HCPF investigating provider-portal/CBMS mismatches, EMS denials and specialty long-stay claims
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Summary
HCPF said it is investigating reports of mismatched date-of-death data between the Medicaid provider portal and CBMS that cause claim and payment issues, is analyzing EMS fee-for-service denials potentially routed to managed care, and is reviewing specialty hospital claims with possibly excessive lengths of stay.
Andrew Avalos told attendees the department is aware of an ongoing problem raised by a provider involving mismatched date-of-death information between the Medicaid provider portal and CBMS that is causing claim submission and payment problems. He said the department does not yet have a dedicated contact for these instances but will investigate the scope and keep the item on future agendas until resolved.
Avalos also described a broader issue affecting EMS fee-for-service claims: the MMIS may be improperly requesting that some services be billed to managed care entities, producing denials. He said the department is working to identify impacts and correct the issue and expects to report further at the March meeting.
Separately, Avalos said staff are performing an internal review of specialty hospital claims that appear to have excessively long stays and are assessing the appropriateness of payments in those instances given budget concerns; the department will follow up when research is complete.
For each item, Avalos directed providers to contact Della (email on the slides) or himself for further information and said the department will attempt to reach impacted providers if significant progress occurs between meetings.