Chapter Four Billing Instructions

Transcription

1 Chapter Four Billing Instructions In this Chapter Section Title Page Choosing the Correct Claim Form Coding Requirements (HCPCS, ICD-9-CM, E & M) Evaluation and Management Services Diagnosis Procedures Modifiers How to Complete the HCFA Basic Rules Before You Begin Instructions for Completing the HCFA Place of Service Codes (POS) Prior Authorization Instruction for Completion of the Prior Authorization Form How to Bill for Newborns Required Attachments and How to Complete Attachments Sterilization Consent Form Hysterectomy Acknowledgment of Consent Abortion Certification Sample Claims and Forms Where to Send Your Claim How to Resubmit a Denied Claim Medicare Crossovers General Information How to File a Claim for a Dually Eligible Recipient The Remittance Advice When Your Patient Has Other Insurance Sample Remittance Advice How to Read Your Remittance Advice Adjustments and Refunds Refunding Money to Wyoming Medicaid Incorrectly Billed or Keyed Claims Third Party Recovery After Medicaid's Payment How to File a Void or Adjustment Request How to Complete the Adjustment Request Form Where to Send the Adjustment Request

2 Choosing the Correct Claim Form You must use the HCFA-1500 form when requesting payment for services authorized under the Wyoming Medicaid program. An example of the claim form is depicted in this section. In certain instances, attachments may be required. Examples of the attachments and instructions on how to complete are discussed in this section. If you do not use the required attachments, your claim will be denied. Consultec does not supply the HCFA-1500 claim form. The HCFA-1500 may be ordered from an independent printer or from one of the following companies: Standard Register Company Moore Business Forms When your claim is received by Consultec's Document Control section, it is screened for missing information or necessary attachments. From time to time, there may be reasons why a claim is returned to you. The "Return to Provider Letter" will clearly state the reason the claim was rejected. Once the problem is corrected, return the claim to Consultec for processing. Claims are processed weekly. Checks are printed twice monthly. Under normal conditions, a claim can be processed from receipt to payment within 10 to 20 days. A check is mailed in the same envelope with the Remittance Advice if the claims were approved for payment. 4-2

3 Coding Requirements (HCPCS, ICD-9-CM, E & M) Wyoming Medicaid Coding Guidelines When coding for Wyoming Medicaid you should be aware that CPT-4 codes and modifiers including their respective definitions were developed by the American Medical Association for providers to describe their services numerically for claim submission to insurers. These codes serve insurers as guidelines for claim adjudication but are not legally binding. Wyoming Medicaid has established specific guidelines, which must be followed for reimbursement. Wyoming Medicaid requires the use of uniform procedure and diagnosis coding on all claims. Evaluation and Management Services: Wyoming Medicaid follows the CPT-4 conventions regarding level of services for evaluation and management services. Diagnosis: Procedures: ICD-9 numeric diagnosis codes must be used. The code must include the fourth and fifth digit as appropriate. CPT (Physician's Current Procedural Terminology), National Codes (A-V) assigned by the Health Care Financing Administration and local codes (W-Z) assigned by Medicaid for billing Medicaid must be used. NOTE: Procedure codes which are described, as "unlisted procedures" must be submitted on paper with a report attached to the claim for manual review. These codes should only be used for a new or unusual service. 4-3

4 Modifiers: Wyoming Medicaid limits the use of modifiers to specific ranges of procedure codes as follows: CODE RANGE TYPE OF SERVICE ACCEPTED MODIFIER ANESTHESIA NO MODIFIERS SURGERY 22, 50, 51, 62, 80, AS RADIOLOGY MRI: 22, 52 (NO FEE INCREASE WILL APPLY) TC, LAB QW 26 ONLY FOR MEDICINE 26, TC EVALUATION/MANAGEMENT NO MODIFIERS A - Z HCPCS, LOCAL CODES RR, RE How to Complete the HCFA-1500 This section tells you how to complete each item of the claim form. Basic Rules Always use the HCFA Use one claim for each recipient. Be sure the information on the form is legible. Before You Begin Is the recipient eligible for Wyoming Medicaid on the date of service? Do you have a copy of the recipient's proof of eligibility? Is the service covered by Wyoming Medicaid? Did you obtain prior authorization, if applicable? 4-4

5 Have you checked to make sure the recipient does not have other insurance? If you do not have all of this information, review the instructions in Chapter 2, "Verifying Recipient Eligibility." If the response to all of the above questions is favorable, you can begin to fill out the claim form following the instructions in this chapter. 4-5

6 Exhibit 4.1 HCFA-1500 Claim Form SECTION INTENTIONALLY LEFT BLANK 4-6

7 Instructions for Completing the HCFA-1500 Claim Item Title Req'd Action 1 Insurance Type X Put an "X" in the "Medicaid" box. 1a Insured's Medicaid ID Number X Enter the recipient's ten-digit Wyoming Medicaid ID number that appears on the Medicaid Identification card. 2 Patient's Name X Enter the recipient's last name, first name, and middle initial as it appears on the Wyoming Medicaid ID Card. 3 Patient's Date of Birth/Sex No entry required. 4 Insured's Name X (When applicable) If the recipient is covered by other insurance, enter the name of the insured. 5 Patient's Address No entry required. 6 Patient's Relationship to Insured X (When applicable) If the recipient is covered by other insurance, mark the appropriate box to show relationship. 7 Insured's Address X (When applicable) Enter the address of the insured. 4-7

8 Claim Item Title Req'd Action 8 Patient Status No entry required. 9a-d Other Health Insurance Coverage X (When applicable) Enter the name of the insurance company and other requested information if the recipient has other insurance. Enter the word "none" or "not applicable" if there is no other insurance coverage. 10a-c Is Patient's Condition Related to? X (When applicable) Enter an "X" in any part(s) that apply and give corresponding information in Item 9a-d. 10d Reserved for Local Use No entry required. 11a-d Insured's Group Number 12 Patient's or Authorized Person's Signature X (When applicable) If there is another policy covering the recipient, enter the name of the insurance company and other requested information. No entry required. 4-8

9 Claim Item Title Req'd Action 13 Payment Authorization Signature 14 Date of current illness, injury or pregnancy 15 Date of Same or Similar Illness 16 Date Patient Unable to Work 17 Name of Referring Physician 17a ID Number of Referring Physician 18 For Services Related to Hospitalization X X X No entry required. Enter the date of illness, injury or pregnancy. No entry required. No entry required. (When applicable) Required when the referring physician does not have a UPIN number. (When applicable) Enter the UPIN number for the referring physician for consultations, and independent laboratory or independent radiologist services. If the provider does not have a UPIN, enter provider's name in Item 17. No entry required. 4-9

10 Claim Item Title Req'd Action 19 Reserved for Local Use 20 Was Laboratory Work Performed Outside Your Office? 21 Diagnosis or Nature of Illness or Injury X No entry required. No entry required. You cannot bill for laboratory work performed by another provider. Enter the ICD-9-CM diagnosis code exactly as it appears in the Codebook. Number one (1) will be identified as the primary diagnosis code. Use the most specific diagnosis code from the ICD-9-CM Code Book. If there is a fourth and/or fifth digit, it is a required part of the code. 22 Medicaid Resubmission No entry required. 23 Prior Authorization X (When applicable) Enter the ten-digit Prior Authorization number from the approval letter if this claim has been prior authorized. Claims for these services are subject to service limits and the twelve-month filing limit. 4-10

11 Claim Item Title Req'd Action 24 Claim Line Detail A Dates of Service X Enter the beginning date of service (From Date) in month, day, and year format, such as 06/21/93 for June 21, If the same procedure is provided on consecutive days, also enter the last date of service (To Date). Note: If services are performed on a single date, a "To Date" is not necessary. B Place of Service X Enter the two-digit Place of Service (POS) for each procedure performed. C T.O.S. No entry required. Place of Service Codes used for this claim form are listed after the instructions for completing the HCFA

12 Claim Item Title Req'd Action D Procedures, Services or Supplies: HCPCS codes and modifiers X Enter the correct procedure code for the service being billed. For certain types of service, a two-digit modifier must be entered after the procedure code. For a list a valid modifiers see "Coding Requirements" in this Chapter. E Diagnosis Code X Enter the ICD-9-CM code that corresponds to the primary diagnosis or the item number (1-4) from field 21. Enter only one code per line. This is the primary condition you are testing. Note: Use the diagnosis code exactly as it appears in the ICD-9-CM Code Book. Use the most specific diagnosis code from the ICD-9-CM Code Book. If there is a fourth and/or fifth digit it is a required part of the code. 4-12

13 Claim Item Title Req'd Action F Charges X Enter your usual and customary charge for the procedure performed. When billing for multiple visits on one line, enter total charges for all units. G Days or Units X Enter the units of service rendered for each detail line. A unit of service is the number of times a procedure is performed, except for anesthesia. Anesthesiologists, please see note below. NOTE: When only one procedure is performed, a "1" must appear in this field. When the same procedure is performed on consecutive days, enter the number of days when using a From-To date in item 24A. (Antepartum visits are an exception to the from/through span.) Anesthesiologists: Enter the anesthesia time in total minutes. For example: One hour and fifteen minutes should be entered as "75". Do not convert time to units. 4-13

14 Claim Item Title Req'd Action H EPSDT/Family Planning X (When applicable) Enter an "F" if the services on this claim line are for family planning. Enter an "E" if the recipient was referred for services on this claim line as a result of a HEALTH CHECK screening exam. I EMG No entry required. J COB No entry required. K Reserved for Local Use 25 Federal Tax ID Number 26 Patient's Account Number X (When applicable) When the provider number in item 33 is a group number, enter the individual performing practitioner's nine-digit Wyoming Medicaid provider number. No entry required Optional 27 Accept Assignment X Check "Yes." Assignment is required. 4-14

15 Claim Item Title Req'd Action 28 Total Charge X Add together all charges in Column 24F and enter the total amount in this field. 29 Amount Paid X (When applicable) Enter the amount paid by other health insurance coverage. Do not enter prior Wyoming Medicaid payments or the $1.00 copayment here. This field is reserved for third party coverage only. 30 Balance Due No entry required 31 Signature of Physician or Supplier and Date X Sign and date the claim. A personal signature, a facsimile signature, typed signature, computer generated name, or an authorized signature, and date must appear in this field. Providers are responsible for all claims billed using their Wyoming Medicaid provider number whether the provider, the provider s employee, subcontractor, vendor or business agent submits the claim. 4-15

16 Claim Item Title Req'd Action 32 Name and Address for Facility Where Services Rendered 33 Provider's Name, Address, Zip Code, Telephone Number & Wyoming Medicaid Provider Number X X (When applicable) If services were rendered in other than home or office, enter the complete name and address of the hospital, clinic, laboratory, or any facility where services were rendered. Otherwise, no entry required. Enter your provider name, address, zip code, and telephone number. The provider number entered in Item 33 is the one to which Wyoming Medicaid payment is to be made. Enter your nine-digit Wyoming Medicaid Provider Number by the "GRP number". If this provider number identifies a group provider, you must enter the individual performing provider number in Item 24K for each line billed. 4-16

17 Place of Service Codes (POS) Use the following two-digit codes when completing the 12/90 version of the HCFA-1500 claim form. Code Description 11 Office Location, other than a hospital, Skilled Nursing Facility (SNF), Military Treatment Facility, Community Health Center, state or local public health clinic or Intermediate Care Facility (ICF), where the health professional routinely provides health examination, diagnosis and treatment of illness or injury on an ambulatory basis. 12 Patient's Home Location, other than a hospital or other facility, where the patient receives care in a private residence. 21 Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services, by or under the supervision of physicians to patients admitted for a variety of medical conditions. 22 Outpatient Hospital A portion of a hospital which provides diagnostic, therapeutic, (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. 23 Emergency Room - Hospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. 24 Ambulatory Surgical Center A freestanding facility, other than a physician's office where surgical and diagnostic services are provided on an ambulatory basis. 31 Skilled Nursing Facility A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services, which does not provide the level of care or treatment available in a hospital. 4-17

18 Code 32 Nursing Facility Description A facility, which primarily provides residents skilled nursing care and related services for rehabilitation of injured, disabled, or sick person, or on a regular basis health-related care services above the level of custodial care to other than mentally retarded individuals. 33 Custodial Care Facility A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component. 41 Ambulance - Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. 42 Ambulance - Air or Water An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. 53 Community Mental Health Center A facility that provides comprehensive mental health services on an ambulatory basis primarily to individuals residing or employed in a defined area. 61 Comprehensive Inpatient Rehabilitation Facility A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. 62 Comprehensive Outpatient Rehabilitation Facility A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. 65 End Stage Renal Disease Treatment Facility A facility other than a hospital, which provides dialysis treatment, maintenance and/or training to patients or caregivers on an ambulatory or home-care basis. 71 State or Local Public Health Clinic A facility maintained by either state or local health departments that provide ambulatory primary care under the general direction of a physician. 4-18

19 Code Description 72 Rural Health Clinic A certified facility which is located in a rural medically undeserved area that provides ambulatory primary medical care under the general direction of a physician. 81 Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office. 99 Other Unlisted Facility Other service facilities not identified above. Prior Authorization Some procedures require Wyoming Medicaid's approval (prior authorization) before you provide the service. The prior authorization form must be submitted to Consultec before performing the services in question. (Retain a copy for your files.) The request will be approved or denied and you will receive a letter informing you of the decision. If the request is approved, a prior authorization number will be listed on the approval letter. This number must be in field 23 on the HCFA-1500 claim form. To order the PA form, refer to Chapter 6. A copy of the PA form and instructions on completing the form follow this section. Reimbursement will not be made when you fail to obtain prior authorization for specified services. Telephone authorization may be granted in cases of medical emergency where the health of the patient would be endangered. To obtain emergency authorization, please call or (307) locally. Telephone prior authorization is not a guarantee of coverage. You must complete the prior authorization form noting the verbal approval and submit to Consultec. 4-19

20 SERVICES REQUIRING PRIOR AUTHORIZATION DME/MEDICAL SUPPLIES and PROSTHETICS/ORTHOTICS - Medical Supplies Provider Manual EXPANDED HEALTH CHECK SERVICES - Refer to Medical Services VISION THERAPY RECONSTRUCTIVE SURGERY PROCEDURES LTC WAIVER SERVICES The plan of care will come to the Division on Aging and will be entered into the system as approved by the Division on Aging. Wyoming Medicaid requires prior authorization for some medical services and supplies. In order for prior authorization to be obtained, submit the Wyoming Medicaid Prior Authorization form to Consultec. When required, PRIOR AUTHORIZATION OF SERVICES AND SUPPLIES MUST BE OBTAINED BEFORE THE SERVICES ARE RENDERED. The form to use is located at the end of this section and may be copied. Retain a copy of the prior authorization for your records. The list of medical supplies and services requiring prior authorization is found in the Coverage Index of the Medical Supply Manual. Other services requiring prior authorization include: Expanded Health Check Services Vision Therapy Reconstructive Surgery Procedures Authorization can be obtained by telephone at one of the following numbers: For areas outside of Cheyenne Touch tone telephone only Local Any phone If services, supplies, or equipment are approved, a pending number is issued. Telephone prior authorization is not a guarantee of coverage. You must complete the prior authorization form noting the verbal approval and submit it to Consultec. A determination of payment will not be made until documentation is submitted. If a provider needs to obtain prior authorization outside of regular business hours, or on a weekend or holiday they must notify Consultec on the next business day. 4-20

21 Prior authorization requests are to be sent directly to Consultec. If services are approved, a prior authorization number will be assigned and a letter sent to the provider. If services are denied, the provider will be notified and allowed to submit a reconsideration request according to the Wyoming Medicaid Administrative Rules. Failure to submit a reconsideration request within the time frames outlined in the Administrative Rule will prevent any further action in the matter. Once the prior authorization number is obtained, the number must be placed in the appropriate field on the claim. (Field 23 for the HCFA-1500). The services on the claim must match the services on the prior authorization form or the services will be denied. All prior authorization requests must include: 1. A completed prior authorization form 2. The codes with which services will be billed 3. A physician s prescription. Be sure that the form completely explains or describes: Diagnoses - including secondary conditions that might influence the need for services. For instance, when a power wheelchair is requested for a paraplegic, it is important to have an upper body functional assessment. The present clinical condition of the patient The prognosis - How long will the condition last? Will it improve or worsen? An explanation of why this particular service or equipment is necessary to the life or health of the patient, how it will improve their life, or how it will influence their prognosis. A description of the patient s social support system, e.g., homebound, lives alone, family/community support, etc. Any additional information to document medical necessity. Prior authorization will not be granted without this information, and requests will be returned to providers when they are incomplete. Also, when additional information is requested, the prior authorization record will be pended for 30 days. If the additional information is not received within 30 days, the prior authorization will be purged, making it necessary for you to initiate the process again. The length of time granted for the prior authorization will be based on the diagnosis and prognosis for the patient, but will not be granted in excess of one-year periods. Submit the prior authorization form to: Consultec PO Box 667 Cheyenne, WY

22 Limitations - Approved prior authorizations are valid only if: 1. The client is Medicaid-eligible at the time services are provided. It is the responsibility of the provider to verify the client s Medicaid eligibility for the date of services. 2. The client s condition meets the Wyoming Medicaid coverage criteria for the item at the time of purchase or for the duration of the rental period. 3. For rentals, the item is used appropriately by the client for the duration of the rental period. 4. The client s living arrangement does not change. Movement to a nursing facility, ICF-MR or hospital may invalidate an approved prior authorization; and 5. All Wyoming Medicaid policies are followed. 4-22

23 Exhibit 4.2 Prior Authorization Form WYOMING MEDICAID PRIOR AUTHORIZATION FORM I. PATIENT INFORMATION II. PROVIDER INFORMATION 1.DOB 2.SEX 3.AGE 4. MEDICAID ID # 9. PROVIDER NUMBER 10.TELEPHONE 5. PATIENT NAME (LAST, FIRST, MI) 11. PROVIDER NAME 6. STREET ADDRESS STREET ADDRESS 7. CITY, STATE, ZIP CODE MAILING ADDRESS 8. PHONE NUMBER ( ) - CITY, STATE, ZIP CODE III. SERVICE INFORMATION 12. DATES OF SERVICE MM/DD/YY FROM TO 13. PROPOSED MEDICAL SUPPLIES, PHARMACY, SURGICAL PROCEDURES OR OTHER SERVICES, (LIST PRIMARY PROCEDURE FIRST) 14. PROCEDURE, NDC OR REVENUE CODES 15.UNITS 16. ESTIMATED COST 17. STATE USE ONLY-APPROVED UNITS AMOUNTS A. B. C. D. E. 18. SUMMARY OF HISTORY (DIAGNOSIS, DATE OF ONSET, PROGNOSIS, PHYSICAL EXAMINATION, LABORATORY, X-RAY STUDIES, PHARMACY, AND APPLICABLE DOCUMENTATION MUST BE SUPPLIED IN SUFFICIENT DETAIL TO SATISFY THE MEDICAL NECESSITY FOR THE PRESCRIBED SERVICE. ADDITIONAL DOCUMENTATION MAY BE ATTACHED WHEN NECESSARY.) 19. REFERRING WYOMING PHYSICIAN: TELEPHONE NUMBER: (IF THIS AUTHORIZATION REQUEST IS FOR SERVICE TO BE RENDERED OUT-OF-STATE, A BRIEF JUSTIFICATION STATEMENT IS REQUIRED) 20. VERBAL AUTHORIZATION GIVEN BY: DATE: PA NUMBER: 21. TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS TRUE, ACCURATE, AND COMPLETE AND THE REQUESTED SERVICES ARE MEDICALLY INDICATED AND NECESSARY TO THE HEALTH OF THE PATIENT. SIGNATURE OF PROVIDER: DATE: IV. AUTHORIZATION (FOR STATE USE ONLY) AUTHORIZATION IS VALID FOR SERVICES 22.FROM DATE: 23.TO DATE: 24. PRIOR AUTHORIZATION NUMBER PROVIDED:(SIGNATURE & DATE AUTHORIZED) 25. COMMENTS/EXPLANATION: NOTE: AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO THE PATIENT'S ELIGIBILITY AND WYOMING BENEFIT LIMITATIONS. BE SURE THE MEDICAID IDENTIFICATION CARD IS CURRENT BEFORE RENDERING SERVICES. HCF/UMU105 CONSULTEC, INC. * P.O BOX 667 * CHEYENNE, WY * (307) (In Cheyenne) * FAX: (307) /

24 Instructions for Completion of the Prior Authorization Form I. PATIENT INFORMATION 1. Date of birth, sex, age, Medicaid Identification No. are required (items 1-4). 2. Name (recipient), city and state are required items (items 5 & 7). 3. Street address, zip code and phone # are optional but helpful (items 6 & 8). II.PROVIDER INFORMATION 1. Provider identification number (nine-digit unique Wyoming Medicaid provider number), provider name, phone number and address are required (items 9-11). III.SERVICE INFORMATION 1. Date(s) of services (item 12) is required. 2. Proposed services (written description), procedure codes, number of units (number of each service), and estimated cost are required (items 13-16). The estimated cost is the cost (or rental) times the number of units. (Units can be days, months, or services, etc.) *NOTE: RENTAL EQUIPMENT REQUIRES THE MODIFIER -RR* 3. Item 17 (number of units) reflects the number of units and is completed by the state evaluation when prior authorizing the services. 4. Summary of History is required (item 18); please give as much information as possible supporting the need for the service(s) requested including but not limited to documentation of medical necessity and prescriptions. You may attach additional sheets if necessary. *Surgical requests require an attached history and physical. 5. Out of State Services (item 19); Under Referring Wyoming Physician, enter the name or the provider number of the Wyoming physician referring the recipient for out-of-state services; enter the phone number of the referring Wyoming physician. The justification can be brief and can relate to item # Verbal authorization (item 20); Put the name of the person from Consultec who gave the verbal authorization, the date you spoke with them, and the PA number. Remember that this authorization is only a tentative authorization. Until a written request is received, the claim cannot be paid. The written request must be submitted to Consultec prior to submitting the claim. 7. Signature of provider (item 21) is required. IV.AUTHORIZATION 1. Items will be completed by Wyoming Medicaid when prior authorization is approved or denied **NOTE: THERE MAY BE ADDITIONAL INSTRUCTIONS IN THE COMMENT SECTION IMPORTANT NOTE: The assigned PA # MUST appear on the claim form for proper reimbursement. On the HCFA-1500 it is required in field 23. On the UB-92 the PA number is required in field 63. REMINDERS Effective November 1, 1993, all Prior Authorization (PA) requests should be sent directly to the Consultec office. - Prior authorization of services and supplies MUST be obtained before services are rendered - If verbal prior authorization is granted in an emergency, a written request MUST be submitted before the claim can be paid. - PA requests may also be faxed to Consultec ( ). Failure to request the prior authorization prior to the rendering of services will result in denial of the service. Submit the prior authorization form to: Consultec, Inc. P. O. Box 667 Cheyenne, WY Verbal authorizations may be obtained by phoning Consultec at

25 Instruction for Completion of the Prior Authorization Form Item Number Title Action 1 Date of Birth Enter MMDDYY of recipient's date of birth. 2 Sex Enter recipient's sex. 3 Age Enter recipient's age. 4 Medicaid Identification Number Enter the recipient's ten-digit Wyoming Medicaid ID number. 5 Patient's Name Enter last name, first name, and middle initial exactly as it appears on the Wyoming Medicaid ID Card. 6 Patient's Address Enter the street address, including P.O. Box and apartment number, where recipient resides. 7 City, State, Zip Code Enter the city, state, and zip code at which the recipient resides. 8 Phone Number Enter the telephone number of the recipient. 9 Provider Number Enter nine-digit unique Wyoming Medicaid provider number. 10 Provider Telephone Number Enter area code and telephone number of provider, including extension, if appropriate. 11 Provider Name and Address Enter provider name as it appears on the provider enrollment form, with either street address or P.O. box, city, state, and full zip code. 12 Date(s) of Service Enter the date(s) of service this prior authorization will cover. 13 Proposed Services Enter narrative description of service(s) being prior authorized. 14 Procedure/NDC/Re venue Codes Codes for the service(s) being prior authorized should reflect narrative description. 15 Units Enter number of each service being prior authorized. 16 Estimated Cost Enter dollar amount times the units for each service being prior authorized. 17 State Use Only To be completed by the State evaluator. 18 Summary of History Please give as much information as possible supporting the need for the service(s) requested. You may attach additional sheets if necessary. 4-25

26 Item Number Title Action 19 Out-of-State Justification 20 Verbal Authorization Under "Wyoming Referring Physician," enter the name or the provider number of the Wyoming physician referring the recipient for out-of-state services. Under "Phone Number," enter the phone number of the referring Wyoming physician. The justification of out-of-state services can be brief and can relate to number 19. Enter the name verbal authorization was given by, the date authorization was given, and the PA number. 21 Signature/Date The form should be signed by the entity requesting prior authorization of services, with the date of the signature State Use Only These items will be completed by Wyoming Medicaid when prior authorization is approved. Send Prior Authorization Form to: Consultec P.O. Box 667 Cheyenne, WY

27 How to Bill for Newborns If the newborn's number is not available, submit an HCFA-1500 claim for the newborn recipient using the mother's Recipient ID number. Enter the mother's number in Box 1a on the HCFA claim form. Consultec will verify the newborn's number by referencing the mother's Recipient ID number and insert the newborn's number in this field on the claim form. Write "Newborn Claim" on the face of the claim form to alert Consultec to process these claims differently. Send your newborn claims to: Consultec Newborn Claims P.O. Box 547 Cheyenne, WY Required Attachments and How to Complete When providing Medicaid services, certain procedures or conditions require that other forms be used in addition to the claim form when billing for reimbursement. This section describes each required form and tells you how to prepare it for submission. Attachments When billing for services, which require attachments, the attachments must be submitted with the HCFA-1500 claim form. Examples of attachments include: Prior Authorization Request Consent Forms Statement of Medical Necessity 4-27

28 Sterilization Consent Form Federal regulations require that recipients give written consent prior to sterilization for Medicaid to reimburse you for these procedures. Refer to Chapter Nine for details. The Sterilization Consent Form is obtained from Consultec. (See "Ordering Claim Forms" in Chapter Six.) The Sterilization Consent Form must be attached to all claims for Medicaid reimbursement of sterilization related procedures as mandated by the Federal Government. All sterilization claims must be processed according to the following Federal guidelines: GUIDELINES The waiting period between consent and sterilization must not exceed 180 days and must be at least 30 days, except in cases of premature delivery and emergency abdominal surgery. The day the recipient signs the consent form and the surgical dates are not included in the 30-day requirement. A recipient signs the consent form on July 1. To determine when the waiting period is completed, count 30 days beginning on July 2. The last day of the waiting period would be July 31; therefore, surgery may be performed on August 1. In the event of premature delivery, the consent form must be completed and signed by the recipient at least 72 hours prior to the sterilization, and at least 30 days prior to the expected date of delivery. In the event of emergency abdominal surgery, the recipient must complete and sign the consent form at least 72 hours prior to sterilization. The consent form SUPPLIED BY THE SURGEON must be attached to every claim for sterilization-related procedures; i.e., ambulatory surgical center clinic, physician, anesthesiologist, inpatient or outpatient hospital. Any claim for a sterilization-related procedure which does not have a signed, valid consent form will be denied. All blanks on the consent form must be completed with the requested information. The consent form must be signed and dated by the recipient, the interpreter (if one is necessary), the person who obtained the consent, and the physician who will perform the sterilization. The physician statement on the consent form must be signed and dated by the physician who will perform the sterilization on the date of the sterilization or after the sterilization procedure was performed. The date on the sterilization claim form must be identical to the date and type of operation given in the physician's statement. 4-28

29 Exhibit 4.3 Sterilization Consent Form STERILIZATION CONSENT FORM NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. CONSENT TO STERILIZATION I have asked for and received information about sterilization from. When I first asked for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible. I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN. I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized. I understand that I will be sterilized by an operation known as a. The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs. I am at least 21 years or age and was born on. Month Day Year I,, hereby consent of my own free will to be sterilized by (doctor) by a method called. My consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed. I have received a copy of this form. Date: Signature Month Day Year You are requested to supply the following information, but it is not required: Race and ethnicity designation (please check) American Indian or Alaska Native Black (not of Hispanic origin) Asian or Pacific Islander Hispanic White (not of Hispanic origin) INTERPRETER'S STATEMENT If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in language and explained its contents to him/her. To the best of my knowledge and belief he/she understood this explanation. STATEMENT OF PERSON OBTAINING CONSENT Before signed the consent form, I name of individual explained to him/her the nature of the sterilization operation, the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure. Signature of person obtaining consent Date Facility Address PHYSICIAN'S STATEMENT Shortly before I performed a sterilization operation upon on, Name of individual to be sterilized Date of sterilization operation I explained to him/her the nature of the sterilization operation, specify type of operation the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure. (Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph that is not used.) (1) At least thirty days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed. (2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable box and fill in information requested): Premature delivery Individual's expected date of delivery: (Date) Emergency abdominal surgery: (Describe circumstances): Signature of Interpreter Date Physician Date HCF

30 Use the following instructions to complete the Sterilization Consent Form. PART 1 CONSENT TO STERILIZATION 1 Enter the name of the physician or the name of the clinic from which the recipient received sterilization information. 2 Enter the type of operation. 3 Enter the recipient's date of birth (MM/DD/YY). 4 Enter the recipient's name. 5 Enter the name of the physician performing the surgery. 6 Enter the type of operation. 7 The recipient to be sterilized signs name here. 8 The same recipient in #7 dates signature here. 9 Check one box appropriate for recipient. This item is requested but NOT required. PART 2 INTERPRETER'S STATEMENT 10 Enter the name of the language the information was translated to. 11 Interpreter signs name here. 12 Interpreter dates signature here. PART 3 13 Enter recipient's name. 14 Enter the type of operation. STATEMENT OF PERSON OBTAINING CONSENT 15 The person obtaining consent from the recipient signs here. 16 The person obtaining consent from the recipient dates signature here. 17 The person obtaining consent from the recipient enters the name of the facility where the person obtaining consent is employed. 18 The person obtaining consent from the recipient enters the complete address of facility in #17 above. Address must be complete, including state and zip code. 4-30

31 PART 4 PHYSICIAN'S STATEMENT 19 Enter the recipient's name. 20 Enter the date of sterilization operation. 21 Enter the type of operation. 22 Check applicable box: If premature delivery is checked, you must write in the expected date of delivery here. If emergency abdominal surgery is checked, describe circumstances here. 23 Physician who performs the sterilization signs here. 24 The physician's signature must be dated. 4-31

32 Exhibit 4.4 Sample Hysterectomy Consent Form HYSTERECTOMY ACKNOWLEDGMENT OF CONSENT COMPLETE PART A IF CONSENT IS OBTAINED PRIOR TO SURGERY It is anticipated that will perform a hysterectomy on me. I understand that there are medical indications for this surgery. It has been explained to me and I understand that this hysterectomy will render me permanently incapable of bearing children. Diagnosis: Signature of Patient: Date: Signature of Person Explaining Hysterectomy: Date: COMPLETE PART B IF CONSENT IS OBTAINED AFTER SURGERY On (Date) (Physician) performed a hysterectomy on me. I understand that there were medical indications for this surgery. Prior to the procedure the doctor again explained to me that this surgery would render me permanently incapable of bearing children. Diagnosis: Signature of Patient: Date: Signature of Person Explaining Hysterectomy: Date: COMPLETE PART C IF NO CONSENT IS OBTAINED Diagnosis: Check which is applicable: [ ] Other reason for sterility [ ] Previous tubal Date: [ ] Emergency situation (describe) Physician Signature Date HCF

33 Hysterectomy Acknowledgment of Consent A copy of the completed Hysterectomy Acknowledgment of Consent form must be attached to each HCFA-1500 claim form when billing for hysterectomy related services before Wyoming Medicaid will consider the claim for payment. The surgeon is required to supply other billing providers (hospital, assistant surgeon, anesthesiologist) with a copy of the completed Hysterectomy Acknowledgment of Consent form. Use the following instructions to complete the Hysterectomy Consent Form. PART A CONSENT OBTAINED PRIOR TO SURGERY 1 Enter the name of the physician performing the surgery. 2 Enter the narrative diagnosis for the recipient's condition. 3 The recipient receiving the surgery signs here and dates. 4 The person explaining the surgery signs here and dates. PART B CONSENT OBTAINED AFTER SURGERY 5 Enter the date and the physician s name who performed the hysterectomy. 6 Enter the narrative diagnosis for the recipient's condition. 7 The recipient receiving the surgery signs here and dates. 8 The person explaining the surgery signs here and dates. PART C NO CONSENT IS OBTAINED 9 Enter the narrative diagnosis for the recipient's condition. 10 Check applicable box: If other reason for sterility is checked, you must write what was done. If previous tubal is checked, you must enter the date of the tubal. If emergency situation is checked, you must enter the description. 11 The physician who performed the hysterectomy signs here and dates. 4-33

34 Abortion Certification The Wyoming Medicaid Abortion Certification form must accompany all claims for abortion related services. This requirement includes, but is not limited to, claims from the attending physician, assistant surgeon, anesthesiologist, and hospital. Refer to a sample of the form and instructions for completing the form on subsequent pages in this chapter and further information in Chapter Nine. Use the following instructions to complete the Abortion Certification Form. 1 Enter the name of the attending physician or surgeon. 2 Check the option (1, 2, or 3) that is appropriate for the recipient. 3 You must enter the name of the recipient receiving the surgery and their address. 4 The attending physician or surgeon signs here. 5 Enter the performing physician's address. 4-34

35 Exhibit 4.5 Sample Abortion Certification Form ABORTION CERTIFICATION FORM I, Doctor, certify that: (1) my patient suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place her in danger of death unless an abortion is performed; or (2) this pregnancy is a result of sexual assault as defined in W.S which was reported to a law enforcement agency within 5 days after the assault or within 5 days after the time the victim was capable of reporting the assault; or (3) the pregnancy is the result of incest. Patient Name: Address: Physician Signature: Address: 4-35

36 Medical Necessity Documentation of Medical Necessity Wyoming Medicaid covers certain procedures only when medical necessity has been determined and documented. A Documentation of Medical Necessity form must be submitted as an attachment to the claim. Wyoming Medicaid will not reimburse for services requiring a Documentation of Medical Necessity form if the form is not attached at the time the claim is submitted to Consultec for payment. 4-36

37 Exhibit 4.6 CERTIFICATE OF MEDICAL NECESSITY I. PATIENT INFORMATION II. PROVIDER INFORMATION 1. DATE OF BIRTH 2. SEX 3. AGE 4. MEDICAID IDENTIFICATION NO. 9. PROVIDER NUMBER 10. PHONE NO. (INCLUDING AREA CODE) 5. PATIENT NAME (LAST, FIRST, MI) 11. PROVIDER NAME AND ADDRESS 6. STREET ADDRESS 7. CITY, STATE, ZIP CODE 8. PHONE NUMBER III. SERVICE INFORMATION 12. SUMMARY OF HISTORY (PHYSICAL EXAMINATION, LABORATORY, X-RAY STUDIES, PRESCRIPTIONS AND OTHER APPLICABLE DOCUMENTATION MUST BE SUPPLIED IN SUFFICIENT DETAIL TO SATISFY THE MEDICAL NECESSITY FOR THE PRESCRIBED SERVICE. ADDITIONAL DOCUMENTATION MAY BE ATTACHED WHEN NECESSARY.) 13. IF THIS SERVICE WAS PERFORMED OUT-OF-STATE PLEASE PROVIDE A BRIEF JUSTIFICATION STATEMENT 14. TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS TRUE, ACCURATE AND COMPLETE AND THE REQUESTED SERVICES ARE MEDICALLY INDICATED AND NECESSARY TO THE HEALTH OF THE PATIENT. SIGNATURE OF PHYSICIAN OR PROVIDER IV. APPROVAL (FOR AGENCY USE ONLY) 15. COMMENTS/EXPLANATION DATE APPROVED: YES NO DATE SIGNATURE NOTE: APPROVAL DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO PATIENT'S ELIGIBILITY AND WYOMING BENEFIT LIMITATIONS. BE SURE THE IDENTIFICATION CARD IS CURRENT BEFORE RENDERING SERVICE. HCF

38 Instructions for Completion of the Documentation of Medical Necessity Form Item Description Action 1 Date of Birth Enter MMDDYY of the recipient's date of birth. 2 Sex Enter the recipient's sex. 3 Age Enter the recipient's age. 4 Medicaid Identification Number Enter the ten-digit Wyoming Medicaid recipient identification number. 5 Patient Name Enter the recipient's last name, first name, and middle initial exactly as it appears on the Wyoming Medicaid Identification Card. 6 Street Address Enter the recipient's complete street address, including apartment number or post office box. 7 City, State, Zip Code Enter the recipient's city, state, and zip code relating to the address information in item 6. 8 Phone Number Enter the recipient's telephone number. 9 Provider Number Enter the nine-digit Wyoming Medicaid provider number. 10 Phone Number Enter the provider's telephone number. 11 Provider Name and Address 12 Summary of History 13 Out-of-State Justification Enter the billing provider's complete name and address as it appears on the Provider Enrollment Form. Include all of the supporting documentation for the services requiring a Documentation of Medical Necessity. Additional sheets may be attached if necessary. A narrative statement justifying out-of-state service, if applicable. 14 Signature/Date The signature of the provider or physician submitting the medical necessity and the date the Documentation of Medical Necessity was signed must be present. For Use by Wyoming Medicaid Wyoming Medicaid employees will approve or deny these services based on the information supplied. 4-38

39 Sample Claims and Forms Exhibit 4.7 Completed HCFA-1500 Claim Forms Exhibit 4.7(a) Completed HCFA-1500 for Anesthesia Services SECTION INTENTIONALLY LEFT BLANK 4-39

40 Exhibit 4.7(b) Completed HCFA-1500 for Ambulance Services SECTION INTENTIONALLY LEFT BLANK 4-40

41 Exhibit 4.7(c) Completed HCFA-1500 for Physician Services SECTION INTENTIONALLY LEFT BLANK 4-41

42 Exhibit 4.7(d) Completed HCFA-1500 for Durable Medical Equipment Services SECTION INTENTIONALLY LEFT BLANK 4-42

43 Exhibit 4.8 Sample Sterilization Consent Form SECTION INTENTIONALLY LEFT BLANK 4-43

44 Exhibit 4.9 Sample Hysterectomy Acknowledgment of Consent Form HYSTERECTOMY ACKNOWLEDGMENT OF CONSENT COMPLETE PART A IF CONSENT IS OBTAINED PRIOR TO SURGERY It is anticipated that will perform a hysterectomy on me. I understand that there are medical indications for this surgery. It has been explained to me and I understand that this hysterectomy will render me permanently incapable of bearing children. Diagnosis: Signature of Patient: Date: Signature of Person Explaining Hysterectomy: Date: COMPLETE PART B IF CONSENT IS OBTAINED AFTER SURGERY On (Date) (Physician) performed a hysterectomy on me. I understand that there were medical indications for this surgery. Prior to the procedure the doctor again explained to me that this surgery would render me permanently incapable of bearing children. Diagnosis: Signature of Patient: Date: Signature of Person Explaining Hysterectomy: Date: COMPLETE PART C IF NO CONSENT IS OBTAINED Diagnosis: Check which is applicable: [ ] Other reason for sterility [ ] Previous tubal Date: [ ] Emergency situation (describe) Physician Signature Date HCF