HP Provider Relations October 2010 CMS-1500 Billing.

HP Provider RelationsOctober 2010

CMS-1500 Billing

CMS-1500 Billing October 20102

Agenda

– Objectives

– CMS-1500

– Claim Form Billing Guidelines - Various Specialties

– Crossover Claims

– Consent Form, Sterilization and Partial Sterilization

– Mail Order Incontinence, Ostomy, and Colostomy Supplies

– Prior Authorization

– Code Sets

– Fee Schedule

– ANSI version 5010 and CCI

– Common Denials

– Helpful Tools

– Questions


Objectives

Following this session, providers will be able to:

– Identify their provider classification

– Bill claims correctly for various specialties

– Submit crossover claims successfully

– Understand the sterilization consent completion

– Know the program exclusions

– Have more information about prior authorization

– Identify the various provider code sets

– Find and understand how the fee schedule can assist providers

– Understand the requirements of ANSI Version 5010

– Know the common denial causes and resolutions

Learn1500 claims


Types of 1500 Claims

– 837I – Electronic transaction• Companion Guide available on IHCP Web

site: www.provider.indianamedicaid.com

– Web interChange

– Paper claim

– Replacement/Adjustment request (for a previously paid claim)

http://provider.indianamedicaid.com/


Web interChange – 1500 Electronic filing


Paper Claim Form Locators – CMS-1500


Paper Claim Form LocatorsCMS-1500

Fields Description

1 INSURANCE CARRIER SELECTION – Enter X for Traditional Medicaid. Required.

1a INSURED’S I.D. NUMBER (FOR PROGRAM IN ITEM 1) – Enter the member IHCP identification (RID) number. Must be 12 digits. Required.

2 PATIENT’S NAME (Last Name, First Name, Middle Initial) – Provide the member’s last name, first name, and middle initial obtained from the Automated Voice Response (AVR) system, electronic claim submission (ECS), Omni, or Web interChange verification. Required.

9 OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) – If other insurance is available, and the policyholder is other than the member shown in fields 1a and 2, enter the policyholder’s name. Required, if applicable.

9a OTHER INSURED’S POLICY OR GROUP NUMBER – If other insurance is available, and the policyholder is other than the member noted in fields 1a and 2, enter the policyholder’s policy and group number. Required, if applicable.

9c EMPLOYER’S NAME OR SCHOOL NAME – If other insurance is available, and the policyholder is other than the member shown in fields 1a and 2, enter the requested policyholder information. Required, if applicable.



Fields Description

9d INSURANCE PLAN NAME OR PROGRAM NAME – If other insurance is available, and the policyholder is other than the member shown in field 1a and 2, enter the policyholder’s insurance plan name or program name information. Required, if applicable.

10 IS PATIENT’S CONDITION RELATED TO – Enter X in the appropriate box in each of the three categories. This information is needed for follow-up third-party recovery actions. Required, if applicable.

10a EMPLOYMENT (CURRENT OR PREVIOUS) – Enter X in the appropriate box. Required, if applicable.

10b AUTO ACCIDENT – Enter X in the appropriate box. Required, if applicable.

PLACE (State) – Enter the two-character state code. Required, if applicable.

10c OTHER ACCIDENT – Enter X in the appropriate box. Required, if applicable.

11 INSURED’S POLICY GROUP OR FECA NUMBER – Enter the member’s policy and group number of the other insurance. Required, if applicable.

11a INSURED’S DATE OF BIRTH – Enter the member’s birth date in MMDDYY format. Required, if applicable.

SEX – Enter an X in the appropriate sex box. Required, if applicable.



Fields

Description

11b EMPLOYER’S NAME OR SCHOOL NAME – Enter the requested member information. Required, if applicable.

11c INSURANCE PLAN NAME OR PROGRAM NAME – Enter the member’s insurance plan name or program name. Required, if applicable.

11d IS THERE ANOTHER HEALTH BENEFIT PLAN? Enter X in the appropriate box. If the response is Yes, complete fields 9a–9d. Required, if applicable.

14 DATE OF CURRENT ILLNESS (First symptom date) OR INJURY (Accident date) OR PREGNANCY (LMP date) – Enter the date of the last menstrual period (LMP) for pregnancy-related services in MMDDYY format. Required for payment for pregnancy-related services.

16 DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION – If field 10a is Yes, enter the applicable FROM and TO dates in a MMDDYY format. Required, if applicable.

17 NAME OF REFERRING PROVIDER OR OTHER SOURCE – Enter the name of the referring physician. Required, if applicable. For waiver-related services, enter the provider name of the case manager. Required for Care Select PMP.

Note: The term referring provider includes those physicians primarily responsible for the authorization of treatment for lock-in or restricted card members.



Fields Description

17 NAME OF REFERRING PROVIDER OR OTHER SOURCE – Enter the name of the referring physician. Required, if applicable. For waiver-related services, enter the provider name of the case manager. Required for Care Select PMP.

Note: The term referring provider includes those physicians primarily responsible for the authorization of treatment for lock-in or restricted card members.

17a ID NUMBER OF REFERRING PROVIDER, ORDERING PROVIDER OR OTHER SOURCE – Not used.



Fields Description

17b NPI – Enter the 10-digit numeric NPI of the referring provider, ordering provider, or other source. Required when applicable and for Care Select PMPs.

18 HOSPITALIZATION DATES RELATED TO CURRENT SERVICES – Enter the requested FROM and TO dates in MMDDYY format. Required, if applicable.

19 RESERVED FOR LOCAL USE – Enter the Care Select primary medical provider (PMP) two-digit alphanumeric certification code. Required for Care Select members when the physician rendering care is not the PMP or a physician in the PMP’s group or a clinic.

Note: Report the PMP qualifier and ID number in 17a.

21.1 to 21.4.

DIAGNOSIS OR NATURE OF ILLNESS OR INJURY – Complete fields 21.1, 21.2, 21.3, and/or 21.4 to field 24E by detail line. Enter the ICD-9-CM diagnosis codes in priority order. A total of four codes can be entered. At least one diagnosis code is required for all claims except those for waiver, transportation, and medical equipment and supply services. Required.



Fields Description

22 MEDICAID RESUBMISSION CODE, ORIGINAL REF. NO. – Applicable for Medicare Part B crossover claims only. For crossover claims, the combined total of the Medicare coinsurance, deductible, and psych reduction must be reported on the left side of field 22 under the heading Code. The Medicare paid amount (actual dollars received from Medicare) must be submitted in field 22 on the right side under the heading Original Ref No. Required, if applicable.

24A to 24I

Top Half – Shaded Area

NATIONAL DRUG CODE INFORMATION – The shaded portion of fields 24A to 24I is used to report NDC information. Required as of August 1, 2007.

To report this information, begin at field 24A as follows:

1.Enter the NDC qualifier of N4

2.Enter the NDC 11-digit numeric code

3.Enter the drug description

4.Enter the NDC Unit qualifierF2 – International UnitGR – GramML – MilliliterUN – Unit

5.Enter the NDC Quantity (Administered Amount) in the format 9999.99



Fields Description

22 MEDICAID RESUBMISSION CODE, ORIGINAL REF. NO. – Applicable for Medicare Part B crossover claims only. For crossover claims, the combined total of the Medicare coinsurance, deductible, and psych reduction must be reported on the left side of field 22 under the heading Code. The Medicare paid amount (actual dollars received from Medicare) must be submitted in field 22 on the right side under the heading Original Ref No. Required, if applicable.

24A to 24I


NATIONAL DRUG CODE INFORMATION – The shaded portion of fields 24A to 24I is used to report NDC information. Required as of August 1, 2007.

To report this information, begin at field 24A as follows:

1.Enter the NDC qualifier of N4

2.Enter the NDC 11-digit numeric code

3.Enter the drug description

4.Enter the NDC Unit qualifierF2 – International UnitGR – GramML – MilliliterUN – Unit

5.Enter the NDC Quantity (Administered Amount) in the format 9999.99



Fields Description

24E DIAGNOSIS CODE – Enter number 1–4 corresponding to the applicable diagnosis codes in field 21. A minimum of one, and a maximum of four, diagnosis code references can be entered on each line. Required.

24F $ CHARGES – Enter the total amount charged for the procedure performed, based on the number of units indicated in field 24G. The charged amount is the sum of the total units multiplied by the single unit charge. Each line is computed independently of other lines. This is a 10-digit field. Required.

24G DAYS OR UNITS – Provide the number of units being claimed for the procedure code. Six digits are allowed, and 9999.99 units is the maximum that can be submitted. The procedure code may be submitted in partial units, if applicable. Required.

24H EPSDT Family Plan – If the patient is pregnant, indicate with a P in this field on each applicable line. Required, if applicable.



Fields Description

24I


RENDERING ID QUALIFIER – Enter the qualifier indicating what the number reported in the shaded area of 24J represents – 1D for IHCP LPI rendering provider number or ZZ for rendering provider taxonomy code.

1D is the qualifier that applies to the IHCP provider number (LPI) for atypical nonhealthcare providers. The LPI includes nine numeric characters. Atypical providers (for example, certain transportation and waiver service providers) are required to submit their LPIs.

ZZ is the qualifier that applies to the provider taxonomy code. The taxonomy code includes 10 alphanumeric characters. The taxonomy code may be required for a one-to-one match.

Taxonomy – Enter the taxonomy code of the rendering provider. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the provider has multiple locations.

24J


RENDERING PROVIDER ID – Enter the LPI if entering the 1D qualifier in 24I for the Rendering Provider ID. Required, if applicable for non-healthcare providers only.

LPI – The entire nine-digit LPI must be used. If billing for case management, the case manager’s number must be entered here.



Fields Description

24J

Bottom Half

RENDERING PROVIDER NPI – Enter the NPI of the rendering provider. Required if applicable.

28 TOTAL CHARGE – Enter the total of all service line charges in column 24F. This is a 10-digit field, such as 99999999.99. Required.

29 AMOUNT PAID – Enter the payment received from any other source, excluding the Medicare paid amount. All applicable items are combined and the total entered in this field. This is a 10-digit field. Required, if applicable.

Other insurance – Enter the amount paid by the other insurer. If the other insurer was billed but paid zero, enter 0 in this field. Attach denials to the claim form when submitting the claim for adjudication.

30 BALANCE DUE – TOTAL CHARGE (field 28) – AMOUNT PAID (field 29) = BALANCE DUE (field 30). This is a 10-digit field, such as 99999999.99. Required.



Fields Description

31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS – An authorized person, someone designated by the agency or organization, must sign and date the claim. A signature stamp is acceptable; however, a typed name is not. Providers that have signed the Signature on File certification form will have their claims processed when a signature is omitted from this field. The form is available on the IHCP Web site, Provider Services page at http://www.indianamedicaid.com/ihcp/ProviderServices/provider_enroll.asp. Required if applicable.

DATE – Enter the date the claim was filed. Required.33 BILLING PROVIDER INFO & PH # – Enter the billing provider office location name,

address, and the ZIP Code+4. Required.

Note: If the Postal Service provides an expanded ZIP Code (ZIP Code + 4) for a geographic area, this expanded ZIP Code must be entered on the claim form.

33a BILLING PROVIDER NPI – Enter the billing provider NPI. Required.

http://www.indianamedicaid.com/ihcp/ProviderServices/provider_enroll.asp



Fields Description33b BILLING PROVIDER QUALIFIER AND ID NUMBER – Healthcare providers may enter

a billing provider qualifier of ZZ and taxonomy code. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the provider has multiple locations.

If the billing provider is an atypical provider, enter the qualifier 1D and the LPI. Required.

Note: Qualifiers are ZZ = Taxonomy and 1D = LPI

ExplainBilling guidelines


Billing Guidelines

– Billing Provider – Provider classification assigned to a billing entity or solo practitioner at a service location

– Group Provider – The classification given to a corporation or other business structure that has rendering providers linked that are the performers of the services provided

– Rendering Provider – A provider that performs the services for a group or clinic and is linked to the group or clinic

– Dual – A billing provider performing services as a sole proprietor at an assigned service location and is also a rendering provider working for a group

Provider classifications


Billing Guidelines

– Use Current Procedural Terminology (CPT®) codes 00100-01999 (refer to IHCP Provider Manual chapter 8 for more information)

– Claim is processed in minute increments. Bill the actual time in minutes and include it in field 24G

– One unit = 15 minutes

– Additional units are allowed based on a patient’s age when billing for emergency services (bill using procedure code 99140)

Anesthesia

CPT is copyright 2009 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.


Billing Guidelines

– Providers bill postoperative pain management using code 01996

– The IHCP does not separately reimburse this code on the same day the epidural is placed• However, it is reimbursed for subsequent days

when an epidural is managed

Anesthesia


Billing Guidelines

– Package A services are limited to 50 chiropractic services per member, per calendar year • The IHCP reimburses for no more than five office visits within the 50 visits

– Package B reimbursement is available for medically necessary pregnancy-related services. Refer to chapter 8 of the IHCP manual for a listing of pregnancy diagnosis codes.

– Package C members are allowed five office visits and 14 therapeutic physical medicine treatments per member, per calendar year

Chiropractic services


Billing Guidelines

– The following are covered codes for office visits:• 99201, 99202, 99203, 99211, 99212, 99213

– The following are covered codes for manipulative treatment:• 98940-98943

Chiropractic services


Billing Guidelines

– The IHCP reimburses for physician office injectable drugs using Healthcare Common Procedure Coding System (HCPCS) J codes and CPT immunization codes

– Pricing includes the current average wholesale price plus a $2.90 administration fee

– The IHCP reviews pricing for a physician office administered drug each quarter

– To price appropriately, HCPCS code J3490 must be submitted with the appropriate NDC, name, strength, and quantity

Injections


Billing Guidelines

– The IHCP Provider Manual contains lists of J codes that require a National Drug Code (NDC)• Chapter 8, Section 4

– For paper CMS-1500 claims forms, report NDC information in the shaded area of field 24 of the CMS-1500 claim form refer to bulletin BT200713 dated May 29, 2007

– The NDC is not used for provider reimbursement

Injections and NDC codes


Billing Guidelines

– Effective January 1, 2007, outpatient mental health services are carved-in to the risk-based managed care (RBMC) delivery system

– Services provided to RBMC members by the following specialty types are the responsibility of the managed care organizations (MCOs), effective January 1, 2007:• Freestanding Psychiatric Hospital• Outpatient Mental Health Clinic• Community Mental Health Center• Psychologist• Certified Psychologist• Health Service Provider in Psychology (HSPP)• Certified Clinical Social Worker• Psychiatric Nurse• Psychiatrist

Mental health RBMC


Billing Guidelines

Services that are the MCO’s responsibility:

– Office visits with a mental health diagnosis

– Services ordered by a provider enrolled in a mental health specialty, but provided by a nonmental health specialty (such as a laboratory and radiology)

– Mental health services provided in an acute care hospital

– Inpatient stays in an acute care hospital or freestanding psychiatric facility for treatment of substance abuse, chemical dependency or patients with a mental health diagnosis

Mental health RBMC


Billing Guidelines

– Effective July 1, 2010, MRO services no longer require the use of modifiers to note the midlevel scope of practice

– MRO services require the use of the HW modifier

– Providers should use the NPI of the supervising practitioner, which is the physician or health service provider in psychology (HSPP)

– Group setting should be billed using the U1 modifier

Note: When billing Group setting for addiction counseling, do not use a modifier

Refer to Bulletin BT201023 dated July 8, 2010

Medicaid Rehabilitation Option (MRO)


Billing Guidelines

– MCOs• Anthemwww.anthem.com

• Managed Health Services (MHS)www.managedhealthservices.com

• MDwisewww.mdwise.org

– Behavioral Health Organizations (BHOs)• Magellan (Anthem)

www.magellanhealth.com

• Cenpatico (MHS)www.cenpatico.com

• MDwisewww.mdwise.org

Mental health RBMC

http://www.anthem.com/

http://www.managedhealthservices.com/

http://www.mdwise.org/

http://www.magellanhealth.com/

http://www.cenpatico.com/

http://www.mdwise.com/


Billing Guidelines

Cosurgeons:

– Cosurgeons must append modifier 62 to the surgical services

– Modifier 62 cuts the reimbursement rate to 62.5 percent of the rate on file

Bilateral Procedures:

– To indicate a bilateral procedure, providers bill with one unit in field 24G, using modifier 50

– Use of this modifier ensures that the procedure is priced at 150 percent of the billed charges or the rate on file

Note: If the CPT code specifies the procedure as bilateral, then the provider must not use modifier 50

Surgical services


Billing Guidelines

– Postoperative care for a surgical procedure includes 90 days following a major procedure surgical procedure and 10 days following a minor surgical procedure

– Separate reimbursement is available for care during the global postoperative period for:• Services unrelated to the surgical procedure

• Care not considered routine

• Postoperative care for surgical complications

Surgical services


Billing Guidelines

– When two or more covered surgeries are performed during the same operative session, multiple surgery reductions apply to the procedure based on the following adjustments:• 100 percent of the global fee for the most expensive procedure

• 50 percent of the global fee for the second most expensive procedure

• 25 percent of the global fee for the remaining procedures

– All surgeries performed on the same day, by the same rendering physician, must be billed on the same claim form; otherwise, the claim will be denied and the original claim may be adjusted

Multiple surgery procedures


Billing Guidelines

– A qualified therapist or qualified assistant under the direct supervision of the therapist, must provide the therapy

– Therapy must be provided at the level of complexity that is based on the condition of the member based on the evaluation

– Reimbursement is made only for medically reasonable and necessary therapy

– The IHCP does not cover therapy rendered for diversional, recreational, vocational, or avocational purposes, or for the remediation of learning disabilities or developmental activities that be performed by nonmedical personnel

– Coverage is not provided for rehabilitative services for a member long than two years from the initiation of the therapy unless a significant change in medical condition.

Therapy services requirements


Therapy services requirements

– The IHCP does not cover maintenance therapy

– When a member is enrolled therapy, ongoing evaluations to assess progress or lack of progress are part of the program. The IHCP does not separately reimburse for ongoing evaluations

– One hour of billed therapy must include a minimum of 45 minutes of direct patient care with the balance of the hour spent in related patient services

– The IHCP does not approved any type of therapy services for more than on hour per day, per type of therapy

Billing Guidelines


Billing Guidelines

• The PTA is precluded from performing and interpreting tests, conducting initial or subsequent assessments, and developing treatment plans

• Under direct supervision, a PTA is still required to consult with the supervising physical therapist daily to review treatment

• The consultation can be either face-to-face or by telephone

• Claims will be billed with modifier HM- Less than a bachelors degree with the code billed and the rendering supervisors NPI number

• Pricing for these services will be at 75% of the fee on file for the procedure billed

• Chapter 8, section 4 provides a listing of codes than can be billed by a PTA

Therapy services – Physical Therapist Assistant (PTA) billing


Billing Guidelines

– Routine foot care is only covered if a member has been seen by a medical doctor or doctor of osteopathy for treatment or evaluation of a systemic disease during the six-month period prior to rendering routine foot care

– A maximum of six routine foot care services is covered per rolling 12-month period when the member has one of the following:• Systemic disease of sufficient severity that a

treatment of the disease may pose a hazard when performed by a nonprofessional

• Systemic conditions that result in severe circulatory embarrassment or has had areas of desensitization in the legs or feet

Podiatric services – routine foot care


Billing Guidelines

– ICD-9-CM diagnosis codes that represent systemic conditions that justify coverage for routine foot care:• Diabetes mellitus: ICD-9-CM codes 250.00-

250.91

• Arteriosclerotic vascular disease of lower extremities: ICD-9-CM codes 440.20-440.29

• Thromboangitis oblierans: ICD-9-CM code 443.1

• Post-phlebitis syndrome: ICD-9-CM code 459.1

• Peripheral neuropathies of the feet: ICD-9-CM codes 357.1-357.7

– Routine foot care is not a covered service for Package C members



Billing Guidelines

– Reimbursement is limited to one office visit using procedure code 99211, 99212, and 99213 per member, per 12 months, without obtaining prior authorization

– New patient office visits, using procedure codes 99201, 99202, and 99203 are reimbursable at one per member, per provider, within the last three years as defined by the CPT guidelines

– A visit can be billed separately only on the initial visit

– For subsequent visits, reimbursement for the visit is included in the procedure performed on that date and not billed separately• Exception: If a second, significant problem is addressed on a

subsequent visit, the visit code may be reported with the 25 modifier



Billing Guidelines

– Reimbursement is available for office visits to a maximum of 30 per rolling 12-month period, per IHCP member, without prior authorization (PA), and subject to the restrictions in Section 2 of 405 IAC 5-9-1

– Per 405 IAC 5-9-2, office visits should be appropriate to the diagnosis and treatment given and properly coded

Evaluation and management codes

Procedure Codes

99201-99215 99381-99397

99241-99245 99401-99429

99271-99275


Billing Guidelines

– Professional services rendered during the course of a hospital confinement must be submitted on the paper CMS-1500 claim form or using the electronic 837P transaction

– The IHCP makes reimbursement in accordance with the appropriate professional fee schedule

– The inpatient diagnosis-related group (DRG) reimbursement methodology does not provide payment for physician fees, including the hospital-based physician fee

– New patient office visits are limited to one visit per member, per provider – once every three years

Evaluation and management codes


Crossover Claims

– The Coordination of Benefits Contractor (COBC) crosses over HIPAA-compliant Medicare claims to the IHCP• The Centers for Medicare & Medicaid Services (CMS)

selected Group Health, Inc. (GHI) to be the COBC

– When Medicare denied services cross over to the IHCP, IndianaAIM adjudicates these with a denied status

– The IHCP created edits for these claims• The edits are 0592 and 0593 – Medicare denied details

• Resubmit denied details separately from paid details and include the MRN from Medicare

Processing electronic claims


Crossover Claims

– Allow 60 days for claims to automatically cross over to the IHCP

– Bill denied charges to the IHCP and include the Medicare Remittance Notice (MRN)

– Complete field 22 as follows:• Left side = Coinsurance, deductible, and

psychiatric reduction

• Right side = Medicare payment

– If applicable include the commercial payment amount in field 29 (not used for traditional Medicare)

Processing paper claims


Billing Guidelines

– The IHCP covers the following 14 antepartum visits:• Three visits in trimester one

• Three visits in trimester two

• Eight visits in trimester three

– Providers use the following codes to bill for visits:• First visit – Evaluation and management (E/M) – 99201-99205

• Visits one through six – 59425

• Seventh and subsequent visits – 59426

– Providers use the following modifiers with procedure codes:• U1 for trimester one – Zero through 14 weeks

• U2 for trimester two – 14 weeks, one day through 28 weeks

• U3 for trimester three – 28 weeks, one day through delivery

Obstetric services


Billing Guidelines

– For pregnancy-related claims, indicate the last menstrual period (LMP) in MM/DD/YY format infield 14

• The IHCP will deny claims for pregnancy-related services if there is no LMP

– Indicate a pregnancy-related diagnosis code as the primary diagnosis when billing for pregnancy-related services

Pregnancy-related claims


Billing Guidelines

– Use normal low-risk pregnancy diagnosis codes:• V22.0

• V22.1

– Use high-risk pregnancy codes:• V60.0 through V62.9

For additional information, refer to the IHCP Provider Manual, Chapter 8, Section 4

Pregnancy diagnosis codes


Consent Form


Sterilization and Partial Sterilization

– A sterilization form is not necessary when a patient is rendered sterile as a result of an illness or injury• Providers must note partial sterilization with an

attachment to the claim indicating “Partial Sterilization” and no consent required

– Partial sterilization can also be submitted on the electronic 837P transaction when “Partial Sterilization” is indicated in the claim notes

Partial sterilization


Sterilization Procedure

– Can be performed in the office as an outpatient or in an ambulatory surgical center (ASC)

– Device billed separately on CMS-1500 form using sterilization HCPCS code A9900 – Miscellaneous supply, accessory, and/or service component of another HCPCS code

– Use primary diagnosis code of ICD-9-CM V25.2 – Sterilization

– Print “Sterilization Device Implant” on the claim form or accompanying invoice

– Submit cost invoice with claim

– Submit a valid, signed Sterilization Consent form

– Print Hysteroscopic Sterilization Procedure on the claim form or on the invoice

Refer to BR201006 for more information

Hysteroscopic Sterilization Procedure.


Prior Authorization

– Providers must verify member eligibility to determine the care management organization (CMO) that will process the PA or Update request• CMO information via Web interChange is real time

• Send the PA request to the assigned CMO as of the date of the request

• Send PA updates to the original CMO

– Example:• Member is assigned to MDwise on 4/3/08, when the PA is requested

• On 4/15/10, the member transitions from MDwise to ADVANTAGE

• On 4/23/10, the primary medical provider (PMP) requests a System Update to the PA

• The PMP must request the System Update from MDwise


Prior Authorization

– Members can change between traditional Medicaid fee-for-service, Hoosier Healthwise/RBMC, and Care Select

– When the member changes programs, the receiving organization must honor PAs approved by the prior organization for the first 30 days following the reassignment, or for the remainder of the PA dates of service, whichever comes first

– Example:• Member transitions from Hoosier Healthwise/RBMC to a Care Select CMO on

September 15, 2010

• The MCO approved PA for dates of service 9/6/10 through 10/30/10

• The Care Select CMO must honor the approved PA for 30 days from September 15, 2010


Prior Authorization

– When members transition from one CMO to another CMO, or from Traditional Medicaid to a CMO, the receiving organization must honor the approved PA until the PA expires

Member changes within a program


Prior Authorization

– Each CMO is responsible for processing medical service PA requests and updates for members assigned to their organization at the time of the request

– Traditional Medicaid fee-for-service PA requests are processed by ADVANTAGE Health Solutions

– The PA number format is alphanumeric • Alphanumeric PA numbers will identify the CMO that processed the PA

• The three Eligibility Verification System (EVS) applications will accommodate the alphanumeric value

– Pharmacy PA requests continue to be processed by Affiliated Computer Services (ACS)

Refer to BR2010XX for instructions on the completion of the standardized PA request form


Prior Authorization Contact Information

– ADVANTAGE Health Solutions (fee-for-service)• P.O. Box 40789

Indianapolis, IN 462401-800-269-57201-800-689-2759 (Fax)

– ACS (Pharmacy)• 1-866-879-0106

1-866-780-2198 (Fax)


Prior Authorization Contact Information

– MDwise – CMO• P.O. Box 44214

Indianapolis, IN 46244-02141-866-440-24491-877-822-7186 (Fax)

– ADVANTAGE Health Solutions – CMO• P.O. Box 80068

Indianapolis, IN 462801-800-784-39811-800-689-2759 (Fax)


Code Sets

The following provider types have specific code sets that were set on these dates:

– Chiropractic – April 28, 2005

– Durable Medical Equipment – February 12, 2009

– Hearing Services – February 1, 2005

– HIV Care Coordination – October 1, 2004

– Home Medical Equipment – February 12, 2009

– Optician – February 1, 2005

– Optometrist – June 24, 2008

– Transportation – September 16, 2004

– Vision – October 1, 2004

All Code Sets can be referenced on the www.provider.indianamedicaid.com Web site



Fee Schedule

– The IHCP Fee Schedule is available on the IHCP Web site and provides the following information:• Pricing for procedure codes

• PA requirements for individual procedure codes

• List of noncovered codes


HIPAA 5010

– The mandatory compliance date for ANSI version 5010 and the National Council for Prescription Drug Programs (NCPDP) version D.0 for all covered entities is January 1, 2012

– If submitting claims to the IHCP, you need to prepare for these upgrades to prevent delay in payment

– The IHCP and HP will test transactions on a scheduled basis

– Specific transaction testing dates will be provided at a future date


HIPAA 5010

– Transactions affected by this upgrade:• Institutional claims (837I)

• Dental claims (837D)

• Medical claims (837P)

• Pharmacy claims (NCPDP)

• Eligibility verifications (270/271)

• Claim status inquiry (276/277)

• Electronic remittance advices (835)

• Prior authorizations (278)

• Managed Care enrollment (834)

• Capitation payments (820)


Testing Information

– All trading partners currently approved to submit 4010A1 and NCPDP 5.1 versions will be required to be approved for 5010 and D.0 transaction compliance • All software products used to submit 4010 and NCPDP 5.1 versions must be

tested and approved for 5010 and D.0.

– Testing will begin January 2011 and include:• Clearinghouses, billing services, software vendors, individual providers, and

provider groups

– Providers that exchange data with the IHCP using an IHCP- approved software vendor will not need to test

– Each trading partner will be required to submit a new Trading Partner Agreement


What You Need To Do– If you bill IHCP directly

• Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions

– If you are using a billing service or clearinghouse

• Find out if they are preparing for the HIPAA upgrades to ANSI v5010 and NCPDP vD.0

• IHCP Companion Guides will be available during the fourth quarter of 2010

– Questions should be directed to [email protected]

OR

– Call the EDI Solutions Service Desk• 1-877-877-5182 or (317) 488-5160

– Watch for additional information on the testing process, revised IHCP Companion Guides, and the schedule for transaction testing on this mandated initiative in bulletins, banner pages, and newsletters at www.provider.indianamedicaid.com



National Correct Coding Initiative

– In the 1990s, the Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment

– NCCI has been in place for many years and most providers are familiar with the editing methodologies with Medicare

– Based on input from a variety of sources:• American Medical Association (AMA) CPT Guidelines

• Coding guidelines developed by national societies

• Analysis of standard medical and surgical practices

• Review of current coding practices

What is it?


National Correct Coding Initiative

– The recent healthcare legislation passed into law (H.R. 3962), requires that Medicaid programs incorporate compatible methodologies of the National Correct Coding Initiative (NCCI) into their claims processing system• Section 1761 – Mandatory State Use of National Correct Coding Initiative of this bill

mandates that NCCI methodologies must be effective for claim date of service on or after October 1, 2010.

−Watch future bulletins, banners and newsletters for implementation date.

–The IHCP has embarked on a project that will bring NCCI into the claims processing effective October 1, 2010

–Initial editing will encompass three basic coding concepts:

• NCCI Column I and Column II (also known as bundling)

• Mutually Exclusive (ME) edits

• Medical Unlikely Edits (MUE)

DenyCommon denials for CMS-1500


Edit 2502

– Cause• Medical claims for Medicare Part B coverage for a member have Part B on the

eligibility screen but there is no Medicare MRN with the claim showing Medicare denial

– Resolution• Submit the Medicare payment on the right side of field 22 and the coinsurance,

deductible, or blood deductible on the right side

Recipient covered by Medicare Part B


Edit 558

– Cause• Coinsurance and deductible amount is missing indicating this is not a

crossover claim

– Resolution• Add coinsurance and/or deductible amount and/or Medicare paid amount to

the CMS-1500

• CMS-1500

Add coinsurance and/or deductible amount on the left side of field 22

Add the Medicare Payment amount on the right side in field 22

Coinsurance and deductible amount missing


Edit 1049

– Cause• The member is enrolled in the Care Select Program

• Affects claims for Care Select and the Right Choices Program

– Resolution• Add the member’s PMP information to the claim

• CMS-1500

PMP Taxonomy Code: Box 17a

Precede the taxonomy with Qualifier “ZZ”

PMP NPI: Box 17b

Care Select member’s PMP is missing


Edit 2505

– Cause• This member has private insurance, which must be billed prior to Medicaid

– Resolution• Add the other insurance payment to the claim

• CMS-1500

Add other insurance excluding Medicare payments to field 29

• If the primary insurance denies, the explanation of benefits (EOB) must be sent with the claim, either on paper with a paper claim, or as an attachment if claim is sent on Web interChange

Recipient covered by private insurance


Edit 1047

– Cause• This is a Care Select member

Must have two-digit certification code from the primary medical provider

– Resolution• Add the two-digit certification code from the primary medical provider for that

quarter

• CMS-1500

PMP Certification Code – Box 19

Certification code missing – Care Select member


Edit 2017

– Cause• The member was not eligible for fee-for-service medical assistance on the date

of service because he or she was enrolled in the risk-based managed care program

– Resolution• Verify eligibility on any EVS and bill the appropriate managed care organization

Recipient ineligible on date of service due to enrollment in a managed care organization


Edit 5001

– Cause• Claim being processed is an exact duplicate of a claim on the history file or

another claim being processed in the same cycle

– Resolution• Research prior claims billed for “paid” status

Exact duplicate


Edit 0593

– Cause• Occur when Medicare denies a detail line

• Are not crossover claims

• Do not include the paid detail lines on the new claim

• Processed as third-party liability (TPL) claims

• Include the Medicare Remittance Notice (MRN) with the claim

– Resolution• Denied detail lines must be billed on a separate claim form

Medicare denied detail


Edit 4021

– Cause• Procedure code billed is restricted to a specific program

– Resolution• Verify eligibility and submit claim with appropriate procedure code

• Verify the service rendered is covered by the members plan

Procedure code vs. program indicator


Edit 0513

– Cause• The member name and the member identification number (RID) on the claim

do not match the member database

– Resolution• Verify member name and RID on any EVS

• Resubmit claim with corrected name and/or RID

Member name and number disagree

Find HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP Web site at www.indianamedicaid.com

– IHCP Provider Manual (Web, CD-ROM, or paper)

– HCBS Waiver Provider Manual (Web)

– Customer Assistance• Local (317) 655-3240

• All others 1-800-577-1278

– Written Correspondence• HP Provider Written CorrespondenceP. O. Box 7263Indianapolis, IN 46207-7263

– Provider field consultant

http://www.indianamedicaid.com/

HP Provider Relations October 2010 CMS-1500 Billing.

Documents

Transcript of HP Provider Relations October 2010 CMS-1500 Billing.