Transportation.. the right way. HP Provider Relations/October 2013

Transcription

1 Transportation.. the right way HP Provider Relations/October 2013

2 Agenda Session objectives Transportation services Provider enrollment Member eligibility Billing guidelines Copayment amounts and exemptions Prior authorization Common denials Frequently asked questions Helpful tools Q&A 2

3 Objectives At the end of this session, providers will understand: Enrollment, recertification, and revalidation Eligibility verification Correct billing practices Copayments and copayment exemptions Prior authorization Common claim denials Helpful tools 3

4 Transportation Services

5 Types of Transportation Services Advanced Life Support ALS Care given at the scene of an accident, act of terrorism, or illness; care given during transport; care given at the hospital by a paramedic or emergency medical technician-intermediate; and care that is more advanced than the care usually provided by an emergency medical technician or an emergency medical technicianbasic advanced Basic Life Support BLS BLS services do not include invasive medical care techniques or advanced life support Commercial or Common Ambulatory Service CAS Transporting ambulatory members to or from an IHCP covered service 5

6 Types of Transportation Services Commercial or Common Ambulatory Service CAS Transporting ambulatory members to or from an IHCP covered service Non-ambulatory Service NAS Transporting non-ambulatory services (member must travel in a Taxi wheelchair) to or from an IHCP-covered service Taxi providers transport members to or from an IHCP covered service May operate under authority from a local governing body (city taxi or livery license) 6

7 Enrollment

8 Enrollment Meet the Requirements Reference the IHCP Provider Type and Specialty Matrix to determine documentation requirements 8

9 Enrollment Always Use the Most Recent Forms

10 Enrollment Always Use the Most Recent Forms

11 Enrollment Reminders Review the matrix: Choose the correct provider specialty Prepare the documentation requirements Motor Carrier Certificate Proof of auto insurance Copy of driver s license for all drivers Fingerprint and background checks; surety bond BT requirements Application fee IHCP Affordable Care Act requirements IHCP Bill Pay site ***Additional documentation my be required Download the most recent version of the Provider Enrollment form ****Enrollment with Traditional Medicaid does not automatically enroll a provider with the managed care entities 11

12 Enrollment Recertification

13 Enrollment Recertification When a provider is required to recertify, a notification is sent to the provider 90 and 60 business days prior to the end date of a provider's eligibility to participate in the IHCP Valid and current licenses Certificates Proof of insurance If a provider fails to recertify before their eligibility end date, the provider must reenroll with the IHCP by submitting a new IHCP Provider Packet in its entirety 13

14 Enrollment Revalidation Under the Affordable Care Act (ACA), the Indiana Health Coverage Programs (IHCP) is required to revalidate all provider enrollments The ACA screening criteria apply during revalidation Providers will receive notification letters with instructions for revalidating 90 and 60 days before their revalidation deadline Providers should not take any steps to revalidate until they receive their notification letters Providers that fail to submit revalidation paperwork in a timely manner will be deactivated from participation in the IHCP as of the deadline date 14

15 Eligibility

16 Verify Eligibility Web interchange, AVR, Omni swipe 16

17 Verify Eligibility Key Areas Member is eligible Member has a nursing facility (NF) level of care Member is a Qualified Medicare Beneficiary (QMB) ALSO Have all Medicaid benefits ONLY Only have coverage for Medicare coinsurance and deductible Spend-down NEVER collect spend-down in advance Enrolled in Hoosier Healthwise risk-based managed care (RBMC) Follow guidelines for the appropriate managed care entity Third-party liability (TPL) insurance Medicare and TPL are primary Benefit limits exhausted Prior authorization may be required 17

18 Billing Guidelines

19 Billing Guidelines What Is a Trip? For billing purposes, a trip is defined as transporting a member from the initial point of pickup to the drop-off point at the final destination Cancelled transportation appointments or no show by the member is NOT a billable fee to the IHCP and the member can NOT be billed Transportation must be the least expensive type of transportation available that meets the medical needs of the member Trips must be billed according to the level of service rendered and not according to the vehicle type

20 Billing Guidelines What Is a Trip? Provider transports a member on the same date of service, but different trip levels (for example the to trip was a CAS trip, and the return trip was a NAS trip, with mileage for each base), these base trips must be billed on two different claim forms with the corresponding mileage for each base The provider makes a round trip, or two one-way trips for the same member, same date of service, and same level of base code, both runs should be submitted on the same detail with two units of service All mileage for the trip must be billed on the one detail with the total number of miles associated for the roundtrip to include the first 10 miles 20

21 Billing Guidelines Mileage Mileage does not start until the member is in the vehicle (loaded mileage) Transportation providers are expected to transport members along the shortest, most efficient route to and from a destination Mileage must be documented on the trip sheet using odometer readings or mapping software programs Mileage is reimbursed, in addition to the base rate, under the following circumstances: Ambulance providers are reimbursed for loaded mileage of the trip regardless of the type or level of service being billed Taxi providers are not reimbursed for mileage and are not required to submit mileage with their claim; however, the mileage must be documented 21

22 Billing Guidelines Mileage Mileage does not start until the member is in the vehicle (loaded mileage The first 10 miles of a CAS or NAS trip are billed into the base rate with no separate reimbursement for mileage For trips less than 10 miles, the IHCP does not require the provider to bill mileage; however, if the provider does bill mileage, the IHCP processes the mileage as a denied line item CAS and NAS providers must bill for all mileage when travel exceeds 10 miles one way Total mileage should be billed including the first 10 Fractional miles are not allowed If the provider transports the member between 15.0 and 15.4 miles, the provider should bill 15 miles; if the trip is between 15.5 miles and 16.0 miles, the provider should bill 16 miles 22

23 Billing Guidelines Multiple Passengers When two or more members are transported simultaneously from the same county to the same vicinity for medical services, the second and subsequent member transported in a single CAS or NAS vehicle is reimbursed at one-half the base rate For example, no mileage should be billed in conjunction with T Nonemergency transport; commercial carrier, multi-pass, individualized service provided to more than one patient in the same setting The full base code, mileage, and waiting time are reimbursed for the first member only The IHCP does not provide reimbursement for multiple passengers in ambulances or family member vehicles Additional reimbursement is not available for multiple passengers when the billing provider does not bill non-ihcp customers for these services 23

24 Billing Guidelines Multiple Destinations Member is transported to multiple points in succession, the provider may not bill for a trip between each point of the destination The following examples offer explanations of this concept: Example 1: A vehicle picks up a member at home and transports the member to the physician s office. This is a one-way trip. Example 2: A vehicle picks up a member from home and transports the member to the physician s office. The provider leaves, and later the same vehicle picks the member up from the physician s office and transports the member back to the member s home. This is considered two one-way trips. Example 3: A vehicle picks up the member from the physician s office and transports the member to the laboratory for a blood draw, waits outside the laboratory for the member, and then transports the member home. This is a one-way trip, even though there was a stop along the way. A stop along the way is not considered a separate trip. 24

25 Billing Guidelines Rotary Wing Air Ambulance Requires a prior authorization Providers are required to bill for both the base rate and mileage codes Claims no longer require an attachment for a cost invoice Can be submitted electronically Each code is reimbursed at a specific rate per the IHCP Fee Schedule Refer to IHCP Provider Manual, Chapter 8, Section 4 25

26 Billing Guidelines Taxi Taxi providers cannot transport outside the jurisdiction designated by their city taxi license To transport outside the jurisdiction, the taxi provider must be enrolled as a common carrier If a taxi transports across county borders, the Indiana Department of Revenue s Motor Carrier Services Division must certify taxi transport as a common carrier 26

27 Billing Guidelines Modifiers Providers must include the origin and destination modifiers with the base rate procedure codes The first character of the two-digit modifier indicates the transport s place of origin The second character indicates the destination When a member is transported by more than one transportation company on the same date of service, use of the modifiers helps to prevent one of the claims from denying as a duplicate of the other provider s claim A list of appropriate modifiers can be found in the IHCP Provider Manual in Chapter 8, Section 4 27

28 Billing Guidelines Modifiers Modifier Description D Diagnostic or therapeutic site, other than P or H E Residential, domiciliary, or custodial facility (nursing home, not SNF) G Hospital-based dialysis facility (hospital or hospital-related) H Hospital I Site of transfer between types of ambulance J Nonhospital-based dialysis facility N Skilled nursing facility (SNF) P Physician office R Residence S Scene of accident or acute event

29 Billing Guidelines Diagnosis Dialysis Nursing Home General V560 V561 V568 V Required to bypass 20 one-way trip limitation Required on all dialysis claims Required to bypass 20 one-way trip limitation Required on all nursing home Will not bypass 20 oneway trip limitation Required on all claims except dialysis and nursing home

30 Billing Guidelines Attendant An additional attendant may be needed in situations where the driver cannot load the member without help, such as when wheelchair-bound member lives upstairs and the residence has no wheelchair ramp In this situation: The additional attendant who assists must be an employee of the billing provider and is not required to remain for the trip Providers must document the need for an additional attendant on the driver s ticket Claims must include the appropriate procedure codes and modifiers 30

31 Billing Guidelines Accompanying Parent/Attendant Accompanying parent Members younger than 18 years of age need an adult to accompany them to a medical service The provider should bill the appropriate accompanying parent or attendant code Accompanying attendant When adult members need an attendant to travel with them for a medical service, the provider should bill the appropriate accompanying parent or attendant code 31

32 Billing Guidelines Accompanying Parent/Attendant The following guidelines are for billing the accompanying parent or attendant codes: The procedure code for the base rate and the accompanying parent or attendant is billed under the IHCP member identification number (RID) Additional reimbursement is not available for accompanying parent or attendant when the billing provider does not bill non-ihcp customers for like services The provider must maintain documentation on the driver s ticket to support that the accompanying parent or attendant was transported with the IHCP member This documentation must include the name, signature, and relation of the accompanying parent or attendant 32

33 Billing Guidelines Wait Time Wait time in excess of 30 minutes is reimbursable when: The vehicle is parked outside the medical service provider, awaiting the return of the member to the vehicle and if the member is transported 50 miles or more one-way PA is obtained for all codes associated with trips of 50 miles or more one-way, including waiting time The first 30 minutes of wait time is not covered; however, the total wait time must be included on the claim, or the claim will not be paid appropriately One unit of service is billed for each 30 minutes of wait time (round to nearest unit) Documentation, including start and stop times, must be maintained on the driver s ticket to support the wait time billed 33

34 Billing Guidelines Web interchange Bill the correct code and modifier for the level and type of service provided IHCP Provider Manual, Chapter 8, Section 4 34

35 Billing Guidelines Web interchange 35

36 Billing Guidelines Web interchange 36

37 Billing Guidelines Web interchange 37

38 Member Copayments

39 Member Copayment Amounts IHCP requires a copayment for transportation services The copayment shall be made by the recipient and collected by the provider at the time the service is rendered Medicaid reimbursement to the provider shall be adjusted to reflect the copayment amount for which the recipient is liable Members cannot be denied services for inability to pay copay at the time of service The member may be billed Copayment Description $0.50 Services for which the IHCP pays $10.00 or less $1.00 Services for which the IHCP pays $10.01 to $50.00 $2.00 Services for which the IHCP pays $50.01 or more 39

40 Copayment Exemptions Copayments are not required for: Members younger than 18 years old An assistant or accompanying adult traveling with a member younger than age 18 years old Pregnancy (indicated by checking yes or no radio button or entering Y in field 24H on a paper claim) Services furnished to individuals who are patients in: Inpatient hospital Nursing facilities Intermediate care facility for individuals with intellectual disability 40

41 Prior Authorization

42 Prior Authorization Requirements Trips exceeding 20 one-way trips per rolling 12-month period require prior authorization (PA) Other services that require PA: Air ambulance transportation Bus transportation Interstate transportation or transportation services rendered by a provider located out-of-state in a nondesignated area 42

43 PA Requirements Trips of 50 miles or more one way require PA When requesting PA, providers should include codes for all services: Base rate Mileage Wait time Accompanying parent or attendant or additional attendant Signature stamps Providers may use signature stamps on the PA request form; see IHCP Provider Manual, Chapter 6, Section 1 43

44 PA Requirements Exceptions Emergency ambulance services Hospital admission or discharge Transportation to a hospital for admission or from a hospital to home after discharge is exempt from 20 one-way trip limitation Members on renal dialysis V56.0, V56.1, or V56.8 (required to bypass PA) Members in nursing homes V70.5 (required to bypass PA) 44

45 PA Contacts Traditional Medicaid fee-for-service Traditional Medicaid fee-for-service PA requests are processed by: ADVANTAGE Health Solutions P.O. Box Indianapolis, IN (Fax) PA submission available on Web interchange 45

46 PA Contacts Care Select Each care management entity (CME) is responsible for processing PA requests for its respective Care Select members: MDwise Care Select P.O. Box Indianapolis, IN (Fax) ADVANTAGE Health Solutions P.O. Box Indianapolis, IN (Fax) 46

47 PA Submission Web interchange Insert screen shot of pa submission 47

48 Common Denials

49 Edit 4080 Mileage is not reimbursable unless the recipient is transported 11 miles or more one way please verify and resubmit Cause: System is deducting first 10 miles from the claim Resolution: The initial 10 miles are included in the base rate; mileage is only reimbursed for 11 miles or more Providers should bill the total miles traveled for each trip IndianaAIM will automatically calculate the appropriate mileage reimbursement 49

50 Edit 6803 Prior authorization required for one-way trips in excess of 20 Cause: Member has already had 20 trips paid Resolution: Make sure to check for benefit limits reached on eligibility prior to transporting member Submit a PA request for more trips then resubmit claim after approved PA is received 50

51 Edit 5000 Possible duplicate Cause: Two round trips made in one day; the second trip denies as a duplicate Resolution: Indicate four units on one line Combine total mileage on one line Maintain documentation for the two separate round trips 51

52 Edit 2007 QMB recipient Cause: Member enrolled in Medicare Resolution: Verify eligibility and review QMB Only versus Also to see if member eligible for service 52

53 Frequently Asked Questions

54 Frequently Asked Questions Why is the copayment deducted from my claim twice? Do not deduct copayment amount when submitting claims The IHCP systematically deducts the copayment from the claim payment Why is a copayment deducted when the patient is pregnant? To bypass the copayment edit, indicate yes in pregnancy field on paper claim field 24H and on an electronic claim pregnancy button Why is a copayment deducted when I transport a patient to the hospital for admission? Indicate the appropriate two-digit place of service code 54

55 Frequently Asked Questions Why do I receive denials for the 20-trip limit when I transport a nursing facility patient? To bypass the 20-trip limit denial, you must use diagnosis code V70.5 when transporting a nursing facility patient If I make two round trips in one day, why does the second round trip deny as a duplicate? Maintain documentation for the two separate trips The IHCP will pay claims for both trips if you bill them on one detail line indicating 4 units of service Why are 10 miles of each one-way trip deducted from my mileage? The initial 10 miles are built into the base rate Mileage is only reimbursed for 11 miles or more 55

56 Find Help

57 Helpful Tools IHCP Provider website at indianamedicaid.com IHCP Provider Manual (web, CD, or paper) IHCP Provider Manual, Chapter 8, Section 4 Customer Assistance or (317) in the Indianapolis local area Provider field consultant Locate area consultant map on: indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or Web interchange > Help > Contact Us HP Written Correspondence P.O. Box 7263 Indianapolis, IN

58 Q&A