Prestige Tips for Billing and Auths in 2019 (Part 1)

Having Prestige troubles? Seems like they really pulled a fast one everyone by asking for the referring physician as part of their claims. This isn’t the only issue I’ve seen over the past few months as they assumed a much larger role as a FL Region 9 Medicaid MMA. I’m hearing a lot of concerns about missing payments, denied claims, authorization reductions, etc. That said, I wanted to share some tips/information for all those providers struggling with the “2019 Prestige Woes”.

I’ve separated this article into two sections to address the items that most providers are struggling with this year; Billing Errors and Fixing Denied Claims. Part 2 will cover Authorization challenges and tips for Prestige.

Billing Errors:

Issue #1 (Missing ROPA): On Jan 1st 2019, Prestige decided to start denying claims that didn’t include a Referring, Ordering, Prescribing, or Attending (ROPA) Physician’s name and NPI number. This came as a surprise to many providers as Prestige is the first MMA in Florida to require this information on claims. In fact, most outside billing agencies don’t even ask for the referring physician’s info before sending your claims; that’s a mistake. The MMAs are required by federal law to collect this information in order to approve reimbursements even though some don’t take the time to do so. Also note, they will NOT approve the claim if you list an NPI for a facility instead of the individual provider. Some providers are sending claims with facility NPIs listed and their claims are being denied yet again. This has been extremely frustrating for a lot of owners/providers over the past month.

Recommendation to fix: Put an individual provider’s name and NPI on your claims. If you need to look up an NPI, I use https://npidb.org/npi-lookup/ as a look-up tool.

Issue #2 (Ghost TPLs): Again, as of Jan 1st, Prestige had a system error that assigned some outdated or erroneous Primary Insurers to certain patients. This caused a number of claims to be denied for no TPL information. Your remittance documents should say as much but for many providers this was quite confusing since those patients never had TPLs. The good news is the damage is done and we shouldn’t see any more changes like that in the near future (I hope I don’t eat those words…fingers crossed).

Recommendation to fix: Call Prestige’s provider service line at (800)617-5727 option 2 for the claims department. Ask them to check the member’s account for a TPL Insurance and if there is one on file, ask them to send a request to their TPL department to check the patient’s eligibility for that TPL. They may automatically re-process all your claims and you may need to send corrected claims but that should fix the issue.

Issue #3 (COC): The Continuity of Care (COC) period for Prestige is over as of 2/1/2019. Unfortunately, they only approved most COC authorizations for 60 days through 1/31/2019. Again, very tricky of them.

Recommendation to fix: Make sure all your Prestige patients have a new authorization that begins on 2/1/2019.

Issue #4 (Place of Service): As of April 2018, Prestige outsourced the Home Health portion of their contract to a third-party administrator named “Coastal Care”. What does that mean to you? If you treat patients in Place of Service (POS) “12” or “Home”, your claims will deny and Prestige will say that you need to send those claims to Coastal Care. 

Recommendation to fix: Unfortunately, this seems to be an on-going issue as Coastal Care is supposed to manage “Home Health Agencies (HHA)” not therapy services provided at POS 12. While some therapy companies are designated as HHAs, most are just offices that also provide services in a home setting by request. I recommend you reach out to your provider rep and explain the difference so we can work together on a solution. 

Fixing Denied Claims:

Once claims are denied, there are a couple options for getting them fixed correctly. However, some are faster than others. Option #1 is to fix the claim information, add “7” in box 22 on the HCFA-1500 claim form, and the original claim ID # in box 22 to the right of the dividing line.

Then print and mail your corrected claims to:

Prestige Health Choice

ATTN: Claims Department

P.O.Box 7367

London, KY 40742

The easier and quicker option #2 is to sign up for a software named ClaimMD. ClaimMD is an electronic claims submission system and clearinghouse that allows you to submit corrected claims electronically to most insurers. You can use the system for a number of tasks but the basic package costs $100 per month and allows unlimited claims submissions. If you or your office staff spends 2-5 hours per month on sending these corrected claims then look no further; this should be a great fit for your office. The added bonus is that those claims batch to insurers within hours of submission so there’s no need to wait for snail mail and slow processing times any longer. Interested? Contact sales@claim.md and don’t forget to tell them I sent you.

I hope this helps improve your experience with Prestige as I know they can be frustrating at times but as long as you follow the rules they are actually one of the better Medicaid Payors to work with in Region 9. Proud of Region 9 for keeping ATA affiliates out in the cold down here! #Region9holdstheline

Stay tuned for Part 2 next week!