Vision Services. Traditional Fee-for-Service. Indiana Health Coverage Programs DXC Technology October

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1 Vision Services Traditional Fee-for-Service Indiana Health Coverage Programs DXC Technology October

2 Session Objectives Reference Materials Provider Healthcare Portal Coverage Updates Billing Secondary Claims on Portal Helpful tools Questions 2

3 Reference Materials Reference material, code sets, fee schedules 3

4 Reference Materials Providers can stay abreast of current developments and research issues: Banners and bulletins News and announcements Provider Reference Materials Medical Policy Manual Vision Services provider reference module Code Sets Subscribe to notices Professional Fee Schedule 4

5 5 Reference Materials

6 6 Vision Services Reference Module

Vision Code Sets Vision Services Codes Table 1 Vision Services Code Set for Opticians (Specialty 190) Table 2 Vision Services Code Set for Optometrists (Specialty 180) Table 3 Procedure

7 Vision Code Sets Vision Services Codes Table 1 Vision Services Code Set for Opticians (Specialty 190) Table 2 Vision Services Code Set for Optometrists (Specialty 180) Table 3 Procedure Codes for Eye Exams and Other Ophthalmological Services Limited to One Unit per Member per Day Table 4 ICD-10 Diagnosis Codes for Optometrist Billing of Visual Evoked Potential (VEP) Testing 7

8 8 Professional Fee Schedule

9 Provider Healthcare Portal Portal overview, web-based training, benefit limit details, Written Correspondence, billing members 9

10 Provider Healthcare Portal What can you do in the Provider Healthcare Portal? Submit, copy, edit, void claims Check on status of claims Verify eligibility View, print remittance advices Request prior authorization Provider enrollment and revalidation Secure correspondence And more.. 10

11 11 Provider Healthcare Portal Login Page

12 Provider Healthcare Portal Web-based training 12

Portal Benefit Limits Details Benefit limit details listed in Portal eligibility screen:* 6195 FRAMES INITIAL OR REPAIR/REPLACEMENT 21 YRS OLDER 6196 FRAMES INITIAL/REPLACEMENT MEMBER 21 YRS YOUNGER

13 Portal Benefit Limits Details Benefit limit details listed in Portal eligibility screen:* 6195 FRAMES INITIAL OR REPAIR/REPLACEMENT 21 YRS OLDER 6196 FRAMES INITIAL/REPLACEMENT MEMBER 21 YRS YOUNGER 6271 LENSES INITIAL/REPLACEMENT, MEMBER 21 YRS YOUNGER 6272 LENSES INITIAL REPAIR/REPLACEMENT MEMBER 21 YRS OLDER 6297 ROUTINE VISION EXAM LIMIT TO 1/12 MONTHS AGE ROUTINE VISION EXAM LIMIT 1/24 MONTHS AGE *All benefit limitations the member has already met will display on the eligibility screen. If the limitation does not appear, the member is still eligible to receive that services. (based on fee-for-service claim data only) 13

Benefit Limits Written Correspondence 14 Vision service providers may not have the most current information available about services previously rendered to a member and paid by the IHCP.

14 Benefit Limits Written Correspondence 14 Vision service providers may not have the most current information available about services previously rendered to a member and paid by the IHCP. This situation can result in reduced reimbursement or no reimbursement for rendered services. Providers may submit secure correspondence through the Portal or write to the Written Correspondence Unit to inquire whether particular members have exceeded their service limitations. Providers should allow up to four business days for a response.

15 15 Coverage

$Coverage 16 The IHCP provides reimbursement for routine vision services, subject to the following restrictions: One routine vision care examination and refraction is covered for members 20 years old$

16 Coverage 16 The IHCP provides reimbursement for routine vision services, subject to the following restrictions: One routine vision care examination and refraction is covered for members 20 years old and younger, per rolling 12-month period One routine vision care examination and refraction is covered for members 21 years old and older, per rolling 24-month period If medical necessity dictates more frequent examinations, documentation of such medical necessity must be maintained in the provider s office, and prior authorization must be obtained

$the service falls under the routine or medical benefit 17 If the primary reason for the visit was swelling or mass of the eye, but a routine vision exam and refraction were performed, the exam should$

17 Routine Vision Versus Medical Examinations When a patient is seen for a medical and routine vision service on the same date, the primary reason for the encounter should be used to determine whether the service falls under the routine or medical benefit 17 If the primary reason for the visit was swelling or mass of the eye, but a routine vision exam and refraction were performed, the exam should be coded with the swelling and mass of the eye (medical) diagnosis, and the refraction should be coded with the routine diagnosis

$Coverage: Lenses The prescription of lenses, when required, is included in the procedure code 92015 Determination of refractive state It includes specification of lens type, monofocal, bifocal, lens$

18 Coverage: Lenses The prescription of lenses, when required, is included in the procedure code Determination of refractive state It includes specification of lens type, monofocal, bifocal, lens power, axis, prism, absorptive factor, impact resistance, and other factors The IHCP does not provide coverage for all lenses If a member chooses to upgrade to progressive lenses, transitional lenses, antireflective coating, or tint numbers other than 1 or 2, the basic lens V code can be billed to the IHCP The upgrade portion can be billed to the member only if the member was given an appropriate advance notification (signed waiver) of the noncovered service, and if a separate procedure code for the service exists 18

Coverage: Frames Reimbursement is available for frames, including but not limited to plastic or metal Providers should bill for frames using V2020 Frames,

19 Coverage: Frames Reimbursement is available for frames, including but not limited to plastic or metal Providers should bill for frames using V2020 Frames, purchase Providers who receive payment from the IHCP for frames may not bill the member for any additional cost that is more than the IHCP reimbursement 19

20 Coverage Frames Maximum reimbursement for frames is $20, unless medical necessity requires more expensive frame Medical necessity examples: Special frames to accommodate a facial deformity or anomaly Frames with special modifications, such as a ptosis crutch Allergy to standard frame materials Frames for an infant or child where special-size frames that are unavailable for $20 or less must be prescribed All claims for more expensive frames must be accompanied by documentation supporting medical necessity. Providers must submit a manufacturer s suggested retail price (MSRP) or cost invoice and charges for medically necessary deluxe frames with procedure code V2025. The IHCP reimburses medically necessary deluxe frames at 75% of the MSRP or 120% of the cost invoice. 20

Coverage: Replacement Eyeglasses Members younger than 21 years of age may be eligible for a replacement pair of eyeglasses one year from the date their previous eyeglasses were provided Members 21

21 Coverage: Replacement Eyeglasses Members younger than 21 years of age may be eligible for a replacement pair of eyeglasses one year from the date their previous eyeglasses were provided Members 21 years old and older may be eligible for a replacement pair of eyeglasses five years from the date their previous eyeglasses were provided If a member needs replacement eyeglasses due to loss, theft, or damage beyond repair, prior to the established limitations, use the U8 modifier to bill for the replacement lenses or frames 21

Coverage: Replacement Eyeglasses Replacement frames and lenses are covered only when medical necessity guidelines are met or when necessary due to loss, theft, or damage beyond repair If a member

22 Coverage: Replacement Eyeglasses Replacement frames and lenses are covered only when medical necessity guidelines are met or when necessary due to loss, theft, or damage beyond repair If a member needs replacement eyeglasses due to a change in the prescription, and it is prior to the established limitations, the modifier SC Medically necessary service or supply, must be used to bill for this service. The minimum prescription or change meets the following criteria: A change of 0.75 diopters for members six to 42 years old A change of 0.50 diopters prescription or change for members more than 42 years old An axis change of at least 15 degrees 22

23 23 Updates

Rendering Linkage (EOB 1010) The IHCP has temporarily converted EOB 1010, ARC B7, and Remark N570 to postand-pay status, meaning that the system will allow claims and claim details with the issue to

24 Rendering Linkage (EOB 1010) The IHCP has temporarily converted EOB 1010, ARC B7, and Remark N570 to postand-pay status, meaning that the system will allow claims and claim details with the issue to pay. However, the EOB 1010, ARC B7, and Remark N570 messages will continue to post on the RAs. The post-and-pay status will be in place through December 31, 2017, allowing providers ample time to link rendering providers to the appropriate group locations to support proper claims adjudication. Effective January 1, 2018, the EOB 1010, ARC B7, and Remark N570 will revert to a denial status. 24

Red-and-white claim form requirement Effective January 1, 2018 the IHCP will require the below claim types to be submitting for processing on the appropriate red and white forms.

25 Red-and-white claim form requirement Effective January 1, 2018 the IHCP will require the below claim types to be submitting for processing on the appropriate red and white forms. CMS-1500 (02-12) professional claims UB-04 (CMS-1450) institutional claims The IHCP will no longer accept copied (black and white) claim forms on or after January 1, Claims not received on the red-and-white claim form on or after January 1, 2018, will be returned to the provider. Note: This requirement does not effect the ADA Form 1260 as that form is only available only in black and white. 25

26 Billing Secondary Claims on the Provider Healthcare Portal 26

27 When Is the Primary EOB Required for Other Insurance (TPL)? When the TPL has denied the service as noncovered Exception If the TPL primary EOB contains an acceptable denial ARC code, the secondary windows can be completed with the ARC code, and no EOB is required When TPL has applied the entire amount to the copay, co-insurance, or deductible Services that are NONCOVERED by the primary are NOT filed as a secondary claim. 27 The secondary windows may be completed to bypass the need for the primary EOB attachment for TPL CLAIMS only

28 When Is the Primary EOB for Other Insurance Information (TPL) not Needed? The primary insurance COVERS the service and has PAID on the claim Actual dollars were received 28

29 How to Complete Other Insurance (TPL) on the Provider Healthcare Portal 29

30 30 Step 1: Other Insurance (TPL) at the Header

31 31 Step 2: Other Insurance (TPL) Header

32 32 Step 3: Other Insurance (TPL) Header

33 33 Step 4: Other Insurance (TPL) Header

34 34 Step 1: Other Insurance (TPL) Detail

35 35 Step 2: Other Insurance (TPL) Detail

36 36 Step 3: Other Insurance (TPL) Additional Details

37 37 Step 4: Other Insurance (TPL) Additional Details

38 When Is the Primary Medicare or Medicare Replacement Plan EOB Required? When Medicare or the Medicare Replacement Plan denies the service 38

39 When Is the Primary EOB for Medicare or Medicare Replacement Plans not Needed? The Medicare or Medicare Replacement Plan COVERS the service. Actual dollars were received Entire or partial amount was applied to deductible, co-insurance or copay 39

40 How to Complete Medicare or Medicare Replacement Plans on the Provider Healthcare Portal 40

41 41 Step 1: Other Insurance (TPL) at the Header

42 42 Step 2: Medicare or Medicare Replacement Plan Header

43 43 Step 3: Medicare or Medicare Replacement Plan Header

44 44 Step 4: Medicare or Medicare Replacement Plan Header

45 45 Step 5: Medicare or Medicare Replacement Plan Header

46 46 Step 6: Medicare or Medicare Replacement Plan Header

47 47 Step 1: Medicare or Medicare Replacement Plan at Detail

48 48 Step 2: Medicare or Medicare Replacement Plan at Detail

49 49 Step 3: Medicare or Medicare Replacement Plan at Detail

50 50 Step 4: Medicare or Medicare Replacement Plan at Detail

51 51 Step 5: Medicare or Medicare Replacement Plan at Detail

52 52 Step 6: Medicare or Medicare Replacement Plan at Additional Details

53 53 Step 7: Medicare or Medicare Replacement Plan at Additional Details

54 54 Step 8: Medicare or Medicare Replacement Plan at Additional Details

55 55 Step 9: Medicare or Medicare Replacement Plan at Additional Details

56 56 Step 10: Medicare or Medicare Replacement Plan at Additional Details

57 57 Helpful Tools

58 Helpful Tools IHCP website at indianamedicaid.com IHCP Provider Reference Modules Medical Policy Manual Customer Assistance available 8am-6pm EST Monday Friday IHCP Provider Relations Field Consultants See the Provider Relations Field Consultants page at indianamedicaid.com Secure Correspondence via the Provider Healthcare Portal Written Correspondence DXC Technology Provider Written Correspondence P.O. Box 7263 Indianapolis, In

59 59 Questions Following this session please review your schedule for the next session you are registered to attend

Vision Services. HP Provider Relations October 2012

Vision Services. HP Provider Relations October 2012 Vision Services HP Provider Relations October 2012 Agenda Objectives Common Denials Provider Code Sets Billing Procedures Lenses Frames Benefit Limit Verification Prior Authorization Find Help Q&A CPT