Training Documentation Durable Medical Equipment 2017 Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
TABLE OF CONTENTS Introduction... 2 1.1 Preauthorization Process... 2 1.1.1 Services Requiring Preauthorization... 2 1.2 Out-of-Area Members... 3... 4 1.3 CMS 1500 Claim Form Requirements... 4 1.4 Special Requirements... 5 1.5 Miscellaneous Information... 8 1.5.1 Submission of Claims... 8 1.5.2 Rental and Purchase of DME... 9 1.5.3 Reimbursement for Repair of Equipment... 9 1.5.4 Maintenance of Equipment... 10 1.5.5 Coverage and Payment Determinations... 10 1.6 Enteral Nutrition Therapy Services... 11 1.7 Reimbursement... 12 3.0 Ancillary Audits/Request for Medical Records... 13 2017 Training Documentation: DME 1 Table of Contents
INTRODUCTION The Participating Ancillary Provider Agreement (Agreement) allows for direct reimbursement to Durable Medical Equipment (DME) providers for services provided to Capital BlueCross, Managed Care, and out-of-area members according to the member s contract. The Capital BlueCross programs include Traditional, Comprehensive, Point of Service, PPO, BlueJourney PPO, Keystone Health Plan Central (KHP Central), and BlueJourney HMO. DME claims are submitted electronically or via paper CMS 1500 Claim Forms. The following sections address Preauthorization, Billing, Reimbursement, and Quality Assessment aspects of the various programs administered by Capital BlueCross. Guidelines are provided for products offered by Capital BlueCross. Providers are reminded that the Capital BlueCross Provider Manual is a source of additional detailed information pertinent to your provider agreement. Please provide all appropriate personnel with copies of these instructions. If you have an arrangement with a company/vendor for billing services, it is important that the appropriate billing information is shared with them. 1.1 Preauthorization Process 1.1.1 Services Requiring Preauthorization Preauthorization is required for (1) all purchases and repairs with a billed charge amount equal to or greater than $500 per unit, and (2) all rental items shown on the Preauthorization list, regardless of price per unit. Custom wheelchairs require prior authorization. Although an itemization of the chair and related options and accessories is required during the review process, when billing the claim providers are instructed to bill one line item using procedure code E1220 with one (1) unit. All Enteral Nutrition requires Preauthorization. Medical necessity criteria are established within Medical Policy 2.015 entitled Enteral Nutrition. Specific numbers of units, brand of formula, condition of the member, the member s height and weight, and the length of time of the request should be included in the request for Preauthorization. It is important to note that enteral nutrition therapy services provided to KHP Central, POS, and BlueJourney HMO members require a referral. Note: For CPAP equipment, a one-month rental period is required to demonstrate that patient is compliant before a purchase can be made. 2017 Training Documentation: DME 2 Introduction
Services requiring but not receiving Preauthorization will be denied. The ordering provider is responsible for ensuring that Preauthorization is obtained. If an authorization has not been obtained by either the Primary Care Physician (PCP) or the specialist, the DME provider may contact Clinical Management to request one. The DME provider should have the patient s clinical information on hand when they call. Failure to obtain Preauthorization for services to be performed by a Capital BlueCross contracting provider will result in denial of payment. Commercial members may not be billed for denied services unless they have signed a statement of financial liability form listing the specific service and indicating they will be financially responsible. This statement must be signed after the member has been informed that the Plan will not cover the specific services due to the fact that Preauthorization was not obtained, but before services are rendered. For BlueJourney HMO and BlueJourney PPO members, services requiring Preauthorization that are not preauthorized will be denied provider liability. DME that does not require Preauthorization (regardless of the charge) include: Oxygen and related equipment Nebulizers Bili (bilirubin) blankets (lights to treat newborns) Breast pumps Breast pumps that are deemed allowable purchases and rentals do not require authorization. Specifically, the purchase of breast pump (E0603) will be permitted based on applicable member benefits although a higher cost share for the purchase may result for the patient rather than the rental of a breast pump. The hospital-grade electric breast pump (example E0604) is noncovered as a purchase nor a rental. Because it is considered institutional equipment, the hospital-grade electric breast pump is not reasonable and necessary for use in the home setting. 1.2 Out-of-Area Members Preauthorization for members of other Blue Cross plans is not provided by Capital BlueCross Clinical Management. Check to see if Preauthorization is required when verifying eligibility and benefits with the patient s home plan by calling 1.800.676.2583. If Preauthorization is obtained, the Preauthorization number should be entered in Block 33 of the CMS 1500 Claim Form. Out-of-area members are required to follow the member s Home Plan guidelines for Preauthorization of DME purchases, rentals, or repairs. 2017 Training Documentation: DME 3 Introduction
BILLING INSTRUCTIONS 1.3 CMS 1500 Claim Form Requirements CMS 1500 CLAIM FORM: ALL LINES OF BUSINESS KEY: R = Required IA = Use if Appropriate D = Desired NR = Not Required * = See Special Requirements BLOCK # DESCRIPTION REQUIREMENT Block 1 Claim Type R* Block 1a Insured s ID Number R* Block 2 Patient s Name R* Block 3 Patient s Birth Date and Sex R Block 4 Insured s Name R Block 5 Patient s Address R Block 6 Patient Relationship to Insured R Block 7 Insured s Address R Block 9 Other Insured s Name IA* Block 9a Other Insured s Policy or Group Number IA Block 9d Insurance Plan Name or Program Name IA* Block 10 Is Patient s Condition Related to: R Block 11 Insured s Policy Group or FECA Number IA* Block 11a Insured s Date of Birth IA Block 11c Insurance Plan Name or Program Name R* Block 11d Is There Another Health Benefit Plan? R Block 12 Patient s or Authorized Person s Signature R Block 13 Insured s or Authorized Person s Signature R Block 14 Date of Current Illness/Injury/Pregnancy IA Block 17 Name of Referring Physician or Other Source D Block 17a Other ID # IA Block 17b NPI # IA Block 18 Hospitalization Dates Related to Current Services IA Block 20 Outside Lab? IA Block 21 Diagnosis or Nature of Illness or Injury R* Block 23 Prior Authorization Number IA* Block 24a Date(s) of Service R* Block 24b Place of Service R Block 24d Procedures, Services, or Supplies R* Block 24e Diagnosis Pointer R 2017 Training Documentation: DME 4
CMS 1500 CLAIM FORM: ALL LINES OF BUSINESS KEY: R = Required IA = Use if Appropriate D = Desired NR = Not Required * = See Special Requirements BLOCK # DESCRIPTION REQUIREMENT Block 24f $ Charges R* Block 24g Days or Units R Block 24j Rendering Provider ID # R* Block 25 Federal Tax ID Number R Block 26 Patient s Account Number R Block 27 Accept Assignment R* Block 28 Total Charge R* Block 29 Amount Paid R Block 31 Signature of Physician or Supplier R Block 32 Service Facility Location Information R* Block 33 Billing Provider Info and Ph # R* Block 33a NPI # R* 1.4 Special Requirements Block 1 (Claim Type) Type an X in the appropriate box based on the following guidelines: Medicare BlueJourney HMO and BlueJourney PPO Other all other lines of business Block 1a (Insured s ID Number) Include the alpha prefix shown on the member s identification card. When there is no alpha prefix on an ID card for a BlueCard member, the claim should be filed directly to the member s Blue Plan. If the member s identification number includes a two-digit suffix, include the suffix in this block. Block 2 (Patient s Name) Enter the patient s name exactly the way that it appears on the identification card. Block 9 (Other Insured s Name) Required if Block 11d is filled in. Block 9d (Insurance Plan Name or Program Name) Required if Block 11d is filled in. Block 11 (Insured s Policy Group or FECA Number) Required for KHP Central claims. 2017 Training Documentation: DME 5
Block 11c (Insurance Plan Name or Program Name) Type the applicable Program name or Plan name/code. Block 21 (Diagnosis or Nature of Illness or Injury) Type the ICD 10 CM code(s) and narrative description(s) in priority order. Use of E codes for primary and secondary diagnoses is inappropriate and will cause the claim to be returned to the provider. Block 23 (Prior Authorization Number) When applicable, use this locator to record the Preauthorization number. Block 24a (Date[s] of Service) When billing for the monthly rental of an item, do not submit a CMS 1500 Claim Form until the month s rental is complete. When billing for the purchase of an item, use the date of delivery as the date of service. Specifically regarding items that are not in stock and are on order, do not bill until the item is delivered or received by the member. Advance billing is not permitted and payment is made only after services have been provided. When billing for a monthly rental, the Through Date on the first month s claim should not be the same as the From Date on the following month s claim. The From Date on the second claim should be the date following the Through Date on the first claim. If the two dates are the same, that date of service on the second claim will reject as a duplicate. The following example is provided to help clarify the proper billing procedure: 1st Claim 2nd Claim 1-16 2-15-11 2-16 3-15-11 Block 24d (Procedures, Services, or Supplies) When billing for DME as defined in the Agreement, use the most appropriate standard billing codes and modifiers. Bill one modifier only per line item that reflects if the item was purchased, rented, replaced, or repaired. A description of services is necessary only for services which do not have an appropriate procedure code and a miscellaneous HCPCS code is used. For Custom Wheelchairs, providers are instructed to bill one line item using procedure code E1220 with one (1) unit. 2017 Training Documentation: DME 6
Block 24f ($ Charges) Type the full charge for each service billed. Do not type the contracted rate(s). Do not use dollar signs ($) or decimals. Skip a space between dollars and cents. Do not report a zero charge. Payment for deluxe or special features may be made only when such features are prescribed by the attending physician and when medical appropriateness criteria have been met. To be medically necessary, a deluxe or special feature must be necessary in the effective treatment of the patient s condition and serve a therapeutic purpose as determined by the Plan. Deluxe or special features supplied for reasons of aesthetics or convenience, including special colors and other items that do not serve a therapeutic purpose, are not covered and are the sole responsibility of the member. This information must be discussed with the member prior to the rental or purchase of the equipment in order for the provider to be able to bill the member for any deluxe or special features that are not covered. Only the eligible charge amount of the equipment, excluding the deluxe or special features, should be reflected in Locator 24f of the CMS 1500 Claim Form. Note: When procedure code L8035 custom breast prosthesis; molded to patient model, has been authorized for KHP Central HMO or BlueJourney HMO members, the item s actual charge amount should be billed instead of the eligible charge amount as directed above. Block 24j (Rendering Provider ID #) For paper claims only, type the NPI number in the shaded area of the block. For electronic submission Item 24j must be blank. Block 27 (Accept Assignment) Required for BlueJourney HMO and BlueJourney PPO claims. Block 28 (Total Charge) Type the total charge for the services indicated on claim (total of all charges in Item 24f). Do not use the dollar sign ($) or decimals. Skip a space between dollars and cents. Block 32 (Service Facility Location Information) Indicate the location where the service was rendered. The nine-digit ZIP Code is required for the service facility location. Block 33 (Billing Provider Info and Ph #) Type the provider s billing name, address, nine-digit ZIP Code, and phone number. The phone number is to be entered in the area to the right of the block title. Do not use punctuation. The billing provider address must be reported as a street address. Claims reporting a Post Office (PO) Box will be rejected on the submitter s Accept/Reject (AR) Report. Block 33a (NPI #) Type the NPI number of the billing provider. 2017 Training Documentation: DME 7
1.5 Miscellaneous Information 1.5.1 Submission of Claims Services are reported using the CMS 1500 Claim Form. To avoid billing confusion and duplicate processing, please advise your patients that you are submitting a claim to Capital BlueCross on his/her behalf. Fill in all the information that is requested. Items 24A through 24G, 24I, and 24J must be completed for each charge listed. Do not report services on the claim for which no charge was made. Multiple hard copy claims submitted for the same patient for services performed on the same day must be stapled together. This procedure also applies when different dates of service (for the same patient) are being submitted together. It is important that you report all other essential information on each claim form. Prescription Physician s prescription must be maintained by the DME provider for audit purposes as part of the patient s record. Please DO NOT submit the prescription with the CMS 1500 Claim Form. Letter of Medical Necessity (CMN) Please DO NOT include the CMN when submitting a claim. However, the CMN must be kept on file by the DME provider for audit purposes. The CMN should include the patient s diagnosis, the severity of the symptoms, prognosis, the reason the equipment is required, physician s estimate (in months) of the duration of its need, the reason the item is needed for treatment, and documentation that its use is being supervised. Note: For ongoing rentals, a new CMN should be obtained yearly and maintained within the patient s file. Claims for Out-of-Area Members Unique billing guidelines exist for the submission of claims for out-of-area members. Claims should be submitted to the Blue Plan in the state to which the equipment was shipped or in which it was purchased at a retail store. 2017 Training Documentation: DME 8
1.5.2 Rental and Purchase of DME Rental and purchase of DME consisting of the following physician-prescribed items may be covered: Medically necessary equipment appropriate for use in a home setting, which can withstand repeated use to improve functions of a body part and is not generally useful to a person in the absence of an illness or injury. Medical supplies that are essential in, and directly related to, supporting and/or carrying out therapeutic or diagnostic services. The supplies generally cannot withstand repeated use and are considered disposable. Rental equipment payment is limited to the fee schedule purchase price. Once rentals meet the fee schedule purchase price, you can no longer bill for a rental. If an item is reflected with a purchase price only on the fee schedule, the item cannot be provided as a rental. It can only be purchased. Items that are reflected as purchase only will be denied if billed as a rental. If an item is reflected with a rental price only on the fee schedule, the item cannot be purchased. It can only be rented. Items that are reflected as rental only will be denied if billed as a purchase. Note: Cumulative payment for the rental of DME items that can be purchased will not exceed the fee schedule purchase price. Note: When equipment is purchased, the amount of prior rental payments must be deducted from the fee schedule purchase price before submitting the claim to Capital BlueCross. 1.5.3 Reimbursement for Repair of Equipment (a) Rental Equipment The Agreement states that repairs for rental equipment is the responsibility of the DME provider. Do not bill Capital BlueCross or the patient for these repairs. The cost of repairs for rental equipment is included in the monthly rental reimbursement. It is not eligible to be billed or paid for separately. 2017 Training Documentation: DME 9
(b) Purchased Equipment The repair of components and accessories necessary for effective functioning of covered physician-prescribed equipment is eligible for payment if the subscriber owns the equipment. Bill the equipment HCPCS with the applicable repair modifier in Field Locator 24d of the CMS 1500 Claim Form. The payment for a DME repair may not exceed the current purchase price of the equipment as it appears on the fee schedule. Replacement of purchased DME: When the DME is irreparably damaged, unless such damage resulted from misuse and/or abuse. When worn DME is beyond its useful life. When required because of a change in the member s condition. 1.5.4 Maintenance of Equipment Reimbursement for maintenance services performed during the period when Capital BlueCross is making rental payments for the DME is included in the rental reimbursement. Once the allowed amount for rentals equals the fee schedule purchase price, maintenance services may be billed as repairs. Maintenance services cannot be billed more frequently than once every six months. Payment for maintenance services cannot exceed the rental amount for the equipment on the fee schedule. 1.5.5 Coverage and Payment Determinations Coverage and payment determinations regarding DME are made in accordance with Medicare s coverage guidelines unless a specific individual Capital BlueCross Medical Policy or Administrative Bulletin indicates otherwise. Supplies and accessories necessary for the effective functioning of DME such as hoses, filters, mouthpieces, etc., will be separately reimbursed only if the beneficiary owns the equipment. Therefore, for items that cannot be purchased (e.g., ventilators), accessories such as circuits, filters, mouthpieces, tubing, cannulas, regulators, batteries, and humidifiers are considered part of the monthly rental allowance and are not separately reimbursed. Supplies and accessories necessary for the effective functioning of other DME that may be purchased, after first being rented, such as intrapulmonary percussive ventilation systems (IPV), apnea monitors, and pulses oximeters, are not separately reimbursable during the rental period of the equipment. 2017 Training Documentation: DME 10
Stationary oxygen contents (E0441, E0442) should only be billed if the member owns a stationary system or owns both a stationary and portable system. Portable contents (E0443, E0444) are separately payable only when the coverage criteria for home oxygen have been met and the member either: Owns a stationary system (concentrator, gaseous, or liquid) and rents or owns a portable system; or Does not own a stationary system (concentrator, gaseous, or liquid) and rents or owns a portable system. Back-up or secondary DME, including ventilators, are not covered services. Back-up or secondary DME refers to a piece of equipment that is identical or similar to the one already in use and is being utilized to meet the same medical needs of the patient. 1.6 Enteral Nutrition Therapy Services Preauthorization is required for enteral nutrition therapy services. The request for Preauthorization should include the specific number of units, brand of formula, condition of the member, the member s height and weight, and the length of time of the request. Enteral nutrition therapy claims are reviewed for medical necessity on a prepayment basis. Benefits for enteral nutrition products are covered for medical foods, as defined by the U.S. Food and Drug Administration, that are administered through a feeding tube, or orally (if they provide 50 percent or more of the total nutritional intake). This topic is discussed in Capital BlueCross medical policy MP-2.015 (located in the Medical Policies section of the Provider Library on the Capital BlueCross health plan home page via the NaviNet portal). However, it is important to note that enteral nutrition therapy services provided to KHP Central, POS, and BlueJourney HMO members require a referral. Billing for enteral nutrition therapy consists of the following two components: per diem and enteral formula using the most applicable Level II HCPCS codes. When billing for enteral nutrition therapy for other than BlueJourney HMO and BlueJourney PPO members, list the HCPCS Level II S per diem code that most accurately describes the service rendered to the patient. The following benefit exclusions regarding enteral nutrition are not covered: Blenderized baby food, regular shelf food, or special infant formulas. 2017 Training Documentation: DME 11
As a reminder, providers will be liable for the charges for this denied service unless the provider obtains from the commercial member, prior to initiation of the service, a written acknowledgement of financial responsibility that specifically describes the nature of the service and that the provider believes Capital BlueCross deems such service as noncovered. A general, nondescriptive waiver that states the member will be liable is insufficient. All current rules and procedures for appealing claims will continue to apply. The following codes should not be billed since they are included in the per diem reimbursement: B4034 B4035 B4036 B9000 B9002 B9998 If these codes are billed, they will be denied as an incorrect billing code. The nutrients for enteral nutrition therapy are included on the fee schedule and will be priced based on the units billed for the HCPCS code. 1.7 Reimbursement Claims will be reimbursed according to the benefits in effect under the member s contract at the time services are rendered and the provisions of the Capital BlueCross member DME agreement or, for BlueJourney HMO and BlueJourney PPO members, the Medicare fee schedule. 2017 Training Documentation: DME 12
3.0 ANCILLARY AUDITS/REQUEST FOR MEDICAL RECORDS Capital BlueCross or its designee may request medical records at any time for any purpose, including without limitation, to make a determination related to a submitted claim or to investigate a potential quality of care issue. Medical record reviews may also be performed as necessary to assess, for example, member complaints and compliance with quality improvement activities. Capital BlueCross will provide a list of medical records needed for review and the purpose of the audit. A Corrective Action Plan may be initiated if deficiencies are identified. When requested, the DME provider should submit medical records to the address or fax number identified on the Capital BlueCross medical information request form. 2017 Training Documentation: DME 13 Ancillary Audits/Request for Medical Records