Wyoming Medicaid Covered Services & Billing …...(speak to agent) Questions concerning claims,...

Immunization Conference

Wyoming Medicaid

Covered Services & Billing Requirements

May 11 & 12, 2016

Presenter’s: Melissa Davis & Elisa Mauch, Field Representative’s

What is Medicaid?

• Medicaid helps pay for healthcare services for children, pregnant women, families with children, and individuals who are aged/blind/disabled who qualify based on citizenship, residency, family income, and sometimes resources and healthcare needs.

• Non- citizens may be eligible for emergency services.

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CMS 1500 Provider Manual

Located on the Medicaid website http://wymedicaid.acs-inc.com

Select Provider

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http://wymedicaid.acs-inc.com/




• Select Provider Manuals and Bulletins(Navigation Bar on Left)

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• Select Nurse Practitioner within the CMS 1500 Provider Manual and Bulletins section

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• Select CMS 1500 Provider Manual

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• Review for New/Updated Information

• Important Policy Changes/Additions section

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• CMS 1500 Provider Bulletins Section

• Additional Links section - Medicaid and State Healthcare Benefit Plans

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Covered Services Chapter 21 – Covered Services - Practitioner

Services Section 21.1 – Physician and Nurse Practitioner Services

Covered services and billing requirements specific to physicians and practitioners

21.7.1 – Immunizations

WyVIP

Private stock

Administration

Billing examples

21.17 – Public Health Services

Definition

Non-Covered Services

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21.7.1 Immunizations

Billing Procedures (21.7.1) WyVIP supplied vaccines

Private Stock - Privately purchased vaccines

WyVIP Supplied Provided free of charge to eligible Medicaid clients 18 years and younger

Vaccine reimbursement: $0 reimbursement for vaccine (i.e. TDAP, MMR, influenza, etc.)

Bill with vaccine procedure code (90477-90748) and SL modifier (indicates WyVIP)

Administration reimbursement: reimburses from fee schedule

Bill appropriate vaccine administration code

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Private Stock / Privately Purchased Vaccines (21.7.1)

WyVIP was out of stock

The vaccine was not supplied through the WyVIP Program

Vaccine reimbursement: reimburses at cost (invoice) or from fee schedule, dependent on procedure code and client’s age

Bill appropriate vaccine procedure code

Do not bill with the SL modifier

Administration reimbursement: reimburses from fee schedule regardless of how the vaccine was acquired

Bill appropriate vaccine administration code

Bill usual and customary charges

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Private Stock / Privately Purchased Vaccines (continued)

Private Stock Payment Methodology

Clients 19 yrs and older / Fee Schedule

No invoices required

Vaccine procedure codes

Influenza (90656 - $15.00, 90658 - $20.00 , 90660 - $15.00)

Tetanus (90703 - $15.00)

MMR (90707 - $15.00)

TD (90714 - $15.00)

TDAP (90715 - $30.00)

Clients 18 yrs and under / Invoice

Invoices required (Medicaid Fee Schedule)

Vaccine procedure codes same as above

Invoices required / Invoice

All other vaccine codes for any age

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Medicaid Fee Schedule

http://wymedicaid.acs-inc.com (Wyoming Medicaid Website)

Select Provider

Select Fee Schedules

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• Accept the agreement

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• Select Try our Procedure Code Search page

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• Enter Procedure Code

• Select Search

• Review the Procedure Code Legend for important and helpful information

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Vaccination Administration Codes

(18 or younger, with counseling)

Administration Codes – Ages 0 – 18 with Face-to-Face Vaccine Counseling

CPT

Code Description

90460

Immunization administration through 18 years of age via any route of administration, with

counseling by physician or other qualified health care professional; first or only component of

each vaccine or toxoid administered

90461

Immunization administration through 18 years of age via any route of administration, with

counseling by physician or other qualified health care professional; each additional vaccine or

toxoid component administered (list separately in addition to code for primary procedure)

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For each vaccination given, the first or only component (antigen) is billed using 90460, each additional

component/antigen is billed using 90461. Like codes must be combined onto one line with multiple units.

90461 is reimbursed at $0, and is used for tracking purposes only.

Administration Code Billing Scenario 1

Eligible client is a 4 year old child which received the influenza vaccine with counseling

Administration code billing would look like this:

Explanation

The Influenza vaccine has only 1 component, only 1 unit of 90460 is reported, to indicate the 1st or only component the client was vaccinated for.

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Code Units Billed Charge Reimbursement

90460 1 $21.72 $21.72

Vaccine Total

Components

90460 (first/only

component)

90461 (additional

components)

Influenza 1 1 0


Eligible client is a 4 year old child which received an influenza and MMR vaccine with counseling

Administration code billing will look like this:

Explanation

The Influenza vaccine has only 1 component, only 1 unit of 90460 is reported, to indicate the 1st or only

component the client was vaccinated for. The MMR vaccine has 3 components, one unit of 90460 is

reported to indicate the 1st component, and 2 units of 90461 are reported to account for the other 2

components of the MMR vaccine. The units are combined on the claim to show 2 units of 90460 (1st

components) and 2 units of 90461 (additional components).

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90460 2 $43.44 $43.44

90461 2 $0.00 $0.00


Eligible client is a 4 year old child which received an MMR, Varicella, and DTAP-IPV vaccine with counseling

Administration code billing will look like this:

Explanation

The MMR vaccine has 3 components, one unit of 90460 is reported to indicate the 1st component, and 2 units of 90461 are reported to account for the other 2 components of the MMR vaccine. The varicella vaccine has only 1 component, one unit of 90460 is reported to indicate the 1st/only component. The DTAP-IPV vaccine has 4 components, one unit of 90460 is reported to indicate the 1st component, and 3 units of 90461 are reported to account for the other 3 components of the DTAP-IPV vaccine. The units are combined on the claim to show 3 units of 90460 (1st components) and 5 units of 90461 (additional components).

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90460 3 $65.16 $65.16

90461 5 $0.00 $0.00

Vaccination Administration Codes

(19 or older, no counseling provided) Administration Codes – Face-to-Face Vaccine Counseling Not Provided

CPT

Code Description

90471

Immunization administration (includes percutaneous, intradermal, subcutaneous, or

intramuscular injection); one vaccine (single or combination vaccine/toxoid) Do not report in

conjunction with 90473.

90472 Each additional vaccine (single or combination vaccine/toxoid). List separately in addition to

code for primary procedure (90471 or 90473).

90473 Immunization administration by intranasal or oral route; one vaccine (single or combination

vaccine/toxoid) Do not report with 90471.

90474 Each additional vaccine (single or combination vaccine/toxoid). List separately in addition to

code for primary procedure (90471 or 90473).

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For vaccinations where face-to-face counseling is not provided, 90471 or 90473 is reported for the first

vaccine, and 90472 or 90474 (units combined for multiples) for each additional vaccine.

Common Claim Denial Reasons

• Claim submitted on paper – As of July 1, 2015 all claims must be submitted electronically.

• Not submitting attachments – two ways to send attachments

• Electronically – attachments can be submitted by using the Secure Web Portal. You do not have to submit claims through the web portal in order to utilize this option. The Attachment Control Number must be filled in and match the attachment control number put on the claim.

• By Mail- when mailing in your attachments you must include the Attachment Cover Sheet. This can be found on the Medicaid Website under Forms. The Attachment Control Number must be filled in and match the attachment control number put on the claim.

• Facility or Treating Provider are not enrolled in Wyoming Medicaid.

• Both facility and treating providers must be actively enrolled with Wyoming Medicaid in order to bill for services rendered.

• Billing with Medicaid Provider number instead of NPI. Must always bill using your NPI number.

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Important Phone Numbers

IVR – 800-251-1268

Eligibility, check status, lock-in status, insurance information, claims status

Provider Relations – 800-251-1268, press 1, 5, 0 (speak to agent)

Questions concerning claims, procedure codes, eligibility, payments, verify client information, remittance advices, etc.

800-251-1268, press 3 for Web portal password resets, access to LT101 Inquiry, etc.

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Important Web Resources

Wyoming Medicaid http://wymedicaid.acs-inc.com

Medicaid provider manuals

fee schedule

Contact Us – IVR Navigation Tips

Secured Provider Web Portal

Remittance Advice

Claims Submission

LT101 Inquiry

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Questions?

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Wyoming Medicaid Covered Services & Billing …...(speak to agent) Questions concerning claims,...

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Transcript of Wyoming Medicaid Covered Services & Billing …...(speak to agent) Questions concerning claims,...