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["\n\n\n\n\n","Molina Healthcare of Ohio \nClaims Payment Systemic Errors ",null,null,null,"OCTOBER 2023"]
["The current Claims Payment Systemic Errors (CPSEs) are listed below. Resolved issues previously reported will be removed from this log, and may be found in archived reports. \nPlease review the log for updates prior to contacting Provider Services at (855) 322-4079."]
["Unique ID and Description of CPSE","Line of Business","Date CPSE was First Identified","Billing Provider Type(s) Impacted by CPSE (select all that apply)","Timeline for Fixing CPSE","Date(s) and/or Date Span(s) of Corrected Claims Adjustments","CPSE Status"]
["Unique ID:269\nConfirmed CPSE:\nNew Marketplace fee schedule allowed payments for BH codes listed on the TPL bypass list to process for payment. Due to the new fee schedule and the configuration to allow those payments, claims that should pay as primary for 84/95 providers stopped paying as primary and only processed under the Medicaid line of business if Marketplace allowed patient responsibility resulting in the provider being underpaid.  ","Medicaid & MyCare","2023-04-17","84-Ohio Department of Mental Health (Community Mental Health) Provider \r\n95-ODADAS Certified/Licensed (SUD) Treatment Program","2023-07-06","Workaround started 4/24/2023\nETA 10/14/2023\nAdjustment Batch 1 Completed 10/5/2023\nAdjustment Batch 2 Completed 10/4/2023\nAdjustment Batch 3 ETA 9/12/2023- 10/24/2023\nRecovery Batch 1 Completed 9/25/2023\nRecovery Batch 2 Completed 10/11/2023","Fix is complete"]
["Unique ID:275\nConfirmed CPSE:\nMolina received a incorrect file from our Credit Balance Vendor requesting offset in error when they meant to send a remit file. Molina is currently reviewing file to create refunds to Providers who claims were recouped in error when they submitted a refund check to Molina. ","Medicaid","2023-05-17","82-Ambulance\r\n01-Hospital (Outpatient)\r\n76-Durable Medical Equipment Supplier\r\n21-Professional Medical Group","2023-07-10","Checks reissued 4/20/2023, 5/9/2023, 5/18/2023, 5/25/2023, 6/13/2023, 6/20/2023, 8/10/2023, 10/2/2023","Complete"]
["Unique ID:279\nConfirmed CPSE:\nOn 12/1/2022 Cotiviti’s CV Edit 6268 DP 11471 was turned on, modification wasn’t made to exclude chiropractors from edit. They should be excluded due to ODM’s guidance and allowing chiropractor’s to bill an E/M with spinal manipulation on the same day with modifier 25 and the NCCI bundle would be bypassed for these services.   ","Medicaid","2023-06-16","27-Chiropractor Individual","2023-07-23","Adjustment Completed 9/13/2023","Complete"]
["Unique ID:281\nConfirmed CPSE:\nBH claims are incorrectly denying for inconsistent modifier(s) for providers with QMHS Specialties.","Medicaid & MyCare","2023-06-23","84-Ohio Department of Mental Health (Community Mental Health) Provider ","2023-08-25","Adjustment Batch 1 Completed 9/8/2023\nAdjustment Batch 2 Completed 9/13/2023","Complete"]
["Unique ID:282\nConfirmed CPSE:\nEmergency room claims for non emergent usage were being reimbursed at a higher level of care instead of being downcoded to lower level of care for E and M services per OAC 5160-2-77","Medicaid & MyCare","2023-07-13","01-Hospital (Outpatient)","2023-08-15","ETA 1/9/2024\nAdjustment ETA 9/7/2023-10/19/2023\n","Fix is complete"]
["Unique ID:284\nConfirmed CPSE:\nProviders that submit claims with attachments through Availity, the submission is either completely missing the attachment or the attachment is being delay causing some claims to deny.","Medicaid & MyCare","2023-07-19","00-All provider types","2023-08-08","ETA 1/15/2024\nAdjustment Completed 9/12/2023","Fix is complete"]
["Unique ID:285\nPotential CPSE:\nBH providers with specialty listed of Nurse Practitioner claims are denying for Ordering Provider in error.","Medicaid & MyCare","2023-07-28","84-Ohio Department of Mental Health (Community Mental Health) Provider ","ETA 11/25/2023","ETA 1/24/2024\nWorkaround started 9/25/2023","Ongoing \nremediation"]
["Unique ID:286\nPotential CPSE:\nMolina’s claim loader experienced intermittent slowness which causes incomplete loads in the pre-adjudication database.","Medicaid & MyCare","2023-08-02","21-Professional Medical Group\r\n95-ODADAS Certified/Licensed (SUD) Treatment Program","ETA 11/30/2023","ETA 1/29/2024\nWorkaround started 8/18/2023","Ongoing \nremediation"]
["Unique ID:288\nPotential CPSE:\nClaims for B4157-B4162 that requires an Invoice are paying in error when claim is received without the invoice. \n","Medicaid & MyCare","2023-08-03","76-Durable Medical Equipment Supplier","2023-08-10","No Adjustment Required","Complete"]
["Unique ID:289\nConfirmed CPSE:\nInpatient claims with DOS that span before and after 7/28/23 are pricing incorrectly.\n","Medicaid & MyCare","2023-08-09","01-Hospital (Inpatient)","2023-09-05","ETA 2/5/2024\nAdjustment batch 1 completed 9/19/2023\nAdjustment batch 2 completed 9/7/2023\nAdjustment batch 3  completed 8/25/2023","Fix is complete"]
["Unique ID:290\nPotential CPSE:\nOptum has identified an issue with the Medicaid APG Pro Pricer when multiple significant procedure discounting is being erroneously applied to claims lines that should receive full payment.","Medicaid & MyCare","2013-08-10","01-Hospital (IP & OP)","2023-08-22","ETA 2/6/2024","Fix is complete"]
["Unique ID:291\nConfirmed CPSE:\nMCPF solution is denying claims in error when the provider is actively registered with ODM","Medicaid & MyCare","2023-08-14","00-All provider types","2023-08-29","Adjustment Batch 1 Completed 9/13/2023\nAdjustment Batch 2 Completed 9/8/2023","Complete"]
["Unique ID:292\nPotential CPSE:\nOptum has identified an issue with the fee schedule rates for the Opioid Treatment Program (OTP) procedure codes  G2069-G2070, G2072-G2073. Incorrect fee schedule rates for these codes were inadvertently included in the APC and Physician Fee Schedule Data Files, effective 1/1/2023.  As a result, claim lines submitted with one of these procedure codes for dates of service on or after 1/1/2023, will receive incorrect reimbursement. \nAfter Final Review, NOT A CPSE ","Medicaid & MyCare","2023-08-14","01-Hospital (Outpatient)","2023-08-21","After Final Review, NOT A CPSE ","Complete"]
["Unique ID:293\nConfirmed CPSE:\nOn 8/15/23, one of our vendors reported a system error affecting add-on codes causing them to deny in error. The configuration saver tool was used to load the Q3 Knowledgebase on 8/12/23, this caused the files to return errors.\n","Medicaid","2023-08-15","84-Ohio Department of Mental Health (Community Mental Health) Provider \r\n95-ODADAS Certified/Licensed (SUD) Treatment Program\r\n12-Federally Qualified Health Center\r\n21-Professional Medical Group","2023-08-15","Adjustment ETA 10/9/2023 - 11/20/2023","Fix is complete"]
["Unique ID:294\nPotential CPSE:\nOutpatient hospital Medicare claims for the provider Bon Secours Mercy/Mercy Health Partners of SW OH have paid at the incorrect rate. This issue may have potentially impacted the Medicaid claim when coordination of benefits was applied.     \n","Medicaid & MyCare","2023-08-21","01-Hospital (Outpatient)","ETA 12/19/2023","ETA 2/17/2024","Ongoing \nremediation"]
["Unique ID:295\nConfirmed CPSE:\nOptum incorrectly calculating LTCH reimbursement for claims with a Thru or Discharge Date on or after 5/12/2023 and a From or Admission Date prior to 5/12/2023.","Medicaid & MyCare","2023-09-06","00-All provider types","2023-09-14","ETA 5/21/2024","Fix is complete"]
["Unique ID:296\nPotential CPSE:\nServices should have been configured within the non-par lab contract. \nAfter Final Review, NOT A CPSE ","Medicaid","2023-09-09","00-All provider types","ETA 3/2/2024 ","After Final Review, NOT A CPSE ","Complete"]
["Unique ID:297\nNew Potential CPSE:\nMMP Medicaid review was transferred in June 2022, from Ohio team to the MMP team, ACT attribute was not updated in QNXT resulting in claim denials. ","MyCare","2023-09-21","84-Ohio Department of Mental Health (Community Mental Health) Provider ","ETA 3/18/2024","ETA 6/11/2024","Ongoing \nremediation"]
["Unique ID:298\nNew Confirmed CPSE:\nHearing services paid incorrectly under the fee for services professional contracts.","Medicaid & MyCare","2023-09-26","76-Durable Medical Equipment Supplier","ETA 3/21/2024","ETA 6/14/2024","Ongoing \nremediation"]
["Unique ID:299\nNew Potential CPSE:\nMolina is incorrectly applying Patient Liability to claims when the member has a patient liability type is waiver or pro-rated waiver  ","Medicaid & MyCare","2023-10-04","00-All provider types","ETA 3/29/2024","ETA 6/25/2024","Ongoing \nremediation"]
["Unique ID:300\nNew Potential CPSE:\nQNXT is not sending all of the Inpatient procedure codes to AMS XML file causing invalid denials. An update is set to be released at the end of 10/2023, edit will be turned off until we can confirm QNXT update is installed and tested to ensure all logic and file transfers are correct. ","Medicaid & MyCare","2023-09-19","01-Hospital (Inpatient)","ETA 3/14/2024","ETA 6/7/2024","Ongoing \nremediation"]
["Unique ID:301\nNew Potential CPSE:\nClaims incorrectly rejected for “Member Not Found” error. Claim routing process between Molina HPs and lines of business failed to recognize the member billed on the claim as a Molina OH claim because a key table used to look up the member information failed to update on different dates in 2023. ","Medicaid","2023-09-01","00-All provider types","ETA 2/28/2024","ETA 5/22/2024","Ongoing \nremediation"]
["Unique ID:302\nNew Potential CPSE:\nOhio Medicaid outpatient claims are denying revenue code 250 lines for missing/incomplete/invalid procedure code. Per the Ohio Medicaid Hospital billing guidelines manual, no HCPCS is required for Ohio Medicaid claims when billed as outpatient.  ","Medicaid","2023-10-13","04-Outpatient Health Facility","ETA 4/8/2024","ETA 7/3/2024","Ongoing \nremediation"]

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["MCE Online CPSE Report Guidelines"]
["Each time a CPSE report is updated, the previous month's report is to remain available, at a minimum."]
["The date the report was posted is to be clearly visible at the top of the report."]
["Contact information should be clearly listed on each report for providers to utilize if they have questions."]
["If the MCE posts the online CPSE report to their provider portal where log-in access is required, a direct link to the online CPSE report is to be provided with the ODM report submission each month."]
["Template Column Header","Template Column Instructions"]
["Column A: Unique ID and Description of CPSE","• Each CPSE is to be given a unique identifier, stated at the beginning of the description.\n• In this column, a clear and complete description of the CPSE is required. The description needs to include specifically what is being impacted (e.g. procedure codes, modifiers, places of service, etc.). The description needs to be understandable at a high level to individuals outside of the MCE and should not include acronyms or MCE specific language.\n• Each CPSE needs to be labeled as a potential or confirmed CPSE. Once a potential CPSE is confirmed, the description needs updated. \n• If any previously reported CPSE is later found to not be a CPSE, the description needs updated to add a statement reporting that the issue was found to not be a CPSE. The issue may then be removed from the next report."]
["Column B: Date CPSE was First Identified","• In this column, the date the CPSE was first identified by the MCE and/or their contracted vendor is required. If the MCE was notified by their vendor on a date after the vendor identified the CPSE, the date the vendor identified the CPSE should be listed rather than the date the MCE was notified. "]
["Column C: Billing Provider Type(s) Impacted by CPSE (select all that apply)","• This column should include all billing provider types impacted by the CPSE. This information should be updated as needed if it changes.\n• This column refers to the billing provider, not the rendering provider.\n• Provider type \"00-All Provider Types\" is to be used sparingly and only when all provider types on the list could be and/or already are impacted by the CPSE.\n• There is a list of billing provider types on the \"CPSE Provider Types\" tab for reference that matches the drop down list on the template. If there is a provider type believed to be missing from the template, update the description in column A to include that provider type and notify ODM."]
["Column D: Timeline for Fixing CPSE","• This column should include the date(s) the system was fixed. An estimated date may be used until an exact date is known. This should be updated as needed. "]
["Column E: Date(s) and/or Date Span(s) of Corrected Claims Adjustments","• In this column, the individual date(s) and/or date span(s) for any corrected claims adjudication is required. This includes system and manual adjustments. An estimated date may be used until an actual date is known.\n• If a date span lasts over 30 days, a brief explanation as to the cause of the length is needed.\n• If the plan choses to not complete claim adjustments, that needs to be stated in this column.\n• If the plan has to process recoupments due to overpayments, that needs indicated in this column."]
["Column F: CPSE Status","• This column should report the status of each CPSE (e.g. ongoing, in progress, fix is complete, completed, etc.) and updated when it changes."]

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["ODM Provider Types","23-Acupuncturist"]
[null,"82-Ambulance"]
[null,"46-Ambulatory Surgery Center"]
[null,"68-Anesthesia Assistant Individual"]
[null,"74-Assisted Living Facilities"]
[null,"43-Audiologist, Individual"]
[null,"73-Certified Registered Nurse Anesthetist (CRNA) Individual"]
[null,"27-Chiropractor Individual"]
[null,"50-Clinic"]
[null,"65-Clinical Nurse Specialist Individual"]
[null,"30-Dentist, Individual"]
[null,"07-Dietitian"]
[null,"76-Durable Medical Equipment Supplier"]
[null,"59-End-Stage Renal Disease (Dialysis) Clinic"]
[null,"12-Federally Qualified Health Center"]
[null,"44-Hospice"]
[null,"01-Hospital (Inpatient)"]
[null,"01-Hospital (Outpatient)"]
[null,"01-Hospital (IP & OP)"]
[null,"79-Independent Diagnostic Testing Facility"]
[null,"80-Indepedendent Laboratory"]
[null,"52-Independent Marriage and Family Therapist"]
[null,"54-Licensed Independent Chemical Dependency Counselor"]
[null,"37-Licensed Independent Social Worker (LISW)"]
[null,"16 & 60-Home Health Agency"]
[null,"26-Non-Agency Home Care Attendant"]
[null,"25-Non-Agency Personal Care Aide"]
[null,"89-Non-State Operated ICF-IID"]
[null,"71-Nurse Midwife Individual"]
[null,"72-Nurse Practitioner Individual"]
[null,"86-Nursing Facility"]
[null,"41-Occupational Therapist, Individual"]
[null,"95-ODADAS Certified/Licensed (SUD) Treatment Program"]
[null,"84-Ohio Department of Mental Health (Community Mental Health) Provider "]
[null,"75-Optician"]
[null,"15-Optical Laboratories"]
[null,"35-Optometrist Individual"]
[null,"70-Pharmacy"]
[null,"69-Pharmacist Individual"]
[null,"39-Physical Therapist, Individual"]
[null,"24-Physician Assistant"]
[null,"20-Physician/osteopath, individual"]
[null,"36-Podiatrist Individual "]
[null,"81-Portable X-Ray Supplier"]
[null,"38-Private Duty Non-Agency RN or LPN"]
[null,"47-Professional Clinical Counselor"]
[null,"31-Professional Dental Group"]
[null,"21-Professional Medical Group"]
[null,"02-Psychiatric Hospital"]
[null,"03-Psychiatric Residential Treatment Facility (PRTF)"]
[null,"42-Psychologist, Individual"]
[null,"05-Rural Health Clinic"]
[null,"40-Speech Language Pathologist, Individual"]
[null,"88-State Operated ICF-IID"]
[null,"55-Waivered Services Individual "]
[null,"45-Waivered Services Organization"]
[null,"83-Wheelchair Van"]
[null,"00-All provider types"]