Georgia Medicaid reprocessing of NCCI edit claims

Medicaid posted a message today titled: NCCI/MUE Mass Adjustment for Physicians, DME, Health Check and Other Providers

If you have a Remittance Advice dated 1/20/2016 posted this past weekend, it contains claims that are being reprocessed/denied due to an NCCI edit system process that Medicaid is having to perform for dates back to October 1st, 2010 through February 28, 2014. These claims are being reprocessed with a new ICN that starts with "52" Region Code. This is a delayed mass reprocessing non‐check related code. At first I thought this meant it would not affect you financially. It will, just not now....

Details about this reprocess:

- You will have 30 days to adjust claims between January 29th and February 29th that are reported denied in this report.

- Any negative balance that states "owed to state" will not be recouped until after the allowed 30 days to adjust claims ﴾until after February 29th﴿

- You can not adjust any claims until January 29th. Do not void claims, instead correct errors discovered and then click adjust ﴾is my understanding at this point from Medicaid reps﴿

Most issues I am finding are the following:

- Medicaid has paid too many units for a cpt/date of service

- NCCI edits did not allow CPT codes together ﴾example: 97530 with 97535, or 92507 with 92609﴿ ‐ This will need a 59 modifier on the claim for one of the CPTs.

Note in the banner message description:

Details regarding Physicians, Mid‐level providers, DME, Health Check and other provider claims impacted by the mass adjustment for NCCI or MUE that will be mass adjusted are provided below:

• Professional and DME claims ﴾Claim Type M﴿ for all provider categories of services with a date of payment on or after October 1, 2010 through February 28, 2014.

• Procedure codes that were not billed in compliance with their MUE UOS limits will be reprocessed. Detail lines for the procedure codes billed ﴾Units Billed﴿ with too many units will be denied for payment.

• Providers must review the ' Units Billed' to ensure the procedure codes on their claims are billed in accordance with the allowed MUE limit effective for the claim's date of service.

• Providers should adjust the impacted claims, correcting the units billed. The impacted claims should not be voided and new day claims should not be submitted. If the entire claim denied, the providers should resubmit with the appropriate number of units. No other adjustments should be made to any other detail lines. Any other adjustments will be recouped without recourse, and the Office of the Inspector General Program Integrity ﴾OIG PI﴿ will be informed.

• Providers will have a thirty day window from the initial date the denied claim appeared on your RA to resubmit the adjusted claim electronically through the secure web portal, through a billing vendor, or through EDI/837 transaction.

• Providers must adjust their claims within this thirty day timeframe to be eligible for payment for these adjusted detail lines. CMS has not, and will not, grant any additional extensions for this DCH initiated Mass Reprocessing for the MUE edits.

Providers will see an accounts receivable ﴾A/R﴿ balance on the special remittance advice posted January 20, 2016 and payments on the very next remittance advice posted January 22, 2016. A small number of claims had a change of ownership. The Liability ﴾A/R﴿ will initially remain with the former owner for these claims. Payment will be given to the new owner which will appear on the remittance advice posted January 22, 2016. The Liability ﴾A/R﴿ will then be transferred to the new owner.

All resubmitted claims must contain the NCCI associated modifier, MUE ﴾UOS﴿, and be billed according to the applicable Part II Policies and Procedures Manual. Please refer to guidance provided in the applicable manual. Manuals can be viewed at https://www.mmis.georgia.gov/portal/ by selecting the Provider Information tab and clicking on Provider Manuals.

Again, please note that changes made to claims outside the scope of the NCCI adjustment period will be automatically recouped with no appeal recourse and referred to the OIG PI.