Basic Billing 2013 Ohio Medicaid Home Care Agencies

Transcription

1 Basic Billing 2013 Ohio Medicaid Home Care Agencies

2 Ombudsman Kathy Frye Laura Gipson Dwayne Knowles Kenneth Morgan Jamie Speakes Meagan Lyle, Manager Office of Ohio Health Plans External Business Relations 2

3 External Business Relations Investigate and resolve billing issues Identify system and policy issues Speak at seminars for provider associations Conduct individual consultations with providers Conduct basic billing trainings 3

4 Agenda Medicaid Overview Policy Overview MITS Websites 4

5 Medicaid Overview 5

6 Ohio Department of Medicaid Covered Families and Children (Healthy Start and Healthy Families) Aged, Blind or People with Disabilities Home and Community Based Waivers Medicare Premium Assistance Hospital Care Assurance Program Medicaid Managed Care (ODM) 6

7 Ohio Medicaid Benefits Home Health Services Transportation services Physician Services Inpatient/ Outpatient Services Nursing Facility Dental services Durable medical equipment Hospice Services Behavioral Health Pharmacy Services Vision 7

8 Medical Necessity The fundamental concept underlying the Medicaid Program. All services must meet accepted standards of medical practice 8

9 Interactive Voice Response System (IVR) All calls are directed through the IVR prior to accessing the customer call center staff Providers are responsible for granting and maintaining IVR access for their billing entities or trading partners Provider Assistance staff are available weekdays from 8:00 am to 4:30 pm Because of HIPAA laws you must authenticate with your Provider Identification Number (PIN) to access Protected Health Information (PHI) 9

10 Tear on Perforation. Ohio Medicaid Card for individuals not on a specific program under Medicaid Issued monthly Notice to the Consumer: Please carry this card at all times and present this card whenever you request Medical service. If this card is lost or stolen, contact the county department of job and family services at once. Notice to Prov iders of Medical Serv ices: If there is evidence of tampering or if card is mutilated contact the local county department of job and family services. Check Void After Date to be sure the client is eligible for service. Questions regarding claims for services should b e directed to the Ohio Department of Job and Family Services, Interactive Voice Response System (IVR) at , or the Provider Network Management Section at , Option 1. Note: Use the billing number for all claim submissions. County Case/Category/Sequence Eligibility Begin Date Void After Date Ohio Medicaid Consumer s Signature: Ohio Department of Job and Family Services Consumer Hotline or TDD Tear on Perforation. Ohio Medicaid Billing Number Eligible Individual Date of Birth Medicare Number TPL Other Insurance Codes 10

11 SPENDDOWN VS. PATIENT LIABILITY 11

12 When a consumer s Medicaid s Monthly Income There is a Need Standard SPENDDOWN! 12

13 Medicaid Spenddown 5101: If a non waiver consumer has an income that exceeds the Medicaid need standard, the consumer must incur medical expenses that will reduce his/her income to the Medicaid need standard. The department defines incurred expenses as expenses that the client is obligated to pay. When the spenddown amount is incurred, the consumer must contact his/her caseworker at his or her local CDJFS to be eligible for Medicaid. 13

14 Medicaid Spenddown (Continued) Three ways spenddown can be met: ONGOING: Routinely occurring medical expenses, of the same type and amount each month, that are not covered by Medicaid PAY IN: The spenddown amount is paid to the CDJFS DELAYED: Medical expenses vary from month to month, must verify the incurred amount with the CDJFS 14

15 Medicaid Spenddown Example When a Medicaid consumer s monthly income exceeds the need standard there is a Spenddown. Consumer s Monthly Income _ Medicaid Need Standard = Spenddown $ $ $

16 PATIENT LIABILITY A consumer on a waiver program may have a patient liability instead of a spenddown. The department defines patient liability expenses as expenses that the client is obligated to pay. Refer to the consumer s All Services Plan for the liability amount and the provider(s) who receives the liability payment. 16

17 Provider Agreement 5101: The provider agreement is a legal contract between the state and the provider. In that contract, you agreed to: Accept the allowable reimbursements as payment infull and will not seek reimbursement for that service from the patient, any member of the family, or any other person Maintain records for 6 years 17

18 You also agreed to: Provider Agreement (Continued) Render medically necessary services in the amount required Recoup any third party resources available Inform us of any changes to your provider profile within 30 days Abide by the regulations and policies of the state 18

19 Provider Reimbursement 5101: : The department s payment constitutes payment infull for any of our covered services Providers are expected to bill the department their usual and customary charges (UCC) The department reimburses the provider at the Medicaid rate (established fee schedule) or the UCC, whichever is the lesser of the two. 19

20 Coordination of Benefits 5101: Medicaid is the payer of last resort. Therefore, providers must obtain a payment or denial from other payers prior to billing Medicaid. Providers who have gone through reasonable measures to obtain all third party payments, but who have not received a payment (or received a partial payment) from other payers, may submit a claim to Medicaid requesting reimbursement for the rendered service(s) in accordance to OAC rule 5101:

21 Recipient Liability 5101: A Medicaid consumer cannot be billed: When a Medicaid claim has been denied Unacceptable claim submission Failure to request a prior authorization Retroactive Peer Review determination of lack of medical necessity 21

22 Medicaid Subrogation Rights 5101: Section of the Ohio Revised Code requires that a Medicaid consumer provide notice to the department prior to initiating any action against a liable third party The department will take steps to protect its subrogation rights if that notice is not provided For questions, contact the Coordination of Benefits Section ( ) 22

23 Electronic Funds Transfer (EFT) ODJFS suggests electronic funds transfer (EFT) for payment instead of paper warrants. Benefits of direct deposit include: Receipt of payment quicker: Funds are transferred directly to your account on the day paper warrants are normally mailed No more worry about lost or stolen checks or postal holidays delaying receipt of your warrant If you move your payment will still be deposited into your banking account For additional information and to begin receiving funds electronically, you will find the Direct Deposit/EFT form at: 23

24 Policy Overview 24

25 State Plan OAC Rules Based on your provider agreement, you are obligated to abide by the regulations and policies of the state. Therefore, you must read and understand all Ohio Administrative Code (OAC) rules that pertain to your provider type. Please refer to the OAC rules noted below for OAC rules pertaining to state plan home care services: 5101: , Home Health Services 5101: , Home Health & PDN Visit Policy 5101: , Home Health Services 25

26 Private Duty Nursing OAC Rules For OAC rules pertaining to state plan private duty nursing (PDN) services, start with the rules noted below: 5101: , PDN Services, Requirements, Coverage, etc. 5101: , PDN Service Authorization 5101: , PDN Reimbursement 26

27 ODJFS Waiver OAC Rules For OAC rules pertaining to ODJFS waiver services, start with the rules noted below: 5101: , Definitions 5101: , Conditions of Participation 5101: , Covered Services, Requirements, Specifications 5101: , Reimbursement Rates and Billing 27

28 Policy Updates Policy updates from Ohio Medicaid announce the changes to Ohio Administrative Code that may affect providers. There are two types of letters: Community Services Transmittal Letters (CSTL) Medical Assistance Letters (MAL) 28

29 STATE PLAN SERVICES VS. WAIVER SERVICES 29

30 What are State Plan Services? STATE PLAN SERVICES are services that all Medicaid recipients can receive if they are medically necessary and Ohio Administrative Code (OAC) rules allow those recipients to receive the services. ODJFS submits a State Plan to the federal government that describes how the Medicaid program is administered. Medicaid is an entitlement program. Therefore, all Medicaid recipients are entitled to receive State Plan services if they are medically necessary and allowable based on OAC rules. 30

31 What are Waivers? The term waiver refers to an exception to federal law that waives certain Ohio Medicaid eligibility requirements and allows eligible Medicaid recipients to cost effectively live in their communities instead of nursing homes or hospitals. Since waiver programs are not entitlement programs, only recipients enrolled on a waiver program can receive waiver services from that waiver program. 31

32 Waiver Programs Administered By ODJFS The Ohio Home Care Waiver This waiver program serves recipients who are under the age of 60 and are not mentally retarded or developmentally delayed. The Transitions DD Waiver This is wavier is currently administered by the Ohio Department of Developmental Disabilities (DODD). The Transitions Carve Out Waiver This is a waiver program for 60 year old (or older) recipients who were on the Ohio Home Care waiver. 32

33 Who Can Provide State Plan Home Health Services? Only a Medicare Certified Home Health Agency can provide State Plan Home Health services. State Plan Home Health Services: G0154 RN& LPN services G0156 Aide/Personal Care G0151 Physical Therapy G0152 Occupational Therapy G0153 Speech Therapy 33

34 MODIFIERS FOR STATE PLAN HOME HEALTH SERVICES U1 is for infusion therapy U2 is for the 2 nd visit on the same day U3 is for the 3 rd visit on same day U5 is for recipients age 20 and younger HQ is the group modifier 34

35 Who Can Provide State Plan Private Duty Nursing (PDN) Services? T1000 RN & LPN services A Home Health Agency or independent nurse can provide PDN services. Refer to MAL 515 and OAC rule 5101: for an overview of the prior authorization process. 35

36 MODIFIERS FOR STATE PLAN PDN SERVICES U1 is for infusion therapy U2 is for the 2 nd visit on the same day U3 is for the 3 rd visit on same day U4 is for a visit over 12 hours up to 16 hours U5 is for recipients age 20 and younger U6 is for recipients age 21 and older HQ is the group modifier 36

37 Waiver Programs Administered By ODJFS (Procedure codes) Waiver Nursing & Personal Care Services: T1002 RN Services T1003 LPN Services T1019 Personal Care/Aide Services When an RN or LPN is providing a waiver service, the appropriate procedure code and modifier must be used. 37

38 Waiver Programs Administered By ODJFS (Modifiers) U1 is for infusion therapy, RNs only U2 is for the 2 nd visit on the same day U3 is for 3 rd (or more) visit on same day U4 is for a visit over 12 hours up to 16 hours HQ is the group modifier 38

39 Waiver Programs Administered By ODJFS (Procedure codes) Waiver Services, continued: H0045 Out of Home Respite Care Services S0215 Non Emergency Transportation Services S5101 Day Care Services, Adult Half Day S5102 Day Care Services, Adult Full Day S5160 Emergency Response Services Installation S5161 Emergency Response Services Monthly Fee S5165 Minor Home Modifications S5170 Home Delivered Meals T2029 Specialized Medical Equipment 39

40 Services At a Glance The Services at a Glance chart has been developed as a way to quickly see the major components of State Plan and of Waiver Services. 40

41 Fix The Problem Before It Becomes A Problem That Can t Be Fixed. 41

42 Problems That Must Be Fixed Prior To Submitting Claims Follow the All Services Plan. Understand the terminology (e.g., state plan, waiver). Read and understand the OAC rules. Make sure your billing staff or billing company have all the information they need to submit claims for you (e.g., correct dates of service, procedure codes, modifiers). 42

43 BILL ALL WAIVER SERVICES ACCORDING TO THE ALL SERVICES PLAN 43

44 Waiver Services You or your agency must provide waiver services according to the All Services Plan. Contact your case manager for details. 44

45 Waiver Programs Administered By Other State Agencies When billing for waiver services for recipients on other waiver programs (e.g., PASSPORT), contact the appropriate state or county agency for billing instructions. 45

46 Key Points Follow the billing instructions. Bill all services in chronological order. Each line on a claim represents a visit or a service. Most services are billed in multiple units. Bill for services using the appropriate procedure code and modifier. Some services may require multiple modifiers. Only bill for the services noted on the All Services Plan. 46

47 CALCULATION FOR NURSE SERVICES [(Total Units 4) x Unit Rate] + Base Rate = Medicaid Maximum EXAMPLE: Noted below is the Medicaid maximum calculation for a 12 hour state plan or waiver nursing visit. 12 (hours) x 4 = 48 (convert hours to units) 48 4 (minus base rate) = x $5.69 (unit rate) = $ $ $52.20 (plus base rate)= $ (Medicaid Maximum) 47

48 Medicaid Information Technology System (MITS) 48

49 MITS General Information Medicaid Information Technology System MITS is the new Web based, Medicaid management system MITS design is based upon the Medicaid Information Technology Architecture (MITA) MITS is a.net environment able to process transactions in real time 49

50 Provider Contracts In MITS, a provider will have a provider contract that determines the Medicaid population the provider is contracted to provide services to and receive reimbursement. MITS General Information If an agency provides state plan private duty nursing services to a Medicaid recipient, the agency must have a Private Duty Nursing contract. If an agency provides ODJFS waiver nursing services to a Medicaid recipient, the nurse must have an ODJFS Waiver Nursing contract. If providers have questions regarding their contract, they should contact Provider Enrollment ( ). 50

51 MITS General Information Internal Control Number (ICN) The ICN replaced the Transaction Control Number (TCN) All claims will be assigned an ICN Region Code Calendar Year Julian Day Claim Type/Batch Number Number of Claim in Batch 51

52 MITS General Information Internal Control Number (ICN) Primary region codes new claim submission 10 Paper Claim without attachment 11 Paper Claim with attachment 20 Electronic 837 without attachment 21 Electronic 837 with attachment 22 Web Portal without attachment 23 Web Portal with attachment 52

53 MITS General Information Primary Region Codes, continued 50 Adjustment Non check Related 51 Adjustment Check Related 52 Mass Adjustment Non Check Related 53 Mass Adjustment Check Related 54 Mass Adjustment Void Transaction 55 Mass Adjustment Provider Retro Rates 56 Adjustment Void Non Check Related 57 Adjustment Void Check Related 58 Adjustment Internet claims 53

54 MITS General Information Converted Claims Claims in MMIS were converted for historical purposes and are denoted by the ICN region code 40 Claims converted from MMIS to MITS can only be voided 54

55 Technical Requirements System Requirements Internet Access (high speed works best) Internet Explorer version 8.0 and above or Firefox MAC Users download Internet Explorer for MAC Turn off pop up blocker functionality How do I Access the MITS Portal? Go to The ODJFS Welcome Page displays Select the Medicaid Information Technology System (MITS) link 55

56 System Requirements 56

57 Navigation MITS Web Portal Navigation Copy, Paste, and Print features will work in the MITS Portal Back feature will not work in the MITS Portal MITS Web Portal access will time out after 15 minutes of inactivity 57

58 Navigation Panel Help The? button in the upper right corner of a panel may be selected to reveal panel information 58

59 Field Help Navigation Clicking a field title will open a box containing field information 59

60 MITS Account Ohio Medicaid Providers must create a MITS web portal account to access the system. Setting up the account can be a three step process. The Administrator Account Setup Agent Account Setup Assigning Agent Roles 60

61 Administrator Account Setup MITS Account One account per billing NPI Only one person may set up an Administrator Account Access to all secure information Responsible for assigning roles to agents Unlimited Agents Responsible for maintaining the provider s MITS Portal account including demographic information 61

62 MITS Account 62

63 MITS Account 63

64 Agent Account Setup MITS Account Each Agent needs only one account Agents set up own accounts Administrator Account holder sets up Agent roles Each Agent account is role based Accounts setup by Pay to NPI Agent User ID remains the same Access to different NPIs can be granted Agents access may be revoked by role and NPI 64

65 MITS Account 65

66 MITS Account 66

67 MITS Account 67

68 MITS Account Each agent is assigned one or more of the following roles Eligibility Prior Auth Search Prior Auth Submit Claim Search Claim Submission 1099 Information (includes remittance advices) 68

69 MITS Account Agent Maintenance Panel 69

70 MITS Account 1 MITS Web Portal Access Flowchart Provider Account Setup 2 3 Agent Account Setup Provider Assigns Role(s) 70

71 MITS Account 71

72 MITS Account Switch Provider Panel 72

73 Reminder MITS Account MITS Portal is Web based and as long as access is still active, agents will be able to log into your account(s) so remove their access as soon as they leave the office. 73

74 Updating Provider Demographics MITS Account Perform updates via the MITS Web Portal by selecting Providers and then Demographic Maintenance from the main menu Reminder: Per Ohio State Law, Providers must notify the State within 30 days of any change to demographics 74

75 Re enrollment Processes and Features All new providers or current providers who are reenrolling must use the MITS Web Portal Check the status of re enrollments via the MITS Web Portal 75

76 Re enrollment 76

77 Re enrollment 77

78 Re enrollment Application Tracking Number (ATN) The 6 digit ATN will be assigned at the beginning of the enrollment process Up to 3 days to complete the application Check status of applications once completed 78

79 Re enrollment 79

80 Eligibility Verification Providers can use the MITS Web Portal to search and verify recipients eligibility for benefit programs Eligibility information is found on the Eligibility Verification Request Panel 80

81 Eligibility Verification Verification of the following: Medicare Managed Care Benefit Plan Long Term Care Third Party 81

82 Eligibility Verification 82

83 Eligibility Verification 83

84 Claim Submission Methods of Claim Submission Electronic Data Interchange (EDI) MITS Web Portal Paper claims Paper claims will not be accepted after 1/1/2013 If you currently submit paper, plan for the transition now to either EDI or MITS portal 84

85 Comparison of EDI and Portal Claim Submission EDI Need to contract with a trading partner or create/or purchase own software. Fees for claims submitted Claims received electronically via the trading partner by 12:00 am Wednesday will be processed for adjudication over the weekend. No limit to number of claims you can submit each day. Portal Free submissions Providers need access to the internet. Claims received by 5:00 pm Friday will be processed for adjudication over the weekend. Limit of 50 claims per day, and this may change to unlimited claims in the near future. When the change occurs, providers will be notified. 85

86 Claim Submission Electronic Data Interchange Information for Trading Partners jfs.ohio.gov/ohp/tradingpartners/info.stm Companion Guides 837 Health Care Claim Professional EDI Information Guide Technical Questions/EDI Support Unit MMIS EDI 86

87 Claims Entry Format are divided into different sections called panels Each Panel will have an asterisk (*) for a portal required field. There are some fields that are situational for claims adjudication that do not have an asterisk, but are required for adjudication. Add/Delete/Copy Search Description Numeric Claim Submission 87

88 Claim Submission Billing instructions for submitting claims via the MITS Web Portal are accessible via emanuals, and these instructions will provide information that includes (but isn t limited to): Field level information; A brief explanation of options in drop down menus (e.g., Medicare Assignment, Release of Information); Provider specific information (e.g., which providers must enter diagnosis codes). 88

89 Claim Submission Multiple Visits in One Day If a provider is providing multiple visits in one day, all of the visits must be noted on a single claim. 89

90 Claim Submission 90

91 Claim Submission (Billing/Service Information Panel) Complete all of the appropriate fields. Fields marked with an asterisk (*) must be completed. If providers received patient liability payments from clients, denote the payment in the Patient Amount Paid field. 91

92 Claim Submission (Diagnosis Panel) A diagnosis is optional on claims with any of the following procedure codes: G0151, G0152, G0153, G0154, G0156, H0045, S0215, S5101, S5102, S5125, S5160, S5161, S5165, S5170, T1000, T1002, T1003, T1019, T2029. However, if one or more diagnoses are specified, then each claim line in the 'Detail' panel must point to (be associated with) at least one diagnosis. 92

93 Claim Submission (Other Payer Panel) Considering Medicaid is the payer of last resort, providers must receive a payment or denial from other payers (i.e., payers other than Medicaid) prior to submitting claims to Medicaid, and these claims must reflect the other payers payment and/or denial information. Submitting claims with Other Payer information will be discussed in a separate section of this presentation. 93

94 Claim Submission (Detail Panel) Complete all of the appropriate fields. Fields marked with an asterisk (*) must be completed. 94

95 Claim Submission (Attachment Panel) In most situations, home care providers will not include an attachment with claims. 95

96 Claim Submission (Delayed Submission/Resubmission Panel) If a claim was initially received within 365 days from the 1 st date of service on the claim, but the claim was adjusted or resubmitted within 180 days after the initial claim was paid or denied, denote the ICN of the initial claim. This process establishes timely filing for adjusted/resubmitted claims. 96

97 Claim Submission (Claim Status Panel) This panel denotes the status of claims. If the claim was submitted and the status is Not Submitted Yet refer to the top of the claim for error messages. Correct the errors (as noted in the error messages) and resubmit the claim. When the claim is appropriately submitted, the status of the claim will be: Paid, Denied, or Suspended 97

98 TPL Submission Other Payer Information Third Party Liability (TPL) claims must be submitted EDI or via web portal HIPAA compliant adjustment reason codes and amounts are required Other payer information can be reported at the claim level (header) or at the line level (detail). This includes primary other payer payments or denials Allowed amount is required for other payer TPL. MITS will automatically calculate the allowed amount. 98

99 SUBMITTING COMMERCIAL PAYER DENIAL INFORMATION AT THE CLAIM LEVEL Click the Other Payer Amount and Adjustment Reason Code link to denote the appropriate CAS Group Code, ARC Amount, and ARC. 99

100 SUBMITTING COMMERCIAL PAYER PAYMENT INFORMATION AT THE CLAIM LEVEL Click the Other Payer Amount and Adjustment Reason Code link to denote the appropriate CAS Group Code, ARC Amount, and ARC. 100

101 Adjusting, Voiding, & Copying Claims Paid claims can be Adjusted Voided Copied 101

102 Adjusting, Voiding, & Copying Claims Adjusting paid claims Select the claim to adjust Change the necessary information within the header and detail, as applicable Click the adjust button 102

103 Adjusting, Voiding, & Copying Claims Adjusting paid claims Once you click the adjust button A new claim is created and assigned its own adjustment ICN Refer to the information in the Claim Status Information and EOB Information areas at the bottom of the page to see how your new claim processed. 103

104 Adjusting, Voiding, & Copying Claims Adjustment Terminology Original or active claim referred to as Mother Claim New adjusted or voided claim is referred to as the Daughter Claim Credit Balance If a claim adjusts for more than the original amount, the provider will receive an additional payment Account Receivable If funds are due back to the state 104

105 Adjusting, Voiding, & Copying Claims Adjustment Example Originally paid $ Now paid $50.00 The provider s additional payment. Credit Balance $ Originally paid $ Now paid $45.00 Money due to State. Account Receivable ($5.00) 105

106 Adjusting, Voiding, & Copying Claims Voiding paid claims Select the claim you wish to Void Click the void button at the bottom of the page The status of the original claim does not change however, the claim is flagged as non adjustable in MITS An adjustment claim is automatically created and given a status of Denied 106

107 Adjusting, Voiding, & Copying Claims Void Example Originally paid $ Reversal Void Account Receivable ($45.00) 107

108 Adjusting, Voiding, & Copying Claims Copying Paid Claims Search and open the claim you want to copy At the bottom of the claim, select Copy claim Make your changes to the fields The submit and cancel buttons display at the bottom of the new page Select Submit when changes are made Claim is assigned a new ICN 108

109 Remittance Advice Remittance Advices for claims processed are available on the MITS Web Portal 109

110 Remittance Advice Pages are titled by claim type and outcome CMS 1500, Inpatient, Outpatient, Long Term Care, and Dental Medicare Crossovers A, B and C Paid, Denied, and Adjustments Adjustment Page Identifies the original claim header information and the new adjusted claim 110

111 Financial Transactions Non claim specific payouts Claim and non claim refunds Accounts receivable tracking Summary Page Remittance Advice Provides current payment information Per month information Year to date information 111

112 Remittance Advice Informational pages Banner Messages Provides messaging to the provider community EOB Code Descriptions Provides a comparison of the codes to the description that appeared on claims on the paid, denied and adjustment pages TPL Information If a claim was not paid due to the recipient having another payer source (Third Party Liability) this section provides other insurance information 112

113 MMIS Remittance Advices Historical Remittance Advices (RA) created prior to MITS will continue to be available on the old Medicaid Provider Portal. Only the RA function will be active on the previous web portal, and it will continue to be available 18 months from August 2,

114 Websites 114

115 ODJFS Main Website ODJFS Consumer Website ODJFS Provider Website MITS Website MITS etutorial Website External Training emanuals ODJFS Websites 115

116 CareStar Website Access the CareStar website for the following information: All Services Plans Training opportunities Basic information regarding background checks Finding new clients/cases 116

117 Washington Publishing Website edi.com/reference/ The Washington Publishing website provides adjustment reason codes (ARCs) that must be noted on claims that involve other payers. The common ARCs are noted below: 1 (Deductible) 2 (Coinsurance) 3 (Copayment) 45 (Contractual Obligation/Write-Off) 96 (Non-Covered Services) 117

118 Questions 118