Apple Health (Medicaid): Clarification of the CPE Benchmarking Process

Washington State Health Care Authority sent this bulletin at 07/07/2017 01:45 PM PDT

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Apple Health (Medicaid): Provider Alert

Attention CPE Hospitals:

On April 11, 2017, the Health Care Authority (agency) sent communications to certified public expenditure (CPE) hospitals regarding recoupment of fee-for-service (FFS) claims related to the CPE Benchmarking Process and Healthy Options Blind Disabled (HOBD) clients.

In that communication we informed you that we will recoup claims that are not authorized by the agency-contracted managed care organizations (MCOs). The claims are being recouped in accordance with the MCO contract.

Several responses asserted that some of the authorizations were valid and that we should not recoup the payments.

It is our goal to recoup only those claims without a valid agency-contracted MCO authorization. Therefore, we want to clarify some procedural steps in the CPE Benchmarking Process.

Inpatient Involuntary Treatment Act (ITA) claims

Inpatient ITA claims for HOBD clients who are not enrolled in the Fully Integrated Managed Care (FIMC) (Clark and Skamania Counties) will be excluded from the CPE Benchmarking Process if the CPE hospital includes:

  1. The correct Special Claims Indicator (SCI=I) in the appropriate field on the claim; and
  2. A Behavioral Health Organization (BHO)-approved authorization number in the appropriate field on the claim.

Inpatient ITA claims for HOBD clients that are enrolled in FIMC will be included in the CPE Benchmarking Process if the CPE hospital includes:

  1. The correct Special Claims Indicator (SCI=I) in the appropriate field on the claim; and
  2. An approved authorization number from either Molina Health Care or Community Health Plan of Washington in the appropriate field on the claim.

Authorizations denied by the agency-contracted MCO

When an agency-contracted MCO notifies the agency of denied authorizations related to services billed to us and paid FFS, we will forward the denied claim numbers (TCNs) and authorization information to the affected CPE hospital. At that point, the MCO and CPE hospital must work together to resolve any authorization issues related to the paid FFS claim.

Without additional information or an approved authorization from the MCO, we will recoup the claim containing the denied authorization number.

  • This includes any claims in which only some of the billed services were authorized. We cannot partially pay or partially deny claims related to the CPE Benchmarking Process based on partially approved authorizations, or when additional services not authorized by the MCO were billed to us.

If the MCO reverses its decision to deny the authorization and allows the claim to remain paid, the claim will continue to be included in the CPE Benchmarking Process.

  • The MCO must send a written communication about the reversed decision to the hospital and a copy to the agency within five business days of the decision. The communication must state that the authorization denial was reversed. The claim will remain as paid and will be included in the CPE Benchmarking Process.

  • We will recoup claims containing an authorization denied by the MCO if we do not receive a copy of this communication.