Claims and attachments that cannot be clearly microfilmed or photocopied will be returned. If a provider feels that a claim has been paid incorrectly and wants the claim to be adjusted, the provider must submit an Individual Adjustment Request form to Conduent.
An adjustment is a post-payment request by a provider to adjust a specific claim. No adjustment request can be submitted until a claim has been paid. Denied claims cannot be adjusted. A provider should complete the adjustment request, attach a copy of the related remittance advice, and submit the form to Conduent, who reviews the adjustment requests for completeness and timely filing.
Adjustment requests must be submitted in accordance with the timely filing requirements. Incomplete forms or forms that are not received within the filing limit will be returned to the provider. Adjustment requests that pass the initial screening are submitted for processing. The requirements for adjusting a claim are as follows:.
All pertinent information must be provided. Download the Individual Adjustment Request form from the website. Complete Section B with information about the claim. Remember to fill in only the items that need to be corrected. Field: 1. Field: 2. Field: 3. When adjusting a claim that has been previously adjusted, use the ICN of the latest claim. Field: 4. Field: 5. Field: 6. Date of payment Description: Date claim was paid is found on remittance advice.
Field: 7. Amount of payment Description: The amount of payment from the remittance advice. Section B Field: 1. Units of service Description: If a payment error was caused by an incorrect number of units, complete this line. Billed amount Description: If the billed amount is incorrect, complete this line. Net Billed - TPL or Medicare paid Description: If the payment error was caused by a missing or incorrect insurance credit, complete this line.
Net is billed amount minus the amount third party liability or Medicare paid. Field: 8. Adjustment requests will not be accepted by telephone. Correct all errors on the original claim form with one adjustment request by attaching a copy of the claim or remittance advice. Adjustments and voids are processed as replacement claims. In processing, the original payment is completely deducted and the adjustment is processed as a regular claim.
The net result is a transaction that will increase or decrease your check. Verify the correct NPI number and taxonomy are on the claim.
Reasons for Return or Denial: Authorized signature missing How to Prevent Returned or Denied Claims: Each claim must have an authorized signature belonging to the provider, billing clerk, or office personnel. The signature may be typed, stamped, handwritten, or computer-generated. Services covered in this manual require a ADA claim form.
Use dark ink and center the information in the field. Information must not be obscured by lines. Reasons for Return or Denial: Member number not on file, or member was not eligible on date of service How to Prevent Returned or Denied Claims: Before providing services to the member, verify member eligibility by using one of the methods described in the Member Eligibility and Responsibilities chapter of the General Information for Providers manual.
Eligibility may change monthly. Reasons for Return or Denial: Prior authorization number is missing implants only How to Prevent Returned or Denied Claims: Prior authorization is required for certain services, and the prior authorization number must be on the claim form. Reasons for Return or Denial: Prior authorization does not match current information How to Prevent Returned or Denied Claims: Claims must be billed and services performed during the prior authorization span. The claim will be denied if it is not billed according to the spans on the authorization.
Reasons for Return or Denial: Duplicate claim How to Prevent Returned or Denied Claims: Check all remittance advices for previously submitted claims before resubmitting. When making changes to previously paid claims, submit an adjustment form rather than a new claim form.
Reasons for Return or Denial: Claim past day filing limit How to Prevent Returned or Denied Claims: Conduent Claims Processing must receive all clean claims and adjustments within the timely filing limits described in this chapter. To ensure timely processing, claims and adjustments must be mailed to Conduent Claims Processing at the address shown in Key Contacts.
Verify the procedure code is valid for your provider type. If a dental clinic is to be reimbursed for the dental work by a treating dentist, then the clinic must also have an NPI number. If any information you listed on your original provider enrollment application changes, you must notify Provider Enrollment in writing. Examples include but are not limited to change of address, change of tax identification number, cessation of practice, and lapse of license.
Each year Conduent requests a copy of your license and other certification. This documentation must be submitted within 60 days of the request. Notice should be addressed to Provider Relations. Reinstatement will be contingent upon provisions of State law.
As with any other patient, providers should ensure that services to a patient are not terminated in a manner that could be considered a violation of professional ethics considerations. The provider agreement requires that clinical records fully disclose the extent of services provided. Clinical record documentation should meet the following standards:. Providers must retain clinical and financial records, including information regarding dates of service, diagnoses, services provided, and bills for services, for at least 6 years and 3 months from the end of the federal fiscal year July 1—June 30 in which the services were rendered.
If an audit is in progress, the records must be maintained until the audit is resolved. Records must be accessible to authorized personnel during normal business hours for the purpose of reviewing, copying, and reproducing documents.
These entities shall have access to records even if the provider chooses to no longer participate in the program. Providers must furnish copies of claims and any other documentation upon request. The forms listed below are available on the Forms page of the Provider Information website. The Dental Plan Fact Sheet is included in this chapter. DPHHS is responsible for determining payment rates, benefit coverage, member eligibility, and retrospective utilization review.
Conduent also processes dental claims and verifies benefits. A complete list of HMK covered dental codes can be found at hmk. Box Helena, MT Submit trauma-related dental claims to Healthy Montana Kids at the address at the bottom of the page. Claims will be processed under the medical benefit and submitted to the address below:.
In her role, Ms. Prior to her current position, Ms. In this position she was responsible for the administration of managed health care for physical, behavioral and dental health for both Medicaid and CHIP for the State of Utah. Prior to joining the Department of Health in , Ms. Chacon served in this capacity for 12 of her 29 years with the Utah Department of Human Services. Dean Rosen has played a leading role in developing and advancing health policy for more than 20 years.
A partner at Mehlman Castagnetti, Dean joined the firm to direct its health care practice in September after five years as the chief health care advisor to Senate Majority Leader William H. Frist R-TN. Dean has held senior positions in both the U. Senate and the House of Representatives, serving in the Congressional Leadership as well as on key health care committees. He also served in several senior positions with the Health Insurance Association of America.
He has helped shepherd through Congress major legislation involving a variety of policy areas, including Medicaid and Medicare reform, FDA regulation, health insurance coverage and health care quality.
Throughout his career, he has forged strong working relationships with key decision-makers on both sides of the political aisle in Congress and within the broader health policy community. Chris Jennings is a decades-long health policy veteran of the White House, the Congress and the private sector. In his decade with the U.
He also served in a major role for the U. Bipartisan Commission on Comprehensive Health Care. Jennings has advised eight Presidential campaigns, the , and Democratic Platform Drafting Committees, and multiple gubernatorial and Senate candidates.
Jennings Policy Strategies JPS is a nationally respected health care consulting firm committed to assisting foundations, purchasers, health systems, and aligned stakeholders develop policies to ensure higher quality, more affordable and sustainable health care. Erika started her career managing a homeless shelter in the Mississippi Delta and has since served in a variety of capacities across health care and human services including positions at Duke University and the World Health Organization.
Prior to working for the foundation, Chris spent six years as a senior health policy analyst for the U. Government Accountability Office, contributing to numerous reports for Congress on Medicaid, Medicare and private health insurance payment policy. Dickerson has over 30 years of experience in the field of public health and strategic policy development. Her primary focus is to develop and implement state Medicaid policies in the areas of nursing and intermediate care facilities, home and community-based waivers, maternal and child health and developmental disabilities.
Dickerson also coordinates with the Centers for Medicare and Medicaid Services and interpret federal guidelines, draft legislative language and perform comparative analysis to determine the most appropriate delivery of services for individuals and families. Dickerson has extensive experience in administering health services programs through collaborative partnerships with state agencies, local health departments, managed care organizations, hospitals, pharmacies and community-based organizations.
In addition, she has been instrumental in creating non-traditional health education programs for under-served populations and has been nationally recognized for her statewide leadership in the implementation of efforts in high-risk communities. Marie Ganim, Ph. In this role, she ensures the solvency of health insurers, protects consumers, encourages the fair treatment of providers, and works to improve health care quality, accessibility, and affordability.
The Office of the Health Insurance Commissioner was created in to oversee both health insurance regulation and health policy for the state. Her previous career includes serving as a principal at the multinational law firm Dentons where she led the Health Policy and Health Insurance Exchange Teams, as an advisor to Massachusetts Governor Mitt Romney on health policy and federal programs, and as senior management for both the Salt Lake and Atlanta Olympic Games.
Jean is a Registered Nurse that has over 30 years in hospital, home care and hospice administration. She holds a masters of science degree in nursing as a clinical nurse specialist and masters degree in hospital administration.
She is married and has four children and six grandchildren. Heather has over a decade of experience in human service specifically related to health care policy. She specializes in government affairs, public relations, coordinated project management and strategic planning. He previously served as chief administrative officer and interim chief of staff to Gov. John Hickenlooper and has an extensive history of public service.
Kevin brings a strong understanding of local, state, and federal government and stakeholder engagement to this role. For his time at Connect for Health Colorado, Kevin has been focused on improving the customer experience so they can focus on health insurance with tax credits implications.
Kevin has held many senior leadership roles for the city and county of Denver. He was elected to the Denver Board of Education in and Kevin graduated with a B. Kevin is known as a collaborative non-partisan problem solver for Colorado issues. Jennifer Sullivan, M. Holcomb effective January 9, Sullivan is dedicated to building effective and efficient delivery of health care and social services to Hoosiers.
She takes a public health approach to policy decisions and is committed to strategic alignment across government and the private sector to improve health outcomes and fill unmet social needs. FSSA is a health care and social service delivery and integration agency. The mission of FSSA is To compassionately serve our diverse community of Hoosiers by dismantling long-standing, persistent inequity through deliberate human services system improvement.
Theriot attended medical school at the University of Louisville UofL then went on to complete her Pediatric residency and a chief resident year before joining the faculty at UofL. Theriot served as the director of the General Pediatrics Clinical Research Unit and prior to that as the medical director of the Children and Youth Project; a multidisciplinary primary care clinic serving the inner-city high-risk children of Louisville Kentucky. Theriot is a certified physician executive and is a professor of Pediatrics at UofL.
In addition to her administrative duties with Medicaid, she continues to see patients weekly in clinic at UofL and teach pediatric residents. Sudders has held leadership roles across the public and private sectors, including serving as the Massachusetts Commissioner of Mental Health, a non-profit CEO, and associate professor and program chair at Boston College School of Social Work, a top ten nationally-ranked program.
She is the recipient of many civic, social work, and professional honors. Tim has over 20 years of experience implementing state government systems, including end-to-end management of the entire software development lifecycle from contract negotiations and project initiation, through implementation, certification, and post-production operations.
His work focuses on immigration issues affecting children and families and implications of immigration enforcement and policy for health and human services programs and agencies. From , Mr. ACF includes the Office of Refugee Resettlement and a wide range of other programs assisting low-income and vulnerable children, families and communities. Previously, Mr. Additionally, Zimmerman served as the Health Care Administration policy director, deputy director of managed care and payment policy division and as the budget and legislative director.
Thomas Novak is the Medicaid Interoperability lead in the Office of Policy at ONC where he supports the advancement of Medicaid interoperability in the drafting and review of federal regulations. Prior to MassHealth, Tara served as the founding Administrative Director for the Kraft Center for Community Health Leadership at Partners HealthCare, a then-new entity focused on improving access to high quality healthcare in traditionally underserved communities by strengthening the workforce in community health centers.
She previously held leadership roles in global health, first at the Harvard T. She has also consulted at numerous community health centers and nonprofits. She conducts interdisciplinary work on planning for hazards and risks in order to reduce physical and social vulnerabilities and seek ways to build resilience in vulnerable, marginalized communities.
Her research also emphasizes active community participation in research, education and decision-making processes to address the present and potential impact of climatological risks. She is also conducting research on adaptation approaches to sea level rise in Florida and developing work on climate resilience planning in the Caribbean. Carney Delaware. Joe has been in his current position since Joe graduated with a B. House of Representatives. He was Rep.
In addition, Joe has several years of experience as a professional mental health counselor. Wilmarie has represented the state before legislative and executive branches in strengthening advocacy systems. Wilmarie has led teams in state studies and evaluations on elder abuse, financial exploitation, and guardianship issues impacting the aging population; Wilmarie has been a featured speaker at local, state and national forums covering topics from advocacy, protection, quality strategy, performance measures, and state funded programs.
It includes establishing sound quality components that include early implementation strategy, performance measures, performance improvement projects, long-term evaluation while collaborating with internal and external stakeholder engagement. Wilmarie has served as a board member in national, state and local organizations influencing public policy, education, older adults, and the arts. Kierra S.
Her dissertation research specifically explores John Henryism an active coping mechanism against stressors , socio-economic status, and health disparities among Blacks. Having joined the Kirwan Institute in , Kierra has collaborated with state, county and city public health departments, as well as non-for-profit organizations, to assess health outcomes, such as infant mortality, and make policy and practice-based recommendations to address the disparities.
After completing her doctoral degree, she intends to continue her scholarship to better understand health among Black populations across the socio-economic gradient. In his role, he facilitates change across the state system of government, creating more inclusive state agencies and promoting equity in state programs and services. Prior to this in , Dr. She also teaches medical and public health students on topics related to health inequities, public health leadership and management, physician advocacy, and community organizing health.
Currently, Dr. She is a pediatrician and board certified in Preventive Medicine and Public Health. A Commitment to Advance Health Equity. Dee Jones is the Executive Director of the North Carolina State Health Plan, which provides health care coverage to more than , teachers, state employees, retirees and their dependents.
Dee holds an M. Elisabeth is recognized as a health policy expert and has a strong track record of protecting, preserving, and expanding access to health care, particularly for lower-income Coloradans. She has helped to shepherd legislation and programs that increased coverage, reduced health access barriers and led to significant changes in the Colorado health landscape.
She competed a Ph. Previously, Dr. Jessica Rhoades is an accomplished health care policy and advocacy leader with broad expertise and experience in Medicaid, the Affordable Care Act, health insurance and payment and delivery system reform. She has served as health care policy advisor to two governors. Her work in the private sector includes working in public affairs for a national health care provider covering 14 states. Highlights include the work she did with the Ohio Department of Health to define food deserts and the communities impacted by them.
Ellie Hartman, Ph. He is a physician, researcher, and public servant dedicated to improving health for vulnerable populations. Prior to coming to Virginia, he was a National Clinician Scholar at the University of Pennsylvania where his work focused on two areas: 1 improving health for populations with high rates of HIV infection, substance use disorders, mental illness, and justice involvement and 2 applying insights from behavioral economics and clinical trial design to test strategies and technologies to help form healthy habits.
He is excited to learn and collaborate to improve the health and well-being of the individuals, families, and communities who call Virginia home. Jeremy Vandehey, J. Hospital Consolidation. Jaime S. King is the Bion M. Concentration on Law and Health Sciences. She is the Co-Founder and Executive Editor of The Source on Healthcare Price and Competition, a multi-disciplinary web-based resource about healthcare price and competition. Professor King has testified before Congressional committees on health insurance mergers and price transparency and currently sits on the Board of the American Society of Law, Medicine, and Ethics.
She holds a Ph. Carissa Dougherty, LCSW, has over 18 years experience providing direct clinical practice, program management, and policy work. Dougherty previously managed an array of permanent and transitional supportive housing programs for persons with mental health and substance use issues. She has co-chaired the local homeless Continuum of Care and provided Mental Health First Aid training to hundreds of homeless service and housing providers.
She leads a team of program specialists and policy analysts responsible for stakeholder engagement, system coordination, and policy initiatives. Prior to this role, she served as a Senior Advisor with a focus on coordinating services to address the housing needs for persons with IDD and behavioral health disabilities, exploring the sustainable financing options for health and housing initiatives, and promoting policies and programs that support such endeavors.
Improving Health through Housing. With over 30 years of healthcare experience, Ms. She manages all aspects of affirmative enforcement by the office, including multi-district cases involving antitrust and government program fraud, consumer protection, the opioid epidemic, the Affordable Care Act, immigration, the environment, privacy and data security, as well as cases pending locally.
She handled a broad variety of cases on behalf of the United States, its agencies and employees. She also spent over a decade in law firm practice focusing on business and financial litigation. His team provides support to the Oklahoma Health Care Authority state Medicaid agency in managing the pharmacy benefits for our state Medicaid members.
Jackson, the President of the Maine Senate. Craig practiced law at a firm in Portland, Maine, for two years prior to joining the Maine Legislature in Stacey received her B. As Program Director, Ms. Through this initiative, Ms. Bresaw and her team work to empower employers to challenge stigma and provide supportive work environments for people in recovery and those impacted by substance use disorders.
At Granite United Way, Ms. Bresaw oversees public health strategies and initiatives and works to align these efforts with existing collaborations, partnerships, and Community Health Improvement Plans. In addition, Ms. Born and raised in NH, Ms. Bresaw received her Master of Social Work Degree in from the University of New Hampshire, with a concentration in community and administrative practice.
She has worked in the field of public health and substance use disorders since In her current role, Ms. Bresaw provides ongoing technical assistance and support to key sectors to ensure the use of best practice approaches in public health and prevention. Bresaw has significant experience in the development of strategic plans, logic models, evaluation plans, and work plans designed to impact crucial public health issues in our communities.
Sarah Finne, DMD, MPH brings over 30 years of experience from both private practice dentistry and public health supervision of a large school-based dental program in New Hampshire to her work in Dental Medicaid.
The Office is legislatively mandated as the state coordinating body for suicide prevention, intervention and postvention efforts.
The Office sets statewide priorities and works with state agencies and community organizations to develop and implement effective strategies, including a community grant program, means restriction education initiatives, the Zero Suicide initiative, education and awareness programs, emergency department and hospital outreach and education, the Colorado-National Collaborative, federal grant-funded initiatives, Mental Health First Aid, and a school grant program.
Brummett practiced family and appellate law in both Colorado Springs and the Denver Metro area. At CHIR she directs research on health insurance reform issues.
Her areas of focus include state and federal regulation of private health insurance plans and markets and evolving insurance market rules. Prior to joining the Georgetown faculty, Ms.
From to , Ms. Corlette worked as a professional staff member of the U. After leaving the Hill, Ms. Corlette is a member of the D. Bar and received her J. She lives in Alexandria, Virginia with her husband and two daughters. How to Slice the Pie? Market Segmentation. Richard N. He works to expand publicly funded health coverage; protect patient autonomy, especially in reproductive and end-of-life care; and support safety-net health care providers.
She also comes with prior experience replicating effective youth development interventions and evaluating and improving child welfare and educational programs. Prior to starting at CMS in , Mr. She began her work in the health insurance arena in law school with research on the impact of discriminatory health insurance benefit design on marginalized populations.
In the four years that Ms. Duhamel has been with OSI, her work has focused on regulatory and legislative policy development, including the Surprise Billing Protection Act, legislation to align New Mexico law with the Affordable Care Act, protections against unscrupulous purveyors of short term and limited benefits plans, and guarantees for network adequacy and prompt and transparent benefit utilization review.
Her interests include treating whole families with a special focus on preventative health care, group visits, and medication-assisted treatment for opioid use disorder. Michael White has worked in the field of substance use disorder for over 9 years with an additional 3 years working with children and families. Michael specializes in substance use disorder program development between community agencies and judicial systems and has developed, implemented, and supported the integration of Medication Assisted Treatment into county and state correctional facilities located in Alaska, Arizona, Montana, North Dakota, Wisconsin, and Texas.
At Community Medical Services Michael supervises a team that closely works with Superior Court Drug Court Programs along with coordinating care to and from county and state correctional facilities. His experience also includes working within family courts, Department of Child Safety, and obtaining resources for pregnant women with substance use disorders by collaborating with community partners.
Michael is a national presenter in the areas of Collective Impact as an effective tool for the continuum of care, pregnancy and opioid dependence, along with Opioid treatment within Criminal Justice systems. For more than twenty years, Meredith has worked on behalf of children and their families, spending much of her career working to address the complex needs of children with mental health challenges who become involved with various other child-serving systems, including substance use, juvenile justice and child welfare.
Megan worked on Capitol Hill for 13 years for both Rep. Matt is a person in recovery from a substance use disorder who has spent his career helping those with substance use disorders initiate and sustain recovery. He brings together key individuals and groups that have the talents and resources needed to develop, foster, fund and implement new, integrated community services at the local level. Mark has served as an Ombudsman for Long-Term Care learning firsthand the complex reality our most vulnerable adults live with each day.
Before that role, he served with the US military in various leadership positions with responsibility for small and large-scale, multi-faceted teams and complex financial situations. Grant Foundation. She has published over papers, editorials, intervention training manuals, and several book chapters, focused on improving health care for diverse racial and ethnic populations.
In October , she was elected as a member of the National Academy of Medicine in acknowledgement of her scientific contributions to her field. Leann is the director of the Equity and Inclusion Division for the Oregon Health Authority, joining the agency in Leann has 25 years of leadership experience developing equity, diversity and inclusion programs.
He has 13 years of healthcare experience ranging from systems management to program integrity and mostly focusing on data analysis in various forms. Recently he has been involved in several large payment reform efforts including, implementation of the Enhanced Ambulatory Patient Grouper methodology for outpatient hospitals and developing a per member per month payment model for FQHCs.
Prior to joining the staff of Children and Family Futures, Mr. Katherine L. Gudiksen, Ph. Her work focuses on policies to address rising healthcare costs with an emphasis on state-level interventions to promote competition.
While at The Source, she developed the pharmaceutical page to track and analyze state legislation to address rising drug prices. She also holds an A. This has streamlined and simplified the program for both members and providers, freed up resources for an extensive array of care delivery and value-based payment interventions, and enabled the program to reduce both per member, per month costs and overall spend.
Kate is a graduate of Oberlin College with a B. Her background is in community-based services for older adults, and she is the author of Connecticut Elder Law, a treatise that is republished each year. Both State agencies are responsible for promoting the transparency of health care costs and quality in the State of Maine. MQF is responsible for improving health care quality in the state. Prior to her current role, Ms. She earned her B. Julia works with ADHS leadership and management on a variety of public health functions as related to oral health and has been in her current position for ten years.
She was responsible for developing the first comprehensive state oral health plan for Arizona. She has over 20 years of experience in various public health settings providing needs assessment, policy development and quality assurance at local, state and national levels. In this position Mr. Allen is responsible for developing agency-wide goals, objectives and strategies to eliminate health disparities and promote health equity for all Ohio residents.
Additionally, Mr. Allen works in partnership with national public health organizations, state cabinet-level agencies and a variety of public health programs to target services to disenfranchised groups, measure program performance and assess outcomes.
Allen has served in various public health capacities. Allen has implemented statewide social marketing activities to respond to chronic diseases; developed enterprise-wide program evaluation systems; and pioneered the use of market research analytic tools with GIS mapping capability to respond to health inequities.
Cardenas has played a critical role in the shaping of important health coverage legislation in Maryland including the Maryland Easy Enrollment Health Insurance Program. Cardenas also manages agency relationships with state and federal legislators and regulatory industries; oversees the implementation and administration of the State Reinsurance Program; and provides end-to-end management and oversight of carrier relationships ranging from consumer enrollment to experience.
He has been with the Maryland Health Benefits Exchange since in a variety of roles before assuming his current position in As Assistant Secretary, Jodi supports the development of health and behavioral health policy in the Commonwealth. Jason Rachel, Ph. In this role, he is responsible for providing executive leadership in the management and implementation of both current and new integrated care programs. Rachel directs and oversees all operations, policies, contract compliance and quality monitoring activities within the division to provide high quality, person-centered coordinated care services.
An attorney with extensive experience as a litigator, researcher and advocate, Ms. New Recipes to Control Rx Pricing. She served as legal counsel to the Washington State House of Representatives for twenty years, working on a broad range of health, behavioral health, long term care, human services and criminal justice issues.
After the MT CHIP enrollment process has been completed, beneficiaries will be covered for medical services, including:. Most of these services covered by CHIP benefits will come with small copayments for CHIP recipients, but some preventative care services may be free of cost. MT CHIP will not cover treatments that are not scientifically proven to give medical benefits, such as acupuncture or aromatherapy. To learn more about services covered by CHIP, download our comprehensive guide today.
This account lets you check your eligibility, apply to government assistance programs and get important information about your case. You can update your information by logging into this account as well.
The applicant is younger than 19 years of age. The applicant meets the income requirements. The applicant is not insured or covered by Medicaid benefits. After the MT CHIP enrollment process has been completed, beneficiaries will be covered for medical services, including: Hospital visits. Specialist visits. Emergency services.
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