibility Client-to-provider linkage that needs to exist prior to claims paying in SmartCareMCO New eligibility spans for all clients will begin on 01/01/18. PartnerSolutions.org A department of StarkMHAR

01/01/18 Transition The transition from MACSIS to SmartCareMCO will be service date-based with claims denying if they go to the wrong system. Is the claims DOS on or after 01/01/18? Send to MACSIS. No Yes Send to SmartCareMCO. Claims with dates of service before 01/01/18 will deny in SmartCareMCO. Claims with dates of service after 12/31/17 will deny in MACSIS. PartnerSolutions.org A department of StarkMHAR

01/01/18 Transition (continued) Claims will need to be submitted as soon as possible after December services are provided. OhioMHAS hasn t publicly committed to keeping MACSIS open any later than 06/30/18. PartnerSolutions and its boards will maintain enrollment changes as appropriate in both systems until MACSIS is shut down. There will be a temporary suspension of all enrollments and enrollment changes in MACSIS from 12/18/17 until 01/02/18. No clients will be able to be enrolled or updated during this time by any PartnerSolutions board. PartnerSolutions.org A department of StarkMHAR

SmartCareMCO and Behavioral Health Redesign SmartCareMCO will be adopting most major elements of BH redesign business rules in January. Any BH redesign functionality that won t be in place then is planned on being phased into the system between 01/01/18 and 07/01/18. Ready on 01/01/18 Add-on Codes Diagnostic Rules NCCI PTP/MUE and Medicaid PTP Edits Rates Based on Credential Level Ready by 07/01/18 (planned) ACT Service Bundling Tiered Pricing ASAM Level of Care OTP 7/14/21/28 Day Dosages PartnerSolutions.org A department of StarkMHAR

SmartCareMCO and Behavioral Health Redesign: Add-On Codes Primary service code and any subsequent add-on codes must be part of the same claim. Service date, rendering provider/practitioner modifier, and place of service associated with add-on codes must be the same as those associated with the primary claim line. The denial, reversal, or voiding of a primary claim line will result in the same action being performed on add-code claim lines, too. But denying, reverting, or voiding add-on claim lines won t necessarily result in the same action on the primary claim line. PartnerSolutions.org A department of StarkMHAR

SmartCareMCO and Behavioral Health Redesign: Diagnostic Rules SmartCareMCO will initially adopt the same diagnostic rule set as ODM for all Medicaid-eligible services. Similarly, SmartCareMCO will initially adopt the current diagnostic rule set for all non-Medicaid codes brought over from MACSIS. In the future, diagnostic rules for custom codes will be determined by the boards utilizing them. Diagnostic codes outside of the allowable code set will be allowed to be included on a claim, so long as one of the diagnoses provided is in the allowed list. PartnerSolutions.org A department of StarkMHAR

SmartCareMCO and Behavioral Health Redesign: Edits and Rates NCCI PTP/MUE and Medicaid PTP Edits NCCI PTP and MUE Edits will be enforced and updated quarterly. Medicaid PTP Edits will be enforced. Rates Based on Credential Level Rates may differ based upon the Rendering Provider NPI/Practitioner Modifier and Supervisor NPI on a claim. Direct vs. general supervision PartnerSolutions.org A department of StarkMHAR

Affiliated Practitioner Collection Practitioner affiliation data for medical-based and independently licensed practitioners will be collected via a Medicaid-affiliated practitioner information file provided by OhioMHAS. Medicaid providers only need to affiliate practitioners with ODM and not separately with each payer system. Providers without a Medicaid contract will need to affiliate all of their medical-based and independently licensed practitioners directly with PartnerSolutions. Form will be available from http://www.partnersolutions.org/smartcareresources/. PartnerSolutions.org A department of StarkMHAR

SmartCareMCO and BH Redesign Testing BH redesign-related claims testing for SmartCareMCO was opened up on 09/05/17. All contracted agencies are strongly encouraged to submit test files to us as soon as they re able to generate one. Claims should be for dates of service of 07/01/17 to the present and for non-Medicaid clients. Contact SmartCareSupport@StarkMHAR.org if you need assistance or have any questions. There s no cut-off date for testing later is better than never! PartnerSolutions.org A department of StarkMHAR

SmartCareMCO and BH Redesign Testing (continued) The PartnerSolutions SmartCareMCO Companion Guide and SmartCareMCO Claims EDI Testing Request Form can be downloaded from http://partnersolutions.org/ smartcareresources/. Test files should be uploaded to your agency s directory on https://www.heartlandeast.org/ after following the instructions detailed on the SmartCareMCO Claims EDI Testing Request Form. Testing is the best way to help ensure that your agency s files will successfully process and that your claims won t all deny in January. PartnerSolutions.org A department of StarkMHAR

Common Test File Errors Using incorrect modifiers with the new codes, such as using practitioners that cannot deliver those services Including the same NPI in both the rendering and supervising fields Using invalid rendering, supervising, or ordering NPIs Agency NPIs can t be used for rendering providers. Including both a rendering provider and a practitioner modifier on the same claim detail line, indicating two practitioner types performed the service PartnerSolutions.org A department of StarkMHAR

SmartCareMCO User Accounts Users in SmartCareMCO can be assigned multiple security roles that determine what they can see and do in the system. Roles are selected when requesting an account. Agencies should determine what roles best fit their own staff members work duties and responsibilities. Security roles and permissions will be expanded over time as additional features are introduced into the system. To request an account, submit a SmartCareMCO Provider Account Request/Change Form to SmartCareSupport@StarkMHAR.org. The form can be downloaded from http://partnersolutions.org/smartcareresources/. PartnerSolutions.org A department of StarkMHAR

Security Roles and Permissions If a user is assigned to more than one security role, their permissions are combined. Claims Processor Role Upload 837 and batch claim files Download 835s and RAs View agency-, claim-, and client-related information Clinical Role View agency-, claim-, and client-related information Request authorizations for SFY 2019 View reports (not available on 01/01/18) PartnerSolutions.org A department of StarkMHAR

Security Roles and Permissions (continued) CQI Role View agency-, claim-, and client-related information Enrollment Role View client information Executive Role View agency-, claim-, and client-related information View reports (not available on 01/01/18) PartnerSolutions.org A department of StarkMHAR

SmartCareMCO Security General Information User accounts should never, under any circumstances, be shared among different people. Sessions will timeout after two hours of inactivity. Staff user accounts and permissions will be required to be reviewed and verified by agencies biannually. Password Policy Minimum length of 10 characters At least one uppercase, one numeric, and one special characters are required. Must be changed every six months Accounts will be disabled after 10 unsuccessful login attempts. PartnerSolutions.org A department of StarkMHAR

SmartCareMCO Security (continued) Remote Access SmartCareMCO has the capability of either allowing a user account to access the system from any location or restricting them to a specific static IP address, such as their workplace. This setting is indicated on the SmartCareMCO Provider Account Request/Change Form. This highlights the importance of notifying us regarding employee separation. Account Monitoring Anomalous account activity will be flagged and reviewed. Examples include account activity outside normal business hours or an excessive amount of failed login attempts. PartnerSolutions.org A department of StarkMHAR

Enrollments in SmartCareMCO The enrollment process in SmartCareMCO will largely mirror the current enrollment process and cover the same basic elements. Providers will still send enrollments to the appropriate board contact in the same manner that they do currently. There is a new SmartCareMCO New Member Enrollment/ClientID Request Form that should be used by all providers using the default form for MACSIS. The form can be downloaded from http://partnersolutions.org/smartcareresources/. Enrollment data entry will take longer in SmartCareMCO compared to MACSIS, which may result in enrollments taking additional time to be completed than previously. PartnerSolutions.org A department of StarkMHAR

New Enrollment Form The new enrollment is intended to be filled out and completed electronically using a dedicated .pdf reader, such as Adobe Acrobat. Any enrollments sent after 12/18/17 must use this form or an equivalent form with the same required fields and values. A new residency verification form will also be added to our website in the near future, although there won t be any major changes to it compared to the current one. PartnerSolutions.org A department of StarkMHAR

Enrollment Reminders Enrollments should only be sent for PartnerSolutions boards (i.e., Ashland, Ashtabula, Belmont-Harrison-Monroe, Columbiana, Hancock, Jefferson, Mahoning, Portage, Stark, Trumbull, Union, and Wayne-Holmes). All forms must correspond with the fields and values outlined in the SmartCareMCO Enrollment Form Completion Instructions document. Required fields must always be populated and should never be left blank under any circumstances. Submitted enrollments that are missing any required fields will be returned uncompleted. PartnerSolutions.org A department of StarkMHAR

Enrollment Reminders (continued) Disclosures/release/consent for treatment forms must be signed before a client can be enrolled due to 42 CFR restrictions. If a client fails to sign these documents, regardless of circumstances, no enrollment should be submitted for them. The Stark Board is requiring all of their contracted agencies to include a client s Gender Identity and Sexual Orientation if the enrollment is for a Stark County resident. Enrollments sent to the Ashland Board will be going to a new board contact beginning in January. PartnerSolutions.org A department of StarkMHAR

Enrollment Contacts for 01/01/18 Name Phone # Fax # Email Counties (419) 281-3139 ext. 1228 Patty Walton (419) 281-4988 Ashland pwalton@ashlandmhrb.org Mary Wells (440) 992-3121 (440) 992-2761 Ashtabula ashtabadmlw@suite224.net Belmont, Harrison, Monroe Anita Baker (740) 695-9998 (740) 695-1607 anitab@bhmboard.org Shirley Carter (330) 424-0195 (330) 424-8033 Columbiana scarter@ccmhrsb.org Hancock, Portage, Stark, Trumbull, Union Cindy Hamrick (330) 430-3966 (330) 454-2484 cindy.hamrick@starkmhar.org (330) 264-2527 (330) 674-5772 Sue Zarlengo (330) 264-7879 Holmes, Wayne szarlengo@whmhrb.org Sandy Madzia (740) 282-1300 (740) 282-6353 Jefferson madzias@jcprb.org Marla Ogan (330) 746-2959 (330) 746-1052 Mahoning mogan@mahoningcountyoh.gov PartnerSolutions.org A department of StarkMHAR

Using SmartCareMCO When logging into SmartCareMCO, use either Google Chrome or Internet Explorer. Using other web browsers will likely result in problems, including navigation errors and other bugs. A draft version of the SmartCareMCO Provider User Manual is available on http://partnersolutions.org/smartcareresources/. PartnerSolutions.org A department of StarkMHAR

Provider Functionality in SmartCareMCO on 01/01/18 Upload claim files and download remittance files View clients associated with their agency ClientIDs, coverage plan timespans, copays, claims history, and minimal demographic data View claims associated with their agency Claim statuses, details, and denial reasons View their agency s information Contracted rates, provider site information, and affiliated practitioner data PartnerSolutions.org A department of StarkMHAR

Provider Functionality in SmartCareMCO in the Future Request prior authorizations Some boards have already communicated to us that they will be utilizing the prior authorizations functionality for SFY 2019. Request enrollments within the system, which will then be reviewed by a board staff member Requires additional security development Entering reason or deferment codes within the system for clients who appear to be eligible for Medicaid Expansion (i.e., the JDM22 process currently used by the Stark, Trumbull, and Union Boards) PartnerSolutions.org A department of StarkMHAR

Submitting Production 837 Claim Files 1. While on the My Office tab, click on 837 Import. 2. Click on Import New File... 3. In the 837 File Importpop-up that appears, selectyour agency from the dropdown list. 4. Click on Browse..., select the 837 claim file you wish to upload, and then click on Open. 5. Click on Import File. Your file has now been uploaded. PartnerSolutions.org A department of StarkMHAR

837 Claim File Errors Upon uploading an 837 claim file, a user will know immediately if: a) The file was processed by the system (if processed) b) What claims in the file were processed When processing 837s, SmartCareMCO looks for file format, parsing, and processing errors. The system will display specific error messages on what s wrong in a file whenever possible. PartnerSolutions.org A department of StarkMHAR

837 Claim File Errors (continued) File Format Errors Something is structurally wrong with the file (e.g., it s not in the EDI X12 format). Parsing Errors Something is wrong with a specific loop or segment in the file (e.g., Submitter Name is wrong). Processing Errors Something is wrong with a specific claim or claim line in the file (e.g., the rendering provider on a claim has an invalid NPI number). Equivalent to critical errors in MACSIS PartnerSolutions.org A department of StarkMHAR

Batch Claims Upload Agencies who have PartnerSolutions manually enter claims now will be able to submit claims using a Microsoft Excel template. Batch claim spreadsheets should be limited to a small number of claims and will only cover non-Medicaid reimbursable services on 01/01/18. BH redesign functionality will be added sometime in the near future. Some boards may have providers use this feature to submit claims for non-traditional services that they may have paper billed for in the past. PartnerSolutions.org A department of StarkMHAR

Claims in SmartCareMCO Claims in the system can have seven different statuses. Entry Complete Approved Partially Approved Pended Denied Paid Void Claims will be adjudicated every weeknight and paid every weekend. Users will be able to view claim line details. PartnerSolutions.org A department of StarkMHAR

Claim Status Explanations Status Meaning Entry Complete Claim is in a pre-adjudicated state and will be adjudicated during the automated adjudication process that occurs every weeknight. Approved Claim will be paid at the charged amount during the automated check creation process that occurs every weekend. Partially Approved Claim will be paid at less than the charged amount during the automated check creation process that occurs every weekend. Pended Claim will be in a held state until it is approved, partially approved, or denied by a board staff person. Denied Claim will not be paid. Paid Claim has gone through the automated check creation process and will appear on an 835 file. Void Claim has been terminated. Voided claims can t be reverted. PartnerSolutions.org A department of StarkMHAR

Claims Screen in SmartCareMCO Claims can be filtered and sorted by DOS, insurer, status, procedure code, denial reason, etc. PartnerSolutions.org A department of StarkMHAR

Claims Corrections in SmartCareMCO An updated form must be used to request claims corrections. The form is currently being updated and will be posted to http://www.partnersolutions.org/smartcareresources/ when ready. For 25 or fewer claims in a file, providers will have the option of either resubmitting the claims in need of correction after those claims have been voided or having PartnerSolutions correct them on their behalf. PartnerSolutions.org A department of StarkMHAR

Claims Corrections in SmartCareMCO (continued) For more than 25 claims in a file, providers will have to resubmit those claims in need of correction after they ve been voided. This policy will be revisited after go-live. Claim corrections will be more complex in a post-MACSIS world, and it may be easier for providers to simply resubmit claims due to all of the new elements involved (e.g., add-on codes, etc.). There may be some claims correction scenarios that always require resubmitting claims to correct them, such as for most processing (i.e., critical) errors. PartnerSolutions.org A department of StarkMHAR

Downloading 835 Files 1. While on the My Office tab, click on 835 Export and RAs. 2. Click on a check number. On the Check Details screen, click on 835 File, click on Process Now, and then click on Generate. 3. You ll then be prompted to download the 835. PartnerSolutions.org A department of StarkMHAR