Vendor QA Review

Owned by Tracy Archuleta
Last updated: Apr 21, 2022 by Emily Goleski
6 min read

Non-Medicaid Recoupment

Falling Colors, Inc., as the Administrative Services Organization (ASO) for The Behavioral Health Collaborative, is the payer of last resort for adult BH services funded by the Behavioral Health Services Division (BHSD).  Services for members covered under Medicaid benefits must be billed to the Managed Care Organization (MCOs) or Fee for Service (FFS) Medicaid.  Likewise, services covered by other third-party payers, whether public or private, must be billed to the appropriate payer(s).  Services covered by Medicaid or other payers that have been billed inappropriately to Falling Colors but paid will be recouped by BHSD.  Also, non-Medicaid funds cannot be used to balance bill the unpaid portion of billing by another payer, such as deductibles, co-pays, or amounts exceeding treatment limits.

Audits of payments for Non-Medicaid services will occur on an ongoing basis. BHSD has set the following rules in place to audit claims paid through non-Medicaid funds.  The recoupment details are intended to assist providers in how to appropriately bill non-Medicaid funding.

Client Eligibility

Vendors are responsible to determine the eligibility of a client at the time service is rendered. Non-Medicaid funds are intended for services to individuals not covered by Medicaid. Vendors must check the Medicaid portal prior to administering a service for non-Medicaid reimbursement. By submitting a service for non-Medicaid reimbursement, Vendors are attesting that they have verified a client’s non-Medicaid eligibility. Done here: https://nmmedicaid.acs-inc.com

Depending on the specifics of the scopes of work, additional eligibility criteria may exist. If you are unsure of the eligibility of a client for the non-Medicaid funding you are receiving, please contact your State Agency program manager.

Boxing Ring

Overview

Functionality for Vendors to petition records that have been flagged for recoupment by Lead Agencies has been introduced. For any action taken by Vendors, the Lead Agency will have 7 days to respond, or the petition will be auto-accepted and the record not recouped. Likewise, for any action taken by the Lead Agency, Vendors will have 7 days to respond, or the record will be automatically recouped.

In order for a Lead Agency to flag records for recoupment, they must first contact the Vendor to inform them. The Lead Agency will have to enter in the system whom they spoke to and when in order for records to be considered 'Flagged' and appear for the Vendor to review.

Vendors can petition records flagged for recoupment and attach supporting documentation to accommodate the petition.

After a petition is made, the Lead Agency can request clarification on the petition. The Lead Agency may or may not require the Vendor to include supporting documentation as part of clarification.

Vendors and Lead Agencies can go back and forth between 'Clarification Required' and 'Clarification Provided' as many times as necessary. The Lead Agency can also choose at any time to 'force' a recoupment.

Vendors can choose to accept the recoupment, in which case they agree to repay the aggregate amount via future payment offsets, direct reimbursement, or a combination of both.

From the Home screen:

  1. Click the QA Review drop-down.

  2. Click Boxing Ring.

  3. Records flagged for QA review are displayed grouped by Reason with the closest to the auto-recoupment deadline on top.

  4. Click a record to see details in the Record Status, Record Details, and Record History sections. (Clicking the record will also mark it as Read when clicked for the first time)

  5. Click the ^ icon of each section to expand/hide the section as needed.

  6. Enter data in the search criteria fields on the top of the screen to search for specific records.

Record Icon Definitions

Icon

Definition

 

Record has been flagged for Recoupment by the Lead Agency

 

Pending Vendor Notification by the Lead Agency

 

Clarification to Petition has been provided to the Lead Agency by the Vendor

 

Clarification to Petition Requested by the Lead Agency

 

Recoupment has been Confirmed by the Vendor

Recoupment has been Abandoned by the Lead Agency

Record Action Timeline

Vendors have 7 days to Accept or Petition for Records marked for Recoupment. If they do not Accept or Petition within 7 days the system will auto-recoup the records.

Vendors have 7 days to Submit Clarification on Records marked for Clarification by the Lead Agency. If they do not submit within the 7 days the system will auto-recoup the records.

The Record Status section for each Record will display the # of days remaining in the 7-day countdown.

Read/Unread Record(s) marked for Recoupment

  1. Click the Record(s) in the Envelope column to highlight and mark it as Read or Unread.

Accept Record(s) marked for Recoupment

  1. Click the Record(s) in the Checkmark column to highlight.

  2. Click Accept.

  3. The system will display a total of the record(s) to be recouped.

  4. Click Submit to confirm the acceptance.

  5. The status icon for the record(s) will change from an orange triangle to a handshake.

Petition Record(s) marked for Recoupment

  1. Click the Record(s) in the Checkmark column to highlight.

  2. Click Petition.

  3. Click the Why are the selected records being petitioned field and enter a reason.

  4. Click the file upload field or drag and drop to add supporting documents.

  5. Click Submit to confirm the petition.

  6. The status icon for the record(s) will change from an orange triangle to a P.

Submit Clarification on Record(s) marked for Recoupment

  1. Click the Record(s) in the Checkmark column to highlight.

  2. Click Submit Clarification.

  3. Click the Detailed response to clarification request field and enter information.

  4. Click the file upload field or drag and drop to add supporting documents. (To delete an attachment click the trash can icon next to the document)

  5. Click Submit to confirm the clarification.

  6. The status icon for the record(s) will change from a ? to a P.

Export Record(s) marked for Recoupment to Excel:

  1.  Click the Record(s) in the Checkmark column to highlight.

  2. Click Export to CSV.

  3. An excel CSV file will be displayed.

Repayments

From the Home screen:

  1. Click the QA Review drop-down.

  2. Click Repayments.

  3. Records flagged for Repayment are displayed by the Vendor with the To Be Scheduled, Overdue, Proposed, and Pending Checks Amounts.

  4. Click Provider Name to view details.

Confirm Repayments

  1. Click the Checkbox column on an Installment line to select.

  2. Click Confirm. The system will update the Icon from Proposed to Scheduled in the table.

Download Voucher:

  1. Click the Checkbox column on an Installment line to select.

  2. Click Download Voucher. The system will generate a Zip file.

  3. Select the zip file to view the Voucher pdf to be included with the payment and the Voucher-Services excel file detailing the services being recouped in the payment installment.