How you will benefit

• Automated Voice Response (AVR)
• Claims processing
• Prior Authorization (PA)
• Self-service on the Web  

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Automated Voice Response (AVR)

The AVR is the phone-based eligibility verification system that will replace DHS’ current Automated Information System (AIS). With the AVR, providers will have increased access to client and billing information, including:

• Ability to inquire on the eligibility of up to 25 clients in a single phone session.
• Receipt of a faxed copy of the eligibility verifications.
• Ability to inquire on claim and PA status.

Access to this information will assist the provider with providing appropriate services to clients, as well as assist DHS with making timely and accurate claim payments. For more information about the kind of information you will be able to access using the AVR, click here to open a PDF file.

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Claims processing

For all claims, the replacement MMIS will:

• Process claims in real-time throughout the day, with payments processed on a weekly claim cycle.
• Pay, suspend or deny according to edits and audits to the fullest extent possible.
• Be flexible enough to support varying claim volumes as necessary.
• Provide ability to adjust submitted claims via the secure Provider Web Portal.
• Accept claim submissions of up to:
  • 999 detail lines
  • $9.999,999.99 payment per detail line
  • $99,999,999.99 total claim payment

It also specifically expands claim processing capabilities in the following ways:

EDI claims: Providers will be able to submit up to 999 detail lines via EDI transactions, and perform individual or batch adjustments to previously submitted claims. DHS will continue to support the process of accepting claims with secondary payer information, such as Medicaid-Medicare crossover claims. For more information about EDI changes, go to the EDI page of this site.

Paper claim processing: Use of standardized claim forms for all claims submitted (e.g., CMS-1500 and UB04) will allow quicker, more accurate entry of paper claims into the system. As a result, DHS will transition from unique claim forms to national forms. DHS will also continue to accept DMAP 1036 (Individual Adjustment Requests) and DMAP 505 (Medicaid-Medicare crossover) forms.

Web claims: Providers will able to submit single claims via the new Provider Web Portal, where providers will receive immediate responses indicating whether the claim will suspend, deny or pay. 

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Prior Authorization (PA)

Providers will have two new options for submitting PAs: The Provider Web Portal for online PA submissions, and the HIPAA-compliant EDI 278 transaction.  These processes will gather most of the information needed for DHS to review and make decisions on PAs. Providers can submit additional information via fax or mail as needed.

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