Go-Live 2011! Release Date: 02/14/2011. MITS Go-Live Coming Soon. What is MITS? Provider Information Release # 8.0. Subject: MITS Implementation

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1 Subject: MITS Implementation Go-Live 2011! MITS Go-Live Coming Soon We are pleased to announce that the newmedicaid Information Tecnology System (MITS) implementation will go live in It is important for all providers to make sure they are prepared for the implementation of MITS. Ohio Medicaid has seen many changes since November 2010 such as: November 5, 2010 The Ohio Department of Job and Family Services (ODJFS) announced the extension of the MITS implementation. January 10, 2011 John Kasich was sworn in as the new Governor. January 13, 2011 John McCarthy was named the new Medicaid Director. With these changes and many other staffing changes taking place, we want to assure you that MITS will be implemented in a timely manner. You should continue to prepare your organizations, members and staff for the transition from the current Medicaid Management Information System (MMIS) to MITS. ODJFS, along with our partner, HP, continues to move forward. We are working diligently to ensure that the components of MITS will support the needs of our consumers and providers. Due to the complexity of MITS, we are closely monitoring our progress toward achieving consistent results using readiness criteria to ensure a successful implementation and federal certification. A new implementation or Go-Live date will be identified and announced once all readiness criteria have been met, and our state partners and ODJFS staff are satisfied that the new system is completely functional. The following information is a summary of what has been given to providers in previous publications, communications through the ODJFS Web site, and association meetings. It was also given to providers in training sessions running from September through December We feel it is important to review this information with you again as we prepare for the implementation of MITS. ODJFS will continue to provide progress reports and information as it becomes available. What is MITS? MITS is the Medicaid Information Technology System, a Web-based system that will replace the current MMIS. MITS design is based on the Medicaid Information Technology Architecture (MITA). It will meet the new standard model set by the Centers for Medicare and Medicaid Services (CMS), which every state Medicaid system must comply. One of the great features of MITA is it allows for better data exchange between internal state organizations, other states, and federal and other healthcare partners. MITS will operate in a.net environment, which will allow for processing of transactions in real time. In addition to providing information that is timely and accurate, the.net environment is a more up-to-date CCR_8 0_11_Go_Live_Soon.doc Page 1 of 18

2 development platform, which will make the system more flexible and easier to adapt to the many changes that continue to occur in the Medicaid world. What are the MITS Web Portal Minimum Requirements? To access the new MITS Web Portal, you will need: An Internet connection that includes a desktop Windows environment with browser capability for easy navigation (high speed access works best); Internet Explorer versions or Firefox version ; A unique log-on ID and personal identification number (PIN); and An address for use during account setup. We recommend you turn off your pop-up blocker functionality as the new MITS Web Portal has pop-up features you will want to access. For example, clicking on a third-party liability carrier name will give you a pop-up box with the carrier number, mailing address and phone number. Checking a recipient s eligibility for managed care will give you a pop-up box with the managed care provider ID, mailing address and e- mail address. Other search functions in MITS will provide pop-up boxes, as well. Please note that information will be relayed back to you only if it is available in MITS. Log On Access to the New MITS Web Portal Note: Current Ohio Medicaid providers will not receive a letter with new log-on IDs. If you are a current Medicaid provider, you will use your current billing provider number to set up your new account in the secure MITS Web Portal. The initial password will be the provider s Social Security Number or Employer Identification Number. Each organization or billing National Provider Identifier (NPI) needs to determine who will be its account manager, or administrator. Staff members will need to be notified of the decision so that other individuals do not try to set up an NPI billing account for the same organization. See the account setup steps below. Many providers have asked if they need to re-enroll with a new provider contract in order to access the MITS Web Portal. The answer is NO. If you have a contract and are a current Medicaid provider, you do not need to re-enroll as a provider in order to have access to the MITS Web Portal. All of your provider contract information will be transferred to the new MITS. You will only need to set up your new account for access to the secure MITS Web Portal. The MITS Web Portal secure site uses role-based security to grant access to the different areas available within the portal. Each provider number will have a corresponding administrator who will maintain that account. The administrator's responsibilities will include maintaining provider demographics and account access, defining who has access to the secure MITS Web Portal, and defining what their level of access will be. The individuals given account access by the administrator are referred to as agents. There are three steps to setting up an account and defining account access: 1. Provider Account Setup: The administrator must set up his or her own account for the organization s billing NPI. CCR_8 0_11_Go_Live_Soon.doc Page 2 of 18

3 2. Agent Account Setup: The person who needs access to that account must set up his or her own agent account. Once the agent creates the account, he or she will provide an agent name or agent log-on ID (not password) to the account administrator. Note: Billing agencies are agents that provide a service to the provider. 3. Assigning Roles to Agents: After agents have set up their accounts, then the account administrator will attach specific roles to each agent's account. The administrator will decide the appropriate roles to assign based on the agent s function. Because the MITS Web Portal is Web-based, it is important for administrators to revoke access when an agent s job functions change or when that agent is separated from your employment. All access can be revoked at one time, or individual roles can be added or deleted as necessary. Billing agencies will need to advise providers when an agent leaves their employment, so the administrator can remove that agent s access from the billing account. Step-by-step instructions for Provider Account Setup, Agent Account Setup, and Assigning Roles to Agents can be found in the Online Web Portal User Manuals, which are posted on the ODJFS Web site. Additional information is also provided in a Special Release titled Early Registration, dated 11/01/2010, at Note: Passwords to the MITS Web Portal will expire every 30 days! Provider Information Access for All Providers One important new feature is that all providers will have access to the MITS Portal, including institutional and dental providers. MITS provides a lot of new, up-to-date and enhanced functionality for both state staff and providers. As indicated, institutional providers (UB04), physicians and practitioners (CMS 1500), and dental providers (ADA 2006) will all have access to the new MITS Web Portal. In MITS, claims can be submitted, adjusted, copied or viewed, and attachments can be uploaded as electronic files. Common claim errors will be identified up front so that providers can make needed corrections at the time of claims submission. Providers can obtain claim status for all submitted claims, whether billed on paper, through an electronic data interchange (EDI) process or through the MITS Web Portal. This will eliminate the guesswork of when claims will be paid. These changes and upgrades offer many improvements in efficiency, administrative costs and timeliness. National Provider Identifier (NPI) When MITS goes live, the typical provider must use NPIs in any claim field that requires provider identification (e.g., referring provider, attending provider, operating provider). Claims submitted without an NPI, as well as claims submitted with the generic provider ID number , will be denied. CCR_8 0_11_Go_Live_Soon.doc Page 3 of 18

4 Providers that furnish only non-health-care services are not required to obtain an NPI. We call these atypical providers, and they can continue to submit claims with only their 7-digit legacy Medicaid provider ID number. An atypical provider that has obtained a NPI, however, must use it on claims. Rendering Provider, Billing Provider As MITS processes professional claims, it looks for a relationship a link between the billing provider and the rendering provider. This link is important for Medicaid providers that may submit claims on behalf of their affiliated practitioners, such as hospitals, ambulatory surgery centers (ASCs), hospices and group practices. ODJFS will be activating a rendering provider pay to edit feature. Information has previously been sent to providers and associations urging providers to make sure their affiliations are correct and up to date prior to Go-Live. If claims are now denying, you will need to do that now in order for your claims to process and pay. To record or update practitioner affiliations with a hospital, ASC, hospice, or professional medical or dental group, complete form JFS 06777, Group Practice Provider Information, which can be obtained at the ODJFS Forms Central Web site, Submit the form in one of three ways: 1. Mail it to: ODJFS Provider Enrollment Unit, P.O. Box 1461, Columbus, OH Fax it to: Attach it to an message addressed to: Medicaid_provider_update@jfs.ohio.gov. Be sure to write JFS 06777, Group Practice Provider Information in the subject line. Provider Enrollment New applicants looking to enroll for the first time as Ohio Medicaid providers must use the MITS Web Portal provider application process. Existing providers that are required to re-enroll as contracted providers must do so through the MITS Web Portal by their scheduled due dates. Notices will be sent approximately 120 days in advance of the contract end date. Trading partners, subrecipient state agency providers and other entities that do business with Medicaid also will enroll through the online application process. Please note that paper applications will not be accepted after the MITS Go-Live date. New applicant provider enrollment will be available only via the MITS Web Portal. If a new provider applicant sends in any kind of paper enrollment packet, it will be returned. The paper application forms that are currently posted on the Web will be removed, and providers will not have access to them. The new MITS Web Portal will allow providers to do the following: Submit new provider applications; Attach documents; Quickly check the status of new applications by entering an application tracking number; CCR_8 0_11_Go_Live_Soon.doc Page 4 of 18

5 Complete the application at a later date and time if the process is interrupted. Providers may take up to three days to make updates and complete their applications; and Validate their information through self-service tools. The MITS Web Portal will also: Check for duplicate enrollment applications and status; Screen for required data, such as NPIs, tax IDs and CLIA numbers; Ensure providers are qualified to render services by screening applicants for state licensure, certification, and specialty and sub-specialty certification; Verify provider status with internal and external entities; and Facilitate and increase the efficiency of the provider enrollment process. ODJFS Trading Partners Information for trading partners regarding any updates they need to make prior to MITS implementation will be available in the companion guides. Companion guides for the 835 process, as well as other EDI transactions, are available online. The 835 EDI remittance advices will continue to be sent once a week. For the current companion guides and all the latest updates and news for trading partners, go to General Information New Control Numbers In MITS, the internal control number (ICN) replaces the transaction control number (TCN), and all claims will be assigned an ICN for tracking. Initially, three years of history have been transferred to MITS, and another four years will be added sometime after Go-Live. The new ICN is 13 digits, vs. 17 digits for the TCN. Sample ICN: Region Code Calendar Year Julian Day Claim Type/Batch Number Number of Claim in Batch The region code on a claim can tell a provider many things, mainly how the claim was submitted. The following primary region codes indicate new claim submissions: 10 Paper Claim without Attachment 11 Paper Claim with Attachment CCR_8 0_11_Go_Live_Soon.doc Page 5 of 18

6 20 Electronic 837 without Attachment 21 Electronic 837 with Attachment 22 MITS Web Portal without Attachment 23 MITS Web Portal with Attachment The following primary region codes indicate either that the state has initiated a mass adjustment (codes 52 55) or that the provider has initiated an adjustment (codes) 50,51,56,57 and 58: 50 Adjustment Non-Check-Related 51 Adjustment Check-Related 52 Mass Adjustment Non-Check-Related 53 Mass Adjustment Check-Related 54 Mass Adjustment Void Transaction 55 Mass Adjustment Provider Retro Rates 56 Adjustment Void Non-Check-Related 57 Adjustment Void Check-Related 58 Adjustment Internet Claims A MITS ICN Information handout is available for use as a desk reference. It can be found at under Other MITS Handouts. Attachment Formats For claims that require an attachment, the following are acceptable file formats: bmp doc gif jpg mdi pdf ppt tiff txt xls The size for each attachment must be less than 50 MB, with a maximum number of 10 attachments per submission. Electronic Fund Transfer (EFT) Providers that are currently receiving EFT payments will continue to do so. All current provider EFT information has been transferred into MITS. There are no changes to this process, and Ohio Medicaid will continue to make weekly EFT payments dependent upon transactions made during the weekly financial cycle. CCR_8 0_11_Go_Live_Soon.doc Page 6 of 18

7 Recipient Eligibility Timely, accurate, current and historical eligibility and demographic information for Medicaid recipients will be available in MITS and the MITS Web Portal. Within MITS, the benefit plan determines the services that a consumer may receive, as well as the services that ODJFS has authorized a provider to provide according to state policy. When it comes to checking eligibility, MITS has many new features. For example, it will now be possible to see if someone has exhausted benefit limitations or is on a Medicaid HMO. Information will be provided in real time. However, the basics of eligibility checking will continue in MITS as it has in the past. MITS will obtain a nightly feed of all client eligibility information from the Client Registry Information System-Enhanced (CRIS-e), the online database that supports the processing of Ohio s cash and food assistance, Medicaid and related programs. If the information is incorrect in CRIS-e, then it will also be incorrect in MITS. MITS will also track eligibility data received from the Statewide Automated Child Welfare Information System (SACWIS). Providers may access recipient eligibility information in three ways: the MITS Web Portal, the Interactive Voice Response (IVR) system and a 270/271 HIPAA transaction. The IVR and the MITS Web Portal provide access to recipient eligibility information 24 hours a day, 7 days a week. To verify eligibility, a provider must enter the recipient s Medicaid ID number or Social Security Number, date of birth and date of service. When eligibility is checked through the Web Portal, the following information will be displayed, if it is applicable to the recipient: Benefit/Assignment Plan Medicare Level of Care Patient Liability Determination Service Limitation Lock-In Special Program (Waiver) Long-Term Care Facility Third-Party Liability Placements Managed Care Medicaid Spenddown Available Income Information When the MITS Web Portal is used to verify a recipient's eligibility the monthly patient liability amounts will be shown on the Patient Liability panel. Please Note: The information returned will be based upon the eligibility search date. For example, if a provider checks a recipient's eligibility in December for the month of October, information from September and November will not be included in the search results returned. CCR_8 0_11_Go_Live_Soon.doc Page 7 of 18

8 For more detailed information about eligibility checking in MITS, please read Provider Information Release # 6, which can be found on the ODJFS Web site at Electronic Document Management System (EDMS) EDMS will reduce the volume of paper that is currently being managed as a result of traditional manual processes. By using scanner technology, EDMS facilitates more efficient automated processing and storage of documents. This process will result in quicker resolution of problems that require research, as well as easier storing of required information, such as attachments needed for provider enrollment and claims processing. You will see several references to the EDMS cover sheet throughout this release. This form may be used to mail attachments that you are unable to upload electronically during the provider enrollment, prior authorization requests and claims processing. The EDMS cover sheet is required for mailing attachments; you will be prompted to print it when necessary. Instructions for mailing are on the EDMS form. MITS will automatically join your attachment(s) to the claim, prior authorization or provider enrollment application when it is received at ODJFS using the information supplied on the form by the provider. Claim Information Below is a review of some information we think will help you achieve more accurate and timely claims submission and processing. Additional information can be found in Provider Information Release # 3, on the ODJFS Web site at With the MITS implementation, Ohio Medicaid providers are encouraged to go paperless. For those that currently bill through electronic data interchange (EDI), remember that the new MITS Web Portal is just another tool to supplement your current practice management system. All information will be entered into the portal through a direct data entry process. It is free to everyone, but it is just a small part of MITS functionality. Critical Cutoff Dates The new system is large and complex, and the process of starting it up may require circumstantial schedule adjustments. Specific cut-off dates have not yet been decided, but will be announced prior to Go-Live. During this conversion, Medicaid will stop processing certain types of paper-based transactions submitted directly to ODJFS. This cut-off action is being taken for two reasons: 1. Several claim formats are being discontinued or replaced. The outdated claim forms cannot be processed in MITS. 2. Time must be allowed for current paper transactions to be processed before MITS is implemented. The goal is to begin the new system with the most accurate and up-to-date information possible, with a database that includes all claims already processed by ODJFS. MITS will have the ability to process most transactions through electronic data interchange or the new MITS Web Portal, including: CCR_8 0_11_Go_Live_Soon.doc Page 8 of 18

9 Provider enrollment or reenrollment applications through ODJFS (Web Portal only) Prior authorization requests (Web Portal only) Crossover claims and claims with third-party insurance to ODJFS (EDI or Web Portal) Claims adjustments to ODJFS (EDI or Web Portal) Coding Correct Coding MITS will enforce the correct use of national codes. In particular, the system will check the length of ICD-9 diagnosis codes and ICD-9 procedure codes. For example, if a claim includes a three-digit diagnosis code and the specification in the ICD-9 calls for four digits, then the claim will be denied. This codechecking has always been applied to claims submitted by hospitals, but it will be new for other providers submitting claims with the ICD-9 code set. MITS will also accommodate the ICD-10 when the state implements that code set in the future. With the implementation of MITS, Ohio Medicaid will adopt 30 additional modifiers: Left/right modifiers LT (left side) and RT (right side) will be allowed on surgery and specific diagnostic and therapeutic codes. They will not be allowed on codes for radiology procedures or orthotics/prosthetics. Site modifiers E1-E4 (eyelids); FA and F1-F9 (fingers); TA and T1-T9 (toes); and LC, LD and RC (coronary arteries) will be allowed on surgery and specific diagnostic and therapeutic codes. They will not be allowed on codes for radiology procedures. Modifier 25 will be used with evaluation and management (E&M) codes and affecting adjudication in select circumstances only. These modifiers should be used in accordance with standard national coding guidelines and Ohio Administrative Code (OAC) rules pertaining to ODJFS. A guide to using certain modifiers with surgery procedure codes is available as Appendix A to OAC rule 5101: For additional information, see the Supplemental Information Release dated January 28, 2011, at Providers will also be required to use national Health Care Services Decision Reason Codes on all claims involving coordination of benefits. ODJFS will no longer accept "local-level other-source codes" on claims as a valid explanation of why a primary payer denied a claim or paid less than billed charges. Place of Service (POS) MITS will have edits in place to ensure providers are billing services that are performed in the appropriate settings based upon Ohio Medicaid policy. The Place of Service (POS) code indicates the place where the service was performed. The new edits will check to see if a diagnosis code and/or procedure code is valid or invalid for the POS indicated on the claim. For example, if a claim is billed with a procedure code with a POS indicating the service was provided in a physician s office, and the code is allowed only in a hospital inpatient or outpatient facility, then the claim will be denied indicating the procedure is not valid for POS. CCR_8 0_11_Go_Live_Soon.doc Page 9 of 18

10 For additional information, see the Supplemental Information Release dated January 28, 2011, at Correct Coding Initiative Section 6507 of the Patient Protection and Affordable Care Act requires Medicaid programs to incorporate compatible National Correct Coding Initiative methodologies. The ODJFS Office of Ohio Health Plans (OHP) is currently reviewing federal guidance and analyzing the system impact. It does plan to implement these edits in the future. National Drug Codes (NDC) In order for Ohio to meet the federal requirements for the Medicaid drug rebate program, providers will now be required to submit NDC information when billing for certain J codes such as injectables. An NDC panel is included on claim entry panels in the new MITS Web Portal. The following information is required: NDC Unit of Measure Drug Unit Price Unit Quantity Submitted Attachments Surgical Procedures Requiring Consent Forms Providers will be able to submit these types of claims using either an 837 HIPAA transaction or through the MITS Web Portal. Consent forms can be either uploaded or mailed. If you do not have the ability to scan and upload documents, then you will need to fill out an EDMS cover sheet. EDMS cover sheets are required for all attachments that are submitted by mail. Claim Attachments for 837 Transactions For 837 transactions, providers will indicate a claim attachment by providing the appropriate code in the PWK segment of the 2300 loop. If unable to upload through the 837 process, the claim will be suspended in MITS and providers may wait until they are able to view the claim in the MITS Web Portal. They may then use the attachment panel on the claim to complete the uploading of the attachments or, if needed, mail the attachment with the required EDMS cover sheet. Clinical Claims Editor Claims processing in MITS will include the review and editing of diagnostic and medical procedures. Processing claims using the new clinical claims editor feature will dictate when a Medicaid claim should be paid, denied or suspended for review. This new claims processing system will contain hundreds of CCR_8 0_11_Go_Live_Soon.doc Page 10 of 18

11 payment rules that reflect Medicaid policy. Health care industry standard guidelines will be used to prevent inappropriate payment for duplicate, re-bundled, mutually exclusive, and incidental and pre/post-operative care. This new feature will apply to physician and other practitioner claims. It will not apply to other providers at this time, such as home health providers. Also, institutional claims, including hospital outpatient claims, will not be subject to this process. Providers will be notified in the future if this process changes. Suspended Claims Pay or Deny A new term to the provider community will be the suspended claim. A claim can be in suspense for two reasons: It is waiting on attachments from the provider or It is waiting for action by staff at ODJFS. If a claim has been suspended for attachments, the provider can upload the attachments by finding the claim on the Web Portal and using the attachment process. Attachments that cannot be uploaded can be mailed with the required EDMS cover sheet. Please see the EDMS section of this information release for more information. Suspended claims will not be identified on the remittance advice (RA). Providers may view their suspended claims on the MITS Web Portal by doing a claims search by status (paid, denied or suspended). Do not resubmit a claim that is suspended as that will create a duplicate claim, which also will suspend. OHP staff will have to review the claim to determine how it should be properly adjudicated, so please wait until the suspended claim processes and appears on your RA as either paid or denied. Other Payer Claims Form 6780 The 6780 form will be discontinued upon Go-Live. Instead, during the claim submission process, the MITS Web Portal will give providers access to Other Payer panels, where they can enter all third-party liability information, including other payer amounts and adjustment reason codes. With Medicare crossover claims, Medicare should be treated as an Other Payer entity. Providers can add other payer information as needed by accessing the Other Payer panel. From there, they can enter required information, such as the policy holder s relationship to the insured, the policy holder s last and first names, the policy holder s date of birth, the insurance carrier name, the carrier code, the insured s policy ID, the payer sequence (primary, secondary, tertiary) paid amount and the paid date. Providers will indicate the other payer type such as automobile medical, Blue Cross/Blue Shield, Medicare Part A, Medicare Part B, etc. by choosing the appropriate payer in a drop-down box available in the Claim Filing Indicator field of this panel. Hyperlinks to other payer amounts and adjustment reason codes are located on the Other Payer panel. CCR_8 0_11_Go_Live_Soon.doc Page 11 of 18

12 Timely-Filing Claims Provider Information Release To request an exception to the timely-filing limitation, providers should submit the claim with the JFS form and any appropriate documentation attached. Refer to OAC rule 5101: , "General Claim Submission. The process may not apply to all providers, such as Nursing Facilities. Providers will be notified if this process changes in the future. Claim Limitations The MITS Web Portal limits the number of claims that can be submitted per day. For each billing Provider ID submissions of new day claims may not exceed 50 per day. Providers that are approaching the 50- claim limit for dental, institutional and professional claims will receive an error message. The error message for the copy claim and submit button is: May not exceed 50 new claims per day, per Provider ID. New claims must wait until next day reached daily maximum per Provider ID. Note: New day claims do not include resubmissions, adjustments or voids. For example, if a claim denies, the provider can make the necessary changes and resubmit it, and it will still count as only one claim. Claim Types Paper Claims Using the new MITS Web portal or billing entity for EDI is highly encouraged. Paper claims should be used as a last resort. Please make note of the changes to the paper claim forms required for institutional and dental providers, and work with your software vendors to implement the following changes. There are no changes for providers billing on the professional claim form; they will continue to use the CMS Please note that, after MITS is implemented, only straight Medicaid claims will be accepted on paper. Third-party liability, Medicare crossover and claims with attachments must be submitted electronically, either through EDI 837 HIPAA transaction or through the MITS Web Portal. Institutional Claims Institutional providers are currently using the UB92. However, after MITS is implemented, institutional providers will be required to use the UB04. Any claims received on the UB92 form after MITS implementation will be returned to the provider. Dental Claims Dental providers are currently using the ADA version After MITS is implemented, they will be required to use the ADA version CCR_8 0_11_Go_Live_Soon.doc Page 12 of 18

13 Pharmacy Claims There will be no changes to this process at this time. Pharmacy prior authorizations and claims will continue to be submitted directly to ACS State Healthcare, which processes Ohio Medicaid pharmacy claims. If prior authorization (PA) is needed for durable medical equipment, then the pharmacist should submit the PA request through the MITS Web Portal. First, however, the provider s account administrator must establish the pharmacist as an agent and assign the pharmacist the role for PA Update. Nursing Facilities Nursing facilities will be able to submit claims for facility charges through either the MITS Web Portal or (EDI) 837 HIPAA transactions. It is recommended that nursing facility providers regularly check the MITS Web site at for additional information regarding billing transition dates, to help limit a delay in payment during the transition from MMIS to MITS at Go-Live. Nursing facility providers are limited to billing one claim per month per resident. MITS will create a monthly file that contains information on long-term care paid claims and transmit it to Perseus, the longterm care facility financial management system. Please note that although nursing facilities will be able to submit claims through the MITS Web Portal, ICF- MRs will not. MITS will generate ICF-MR claims automatically just as the MMIS does. Prior Authorization and Pre-certification Many providers have asked what the defined difference is between pre-certification and prior authorization. Pre-certification is the approval of services to be provided in a specific location, such as an inpatient hospital or an outpatient setting. For hospitals, prior authorization is the approval of non-covered services, such as medically necessary cosmetic surgery. For non-institutional services, Ohio Medicaid requires prior authorization for certain durable medical equipment, for certain dental and vision services, for private duty nursing, and for items and services that will be provided to children in excess of established coverage limits. Prior Authorization Requests Note: This information is for fee-for-service providers. Managed care providers will continue to use their current prior authorization processes for consumers who are covered under managed care plans. Paper applications for prior authorization requests will not be accepted after the MITS implementation. Instead, prior authorization requests must be submitted via the MITS Web Portal. When a PA request is successfully submitted through the Web Portal, MITS will generate a unique prior authorization number. Using this PA number, providers can search for a variety of information, including: Requested Effective Date or End Date Requested Units or Dollars Authorized Effective Date or End Date Authorized Units or Dollars CCR_8 0_11_Go_Live_Soon.doc Page 13 of 18

14 Payment Method Balance of Units or Dollars Quantity Used Units or Dollars Several quality control measures will be applied to prior authorization requests so that the system will check to see if the service is included in the list of procedures the provider is authorized to perform under their provider contract. The system also will check for exact duplicates, to prevent a PA request if an identical request is already in the system with the same consumer, same provider, same effective and end dates, same procedure, same modifiers, same tooth number, etc. Pre-certification and prior authorization requests of special services still done by Permedion Providers will enter all pre-certification and prior authorization requests in the MITS Web Portal. OHP will continue using Permedion, the current vendor, to review special services, as well as to perform hospital precertifications. Note: Providers will no longer have access to the Permedion Web site after MITS is implemented. Permedion will have access to MITS so that it can review requests. For more detailed information about prior authorizations in MITS, please read Provider Information Release # 4 at Supporting documentation Providers will be able to submit supporting documentation for PA requests by electronic file upload or by mail. The acceptable file formats are gif, tiff, bmp, jpg, ppt, doc, xls, pdf, txt and mdi. Each attachment must be less than 50 MB, with a maximum number of 10 attachments per submission. If an attachment cannot be uploaded, then it must be mailed with an EDMS cover sheet. Instructions are provided within the prior authorization application process. All Service Plans Throughout provider training, we have been asked several questions regarding All Service Plans. To clarify: Providers will continue to use the My Ohio site ( which is managed by CareStar) for All Service Plans. Prior authorization on All Service Plans for home health (waiver patients) will not be required or managed in MITS. Medicaid State Plan home health services do not need to be prior authorized. CCR_8 0_11_Go_Live_Soon.doc Page 14 of 18

15 Home Health Services Policies for requiring PAs are not changing with the implementation of MITS. For a description of services requiring PAs, providers should reference their companion documents on the ODJFS Web site, at For post-hospital home health services, a Certificate of Medical Necessity Home Care Certificate is required. Providers must complete a JFS form and retain a copy in the recipient s medical record. Procedure codes and modifiers for home health services will remain the same. Transplant Services The process for requesting prior authorization of transplant services will remain unchanged for providers. They will continue to contact the appropriate consortium the Ohio Solid Organ Transplant Consortium or the Ohio Hematopoietic Stem Cell Transplant Consortium to obtain prior authorization. ODJFS will continue to generate the approval and denial notices and send them to providers and consumers. Psychiatric Inpatient Admissions Review of Pre-certification Requests The psychiatric pre-certification process will remain unchanged for providers. Health Care Excel, the current vendor, will continue to review and make determinations on all pre-certification requests for psychiatric inpatient admissions. Health Care Excel will also continue to generate Pre-Certification Decision Notices and send them to providers and consumers. Hospice At this time, there are no changes to hospice service span information. Providers will continue to use the IVR process. They will be notified of any changes to this process in the future. For claims submission, any professional physician services delivered to hospice recipients and billed by hospice providers must have the physician affiliated with the hospice NPI. Please note that this is new. We urge hospice providers to make sure the physicians are affiliated prior to implementation. Please complete the JFS 6777 form, Group Practice Provider Information, for any physicians currently not affiliated with your hospice NPI. Remittance Advice The new, reformatted and user-friendly PDF version of the provider remittance advice available on the MITS Web Portal will expand the reporting of explanation of benefit (EOB) codes. In MITS, the PDF version of the Remittance Advice (RA) will have the Ohio proprietary EOB codes with their full descriptions. RAs from the 835 process will continue to have the HIPPA adjustment and remark codes. When providers receive the new RA, they will see that the pages are titled and separated by claim type and outcome. For example, on the CMS 1500, Inpatient, Outpatient, Long-Term Care, and Dental Claims, there will be separate pages for: All paid claims with a cumulative paid total of the claims CCR_8 0_11_Go_Live_Soon.doc Page 15 of 18

16 All denied claims All adjusted claims with a cumulative adjusted total of the adjusted claims The adjusted pages will identify the original claim information, as well as information on the new adjusted claim. Each adjusted claim will be identified if the adjustment indicates either money owed back to the state or additional money owed to the provider. The new RA will identify crossover information for Medicare A, B, C and D (if applicable). A new Financial Transactions section will include information on: o Non-claim specific payouts which are lump sum adjustments made by the state o Claim and non-claim refunds from providers o Accounts receivable tracking (see below) If an adjustment results in the establishment of an Accounts Receivable, OHP prefers to automatically recoup accounts receivables from provider payments. The Accounts Receivable section of the Remittance Advice is set up to make it easier for providers to track this information. It includes the following: AR number/icn (if the adjustment is claim-related) AR setup date Amount recouped this payment cycle Original amount of the Remittance Advice (the dollar amount at the time the AR was set up) Total recouped (the amount subtracted from the current warrant amount and decreased by the amount of the AR) Balance (how much has been satisfied to date; if the full amount cannot be recouped from one RA, then money will continue to be recouped from subsequent RAs until the balance is paid) Reason code From and through dates Recipient ID Recipient name Remittance Advice Summary The last page on the new RAs will be the Remittance Advice Summary page. This will show claims data for the current RA, month-to-date information and year-to-date claim information. Earnings data will include payment information, refund information and other financial information, such as manual payouts and warrant voids, and net earnings. This information will be for current RA amounts and year-to-date. The year-to-date information is a running total of what the provider s 1099 will be at the end of the calendar year. An example of the new remittance advice, including the Financial Transaction and Summary pages, can be found at CCR_8 0_11_Go_Live_Soon.doc Page 16 of 18

17 For more detailed information, please refer to Provider Information Release # 7 at Access to the Current MMIS Remittance Advices Provider Information Release Providers can view current RA in MMIS by clicking on Medicaid Remittance Advice-Pre-MITS after they log on to the secure MITS Web Portal. Provider Training, Information and Resources OHP and HP offered more than 160 training sessions for providers during the months of September, October, November and into December. Training for pre-implementation has concluded. Providers who were unable to attend the training sessions can view information on the ODJFS Web site, including samples of the newly formatted remittance advice. In addition, handouts from the trainings are available at Just select your provider type at the bottom of the page. Then, on the bottom right side of the page, select the appropriate RA and other handouts, as applicable. Many other valuable resources for providers also are available, such as the bimonthly MITS newsletters, monthly information releases, and Frequently Asked Questions from the training sessions. All of these publications can be found at The following is a list of all important MITS Web addresses: Claims submission Provider Information Release # 3: Prior authorizations Provider Information Release # 4: Eligibility Provider Information Release # 6: Remittance advice Provider Information Release # 7: Example of the new RA, including the Financial Transaction and Summary pages: Bimonthly MITS newsletters, monthly information releases and frequently asked questions: Place of service Supplemental Information Release, January 28, 2011: Modifiers with surgery procedure codes Supplemental Information Release, January 28, 2011: Provider account setup, agent account setup and assigning roles to agents Special Release, Early Registration, dated 11/01/2010: ICN Region Code handout MITS Training handout: CCR_8 0_11_Go_Live_Soon.doc Page 17 of 18

18 Training handouts, including the ICN Region Code handout usable as a desk reference: Companion guides, updates and news for trading partners: JFS 06777, Group Practice Provider Information : CCR_8 0_11_Go_Live_Soon.doc Page 18 of 18