Medical Equipment Guidelines HP Provider Relations October 2010
Agenda – Indiana Medicaid Web site – Billing the Member – Updates – Spend-down – Date of Service – Claim Attachments – Provider Code Sets – Prior Authorization – Capped Rental – Denials and Resolutions – Repair and Replacement – Helpful Tools – Rolling 12 -Month Period – Questions – Mail Order Incontinence, Ostomy, and Colostomy Supplies 2 Medical Equipment Guidelines October 2010
Objectives Following this session, providers will: – Be familiar with the Indiana Medicaid Web site – Understand medical equipment guidelines – Understand guidelines for billing the member – Be familiar with spend-down – Understand the claim attachment process – Be familiar with prior authorization inquiry and Prior Authorization Form – Understand the top denials and resolutions 3 Medical Equipment Guidelines October 2010
Introduce Indiana Medicaid Web site
Indiana Medicaid Member Web Site http: //member. indianamedicaid. com/ 5 Medical Equipment Guidelines October 2010
Indiana Medicaid Member Web Site Member tab 6 Medical Equipment Guidelines October 2010
Indiana Medicaid Member tab – Qualification Guidelines – Medicaid Programs – Apply for Medicaid Benefits – Check Application Status – Search for a Provider – Choose a Health Plan – Presumptive Eligibility – Pharmacy Information 7 Medical Equipment Guidelines October 2010
Indiana Medicaid Provider Web Site http: //provider. indianamedicaid. com/ 8 Medical Equipment Guidelines October 2010
Indiana Medicaid Provider Web Site Provider tab 9 Medical Equipment Guidelines October 2010
Indiana Medicaid Provider Web Site Provider tab 10 Medical Equipment Guidelines October 2010
Provider Tab – Link to the Web inter. Change – Provider Enrollment – Banners – Bulletins – Newsletters – Workshop Information – Provider Education and Assistance – News and Announcements 11 Medical Equipment Guidelines October 2010
Describe Medical equipment services
Updates Procedure Code A 4253 - Blood glucose test or reagent strips for home glucose monitor, per 50 strips – Effective for claims with dates of service on or after January 1, 2010: • Providers are permitted to bill up to four units, or 200 strips, per beneficiary per 30 days • Additional units of A 4253 deny unless prior authorization (PA) is obtained Procedure Code A 4259 – Lancets, per box of 100 – Effective for claims with dates of service on or after January 1, 2010: • Providers are permitted to bill two units, or 200 lancets, per beneficiary per 30 days • Additional units of A 4259 deny unless PA is obtained CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 13 Medical Equipment Guidelines October 2010
Updates Procedure Code K 0739 – Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes – Effective January 1, 2010, K 0739 is a covered code – Replacement for code E 1340 – Claims denied with edit 4021 – Procedure Code vs. Program Indicator should be re-filed Procedure Code E 2609 – custom wheelchair cushion, any size – Effective May 14, 2010, E 2609 is no longer included in the long-term care durable medical equipment (DME) per diem procedure list – Requires prior authorization – May be billed separately to Medicaid 14 Medical Equipment Guidelines October 2010
Updates – Manually Priced Supplies – Effective September 24, 2010, Healthcare Common Procedure Coding System (HCPCS) codes for DME, supplies, and hearing aids that are currently manually priced will require a cost invoice with the claim in conjunction with the retail invoice for claim adjudication • A cost invoice is an itemized bill issued directly from the seller of the supply to the provider listing the goods supplied and stating the sum of money due to the supplier • Claims will continue to be reimbursed using the retail invoice, unless no invoice is submitted by the provider. The cost invoice will aid OMPP to establish rates for HCPCS – Invoices custom-generated by the provider that include the price of the goods plus the provider’s margin will no longer be accepted for HCPCS codes identified in Bulletin 201037 – Claims with a “from” date of service on or after September 24, 2010, submitted with HCPCS procedure codes listed in the table in BT 201037, along with only a retail invoice, or a provider customgenerated invoice, will be denied with: • Explanation of Benefit Code 9024 – Inappropriate invoice attached to the claim, please resubmit with the proper attachment 15 Medical Equipment Guidelines October 2010
Date of Service – The date of service is the date the equipment is delivered, not ordered – For the Indiana Health Coverage Programs (IHCP) to reimburse for medical equipment, the member must be eligible on the date of service (date of delivery) 16 Medical Equipment Guidelines October 2010
Provider Code Sets – The IHCP established code sets to ensure appropriate reimbursement for medical equipment codes – Providers must ensure that they are enrolled as the correct provider type and specialty – Type and specialty can be verified using the Provider Profile option on the Web inter. Change 17 Medical Equipment Guidelines October 2010
Provider Code Sets – The durable medical equipment (DME) provider type is 25 and the following are provider specialties: • 251 – Home medical equipment provider • 250 – DME/Medical supply dealer – Enrolling in the 251 specialty does not cover services in the 250 specialty, and enrolling in the 250 specialty does not cover services in the 251 specialty • Page 5 of the paper Provider Enrollment form lists the primary specialty in box 39; the additional specialty can be handwritten in the unassigned space to the right 18 Medical Equipment Guidelines October 2010
Capped Rental – Certain procedure codes are limited to 15 months of continuous rental – The IHCP evaluates requests from providers for approval of capped rental items • In long-term need situations, a decision may be made to classify the item as “purchase” instead of “rental” – Continuous rental is defined as rental without interruption for a period of more than 60 days • A change in provider does not cause an interruption in the rental period – The provider must service the item at no cost to the IHCP during the rental period • Once the equipment is considered purchased, any nonwarranty repairs are billable – A complete list of procedure codes for capped rental can be found in the Indiana Health Coverage Programs Provider Manual, Chapter 8, Section 4 19 Medical Equipment Guidelines October 2010
Capped Rental The allowed charge is the lower of the 1993 Medicare rental fee schedule amount or the actual submitted charge – The IHCP pays claims until the number of rental payments made reaches the capped rental number of 15 months – When the 15 -month rental period has been exhausted, the DME/home medical equipment (HME) is considered purchased and becomes the property of the Office of Medicaid Policy and Planning (OMPP) – Providers should base their decisions to rent or purchase DME or HME on the least expensive option available for the anticipated period of need 20 Medical Equipment Guidelines October 2010
Capped Rental – Medicare changed the capped rental policy for DME • The new policy states that the capped rental period is 13 months Ø After 13 months, the member owns the DME – Medicare will pay for reasonable and necessary maintenance and service of the DME item • This policy change applies to DME items in which the first month of rental is on or after January 1, 2006 – At this time, Medical Policy has not been directed to make changes to the IHCP’s capped rental policy 21 Medical Equipment Guidelines October 2010
Repair and Replacement – Repair of purchased equipment may require prior authorization based on the Healthcare Common Procedure Coding System (HCPCS) codes – The IHCP does not pay for repair of equipment still under warranty – The IHCP does not authorize payment for repair necessitated by member misuse or abuse, whether intentional or unintentional – The rental provider is responsible for repairs to rental equipment 22 Medical Equipment Guidelines October 2010
Repair and Replacement – The IHCP does not cover payment for maintenance charges of properly functioning equipment – The IHCP does not authorize replacement of medical equipment more than once every five years per member • More frequent replacement is allowed only if there is a change in the member’s medical needs that is documented in writing and significant enough to warrant a change in equipment; such requests require PA – A long-term care (LTC) facility’s per diem rate includes repair costs for equipment 23 Medical Equipment Guidelines October 2010
Rolling 12 -Month Period Is not: – Based on a 12 -month calendar year – Based on a fiscal year – Renewable on January 1 of each year Is: – Based on the first date that services are rendered by a particular provider – Renewable one unit at a time beginning 365 days after the date that services are rendered by a particular provider 24 Medical Equipment Guidelines October 2010
Mail Order Incontinence, Ostomy, and Colostomy Supplies Contracted vendors – OMPP contracted with three vendors to provide incontinence, ostomy, and urological supplies to fee-for-service members – The three contracted vendors are: • • Healthcare Products Delivery, Inc (HPD) 1 -800 -291 -8011 www. hpdinc. net • 25 Binson’s Home Health Care Center 1 -888 -217 -9610 www. binsons. com J & B Medical 1 -866 -674 -5850 www. jandbmedical. com Medical Equipment Guidelines October 2010
Mail Order Incontinence, Ostomy, and Colostomy Supplies – Members must obtain supplies via mail order • The contracted vendor may make other arrangements in emergency situations – The contracted vendors began providing services February 1, 2008, with full implementation completed on June 1, 2008 – A full listing of codes affected by this change is available in the IHCP Provider manual, Chapter 6, Section 5. – The annual maximum allowable reimbursement is $1, 950 per member per rolling calendar period 26 Medical Equipment Guidelines October 2010
Mail Order Incontinence, Ostomy, and Colostomy Supplies – The contracted vendor service applies to the Fee-for-Service and Care Select Programs – Only paid Crossovers and TPL claims are excluded from the program • If Medicare or the TPL denies the claim, the services are limited to the three contracted vendors – The following programs and claim types are not affected by the contract: • 590 Program • Medical Review Team (MRT) • Pre-Admission Screening and Resident Review (PASRR) • Long Term Care (LTC) • Waiver – Risk-based managed care (RBMC) members are excluded – Supplies for these members are billed to the appropriate managed care organization (MCO) 27 Medical Equipment Guidelines October 2010
Learn Billing the member
Billing the member The following circumstances are the only situations in which an IHCP provider may bill a member: – The service rendered is noncovered by the IHCP – The member has exceeded the program limitations for a particular service; for example, the services were denied prior authorization (PA) – Before receiving the service, the member must understand that the service is not covered under the IHCP, and the member is responsible for the charges associated with the service 29 Medical Equipment Guidelines October 2010
Billing the Member – A signed waiver must be maintained in the member’s record that the member voluntarily chose to receive a service that was not covered by the IHCP – The waiver should state: • Member’s name • Reason for noncoverage • Service requested • Estimated charge – 30 The waiver must not contain any conditional language; for example, the words “if” or “and” Medical Equipment Guidelines October 2010
Billing the member – “Medicaid-pending” individuals are responsible to pay the provider • It is the patient’s responsibility to notify the provider of Medicaid approved status within 12 months of the date of service • Providers may bill the patient if there is no notification of Medicaid eligibility within this time period – Providers may also bill the member when a spend-down is applied to their claim 31 Medical Equipment Guidelines October 2010
Spend-down – Member is eligible on the first of the month – Providers may not refuse service to a member pending verification of the status of spend-down for the month – A provider may bill a member for the dollar amount identified beside ARC 178 on the Remittance Advice (RA) statement – The member is not obligated to pay the provider until the member receives the Medicaid Spend-down Summary Notice listing the amount applied to spend-down • Notices are sent on the second business day following the end of the month – Members cannot be billed for more than their spend-down amount – Providers must bill their usual and customary charge to the Indiana Health Coverage Programs (IHCP) 32 Medical Equipment Guidelines October 2010
Spend-down – Providers may discharge a member from their care if a member does not adhere to established payment arrangements of outstanding copayments or spend-down – Providers cannot be more restrictive with spend-down members than with other patients – The first claim processed by the IHCP applies to spend-down, regardless of the date of service within the month – The system uses the billed amount to credit spend-down – Third Party Liability (TPL) amounts are deducted from billed amount prior to crediting spend-down 33 Medical Equipment Guidelines October 2010
Describe Claim attachments
Claim Attachment Feature 35 Medical Equipment Guidelines October 2010
Claim Attachment Feature Attachment Control Number (ACN) – Unique number assigned by provider – Claim- and document-specific – Each ACN may only be used one time – Select the appropriate report type • Report Type describes the document being sent – Transmission Code defaults to “BM” – by mail • Electronic and e-mailed attachments are not accepted 36 Medical Equipment Guidelines October 2010
Claim Attachment Feature 37 Medical Equipment Guidelines October 2010
Claim Attachment Cover Sheet – Available on IHCP home page, under Forms – Complete cover sheet for each claim – Include provider information – Provide member ID – List each ACN pertaining to specific attachment – Indicate the number of pages of documentation submitted per attachment (not including the cover sheet) – Write “ACN #” and the assigned ACN on each page of documentation corresponding to that number – Mail cover sheet and supporting documentation to the address at the bottom of the cover sheet, HP, P. O. Box 7259, Indianapolis, IN, 46207 38 Medical Equipment Guidelines October 2010
Claim Attachment Cover Sheet 39 Medical Equipment Guidelines October 2010
Explain Prior Authorization
Prior Authorization Prior authorization by telephone, fax, or mail – Verify eligibility to determine where to send the PA request • ADVANTAGE Health Solutions – FFS Prior Authorization Department P. O. Box 40789 Indianapolis, IN 46240 1 -800 -269 -5720 Fax: 1 -800 -689 -2759 • ADVANTAGE Health Solutions – Care Select Prior Authorization Department P. O. Box 80068 Indianapolis, IN 46280 1 -800 -784 -3981 Fax: 1 -800 -689 -2759 • MDwise – Care Select Prior Authorization Department P. O. Box 44214 Indianapolis, IN 46244 -0214 1 -866 -440 -2449 Fax: 1 -877 -822 -7186 – Prior authorization for risk-based managed care recipients should be sent to the appropriate entity 41 Medical Equipment Guidelines October 2010
Prior Authorization 278 prior authorization inquiry – Allows the requesting provider to inquire about all nonpharmacy prior authorizations via the Web • It does not matter if the PA was submitted via paper, telephone, fax, or Web – The requesting provider and the named service provider may view a PA without the PA number – All other providers must have the PA number to view a PA 42 Medical Equipment Guidelines October 2010
Prior Authorization 278 Prior Authorization Inquiry 43 Medical Equipment Guidelines October 2010
Resolve Denials and resolutions
Denials and Resolutions Denial – Edit 593 – Medicare Denied Detail – Cause: • At least one detail is a Medicare-denied detail • At least one detail contains Medicare coordination of benefits (COB) information – Resolution: • Submit separate claims for Medicare-denied details and Medicare-covered details Denial – Edit 3001 – Dates of service not on PA master file – Cause: • No prior authorization in Indiana. AIM – Resolution: • Verify the date of service and procedure code billed are correct on the requested PA • Obtain amended/corrected PA if necessary 45 Medical Equipment Guidelines October 2010
Denials and Resolutions Denial – Edit 4021 – Procedure Code vs. Program Indicator – Cause: • Procedure code billed is restricted to a specific program – Resolution: • Verify procedure code is covered for dates of service billed • Verify recipient is eligible for program indicated Denial – Edit 4033 – Invalid Procedure Code/Modifier Combination – Cause: • Modifier used is not compatible with procedure code billed – Resolution: • Verify modifier is valid and appropriate for procedure code 46 Medical Equipment Guidelines October 2010
Denials and Resolutions Denial – Edit 0509 – Net Charge Out Of Balance – Cause: • Claim totals do not balance to the net charge entered on the claim – Resolution: • TPL claims: Ø The net charge on a paper claim form in field 30, should equal the total charge, field 28, less the TPL paid amount, field 29 Ø Field 22 should be blank • Medicare Crossover claims: Ø The total charge, field 28, and the net charge, field 30, should be the same Ø Complete field 22 with paid amount and coinsurance and deductible Note: These claims may be filed on the Web inter. Change 47 Medical Equipment Guidelines October 2010
Denials and Resolutions Denial – Edit 2003 – Recipient Ineligible on Dates of Service – Cause: • Member is not eligible for IHCP services being billed – Resolution: • Verify the claim was sent to the appropriate billing entity Ø Fee-for-Service and Care Select to HP Ø RBMC to the appropriate MCO 48 Medical Equipment Guidelines October 2010
Denials and Resolutions Denial: Edit 6000 – Manual Pricing Required – Cause: Manual pricing is required – Resolution: Submit Manual Pricing • Invoice requirements Ø Date Ø Billed amount per unit (for example, box, case, and so forth) Ø Calories (enteral feeding) Ø Procedure code Ø Member name Ø Member ID number Ø Itemization of repairs • Bulk Invoices – illustrate calculations specific to the member 49 Medical Equipment Guidelines October 2010
Denials and Resolutions Denial: Edit 6000 – Manual Pricing Required – Resolution: Submit Manual Pricing DME SUPPLY MANUFACTURING 1 SUPPLY ROAD ANYWHERE, INDIANA 800 -123 -2345 INVOICE 4/27/09 BILL TO: DME/HME SUPPLIES 200 STATE STREET ANYWHERE, INDIANA ITEM NUMBER/DESCRIPTION EXTRA SET RT ANGLE HCPCS: B 9998 5 sets in a box - ordered 1 box 59. 90/5 = 11. 98 each Member rid# 123456789999 Abe Lincoln *****COST INVOICE******* 50 Medical Equipment Guidelines October 2010 U/M 5/BOX QTY 1 PRICE 59. 90 TOTAL 59. 90
Find Help Resources Available
Helpful Tools Avenues of resolution – IHCP Web site at www. indianamedicaid. com – IHCP Provider Manual (Web, CD-ROM, or paper) – Customer Assistance • Local • All (317) 655 -3240 others 1 -800 -577 -1278 – Written Correspondence • HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN 46207 -7263 – Provider field consultant • View a current territory map and contact information online at www. indianamedicaid. com 52 Medical Equipment Guidelines October 2010
Q&A
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