Indiana First Steps. Provider Billing Manual Effective January 23, 2009

Transcription

1 Indiana First Steps Provider Billing Manual Effective January 23, 2009 State of Indiana Family & Social Services Administration Bureau of Child Development 402 W. Washington, Room W386 Indianapolis, IN Tel: or Fax: Release No /23/2009 Document Dated January 20, 2009 Release # 1.00 Page # 1

2 Revision History Version Changed By Date Revision Description 1.0 Tony Taylor, Business Analyst Team Lead, CSC Covansys 01/23/2009 Document Delivery Document Dated January 20, 2009 Release # 1.00 Page # 2

3 Table of Contents CENTRAL REIMBURSEMENT OFFICE PROVIDER BILLING MANUAL... 4 Section I. Introduction... 4 FSSA- First Steps... 4 Central Reimbursement Office... 4 Enrollment in the Central Reimbursement Office... 4 Web Access... 4 Web Access for Provider Enrollment... 5 Section 2. Service Authorization... 6 Section 3. Billing Instructions... 7 CRO Standard Timelines/Deadlines... 7 Option 1. Online Provider Account Module... 8 Option 2. HCFA 1500 Billing Instructions (bill with this option only when automated claims adjustment/offset is not a viable alternative)... 9 Option 3. Electronic Billing & Claims Certification Statement Trading Partner Agreement General Information Explanation of Provider Payment Resubmission of Rejected Claim Claims Corrections Automated Payment Adjustments/Offsets Manual Overpayment Refund APPENDIX A CLAIMS ADJUDICATION Claim Adjudication Approach Claim Denials Units Authorized Definition of Duplicate Claim New Edits for Authorized Frequency Denials Definition of Authorized Week Timeframe Definition of Authorized Month Timeframe Definition of Claimed Occurrence Total Units Allowed Per Timeframe Units Allowed for a Partial Week Units Allowed for a Partial Month Authorizations with Multiple Detail Lines APPENDIX B CONTACT INFORMATION Indiana First Steps Provider Enrollment Central Reimbursement Office (CRO) Help Desk Document Dated January 20, 2009 Release # 1.00 Page # 3

4 CENTRAL REIMBURSEMENT OFFICE PROVIDER BILLING MANUAL Section I. Introduction Indiana s Family and Social Services Administration (FSSA) implemented the Central Reimbursement Office (CRO) statewide on August 1, The CRO is the financial system for payment of all early intervention services. FSSA- First Steps First Steps is administered by the Bureau of Child Development (BCD) within the FSSA. First Steps brings together families and professionals from education, health, and social services agencies. By coordinating the locally available services, First Steps is working to give Indiana children and their families the widest array of possible early intervention resources. Indiana is committed to a family-centered, community-based system of early intervention services for eligible infants and toddlers and their families. As part of that commitment, the Central Reimbursement Office (CRO) was designed to support family choice about who will provide services and where those services will be provided. Indiana entered Part C entitlement during fiscal year 1995 and has been working diligently to access numerous funding sources identified for early intervention services. Central Reimbursement Office The Central Reimbursement Office (CRO) design includes paying all providers from an interim funding source based on submission of claims. The CRO then seeks reimbursement from an appropriate payment source. This includes, among others, billing private insurance, Children s Special Health Care Services, Medicaid and TANF/TANF MOE for eligible and enrolled children. Enrollment in the Central Reimbursement Office As a provider you will need to first be enrolled with the CRO by completing the enrollment process through CSC Covansys Provider Enrollment (PE) unit. Internet access is available for the required forms and provider enrollment information. It is accessible through web site by following the Indiana First Steps link. The Provider Enrollment Office can be contacted at Option 2. Providers also need to complete a couple more forms if they elect to communicate electronically with the CRO. These forms are the Certification Statement for Providers Submitting Claims by Means Other Than Standard Paper and the Trading Partner Agreement (TPA). The TPA document outlines the provider elections on how they will communicate information with the CRO. With HIPAA legislation enacted, there are standardized file formats that must be followed when sending or receiving Protected Health Information electronically. This agreement is also available on the web site ****IMPORTANT NOTE**** Providers must be enrolled prior to being authorized to deliver services. Web Access The web page allows access to the forms utilized by the CRO/PE office. The forms are in a pdf format for providers to download and print. This web location provides additional links to policy information and the addresses to contact the CRO/Provider Enrollment Office. Once Provider Enrollment at CSC Covansys Document Dated January 20, 2009 Release # 1.00 Page # 4

5 has received all of the requested, completed forms on the checklist from the provider; the enrollment process begins. Web Access for Provider Enrollment Provider enrollment information and forms are available on the web. Placing the cursor on the Service Matrix portion of the box, a floating menu will appear. Select the link for Provider Enrollment as shown below. This page provides links to all of the documents and forms needed to enroll as a provider or to update provider information as a First Steps provider. Document Dated January 20, 2009 Release # 1.00 Page # 5

6 Section 2. Service Authorization Service Authorizations are initiated through the First Steps Cluster System Point of Entry based on receipt of a source document. The system relies on prompt receipt of source documents from service coordinators. These sources include: a) an Individualized Family Service Plan (IFSP) or b) a request for an authorization for Assessment/Evaluation or IFSP Development or c) an IFSP change page. Upon receipt of a source document, the Cluster promptly enters the information into an electronic system that captures sufficient information to create authorizations for services. Daily, or when information warrants, the Cluster connects electronically to the Central Reimbursement Office (CRO) and transfers information to the online system. Please note: State approved CPT codes that can be used for billing are selectable during online claim entry. There may be more than one CPT code listed, but only one is selectable per claim line. When filing a claim, the provider should report the valid CPT code for the procedure that matches the service that was rendered. Problems of missing authorizations could occur should there be any problems or delays in Cluster transmissions of authorized data to the CRO. For Electronic Authorizations please check the website before calling the CRO. Authorizations are a reflection of the services identified on an Individualized Family Service Plan. All service providers/practitioners should have a copy of the IFSP as they begin services for a child and family. Authorizations will follow and should match the services specified on the IFSP including the dates of service, frequency, intensity, location and duration. Authorization start dates will be consistent with the start date identified on the IFSP. Authorizations that are inconsistent with the IFSP should be discussed with the service coordinator immediately. The child's service coordinator is identified on the IFSP itself and on the online authorization. The Service Coordination information is also contained in the HIPAA (278) Authorization file. Practitioners should pay close attention to the end dates of the IFSP and authorization, and they should not extend services beyond the end dates if no new IFSP has been received. Services, other than assessment/evaluation/ifsp development, not covered by an IFSP are not considered reimbursable services. Also, always verify that the authorization used for billing has not been cancelled or discontinued. Providers continue to be responsible for obtaining prior authorization (PA) where PA is required. A separate document is available online, and details the prior authorization requirements for early intervention. Document Dated January 20, 2009 Release # 1.00 Page # 6

7 Section 3. Billing Instructions All Early Intervention services authorized through the Cluster will be paid by the Central Reimbursement Office (CRO). The CRO will pay the claim, determine the appropriate funding source, and in turn seek reimbursement. Providers are not to bill Medicaid (or Web InterChange), Insurance & CSHCS or any other source for early intervention services authorized through the Cluster/CRO. CRO Standard Timelines/Deadlines Claims Processing Turnaround Claims are processed and electronic fund transfers (EFT) are deposited within 10 business days from the date the claim is received. Stale Checks Checks are void if not cashed within 6 months. Claim Filing Deadline Claims must be submitted within 60 days of date of service. Claim Resubmission (Incorrect Authorization) Filing Deadline Previously submitted and rejected claims which can be resubmitted only after a corrected authorization is issued and must be resubmitted within 60 days of the issue date of the corrected authorization. Claim Overpayment Automated Refund Deadline In cases of overpayment providers will not refund payments manually through the submission of checks. The adjustments will be entered on the system against individual claims and the system will deduct the amount of overpayment on subsequent claim(s) payments processed. In cases of underpayments adjustments will be entered on the system against individual claims and the system will augment the amount of the underpayment on the next claim payments processed. Claim Overpayment Manual Refund Deadline Only when automated claims adjustment/offset is not a viable alternative, manual refunds must be made to CRO no later than 180 days from original overpayment date. Providers may choose from 3 billing options: a) online Provider Account Module b) paper HCFA 1500 (use only when automated claims adjustment/offset is not a viable alternative) c) HIPAA 837P, x12 format Bills must be received within 60 days of service delivery. Your timely billing to the Central Reimbursement Office is essential to your reimbursement. Document Dated January 20, 2009 Release # 1.00 Page # 7

8 Option 1. Online Provider Account Module The Online Provider Module allows Early Intervention service providers, enrolled with the Central Reimbursement Office, the opportunity to perform multiple tasks online. A provider may view authorization detail including claims billed against an authorization and submit claims for authorized services. Providers may submit claims online and view the claim processing adjudication detail prior to the submission of the claim. The provider may update their provider account contact information, indicate notifications they would like to receive and view communications from the State. In addition, authorized state personnel may communicate with providers and payees via . In addition to the online Help information available on the Provider Module application page, further assistance is available via the Central Reimbursement Office (CRO) at the following: Option 1. Document Dated January 20, 2009 Release # 1.00 Page # 8

9 Option 2. HCFA 1500 Billing Instructions (bill with this option only when automated claims adjustment/offset is not a viable alternative) Field Number Narrative Description 1a Insured's I.D. Number: This field should include the child ID # from the authorization online. While not a required field this information may be helpful particularly if other items do not match. 2 Patient's Name: Please use the child's name from the authorization. 3 Patient s Birth Date/Sex: Enter the child's birth date in a MM/DD/YY format, and enter an X or check mark in the appropriate sex block Items 4 through 16 are either Not Applicable for Early Intervention (EI)or Not Required. 19 Reserved For Local Use: Please add the therapist s name (currently under discussion). 23 Prior Authorization Number: THIS FIELD MUST BE USED FOR THE CRO AUTHORIZATION NUMBER. This must be included. 24a The field Date(s) of Service should be in the mm/dd/yy format (02/16/09). 24b Place of Service Code: This must be listed and are the HIPAA Place of Service Codes. The list of acceptable codes are: Nursery School/ Child Care Center Homeless Shelter Office/ Outpatient Service Facility Home Hospital In Patient Skilled Nursing Custodial Care Facility Hospice Independent Clinic* Federally Qualified Health Center Intermediate Care Facility/Mentally Retarded Comprehensive Inpatient Rehabilitation Facility Comprehensive Outpatient Rehabilitation Facility Public Health Clinic** Rural Health Clinic Family Day Care Community Setting EI Class/Program Residential Facility 24c Type of Service: Not applicable Document Dated January 20, 2009 Release # 1.00 Page # 9

10 24d Procedures, Services, or Supplies: CPT/HCPCS Code is either the CPT code or the HCPCS code used in the Medicaid billing system. Please refer to the EI-To-CPT Crosswalk available in Appendix B of this document. If the same service is provided on the same day for the same child, the gg modifier must be reported on all subsequent claim lines. The total number of units authorized cannot be exceeded in any combination of services performed. For example, if a child is seen once in the morning and once in the afternoon for the same procedure, the first entry should report the CPT/HCPCS code, the second claim line would report the CPT/HCPCS code + gg. 24e Diagnosis Code: The ICD-9 diagnosis code. 24f $ Charges: The charges must reflect the total charges for that service encounter. For example, if your charges for speech therapy services on-site, are $16.00 per 15 minute increment please put $64 for charges for 60 minutes. Services must be in accordance with the provider s usual and customary charges. Payments will reflect the lesser of the provider's usual and customary charge or the First Steps maximum rate. Bill the actual time delivered in minutes. 24g Days or Units: Data must be referenced in minutes, not in units. This is the most common problem on HCFA 1500 claim submissions and is the primary cause for payment delays or rejections. 25 Federal Tax I.D. Number: This is a required field and reflects the taxpayer ID of the payee. 26 Patient s Account No.: This is an optional field and is used at the provider's discretion. 28 Total Charge: This amount should reflect the sum of line items on the claim. If the sum does not add correctly, the individual line items will take precedence. 29 Amount Paid: Less other applicable credits should be used when applicable. 30 Balance Due: Charges should be the result of subtracting "less Amount Paid" from "Total Charge". This is required. 31 Signature of Physician: A provider's signature must be included. The signature may be that of an administrative official within the organization who has the authority to sign on behalf of the individual practitioner. A certification statement provided later in this document may be completed allowing providers/payees to submit claims noting signature is on file. Date: Enter the date the claim was filed. This is required. The date must be after the latest date entered in the billing section of the claim. 32 Name and Address of Facility Where Services Were Rendered: While this field is optional, the information may be important for follow-up activity. 33 Physician's Supplier s Billing Name, Address, Zip Code & Phone #: Enter the provider s Medicaid Number. This is required. Document Dated January 20, 2009 Release # 1.00 Page # 10

11 Mail completed claims to: Central Reimbursement Office c/o CSC Covansys PO Box 2507 Greenwood, IN The aformentioned fields on the HCFA 1500, are displayed on the next two pages. The initial page has the blank form and on the next page the fields are filled with information. Document Dated January 20, 2009 Release # 1.00 Page # 11

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14 Option 3. Electronic Billing & Claims Certification Statement Electronic Signature Agreement Indiana First Steps This is to certify my request for an electronic signature. Through the use of an electronic signature, you agree that the information you provide is accurate and complete to the best of your knowledge. You also acknowledge that you have read and understand the following statements: Any and all information submitted on my behalf shall be true, accurate, and complete. I accept total responsibility for the accuracy of all information submitted to the web site. The undersigned will hold harmless and indemnify the Indiana Family and Social Services Administration (FSSA) and or its Fiscal Agent Contractor (CSC) from any and all claims, actions, damages, liabilities, costs and expenses, including reasonable attorneys' fees and expenses, which arise out of or are alleged to have arisen out of or as a consequence from the utilization of the web site. I further acknowledge that utilization of the web site does not alter my continuing obligation to comply with all applicable requirements of the Central Reimbursement Office Agreements which I have signed including but not limited to those requirements pertaining to payments, claims, timelines, confidentiality, privacy, records and records retention. I agree to immediately notify the Central Reimbursement Office (CRO) via phone and mail if my password to this web site is lost, stolen, misplaced or has been compromised. I understand it is my responsibility to use the information provided to me on this web site for its intended purposes and to protect any password(s) issued to me. I agree to adhere to the stipulations and conditions outlined in the Family Educational Rights and Privacy Act (FERPA). I understand that violation of any of the provisions of this Agreement shall subject me to the actions set out in the FSSA policies on Central Reimbursement Office Provider Dis-enrollment and shall make access to the web site subject to immediate revocation at the FSSA s option. I understand it is our responsibility to notify the Central Reimbursement Office in the event of lost, stolen or compromised username/password. I understand that access will not be granted to the web site without this Agreement. I certify that I am in compliance with the Central Reimbursement Office Agreements. I warrant that I have the authority to make this agreement. Document Dated January 20, 2009 Release # 1.00 Page # 14

15 CERTIFICATION STATEMENT FOR PROVIDERS SUBMITTING CLAIMS BY MEANS OTHER THAN STANDARD PAPER This is to certify that any and all information contained on any First Steps billings submitted on my behalf by electronic, telephonic, and/or mechanical means of submission, shall be true, accurate, and complete. I accept total responsibility for the accuracy of all information contained on such billings, regardless of the method of compilation, assimilation, or transmission of the information (i. e. either by myself, my staff, and/or a third party acting in my behalf, such as a service bureau). I fully recognize that any billing intermediary or service bureau that submits billings to the Family and Social Services Administration or its Fiscal Agent Contractor is acting as my representative and not that of the FSSA or its Fiscal Agent Contractor. I further acknowledge that any third party that submits billings on my behalf shall be deemed to be my agent for purposes of submission of First Steps Central Reimbursement Office claims. I understand that payment and satisfaction of any claims that shall be submitted on my behalf will be from Federal and State funds, and that any false claims, statements, documents, or concealment of material fact may be prosecuted under applicable Federal and/or State law. The provider will hold harmless and indemnify FSSA from any and all claims, actions, damages, liabilities, costs and expenses, including reasonable attorneys' fees and expenses, which arise out of or are alleged to have arisen out of or as a consequence of the submission of First Steps Central Reimbursement Office billings by the provider through electronic, telephonic, and/or mechanical means of submission unless the same shall have been caused by negligent acts or omissions of the FSSA. I further acknowledge that submitting claims by means other than standard paper does not alter my continuing obligation to comply with all applicable requirements of the Central Reimbursement Office Agreement(s) and/or Riders which I have signed including but not limited to those requirements pertaining to payments, billing timelines, records and records retention. I understand that the FSSA or its designees are prepared to provide necessary technical assistance to assist new providers or to correct technical problems which existing providers may experience. I realize that all communications regarding electronic, telephonic, or mechanical submission of claim shall be between the provider in whose name the claim is submitted and the FSSA or its Fiscal Agent Contractor. I further understand that this technical assistance shall consist of: Identification of data element requirements Identification of record layouts and other electronic specifications Identification of systematic problem areas and recommended solutions I agree to notify either the FSSA or its Fiscal Agent Contractor of any changes in my provider name or address. Further, I agree to comply with such minimum substantive and procedural requirements for claims submission as may be required by the FSSA or its Fiscal Agent Contractor. I certify that I am in compliance with the Central Reimbursement Office Agreement(s) and Rider(s). Fraud and abuse encompasses a wide range of improper billing practices that include misrepresenting or overcharging with respect to services delivered. Fraud generally involves a willful act; abuse involves actions that are inconsistent with acceptable fiscal, business or medical practices. Frequently cited fraudulent or abusive practices include, but are not limited to, overcharging for services provided, charging for services not rendered, accepting bribes or kickbacks for referring patients, and rendering inappropriate or unnecessary services. Procedures and mechanisms employed in the claims and payment surveillance and audit program include, but are not limited to, the following: Review of recipient profiles of use of services and payment made for such Review of provider claims, First Steps Program documentation or data and payment history for patterns indicating need for closer scrutiny Computer-generated listing of duplication of payments Computer-generated listing of conflicting dates of services Computer-generated over-utilization listing internal and/or external checks on such items as procedures, quantity, duration, provider eligibility, recipient eligibility, etc. Staff review and application of established medical services parameters, Field-auditing activities conducted by the Family and Social Services Administration (FSSA) or its representatives, which may include required provider and recipient contacts or request for information. Document Dated January 20, 2009 Release # 1.00 Page # 15

16 In cases referred to law enforcement officials for prosecution, the Indiana Family and Social Services Administration has the obligation, where applicable, to seek restitution and recovery of monies wrongfully paid even though prosecution may be declined by the enforcement officials. Further I understand that violation of any of the provisions of this Certification Statement shall subject me to the actions set out in the FSSA Policy on Central Reimbursement Office Provider Dis-enrollment and shall make the billing privilege established by this document subject to immediate revocation at the FSSA s option. THE UNDERSIGNED HAVING READ THIS CERTIFICATION STATEMENT AND UNDERSTANDING IT IN ITS ENTIRETY DOES HEREBY AGREE TO ALL OF THE STIPULATIONS, CONDITIONS AND TERMS STATED HEREIN. Provider Agency Organization Name Agency Organization Tax ID Authorized Official (printed name) Title Authorized Official (signature) Date Name of electronic claims contact person: Phone No: Document Dated January 20, 2009 Release # 1.00 Page # 16

17 Trading Partner Agreement General Information The CSC Covansys ( CSC ) Trading Partner Agreement (TPA) establishes a formal relationship that allows CSC and its trading partners to exchange electronic transactions in accordance with HIPAA transaction regulations. The TPA outlines the roles and responsibilities of both CSC and its trading partner, to ensure secure electronic transmissions. Any Early Intervention Provider or Agency/Facility that is a direct sender of batch electronic transmissions to CSC must complete the CSC TPA. Trading partners must also complete the Certification Statement for Providers/Agencies Submitting Claims by Means Other than Standard Paper form to be enrolled as an electronic Provider/Agency in the program. The Certification Statement for Providers/Agencies Submitting Claims by Means Other than Standard Paper forms and instructions for their completion are found in the Indiana First Steps Early Intervention Central Reimbursement (CRO) Billing Manual. A TPA is not required by HIPAA, but the ASC Insurance Subcommittee that was charged with developing the Implementation Guides for EDI transactions strongly recommends that trading partners have binding agreements to provide security and assurance in the transfer of electronic information (See Section of any ASC X12 Implementation Guide). CSC has made a business decision to make trading partner agreements a requirement for EDI transmissions based on this recommendation. After CSC receives an original copy of the TPA, contact will be made with information about testing transmissions. When the TPA is received a representative of CSC will sign it and return a photocopy of the original to the trading partner to retain for its records. CSC requires the execution of this TPA with all entities that are sending us direct transmissions. The CSC TPA is comprehensive and should address any issues or legal concerns of our trading partners. CSC will accept up to 5000 claims per 837P batch file. The Implementation Guide recommends the creation of this limitation to avert circumstances where file size management may become an issue. CSC has determined the Electronic Transmitter Identification Number (ETIN), as used in the Implementation Guide, to be the EIN number that was established at the time of enrollment into the Early Intervention Program. EI Providers may send to CSC Covansys the following files/transactions: Transaction Set Document Name / Description Version Number Release 837 Health Care Claim: Professional 4010A1 CSC Covansys is prepared to send the following files/transactions to EI Providers: Transaction Set Document Name/ Description Version Number Release 835 Health Care Claim Payment/Advice 4010A1 278 Health Care Services Review Response 4010A1

18 Providers will see the following table in the Trading Partner Agreement. This allows an EI Provider to choose the transaction they will send electronically. Transaction Set Number Electronic Transactions Sets to CSC Covansys Document Name/ Description Version Release Method (Paper/electronic) 837 Health Care Claim: Professional 4010A1 Providers will see the following table in the Trading Partner Agreement. This allows an EI Provider to choose the transaction they will receive electronically. Transaction Set Number Electronic Transaction Sets from CSC Covanys Document Name/ Description Health Care Claim Payment/Advice Health Care Services Review Response Version Release 4010A1 4010A1

19 Explanation of Provider Payment The online Provider Account Module makes available an Explanation of Payment (EOP) detailing the information on the claims submitted and processed. The EOP includes the claim number assigned to a particular claim processed as well as amounts paid or not covered. When claims are rejected in part or in full, the online EOP will include a rejection code for the provider information in taking corrective action. The HIPAA standard 835 remittance advice is available for providers. This file is transmitted electronically by the CRO. Resubmission of Rejected Claim Resubmission of a previously denied claim must be marked as a resubmission and submitted on paper. If the claim was denied and a correction is required on the authorization, please contact the service coordinator. Corrections to authorizations require verification with the Individual Family Service Plan. Required billing corrections may be done by the provider and marked as such on the resubmitted form. Claims Corrections Corrections to previously submitted and paid claims should be marked as correction and submitted on paper to the Central Reimbursement Office. Example # 1- Not enough service billed: Provider bills and receives payment for services that represent 60 minutes when actual services for that day were 90 minutes. Provider submits an additional claim, marked as "correction" on the face of the claim form, for the incremental 30 minutes of service. In addition, please place an X in the yes block, indicating this is a resubmission of a claim. Example # 2- Too much service billed: Provider bills and receives payment for services that represent 60 minutes when actual services for that day were 30 minutes. Provider submits an additional claim, marked as 'correction' on the face of the claim form, for the reduction of 30 minutes of service. The reduction should be noted with a minus sign or in brackets for both the time and the charges. In addition, please place an X in the yes block, indicating this is a resubmission of a claim. Automated Payment Adjustments/Offsets CRO has implemented a system of automated claims adjustments/offsets to address provider overpayments/underpayments caused by various improper/erroneous billing procedures. When errors are discovered, adjustments will be entered on the system after receipt of proper documentation from providers. In cases of overpayment providers will not refund payments manually through submission of checks. The adjustments will be entered on the system against individual claims and the system will deduct the amount of overpayment on subsequent claim(s) payments processed. In cases of underpayments adjustments will be entered on the system against individual claims and the system will augment the amount of the underpayment on the next claim payments processed.

20 Manual Overpayment Refund Only when automated claims adjustment/offset is not a viable alternative the provider will be mailed two written notices (at 30 and 90 days from original overpayment date) to refund an overpayment discovered by CRO. All manual refunds must be made to CRO no later than 180 days from original overpayment date. When submitting manual claims corrections for overpayment please make the refund check out to: Central Reimbursement Office c/o CSC Covansys P.O. Box Shawnee Mission, KS

21 APPENDIX A CLAIMS ADJUDICATION Claim Adjudication Approach As claims are stored or updated in the application, all of the information undergoes a series of tests to determine whether the claim should be paid in full, denied in full, or partially denied. The Provider s specialties and credentials, previous claims filed for the same authorization, and consistency of the claim information with other information in the system are among the many series of application processing efforts that determine whether a claim or part of a claim can be paid. Application processing is performed first on the claim summary information. If there is a reason that the claim as a whole cannot be paid, each line item is marked with that reason and denied in full. If the claim summary information passes all processing requirements, each line item is then checked. If a line item fails a check, only that line item is denied, and processing continues with the next line item. A partial denial of a line item typically happens in one of two ways. First, a portion of the billed amount can be denied for reason number 12, authorized units exceeded. This happens when the line item contains charges for more units of service (or assistive technology, travel, etc.) than have been authorized and have not been paid on previous claims or previous line items of this claim. In this case, the line item is paid for the authorized units remaining, and the rest of the charges are denied. (Services authorized Weekly or Monthly are an exception to this rule. Please see Total Units Allowed Per Timefame in this document.) Second, a partial amount denied is termed a disallowed amount when the charges exceed the maximum amount allowed for the authorized service, according to the rate schedule established by the State. A disallowed amount is always shown separately and it has no denial reason code. The maximum rate payable for a unit of service is determined by the date of service, the procedure, and the specialty of the Rendering Provider. If the Provider holds effective credentials for multiple specialties that are paid different rates, the highest rate is allowed. When authorized to do so by the State, the operator can shut off all processing checks in order to ensure that a claim is paid in full or denied for a specified reason. The processing check for timely filing (Denial Reason 9) can be shut off separately from other processing.

22 Claim Denials The following charts describe the processing checks performed on a claim: Claim Denial Reasons Claim Summary Information Denial Reason 1 Does the claim data include an authorization number? Can the specified authorization be located in the database? Is the authorization data complete and consistent? Denial Reason 6 Was the authorization discontinued? Denial Reason 7 Does the claim data include a valid Provider Account? Denial Reason 19 Is the claim s Provider Account number consistent with the account number of the authorization? Is the Provider Account data complete and consistent? Claim Line Denial Reasons Claim Line Item Information Denial Reason 3 Is the claim a duplicate? (Previously, this meant that a claim for the same date of service was already paid for the same authorization. This definitionhas been expanded to include claims paid to the same provider for any authorization. This modification is detailed below.) Denial Reason 4 Is the claimed date of service within the authorization date range? Denial Reason 5 Is the child eligible to receive the service? Denial Reason 6 Was the authorization cancelled prior to the date of service? Denial Reason 9 Was the filing limit (time allowed to submit the claim) exceeded? Denial Reason 11 Does the claimed procedure code match the authorized procedure code? Denial Reason 12 Have all authorized units been paid on previous claims or previous line items of this claim? (If some, but not all units have been paid previously, the remaining units are paid even if this results in a partial payment for the line item.) If the claim is for Assistive Technology or Other services, has the authorized dollar amount been paid previously? Denial Reason 13 Does the Provider have the specialty required to perform the service? Is the specialty active on the date of service? Denial Reason 15 Is the number of available units greater than 0? Denial Reason 17 Is the amount billed greater than $0? Denial Reason 18 Is the Provider Account active and open? Denial Reason 33 Was the authorized number of units per occurrence exceeded? (This new edit is detailed below.) Denial Reason 35 Was the authorized number of units per week exceeded? (This new edit is detailed below.) Denial Reason 36 Was the authorized number of units per month exceeded? (This new edit is detailed below.) Disallow Amount Do charges exceed the maximum amount allowed for the procedure?

23 Units Authorized The CRO Claims system (CCG) determines the maximum usage of many types of authorization based on a calculated number of units authorized. For example, an authorization for a service to be rendered 3 times for 1 hour each time would have a total units authorized of 12 units (Four 15-minute units x 3 visits). Once all units authorized have been paid, claims are denied with reason code 12, authorized limit exceeded. The SPOE software has enormous flexibility in the specification of an authorization s number of units. An authorization can be written for x units, y times per z time period, from a start date to an end date. This flexibility adds a great deal of complexity when calculating the maximum number of units intended to be authorized. The ability to convert a specified date range into a number of weeks, months or years was implemented in the previous CSC Covansys system. This method will continue to be used for services that are authorized on a per day or per quarter basis. Authorizations with a frequency of per week or per month will be edited for service dates within each week or month as described in the New Edits for Authorized Frequency Denials section below. The other change effective in January of 2009 is that per year authorizations will be adjudicated exactly as if they are per authorization. Definition of Duplicate Claim The definition of a duplicate claim has been expanded from the previous CSC Covansys system to include claims against different authorizations. Claim lines to be considered Duplicates meet all of the following criteria: Same child Same practitioner and payee Same date of service Same EI Procedure Same CPT code Same or different authorization number Not fully denied or disallowed (some amount is payable) New Edits for Authorized Frequency Denials Previous CSC Covansys Claim Adjudication application processing did not evaluate dates of service claimed within frequency timeframes specified by the authorization. For example, a claim for a service authorized 2 times per week was not edited to determine whether other claims had been paid for dates of service during the same week. Edits have been added to evaluate a claimed date of service and deny a claim line when the number of units authorized for a single occurrence is exceeded or when the total number of units for an Authorized Frequency of either per week or per month is exceeded. Definition of Authorized Week Timeframe For purposes of adjudicating an Authorized Frequency Denial, a Week Timeframe is defined as the window of authorized dates each Sunday through the following Saturday, inclusive. An authorization cannot extend beyond the date range defined by the Start Date (EIAuthorization.StartDate) and either the End Date (EIAuthorization.EndDate) or the Cancel Effective Date (EIAuthorization.CancelDate). Therefore, a Week Timeframe may begin on the Start Date instead of on the previous Sunday, and it may end on the End Date or Cancel Effective Date instead of on the following Saturday. (See Claimed Occurrences Within a Partial Week, below.)

24 Definition of Authorized Month Timeframe For purposes of adjudicating an Authorized Frequency Denial, a Month Timeframe is defined as a calendar month. An authorization cannot extend beyond the date range defined by the Start Date (EIAuthorization.StartDate) and either the End Date (EIAuthorization.EndDate) or the Cancel Effective Date (EIAuthorization.CancelDate). Therefore, a Month Timeframe may begin on the Start Date instead of on the first day of the calendar month, and it may end on the End Date or Cancel Effective Date instead of on the last day of the month. (See Claimed Occurrences Within a Partial Month, below.) Definition of Claimed Occurrence To be considered a Claimed Occurrence, a claim line must meet the following criteria: Same authorization Dates of service within the same Week Timeframe or Month Timeframe The claim line has been adjudicated as payable, not fully denied If there is more than one paid claim for the same date of service, all units count as units within the same occurrence. Total Units Allowed Per Timeframe A claim line will be denied in full if the number of units billed causes the total number of units paid for service dates within the timeframe to exceed the number of units authorized within the timeframe. For example, an authorization is for 60 minutes, twice a week. Claims have been paid for 45 minutes each on Tuesday and Wednesday. A third claim line submitted for 45 minutes on Thursday will be denied in full, as the number of units used for the week (135) would exceed the total number of authorized units per week (120). Units Allowed for a Partial Week All Authorized Occurrences within a Partial Week specified by the authorization can be claimed and edited as payable. No reduction in the number of Authorized Occurrences or in the total number of units allowed within a week is to be made as a result of a Partial Authorized Timeframe. A Partial Authorized Week can be specified by an authorization in two circumstances: A per week authorization does not begin on a Sunday, causing the first Week Timeframe to begin on the authorization Start Date. A per week authorization does not end on a Saturday, causing the last Week Timeframe to end on the authorization End Date or Cancel Effective Date. Examples: An authorization is specified as 3 units per week. The Start Date is a Tuesday, and the End Date is a Thursday several weeks later. The first week is Tuesday through Saturday, and the last week is Sunday through Thursday. Three units may be paid during the first week, and three units may be paid during the last week. An authorization is specified as 3 units per week. The Start Date is a Tuesday, and the Cancel Effective Date is two days later, on Thursday. The first and only week is Tuesday through Thursday, and three units may be paid.

25 Units Allowed for a Partial Month Each partial month timeframe falling within the date range of the authorization (start date through end date or cancel effective date) will be granted a total number of units to be determined by the following rules: 1. If the authorization start date and ending date (end date or cancel date) are both within the same calendar month, units for all occurrences specified by the authorization will be allowed. 2. If the start date and ending date are in different months, only half the occurrences specified by the authorization will be allowed for the first month if the authorization start date is on or after the 17 th day of the month. This will be rounded to a whole number of occurrences. All occurrences will be allowed for the first month if the start date is on or before the 16 th day. The total units allowed is then determined from the allowed number of occurrences. 3. If the start date and ending date are in different months, only half the occurrences specified by the authorization will be allowed for the last month if the authorization ending date is on or before the 16 th day of the month. This will be rounded to a whole number of occurrences. All occurrences will be allowed for the last month if the ending date is on or after the 17 th day. The total units allowed is then determined from the allowed number of occurrences. 4. The total number of units authorized for any month will be determined by multiplying the number of occurrences allowed by the duration for each. Examples: 1. Authorization of 2 units, 3 times per month, 2/20/2009 to 2/28/2009 Allow for February: 6 total units (based on 3 occurrences) 2. Authorization of 2 units, 3 times per month, 2/20/2009 to 4/17/2009 Allow for February: 4 total units (based on half of 3 occurrences, rounded to 2 occurrences) Allow for March: 6 total units (based on 3 occurrences) Allow for April: 6 total units (based on 3 occurrences) 3. Authorization of 2 units, 3 times per month, 2/20/2009 to 3/16/2009 Allow for February: 4 total units (based on 2 occurrences) Allow for March: 4 total units (based on 2 occurrences)

26 Authorizations with Multiple Detail Lines It is possible to have more than one authorization line record per authorization. A SPOE software edit will ensure that if an authorization has a per week or per month frequency, all lines of the authorization will have the same frequency. In this case, the following rules will govern adjudication: The number of units allowed per individual occurrence is the greatest of the number of occurrences on any one of the authorization detail lines. The number of units allowed per week or per month is the sum of the number of units on all authorization detail lines. If there are multiple lines having a mixture of per week, per month, or other frequencies, claims will be denied with Denial Code 1. Contact your service coordinator to have the authorization replaced, as no such authorizations should be allowed. Example: An authorization has two detail lines, the first allowing 1 occurrence per week for 60 minutes and the second allowing 2 occurrences per week for 15 minutes each. A total of 90 minutes will be allowed for the week. Each service date will be allowed a maximum of 60 minutes.

27 APPENDIX B CONTACT INFORMATION Indiana First Steps Provider Enrollment Provider Enrollment or Credentialing Questions Option 2 CRO Provider Enrollment c/o CSC Covansys P.O. Box Shawnee Mission, KS Central Reimbursement Office (CRO) Help Desk Authorization / Billing Questions Option 1 Central Reimbursement Office c/o CSC Covansys P.O. Box 2507 Greenwood, IN SPOE Application, Service Matrix & Provider Account Management Technical Support Option 3 HIPAA Compliant EDI Transactions Option 4