Casemix/MMQ Questions

 

Where can I e-mail feedback about MMQ software?

You can send any feedback about MMQ software to providersupport@mahealth.net.

 

Why does a discharge record carry a casemix category?

When you create a discharge record, the system will carry over the MMQ category submitted on the last MMQ received. The category has no effect on the discharge record.

 

We have been advised that if the response report indicates that the MMQ is pending, the MMQ nurse should tell the person in the facility who is responsible for submitting the status change forms (SC-1) pdf format of status-change-ltc.pdf and the MMQ does not need to be resubmitted. What if three months have lapsed and the long-term-care segment on the eligibility file has not been opened? At that point, will a new MMQ need to be resubmitted?

If the MMQ pends for three months without a long-term-care segment being opened on the eligibility file, it will be rejected, and a new MMQ submission will be required.

 

Since the new and updated 2010 ICD-9-CM codes became effective on 10/1/09, will NewMMIS be able to tell if a new updated code was not on the MMQ and will the tracking show it as an error?

NewMMIS will know by the effective date of an MMQ which ICD-9-CM codes are valid.

 

Why do the ICD-9-CM codes need to be part of the MMQ?

This information is needed for statistical purposes.

 

Why do questions 15 through 24 (below the line) on the MMQ need to be on the submission?

This information is needed for statistical purposes.

 

If during an audit a member's casemix category is reduced, but is not reflected on the eligibility file after a month, what should we do?

The new audited casemix scores should be posted to NewMMIS within a month from the time the audit nurse was at the facility. If the category has not been adjusted within a month, call the Casemix Unit at 1-800-841-2900.

 

We have seen several instances where the casemix category does not appear in the long-term-care segment of the eligibility file. The member is still a resident. What should we do?

MassHealth did not receive an MMQ for that period. You should submit the MMQ.

Back To "Casemix/MMQ Questions" Q & A.


 

Claims Questions

 

When we request an adjustment on paper for a claim that was paid by the old claims processing system, MassHealth has been recouping the entire claim instead of adjusting it. Why?

Providers need to carefully check the adjustment section of the remittance advice for both header and line detail EOB (explanation of benefits) codes. If an EOB code is listed in either field, then there was an error on the submitted adjustment claim. If an adjustment is submitted and there is an error on the replacement claim, MassHealth will recoup the original payment and deny the replacement claim. You will need to resubmit the claim with the correction as noted in the EOB code listed on the remittance advice.

 

Why can't we see denial reason codes on the Provider Online Service Center (POSC) so that we don't have to wait for the remittance advice to determine the status of a claim?

Viewing the status of electronic claims through the POSC varies, based upon the media type used and the time that the claim is submitted. If your claim is submitted via direct data entry (DDE) using the POSC, the status of that claim will appear immediately upon submission of the claim, along with the associated EOB code, if the claim is denied. If you submit a batch of claims using the 837 batch claim submission option, you will be able to view the status of the claims (that is, paid, denied, or suspended) within approximately one hour of submission, assuming that you submit directly to MassHealth.

For claims that have been denied from the batch claim file, you will see the HIPAA adjustment reason code after the financial cycle has been performed for that week (typically on Fridays). Please note that when you check the status of an 837I file in the POSC, the 277 transaction will return the HIPAA adjustment reason codes and HIPAA entity codes and not the proprietary MassHealth edit codes. MassHealth has provided a crosswalk pdf format of 835crosswalk.pdf of these two code sets on the MassHealth Web site to assist providers.

 

Why am I at times unable to adjust or resubmit claims electronically? The buttons are shaded.

Providers are able to resubmit or adjust only claims that were processed by the new claims processing system. They cannot adjust or resubmit claims that were processed by the old claims processing system.

 

Where in Field 50 of the UB-04 must we enter the carrier code for other insurance?

MassHealth has posted on its Web site Special Instructions for Submitting Claims on the UB-04 for Members with Other Health Insurance pdf format of special-instructions-tpl-ub-04.pdf . The document identifies fields on the UB‑04 that must be completed when billing on paper for a member who has TPL, and provides additional instructions for providers who bill using the UB-04 claim form. 
 

 

We cannot find the status of claims on the POSC that were sent as paper claims.

Providers need to verify if the paper claim was filled out according to the instructions in the . Improperly completed claims may be returned to the provider. Submitting a paper claim without the NPI or listing the NPI in the incorrect field on the claim form will prevent your claim from being entered into the system.

 

How do we get adjustment paper claims paid from 2008 (legacy system) and from May 2009 (NewMMIS)?

The process has not changed for claims that are over one year beyond the date of service. You must follow the previously established guidelines for requesting a final deadline appeal (see All Provider Bulletin 186 pdf format of all-186.pdf ).

If a previously paid claim is within one year, the provider can submit an adjustment according to the appropriate guidelines for the type of submission. For electronic claims, review the 837I%20Companion%20Guide for detailed loop/segment information. For direct data entry (DDE), refer to the e-Learning tool available on the Provider Online Service Center. For paper claim submissions, please refer to the on the MassHealth Web site.

Please note that if the claim was processed in the previous (legacy) system, then the provider must submit a paper adjustment to correct an incorrectly paid claim.

 

Will we ever be able to electronically submit a 90-day waiver claim?

There are no plans at this time to allow providers to submit 90-day waiver claims electronically.

 

We have two provider numbers. When a resident changes numbers within the month, the PPA (patient paid amount) is deducted from each claim. Why does this happen?

The PPA should be deducted only once. However, if a provider includes the full PPA on both claims, then the system will default to the PPA on the provider's claims. In this case, the provider should not report the PPA on the claim; the system will deduct the PPA automatically.

 

If a resident changes to hospice, the PPA is being taken out of both our claim and the hospice claim. What do we need to do to fix this?

The claim can be adjusted. The provider should not report the PPA on the claim; the system will default to the PPA on the provider's claim if it is submitted.

 

How do we bill for adjustments?

If the claim was processed in the previous (legacy) system or was a paper submission, the provider must send the correct claim on paper as an adjustment according to the instructions in the . If the claim was processed in NewMMIS, the provider can pull up the paid claim and replace it using the POSC. If performing adjustments via batch (837I), providers must follow the instructions outlined in the 837I%20Companion%20Guide.
 

 

When I submit an adjustment, why does the system take back the whole amount?

Providers need to carefully check the adjustment section of the remittance advice for both header and line detail explanation of benefit (EOB) codes. If an EOB code is listed in either field, there was an error on the submitted adjustment claim and the replaced claim contained errors that did not allow the claim to be processed.

 

What are the billing requirements and instructions in cases where the patient has a primary insurer other than MassHealth (such as LTC insurance)?

Providers need to follow job aids and supplemental instructions on how to bill when the member has MassHealth and another insurance. Both are available on the MassHealth Web page at www.mass.gov/masshealth/newmmis.

 

MassHealth pays in full for a member who was on a 10-day medical leave of absence (MLOA). We submitted an adjustment but NewMMIS took back the entire payment. What do we do? We were told that it has to go to the 90-Day Waiver Unit.

Providers need to carefully check the adjustment section of the remittance advice for both header and line detail explanation of benefits (EOB) codes. If an EOB code is listed in either field, there was an error on the submitted adjustment claim and the replaced claim had errors that did not allow the claim to be processed. If the payment has been recouped and the date of service is older than 90 days, you will need to submit the claim to the 90-Day Waiver Unit as a new claim along with a completed 90-Day Waiver Request Form pdf format of 90-Day Waiver Request Form [90-DWR] and copies of the remittance advice showing where the claim was adjusted.

 

We cannot open our 997 acknowledgments. We see them, but when we try to save or open them, they have an unrecognizable file format. They appear as a .285 file. This needs to be a .doc or .pdf file. How can we get the correct file format?

The 997 is a text file. The ".285" is the file extension, which is comprised of the Julian date of the creation date of the file. Just right-click the file and choose "open with" (Microsoft Word, for example). You should then be able view the 997 file.

For those files that get downloaded as an H.323 Internet Telephony file, rather than the usual type, follow the steps below.

  1. Open Windows Explorer.
  2. Click on Tools, then Folder Options, then File Types.
  3. Search for the ".323" file type in the list, select it and click Delete.
  4. In the resulting dialogue box, which asks if you are sure you want to delete the file extension, click Yes.
  5. Open a new browser window, log into the POSC, and try the download again.

 

NMLOA (nonmedical leave-of-absence) days are not being tracked correctly and claims for NMLOA days are automatically being denied because they are over the 10-day limit. When will this be corrected?

This issue is being researched by the technical team. 
 

 

I use Genecare and do batch processing. How do I get MLOA (medical-leave-of-absence) days paid?

It is important that providers review the MassHealth billing guidelines applicable for MLOA/NMLOAs with their billing intermediaries and software vendors in order to ensure that the batch claim files are being submitted properly.

 

When are we going to be given a schedule of when claims are entered into the system, when they will be processed, and when we will get paid?

Because claims are adjudicated more quickly in NewMMIS, providers can check claims status via the POSC soon after claim submission. The adjudication cycle is different than the payment cycle, however. Claims in a denied or suspended status will appear on the very next remittance advice after the claims are adjudicated. Claims in an approved-to-pay status will not appear on a remittance advice until payment is released. Paid claims will not, therefore, appear on the same remittance advice as denied or suspended claims from the same batch submission. MassHealth will typically issue payments three weeks after the claim has been adjudicated as paid.

 

Does MassHealth still have a special nursing facility claim processing cycle?

There is no longer a special processing period specifically for nursing facilities.

 

Will the remittance advices ever be available in a downloadable 835 format in addition to the pdf format?

The 835 format has always been available to providers, as it was in the previous system. To request access to 835s, contact HIPAA/EDI at 1-800-841-2900. Select Option 1, then Option 8, then Option 3.

 

Why are bed holds billed with room and board paying $0.00?

Providers need to review the EOB codes on the remittance advice to see why the claim has been denied. Reviewing the EOB code will help to determine if the claim was submitted properly. This is especially important when there are claims with multiple lines.

 

Why is a patient paid amount (PPA) being deducted from coinsurance (Part A) claims now? Is a PPA now due when a member is on a Medicare A stay?

All Provider Bulletin 165 pdf format of all-165.pdf informed providers that the PPA would be deducted from crossover claims.

Back to "Claims Questions" Q & A.


 

MassHealth Enrollment Center Questions about Long Term Care

 

Is an SC-1 form required for coinsurance-only claims?

Yes, an SC-1 form pdf format of status-change-ltc.pdf is required, but a level-of-care (LOC) screening is not. Make sure to indicate in Block 20 that the claim is for coinsurance.

 

When a resident is admitted to a nursing facility under Medicare and is applying for MassHealth for coinsurance with intention of returning home, is an LOC screening required?

Effective August 21, 2009, an LOC screening is not needed.

 

May a nurse practitioner sign the SC-1 form for the physician?

No. As stated in Long Term Care Facility Bulletin 99 pdf format of ltc-99.pdf , a physician's signature is required.

 

Is a clinical screening needed for our residents who are enrolled with Medicare Advantage and SCO (Senior Care Options)?

If the member joins a Medicare Advantage plan, a clinical screening may be needed depending on the health plan that is chosen.

A clinical screening by MassHealth or an Aging Service Access Point (ASAP) is not required for SCO members (see ). A clinical eligibility determination (screening) is required when MassHealth will be the primary payer at 100 percent.

 

Is there a time limit for processing Senior Member Benefit Requests (SMBRs) (MassHealth applications for seniors and people who need long term care)?

Per MassHealth regulations at 130 CMR 516.004(A) and (B):

(A) For applicants who do not apply on the basis of a disability, a determination of eligibility must be made within 45 days from the date of receipt of the completed SMBR. All requested information must be received within 30 days of the date of request.

(B) For applicants who apply for MassHealth on the basis of a disability, a determination of eligibility must be made within 90 days from the date of receipt of the completed SMBR, including a disability supplement, if required.

 

Is Block 19 of the SC-1 (MassHealth Requested Payment Date) the first custodial day?

As indicated in Long Term Care Bulletin 99 pdf format of ltc-99.pdf , Block 16 of the SC-1 form pdf format of status-change-ltc.pdf is the date of admission. Block 19 should reflect the start date that MassHealth payment is being requested. 
 

 

How long will it take to receive a decision once an appeal has been filed?

For denial of an application: 45 days
For the termination of MassHealth benefits: 90 days
For a nursing-facility-initiated transfer/discharge (not expedited): 45 days

The timeline may be longer due to overall appeal volume, jurisdictional problems (such as the death of the applicant or the incompetence of the applicant and the need to seek appointments (administrator, guardian, conservator)), multiple appeals on the same application, rescheduled hearings, and record open period (see 130 CMR 610.015(D) pdf format of regs-memb-610.pdf ).

 

We have a resident who is coded to a MassHealth managed care organization (MCO), but we have the letter from the MCO stating the resident has been disenrolled. Why is the resident still coded to the MCO?

MCOs send a list of enrollees and disenrollees to MassHealth on a regular basis. MassHealth does not disenroll a member from an MCO until it receives all of the appropriate information from the MCO. If the facility's claim has been denied because of a discrepancy in enrollment dates, the facility should contact Lisa Gardner via e-mail at lisa.m.gardner@state.ma.us or 617-348-5554.

 

Who updates the residents' long-term-care information in the system?

The MassHealth Enrollment Center (MEC) is responsible for processing and coding residents based on the SC-1/LOC documentation. This also includes the patient paid amount. The MEC is also responsible for establishing a segment for long term care (LTC). This information is automatically sent to NewMMIS, and should be available the day after the case is updated for MassHealth eligibility.

 

Why doesn't the member's MassHealth ID number appear on the Final Notice of Denial for MassHealth (NFL-5A) showing approval?

The MassHealth member ID is a system-generated number and is created only after an applicant is approved for MassHealth. Therefore, the number does not appear on any notice sent before approval. The member ID will appear on the MassHealth card and will also be available on NewMMIS.

 

I have a MassHealth applicant whose social security number (SSN) brings up a different person with a different SSN when I'm checking eligibility via the Provider Online Service Center. What should I do?

In this situation, please call the MassHealth Enrollment Center to resolve the issue.

 

Is the new SC-1 unit in Taunton processing SC-1 forms for the entire state?

No, the Taunton Integration Team is responsible for processing SC-1 forms pdf format of status-change-ltc.pdf from the nursing facilities geographically assigned to the Taunton MEC. 
 

 

When you submit an SC-1 to open a segment after it has been closed for an unknown reason, should we use the original request date or the date the segment is needed?

If there is a need to send an additional SC-1 form pdf format of status-change-ltc.pdf , the original admit date and the MassHealth Request Date should be indicated. Please clearly identify the concern or problem in Block 20.

 

How is a home maintenance needs allowance (HMNA) determined?

Per regulations at , MassHealth allows the deduction for HMNA for maintenance of the member's home when a competent medical authority certifies in writing that a single individual with no eligible dependents is likely to return home within six months after the month of admission. The HMNA is equal to 100 percent of the federal poverty level pdf format of fpl-deskguide.pdf .

As indicated in , in order for the HMNA to be given, the MEC worker must receive an SC-1 form pdf format of status-change-ltc.pdf with the short-term block checked, a physician's signature, and clinical eligibility approval stating short-term stay (Block 21). The HMNA is to be given for a continuous period of institutionalization. If a member returns to the community and remains there for a 30-day period and then reenters a nursing facility for another short-term stay, an HMNA may be given again. There is no limit to the number of HMNAs an applicant or member may receive, as long as there is a break from institutionalization of at least 30 days between stays.

If the individual is on a short-term stay and returns home for less than 30 days, a new HMNA may not be given. The previous HMNA would continue until the end of the six-month period.

 

If a case is closed because the eligibility review form was not returned, is a new SC-1 form required?

No, once the Eligibility Review Form is received and processed, the worker will update NewMMIS to reestablish the segment.

 

If a short-term-stay resident (six months or less) has a monthly income that exceeds the community allowance, does the resident have a patient paid amount (PPA)?

If a currently active, single MassHealth Standard or CommonHealth-eligible community member is screened for a short-term stay, the Chelsea MEC (short-term-care processing unit) will open a segment on NewMMIS. They will not establish a PPA.

 

We have a patient who is on MassHealth Standard, is married, had an emergency admission for short-term care, and has received a short-term screen. We were not aware of the need for Supplement A and Asset Assessments. Under this circumstance is it possible that the member will not qualify for nursing-facility placement?

Whenever a MassHealth Standard member aged 65 or older is admitted to a nursing facility and has a spouse residing in the community, a Supplement A and Asset Assessment must always be completed to determine if the member is eligible for nursing-facility payment. A nursing-facility payment cannot be established until this determination has been made. 
 

 

Is there a break in coverage when a resident moves from short-term care to long-term care? If yes, will the segment be opened back to its original segment?

As indicated in , if the six-month short-term period expires and the member is still a patient at the nursing facility or is no longer on a short-term stay, the following will take place.

The payment segment will be closed by the Short-Term-Care Processing Unit worker. The Short-Term-Care Processing Unit will send an Expiration of Short-Term Stay and Home Maintenance Needs Allowance (ST-CL) cover letter and a Supplement A detailing the need for the supplement to be completed by the nursing facility on behalf of the member. (If the member is under the age of 65, a MER/TRANS form will also be sent to the nursing facility.) The completed forms must be returned to the appropriate MEC with an SC-1 form pdf format of status-change-ltc.pdf , stating that the member is transitioning from a short-term stay to a stay of more than six months. A new level-of-care determination form is notneeded. If all required documentation is received, the segment will be coded with the original date.

 

When a short-term segment is closed, does the PPA (patient paid amount) also go away or does it stay in NewMMIS?

NewMMIS retains a history of all PPAs.

 

We have one provider ID but different service location codes: A, B, and C. Patients keep getting coded to A. When checking the eligibility system, the patient appears to be coded to our facility but actually is not. How do you handle the correct placement of members when a facility has multiple location codes?

It is important that the facility properly indicate the location code on the SC-1 form pdf format of status-change-ltc.pdf . The worker enters the code that is listed on the SC-1 form. If sending an additional SC-1 to correct a problem, please be sure to make a note in Block 20 of the incorrect location code.

 

Why is the facility information not being added on all cases? We are not receiving eligibility reviews for residents that are in our facility.

It is critical that discharge SC-1 forms and SC-1 admit forms be sent to the appropriate MassHealth Enrollment Center as soon as the change occurs. This will ensure that the file is up to date.

 

Are ASAPs (Aging Services Access Points) aware of the importance of dates on the clinical screenings?

Yes. Clinicians from the ASAP network receive oversight from the MassHealth Office of Long Term Care and the Office of Elder Affairs.

 

Are MassHealth Enrollment Centers (MECs) aware that they don't need a clinical screen in order to make someone eligible for coinsurance payments?

Policy and procedural updates are shared with all MEC staff.

 

Why don't intake workers start coding/opening segments as soon as they approve cases?

Depending on the circumstances of the case and the procedures necessary to enter the information into the system, it can take an average of three to four days for a segment to be opened after the case has been approved.

 

Does a nursing facility need to complete a Permission to Share Information (PSI) Form pdf format of psi.pdf in order to speak about a member's case or receive information (for example, notices) on the case?

Per MassHealth regulations at , nursing facilities may receive written notices without the need for either Permission to Share pdf format of psi.pdf or an .

Back to "MassHealth Enrollment Center Questions about Long Term Care" Q & A.


This information is provided by MassHealth .