Frequently Asked Billing Questions from Providers
Q: When can I submit claims to Empower?
A: Since Empower coverage takes effect on March 1, 2019, providers will be able to submit claims for services rendered to eligible members beginning that day, for any covered services rendered March 1.
Q. How and when can I access information electronically about Empower Members?
A: Empower’s Provider Portal allows providers to verify member eligibility, request and track authorizations, view claims payment history and status, view EOPs, and see other information and updates from Empower’s Provider Relations team.
Beginning March 1, 2019, contracted providers may visit our website at www.getempowerhealth.com. Under the Provider Tab select Provider Portal and enter User Name and Password. If you are not registered, click “here” to self-register, and follow the instructions.
Q: How can I verify eligibility of a member?
A: Providers will be able to verify eligibility through Empower’s Provider Portal or through our IVR call system at 855-429-1028 beginning March 1, 2019. You will need the member’s name, date of birth, or Empower ID.
All claims submitted to Empower must have the member’s unique Empower Identification number which can be found on our portal, on a member’s ID card, or by calling our Provider Call Center at 855-429-1028.
Q: Can I submit a claim electronically?
A: Providers are encouraged to participate in Empower’s electronic claims/encounter filing program. Empower can receive ANSI X12N 837, or most current version, professional, institution, or encounter transactions. Empower can also generate an ANSI X12N 835, or most current version electronic remittance advice known as an Explanation of Payment (EOP).
Electronic billing has many benefits to providers. For example, electronic billing reduces your overhead and administrative costs. EDI eliminates the need for paper claims submission. It has also been proven to reduce claim rework (adjustments). Electronic claims have a faster transaction time, as well. An EDI claim averages about twenty-four (24) to forty-eight (48) hours from the time it is sent to the time it is received. This enables providers to easily track their claims. Providers that bill electronically have the same timely filing requirements as providers filing paper claims.
Providers that bill electronically also must monitor their error reports and EOPs, to ensure all submitted claims and encounters appear on the reports. Providers are responsible for correcting any errors and resubmitting the affiliated claims and encounters.
Q: Who is Empower’s clearinghouse?
A: Providers may use different products to bill electronically. Providers may submit claims electronically as long as the software has the capability to send EDI claims to Change Healthcare (formerly Emdeon) through either direct submission or through another clearinghouse/vendor. Electronic Companion guides will be available on our Provider Forms and Resources webpage.
Q: What is Empower’s Payor ID?
A: The Empower Payor ID is 12956.
Providers without Change Healthcare EDI capabilities who are interested in electronic claims submission may contact the Change Healthcare Sales Department at (877) 469-3263, option 6. Providers may also choose to contract with another EDI clearinghouse or vendor who already has EDI capabilities.
After the registration process is completed and providers have received all certification material, providers must:
- Read over the instructions carefully, with special attention to the information on exclusions, limitations, and especially, the rejection notification reports.
- Contact their system vendor and/or Change Healthcare to initiate electronic submissions to Empower (provide Empower Payor ID 12956).
Q: Can I submit a paper claim? What if we do not have a clearinghouse?
A: Providers without electronic billing capability may also submit paper claims using the appropriate National Standard Claim Forms. Claims for professional services and durable medical equipment should be submitted on a CMS-1500 (formerly HCFA 1500) form and claims for hospital based inpatient and outpatient services on a UB-04 (CMS 1450) form. All paper claims should be mailed to:
Empower Healthcare Solutions LLC
PO Box 211446
Eagan, MN 55121
Q: Can I submit batched claims?
A: Yes, providers who do not have an existing relationship with a clearinghouse will need to contact our Provider Relations team to inquire about electronic web submissions through Change Healthcare at EmpowerHealthcareSolutionsPR@Empowerhcs.com.
Q: What claims are excluded from electronic billing?
A: Certain claims are excluded from electronic billing. At this time, the following claims must be submitted on a paper claim:
- Letters of Agreement (LOA) or Single Case Agreements
- Sterilization claims accompanied by appropriate consent forms
- Services provided for members with Commercial Insurance or Medicare Advantage as primary (for these claims, providers must first submit to the primary and then submit any remainder or copays/coinsurance, or other services covered by Empower that were not covered by the primary on a claim form with the EOP/EOB attached from the primary insurer)
- Providers billing on a UB-04/CMS-1450 form that are contracted with vendors that are not transmitting through Change Healthcare
Q: What are the timely claims filing standards for Empower?
A: In accordance with state and Federal requirements, providers must file claims within 365 days from the date of service. The original clean claim must be submitted within 365 days from the date of service and must include all necessary information as outlined in the following sections. In addition, all codes used in billing must be supported by appropriate medical record documentation. A clean claim is defined as a claim for reimbursement submitted to Empower by a health care practitioner, pharmacy or pharmacist, hospital or person entitled to reimbursement that contains the required data elements and any attachments requested by Empower.
Resubmission of previously processed claims with corrections and/or requests for adjustments must be submitted within ninety (90) days of notification of payment/denial. Claims originally rejected for missing or invalid data elements must be corrected and resubmitted within the timeframe identified in the provider agreement. Rejected claims are not registered as received in the claims processing system.
Q: How can I ensure that my electronic claims are not denied?
A: Providers can ensure claims are not denied by the following:
- Verify that all required fields are completed on the CMS-1500 or UB-04 forms
- Verify all diagnosis and procedure codes are valid for the date of service
- Verify referral for specialist or non-primary care physician claims
- Verify enrollee eligibility for services under Empower during the time period in which services were provided
- Verify the services were provided by a participating provider or that the “out- of-network” provider has received authorization to provide services to the eligible enrollee (excluding “self-referral” types of care)
- Verify whether there is Medicare coverage or any other third-party resources and, if so, verify that Empower is the “payer of last resort” on all claims submitted to Empower
- Verify that an authorization has been given for services that require prior authorization by Empower
- Verify that the provider is enrolled with Arkansas Medicaid during the claim date of service and that the claim includes the appropriate NPI code and taxonomy code on file with Arkansas Medicaid (atypical providers, as defined by the state of Arkansas, are not required to submit an NPI. These providers should instead provide the Medicaid ID on loop 2010BB-REF02 segment or for a paper claim, on box 33 or G2).
Q: What if my claim rejected for missing NPI or incorrect NPI?
A: All providers need to make sure that their information is correct with Arkansas Medicaid/DXC. Your NPI, Name and Address need to be correctly registered with Arkansas Medicaid and must match your current W-9 form as provided to Empower.
In order to report your NPI, log on the Arkansas Medicaid HealthCare Provider Portal by entering your user ID and password. Proceed by following the steps to report your NPI. If you have already reported your NPI number to Arkansas Medicaid, your NPI information has been successfully linked to your Arkansas Medicaid Provider number.
If you have any questions or problems regarding your NPI, contact Provider Enrollment at (501) 376-2211 (for local or out-of-state calls) or at (800) 457-4454 (toll free).
Providers who are not eligible for an NPI will continue to use their Arkansas Medicaid provider ID as always.
Q: How can I file a request for appeal, correct a claim, or request a refund?
A: Rejected claims are defined as claims with invalid or missing data elements (such as the provider tax identification number) that are returned to the provider or EDI source without registration in the claims processing system. Since rejected claims are not registered in the claims processing system, the provider must re-submit corrected claims within 365 days from the date of service. This requirement applies to claims submitted on paper or electronically. Denied claims are different than rejected claims and are registered in the claims processing system, but they do not meet requirements for payment under Empower guidelines.
When a claim is denied because of missing or invalid mandatory information, the claim should be corrected, marked as a second submission or a corrected claim, and resubmitted within ninety (90) days of notification of payment/denial either electronically or to the general claim address:
Empower Healthcare Solutions LLC
PO Box 211446
Eagan, MN 55121
If you believe there was an error made during claims processing or if there is a discrepancy in the payment amount, you will be able to call the Provider Services line. Our team of representatives can help you resolve the issue or advise whether a corrected claim or a written appeal needs to be submitted. Please submit Claims Issue Forms to the P.O. Box above.
Providers have the right to appeal the outcome of a claim. The appeal must be submitted in writing and received within 90 days of the last process date and include supporting documentation. The Plan will respond to the appeal within thirty (30) days from the receipt date with a determination or status of the review.
The provider will receive written notification of the outcome of the appeal whether it is upheld or overturned. All upheld determinations will be sent to the provider in a letter with the reason the plan upheld the appeal. Any appeals overturned by the plan will be reprocessed, and the provider will receive an explanation of payment (EOP) as notification.
Resubmitted claims should be resubmitted on paper. Corrected claims can be sent electronically. All corrected claims should have the corrected claim indicator (a 7) on the claim and the original claim number that you are correcting.
Q: How can I check the status of my claim?
A: Providers may view claims status using any of the following methods:
- Online – Check eligibility/claims status by logging into Empower Provider Portal at http://www.getempowerhealth.com
- Telephone – You may also check eligibility and/or claims status by calling Empower at (855) 429-1028.
- Real-Time – Depending on your clearinghouse or practice management system, real-time claims status information is available to participating providers.
Q: I would like to set up EFT/ERA to be paid electronically. How and when can I do this?
A: Just as the state of Arkansas offers electronic funds transfer (EFT) for Medicaid providers today, Empower will offer electronic payment to its provider network. Empower is working with InstaMed to deliver claim payments via electronic remittance advice (ERA) and EFT. ERA/EFT is a convenient, paperless and secure way to receive claim payments. Funds are deposited directly into your designated bank account and include the TRN Reassociation Trace Number, in accordance with CAQH CORE Phase III Operating Rules for HIPAA standard transactions.
Additional benefits of ERA/EFT include:
- Accelerates access to funds with direct deposit into your existing bank account
- Reduces administrative costs by eliminating paper checks and remittances
- Avoids disruption to your current workflow – there is an option to have ERAs routed to your existing clearinghouse
To expedite payment, you can sign up for Instamed Payer Payments. Visit www.instamed.com/eraeft. Even if you are currently enrolled with Instamed, you will be able to add Empower to your Instamed profile closer to March 1, 2019 (Empower Payor ID 12956).
Q: Can I bill the member for covered services if the usual and customary fees are greater than the fee schedule?
A: Empower will only reimburse providers for services that are medically necessary and covered through the PASSE program. Payments made to providers by Empower for Medicaid covered services for Empower members are considered payment in full. Providers are not allowed to bill (also called “balance bill”) members for any covered services provided, even if the provider’s usual and customary charge for the covered services is greater than what is allocated in the Empower fee schedule. Providers also may not make arrangements to provide costlier services or items than those covered by Empower on the condition that the member supplement payments made by Empower.
Q: How do I submit claims as an atypical provider?
A: Atypical providers can submit claims using their Medicaid ID number if they do not have an NPI. CMS defines atypical providers as providers that do not provide health care. This is further defined under HIPAA in Federal regulations 45 CFR section 160.103. Taxi services, home and vehicle modifications, and respite services are examples of atypical providers reimbursed by the Medicaid program. If you are an atypical provider that does not have an NPI, submit your Arkansas Medicaid ID in loop 2010BB in REF02 on the EDI claim or box 33 or G2 on a paper claim.
Q: How should I handle members with Medicare and PASSE coverage?
A: Like all Medicaid programs, the PASSE program is considered the payer of last resort. If medical services are provided to a patient who is entitled to, and is enrolled with, coverage within the original Medicare and Medicaid benefits, it is necessary to file a claim only with Medicare. The claim must be filed according to Medicare’s instructions and sent to the Medicare intermediary. The claim should automatically cross to Medicaid if the provider is properly enrolled with Arkansas Medicaid and indicates the beneficiary’s dual eligibility on the Medicare claim form. When the original Medicare plan intermediary completes the processing of the claim, the payment information is automatically crossed to Medicare’s Coordination of Benefits Agreement (COBA) process and from there crossed to Empower for processing. This process does not include Medicare Advantage. For members with a Medicare Advantage plan, you should follow the same instructions for members with commercial coverage above.
Q: Do I have submit the PA# from the previous vendor when I submit claims?
A: You can submit the prior authorization number from a previous vendor but it is not required.
Q: How do I update address or changes to provider information?
A: To make sure that Empower can process your claims in a timely manner, it is important that providers ensure Empower has accurate billing information on file. Providers also must have a current, active Arkansas Medicaid Provider ID. In addition, information on file with Empower must match the state’s file to avoid delays in payment.
Please confirm with Empower’s Network department (Empower.Network@empowerhcs.com) that the following information is current in our files:
- Provider name (as noted on current W-9 form)
- National Provider Identifier (NPI)
- Tax Identification Number (TIN)
- Taxonomy code
- Physical location address
- Billing name and address (as noted on current W-9 form)
Q: I have additional questions about claims/billing. Who can answer my questions and when can they answer them?
A: Empower’s Provider Services team will be available to help you via phone Monday through Friday (except holidays), from 8:00 AM to 5:00 PM CT. The Empower Provider Manual will also have more information and is posted at www.getempowerhealth.com under the Provider Tab. You may also reach out to your provider relations representative for assistance at EmpowerHealthcareSolutionsPR@Empowerhcs.com.