Pennsylvania Medicaid Workflow

Overview

(As always, private pay is generally self-regulating within the confines of state law and regulatory processes. This article focuses on Medicaid billing in the state of Pennsylvania.)

In the state of Pennsylvania, there are some unique billing processes. This is because select Medicaid visits must be completed using electronic visit verification (EVV), and these verified visits are required to be sent to HHAeXchange (Health Choices Managed Care Organization or Fee-for-Service). Select Medicaid visits are also required to be sent to the state's default aggregator, Sandata.

For Ankota users, that means in addition to regular EVV services, Ankota also delivers appropriate visit data to HHAeXchange to ensure state requirements are met. The Merged Health Care Claim (837) can then be used to file non-EVV billing with the state.

While Ankota supports providers during implementation, tax paperwork, registration with individual payers, and registration with clearinghouses are ultimately the provider organization's responsibility. The state's EVV FAQ and EVV overview provide more information.

This article covers:

• Set-up (HHAX, Sandata, Gainwell)
• Testing (HHAX, Sandata)
• Pre-Billing
• Billing Management for Medicaid Visits (HHAX Billing, State/Gainwell Billing for NON-EVV visits)
• Imported Response Files
• Remittance Advice Management (835s)
• Corrected Claims (HHAX Claim Correction, PA Promise Claim Correction)
• Further Details

HHAX Set-up

Health Choices Managed Care Organization or Fee-for-Service plans are sent to HHAeXchange. Ankota users in Pennsylvania under any of those plans providing any of the following services must register for HHAeXchange: PCA, Individual Supports (DDD), Community Based Supports (DDD), In-Home Respite (DDD and MLTSS), and Home Based Supportive Care (MLTSS).

All services requiring an in-home visit are subject to the EVV mandate including self-directed services except for live-in caregivers. Internally, Ankota users are automatically set up for delivery of EVV visit data to the state as part of implementation, but registration ensures HHAeXchange will accept the data and gives providers access to credentials and the HHAeXchange log-in.

To register with HHAeXchange, providers must go to the Pennsylvania HHAeXchange portal and complete the registration form. You will need the following information:

• Provider name: YOUR COMPANY NAME
• Provider contact name and email address: NAME, EMAIL
• Provider Medicaid ID
• Provider Tax ID
• Vendor name: Ankota LLC
• Vendor address: 1 Franklin Street, Suite 360B, Boston, MA 02110
• Vendor contact name & contact information: Sharon Dodge, COO, sharon.dodge@ankota.com, 844-4-Ankota, extension 703
• If you want HHAx to bill your data, request that option

Questions about PA EVV can be directed to 1-800-248-2152. Additional questions about HHAeXchange can be sent to PAintegration@hhaexchange.com.

HHAeXchange will provide credentials in return. Send Ankota the following:

• Your HHAeXchange credentials
• Any HHAeXchange communications
• Your provider Medicaid ID, Tax ID, and taxonomy codes

Pennsylvania collects the following information:

• Type of service
• Person Serviced
• Dates of Service
• Location of Service
• (Reason & Action codes if needed)
• Name of Caregiver
• Times of Service (start & end time)
• Client data:
  • Medicaid ID in the Medicaid ID field
  • Other ID or same ID in the Client ID field
  • Client address
  • Primary diagnosis code (must be the diagnosis CODE, not the description, and it must be the code assigned by the state, not a general valid diagnosis code)
• Caregiver demographic data:
  • First Name, Last Name
  • DOB
  • SSN
  • ID & Matching Caregiver Code (do not skip UNLESS you do not want the caregiver to send, like the Ankota Support caregiver)
  • Gender
  • Type: 'Both', 'Skilled', or 'Non-Skilled' (this is under Roles); no other Role is allowed by HHAx
  • Hire date
  • Valid email and phone format (if entered)
  • Valid Address (State and 5-digit ZIP required)
  • Role - Skilled, Non-Skilled, or Skilled

Critical Notes

• If switching to Ankota from HHAx EVV, you must close out all visits and bill in HHAx (or notify them you do not wish to bill) before they will allow you to create your username and password for the integration. You cannot even have scheduled current/future visits remaining in HHAX or your integration with Ankota will be blocked.
• Once ready to transition (and any visits in HHAX are closed out/billed), obtain username and password credentials so Ankota can deliver data to HHAx via SFTP. Create these in your portal and share them with Ankota.
• PA does not require caregivers. Also, not all visit types are required to go to HHAx.
• For further questions, contact Pennsylvania HHAX 844-626-6813 option 3 OR phwproviderrelations@pahealthwellness.com or the general 888-801-1660 provider line, or use the HHAX portal to create a Support ticket.
• The HHAX SFTP password expires every 90 days. Every 90 days, log into HHAX and change the password, then update the password in Generations. The password is created via the HHAX portal (Admin → SFTP Setup → choose new password).

Sandata Set-up

Ankota users in Pennsylvania must register with Sandata and with the state. This registration ensures Sandata will accept their data and gives providers access to the Sandata log-in. Internally, Ankota users are automatically set up for delivery of EVV visit data to the state as part of implementation.

To register with Sandata, providers must provide Sandata the following information in the Pennsylvania alternate EVV registration form:

• Subject: Request for EVV Vendor Certification (Ankota)
• Body:
  • Provider name: YOUR COMPANY NAME
  • Provider contact name and email address: NAME, EMAIL
  • Vendor name: Ankota LLC
  • Vendor address: 1 Franklin Street, Suite 360B, Boston, MA 02110
  • Vendor contact name & contact information: Sharon Dodge, Director of Implementation, sharon.dodge@ankota.com, 844-4-Ankota, extension 703

Providers also take EAS training. Sandata will provide credentials in return. Send Ankota the following:

• Any Sandata communications
• Your provider Medicaid ID and the categories and/or subdepartments they apply to

Gainwell Set-up

Apply to Gainwell for a submitter ID (sometimes called a subscriber number) as soon as you contract with Ankota if you have non-EVV billing. There are EDI forms to fill out (101, 102 & 801) in order to obtain that ID. After submission, wait time is a minimum of 10-20 business days (often longer). These forms are typically required to be hard copies, physically mailed in.

HHAX Testing

No state testing processes are required for individual vendors at this time. (Ankota has completed required alt EVV testing.)

Sandata Testing

(No specific testing process at this time.)

Pre-Billing

General

Successful billing starts at the beginning of the client's creation. The processes below will lead to successful billing.

Caregiver Management

• Add caregivers as usual; new caregivers are exported at end of day (after initial launch)
• If you get caregiver failures in your imported response files, correct the caregivers and then re-send the caregivers
• Do not send visits until caregivers are confirmed

Client Management

• Client Entry
• Setting Authorized Service for Clients (entering authorizations)
• Schedule Visits - Calendar-Based Scheduling (or Creating Visits from Patterns)

Visit Management

• Caregivers complete visits or timesheets are entered manually through the office
• Visits are approved automatically or by the office
• Ensure visits are closed, then review and clear the Visit Approval Dashboard
• Code HHAX and Sandata visits as needed

Prevention of Errors/Rejected Claims

• Watch warnings on the Action Center (for missing auths, primary diagnosis codes, IDs, etc.) and address as needed
• Watch warnings on the Visit Approval Dashboard and address as needed
• Manage rejections

Critical Notes

• The Landing Dashboard highlights necessary actions, including managing visits as needed.
• EVV in Pennsylvania is currently expected to be 85% successful, with success defined as either:
  • Telephony confirmation via a home landline phone or FOB
  • Mobile app GPS confirmation (any GPS location, though expected within 0.25 miles of expected location)

HHAeXchange Billing (EVV visits)

The following services require EVV management and are sent to HHAeXchange. Group homes, DDD Supported Living Services (24-hour service), and self-directed personal care services do not require EVV at this time.

Process:

1. Complete the pre-billing process above
2. Bill visits as usual in Ankota
3. Do not bill overlapping months; for example, January and February visits should be in separate invoices
4. Separate out EVV and non-EVV visits to avoid unnecessary rejections from the state
5. Visit data is exported to HHAx upon billing in Ankota
6. Read your imported response files (see section below)
7. Manage corrections
   • Critical note: For HHAX (v5), apply one reason code for manual visits, and at most one action code (optional — system default is applied if skipped).
8. Re-send visits as needed, usually via the Visit Approval Dashboard
9. Release billing in HHAx

Once a visit is accepted in HHAx, if there is an issue, that issue must be corrected in HHAx.

The following payers can be billed via HHAX (they will generate and deliver an 837p file to the payer):

• UPMC LTSS
• UPMC Home Health/Home Nursing
• Keystone First CHC
• Centene PA Health Wellness
• Centene PA Health & Wellness HHCS
• UnitedHealthcare of PA
• Health Partners Plan

State/Gainwell Billing (NON-EVV visits)

1. Complete the pre-billing process above
2. Bill visits as usual in Ankota
3. Do not bill overlapping months; for example, January and February visits should be in separate invoices
4. Separate out EVV and non-EVV visits to avoid unnecessary rejections from the state
5. Bill the state with the exported merged health care claim in the Gainwell portal
   • Use the HIPAA-secure log-in; upload the file in the "upload" section

CareBridge Billing

N/A.

Imported Response Files

Reading Response Files

After connection with HHAx, Ankota provides decoded, easy-to-read response files. Related resources:

• HHAx Response Files (Overview)
• Accessing HHAx Response Files
• Reviewing HHAx Response Files

Correcting Visits (HHAx)

To correct visits rejected by HHAx, make corrections in Ankota and then re-export the visit. See Managing Data Corrections for directions based on the type of error. The Approval Assistant is generally recommended to simplify the visit corrections process. Only use the Duration adjustments section if there are known, strict limitations on the allowed work duration for the selected visit type.

Critical note: For HHAX (v5), apply one reason code for manual visits, and at most one action code (optional — system default is applied if skipped).

Remittance Advice Management (835s)

Remittance advice files, or 835s, may be provided in response to filing Medicaid claims. These function like state receipts of payments. If provided, they can be uploaded to Ankota for automatic application of payments in the A/R records. Ankota does not provide 835s; if you do not receive them from the state, you will need to arrange to receive them.

Related resources:

• Process Remittance Advice (Upload 835 "receipts" received from MMIS into Ankota)
• Post Manual Payments
• Review Billing Reports
• See also: Collections Report, Exceptions Report

Corrected Claims

Generally, claims corrections are handled one of two ways:

• Update the claims in Ankota and re-send
• Update the claims in the location where it was sent

HHAX Claim Correction

To correct claims that were rejected in HHAeXchange:

1. Review your HHAeXchange response files
2. Correct the visits with errors as needed
3. Re-send visits from Ankota by the appropriate method, either:
   • Single visit export
   • Batch visit export (re-completing the affected invoice, which triggers delivery to HHAeXchange)

State/Gainwell Claim Correction

To correct claims that were rejected in the state portal:

1. Review your errors
2. Correct the visits with errors as needed
3. Re-export the 835 Merged Health Care Claim from Ankota
4. Upload the 835 in the state portal/via Gainwell

Further Details

Additional resources:

• The Ankota Training Overview, including videos
• Daily Adjustments
• Manual Visit Entry
• Private Pay Workflow

If placements are not accepted within a certain time frame, they go to a pending queue. Someone should check the system daily to accept new placements; otherwise placements will return to the pending queue.