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Beranda / Reviewing Claims to Ensure Appropriate Coding for Deserved Payments Is One Method of

Reviewing Claims to Ensure Appropriate Coding for Deserved Payments Is One Method of

CMS Guidance: Reporting Denied Claims and Meet Records to T-MSIS

Guidance History

Date Description of Change
iii/13/2020 Original guidance issued
5/28/2020 Language added to clarify the compliance appointment to cease reporting to TYPE-OF-Claim value "Z" as June 2021

Brief Consequence Description

Multiple states are unclear what constitutes a denied merits or a denied encounter record and how these transactions should be reported on T-MSIS claim files.

Groundwork Word

Context

Reason Why CMS Wants States to Submit Denied Claims and Encounters

CMS needs denied claims and encounter records to support CMS' efforts to combat Medicaid provider fraud, waste product and abuse. The data are also needed to compute certain Healthcare Effectiveness Information and Information Set (HEDIS) measures. If a claim was submitted for a given medical service, a record of that service should exist preserved in T-MSIS. Information technology does not matter if the resulting claim or encounter was paid or denied.

For additional background, readers may want to review Appendix P.01: Submitting Aligning Claims to T-MSIS in the T-MSIS Data Dictionary, version 2.3.

Definitions

FFS Claim – An invoice for services or goods rendered by a provider or supplier to a casher and presented past the provider, supplier, or his/her/its representative directly to the state (or an administrative services only claims processing vendor) for reimbursement because the service is not (or is at to the lowest degree not known at the fourth dimension to be) covered under a managed intendance organization under the authority of 42 CFR 438.

Managed Care Come across Claim – A claim that was covered under a managed care organization under the authority of 42 CFR 438 and therefore not paid on a fee-for-service basis directly past the country (or an administrative services but claims processing vendor). Encounter records often (though not always) begin as fee-for-service claims paid by a managed intendance organisation or subcontractor, which are then repackaged and submitted to the state every bit come across records.

Arbitrament – The procedure of determining if a claim should be paid based on the services rendered, the patient'south covered benefits, and the provider's authority to render the services. Claims for which the adjudication process has been temporarily put on agree (e.g., pending additional information, correction) are considered "suspended" and, therefore, are not "fully adjudicated."1

Denied FFS Claim 2  – A merits that has been fully adjudicated and for which the payer entity has determined that it is not responsible for making payment considering the claim (or service on the claim) did not meet coverage criteria. Examples of why a claim might be denied:

  • Services are not-covered
  • Casher's coverage was terminated prior to the date of service
  • The patient is not a Medicaid/CHIP casher3
  • Services or appurtenances have been determined not to be medically necessary
  • Referral was required, but there is no referral on file
  • Required prior authorization or precertification was not obtained
  • Claim filing deadline missed
  • Invalid provider (e.g., not authorized to provide the services rendered, sanctioned provider)
  • Provider failed to reply to requests for supporting data (e.m., medical records)
  • Missing or Invalid Service Codes (CPT, HCPCS, Revenue Codes, etc.) which take not been provided after the payer has fabricated a follow-upwards request for the information

The complete list of codes for reporting the reasons for denials can be found in the X12 Claim Adjustment Reason Code prepare, referenced in the in the Health Care Claim Payment/Advice (835) Consolidated Guide, and available from the Washington Publishing Company.

Denied Managed Care Run into Claim – An encounter claim that documents the services or appurtenances actually rendered by the provider/supplier to the beneficiary, but for which the managed care plan or a sub-contracted entity responsible for reimbursing the provider/supplier has determined that it has no payment responsibility.

Challenges

Contractual Scenarios and Their Impacts on the Creation of Denied Claim or Encounter Records

The contractual relationships among the parties in a state's Medicaid/CHIP healthcare system'southward service delivery chain can be complex. For example, the Medicaid/Chip agency may choose to build and administer its provider network itself through simple fee-for-service contractual arrangements. In such an arrangement, the agency evaluates each merits and determines the appropriateness of all aspects of the patient/provider interaction.  Alternatively, the Medicaid/Scrap agency may choose to contract with 1 or more than managed care organizations (MCOs) to manage the care of its beneficiaries and administer the commitment-of and payments-for rendered services and goods. The agency may contract with the prime MCO on a capitated basis, but then the MCO might choose to build its provider network past: subcontracting with other MCOs on a FFS basis or capitated basis, subcontracting with individual providers on a FFS footing or capitated basis, and/or with some other arrangements. Additionally, the structure of the service delivery concatenation is not limited to a two- or iii-level hierarchy.

While the pay/deny decision is initially made by the payer with whom the provider has a direct provider/payer relationship, and the initial payer's decision will generally remain unchanged as the encounter tape moves up the service delivery concatenation, the entity at every layer has an opportunity to evaluate the utilization record and decide on the appropriateness of the underlying beneficiary/provider interaction. Whenever information technology concludes that the interaction was inappropriate, it tin can deny the claim or encounter tape in office or in its entirety and push the transaction dorsum down the bureaucracy to be re-adjudicated (or voided and re-billed to a non-Medicaid/Chip payer). At each level, the responding entity can attempt to recoup its cost if it chooses. If the recoupment takes the form of a re-adjudicated, adapted FFS claim, the adjusted claim transaction will flow back through the hierarchy and be associated with the original transaction. If the denial results in the rendering provider (or his/her/its amanuensis) choosing to pursue a non-Medicaid/CHIP payer, the provider will void the original merits/meet submitted to Medicaid.

The complication of reporting attempted recoupments4 becomes greater if there are subcapitation arrangements to which the Medicaid/CHIP agency is not a straight party. If the agency is the recipient of recouped funds, a T-MSIS financial transaction would be used to report the receipt. If the bureau is not the recipient, there is no budgetary impact to the agency and, therefore, no demand to generate a financial transaction for T-MSIS.

Regardless of the number of levels of subcontracts in the service delivery chain, it is not necessary for the country to report the pay/deny conclusion fabricated at each level. The land should report the pay/deny decision passed to it by the prime MCO. This process is illustrated in Diagrams A & B.

Diagram A: Decision Tree for Reporting Managed Intendance Come across Claims – Provider/Initial Payer Interactions

Diagram A: Decision Tree for Reporting Managed Care Encounter Claims – Provider/Initial Payer Interactions

Diagram B: Decision Tree for Reporting Encounter Records – Interactions Among the MCOs Comprising the Service Delivery Hierarchy

Diagram B: Decision Tree for Reporting Encounter Records – Interactions Among the MCOs Comprising the Service Delivery Hierarchy

CMS Guidance

  1. All claims or encounters that complete the adjudication/payment process should exist reported to T-MSIS. This is true even if the managed care organization paid for services that should not have been covered past Medicaid. See Diagram C for the T-MSIS reporting determination tree.Diagram C: Decision Tree for Answering the Question of Whether to Submit/Not-Submit Claim or Encounter Record to T-MSIS
  2. Suspended claims (i.e., claims where the adjudication process has been temporarily put on hold) should non be reported in T-MSIS. Additionally, claims that were rejected prior to beginning the adjudication procedure because they failed to see basic merits processing standards should not exist reported in T-MSIS.  NOTE: Transactions that fail to process considering they practice not come across the payer's data standards represent utilization that needs to exist reported to T-MSIS, and equally such, the issues preventing these transactions from beingness fully adjudicated/paid demand to be corrected and re-submitted.
  3. All denials (except for the scenario chosen out in CMS guidance detail # 1) must be communicated to the Medicaid/Chip agency, regardless of the denying entity's level in the healthcare organisation's service delivery concatenation.  It volition not be necessary, however, for the land to identify the specific MCO entity and its level in the commitment concatenation when reporting denied claims/encounters to T-MSIS.  Simply reporting that the encounter was denied will be sufficient.
  4. Voids and Adjustments of previously denied claims or encounter records must be communicated to the Medicaid/CHIP bureau (except for the scenario called out in CMS guidance item # 1), so that the Medicaid/Flake agency can include the information in its T-MSIS files.
  5. The Medicaid/CHIP agency must report changes in the costs related to previously denied claims or encounter records whenever they directly touch the cost of the Medicaid/CHIP programme.  Depending on the nature of the payment arrangements among the entities of the Medicaid/Fleck healthcare arrangement's service supply chain, these may accept the form of voided claims (or encounters), adjusted claims (or encounters), or fiscal transactions in the T-MSIS files.
  6. Whenever an entity denies a claim or run into tape, it must communicate the appropriate reason code up the service delivery chain.
  7. The Medicaid/CHIP agency must include the claim aligning reason code that documents why the merits/run across is denied, regardless of what entity in the Medicaid/Bit healthcare arrangement's service supply concatenation fabricated the conclusion.  This lawmaking should exist reported in the ADJUSTMENT-REASON-Lawmaking information element on the T-MSIS claim file.
  8. To the extent that it is the state's policy to consider a person "in spenddown mode" to exist a Medicaid/Bit casher, claims and see records for the beneficiary must exist reported T-MSIS.
  9. Instructions for Populating Data Elements Related to Denied Claims or Denied Claim Lines.
    States' MMIS systems may flag denied claims (or denied claim lines) differently from one another.  Regardless of how a state identifies denied claims or denied merits lines in its internal systems, the land should follow the guidelines below to identify denied claims or denied claim lines in its T-MSIS files.

    CLAIM-DENIED-INDICATOR – If the entire claim is denied, the Claim-DENIED-INDICATOR should be set to "0".  If some, but not all, of the lines on the claim transaction are denied, the CLAIM-DENIED-INDICATOR should exist set to "1".  If none of the lines on the claim transaction are denied, the Merits-DENIED-INDICATOR should be set to "1". The Claim-DENIED-INDICATOR gear up to "0" is the fashion that T-MSIS information users will place completely denied claim transactions.

    CLAIM-LINE-Condition – If a detail detail line on a claim transaction is denied, its Claim-LINE-Condition code should be 1 of the following values: "542", "585", or "654".  Any other value volition be interpreted as indicating a paid line.  If all of the lines on a claim transaction are denied, then the Claim-DENIED-INDICATOR should be set to "0", rather than setting each line'south Claim-LINE-STATUS to 1 of the denied code values ("542", "585", or "654").

    CLAIM-Condition – Logically speaking, if the CLAIM-DENIED-INDICATOR equals "0" (the unabridged claim is denied), one would await the CLAIM-Condition code information element to equal one of the following values: "542" (Claim Total Denied Accuse Amount), "585" (Denied Charge or Non-covered Charge), or "654" (Full Denied Accuse Corporeality).
    An inconsistency between the CLAIM-DENIED-INDICATOR value and the Claim-STATUS value will trigger a validation edit error.
    Delight note, notwithstanding, that T-MSIS data users will use Claim-DENIED-INDICATOR equals "0" to identify a completely denied claim transaction, regardless of the Claim-Condition value reported on the claim transaction'south header record.

    CLAIM-Status-CATEGORY – Logically speaking, if the CLAIM-DENIED-INDICATOR equals "0" (the entire merits is denied), 1 would expect the Claim-STATUS-CATEGORY value to equal "F2" (Finalized/Deprival-The claim/line has been denied).
    An inconsistency between the CLAIM-DENIED-INDICATOR value and the CLAIM-Status-CATEGORY value will trigger a validation edit error.
    As is the case with CLAIM-Status, however, T-MSIS data users will use Claim-DENIED-INDICATOR equals "0" to place a completely denied merits transaction, regardless of the CLAIM-STATUS-CATEGORY value reported on the claim transaction'due south header record.

    Blazon-OF-Merits – Type-OF-Merits value "Z" should non be used.
    Use of the Type-OF-CLAIM value "Z" will trigger a validation edit fault.
    States will exist required to stop reporting to value "Z" by June 2021. After that betoken, any files non corrected may exist required to be resubmitted.
    The TYPE-OF-CLAIM code should be the code that would have been used if the claims were paid.

[1] Suspended claims are not synonymous with denied claims.  The responsibility-for-payment decision has not however been made with regard to suspended claims, whereas it has been made on denied claims.  Suspended claims should not exist reported to T-MSIS.  NOTE: Paid encounters that do non see the country'south data standards represent utilization that needs to be reported to T-MSIS.  EDI issues preventing these transactions from being fully adjudicated/paid need to exist corrected and re-submitted to the Payer.

[2] A denied merits and a zero-dollar-paid claim are not the same thing.  While both would accept $0.00 Medicaid Paid Amounts, a denied merits is i where the payer is not responsible for making payment, whereas a nada-dollar-paid claim is one where the payer has responsibleness for payment, only for which it has adamant that no payment is warranted.  (Examples include: previous overpayments start the liability; COB rules result in no liability.)

[3] If the payer entity determines during the arbitrament process that it has no payment responsibleness because the patient is not a Medicaid/CHIP beneficiary, it is not necessary for the country to submit the denied merits to T-MSIS. However, if the payer initially makes payment and then later on determines that the beneficiary is not a Medicaid/CHIP beneficiary, then CMS expects the claim to be reported to T-MSIS (as well equally any subsequent recoupments).  (Run into footnote #iv for a definition of "recoupment.")

[4]"Recoupment" means:

  • Recoveries of overpayments made on claims or encounters.
  • TPL recoveries that beginning expenditures for claims or encounters for which the state has, or will, request Federal reimbursement nether Championship Xix or Title XXI.
  • Rebates that offset expenditures for claims or encounters for which the state has, or will, request Federal reimbursement nether Title XIX or Championship XXI.

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Source: https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/53973