Sandhills Center
LME/MCO
Provider IPRS-Waiver
Orientation
Financial Management and Monitoring
• The Finance Department manages the financial
resources of the LME/MCO. This includes:
Management of accountability, availability of funds,
claims processing and payment.
• The Finance Department is responsible for ensuring
compliance with General Statute 159 (The Local
Government Fiscal Control Act) and other general
accounting requirements.
• The Finance/Claims Department supports providers
through training and through its Claims Specialist
Representatives.
Financial Management and Monitoring
Your responsibility as a Contracted
Provider is to:
• Verify consumer insurance coverage at the
time of referral, or admission, or each
appointment, and on a quarterly basis.
• Determine the consumer’s ability to pay
using the Sliding Fee Schedule for all
designated Non-Medicaid services based
on your agency’s contract requirements.
Financial Management and Monitoring
• Bill and report all first and third party payers prior to
submitting claims to SHC.
• Report all billing errors to SHC Claims Department.
• Manage your agency’s Accounts Receivable.
• Submit all documentation which is required for
federal, state, or grant reporting.
• Implement Internal Controls to support audits
performed by Sandhills Center.
Financial Management and Monitoring
• Network Providers shall maintain detailed records of
the administrative costs and expenses incurred
pursuant to their Contract with SHC.
• This includes all relevant information relating to
enrollees for the purpose of audit and evaluation by
DMA.
• Records shall be maintained and available for
review during the entire term of this contract and for
a period of five (5) years thereafter.
• If an audit is in progress or audit findings are
unresolved, records shall be kept until all issues are
resolved.
Financial Management and Monitoring
SHC’s responsibility to Providers is to:
• Certify funding for all contracts in accordance
with G.S. 159. The Finance Department will
review and approve all financial commitments
made by Sandhills Center.
• Assign and monitor maximum funding for
contracts.
• Monitor grant funds.
Financial Management and Monitoring
• Review Financial reports, financial statements
and accounting procedures as applicable.
• Monitor retroactive Medicaid eligibility and
recovery of funds.
• Issue payment and remittance advice (RA) on
paid and denied claims.
• Assist the Quality Management Dept with
claims quality audit process.
Financial Management and Monitoring
• Recover funds based on audit findings.
• Audit providers for coordination of benefits
(COB).
• Manage and pay clean claims within the 48 day
Prompt Pay Guidelines.
• Report credible allegations of Fraud and Abuse
State and Federal Non-UCR Invoicing Rules
The following documentation should be submitted with the invoice:
• Personnel schedule to include FTE percent, Name ID number
and Position Title
• Worksheet that shows expenses by month and year to date.
(Non-UCR Expense Sheet - sample enclosed)
• Certification Statement with authorized provider signature and
title. (see worksheet for statement)
Non-U CR FY12-13 Expenses
Budge t
July
Aug.
S e pt.
Oct.
N ov.
D e c.
Ja n.
Fe b.
M a rch
April
Ma y
June
P rovide r N a me :
P a yroll E xpe nse s:
2011-12
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Wages
Reimbursement Mileage/Supplies
Taxes/Contributions/Benefits
Othe r Ope ra ting E xpe nse s:
Advertising/Interviewing
Employee Record Check
Training, Mtgs/Seminars
Office Rent/Lease
Insurance / Other
Office Utilites/Communication/Building Maint
Supplies, Equip., & Postage
Psychiatrist
Auto Fuel, Reg/Tax, & Maint.
S ub-T ota l of E xpe nse
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
T ota l E xpe nse
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Income
Less Paid Claims - Medicaid
0.00
Less UCR Monthly Income
0.00
N e t Ope ra ting Cost
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
N on-U CR R e que st
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Ce rtifica tion:
I certify that the above data is correct and the expenditures shown have been made for the purpose of and in accordance with applicable
contract terms and conditions and that appropriate documentation to support these cost and expenditures are available for review and audit.
Authorize d S igna ture a nd T itle : ________________________________________
D a te
_________________________________________
Provider requirements prior to
submitting claims to Sandhills
• Provider Contract has been completed and
signed.
• Login and Password has been requested for
Provider Connect and Sandhills Direct Data
Entry Web Tool if applicable.
• Sharefile account has been set up.
• Treatment Authorization Request has been
entered and approved if required.
Share File Account
• Once contract has been approved and
signed, providers will receive notification
that a Share file account has been set up.
Notification will include URL address, User
ID, password and provider instructions.
• A submitter ID and our Receiver ID will
also be included for 837 files.
How is Share File used
• Providers will use to upload 837 files for
processing.
• Electronic files such as 999, 835 and 277
will be uploaded by the MCO for the
provider.
IT Department contact:
edi@sandhillscenter.org
Claims Submission
• Medicaid Claims should be submitted to
Sandhills Center if the members Medicaid
county of eligibility is within our 9 county
catchment area:
• Anson, Guilford, Harnett, Hoke, Lee,
Montgomery Moore, Randolph, Richmond
Private Providers
• Claims must be submitted within 90 days
of Date of Service.
• If a claim is denied, providers have an
additional 90 days from the date of denial
to correct the denial and resubmit.
Hospitals
• Claims must be submitted within 180 days
of Date of Service.
• If a claim is denied, the hospital has an
additional 180 days from the date of denial
to correct the denial and resubmit.
Coordination of Benefits
• Providers are responsible for billing
Medicare and Third Party Insurance prior
to billing Medicaid.
• Current Medicaid Insurance edits will be
used by HP to adjudicate SHC claims.
• If a member has Medicare or Insurance
and payment information is not included
on the claim, the claim will deny.
Claims Submission Cont.
• Checkwrite schedule is located on our
website: www.sandhillscenter.org
For Providers>Finance/Claims
• Billing can be submitted daily.
• Cutoff for weekly 837 files will be
Wednesday at 5:00p.m.
• Direct Data Entry will be 5:00 p.m.
Thursday.
Claims Submission Cont.
• Medicaid Claims can be submitted:
• HIPAA standard EDI Transaction Files
837 Professional Health Care Claim
837 Institutional Health Care Claim
Companion Guides are located on the SHC Website
www.sandhillscenter.org
For Provider>Finance/Claims
Claims Submission Cont.
• Medicaid Claims can be submitted:
• Sandhills Direct Data Entry Web Tool
User Guide is located on the SHC Website
www.sandhillscenter.org
For Providers>Finance/Claims
• Paper Claim
Sandhills Direct Data Entry
Password
• To request your DDE Web Tool login and
password:
Please fill out the Sandhills DDE request
form located on our website:
www.sandhillscenter.org
Click on For Providers >Finance/Claims
E-mail to billing@sandhillscenter.org
Medicaid Claims Adjudication
• Sandhills has contracted with HP
• Claims will adjudicate against all the current
edits used by Medicaid.
• Continue to use the same NPI billing logic as
you did with NC Medicaid (HP)
• Example: If you are a CABHA submitting
enhanced services, the CABHA NPI is your
billing NPI and the Attending/Rendering is the
NPI mapped to the Medicaid Provider Number
for that service.
Denials
• Providers 835 and Remittance Advice will
include the current HIPAA Adjustment
reason codes used by Medicaid.
• A EOB crosswalk can be found on the
SHC website:
www.sandhillscenter.org
For Provider>Finance/Claims
Adjustments/Correction
• Adjustments can be handled three ways:
Electronic 837
Sandhills Direct Data Entry Web Tool
Submit “Claim Inquiry Resolution Form” –
Form is located on SHC website
www.sandhillscenter.org
For Providers>Finance/claims
General Information-Medicaid
• Providers will no longer require the member to
pay a 3.00 copay.
• Provider payment will include 3.00 copay
amount.
• System edits are in place to deny if 3rd party
missing.
• Providers will be held accountable.
• Co-payments, deductibles, payment for missed
appointments or other forms of cost sharing from
Medicaid members, are prohibited.
IPRS Claims Submission
• Can be submitted:
• Provider Connect Web Portal
User Guide is located on the SHC Website
www.Sandhillscenter.org
For Providers>Finance/Claims
• HIPAA standard EDI Transaction Files
837 Professional Health Care Claim
Companion Guides are located on the SHC Website
www.sandhillscenter.org
For Provider>Finance/Claims
Provider Payment
Medicaid and IPRS
• Providers will have the option of receiving
a paper check or electronic funds transfer.
• An EFT request form is located on our
website:
www.sandhillscenter.org
For Providers>Finance/Claims
Keeping Current
It is the responsibility of the provider to research and stay
abreast of new requirements and laws by utilizing all
available resources:
• Monthly Medicaid Bulletins
• DMA and DMH Implementation
Updates
• SHC Communications/
Bulletins
• SHC Website
• Provider Connect News