Wyoming Optometric Association Meeting

Transcription

1 Wyming Optmetric Assciatin Meeting Wyming Medicaid Cvered Services & Billing Requirements January 30, 2015 Presenter: Kilee Thmpsn, Field Representative

2 CMS-1500 Prvider Manual Lcated n the Wyming Medicaid Website Select Prvider Select Prvider Manuals and Bulletins (Navigatin Bar n Left) Select Visin Services within the CMS-1500 Prvider Manual and Bulletins sectin Select CMS-1500 Prvider Manual Review fr New/Updated Infrmatin Imprtant Plicy Changes/Additins sectin CMS-1500 Prvider Bulletins sectin Additinal Links sectin Medicaid and State Healthcare Benefit Plans NDC Crsswalk Carrier Cde List 2

3 CMS-1500 Prvider Manual Chapters 2 9 General Infrmatin Cntains general Wyming Medicaid Plicy that relates t all prviders that bill with the CMS-1500 Claim Frm r submit an 837P claims transactin Chapter 2 Getting Help When Yu Need It Cntains phne numbers and websites Chapter 3 Prvider Respnsibilities Enrllment When t bill a client When NOT t bill a client Recrd keeping requirements 3

4 CMS-1500 Prvider Manual General Infrmatin Chapters 2 9 (cntinued) Chapter 4 Utilizatin Review Review f claims and state/fiscal agent access t recrds Fraud and abuse, and hw t reprt Chapter 5 Client Eligibility Types f eligibility Imprtance f client identificatin Eligibility verificatin 4

5 CMS-1500 Prvider Manual General Infrmatin Chapters 2 9 (cntinued) Chapter 6 Cmmn Billing Infrmatin Basic claim infrmatin Cmpleting the claim frm & examples Cap limits C-payments Prir authrizatin Electrnic claims with attachments Remittance Advices Adjusting claims Timely filing Failure t ntify prviders f eligibility 5

6 CMS-1500 Prvider Manual General Infrmatin Chapters 2 9 (cntinued) Chapter 7 Third Party Liability Dealing with ther insurance Chapter 8 Electrnic Data Interchange (EDI) Wyming Medicaid electrnic services Registering fr the Secured Prvider Web Prtal Chapter 9 Wyming Specific HIPAA 5010 Electrnic Specificatins Wyming Medicaid specific electrnic billing and transactin requirements 6

7 CMS-1500 Prvider Manual Cvered Services Chapter 10 Cvered Services Sectin Visin Services Cvered services and billing requirements specific t visin services Cvered Services fr clients 21 years f age and lder Cvered Services fr clients under the age f 21 Examinatins Eyeglasses High Index Aspheric Plicy Cntact Lenses Visin Therapy Training Aids 7

8 Wyming Medicaid Visin Services Wh Can Prvide Services A licensed Ophthalmlgist 207W00000X A licensed Optmetrist 152W00000X Optician 156FX1800X Reminder: Wyming Medicaid Prvider Re- Enrllment Must be Cmpleted by December 31,

9 Cvered Visin Services 21 and Older Eye Examinatin Cdes: 92002, 92004, 92012, and Treatment f eye disease r eye injury nly Based n apprpriate ICD-9 diagnsis cdes Cntacts and glasses are nt cvered Payment f deductible and/r cinsurance due n Medicare crssver claims fr pst-surgical cntact lenses and/r eyeglasses 9

10 Cvered Visin Services 20 and Yunger Eye Examinatin Cdes: 92002, 92004, 92012, and Medically Necessary Ophthalmlgic Cdes: Eyeglasses 10 Lenses Single visin, bifcal, r trifcal lenses are cvered Ophthalmlgist r ptmetrist must deem medically necessary and physician recrds must reflect medical necessity Cdes: V2700-V2799 require prir authrizatin (PA) Cdes: V2715 and V2784 d nt require PA Plycarbnate lenses (V2784), includes scratch resistant cating, must be billed as an add-n t a standard C-39 lens

11 Cvered Visin Services 20 and Yunger (cntinued) High Index Aspheric Lenses Cdes: V2410, V2430, V2499 Cvered when medically necessary and meet the guidelines Can be used when the pwer in the highest meridian is (minus) 6.00 dipters r mre Can be used fr plus prescriptins when the pwer in the highest meridian is + (plus) 4.00 dipters r mre Lenses shuld be rdered in pairs when ne side is aspheric r high index, then the matching lens shuld als be aspheric r high index even if it desn t meet the threshld 11

12 Cvered Visin Services 20 and Yunger (cntinued) Frames 12 Cdes: V2020-V2499 One set f frames cvered per 365 days Eligibility Prvide client ID, date f birth, and date f service Verify eligibility fr date f service and date f delivery if they will be in separate mnths Exceptins Repair r replace frames if warranty available If n warranty, it will be the client s respnsibility Replacement f lenses within 365 days must be due t medical necessity Must use existing frames

13 Cvered Visin Services 20 and Yunger (cntinued) Medicaid allws up t $76 fr standard frames N Balance Billing If the client wants frames that cst mre than $76, tw ptins exist: Accept $76 as payment in full frm Medicaid fr the frames client pays nthing Client pays the full price and the frames are NOT billed t Medicaid agreement in writing must be placed in the client s file Client may cntract t pay fr ptinal add-n services (tints, catings, etc.) Obtain agreement in writing specific t additins client is agreeing t pay fr 13

14 Visin Cvered Services 20 and Yunger (cntinued) Cntact Lenses Cdes: V2500-V2599 require PA Cvered fr crrectin f pathlgical cnditins when useful visin cannt be btained with regular lenses. PA dcumentatin prvided must supprt medical necessity and address why the client s visin cannt be crrected with eyeglasses. 14

15 Visin Therapy - Cvered Services Wh s Eligible Clients under the age f 21 Clients 21 and ver n the Acquired Brain Injury Waiver (ABIW) Plan, Cmprehensive Adult Waiver (COAW) Plan, and Supprts Adult Waiver (SUAW) Plan Prcedure Cdes Cde: visin therapy Des nt require PA Cde: therapy training aids Submit claims with therapy training aid invice and dcumentatin f medical necessity 15

16 Visin Therapy-Limitatins Cap Limits 32 visin therapy visits per 365 days Medical necessity is required fr services beynd the allwed 32 sessins Diagnsis Cdes Services are cvered fr specific diagnsis cdes (see fllwing charts) If a diagnsis cde is nt cvered, an appeal may be submitted Appeals must be submitted in writing t Prvider Relatins asking that the diagnsis cde be cvered Appeals will be reviewed by the Divisin f Healthcare Financing and if apprved, claims can be submitted fr payment 16

17 Wyming Medicaid Visin Therapy Cvered Diagnsis Cdes Visin Therapy Diagnsis Cdes Amblypia Strabismic amblypia Deprivatin amblypia Refractive amblypia Strabismum (Cncmitant) Mncular estrpia Alternating estrpia Mncular extrpia Alternating extrpia Intermittent estrpia, mncular Intermittent estrpia, alternating Intermittent extrpia, mncular Intermittent extrpia, alternating Accmmdative cmpnent in estrpia 17

18 Wyming Medicaid Visin Therapy Cvered Diagnsis Cdes (cntinued) Visin Therapy Cding Nn-strabismic disrder f bincular eye mvements Cnvergence insufficiency Cnvergence excess Anmalies f divergence Ocular Mtr Dysfunctin Deficiencies f saccadic eye mvements Deficiencies f smth pursuit mvements Heterphria Esphria Exphria General Bincular Visin Disrder General Bincular Visin Disrder Accmmdative Disrder Paresis f accmmdatin Ttal r cmplete internal phthalmplegia Spasm f accmmdatin Nystagmus Nystagmus 18

19 Wyming Medicaid Visin Therapy Cvered Diagnsis Cdes (cntinued) Acquired Brain Injury Prgram and Adult Waiver Disturbances f visin Late effect f intracranial injury withut mentin f skull fracture Nervus system cmplicatin, unspecified Central nervus system cmplicatin Iatrgenic cerebrvascular infarctin r hemrrhage Other nervus system cmplicatins V57.4 Care invlving rthptic training 19

20 ICD-10 Implementatin Date Octber 1, 2015 ICD-10 Cding Infrmatin The Internatinal Classificatin f Diseases, 10th Editin, (ICD-10) is a diagnsis cding system f diseases and signs, symptms, abnrmal findings, cmplaints, scial circumstances and external causes f injury r diseases, and a prcedure cding system fr inpatient prcedures ICD-10 CM fr diagnsis cding This is fr use in all health care settings Diagnsis cding under ICD-10 uses 3 t 7 alphanumeric digits Wyming Medicaid des nt cnduct cding training Date f service driven Fr additinal infrmatin please visit 20

21 Cmmn Denial Reasns and Slutins Client nt eligible fr date f service r the service is nt cvered under the client s plan It is imprtant t verify eligibility f each client, keeping in mind that eligibility is authrized n a mnthly basis and can change frm mnth t mnth. Nt all Medicaid and State Benefit plans cver visin services; sme are limited t prescriptins nly, payment f Medicare premiums, r cverage fr limited diagnses r cnditins. Client eligibility can be verified via the IVR ( ), using either the client s Medicaid ID r their SSN. Frames eligibility can be verified via ptins 1, 5, and then 0. Please prvide client ID, date f birth, and date f service 21

22 Cmmn Denial Reasns and Slutins Prcedure Cde/Age Cnflict As certain services are nly cvered fr individuals f a certain age, it is imprtant t verify the cvered ages fr the prcedure cdes befre perfrming the service and billing, as well as the age f the client. The Wyming Medicaid website cntains a fee schedule search engine which will allw the prvider t enter any prcedure cde t view infrmatin related t: Allwed amunt Prir authrizatin requirement Age limitatins Allwed taxnmies Maximum units Allwed/disallwed mdifiers Medicare cverage (required t be billed t Medicare if client is cvered under Medicare) 22

23 Cmmn Denial Reasns and Slutins Client is cvered by Medicare r anther insurance cmmnly referred t as TPL (Third Party Liability) Medicaid is the payer f last resrt. This means that prviders must bill their claim t ther payers first, btain any payment r denial, and include this infrmatin when billing claims t Medicaid. If prviders find that they are having difficulty btaining respnse frm any insurance (nt including Medicare), they may include a letter dcumenting at least 2 attempts ver a minimum f 90 days and Medicaid will prcess as primary and btain payment frm the ther insurance. If prviders are nn-participatry with any insurance (nt including Medicare), they may include a letter dcumenting this in place f the ther insurance s EOB. Nte: Medicare must be billed primary in all cases, and prviders must include the Medicare EOMB if the prcedure cde is marked as Medicare: Y n the fee schedule 23

24 Cmmn Denial Reasns and Slutins Prcedure cde requires PA Certain services require PA fr medical necessity prir t the service being rendered. Verify if the cde being billed requires PA View Fee Schedule n the website Cntact Prvider Relatins Fill ut the PA Frm Available n the website Chapter 6, Sectin 6.12 f the CMS-1500 Manual 24

25 References The infrmatin reviewed in this presentatin can be fund in the CMS Manual Wyming Medicaid Website Prvider Manuals and Bulletins Click n Prvider / Prvider Manuals and Bulletins / Visin / CMS-1500 Prvider Manual Fee schedule Click n Prvider / Fee Schedules / Accept / Prcedure Cde Search Page IVR Navigatin tips Helps t direct prviders t the apprpriate ptins fr each department Click n Prvider / Cntact Us / Click here fr helpful Prvider IVR Navigatin Tips Remittance Advice Retrieval Frm the Secure Prvider Web Prtal Medicaid and State Healthcare Benefit Plan dcument Click n Prvider / Prvider Manuals and Bulletins / Additinal Links 25

26 References IVR hurs a day / 7 days per week NPI is required IVR Functinality 26 Verify client eligibility Client ID r client SSN and date f service is required Benefit plan Cvered services Limitatins Cap Limits Lck-in TPL / Medicare Buy-in Verify claim status Verify Payment Opt ut t agent

27 References Prvider Relatins (Optin 1,5,0) 9-5 MST Mnday - Friday Bulletin / Manual inquiries Cap limits Claim inquiries Claim submissin prblems Client eligibility Questins n cmpleting frms Payment inquiries Timely filing inquiries Billing issues regarding PA Verifying validity f prcedure cdes Claim vid / adjustment inquiries Medical Plicy (Optin 1,1,4,3) MST Mnday - Friday Questins regarding hw t cmplete the PA frm, and the status f a PA. Cap limit waiver requests

28 Questins? 28

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