Why is the Division of Behavioral Health (DBH) changing claims processing vendors?
DBH’s contract with its current Administrative Service Organization (ASO) vendor, doing business as Optum Alaska, expires on 12/31/2024. To streamline Department of Health (DOH) policies and procedures and offer providers a more efficient claims processing experience, DOH has chosen to reintegrate Behavioral Health Medicaid claims back into the state-owned Alaska Medicaid Management Information System (MMIS) instead of rebidding the contract to maintain a separate ASO.
Who is the new fiscal agent?
DOH partners with HMS Gainwell as the fiscal agent for MMIS Medicaid claims processing.
How will DBH keep providers informed?
DBH is using DOH’s GovDelivery subscription listserv to distribute transition update memos and communications via email and/or SMS text message. Complete the account setup prompts and navigate to the DBH section to subscribe to “DBH Communications”. GovDelivery subscriptions may be updated at any time on the Subscriber Preferences Page; questions and concerns about the subscription platform should be submitted to subscriberhelp.govdelivery.com.
Transition Communications Library:
What do providers need to do to prepare for the transition?
Start updating your clearinghouse or billing system now to ensure readiness for submitting claims to the MMIS. Review the Claims Processing FAQ information below and refer to the Alaska Enterprise 5010 837P Companion Guide to understand technical requirements.
Submit ongoing and outstanding claims to Optum timely PRIOR to your transition date to avoid delays and potential billing issues post-transition.
Visit this FAQ webpage for frequent updates.
Claims Processing
When can providers start billing Behavioral Health Medicaid claims to the MMIS?
Beginning October 1, 2024:
For the following provider types and specialties: Independent Psychologists, Licensed Clinical Social Workers (LCSW), Licensed Professional Counselor (LPC), and LMFT Licensed Marital and Family Therapist (LMFT)
New Claims (date of service October 1, 2024, or later): submit to MMIS
Old claims (date of service prior to October 1, 2024): submit to Optum
The last date to submit any Alaska Medicaid claims to Optum is October 31, 2024.
Beginning November 1, 2024: For all provider types and specialties, including those listed above, plus Autism, Mental Health Clinics, 1115 Waiver Services (1115), and State Plan Community Behavioral Health Service (CBHS).
All Claims (regardless of date of service): submit to MMIS
What Behavioral Health Medicaid claims dates of service are billable to the MMIS?
Claims processing must adhere to all established market rules during transition, including timely filing limitations. During transition, providers must make every effort to submit claims for payment to the appropriate claims processing vendor. Post-transition, providers may bill all unprocessed claims to the MMIS within 1-year of the date of service provision.
How will billing procedures be affected?
Beginning November 1, 2024, all claims that are currently billed through Optum must be billed through the MMIS. Beginning in October, HMS Gainwell will be ready to assist with billing questions. Behavioral health providers have a dedicated phone number to call HMS Gainwell at 855-293-3568 with any question.
General training resources and information on billing through the MMIS is available through the Alaska Medicaid Provider Training Resources page. DBH is working with HMS Gainwell on training schedules and topics with an expected rollout for provider registration in mid-August. Training schedules and registration links will be posted as they are available.
Will the transition cause delays in claims processing and payment particularly those billed through a clearinghouse?
No delays are expected; however, providers may notice a difference in submission response and reimbursement timelines once claims are processed in the MMIS.
In the MMIS, claims received by Monday 12pm AKT are batched for weekly adjudication, with final processing expected on Tuesday evening. Providers may view adjudication results on their RA documents by the following Wednesday. Depending on provider’s payment preferences, paper checks are mailed and electronic fund transfer (EFT) deposits are made on Fridays. System delays impacting these timelines will be communicated as soon as possible via RA messaging.
Providers experiencing delays should promptly contact HMS Gainwell at 855-293-3568 for further assistance.
How will Optum transfer service authorizations to the MMIS?
Optum’s service authorization information will not be transferred to the MMIS. Service authorization requirements for all claims currently processed by Optum are suspended through June 30, 2025. On July 1, 2025, HMS Gainwell will absorb responsibility for service authorization management and will not use historical information in their process. Extracts of Optum’s historical authorization decisions will be retained by the Division for informational purposes only.
How will Optum transfer historically processed and transition timeline claims to the MMIS?
Transfer of Optum processed claims information to the MMIS has been ongoing throughout the contract DBH is coordinating development of comprehensive ASO systems extracts to support provider transition activities and allow DBH uninterrupted access to historical information for post-transition audit and claims review and adjustment.
Claims submitted to Optum on or before October 31, 2024, will be adjudicated for the final payment by Optum. Providers will receive claim decision information and payments from Optum as they do today.
Claims submitted to Optum on or after November 1, 2024, will be automatically denied and must be resubmitted by the provider to the MMIS. The following message will populate when such claims are denied:
Reason Code: 109 - Claim/service not covered by this payer/contractor. You must send the claim/service to the correct payer/contractor.
Remark Code: - Misrouted claim. See the payer’s claim submission instructions.
DBH is working with Optum to ensure claims submitted on or before October 31, 2024, are reconciled by December 31, 2024. Post-transition, HMS Gainwell will be able to work claims with prior dates of service in conjunction with DBH using historical claims data.
What access will providers have to historic billing claims for future auditing purposes?
Providers may contact the MPASS team for historic claim inquiries at
mpassunit@alaska.gov.
Will providers have access to Optum Pay after November 1, 2024?
Yes, Optum Pay access will be available to providers for 13-months following the transition to MMIS on November 1, 2024, at no cost. Your agency’s current Optum Alaska Medicaid log-in and password will remain active until December 31, 2025.
Please contact Provider Relations with any questions related to Optum Pay at akmedicaid@optum.com.
Where should paper claims be submitted during the transition?
For dates of service on or before October 31, 2024, paper claims should be submitted to Optum no later than October 31, 2024, at the following address:
Optum Paper Claims Submission
Optum Behavioral Health
P.O. Box 30760
Salt Lake City, Utah 84130-0760
*Optum will no longer accept paper claims that are postmarked after November 1, 2024.
For date of service on or after November 1, 2024, paper claims should be submitted to HMS Gainwell at the following address:
Alaska Medicaid
P.O. Box 240769
Anchorage, Alaska 99524-0769
What clearinghouse directions are needed to connect with the MMIS?
Start updating your clearinghouse or billing system now to ensure readiness for MMIS claims submission. Review the directions below and refer to the Alaska Enterprise 5010 837P Companion Guide to understand technical requirements.
Alaska Medicaid Electronic claim submission and electronic payment information:
Electronic Remittance Advice (ERA)
Alaska Medicaid Payer ID: 77200
EDI Support
Local:
907.644.6800 (option 1, 3)
Toll Free:
800.770.5650 (option 1, 3)
AKHIPAASupport@Conduent.com
Payer ID 77200 is used in the following data elements: S03 group receiver ID; NM109 of the claim receiver loop M1*41 1000B; NM109 of the NM1*P4 payer loop 2010BB
Where should appeals be submitted during the transition?
On or before November 30, 2024, Optum Alaska will process all appeals for claims with date of service prior to November 1, 2024.
Optum Behavioral Health
Attn: 1st Level Appeals and Complaints
911 W. 8th Avenue, Suite 101
Anchorage, Alaska 99501
Fax: 855.508.9353
On or after December 1, 2024, appeals for all claims dates of service will be processed by AlaskaMedicaid/HMS
Third Party Liability
What is TPL?
Third Party Liability (TPL) is a legal requirement mandating that other sources of coverage pay for medical services before Medicaid will for a Medicaid-eligible individual. Medicaid acts as a secondary payer, covering the remaining balance only after all other liable sources have paid. Both the federal and state governments share the responsibility to ensure that Medicaid is appropriately identifying potentially liable third parties and coordinating benefits to reduce Medicaid program costs.
Why is enforcing TPL important?
- It’s the law that Medicaid is the “payor of last resort”.
- TPL saves State money and resources, ensuring that the Medicaid program is sustainable.
- TPL can help providers receive higher reimbursement rates from other insurers.
- TPL can help expand coverage for Medicaid members.
How is the MMIS set up for TPL services?
The MMIS does not track other coverage per Medicaid participant. However, HCS coordinates with the Division of Insurance to check for “non-covered services” to bypass TPL requirements within the MMIS. There is no TPL avoidance option within the MMIS. The only systematic TPL bypass that is applied is if procedure codes were excluded on the annual “Never Covered” survey that is done by the Division of Insurance (DOI). To keep the TPL process standardized across the entire Medicaid program Behavioral Health providers will need to submit an Explanation of Benefit (EOB) with every claim that has TPL.
Providers must submit documentation supporting that the Primary Carrier does NOT cover the services. Accepted documentation could be one of the following:
- EOB showing denial as non-covered
- Copy of the Handbook from primary showing that the service is excluded from the plan
- A Denial letter from the primary stating that the service is not covered
*An important note: providers do not have to get a new denial or EOB for each claim they bill. If the primary denies and services are non-covered, the same document can be used for the entire admittance. However, please remember that this documentation is required to be submitted with each claim submission, as each individual claim must be reviewed independently as a complete claim.
Why is the TPL process different?
The TPL process that is established in the MMIS will bring the behavioral health process in alignment with the State Plan requirement. The Department is working on a State Plan amendment to update the TPL requirements as well as prioritizing systematic changes that need to occur within the MMIS for modernization.
How do I find a Medicaid Participant’s TPL resources?
Providers can find TPL information for Medicaid participants by choosing one of the following methods:
- Alaska Medicaid eligibility coupons and cards Resource code / carrier code
- Look up the member’s eligibility information in Health Enterprise http://medicaidalaska.com
- Automatic Voice Recognition (AVR) system 855.329.8986 (toll-free)
- Provider Inquiry 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2
How do I report a Medicaid Participant’s TPL resources?
A Provider can report a participant’s TPL resources by emailing
dmatpl@alaska.gov.
Proof of TPL can also be submitted as an attachment with the EOB.
What is the process for providers to report TPL?
Providers are required to submit the Explanation of Benefits (EOB) from the other carrier(s). Ways to provide the EOB include:
- Electronic claim submission
- Provider has 14 days to supply supporting documentation. If not provided, on the 15th day, the claim will deny.
- There is not a mechanism to submit EOB electronically and documents should be sent via DSM or fax the SAME DAY using the
Attachment Fax Cover Sheet form. DSM address and fax numbers are listed on the form.
- Paper claim submission
- Provider must include all documentation with the claim. If no documentation accompanies the claim, the claim is entered, and the claim will be denied.
- Clearinghouses
- Providers need to ensure that they are transmitting the appropriate indicators intended by the providers. Please see the
Electronic Attachment Quick Reference for guidance on attachment indicators.
What are MMIS’ Denial Exception Resolution for TPL?
Excluding Indian Health Services, if the member has other health benefits that may be responsible for partial or total payment of a claim, those benefits are primary and must be billed first.
Providers will receive a denial exception code if there is no evidence of third party billing (no attached EOB and recorded reimbursement amount) on the claim when a member has other benefits. For example:
6280 - Cost Avoid For No EOB And No TPL Dollars.
Providers will also receive a denial exception code if the EOB from the TPL resource is not attached, but a reimbursement amount is recorded on a claim. For example:
6420 - Cost Avoid For No EOB And Has TPL dollars.
TPL Training
HMS is ready to assist providers who have TPL questions and/or concerns. You can find resources on the
Alaska Medicaid website. Also, you can find the
TPL training deck here.
Provider Resources
When will training take place?
HMS Gainwell has begun providing behavioral health specific training sessions. To sign up to attend an offered session, please navigate to the Gainwell learning center login page. General training resources and billing information can be found on the Alaska Medicaid Provider Documentation and Resources page.
Will there be Behavioral Health Specific Townhalls?
Yes. Alaska Medicaid, in partnership with HMS Gainwell, will host monthly virtual town hall meetings throughout the transition period. The first Behavioral Health meeting was held Monday, August 19, 2024. To view the presentation and the FAQ’s that were answered during the townhall, please visit the Alaska Medicaid Messages and Announcements Page.
Future Medicaid townhalls will be posted on the Alaska Medicaid Provider Training website.
If you have previously registered to attend a Town Hall meeting hosted by HMS Gainwell, you do not need to do anything. Registration will be continuous unless an attendee contacts us to be removed from the invitation list.
For anyone who has not previously attended, register the day prior by sending your name, agency affiliation and AK Medicaid Provider ID to Marilee.reinhartdavieau@gainwelltechnologies.com. Registered attendees will receive meeting invitations with web conference link access prior to the start of the scheduled Town Hall.
Will there be one-on-one training available?
HMS Gainwell can support individual provider inquiries and training needs beginning October 1, 2024. If you experience difficulties during the transition, please reach out to HMS Gainwell at 855-293-3568.
What are the business hours to contact HMS Gainwell?
Standard Office Hours:
Monday – Friday 8:00am – 5:00pm
Recipient and Provider Call Centers hours:
Monday – Friday 8:00am – 5:00pm
Service Authorizations Call Center hours:
Monday – Friday 7:00am – 6:00pm
Saturday – Sunday 9:00am – 4:00pm
Can I stop by the Fiscal Agent in person?
HMS Gainwell will schedule appointment times to work with providers on site. Please call provider inquiry at 855-293-3568 to schedule an appointment.
How do providers update their EFT information?
Mail documents to the following address:
Division of Behavioral Health/MPASS
3601 C Street, Ste. 878
Anchorage, AK. 99503
Where can providers view MMIS payment information?
Will providers be able to conduct claims testing in the MMIS?
No; DBH and the Division of Health Care Services are working closely to ensure robust testing of MMIS claims processing rules against the expected payment outcomes. At this time, providers should expect that all claim submissions are processed in a live, production environment. However, providers may send any suggestions for scenario testing for DBH consideration to mpassunit@alaska.gov.
Who should I call if I have trouble with my password for Alaska Medicaid/ Health Enterprise?
Providers can contact their entity’s organizational administrator. If you are the organizational administrator, then contact provider inquiry at 800-770-5650 (option 1) or 907-644-6800 (option1).
Do I need to re-enroll in Medicaid because of the transition.
You do not need to re-enroll in Medicaid if you are currently enrolled. Provider enrollment records are recorded in the MMIS through HMS Gainwell and does not require additional action from the provider. If you are experiencing delays in your current provider enrollment application, please contact HMS Gainwell at AK-enrollment@gainwelltechnologies.com or (800) 770-5650 (Option 1,2).
*Last updated 9/26/2024