To be eligible for participation in the MA program, a provider must enroll and sign a provider agreement. Providers may request enrollment information by taking the following actions:
1. Go to the DHS Web site at services.dpw.state.pa.us.
2. Choose DHS Program Offices and select Office of “Medical Assistance Programs.”
3. On the left, choose Provider Information.
4. Below, choose Provider Enrollment Information.
Providers cannot deny services or discriminate in any way against an MA recipient on the grounds of race, color, national origin, or handicap.
A provider who is enrolled in the MA program must accept the payment from DPW plus any copayments from the recipient as payment-in-full. The provider may not accept any extra payment from the recipient for items or services that are covered by MA.
If a provider has a question about covered services or the billing process, the CAO will refer the provider to one of the provider inquiry telephone numbers. See Appendix J, Points of Contact, for numbers.
A provider who is enrolled in the MA program submits invoices to DHS to request payment for medical services provided to recipients. The provider submits the invoice directly to DHS. Payment is made directly to the provider through PROMISe.
If a provider invoice is rejected because of incorrect recipient ID information, the provider should check EVS to review recipient information. The provider should correct and submit the invoice. If the provider has questions, he or she should call an inquiry unit. See Appendix J, Points of Contact, for numbers.
If a provider does not submit an invoice within 180 days of a service, payment is rejected. Billing by the provider may be delayed because of an invoice that has been rejected in the past, an office error or delay, or a hearing decision. If the delay is more than 180 days, the provider must explain the delay and send the invoice to one of the following addresses:
Outpatient Bill
Office of Medical Assistance Programs
Over 180 Day Exception Unit
P. O. Box 8042
Harrisburg, PA 17105
Inpatient Bill
Office of Medical Assistance Programs
Over 180 Day Exception Unit
P. O. Box 8042
Harrisburg, PA 17105
If a provider cannot receive payment because the recipient is not covered in CIS for the date of the service and 180 days has passed since the service was provided, the CAO will:
If the provider submitted an invoice that was rejected, check to make sure a reject reason code was used.
See whether the individual was eligible for MA when the medical service was received but was not covered in CIS because of an office error or delay.
See whether the individual was eligible because of a fair-hearing decision.
If the individual was eligible, update CIS using the NCE transaction with reason code 094. (See Section 380.1, Noncontinuous Eligibility and Issuing an Access Card, (NCE) Openings.)
If the client was eligible, send a memo to the provider, using the following format:
|
SUBJECT: Provider rejected invoices for people that CIS has identified as ineligible or unknown to the system. TO: (Provider’s Name) FROM: (Executive Director) (CAO) An (administrative error, delay, or fair hearing) has occurred. It affects the eligibility of the following individual: 68 12345 TD 2 6 03 John E. Smith Eligibility Dates – 09/02/90 – 09/21/90 – TD category We hope the above information is enough to help resolve payment to you on behalf of our recipient. You should submit an original invoice along with this memo to the Office of Medical Assistance, Over 180 Day Exception Unit. The address is as follows: (The CAO should enter the appropriate address here. See the addresses above.) |
When the invoice and memo are received from the provider, the Over 180 Day Exception Unit will check CIS and, if needed, ask that Central Office open the budget for the period of eligibility shown on the memo.
If the person was not eligible for MA, let the provider know that payment for services cannot be approved.
Pharmacies may submit invoices through the Electronic Claims Management (ECM) system. ECM is available to all pharmacies. It provides online real-time submission of drug claims and lets pharmacies know the decisions. The ECM shows whether a recipient is eligible and tells how much the drug company should be paid.
ECM requires the same information from providers that paper claims do. For approved claims, ECM returns the following:
An online message about the approval
The amount approved
The recipient’s copayment amount
The Claim Reference Number
For rejected claims, the ECM system reports the rejection and gives a reason for it.
Prospective Drug Utilization Review (PRODUR) alerts providers to possible problems a individual might have with a drug. Alerts are available for:
Drugs that might cause a problem with other drugs;
Drugs that do the same thing;
Prescribed dose is too large or too small;
The prescribed dose would be taken too often or not often enough.
Warnings for pregnancy or age.
Claims will not be rejected because of a PRODUR alert. The provider must show that he or she has read the alert before a claim can be approved for payment.
NOTE: If a provider has a problem with ECM, the CAO should tell him or her to call the PROMISe Provider Inquiry unit at 1-800-932-0938.
As soon as the CAO learns that a provider may be breaking rules, the CAO must send a memo explaining the situation to the following address:
Office of Welfare Fraud Investigation Recovery Management
Director of MA Fraud Control Section
Strawberry Square - 16th Floor
Harrisburg, PA 17120
Updated February 14, 2012, Replacing April 12, 2007