Presumptive Eligibility/ Notification of Pregnancy Updates and Billing HP Provider Relations October 2011
Agenda – Session Objectives – Overview – Qualified Providers – Presumptive Eligibility Member Qualifications – Eligibility Verification System – Notification of Pregnancy – Helpful Tools – Questions 2 Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Objectives Following this session, providers will: – Have an understanding of the Presumptive Eligibility program – Understand the responsibilities of a qualified provider – Understand who qualifies for Presumptive Eligibility – Understand the Eligibility Verification System options – Be able to see the successes of PE enrollment across the state – Be able to see where there is access to PE across the state – Have an understanding of the Notification of Pregnancy 3 Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Define Overview
Presumptive Eligibility – What Is It? – – Inpatient care, hospice, long-term care, delivery services, postpartum and services unrelated to the pregnancy or birth outcome are not covered – 5 For a limited period of time, a pregnant woman, who has been determined by a qualified provider (QP) to be presumptively eligible may receive ambulatory prenatal services while her Hoosier Healthwise application is being processed Implementation of the Presumptive Eligibility program began July 1, 2009 Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Who Is Eligible for Presumptive Eligibility? To be eligible for Presumptive Eligibility (PE), a pregnant woman must: – – Not be a current Medicaid member – Be an Indiana resident – Be a U. S. citizen or a qualified noncitizen – Not be currently incarcerated – 6 Be pregnant, as verified by a professionally administered pregnancy test Have gross family income less than 200 percent of the federal poverty level (FPL) Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Benefit Packages – Package A – Standard Plan – Package B – Pregnancy Coverage – Package C – Children’s Health Plan – Package E – Emergency Services Only – HIP – Healthy Indiana Plan – Package P – Presumptive Eligibility for Pregnant Women 7 Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Presumptive Eligibility Income Standards Family Size Annual Income 2 2, 429 29, 148 3 3, 052 36, 624 4 3, 675 44, 100 5 4, 299 51, 588 6 4, 922 59, 064 7 5, 545 66, 540 8 6, 169 74, 028 Add $624/mo for each additional person 8 Monthly Income Add $7, 476/yr for each additional person Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Why Presumptive Eligibility Is Important – – PE may help lower one of the barriers that prevent low income, uninsured women from seeking early prenatal care – Allows providers to be reimbursed for prenatal services provided earlier in a woman’s pregnancy – Public Law 218 -2007 (HEA 1678) was passed by the State Legislature and signed by the Governor in 2007 – 9 Early enrollment in Medicaid is associated with better birth outcomes Section 55 of this law directed the Office of Medicaid Policy and Planning (OMPP) to apply for federal approval of presumptive eligibility for pregnant women Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Learn Presumptive Eligibility Statistics
Presumptive Eligibility Statistics – 20, 866* Women enrolled in Presumptive Eligibility (PE) – 19, 106 Women enrolled in PE with Medicaid decision: – 14, 848* (78%) Women approved for Hoosier Healthwise through PE – 4, 258* (22%) Women on PE with Medicaid denial. *Data reflective of services from July 1, 2009, to August 2, 2011 11 Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Learn Qualified providers
Who Can Be a Qualified Provider? QPs may include the following provider types/specialties: – Family or general practitioner – Pediatrician – Internist – Obstetrician or gynecologist – Certified nurse midwife – Advanced practice nurse practitioner – Federally qualified healthcare center – Medical clinic – Rural health clinic – Outpatient hospital – Local health department – Family planning clinic 13 Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Who Can Be a Qualified Provider? QPs must meet the following federal and State requirements Federal requirements: – Must be enrolled in Medicaid – Must provide outpatient hospital, rural health clinic, or clinic services as defined in sections 1905 (a)(2)(A) or (B), 1905(a)(9), and 1905(l)(1) of the Social Security Act – Must be trained and certified by the State (or designee) to perform PE functions State-specific requirements: – Must be able to verify pregnancy via a professionally administered pregnancy test – Must have Internet, telephone, printer, and fax access that is available to facilitate the PE and Medicaid application process – Must have Administrator access to Web inter. Change • 14 Complete the Administrator Request Form to set up an administrator Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Are there Qualified Providers across the State? – 275 Qualified Providers (QP) have enrolled – – Only ½ the counties in IN have more than 1 QP point of access Only 7 counties with 10 or more QP locations – – – – Allen – 13 Elkhart – 20 Lake – 20 Madison – 10 Marion – 37 Vanderburgh – 10 Vigo – 15 In many Counties there is still a need for QP’s −Do 15 you know where a QP is located in your county? Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Locating a Qualified Provider To locate a qualified provider, go to the IHCP Web site at www. indianamedicaid. com – Qualified providers are location-specific – Each location must be trained by the State or its designee Note: As a QP site, please ensure that all staff members in all associated locations are trained to assist prospective PE applicants or to refer them to a location that has personnel trained by the state or its designee to assist them in the PE application process 16 Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Explain Eligibility verification
Eligibility Verification The Eligibility Verification System (EVS) communicates information about women with PE the day following the determination by the qualified provider and activation by MAXIMUS – EVS options include: – • Web inter. Change https: //interchange. indianamedicaid. com/ Administrative/logon. aspx • Omni machine • Automated Voice Response (AVR) (317) 692 -0819 or 1 -800 -738 -6770 Note: 18 Only Web inter. Change can be used to submit a member application for PE Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Describe Notification of Pregnancy (NOP)
What Is the Notification of Pregnancy? The OMPP, managed care entities (MCEs), Indiana State Department of Health (ISDH), and other Medicaid stakeholders worked jointly to develop a universal assessment for pregnant women to capture: • • • 20 Maternal Obstetrical History of Prior Births (Still birth, Pre-term, Low Birth Weight) Diagnosis of Pregnancy Risk Maternal Medical History (including conditions that require management during pregnancy, such as hypertension and diabetes) Current Medications Mental Health History and Current Conditions Substance Abuse/Use History Tobacco Use History Social Risk Factors Needed Referrals Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Notification of Pregnancy Medicaid Goals: – Identify health risk factors early in Medicaid-eligible women – MCEs review and provide care coordination to high risk pregnant women – Increase the percentage of pregnant women assessed within the first trimester – NOP data for women on PE demonstrates entry into prenatal care earlier – 67% of the women on PE enter care during the first trimester – 40% of all other women receive an NOP in the first trimester l Reduce smoking rates for pregnant women l Monitor pregnant women with a BMI >30 21 Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Notification of Pregnancy 19, 559 NOP’s completed – – 5, 689 NOPs for women on PE – 13, 870 NOPs for all other members NOPs completed during each trimester – – First trimester – 9, 250 – Second trimester – 9, 100 – Third trimester – 1, 209 NOP identified pregnancy risks – – – l Normal – 69% (13, 459) High – 31% (6, 100) NOPs completed by age range − − − Under 15 15 -18 years 19 -25 years 26 -35 years 36 -45 years 46 -55 years 19 1, 325 11, 098 6, 315 789 13 Data collected Between July 1, 2009 and July 31, 2011: 22 Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
Notification of Pregnancy Billing guidelines – Submit a claim to the appropriate managed care entity to request reimbursement for completion of a valid NOP form using procedure code 99354 with modifier TH – Providers can submit a claim to receive $60 for submission of a valid NOP form per pregnancy – There is no reimbursement when the NOP form is – – – 23 Submitted more than five calendar days from the date of service A duplicate, there is already an NOP in the system for this woman’s pregnancy Submitted for pregnancies beyond 29 weeks gestation Presumptive Eligibility/Notification of Pregnancy Updates and Billing October 2011
THIS CONCLUDES THE HP PORTION OF THE PRESUMPTIVE ELIGIBILITY PRESENTATION. THANK YOU FOR YOU TIME QUESTIONS AND ATTENTION!
Managed Care Entity Billing Requirements and Updates: Presumptive Eligibility and Notification of Pregnancy Presented by Anthem Blue Cross and Blue Shield, MDwise and Managed Health Services (MHS) October 2011 25
Managed Care Entity Billing Requirements and Updates Welcome! Thank you for the compassion and dedication with which you serve Hoosier Healthwise and Healthy Indiana Plan members. Today we will share important information with you about billing requirements, covered services and much more. 26
Presumptive Eligibility Covered Services The Managed Care Entities (MCEs) follow the State’s guidelines for covered services: All services require pregnancy diagnosis and providers must adhere to MCE prior authorization requirements. Covered pregnancy-related services are limited to Hoosier Healthwise and include: l Outpatient professional services, including mental health l Outpatient services for other conditions that might complicate the pregnancy l Lab Work l Pharmacy l Transportation for emergency and non-emergency services related to pregnancy 27
Package P Non-covered Services l Inpatient hospital stay l Abortion l Labor and delivery l Sterilization l Post partum care l Ectopic pregnancy l Hysterectomy l Abnormal products of contraception l Family planning service l Newborn Services l Hospice l Long term care 28
Presumptive Eligibility Billing Requirements – All Managed Care Entities General Claims Submission l The presumptive eligible (PE) member’s MCE is responsible for claims payment. l Claim timeliness requirements still apply. l Standard claim forms and filing processes should be followed. l Claim submission guidelines may vary by MCE (refer to the MCE’s website and/or claim companion guides). l Providers may also refer to Chapter 8 in the Indiana Heath Coverage Provider Manual for billing instructions which can be found at www. indianamedicaid. com/manual. . 29
Presumptive Eligibility Billing Requirements – All Managed Care Entities General Claims Submission l Claims must be billed with the 550 PE RID during PE period and billed with the standard Hoosier Healthwise RID during Package A or B periods. The PE coverage period is time-limited and claims could deny for use of wrong PE/RID number. l In the case of retroactive Medicaid coverage for the member, the Hoosier Healthwise RID must be used. 30
Claim Resubmission Guidelines Resubmitted claims need to be clearly marked as resubmissions per the MCE’s billing guidelines: l Anthem: Providers have 60 days from the date of initial determination to resubmit claims. Adjustments are processed within time frames set by Indiana law. l MDwise: Providers should reference the MDwise Quick Contact Sheet at www. mdwise. org at Contact Info or contact the member’s delivery system claims department. Reference the Extended Filing Limit Bulletin at www. mdwise. org , Announcements for claim filing limit information and FAQs. 31
Claim Resubmission Guidelines Resubmitted Claims (continued) l MHS: Providers have 60 days from date of initial determination to resubmit claims to MHS. Adjustments are processed within 30 days. l Please contact the responsible MCE for claim status questions. 32
Presumptive Eligibility Billing Requirements - MHS Eligibility Verification l MHS will utilize the Hewlett Packard (HP) Web inter. Change system to verify eligibility on the date of determination until complete eligibility data is received from HP. (Up to three days. ) Claim Submission l Providers must use standard claim forms for billing. l MHS follows the Centers for Medicare and Medicaid Services (CMS) guidelines for claim information and completion of required fields. l MHS can process claims submitted electronically, by paper and via the web. 33
Presumptive Eligibility Billing Requirements - MHS Claims Submission (continued) l Electronic claim submission is preferred and allows for more timely payment. (98% processed in 21 days. ) l Submission deadline is 365 days from date of service for non-participating providers and by contract otherwise. l Resubmitted claims must be received within 60 days from the initial determination. l Claims appeal requests must be received within 60 days from the initial determination. 34
Presumptive Eligibility Billing Requirements - MHS Out of Network Provider Billing To process out-of-network claims, the following data is needed for the RENDERING provider of service: l NPI Number, Taxonomy, ZIP plus 4 l Tax ID l PE ID Number on Claim (if billed during PE period) l Medicaid RID for packages A or B under Hoosier Healthwise (HHW) Note: W 9 must be on file with MHS and provider must be on the HP daily provider table for payment to be made by MHS. 35
Presumptive Eligibility Billing Requirements - Anthem Claim Submission l Submit Anthem claims with YRH prefix with appropriate PE “ 550” or Medicaid RID number based on eligibility for date of service. l Allow for processing time: 21 days for electronic claims and 30 days for paper claims. l Submit claims within 90 days to: Attn: Claims Anthem Blue Cross and Blue Shield P. O. Box 10787 Atlanta, GA 30348 36
Presumptive Eligibility Billing Requirements - Anthem For more information, providers may reference Anthem’s Provider Operations Manual by going to: l www. anthem. com l Under Other Anthem Websites, click on Providers l Under Providers │Spotlight, click on State Sponsored Plans – Indiana Hoosier Healthwise and Healthy Indiana Plan l On the State Sponsored Plans landing page, click on the link, Indiana Hoosier Healthwise and Healthy Indiana Plan (HIP) l Scroll down to the header, Provider Communications l Click on Provider Operations Manual and Important Updates 37
Presumptive Eligibility Billing Requirements - Anthem Out-of-Network Providers To process out-of-network claims, the following data is needed for the RENDERING provider of service: l NPI l Taxonomy l Tax ID l PE ID (550) for package P or Medicaid RID for packages A or B under HHW l Filing limit is 365 days from the date of service Note: W 9 must be on file with Anthem and Provider must be on HP Daily Provider Table for payment to be provided by Anthem. 38
Presumptive Eligibility Billing Requirements - MDwise Claim Submission l Providers are encouraged to submit their claims electronically. l In-network MDwise providers must submit claims to the delivery system claims department where the member is assigned. l Providers should reference the MDwise Quick Contact Sheet at www. mdwise. org at Contact Info or contact the applicable delivery systems for specific instruction on electronic claims submission. 39
Presumptive Eligibility Billing Requirements - MDwise Claim Submission l Please note that all electronic claims must be submitted using the HIPAA compliant transaction and codes sets. l Providers may submit paper claims to the applicable delivery system address (see quick contact sheet). Note: Red claim forms should be utilized. l Reference the Extended Filing Limit Bulletin at www. mdwise. org , Announcements for claim filing limit information and FAQs. 40
Presumptive Eligibility Billing Requirements - MDwise Claim Filing Limits l In-network Providers Filing limit is 90 from date of service as of 1/1/2011 l Out-of-network Providers Filing limit is 365 days from the date of service Note: All providers are responsible for checking eligibility at the time of each visit. Please visit my. MDwise Provider Portal at www. mdwise. org to verify member’s PMP and delivery system. The provider portal is free! 41
Presumptive Eligibility Billing Requirements - MDwise Out-of-Network Providers l To process out-of-network claims, the following data is needed for the rendering provider: NPI, taxonomy, zip plus 4 Tax ID LPI (Medicaid ID preferred) PE ID number on claim (if billed during PE period) or Medicaid RID for packages A or B under HHW Note: W 9 must be on file with MDwise and Provider must be on the HP daily provider table for payment to be provided by MDwise. 42
Presumptive Eligibility Billing Requirements - All MCEs Retroactive Hoosier Healthwise Coverage l Non-covered PE services may become covered if member becomes fully eligible for Package A or B. In most circumstances, the retroactive time period will be assigned back to PE determination date. Some members may have retroactive coverage that goes back further than the PE determination date. Claims periods of time prior to PE should be billed to HP unless assigned to MCE. l Providers should track claim denials during PE period for future submission should the women become enrolled in Package A or B. l When the member changes from Package P to Package A or B coverage, NEW claims must be resubmitted to the responsible MCE using the Medicaid RID only for retroactively covered Medicaid coverage. 43
MCE Prior Authorization Requirements MHS l Prior authorization requirements for Package B HHW apply. l Prior authorization requests must be received within two days prior to the planned date of service. l Requests can be submitted via FAX to 1 -866 -912 -4252 or online at www. mhsindiana. com. l Requests can also be made by calling 1 -877 -647 -4 U 4 U, prompt 2. 44
MCE Prior Authorization Requirements MDwise l Providers should reference the MDwise Quick Contact Sheet at www. mdwise. org at Contact Info or contact the member’s MDwise delivery system for authorization requirements. Anthem l Before services are provided, call the Utilization Management Department at 1 -866 -408 -7187. Note: Please utilize the Universal Prior Authorization Form for all MCEs for all PA requests with the exception of Behavioral Health services. 45
Full and Hold Panels Primary Medical Physician Assignment If the MCEs are not able to contact the member prior to their start date, they will automatically assign the member to a PMP. If the member is not satisfied with the provider selection they will be allowed to change their PMP. (HHW only. ) Hoosier Healthwise (HHW) If a member does not select a plan within 30 days, one will be assigned for them. After 90 days, the member will be locked into the MCE for the remainder of their enrollment period. Note: If a member does not choose a PMP within their MCE, one will be automatically assigned to the member by the MCE. 46
Full and Hold Panels Primary Medical Physician Assignment (continued) Note: If a PMP disenrolls from an MCE and goes to another MCE, members WILL NOT automatically follow the PMP to the new MCE. The members will have to call Maximus to request the change for just cause. Hold Panel If panel is on hold, the member will need to select a different provider that has a open panel within the same network. l There is no auto assignment in PE. Members must select a PMP and MCE to have PE coverage activated. l Member’s automatically follow their PMP when they are assigned to from Package P to Package B. 47
Presumptive Eligibility Claims Tips - All MCE’s PE Top Denial Reasons and Solutions Reason: Package P pregnancy diagnosis not on the claim form. Solutions: l Anthem: Diagnosis code must be primary on the claim form. l MHS & MDwise: Diagnosis must be on the claim form. Note: Reference IHCP Manual, Chapter 8, Section 4. 48
Presumptive Eligibility Claims Tips - All MCE’s PE Top Denial Reasons and Solutions l Member Not Eligible: Be sure to file with the appropriate PE “ 550” or Medicaid RID number based on eligibility for the date of service. You need to check eligibility via the Web inter. Change prior to services being rendered. MDwise- Please utilize my. MDwise Provider Portal at www. mdwise. org to verify the member’s PMP and delivery system. Anthem: Claims must have YRH prefix before PE “ 550” or Medicaid RID number. 49
Presumptive Eligibility Claims Tips - All MCE’s PE Top Denial Reasons and Solutions (continued) l No Authorization on File: Please see MCE’s website for Prior Authorization (PA) requirements and forms. Note: Please utilize the Universal Prior Authorization Form for all PA requests with the exception Behavioral Health services. l Duplicate claim/services: Allow appropriate time frame for claim payment. Note: Reference IHCP Manual, Chapter 8, section 4. 50
Notification of Pregnancy 51
Importance of Notification of Pregnancy The early identification of pregnant members is important to: l Help ensure better birth outcomes l Identify risk factors and high-risk pregnancies l Coordinate case management l Obtain referrals l Reduce the number of early deliveries l Reduce the number of pregnant women who smoke Providers are reimbursed for submitting the Notice of Pregnancy (NOP) Form. 52
Notification of Pregnancy (NOP) Billing Guidelines CPT Code/Modifier Combination l 99354 TH - * Note NOP is not covered for HIP members. l Reimbursement is $60 l One per member, per pregnancy l Only permitted on successfully submitted, complete and timely NOPs Submit via Web inter. Change Pregnancy is 29 weeks or less Entered in Web inter. Change within 5 calendar days of date of service Note: Provider or provider designee should complete the NOP form. 53
Notification of Pregnancy (NOP) Billing Guidelines PE members will be in Web inter. Change the day following approval of PE. l l Providers must wait to enter NOP until the day after PE is determined. The same requirements for successful, complete, timely submission of the NOP apply for PE women. 54
Notification of Pregnancy Top Denial Reasons & Solutions - All MCE’s l l NOP not filed timely: A valid NOP form must be submitted via Web inter. Change within 5 calendar days of the date of service in order to be reimbursed. Duplicate NOP. Reimbursement for NOP submission limited to one time per pregnancy. Member is over 29 weeks gestation: The member must be less than 30 weeks gestation for the provider to be eligible for reimbursement. Eligibility: Be sure to file with the appropriate PE “ 550” or Medicaid RID number based on eligibility for the date of service. 55
Notification of Pregnancy Wrap Up Provider Benefits l NOP data used to support provider plan of care with services and resources available through MCE’s according to case management risk stratification guidelines developed by the State. Care and Case Management programs from MCE. Supplemental member education materials, services and phone calls. l Assist provider in linking member to community resources. l Additional revenue source - $60 per NOP/member/pregnancy. 56
Notification of Pregnancy Wrap Up Provider Benefits l High Risk: A woman must have at least two medical risk factors in her current pregnancy or an obstetrical history that places her at risk for pre-term birth or poor pregnancy outcome. May receive additional antepartum care visits for high risk pregnancies beyond the maximum 14 visits allowed for normal pregnancy. Reimbursement of additional $10 per prenatal visit. Note: Per Banner BR 201134, In order for providers to received additional visits and reimbursement they must submit an NOP. 57
Notification of Pregnancy Wrap Up Member Benefits l Access to educational materials. l Dedicated care or case management programs. l Opportunity for additional visits with provider if high risk. l Early referral and access to community resources. 58
Resources – – – IHCP Web site at www. indianamedicaid. com E-mail: pehelp@fssa. in. gov Presumptive Eligibility Bulletins • BT 200910 and BT 200920 NOP Bulletins • BT 200914, BT 200921, and BT 200941 Presumptive Eligibility Provider Manual (Web, CD-ROM, or paper) HP Customer Assistance • Local (317) 655 -3240 • All others 1 -800 -577 -1278 59
Resources Written Correspondence – P. O. Box 7263 Indianapolis, IN 46207 -7263 – Provider field consultant – View a current map territory map and contact information online at http: //provider. indianamedicaid. com/contact-us/provider-relationsfield-consultants. aspx • 60
Resources Anthem- www. Anthem. com l State Sponsored Plans-Indiana Hoosier Healthwise l Phone: 1 -866 -408 -6132 MDwise - www. MDwise. org l Phone: 800 -356 -1204 MHS- www. mhsindiana. com l Phone: 1 -877 -647 -4 U 4 U (4848) Medicaid Fee Schedule l Indianamedicaid. com/fee schedule 61
Questions? Thank You from your Managed Care Entities 62
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