DME/HME What you need to know. HP Provider Relations/October 2014

Transcription

1 DME/HME What you need to know HP Provider Relations/October 2014

2 Agenda Objectives Revalidation Provider Code Sets Fee Schedule Manual Pricing Guidelines Capped Rental Repair and Replacement Mail Order Supplies Preferred Diabetic Supply List Billing the Member Prior Authorization Denials and Resolution Helpful Tools Questions 2

3 Objectives Following this session, providers will: Understand revalidation Know where to find code sets and the Fee Schedule Understand home medical equipment (HME) and durable medical equipment (DME) coverage Know how to complete the Prior Authorization form and prior authorization inquiry process Have knowledge of claim research 3

4 Revalidation

5 Revalidation Are all provider types required to revalidate? Federal regulations require all providers to revalidate their enrollment and fulfill screening requirements, where applicable DME and HME are revalidated every three years Are providers notified when it is time to revalidate? When it is time to revalidate, you will receive notice of the revalidation deadline Letters with instructions for revalidating are sent 90 and 60 days before the revalidation deadline We have multiple service locations can we revalidate them all at once? Providers should not take any steps to revalidate until they receive their notification letters 5

6 Revalidation Will anything happen if the revalidation is not completed? Providers that fail to submit revalidation paperwork in a timely manner may be deactivated from participation in the Indiana Health Coverage Programs (IHCP) as of the deadline date Deactivation may result in a nonparticipation period and denial of payment Will a note on letterhead be sufficient to revalidate the profile? For each revalidation, a complete enrollment packet and supporting documents must be completed; screening requirements must also be met Can a copy of the enrollment packet used for the initial enrollment be sent? The most current version of the enrollment application from indianamedicaid.com must be completed Outdated versions will be returned to the provider, resulting in a delay in revalidation 6

7 Revalidation Reminders See the IHCP Provider Type and Specialty Matrix to determine documentation requirements: provider.indianamedicaid.com/ media/27745/matrix.pdf Use the most current form from the website Include all required supporting documentation 7

8 Revalidation Always Use the Most Current Forms 8

9 Revalidation Always Use the Most Current Forms 9

10 Code Sets and Fee Schedule

11 Provider Code Sets The IHCP established provider code sets for specialty 250 DME (Durable Medical Equipment) and specialty 251 HME (Home Medical Equipment) Enrolling in specialty 251 does not cover services in specialty 250, and enrolling in specialty 250 does not cover services in specialty 251 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 Web interchange 11

12 Viewing Provider Code Sets 12

13 Viewing Provider Code Sets 13

14 Viewing Provider Code Sets 14

15 Viewing Provider Code Sets 15

16 Fee Schedule Access the Fee Schedule to determine: Reimbursement rates Pricing effective dates Prior authorization requirements Program coverage Applies to traditional fee-for-service Medicaid and Care Select 16

17 Accessing the Fee Schedule 17

18 Accessing the Fee Schedule 18

19 Accessing the Fee Schedule 19

20 Accessing the Fee Schedule 20

21 Accessing the Fee Schedule Understanding the Instructions 21

22 Manual Pricing

23 Manufacturer s Suggested Retail Price (MSRP) Claims will be paid at 75% of MSRP If an item does not have an MSRP (for example, custom items), claims will be paid at 120% of cost MSRP-approved documentation: Manufacturer s invoice showing MSRP Quote from the manufacturer showing the MSRP, suggested retail price, or retail price Manufacturer s catalog page showing the MSRP, suggested retail price, or retail price The publication date of the catalog must clearly show on the documentation MSRP pricing from the manufacturer s website The manufacturer s web address must be visible on printed documentation from its website 23

24 Manufacturer s Suggested Retail Price (MSRP) MSRP documentation must include: Manufacturer s name clearly visible on the header of the documentation MSRP pricing (for example, MSRP/Retail) typed from manufacturer No handwritten notes or pricing will be accepted Description of item Specific HCPC code Date must be within one year of date of service 24

25 Manufacturer s Suggested Retail Price (MSRP) MSRP approved documentation: Manufacturer s invoice showing MSRP, suggested retail price, or retail price Quote from the manufacturer showing the MSRP, suggested retail price, or retail price Manufacturer s catalog page showing the MSRP, suggested retail price, or retail price The publication date of the catalog must clearly show on the documentation MSRP pricing from the manufacturer s website The manufacturer s web address must be visible on printed documentation from its website 25

26 Approved MSRP Documentation Invoice Manufacturer s Logo Manufacturer s Name Date Effective September 2014 Updated October 1, 2014 Descriptions Manufacturer s suggested retail price 26

27 Approved MSRP Documentation Quote 10/1/

28 Approved MSRP Documentation Catalog Page Effective September 2014 Updated October 1,

29 Approved MSRP Documentation Website 10/1/

30 Invoice Requirements Manufacturer s cost invoice Invoice date must be within one year of the date of service Invoice should include: Manufacturer s name Provider s name Purchase date Product description and Healthcare Common Procedure Coding System (HCPCS) code Quantity purchased Cost per item 30

31 Invoice Requirements Manufacturer s cost invoice DME SUPPLY MANUFACTURING INVOICE 1 SUPPLY ROAD 09/18/2014 ANYWHERE, INDIANA BILL TO: DME/HME SUPPLIES 200 STATE STREET ANYWHERE, INDIANA ITEM NUMBER/DESCRIPTION U/M QTY PRICE TOTAL ELECTRONIC BOTTOM HOUSING/JOYSTICK EA HCPCS:E1356 **********COST INVOICE************* 31

32 DME Items in Kits DME items that are not prepackaged from the manufacturer must include: A list of ordered items included in the kit The exact description of the items from the manufacturer s invoice How many items are in each box or case How many items were used in each kit Item Description Number in case, box, etc., on manufacturer s invoice CAP-MALE LUER LOCK 2000 IN CASE SET ADMIN RATE FLOW 83 IN 20 DP 15 MIC Number included in kit 5 ITEMS IN KIT 50 IN CASE 4 ITEMS IN KIT 32

33 Invoice Requirements Manufacturer s Cost Invoice DME SUPPLY MANUFACTURING INVOICE 1 SUPPLY ROAD 09/19/2014 ANYWHERE, INDIANA BILL TO: DME/HME SUPPLIES 200 STATE STREET ANYWHERE, INDIANA ITEM NUMBER/DESCRIPTION U/M QTY PRICE TOTAL EXTRA SET RT ANGLE HCPCS: B9998 5/BOX sets in a box - ordered 1 box 59.90/5 = each **********COST INVOICE************* 33

34 Manual Pricing B9998 Enteral Supplies 34

35 Guidelines

36 Date of Service for Billing The date of service is the date the equipment is delivered, not ordered Date of service for items that are mailed is the date the item is shipped For the IHCP to reimburse for medical equipment, the member must be eligible on the date of service, which is the date of delivery 36

37 Rolling 12-Month Period What it is not: Based on a 12-month calendar year Based on a fiscal year Renewable on January 1 of each year What it 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 37

38 Continuous Positive Airway Pressure (CPAP) The IHCP reimburses for CPAP systems for members meeting one of the following criteria: A diagnosis of obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) equal to or greater than 15 events per hour, documented in a recorded polysomnography A diagnosis of OSA with an AHI from five to 14 events per hour documented in a recorded polysomnography with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia or hypertension, ischemic heart disease, or history of stroke A diagnosis of moderate or severe OSA in a member for whom surgery is a likely alternative to CPAP Copies of the member s sleep lab evaluation, including a polysomnography, must be retained in the physician s record 38

39 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 IHCP Provider Manual, Chapter 8, Section 4 39

40 Capped Rental 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 Family and Social Services Administration (FSSA) Providers should base their decisions to rent or purchase DME or HME on the least expensive option available for the anticipated period of need 40

41 Capped Rental Medicare capped rental policy for DME The policy states that the capped rental period is 13 months After 13 months, the member owns the DME Medicare will pay for reasonable and necessary maintenance and service of the DME item At this time, Medical Policy has not been directed to make changes to the IHCP s capped rental policy 41

42 Repair and Replacement Repair of purchased equipment may require prior authorization based on the 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 42

43 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 43

44 Mail Order Incontinence, Ostomy, and Colostomy Supplies Contracted vendors FSSA contracted with two vendors to provide incontinence, ostomy, and urological supplies to fee-for-service (FFS) members All FFS members are required to obtain incontinence, ostomy, and urological supplies through mail order from one of these contracted providers The two contracted vendors are: Binson s Home Health Care Center binsons.com J & B Medical jandbmedical.com 44

45 Mail Order Incontinence, Ostomy, and Colostomy Supplies Members must obtain supplies via mail order The contracted vendor may make other arrangements in emergency situations A full list 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 12-month period 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 provider denies the claim, the services are limited to the two contracted vendors 45

46 Mail Order Incontinence, Ostomy, and Colostomy Supplies The following programs and claim types are not affected by the contract: 590 Program Medical Review Team (MRT) Pre-Admission Screening 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 entity (MCE) 46

47 Preferred Diabetic Supply List 47

48 Preferred Diabetic Supply List Billing Professional claims, including paper CMS-1500, electronic 837P, and Medicare crossover claims for blood glucose monitors and diabetic test strips, must be submitted to the fee-for-service (FFS) medical benefit for all Indiana Medicaid and Healthy Indiana Plan members Claims for the following procedure codes require the National Drug Code (NDC) or NDC and modifier, depending on the vendor of the product being dispensed: E0607 Home blood glucose monitor A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips 48

49 Preferred Diabetic Supply List Billing Claims billed for an NDC included on the Preferred Diabetic Supply List (PDSL) do not require the addition of modifier U1 If modifier U1 is included with a preferred blood glucose monitor or diabetic test strip NDC, the claim will be denied for edit 4300 Invalid NDC-to-procedure code combination Claims billed for a blood glucose monitor or diabetic test strip not listed on the PDSL require the addition of modifier U1, along with the NDC and appropriate procedure code Claims billed for an NDC not on the PDSL are denied with edit 4300 Invalid NDC-to-procedure code combination when modifier U1 is not included 49

50 Preferred Diabetic Supply List Billing CMS-1500 Form Enter the NDC qualifier of N4 Enter the NDC 11-digit numeric code Enter the drug description Enter the NDC Unit qualifier F2 International Unit GR Gram ML Milliliter UN Unit 50

51 Preferred Diabetic Supply List Billing CMS-1500 Form Enter the NDC quantity (administered amount) in the format See the IHCP Provider Manual, Chapter 8, Section 4 51

52 When Is It Appropriate to Bill the Member?

53 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 during 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 53

54 Billing the Member A signed waiver should 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 The waiver must not contain any conditional language for example, the words if or as long as 54

55 Billing the Member Medicaid-pending individuals are responsible for paying 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 55

56 Prior Authorization

57 Prior Authorization Prior authorization by telephone, fax, or mail Verify eligibility to determine where to send the PA request ADVANTAGE Health Solutions SM FFS Prior Authorization Department P.O. Box Indianapolis, IN Fax: ADVANTAGE Health Solutions Advantage Care Select and MDwise Care Select Prior Authorization Department P.O. Box Indianapolis, IN Fax: Prior authorization for risk-based managed care recipients must be sent to the appropriate entity

58 Prior Authorization Prior authorization by telephone, fax, or mail 58

59 Prior Authorization DME/HME PROVIDER 59

60 Prior Authorization 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 60

61 Denials and Resolution

62 Denials and Resolutions Denial Edit 0217 NDC Missing Cause: NDC information is missing NDC is not in the proper format Resolution: Resubmit the claim with the NDC Denial Edit 0218 NDC is not in a valid format Cause: Qualifier, unit of measure, or NDC is not in the correct format Resolution: Verify the information submitted is accurate 62 See IHCP Provider Manual, Chapter 8, Section 4

63 Denials and Resolutions Denial Edit 0593 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 IndianaAIM Resolution: Verify that the date of service and procedure code billed are correct on the requested PA Obtain an amended or corrected PA, if necessary 63

64 Denials and Resolutions 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 Denial Edit 0226 Referring NPI/LPI is missing Cause: Referring Legacy Provider Number (LPI) or National Provider Identifier (NPI) is missing Resolution: Verify that the referring NPI is on the claim in the equivalent of box 17B of the paper form Verify that the NPI listed is the individual referring, not the group 64

65 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: The net charge on a paper claim form in field 28 should equal the total charge; Field 29 contains the TPL actual paid amount Field 22 should be blank Medicare crossover claims: The total charge is in field 28 Complete field 22 with paid amount and coinsurance and deductible Note: These claims may be filed on Web interchange 65

66 Denials and Resolutions Denial Edit 2003 Recipient Ineligible on Dates of Service Cause: Member is not eligible for IHCP services being billed Resolution: VERIFY ELIGIBILITY EVERY TIME BEFORE PROVIDING SERVICE Verify that the claim was sent to the appropriate billing entity Fee-for-service and Care Select to HP RBMC to the appropriate MCE 66

67 Denials and Resolutions Denial Edit 6000 Manual Pricing Required Cause: Manual pricing is required Resolution: Cost invoice and MSRP Invoice is required for fee-for-service and Care Select Date Billed amount per unit (for example, box, case, and so forth) Calories (enteral feeding) Procedure code Member name Member ID number Itemization of repairs Bulk invoices Illustrate calculations specific to the member 67

68 Find Help

69 Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual Customer Assistance Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN Provider field consultant View a current territory map and contact information online at indianamedicaid.com 69

70 Q&A