Durable & Home Medical Equipment (DME & HME)

Transcription

1 Durable & Home Medical Equipment (DME & HME) Fee-for-Service Indiana Health Coverage Programs DXC Technology October 2017

2 Session Objectives Reference Materials Provider Healthcare Portal Service Descriptions Manual Pricing Updates Helpful tools Questions 2

3 Reference Materials Reference material, code tables, 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 DME & HME Reference Module Code Tables Subscribe to notices Fee schedules 4

5 5 Reference Materials

6 6 New Look for Subscribers!

7 7

8 8 DME & HME Reference Module

9 9 DME & HME Code Tables

10 10 Procedure Codes Requiring Attachments

11 11 Professional Fee Schedule

12 Provider Healthcare Portal Portal overview, web-based training, benefit limit details, Written Correspondence, billing members 12

13 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.. 13

14 14 Provider Healthcare Portal Login Page

15 15 Provider Healthcare Portal User Access

16 16 Search Payment History

17 Portal Benefit Limits Details Example Benefit limit details listed in Portal eligibility screen:* 6113 DME Limited to $2,000 per Recipient per Calendar year 6114 DME Limited to $5,000 per Recipient per Lifetime 6085 Incontinence supplies limited to $1950/Rolling Year *If the limitation does not appear on the eligibility screen, the service is available (based on fee-for-service claim data only) 17

18 Portal Benefit Limits Details Benefit limits are found on the Eligibility page 18

19 Provider Healthcare Portal Web-based training 19

20 DME, HME, Supplies Provider Type, Description of Services, Classifications 20

21 Provider Type Provider Type 25 Specialty 250 DME Specialty 251 HME Must have HME license Each specialty has it s own code set Revalidation required every 3 years: Application fee & Background check Fingerprinting Refer to > IHCP Provider Type and Specialty Matrix for additional requirements 21

22 Description of Service Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and generally is not useful to a recipient in absence of illness or injury Must be ordered in writing by a physician Written order must be kept on file by physician and rendering provider 22

23 Description of Service Items include but are not limited to the following: Capped rental items Inexpensive or other routinely purchased items Items requiring frequent or substantial servicing Customized items Prosthetic and orthotic devices Oxygen and oxygen equipment 23

24 Capped Rental Items Capped rental items are procedure codes limited to 15 months of continuous rental Continuous rental: rental without interruption for a period of more than 60 days If rental period exceeds 60 days, and the interruption reasons are justified, a new PA request must be submitted to begin a new 15- month rental period Justification could change in medical necessity, hospitalization, or nursing facility stay A change in provider does not cause an interruption in rental period Capped rental items are subject to prior authorization 24

25 Items Requiring Frequent or Substantial Servicing For items requiring frequent or substantial servicing, IHCP reimburses providers for rental payments only, as long as equipment is deemed medically necessary Claims for the purchase of these items are denied Repair of rental items is responsibility of rental provider Table 4 Procedure Codes for Equipment and Supplies Classified by the IHCP as Needing Frequent and Substantial Servicing 25

26 Customized Items Custom equipment: equipment uniquely constructed or substantially modified to meet specific needs of an individual patient, according to description and orders of member s treating physician Due to their unique aspects, these items cannot be grouped with similar items for purposes of payment Suppliers must submit documentation of cost of item, including cost of labor and types of materials used in customizing item Customized items must be billed using HCPCS code E1399 requires PA 26

27 Prosthetic and Orthotic Devices All prosthetic and orthotic devices billed under HCPCS L codes are paid in lump sum amounts and may not be rented Prosthetic and orthotic devices billed with HCPCS L codes Requires PA All PA reviews based upon medical necessity 27

28 Oxygen and Oxygen Equipment IHCP reimburses liquid and gaseous oxygen systems as rental-only items, subject to PA Reimbursement for oxygen contents is included in reimbursement of oxygen system and is not separately reimbursable for rented systems Oxygen contents are separately reimbursable when a third party has purchased an oxygen system, or IHCP or third party has rented or purchased a portable oxygen system Accessories, including but not limited to cannulas, masks, and tubing, are also included in allowance for rented systems and are not separately reimbursable Accessories are separately reimbursable with a purchased system 28

29 29 Manual Pricing

30 Manually Priced Items Reimbursement for many DME services and supplies, including those that are billed with a non-specific HCPCS code with a description such as unspecified, unclassified, or miscellaneous are based on manual pricing Manually priced HCPCS codes are reimbursed at 75% of manufacturer s suggested retail price (MSRP) 30

31 Manually Priced Items Documentation submitted with each claim may be monitored or subject to a post-payment review Manually priced DME, medical supply, and hearing aid procedure codes will continue to be reimbursed at 75% of MSRP Codes without an MSRP will be reimbursed at provider s cost plus 20% 31

32 Manually Priced Items Manufacturer s retail invoice or suggested retail price (MSRP) is required as acceptable documentation: o Manufacturer s invoice showing MSRP, suggested retail price, or retail price o Quote from manufacturer showing MSRP, suggested retail price, or retail price o Manufacturer s catalog page showing MSRP, suggested retail price, or retail price (publication date of catalog must clearly show on documentation) o MSRP pricing from manufacturer s website (manufacturer s web address must be visible on printed documentation from its website) 32

33 Manufacturer s Suggested Retail Price MSRP documentation must include: Manufacturer s name clearly visible on header of documentation MSRP pricing (for example, MSRP/Retail) typed from manufacturer o No handwritten notes or pricing will be accepted Description of item Specific HCPCS code 33

34 Manufacturer s Logo Approved MSRP Documentation Manufacturer s Name Date Descriptions Manufacturer s suggested retail price 34

35 35 Approved MSRP Documentation Quote

36 Approved MSRP Doc. Catalog Page Catalog page must have publication date 36

37 37 Approved MSRP Documentation Website

38 38 Updates

39 DME Codes No Longer Billed with NU Effective April 28, 2017, the IHCP revised billing guidelines for DME codes billed with NU modifier Claims billed with NU will be denied with EOB code 4033-Invalid procedure code modifier combination Refer to banner BR for a list of affected codes (most are Q codes) 39

40 DME & Supplies Covered as Home Health Service Effective May 1, 2017, the IHCP revised coverage policy for home health services For coverage of certain DME & supplies as a home health service, documentation of face-to-face encounter must occur no more than six months before start of service. Examples: Decubitus care equipment Oxygen and related respiratory equipment Monitoring devices Compression devices Refer to bulletin BT for complete list 40

41 Red-and-White Claim Form 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. 41

42 42 Helpful Tools

43 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

44 44 Questions Following this session please review your schedule for the next session you are registered to attend