Mar 15, 2021 —
Paramount Insurance Company Claims Payment Systemic Errors (CPSE) March 15, 2021 The current Claims Payment Systemic Errors (CPSEs) for Paramount Advantage Medicaid are reported below. If you have any questions, please contact your Provider Relations Representative or call Provider Relations at 800-891-2542. Date CPSE Number of was First Billing Provider Type(s) Impacted by Claims Description of CPSE Identified CPSE (select all that apply) Timeline for Fixing CPSE Date(s) and/or date span(s) of Corrected Claims Adjustments Impacted CONFIRMED CPSE. In ODM BH Redesign, SUD 12/23/19 95-ODADAS Certified/Licensed (SUD) Treatment Due to system limitations, this will Claims will be monitored on a weekly basis and adjustments processed manually. Initial Residential H2034, H2036 the Authorization Program continue to be a manual process, with adjustments were completed 2/20/20. The most recent adjustments were completed Requirement is as follows: In a Calendar year, Up to 30 consecutive days without prior authorization. Prior authorization then must support the medical necessity of continued stay, if not, only the initial 30 consecutive days are reimbursed. Applies to first two claims reviewed on a weekly basis. 1/12/21, 2/2/21, 2/19/21 and 3/9/21. Effective with dates of service 6/1/21, this issue may be resolved with implementation of new claims processing application. Final testing has not been completed at this time. stays; any stays after that would be subject to Paramount will monitor claim denials full prior authorization. Paramount does not have configuration to monitor this, so claims have been reviewed retrospectively, and identified for take back and denial for no prior authorization. through dates of service 5/31/21. CPSE Status Ongoing CONFIRMED CPSE: A provider was put on review to deny claims for medical record review (EM denial). If a practioner who affiliated with this provider also practices elsewhere, those claims are also denying. 2/19/20 CONFIRMED CPSE: Some providers were not 4/3/20 updated correctly in the claims processing system to show their participating status. This caused some claims to deny based on Reimbursement Policy RM-001, which requires prior authorization from nonparticipating providers. Multi-departmental team is working on a network analysis to compare the provider status in the credentialing application with provider status in the claims system. As provider status is updated in the claims processing system, claims denied in error will be adjusted. CONFIRMED CPSE: COVID-19 telehealth claims billed with modifier 95, GT, and GQ denied in error. 5/21/20 95-ODADAS Certified/Licensed (SUD) Treatment Program 46-Ambulatory Surgery Center 20-Physician/osteopath, individual 24-Physician Assistant 36-Podiatrist Individual 35-Optometrist Individual 01-Hospital (IP & OP) 21-Professional Medical Group Effective with dates of service 6/1/21, This issue has been finalized. Claims were reviewed and adjusted on a weekly basis. Final we expect this issue to be resolved with adjustment timeline is 2/24/20-1/4/21. implementation of new claims processing application. Paramount will monitor claim denials through dates of service prior to 6/1/21 on a weekly basis. On 3/2/21 it was confirmed that fix installed on 11/16/20 resolved this issue for new claims. All claims that were received prior to the fix date have now been adjusted. Project to review and update providers This project has been finalized. Claims were reviewed and adjusted on a weekly basis. Final was completed on 7/27/20. adjustment timeline is 4/30/20-2/5/21. 4124 560 Complete Complete 50-Clinic 12-Federally Qualified Health Center 01-Hospital (Outpa ent) 37-Licensed Independent Social Worker (LISW) 41-Occupa onal Therapist, Individual 39-Physical Therapist, Individual 24-Physician Assistant 20-Physician/osteopath, individual 36-Podiatrist Individual 42-Psychologist, Individual 21-Professional Medical Group System configuration was updated on 6/1/20. Additional configuration updates were made for institutional claims on 10/15/20. Final adjustments were completed 2/4/21-2/5/21. Entire adjustment timeline is 6/26/202/25/21. 8349 Complete Page 1 Updated 3/12/2021 Paramount Insurance Company Claims Payment Systemic Errors (CPSE) March 15, 2021 The current Claims Payment Systemic Errors (CPSEs) for Paramount Advantage Medicaid are reported below. If you have any questions, please contact your Provider Relations Representative or call Provider Relations at 800-891-2542. Date CPSE Number of was First Billing Provider Type(s) Impacted by Claims Description of CPSE Identified CPSE (select all that apply) Timeline for Fixing CPSE Date(s) and/or date span(s) of Corrected Claims Adjustments Impacted CONFIRMED CPSE: A provider was put on 6/15/20 95-ODADAS Certified/Licensed (SUD) Treatment The implementation date for the new Adjustments will be ongoing and processed manually on a weekly basis. Timeline for ODM's sanctioned list. (HQ denial). If a Program system has been updated to 6/1/21. adjustment project is 7/16/20 - until all claims are received for dates of service through practioner who works at that provider practices elsewhere, those claims also deny. Paramount will continue to monitor claim denials for all dates of service prior to the system changeover. 5/31/21 in old system. Most recent adjustments were processed 2/3/21 and 2/19/21. CPSE Status Ongoing CONFIRMED CPSE: A programming job is 7/21/20 unlocking some claims allowing them to pay before vendor edits are returned and applied to claim. PROVIDER NOTIFICATION: There is a 8/20/20 software issue with EAPG version 3.14. Lower leg diagnosis codes incorrectly assign to the wrong EAPG when billed as the principal diagnosis. CONFIRMED CPSE from RX vendor CVS: Correct date is Tresiba, Tacrolimus, Pimecrolimus, and 9/29/2020. Symlin prescription step therapy claims were January report paying in error for members whom had no had incorrect historical fills date. POTENTIAL CPSE: On 6/11/20 MUE edits were moved into production. This update caused duplicate edits to be turned off in bundling software. NOT CPSE: This was determined not to be a CPSE. Duplicate edits were applied. 10/5/20 70-Pharmacy 20-Physician/osteopath, individual 24-Physician Assistant 76-Durable Medical Equipment Supplier 21-Professional Medical Group 01-Hospital (Outpatient) 70-Pharmacy 00-All provider types This project is now in the final testing phase with IT. Expected to be moved into production the week of 3/22/21. Refunds requests from initial report were sent 7/28/20-9/18/20. In Process At the earliest, this issue is expected to Adjustment project will be initiated after final updates have been received. be addressed/fixed with the release of EAPG Grouper 3.16 in 2021. n/a In Process Corrected on 10/06/20 Further analysis determined the impact was much smaller than originally believed due to 1060 Complete PA's or transition fill logic applying to many of previously identified claims. Number of claims Updated to 155 updated. Invoice credits were applied to client's March month-end admin fee invoice. n/a No claims required adjustment. n/a Complete CONFIRMED CPSE: Effective 3/9/20, ODM 12/1/20 Behavioral Health providers cannot bill place of service 02 for telehealth services. Some claims paid when they should have denied. 84-Ohio Department of Mental Health (Community System updates were completed Mental Health) Provider 12/30/20. 95-ODADAS Certified/Licensed (SUD) Treatment Program Adjustments were completed on 1/13/21. Refund requests were sent 1/18/21. 3642 Complete CONFIRMED CPSE: Effective 11/15/20, ODM 9/16/20 Telehealth Guidelines state the GT modifier must be included on telehealth claims. Place of service 02 no longer accepted, except on home health claims. Claims were paid when they should have denied. 21-Professional Medical Group 12-Federally Qualified Health Center 37-Licensed Independent Social Worker (LISW) 05-Rural Health Clinic System updates completed 12/30/20. Adjustments were completed 2/17/21. Refund requests were sent 2/26/21. 5156 Complete CONFIRMED CPSE - Some coding vendor denial codes were not reapplied to claims that were processed through batch adjustment. CONFIRMED CPSE - From 3/9/20-11/25/20 CPT code 97110 was mapping to telehealth benefits for services delivered by chiropractors. Some claims paid that should have denied. POTENTIAL CPSE: Claims approved on an exception basis after medical record review re-deny due to Medical Policy programming edits. 11/19/20 11/25/20 10/14/20 82-Ambulance 01-Hospital (Inpa ent) 12-Federally Qualified Health Center 21-Professional Medical Group 27-Chiropractor Individual 21-Professional Medical Group System update completed 11/23/20. Adjustments were completed on 1/25/21. Configuration was updated on 11/25/20. Adjustments were completed on 1/12/21. Refund requests were sent 1/15/21. IT is scheduled to begin the testing phase for this project the week of 3/15/21. Adjustment project will be completed within 60 days of system updates. 94 Complete 180 Complete In Process Page 2 Updated 3/12/2021 Paramount Insurance Company Claims Payment Systemic Errors (CPSE) March 15, 2021 The current Claims Payment Systemic Errors (CPSEs) for Paramount Advantage Medicaid are reported below. If you have any questions, please contact your Provider Relations Representative or call Provider Relations at 800-891-2542. Date CPSE Number of was First Billing Provider Type(s) Impacted by Claims Description of CPSE Identified CPSE (select all that apply) Timeline for Fixing CPSE Date(s) and/or date span(s) of Corrected Claims Adjustments Impacted POTENTIAL CPSE - Some claims for dialysis 11/11/20 59-End-Stage Renal Disease (Dialysis) Clinic Fee schedule was updated on 12/16/20. Adjustments were completed on 1/21/21. 6 services billed with CPT 90989 were not paid at the correct rate. NOT CPSE: This was determined not to be a CPSE - only 6 claims. POTENTIAL CPSE - Some Behavioral Health services that should have paid under EAPG 12/8/20 01-Hospital (Outpatient) Optum update was moved into production on 9/28/20. Adjustments are expected to be completed 3/15/21-3/19/21. pricing methodology were denied. NOT CPSE: This was determined not to be a CPSE- only 6 providers impacted. Investigation determined the issue is that some CPT codes on the 7/1/20 covered code listing were retroactive to 1/1/20. These codes were not included in Optum update until 9/28/20. CPSE Status Complete In Process CONFIRMED CPSE: Beginning 1/5/21, claims from the COVID-19 emergency period from non-par providers denied for no precertification upon adjustment. 1/21/21 21-Professional Medical Group 59-End-Stage Renal Disease (Dialysis) Clinic 44-Hospice Completed 1/25/21. Adjustments were completed on 1/26/21. 38 Complete CONFIRMED CPSE: Immunization claims 2/3/21 processed 11/5/20-2/3/21 mapped to an incorrect fee schedule causing overpayments. CONFIRMED CPSE: Some claims to denied KN 7/28/20 due to MUE edits set to 0 in Claim Check. 10/16/20 3/15/21 REOPENED PRIOR CPSE: There was a subset of codes that still denied after 9/3/20 system update. 21-Professional Medical Group 12-Federally Qualified Health Center 21-Professional Medical Group 05-Rural Health Clinic Completed 2/3/21. Adjustments were completed 2/9/21. Refund requests were sent 2/26/21. Configuration was updated on 8/4/20. Additional configuration updates were moved to production on 9/3/20. 3/15/21 update: Configuration update was completed on 11/24/20 for the subset of codes still denying and final testing was completed on 1/26/21. Adjustments for initial project were completed 9/9/20-9/10/20. Adjustments for updated subset of codes were completed on 3/1/21-3/2/21. 2706 Complete 5594 in 2020 124 in 2021 5718 total Complete CONFIRMED CPSE: Claims billed for CPT 2/8/21 90785 denied for invalid place of service (FO) when they should have paid. CONFIRMED CPSE: Claims billed for CPT 2/8/21 90785 with modifier GT after date of service 11/15/20 denied as service not appropriate with video service (IE) when they should have paid. CONFIRMED CPSE - Telehealth office visit 1/8/21 claims for non-par providers were paid without prior authorization for dates of service 7/1/20 and after. CONFIRMED CPSE: Optum updates for the 1/14/21 2021 Covered Codes Listing (including COVID testing U0005) were not moved into production until 2/2/21. 84-Ohio Department of Mental Health (Community Completed 2/8/21. Mental Health) Provider 95-ODADAS Certified/Licensed (SUD) Treatment Program 01-Hospital (Outpa ent) 21-Professional Medical Group 84-Ohio Department of Mental Health (Community Projected date is 3/19/21. Mental Health) Provider 95-ODADAS Certified/Licensed (SUD) Treatment Program 37-Licensed Independent Social Worker (LISW) 21-Professional Medical Group 21-Professional Medical Group Completed 2/1/21 01-Hospital (Outpatient) Completed 2/2/2021 Adjustments expected to be completed between 3/18/21-4/15/21 Adjustment project will be completed within 60 days of system updates. Refund requests are estimated to be sent 3/25/21-5/25/21. Adjustments are estimated to be completed 3/15/21-4/2/21. In Process In Process In Process In Process Page 3 Updated 3/12/2021 Paramount Insurance Company Claims Payment Systemic Errors (CPSE) March 15, 2021 The current Claims Payment Systemic Errors (CPSEs) for Paramount Advantage Medicaid are reported below. If you have any questions, please contact your Provider Relations Representative or call Provider Relations at 800-891-2542. Date CPSE Number of was First Billing Provider Type(s) Impacted by Claims Description of CPSE Identified CPSE (select all that apply) Timeline for Fixing CPSE Date(s) and/or date span(s) of Corrected Claims Adjustments Impacted CONFIRMED CPSE: 2020 professional and 1/25/21 21-Professional Medical Group Completed 2/12/21 Adjustments are estimated to be completed 3/25/21-4/13/21. technical rates were reversed for some CPT codes when loaded into the system. CPSE Status In Process POTENTIAL CPSE: Claims billed with modifiers 1/27/21 were underpaid for Nurse Practitioners due to a qualifier setting in the Medicaid pay class. POTENTIAL CPSE: Codes 0047U, 0097U, 3/10/21 G0480-G0483, and V2531 were on the 2021 ODM covered code list. Denial explain codes were not removed from code set up when fees were loaded which caused claims to deny. 72-Nurse Prac oner Individual 21-Professional Medical Group 21-Professional Medical Group 80-Indepedendent Laboratory Completed 1/27/21 Completed 3/10/21 Adjustments are expected to be completed 3/25/21-4/25/21. Adjustments are expected to be completed 3/25/21-4/25/21. In Process In Process Page 4 Updated 3/12/2021Microsoft: Print To PDF