Wednesday, September 29, 2010

UB 04 - Claims Processing

The federal government requires DMAP to process Medicaid claims through an automated claim processing system known as MMIS - the Medicaid Management Information System. This system is a combination of people and computers working together to process claims.

Paper claims submitted by mail go first to the DHS Office of Document Management (ODM) Imaging Unit.

 The document is scanned through an Optical Character Recognition (OCR) machine and the claim is given an Internal Control Number (ICN).
 The scanned documents are then identified and sorted by form type and indexed by identifiers such as client name, prime identification number, the date of service, and provider number.
 Finally, the data and images are stored on an Electronic Document Management System (EDMS).
Once the claim is scanned through the Optical Character Reader, staff can immediately access submitted claim information by checking certain MMIS screens. The fewer questions the computer asks, the more quickly it can process the claim.

The system performs daily edits for presence and validity of data. Once a week, the system audits all claims to ensure that they conform to medical policy. Every weekend, a payment cycle runs, and the system produces checks for claims that successfully pass all edits and audits.

DMAP staff members will see the claim only if MMIS cannot make a payment decision based on the information submitted. The system directs the claim to DMAP staff for specific medical or administrative review. This type of claim is a suspense (suspended) claim.

DMAP does not return denied claims to providers. Instead, DMAP mails a listing of all claims paid and/or denied to the provider (with payment if appropriate). The listing is called a Remittance Advice (RA).

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