Adjustments
System Problems
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Adjustment Process
Adjustment requests may be submitted to DHS for enrollees who are incorrectly enrolled in or disenrolled from MCOs due to systems problems. Errors specific to MCO enrollment/payment should be reported your DHS Enrollment Coordinator.
MCO coverage may need to be adjusted outside the first year MCO change or open enrollment periods. Adjustment requests may be filed by county staff, the state ombudsman, MCOs or MinnesotaCare Enrollment Reps and sent to DHS Enrollment Coordinators for processing. Adjustments are reviewed by DHS staff before a decision is made. In some instances, looking up information on the system is sufficient. In other cases, calling the MCOs involved, the workers, if needed, and in other instances, contacting the recipients themselves may be necessary to make the most appropriate decision. Much of this can be completed and resolved at the county level, as the county is the first point of contact. Counties need to notify the affected MCO(s) of an adjustment as soon as possible, both by phone and in writing.
County staff may send Adjustment Requests through DHS-SIR Mail (MMIS tab) using Web Form Link: MADJ
MinnesotaCare staff may send newborn adjustments on MS-Outlook to e-mail address: DHS HPEN/MADJ
In certain instances DHS staff will notify the worker that coding must be corrected. This coding must be corrected before an adjustment can be made. If coding is not corrected, the adjustment will be denied, possibly resulting in reduced or no service to the recipients and possible billing problems.
Please include the following when requesting an adjustment:
If an adjustment is approved and processed as requested, the payment or recovery claim on the remittance will be the sole notification from the State to the MCO. If an adjustment request has been modified or denied, the State will respond to the person submitting the request via the same format the request was received. i.e. to the county via email, to the MCO via fax.
MinnesotaCare may submit adjustments by e-mail to DHS HPEN-MADJ with “Newborn Adjustment” in the subject line.
Adjustments
Adjustment Types
Due to continuity of care issues there may be situations that do not fit any of the policy examples listed below. If you have a case that does not fit the policy example or you think is different, please contact your DHS Enrollment Coordinator to discuss the case.
Basis of Eligibility/Change in Major Program
When there is a change in major program or eligibility type which affects managed care, the worker will enter the managed care change on MMIS effective the next available month. For MinnesotaCare enrollees who become pregnant, the major program change would be effective, on RELG, retroactively to the confirmed date of conception. The MCO is only responsible to cover the benefit set they received a capitation payment for. That benefit set is reflected by the product id on RPPH. Services covered by the increased benefit set should be submitted to DHS on a fee-for-service basis. There will not be adjustments in these situations.
MinnesotaCare Example 1
The prepaid MinnesotaCare enrollee is active with major program “BB” eligibility for January, February and March. On March 10, the enrollee provides documentation regarding her pregnancy. The documentation confirms the date of conception as being in January. On RELG the rep would correctly replace the major program “BB” eligibility span with a major program “LL or KK” span with an effective date of 1/1. A new MCO enrollment span will systematically be added to RPPH with the new product id with an effective date of 4/1.
If the change in address involves a change in county of residence the financial worker should be sure to complete all eligibility updates on MMIS prior to changing the case address on MAXIS. This is particularly important to avoid potential managed care edits that would apply to the new county of residence. It is not necessary to update the RPPH screen. MMIS will redetermine MCO availability for the new county of residence at the next capitation that follows the move. The MinnesotaCare rep will enter the address change after the monthly billing cycle/cut-off, but before the managed care enrollment cut-off in the month before the change is effective. There will not be adjustments in these situations.
PMAP Example 1
The enrollee contacts the worker 12/1 stating they are going to move to a new county on 1/1. The worker updates the address on the system but does not transfer the case to the new county until the enrollee has moved. DO NOT update RPPH before transferring cases on SPEC/XFER in MAXIS.
PMAP Example 2
The enrollee contacts their worker after managed care cut-off to report their move out of state. They request their case closed as soon as possible. Since the capitation payment has already been issued to the MCO for next month the earliest the worker can close MCO enrollment is the last day of the next month.
MinnesotaCare Example 1
The member moves on 1/12 to a county that does not have the member’s MCO. On 1/30 the enrollee notifies the rep that the move has occurred. As the February capitation was issued, when the rep enters the change the system will close the RPPH span effective 2/28 and create a new MCO span effective 3/1.
Minnesota Care Example 2
The enrollee contacts the rep 12/1 stating that they are going to move 3/1. The rep does not change the address on the system until February. This change must be entered after the monthly billing cycle/cut-off, but before the managed care enrollment cut-off in February. When the worker enters the change the system will determine the action needed for managed care enrollment.
Coding Error
When there is a coding error the worker or rep will enter the correction on MMIS effective the next available month. Situations will be looked at on an individual basis to determine the need for an adjustment.
PMAP Example 1
On 1/5 the worker codes the enrollee into the wrong MCO effective 2/1 and the error is discovered by the enrollee on 1/8 via the enrollment notice. The enrollee contacts the worker regarding the error on 1/8. Since the February capitation has not been paid, the worker should delete the wrong enrollment span and enter the correct enrollment span. This is not an adjustment situation.
PMAP Example 2
On 1/5 the worker codes the enrollee into the wrong MCO effective 2/1 but the error is not discovered by the enrollee until after capitation when they receive the MCO membership packet. The enrollee contacts the worker regarding the error. The worker is unable to correct the error for February as a capitation payment has been paid. The worker should explain this to the enrollee and determine if this will cause a problem for the enrollee. If the enrollee and the worker determine that there will not be access problems then the worker will change the MCO effective 3/1. If the enrollee and the worker determine a continuity of care issue exists, contact your DHS enrollment coordinator before submitting an adjustment. Exceptions will only be allowed as a last resort.
PMAP Example 3
The PMAP case is autoclosed for 12/31, but the system creates one month rolling medical eligibility for January. If the enrollee provides the verification after managed care capitation, but on or before the last business day in January, and the worker does not remove the end date on RPPH this will be considered a coding error. If this does not cause service issues for the recipient, then the worker will code the recipient into the MCO effective 3/1. If there is a continuity of care issue, contact your DHS enrollment coordinator regarding a possible adjustment to reenroll the client into the MCO.
MinnesotaCare Example 1
On 1/5 the enrollment form is scanned incorrectly and codes the enrollee into the wrong MCO effective 2/1 and the error is discovered by the enrollee on 1/8 via the enrollment notice. The enrollee contacts MinnesotaCare regarding the error on 1/8. MinnesotaCare will notify the managed care enrollment coordinator to delete the wrong enrollment span and enter the correct enrollment span, since the February capitation payment has not been paid. This is not an adjustment situation.
MinnesotaCare Example 2
On 1/5 the enrollment form is scanned incorrectly and codes the enrollee into the wrong MCO effective 2/1 but the error is not discovered by the enrollee until after capitation when they receive the MCO membership packet. The enrollee contacts MinnesotaCare regarding the error. The MCO enrollment cannot be corrected for February, as a capitation payment has been paid. MinnesotaCare should explain this to the enrollee and determine if this will cause a problem for the enrollee. If it is determined that there will not be access problems then MinnesotaCare will notify the managed care enrollment coordinator to change the MCO effective 3/1. If a determination is made that a continuity of care issue exists and the enrollee needs to access services through the correct MCO, an adjustment must be requested. The MCOs will need to be notified of the situation and the need for an adjustment. When there is a phone-in coding (enrollment error) for Prepaid MinnesotaCare, MinnesotaCare will notify the enrollment coordinator to enter the correction on MMIS.
Death
When medical eligibility is terminated due to death, capitation payments issued for any month(s) following the month of death must be recovered. Death adjustments no longer need to be requested through MADJ. DHS identifies and recovers any capitation claims after the date of death. These recoveries are identified through an MMIS report created monthly.
Enrollment Form Error
When there is an enrollment form error (i.e., client error), the client must complete a new enrollment form. After a new enrollment form is received, the county worker or managed care enrollment coordinator will enter the correction on MMIS effective the next available month. There will not be adjustments in these situations. (For any system related problems associated with system maintained enrollment form information contact your DHS Enrollment Coordinator).
Incarceration
An MA recipient who is incarcerated loses MA eligibility. When the worker fails to close MA eligibility and if at initial enrollment the enrollee is incorrectly enrolled into PMAP, the enrollee should be coded out of the MCO when the mistake is discovered and an adjustment should be requested to recover capitations paid to the MCO erroneously. If the enrollee has been enrolled in PMAP ongoing, the enrollee must be disenrolled from the MCO the first of the next available month. There will not be adjustments in these situations. A MinnesotaCare enrollee who is incarcerated loses MinnesotaCare eligibility at the time of their renewal of eligibility. A MinnesotaCare applicant residing in a correctional or detention facility is not eligible for MinnesotaCare. See Provision of Services for Incarcerated Persons. There will not be adjustments in these situations.
Inpatient Adjustments
All MA MCO contracts specify that when termination takes place due to ineligibility for MA or for participation in the prepaid MA program and the enrollee is hospitalized in an acute care facility on the effective date of ineligibility, MCO coverage will cease on the first day following discharge from the hospital. The State will not pay to the MCO a capitation payment for any month after the month in which the enrollee’s eligibility for MA or MinnesotaCare was terminated. Actual dates for admission and discharge must be part of all documentation.
Inpatient at Time of Enrollment, PMAP
MCO coverage of clients who are hospitalized in an acute care facility at the time coverage otherwise would become effective shall commence the first of the month following the month of discharge from the hospital. An adjustment should be requested to recover the capitation paid to the MCO.
Example:
The enrollee is enrolled into the MCO for 2/1. On 1/28 the enrollee is hospitalized. On 2/5 the enrollee is discharged from the hospital. The capitation payment for February would need to be recovered. The worker or the MCO should send an adjustment request.
Inpatient at Time of Enrollment, MinnesotaCare
MCO coverage of MinnesotaCare enrollees who are hospitalized in an acute care facility at the time coverage otherwise would become effective shall commence upon discharge from the hospital. MN Statute 256L.05 subd.3. An adjustment is not necessary in these situations.
Example:
The enrollee is enrolled into the MCO for 2/1. On 1/28 the member is hospitalized. On 2/5 the enrollee is discharged from the hospital. The capitation payment for February would not be recovered. MCO coverage begins at midnight on the day after discharge from the hospital. The MCO is not responsible for any hospital related claims through the date of discharge.
Inpatient at Time of Enrollment, MSHO Enrollee
MSHO enrollees who are hospitalized in an acute care facility on the first effective date of coverage will remain in the MCO. Hospital costs for the stay begun before enrollment shall not be the responsibility of the MCO. An adjustment is not necessary in these situations.
Example:
The enrollee is enrolled into MSHO for 2/1. On 1/28 the enrollee is hospitalized. On 2/5 the enrollee is discharged from the hospital. The capitation payment for February would not be recovered. MSHO coverage would begin 2/1. The MCO is not responsible for any hospital related claims through the date of discharge. An adjustment is not necessary in these situations.
Inpatient at Time of MCO Change
PMHCP enrollees’ who are hospitalized in an acute care facility on the effective date of their enrollment into a different MCO, ex. first year change, open enrollment, etc. will not be allowed to change MCOs until the month following their discharge. The MCO in effect at the time of hospital admission is responsible for the enrollee’s benefit set through the end of the month of discharge. An adjustment should be requested to recover the capitation paid to the new MCO along with a request to pay the old MCO.
Placements in State Institutions
For recipients who are in a state institution, including Regional Treatment Centers (RTC), Institutions for Mental Disease (IMD), and state-operated long term care facilities at the time of initial enrollment in the MCO, the effective date of enrollment will be delayed until the month following the enrollee’s discharge from the facility. Prior to requesting the adjustment, the county financial worker should end MCO enrollment and enter “ZZ” exclusion for the next available month. An adjustment should be requested to recover the capitation paid to the MCO. If the MCO places an enrollee in a state institution, for acute care services, or the enrollee is placed by court order the enrollee will remain enrolled in the MCO. If, via the placement, the enrollee is placed in an RTC bed licensed as an inpatient bed MinnesotaCare inpatient co-pays and limitations will apply to the applicable MinnesotaCare benefit sets.
Example:
The enrollee is initially enrolled into the MCO for October 1. On 9/27 the enrollee enters a Regional Treatment Center (RTC). The county financial worker should end MCO enrollment effective 10/31 and enter “ZZ” exclusion effective 11/1. The county financial worker or MCO should request an adjustment to recover the October capitation.
Newborn
For newborns born on or after 10/1/04, to a mother covered by a MCO for the month of birth, by contract DHS guarantees retroactive payment to the same MCO for an eligible newborn for the birth month, unless the newborn meets an exclusion reason (see PMAP Excluded Populations). If the newborn is enrolled into the MCO on MMIS within 90 days of birth, the MCO will be paid retroactively for the birth month and all succeeding months unless a MCO change is requested. Submit an adjustment request through DHS- SIR Web Mail using e-mail address MADJ to pay the MCO for the appropriate month(s). If the newborn is not added to the case within 90 days, the county should enroll the newborn for the next available month and request a payment adjustment to pay the MCO for the birth month only. Newborns born between 10/01/03 and 09/30/04 should be added to the same MCO mom is enrolled in for the next available month, meeting managed care cut-off, based on when the baby is added to the case. There is no need for an adjustment request in these situations. MinnesotaCare newborns follow MA policy, submit an adjustment request via Outlook email to HPEN, subject line “Newborn Adjustment”, to add retroactive MCO coverage for newborns born on or after 10/01/04. MMIS will automatically open MCO enrollment for newborns born before 10/01/04 for the next available month.
Payment Application Error
If the MinnesotaCare premium payment is applied to the wrong obligation it may result in either a delay in enrollment or a non payment cancellation. If this happens and the enrollee is given retroactive MinnesotaCare eligibility, the enrollee will have fee-for-service coverage.
Reinstatement
An enrollee whose termination from the MCO has been entered into MMIS by the monthly managed care enrollment cut-off date may be reinstated for that month with no lapse in coverage, if medical eligibility is reestablished and entered into MMIS on or before the last working day of the month. This will result in an appropriate retroactive capitation payment. No adjustment should be requested in this situation.
System Error
If the system prevents or inaccurately enrolls a client into managed care, contact your DHS Enrollment Coordinator.
TPL
For enrollees who have private prepaid health care coverage through an MCO, the MCO must coordinate benefits in accordance with MN Rules Part 9505.0070 and Minnesota Statute section 62A.046. There will be no adjustments in these situations.
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