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Provider Frequently Asked Questions
(Kansas)
(click here for Pharmacy Frequently Asked Questions)
- How do I contract with CMFHP?
- What is CMFHP's credentialing process?
- What is CMFHP's timely filing requirement?
- Is a written referral required for a member to see a specialist(s)?
- How long does it take CMFHP to process a claim?
- Who do I talk to about claims inquires?
- What is the process to have a claim payment reviewed by CMFHP?
- How does CMFHP determine if the member has other insurance information?
- Where do I file claims?
- How do I use the website to look up claims for my practice?
- How do I get login access to the CMFHP website?
- What do I do if my website log on ID or password is no longer working?
- How frequently is eligibility information updated on the website?
- How frequently is claims information updated on the website?
- Who is my Provider Relations Representative?
- How can HealthWave recipients switch to CMFHP?
- Where can I access the CMFHP Provider Administration Manual?
- Can I receive payment for services provided if I am not the member's designated PCP?
- What is the process if I need to have a member dismissed from my practice?
- Do HealthWave patients get ID cards from CMFHP?
- What is the top reason for delays in processing claims?
- What is the top denial reason for claims?
- What is Code Review?
- When services are provided by a Nurse Practitioner or Physician Assistant, what provider number should be used to file the claim?
- What is the proper way to code a claim for more than one surgical procedure performed on the same day?
- What is the proper way to code a claim for a team surgery? (i.e. assistant surgeon, co-surgeon)
- How do I bill for services when the baby does not have a Kansas Medicaid ID number?
- If I am a rural health care provider, how do I bill for services?
- Why are my emergency room charges being denied?
- Why are my observation room charges being denied?
- What process do I follow when our practice is adding a new provider?
- What do I do when CMFHP has made duplicate claim payments to us?
- Why is taking so long to get a refund letter or for you to recoup the overpayment?
- If I receive a refund letter and I disagree with it, who do I call?
- When will my providers be credentialed?
- Should I use the Vaccine for Children (VFC) for CMFHP members or our private stock?
- Should I use the Vaccine for Children stock for Title 19 and Title 21 members?
- If there is primary insurance such as Blue Cross and then CMFHP is the secondary carrier, do I use our private stock or VFC stock?
How do I contract with CMFHP?If you are interested in contracting with us, please contact the Provider Relations Representative associated within the area where you are located. They will work with you on getting an application and a contract. |
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What is CMFHP's credentialing process?CMFHP will accept the CAQH application or the State of Kansas Standard application. Once applications and contracts are received by CMFHP, the applications are screened for completeness. If something is missing, we will contact your office for the necessary information. When we have received the complete information, then we begin the credentialing process. Typically, our turn-around time to credential a provider is 90 days. Once the credentialing process is completed, you will receive a letter from CMFHP notifying you of your approval or denial. Approvals will include your effective date as well as a fully executed contract for your files.If you have questions about the status of your application or questions about the credentialing process, you may contact our Credentialing Department at 816-559-9443. |
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What is CMFHP's timely filing requirement?Our provider contracts indicate the provider must file a claim with us within 90 days from the date of service. However, you should be aware that we do not deny claims as untimely until 180 days from the date of service. Further, it is important to clarify the initial date for the timely filing requirement does not begin until the provider has all the information necessary to submit the claim. For example, your office/facility is informed by the patient that he or she has commercial insurance, but in fact it is determined (after receipt by your office/facility of the remit from the commercial insurer) that the patient is covered by CMFHP. The timely filing deadline for CMFHP would not begin until you (using reasonable effort) were able to determine the correct claim submission information to submit the claim to us.Also, in recognition of special circumstances with regard to obstetrical services, we provide an exception to the timely filing requirement for physician claims for prenatal care and delivery. These claims must be submitted within 12 months from the date of service. This payment guideline is included within our Provider Administration Manual. |
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Is a written referral required for a member to see a specialist(s)?CMFHP does not require written referrals to in network providers. PCPs may verbally refer a member to a specialist within the CMFHP network and document in the member's chart that this has been done. Referrals to an out of network provider require prior authorization. Contact our Health Services Department at 1-888-691-4874, option 1 for an out of network authorization. |
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How long does it take CMFHP to process a claim?We have an excellent track record for claims payment. 70% of our HealthWave claims are processed electronically and the balance are scanned into our system upon receipt for automated processing. We work with a number of clearinghouse providers including: ASK/EDI Midwest, Gateway EDI, EMDEON and SSI. Our 1st quarter average to pay HealthWave claims was 23 days. We are still assisting providers who may have claim submission issues. It is important that providers include their 6-digit CMFHP provider number on every claim submission. |
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Who do I talk to about claims inquires?We process and pay all of our claims in our local Kansas City office. We do not use any offsite service centers. Because we pay claims in-house, individual claims issues can be resolved in a single phone call. Our Customer Service and Provider Relations staff works directly with you for fast resolution of issues. Call us at 1-877-347-9363 for help. |
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What is the process to have a claim payment reviewed by CMFHP?When you have a question about a claim, you can call Customer Service at 1-877-347-9363. Customer Service can look up the claim to determine if it has been received, in process, paid, denied or pending. If a provider feels a claim was not processed correctly, a Customer Service or Provider Relations Representative will review the claim for accuracy. Because our claims are processed in-house, needed corrections can be made to a claim in a timely fashion. |
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How does CMFHP determine if the member has other insurance information?Since CMFHP is the payer of last resort we first look for other payment resources. We are provided information from the State concerning COB information. We also get information from providers when an EOB is submitted with a claim. If you have other insurance information without an EOB, include the information on the claim submission. COB information should be available on the website within the next few months. |
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Where do I file claims?The mailing for claims is as follows:Children's Mercy Family Health Partners (CMFHP) P.O. Box 411806 Kansas City, MO 64141-1806 For electronic claim filings, we use the EDI vendors listed below. Vendor CMFHP Payer ID No. ASK/EDI 31472 GateWay 31472 SSI 31472 Emdeon/WebMD 31472 |
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How do I use the website to look up claims for my practice?Once you are set up as an authorized user, you will follow the easy steps below to check your claims status:Login using your assigned user id and password. Go to the Office Manager menu item and then:
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How do I get login access to the CMFHP website?Since this is a secured area, you will need to contact your Provider Relations Representative to get access to view this information. Your Provider Relations Representative will provide you with password and login identification. Please remember to notify your Provider Relations Representative of changes in your staffing that may affect access, such as an employee leaving. |
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What do I do if my website log on ID or password is no longer working?If the message you receive is that your password has expired, contact Customer Service and they will re-active it for you. Any other issues, please contact your provider relations representative. |
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How frequently is eligibility information updated on the website?Eligibility information is updated daily. |
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How frequently is claims information updated on the website?Claims information is live data. |
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Who is my Provider Relations Representative?You can view the list of representatives here. |
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How can HealthWave recipients switch to CMFHP?Members may change HealthWave health plans for any reason at any time. They can call the Managed Care Enrollment Center at 1-866-305-5147 for help in changing health plans. The change may be effective the first of the next month. |
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Where can I access the CMFHP Provider Administration Manual?Click here to view the HealthWave Provider Administration Manual. |
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Can I receive payment for services provided if I am not the member's designated primary care provider?On occasion members may be confused and seek care from a provider that is not their designated PCP. This may occur with another physician within a group practice or with a provider in an entirely different practice. We understand this happens and we want you to know how we handle these circumstances. First, we would not deny payment for any claim solely based on the member having received services from a provider other than his/her designated PCP. As long as the provider is in our network, whether the member's designated PCP or not, and the member was otherwise eligible for coverage, we would process the claim for payment. This is also the case for services provided by a participating referral specialist. We encourage members to use their designated PCP for the coordination of all services; however, as a practical matter we do not have a formal referral process and therefore would not deny payment for the services of any participating referral provider solely based on no referral from the PCP. |
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What is the process if I need to have a member dismissed from my practice?If you are unable to establish a working relationship with a member and need to dismiss him/her from your practice, you must notify the member and CMFHP in writing of this request. The member must be given 30 days notice of this change and still be treated by your office for emergent and urgent medical conditions. If the request for dismissal is due to potential fraud or abuse by the member, please contact the Compliance Officer at 816-559-9494. |
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Do HealthWave patients get ID cards from CMFHP?All members are sent ID cards with their welcome packet upon assignment to the plan that includes a member handbook, provider directory, health risk assessment and a postcard to request a PCP change. Members will have the opportunity to change PCPs by calling Customer Service at 1-877-347-9363, going to our website at www.fhp.org or mailing the post card back to us. |
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What is the top reason for delays in processing claims?Claims received without the CMFHP provider number or NPI, or an incorrect CMFHP provider number or NPI, must be researched manually. Claims received without a CMFHP provider number or NPI will be returned to the provider. Claims with incorrect CMFHP provider number or NPI may cause an incorrect payment. This is the biggest delay in processing a provider's claim. |
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What is the top denial reason for claims?CMFHP highest denial is for duplicate filing of claims already received. Claims should not be resubmitted in less than 30 days of the original claim submission. Always check the CMFHP website to check the status of the original claim. |
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What is Code Review?Code Review is a software program that checks for correct CPT procedural coding on CMS1500 claims. The software reviews claims and claim history for unbundling, fragmented, up-coding, duplicate coding, invalid coding, mutually exclusive procedures and global periods of procedural coding. Code denials for these reasons will be displayed on the CMFHP remittance advice as 99 - Code Review; IC - Incidental. |
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When services are provided by a Nurse Practitioner or Physician Assistant, what provider number should be used to file the claim?If your office files claims under a group name for services provided by a Nurse Practitioner or Physician Assistant, you may have received a CMFHP provider number to use. This allows for the proper KS Medicaid reimbursement for ARNP and PA mid level providers. If your office files claims without the appropriate provider number, the incorrect provider reimbursement is dispensed and a refund should be generated for the overpayments. If you are not sure if your office is filing with the correct provider number, please contact your CMFHP Provider Relations Representative. |
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What is the proper way to code a claim for more than one surgical procedure performed on the same day?CMFHP follows AMA and CMS guidelines to determine which CPT codes are to be identified for a payment reduction following multiple surgery guidelines. All services should be submitted on the same CMS1500 claim form. The highest relative value procedure will be paid at 100% of the allowable. Subsequent procedures should be billed with a 51 modifier. Subsequent procedures will be reduced, if applicable, following the multiple surgery guidelines outlined in your Provider Administration Manual. Bilateral procedures should be billed on one line with the 50 modifier. It is not correct to bill multiple units to signify a bilateral procedure. |
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What is the proper way to code a claim for a team surgery? (i.e. assistant surgeon, co-surgeon)Both surgeons must be of different specialties in order to meet the AMA guidelines describing a team surgery. Both providers must bill the procedures with a 62 modifier to describe their services. The procedure must be recognized by the AMA as a potential team surgical procedure. If the different specialty requirement is not met, then one surgeon should be the primary and assistant surgeon services identified using the 80 modifier. |
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How do I bill for services when the baby does not have a Kansas Medicaid ID number?Newborns of eligible plan members will be covered for expenses submitted under the mother's Beneficiary number for the first 45 days. The case where the mother is uninsured, the newborn's permanent Beneficiary number would have to be received before payment is rendered. |
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If I am a rural health care provider, how do I bill for services?If the service is for a RHC qualified service, you must bill with your CMFHP RHC group provider ID #/NPI # in order for you to be reimbursed correctly by CMFHP and the State. CMFHP uses this provider number to pull encounter data to the State for them to process your wrap payment for Title 19 members. For services provided that do not qualify as RHC, these services should be billed under the individual provider ID #/NPI #. For specialist's services within your RHC, you should also bill with their individual CMFHP provider ID#/NPI#. If the Primary Care Provider provides a non RHC services, you will need to bill using their individual provider ID#/NPI#. |
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Why are my emergency room charges being denied?You must bill with the emergency room revenue code of 450 with the appropriate evaluation and management code along with the ET modifier. |
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Why are my observation room charges being denied?You must bill with the observation room revenue code of 762 with the evaluation and management code 99218 along with the ET modifier. |
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What process do I follow when our practice is adding a new provider?Contact your Provider Relations Representative to inform them of the provider you are adding and they will send you the application. |
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What do I do when CMFHP has made duplicate claim payments to us?If you have a few, contact Customer Service and let them know which are duplicate payments and whether or not you want a letter sent or if we can recoup the duplicate payment on a future check. If you have more than a few, contact your provider relations representation who will work with you. |
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Why is taking so long to get a refund letter or for you to recoup the overpayment?Our IT Department has created a new system generated refund letter that our Claims Department just started using. We apologize for the delay but wanted to be sure we had a good process in place to handle these requests. |
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If I receive a refund letter and I disagree with it, who do I call?If it is regarding membership, please contact Customer Services Department and they will look into the problem. All other issues, please contact your Provider Relations Representative. |
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When will my providers be credentialed?When we started receiving all the applications last fall, we were allowed to do "provisional" credentialing since we already had a contract with the State. We received no less than 3 thousand applications and have been working very hard to get them caught up. Any of those that we had received prior to April 1st are in the provisional status. Any applications that we received after April 1st, we are handling as they come in. We had a temporary person helping out this summer and was able to get more providers through credentialing than normal. As those providers in the provisional status finish the credentialing process, a Welcome Letter is sent at that time so that you know that the credentialing process is completed. |
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Should I use the Vaccine for Children (VFC) for Children's Mercy Family Health Partners' members or our private stock?You must use your VFC stock as they are Medicaid members. |
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Should I use the Vaccine for Children stock for Title 19 and Title 21 members?Yes, you should use your VFC stock for both. |
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If there is primary insurance such as Blue Cross and then CMFHP is the secondary carrier, do I use our private stock or VFC stock?If the primary insurance carrier covers immunizations then you need to use your private stock. However, if the immunizations are not covered by the primary carrier or will be applied to their deductible by the primary carrier, then use your VFC stock. |
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Pharmacy Frequently Asked Questions (Kansas)
- How are medications chosen for inclusion on your Preferred Drug List (PDL)?
- As new information becomes available, the PDL may change from time to time. How can I best access the most current version of the CMFHP PDL?
- I get confused about when to complete a medication exception form and when to do a prior authorization on a drug listed in the CMFHP PDL. Can you help me?
- I would like to have a hard copy of the CMFHP PDL. Whom should I contact to get a copy for my office or pharmacy?
- What does it mean if a drug is listed in the formulary as a "step therapy"?
- Sometimes I have questions and need to talk with the pharmacy department directly. Who should I contact and what are their hours of operations?
How are medications chosen for inclusion on your Preferred Drug List (PDL)?Medications included in the CMFHP Preferred Drug List are chosen by an advisory committee called the Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is responsible for developing, managing, updating, and administering the PDL. The P&T Committee is comprised of primary care providers, specialty providers and pharmacists. Members are from both the Children's Mercy organization and our provider network. To ensure integrity in the decision-making process, all current and potential P&T members must disclose any potential conflicts of interest that may interfere with that individual's ability to evaluate therapeutic classes of medication in an unbiased manner. |
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As new information becomes available, the PDL may change from time to time. How can I best access the most current version of the CMFHP PDL?It is true that a good Preferred Drug List will evolve as new evidence and products become available on the market. Currently, the most up to date version of the PDL is available on the CMFHP website.In June 2007, CMFHP will also have its PDL accessible through Epocrates™. If you are a current user of Epocrates™, you will receive notification from Epocrates™ when the CMFHP PDL is available for your use. Each time the PDL is revised, the updated version will be available through both of these web-based tools. Updates and PDL changes will also continue to be communicated in pharmacy and provider newsletters that are distributed on a routine basis. |
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I get confused about when to complete a medication exception form and when to do a prior authorization on a drug listed in the CMFHP PDL. Can you help me?A medication exception form is required when you wish to have a medication for your patient that is not included in the PDL. You can find a medication exception form here.A prior authorization is required for a medication that is included in the PDL but is only approved for a patient that presents with specific clinical characteristics. For example, Sporonox capsules are listed in the PDL but require prior authorization before prescriptions for the capsules can be filled. Copies of the prior authorization criteria sets are posted on the CMFHP website in the Provider Resources section. Once you have responded to the questions on the prior authorization form, fax the form to Caremark for their review at 1-952-820-3513. If Caremark is unable to determine whether the prior authorization request should be approved, the request will be forwarded to CMFHP for the final determination. |
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I would like to have a hard copy of the CMFHP PDL. Whom should I contact to get a copy for my office or pharmacy?Historically, CMFHP has printed a hard copy of its PDL once per year. If you are a physician and have not received a copy of the PDL yet, please contact your Provider Relations Representative and he/she will be happy to provide you with one or more copies for your office. |
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What does it mean if a drug is listed in the formulary as a "step therapy"?Step therapy requires the use of one or more prerequisite drugs that meet specific conditions prior to the use of another drug or drugs. Medications that require step therapy are on the formulary, but will not be considered by Caremark unless qualifying medications are found in the members' medication claims history. Sample medication and prescriptions obtained by coupons are not considered for the qualification requirement. If the patient was previously with another fee-for-service Medicaid, we will not have the claims history. |
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Sometimes I have questions and need to talk with the pharmacy department directly. Who should I contact and what are their hours of operations?Pharmacy related questions can be directed to the CMFHP Authorization staff. To speak with a Prior Authorization staff member, please contact 1-888-691-4874 between the hours of 8am and 5pm CST. |
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