Sandhills Center
LME/MCO
Provider 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:
• 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
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