DME Provider Training September 2009
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1 Wyoming EqualityCare DME Provider Training September 2009
2 2 Introductions Sara Walk Provider Services Manager Office of HealthCare Financing Equality Care Amy Buxton Field Representative ACS Rosemary Curtin RN, MA, CCP,CPHQ Coordinated Care Supervisor ACS Bowers Tracy Cline Account Manager ACS Bowers Sue Kozieja RN, BSN, CCM Clinical Support ACS Bowers
3 3 Agenda EqualityCare s Partnership with ACS Bowers Policy Changes 5/1/09 General Policies Coverage Criteria & PA Requirements Suggestions/Reminders/Answers ACS / EqualityCare website guide Wrap up Contact Numbers
4 4 Partnership with Bowers Wyoming EqualityCare moved the DME PA Services from ACS Administrative office to ACS Bowers nursing team 7/1/2008 to help enhance the level of provider service to facilitate patient care nurses work with the providers to assist throughout the PA process.
5 5 Policy Changes 5/1/09 General Policies i Wi Written orders no longer required when the documentation requirements include a CMN, and the CMN contains the necessary elements of a written order (including physician signature) Stamped signature will be accepted in lieu of a Physician hand signature RA Banners replaced provider bulletins to convey information about policy changes
6 6 Policy Changes 5/1/09 Coverage Criteria i Policies i Mileage outside the normal service area Added coverage for delivery of DME Gait Trainers New policy Continuous Glucose Monitoring System New policy Standers / Standing Frames New policy; separated from walkers Wheelchair Seating Systems (separated from wheelchair policy for simplification) New policy separated from wheelchair policy
7 7 Policy Changes 5/1/09 Coverage Criteria i Policies i Prior Auth Requirements have been added to the following: Beds & Accessories Blood Glucose Monitoring Systems PA required on for Continuous Systems Commodes PA required for E0170 only Infusion Pumps PA required for pump rental & maintenance codes Orthotics & Prosthetics Traction Equipment
8 8 Policy Changes 5/1/09 Coverage Criteria i Policies i PA requirements have been removed from the following Commodes except for E0170 Oxygen and Related equipment (PA requirements changed 8/1/08) Walkers Wheelchair repairs No longer require an MD prescription CMN can be signed by ATP and submitted same day repairs were completed
9 9 Policy Changes 5/1/09 Coverage Criteria i Policies i Battery changes Covered if they require a skilled technician Ventilators No longer subject to rental cap Infusion Pumps, External Subject to 10 month capped rent Routine maintenance codes can be billed after cap
10 10 Lifts Policy Changes 5/1/09 Coverage Criteria i Policies i Seat Lift Mechanisms The lift mechanism is covered, but providers will be allowed to bill a non-covered code for the recliner, and therefore can bill the client for the chair/recliner Wheelchair Seating Systems No longer limited to those under age 21 PA response letter ACS Bowers will soon be implementing a new & improved version
11 11 Suggestions/Reminders/Answers Modifier Codes Need to bill with correct modifier (RR & TH) A code without modifier is considered a purchase NPI number & Tax ID number What is the difference?? Home Infusion Questions How do we verify drug coverage? NDC codes - call GHS HCPCS codes - call ACS Where are claims submitted? DME supplies (HCPCS codes ) submit to ACS Pharmacies (NDC codes) - submit to GHS.
12 12 Suggestions/Reminders/Answers How does Home Infusion Therapy fit with ACS and Good Health Systems as it relates to Wyoming Medicaid? The only thing that has changed is how Point of Sale claims are processed - claims with NDC codes are now processed through GHS. Claim Questions Does the plan accept electronic claims? Medicare not covered codes - Must Medicare be billed for denial or can it be submitted directly to EqualityCare?
13 13 Suggestions/Reminders/Answers Medicare and PA Process If a DME item or supply is covered by Medicare, no prior authorization is required. If an item or supply is NOT COVERED by Medicare, and it is also an item that requires PA, then providers should follow standard PA procedures. ACS Bowers may ask provider to submit a copy of the Medicare ABN number that includes the reason the provider has determined that the client does not meet Medicare criteria. If the item or service is one that IS COVERED by Medicare but the provider isn t certain whether the client meets Medicare criteria, the provider may request a PA
14 14 Suggestions/Reminders/Answers Prior Auth Questions What is the Prior Auth Process? Submit a completed PA form, with all required documentation, to ACS Bowers by faxing to (414) Make sure the PA form is complete Use the correct HCPCS code. Refer to the DME Covered Services Manual for details Does EqualityCare allow retrospective authorizations? NO it is the providers responsibility to obtain authorizations, PRIOR to delivery of service on codes identified as requiring a PA After an approval, can the PA request be Amended? No a new PA must be submitted for additional items or accessories
15 15 ACS Wyoming EqualityCare Website
16 16 Click here to access the DME Covered Services Manual
17 17 Locating DME Covered Services Manual Next, click here to access the DME Covered Services Manual
18 18 DME Covered Services Manual General guidelines & policies are at the front of the Manual. The most current policies are always in the Manual, bookmarked for ease
19 19 DME Covered Services Manual Note Archived Policies are at back of Manual for reference
20 20 Back to Home Page Click here to start the HCPCS code look-up feature
21 21 HCPCS Code Look-Up Next, accept the user agreement terms by clicking here
22 22 HCPSC Code Look-up Then, click here to locate the code search feature
23 23 HCPCS Code Look-up Enter the code here
24 24 title Example of results received. For help, click here
25 25 title Example of a search by procedure description
26 26 Closing We hope this information has been helpful. We encourage continued suggestions and feedback from providers many changes and updates have been results from providers raising awareness regarding trends and issues. We assure you that it will be taken seriously and we will continue to provide the highest quality service in order to facilitate provider relations and meet clients needs.
27 27 For Questions Eligibility, claims, & coverage questions ACS for providers and for clients 9am-5pm (MCT) Monday through Friday DME prior authorizations ACS Bowers am-4pm (MST) Monday through Friday ACS Provider Relations or in Cheyenne 9am-5pm (MCT) Monday through Friday ACS Wyoming EqualityCareWebsite acs-inc com/
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