Pennsylvania PROMIS e October10, 2003

Transcription

1 Pennsylvania PROMISe

2 Topics What s PROMISe Why Change What s Changing Initial Provider Training Public Awareness Questions 2

3 What s PROMISe? Provider Reimbursement and Operations Management Information System (PROMISe): Is a new claims processing system that will support Medicaid and non-medicaid (human/social service) programs Replaces MAMIS Will be implemented in March

4 Why Change? Incorporate claims processing needs of non-medicaid programs Enhance support for providers and managed care organizations Comply with HIPAA Improve access to program information Replace dated technology Enhance system maintenance capabilities 4

5 What s Changing? New Provider Identification Logic New Provider Type Matrix include Specialty & Sub-specialty PROMISe System is Windows based Combination of Fee-for-Service claims & Encounter Data HIPAA compliant invoicing includes standard codes sets 5

6 What s Changing (cont.) New Fraud & Abuse Detection System (FADS) that will link all databases Master Provider Index (MPI) holding base authorization of all Providers for the Dept of Public Welfare (interface w/ PROMISe) Interface with HCSIS (Home & Community Services Information System) 6

7 Information returned by EVS Enhancements come with PROMISe TM OLD Single Date of Service Request MCO with PCP (if available) FCN with no other information 7 NEW Date Range back 2 yrs from current date. Detail information provided. Check coverage of Service or Drug (not available on Voice access) in Feefor-Service coverage Date segments of MCO w/ PCP for individual dates of coverage Date segments of Family Care Network (FCN) w/ PCCM for individual dates of coverage Last date of EPSDT screening and/or dental exam

8 Changes for Provider Identification - Item OLD NEW Provider # Provider Type Address Codes 8 digit Medical Assistance Provider # 2 digit type assigned by service or program participation 2 digit code assigned for address 9 digit PROMISe Provider # 2 digit type assigned by service provided; Specialty & sub- Specialty (3 digit each) 4 digit Service Location based on Provider Type and servicing address See Handout 8

9 PROMISe PROMISe Project Provider Number (1 or more) Certificates (not CLIA) (1 or more) Provider Program Eligibility (such as Fee for Service, Managed Care, Crossover, SPBP, HCSIS to be further defined) (Many to many) (1 or more) Service Location (Only 1) Provider Type (1 or more) Specialty Subspecialty (Only 1) (Optional) License (Recipient/Reference Subsystems) Recipient Service Program (such as HCBP 1, HCBP 2, PDA Waiver, SPBP, Behavioral Health, Physical Heath being defined) One Provider Number can have many Service Locations One Service Location can have only one Provider Type One Service Location can have many Certifications (not CLIA) One Service Location may have more than one CLIA certifications One Service Location can have many Provider Eligibility Programs One Provider Type can have multiple Specialties (but must have at least one) One Specialty can have many Subspecialties (or none) The Provider Type may have one License number 9

10 PROMISe TM Claim Types PAPER CMS-1500 ADA v UB-92 ELECTRONIC 837 Dental 837 Professional 837 Institutional NCPDP Pharmacy Interactive NCPDP Pharmacy Batch 10

11 Providers using electronic claims submission must comply with all HIPAA electronic submission (appropriate 837) criteria; including submission of Eligibility Verification System inquiries/responses (270/271 format) HIPAA information available at 11

12 How will claims be submitted electronically? Diskette CD FTP (for MCOs only) Tape Bulletin Board Internet 12

13 Will there be invoicing changes? Outpatient Hospital Claims paper claims changed from CMS-1500 to UB-92 LTC - paper claims changed from PA proprietary form to UB-92 13

14 Will There Be Invoicing Changes? Drug Claims must be submitted electronically. Includes claims submitted by pharmacies, physicians, and CRNPs. Pharmacies submit using NCPDP format, physicians and CRNPs use 837P Provider Electronic Solution Updated to support PROMISe changes 14

15 Invoice Processing - Invoice types Procedure Codes PROMISe Project Item OLD NEW Proprietary invoices made available Local codes for some services and items HIPAA standard invoices (paper) CMS 1500 ADA v2000 UB 92 Mostly standardized code sets still in development Invoice submission Paper and electronic Paper, electronic and Internet Internet use will require use of PIN and Password 15

16 Will There Be On-Line Adjudication? PROMISe adjudicates claims as they are submitted on-line, real time No separate daily and weekly editing Number of edits will increase to approximately 1700 Reimbursement process through Treasury will continue as is Claim status will be available via the Internet 16

17 How Will RAs Change? Twenty-four months of paper image RA history is available via the Internet Providers can elect to receive RAs electronically no paper Format will remain the same 17

18 Provider Internet Access Main Menu 18

19 PROMISe Project This is an entry window that allows the Provider to submit claims online or do Inquiry functions. Provider chooses the appropriate HIPAA electronic claim type. 19

20 PROMISe Project HIPAA Professional Invoice 20

21 Provider Claim Inquiry Internet 21

22 PROMISe Project Result of Claims search 22

23 This screen allows the Provider to request RAs for a certain date range. By clicking on the blue date, you can download a copy of the actual RA. 23

24 PROMISe Project HIPAA Compliant EVS transaction 24

25 New Information New PROMISe Provider Enrollment form on the OMAP Internet site on 12/1/03 New PROMISe Provider Numbers will be issued mid-january, 2004 Simultaneous conversion to PROMISe EVS system on 2/19/04 25

26 Initial Provider Training WHERE: 304 Regional training sessions throughout the Commonwealth WHEN: October 14, 2003 through February 19, 2004 HOW: Workshops (face-to-face) & e- Learning course available on the web at promise.dpw.state.pa.us (no www ) PROMISe Provider Training Announcement Pamphlet mailed 9/15/03 Internet registration at 26

27 Public Awareness Meetings with Provider Associations Remittance Advice Messages Messages on Provider Inquiry Lines DPW Internet Site ( 27

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