Medical Equipment/ Manual Pricing Guidelines. HP Provider Relations October 2012

Transcription

1 Medical Equipment/ Manual Pricing Guidelines HP Provider Relations October 2012

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

3 Objectives Following this session, providers will: Understand medical equipment guidelines Understand guidelines for billing the member Be familiar with spend-down Understand the claim attachment process Be familiar with the Prior Authorization form and prior authorization inquiry process Understand the top denials and resolutions 3

4 Describe Provider Code Sets

5 Provider Code Sets The IHCP established provider code sets for DME (Durable Medical Equipment), specialty 250, and HME (Home Medical Equipment) specialty 251 Enrolling in the 251 specialty does not cover services in the 250 specialty, and enrolling in the 250 specialty does not cover services in the 251 specialty Providers must ensure that they are enrolled as the correct provider type and specialty Type and specialty can be verified using the Provider Profile option on the Web interchange 5

6 Viewing Provider Code Sets 6

7 Viewing Provider Code Sets 7

8 Viewing Provider Code Sets 8

9 Viewing Provider Code Sets 9

10 Viewing Provider Code Sets 10

11 Viewing Provider Code Sets 11

12 Explain Fee Schedule

13 Fee Schedule Access the fee schedule to determine: Reimbursement rates Pricing effective dates Prior authorization requirements Program coverage Applies to Traditional Fee-for-Service Medicaid and Care Select 13

14 Accessing the Fee Schedule 14

15 Accessing the Fee Schedule 15

16 Accessing the Fee Schedule 16

17 Accessing the Fee Schedule 17

18 Accessing the Fee Schedule 18

19 Accessing the Fee Schedule 19

20 Understanding Fee Schedule Instructions 20

21 Instruct Manual Pricing

22 Manufacturer s Suggested Retail Price (MSRP) For date of service (DOS) May 18, 2012, and after: Claims will be paid at 75% of MSRP If an item does not have an MSRP (i.e. custom items), claims will be paid at 120% of cost. MSRP approved documentation: Manufacturer s invoice showing MSRP, suggested retail price, or retail price Quote from the manufacturer showing the MSRP, suggested retail price, or retail price Manufacturer s catalog page showing the MSRP, suggested retail price, or retail price (the publication date of the catalog must clearly show on the documentation) MSRP pricing from the manufacturer s website (the manufacturer s web address must be visible on printed documentation from it s website) MSRP documentation must include: Manufacturer s name clearly printed on the header of the documentation MSRP pricing (for example, MSRP/Retail) typed from manufacturer (no handwritten notes/pricing will be accepted) Date must be within one year of date of service 22

23 Approved MSRP Documentation Invoice Manufactures Name Date descriptions Manufacturer s Suggested Retail Price 23

24 Approved MSRP Documentation Quote 24

25 Approved MSRP Documentation-Catalog Page 25 Footer Goes Here

26 Approved MSRP Documentation Website 26

27 Manufacturer s Suggested Retail Price (MSRP) Date must be within one year of the date of service MSRP approved documentation: Manufacturer s invoice showing MSRP, suggested retail price, or retail price Quote from the manufacturer showing the MSRP, suggested retail price, or retail price Manufacturer s catalog page showing the MSRP, suggested retail price, or retail price (the publication date of the catalog must clearly show on the documentation) MSRP pricing from the manufacturer s website (the manufacturer s web address must be visible on printed documentation from it s website) 27

28 Invoice Requirements Manufacturer's cost invoice For dates of service July 1, May 18, 2012 Both the MSRP and cost invoice are required. The product on the cost invoice must match the product identified on the MSRP Invoice date must be within one year of the date of service Invoice should include: Manufacturer s name Provider s name Purchase date Product description and Healthcare Common Procedure Coding System (HCPCS) code Quantity purchased Cost per item 28

29 Invoice Requirements Manufacturer's cost invoice DME SUPPLY MANUFACTURING INVOICE 1 SUPPLY ROAD 12/28/2011 ANYWHERE, INDIANA BILL TO: DME/HME SUPPLIES 200 STATE STREET ANYWHERE, INDIANA ITEM NUMBER/DESCRIPTION U/M QTY PRICE TOTAL ELECTRONIC BOTTOM HOUSING/JOYSTICK EA HCPCS:E1356 **********COST INVOICE************* 29

30 DME Items in Kits DME items that are not prepackaged from the manufacturer must include: A list of ordered items included in the kit The exact description of the items from the manufacturer s invoice How many items are in each box or case How many items were used in each kit Item Description Number in case, box etc. on manufacturer s invoice CAP-MALE LUER LOCK 2000 IN CASE SET ADMIN RATE FLOW 83 IN 20 DP 15 MIC Number included in kit 5 ITEMS IN KIT 50 IN CASE 4 ITEMS IN KIT 30

31 Invoice Requirements Manufacturer s Cost Invoice DME SUPPLY MANUFACTURING INVOICE 1 SUPPLY ROAD 12/20/2011 ANYWHERE, INDIANA BILL TO: DME/HME SUPPLIES 200 STATE STREET ANYWHERE, INDIANA ITEM NUMBER/DESCRIPTION U/M QTY PRICE TOTAL EXTRA SET RT ANGLE HCPCS: B9998 5/BOX sets in a box - ordered 1 box 59.90/5 = each **********COST INVOICE************* 31

32 Describe Claim Attachments

33 Claim Attachment Feature 33

34 Claim Attachment Feature 34

35 Claim Attachment Feature Attachment control number (ACN) Unique number is assigned by provider ACN is claim- and document-specific Each ACN can only be used one time Select the appropriate report type Report Type describes the document being sent Transmission Code defaults to BM (by mail) Electronic and ed attachments are not accepted 35

36 Claim Attachment Cover Sheet 36

37 Claim Attachment Cover Sheet Available on IHCP home page, under Forms Complete cover sheet for each claim Include provider information Provide member ID List each ACN pertaining to specific attachment Indicate the number of pages of documentation submitted per attachment (not including the cover sheet) Write ACN # and the assigned ACN on each page of documentation corresponding to that number Mail cover sheet and supporting documentation to the address at the bottom of the cover sheet HP, P.O. Box 7259, Indianapolis, IN,

38 Identify Medical Equipment Guidelines

39 Date of Service for Billing The date of service is the date the equipment is delivered, not ordered Date of service for items that are mailed is the date the item is shipped For the Indiana Health Coverage Programs (IHCP) to reimburse for medical equipment, the member must be eligible on the date of service, which is the date of delivery 39

40 Rolling 12-Month Period Is not: Based on a 12-month calendar year Based on a fiscal year Renewable on January 1 of each year Is: Based on the first date that services are rendered by a particular provider Renewable one unit at a time beginning 365 days after the date that services are rendered by a particular provider 40

41 Capped Rental Certain procedure codes are limited to 15 months of continuous rental The IHCP evaluates requests from providers for approval of capped rental items In long-term need situations, a decision may be made to classify the item as purchase instead of rental Continuous rental is defined as rental without interruption for a period of more than 60 days A change in provider does not cause an interruption in the rental period The provider must service the item at no cost to the IHCP during the rental period Once the equipment is considered purchased, any nonwarranty repairs are billable A complete list of procedure codes for capped rental can be found in the Indiana Health Coverage Programs Provider Manual, Chapter 8, Section 4 41

42 Capped Rental The IHCP pays claims until the number of rental payments made reaches the capped rental number of 15 months When the 15-month rental period has been exhausted, the DME/home medical equipment (HME) is considered purchased and becomes the property of the Office of Medicaid Policy and Planning (OMPP) Providers should base their decisions to rent or purchase DME or HME on the least expensive option available for the anticipated period of need 42

43 Capped Rental Medicare capped rental policy for DME The policy states that the capped rental period is 13 months After 13 months, the member owns the DME Medicare will pay for reasonable and necessary maintenance and service of the DME item At this time, Medical Policy has not been directed to make changes to the IHCP s capped rental policy 43

44 Repair and Replacement Repair of purchased equipment may require prior authorization based on the HCPCS codes The IHCP does not pay for repair of equipment still under warranty The IHCP does not authorize payment for repair necessitated by member misuse or abuse, whether intentional or unintentional The rental provider is responsible for repairs to rental equipment 44

45 Repair and Replacement The IHCP does not cover payment for maintenance charges of properly functioning equipment The IHCP does not authorize replacement of medical equipment more than once every five years per member More frequent replacement is allowed only if there is a change in the member s medical needs that is documented in writing and significant enough to warrant a change in equipment; such requests require PA A long-term care (LTC) facility s per diem rate includes repair costs for equipment 45

46 Mail Order Incontinence, Ostomy, and Colostomy Supplies Contracted vendors Effective February 01, 2012, the OMPP contracted with two vendors to provide incontinence, ostomy, and urological supplies to fee-forservice (FFS) members All FFS members will be required to obtain incontinence, ostomy, and urological supplies through mail order from one of these contracted providers The two contracted vendors are: Binson s Home Health Care Center binsons.com J & B Medical jandbmedical.com 46

47 Mail Order Incontinence, Ostomy, and Colostomy Supplies Members must obtain supplies via mail order The contracted vendor may make other arrangements in emergency situations A full listing of codes affected by this change is available in the IHCP Provider Manual, Chapter 6, Section 5 The annual maximum allowable reimbursement is $1,950 per member per rolling 12-month period The contracted vendor service applies to the Fee-for-Service and Care Select programs Only paid crossovers and TPL claims are excluded from the program If Medicare or the TPL denies the claim, the services are limited to the two contracted vendors 47

48 Mail Order Incontinence, Ostomy, and Colostomy Supplies The following programs and claim types are not affected by the contract: 590 Program Medical Review Team (MRT) Pre-Admission Screening Resident Review (PASRR) Long Term Care (LTC) Waiver Risk-based managed care (RBMC) members are excluded Supplies for these members are billed to the appropriate managed care entity (MCE) 48

49 Changes to the Preferred Diabetic Supply List Effective for claims with dates of service on or after January 1, 2011, all Indiana Medicaid and Healthy Indiana Plan members using a blood glucose monitor were required to convert to one of the preferred blood glucose monitors and corresponding test strips Preferred Diabetic Supply List Blood glucose monitor Freestyle Lite System Kit Freestyle Freedom Lite System Kit Precision Xtra Meter Accu-chek Aviva Care Kit Corresponding test strip Freestyle Lite Test Strips Freestyle Lite Test Strips Precision Xtra Test Strips Accu-chek Aviva 49

50 Preferred Diabetic Supply List Billing Effective for claims with dates of service on or after January 1, 2011: Professional claims, including paper CMS-1500, electronic 837P, and Medicare crossover claims for blood glucose monitors and diabetic test strips, must be submitted to the fee-for-service (FFS) medical benefit for all Indiana Medicaid and Healthy Indiana Plan members The modifiers NU (indicating a new product) and RR (indicating a rental product) are no longer used Claims with a date of service of January 1, 2011, and after, which contain either of these modifiers, are denied For claims with dates of service prior to January 1, 2011, the NU or RR modifier is still required for claims payment 50

51 Preferred Diabetic Supply List Billing Effective for claims with dates of service on or after January 1, 2011: Claims for the following procedure codes require the National Drug Code (NDC) or NDC and modifier, depending on the vendor of the product being dispensed: E0607 Home blood glucose monitor A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips Claims billed for an NDC included on the Preferred Diabetic Supply List (PDSL) do not require the addition of modifier U1 If modifier U1 is included with a preferred blood glucose monitor or diabetic test strip NDC, the claim will be denied for edit 4300 Invalid NDC-to-procedure code combination Claims billed for a blood glucose monitor or diabetic test strip not listed on the PDSL require the addition of modifier U1, along with the NDC and appropriate procedure code Claims billed for an NDC not on the PDSL are denied with edit 4300 Invalid NDC-toprocedure code combination when modifier U1 is not included 51

52 Preferred Diabetic Supply List Billing Effective for claims with dates of service on or after January 1, 2011: CMS-1500 Form Enter the NDC qualifier of N4 Enter the NDC 11-digit numeric code Enter the drug description Enter the NDC Unit qualifier F2 International Unit GR Gram ML Milliliter UN Unit Enter the NDC Quantity (Administered Amount) in the format Refer to the IHCP Provider Manual, Chapter 8, Section 4 52

53 Learn Billing the Member

54 Billing the Member The following circumstances are the only situations in which an IHCP provider may bill a member: The service rendered is noncovered by the IHCP The member has exceeded the program limitations for a particular service; for example, the services were denied during prior authorization (PA) Before receiving the service, the member must understand that the service is not covered under the IHCP, and the member is responsible for the charges associated with the service 54

55 Billing the Member A signed waiver must be maintained in the member s record that the member voluntarily chose to receive a service that was not covered by the IHCP The waiver should state: Member s name Reason for noncoverage Service requested Estimated charge The waiver must not contain any conditional language; for example, the words if or and 55

56 Billing the Member Medicaid-pending individuals are responsible to pay the provider It is the patient s responsibility to notify the provider of Medicaid approved status within 12 months of the date of service Providers may bill the patient if there is no notification of Medicaid eligibility within this time period Providers may also bill the member when a spend-down is applied to their claim 56

57 Spend-down Member is eligible on the first of the month Providers may not refuse service to a member pending verification of the status of spend-down for the month A provider may bill a member for the dollar amount identified beside ARC 178 on the Remittance Advice (RA) statement The member is not obligated to pay the provider until the member receives the Medicaid Spend-down Summary Notice listing the amount applied to spend-down Notices are sent on the second business day following the end of the month Members cannot be billed for more than their spend-down amount Providers must bill their usual and customary charge to the Indiana Health Coverage Programs (IHCP) 57

58 Spend-down Providers may discharge a member from their care if a member does not adhere to established payment arrangements of outstanding copayments or spend-down Providers cannot be more restrictive with spend-down members than with other patients The first claim processed by the IHCP applies to spend-down, regardless of the date of service within the month The system uses the billed amount to credit spend-down Third-party liability (TPL) amounts are deducted from billed amount prior to crediting spend-down 58

59 Explain Prior Authorization

60 Prior Authorization Prior authorization by telephone, fax, or mail Verify eligibility to determine where to send the PA request ADVANTAGE Health Solutions FFS Prior Authorization Department P.O. Box Indianapolis, IN Fax: ADVANTAGE Health Solutions Care Select Prior Authorization Department P.O. Box Indianapolis, IN Fax: MDwise Care Select Prior Authorization Department P.O. Box Indianapolis, IN Fax: Prior authorization for risk-based managed care recipients should be sent to the appropriate entity 60

61 Prior Authorization Prior authorization by telephone, fax, or mail 61

62 Prior Authorization Prior authorization inquiry Allows the requesting provider to inquire about all nonpharmacy prior authorizations via the web It does not matter if the PA was submitted via paper, telephone, fax, or web The requesting provider and the named service provider may view a PA without the PA number All other providers must have the PA number to view a PA 62

63 Prior Authorization Prior authorization inquiry 63

64 Resolve Denials and Resolutions

65 Denials and Resolutions Denial Edit 0217 NDC Missing Cause: NDC information is missing NDC is not in the proper format Resolution: Resubmit the claim with the NDC Denial Edit 0218 NDC is not in a valid format Cause: Qualifier, unit of measure, or NDC is not in the correct format Resolution: Verify the information submitted is accurate Refer to IHCP Provider Manual, Chapter 8, Section 4 65

66 Denials and Resolutions Denial Edit 0593 Medicare Denied Detail Cause: At least one detail is a Medicare-denied detail At least one detail contains Medicare coordination of benefits (COB) information Resolution: Submit separate claims for Medicare-denied details and Medicare-covered details Denial Edit 3001 Dates of service not on PA master file Cause: No prior authorization in IndianaAIM Resolution: Verify the date of service and procedure code billed are correct on the requested PA Obtain amended/corrected PA if necessary 66

67 Denials and Resolutions Denial Edit 4021 Procedure Code vs. Program Indicator Cause: Procedure code billed is restricted to a specific program Resolution: Verify procedure code is covered for dates of service billed Verify procedure code is covered for the member program via the Fee Schedule Denial Edit 4033 Invalid Procedure Code/Modifier Combination Cause: Modifier used is not compatible with procedure code billed Resolution: Verify modifier is valid and appropriate for procedure code 67

68 Denials and Resolutions Denial Edit 0509 Net Charge Out Of Balance Cause: Claim totals do not balance to the net charge entered on the claim Resolution: TPL claims: The net charge on a paper claim form in field 30 should equal the total charge, field 28, less the TPL paid amount, field 29 Field 22 should be blank Medicare Crossover claims: The total charge, field 28, and the net charge, field 30, should be the same Complete field 22 with paid amount and coinsurance and deductible Note: These claims may be filed on Web interchange 68

69 Denials and Resolutions Denial Edit 2003 Recipient Ineligible on Dates of Service Cause: Member is not eligible for IHCP services being billed Resolution: Verify the claim was sent to the appropriate billing entity Fee-for-Service and Care Select to HP RBMC to the appropriate MCE 69

70 Denials and Resolutions Denial Edit 6000 Manual Pricing Required Cause: Manual pricing is required Resolution: Submit Manual Pricing and MSRP Invoice requirements Date Billed amount per unit (for example, box, case, and so forth) Calories (enteral feeding) Procedure code Member name Member ID number Itemization of repairs Bulk Invoices Illustrate calculations specific to the member 70

71 Find Help Resources Available

72 Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual (Web, CD, or paper) Customer Assistance Local (317) All others Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN Provider field consultant View a current territory map and contact information online at indianamedicaid.com 72

73 Q&A