april 2009 prenatal care coordination billing presented by the eds provider relations field...
TRANSCRIPT
April 2009
Prenatal Care Coordination BillingPresented by the EDS Provider Relations Field Consultants
PRENATAL CARE COORDINATION BILLING2 / April 2009
• IHCP
• Provider Enrollment
• Provider Updates
• Member Eligibility
• Benefit Packages
• Care Coordination Services
• Notice of Pregnancy
• Presumptive Eligibility
• Managed Care
Welcome and Announcements
Agenda
•Care Management Organizations
•Billing
•Remittance Advice
•Adjustments
•Paper Claim Filing
•Top Five Denials
•Helpful Tools
•Questions
PRENATAL CARE COORDINATION BILLING3 / April 2009
Indiana Health Coverage Programs
•Traditional Medicaid
•590
•Fee-for-Service
PRENATAL CARE COORDINATION BILLING4 / April 2009
New Provider Enrollment
•Enrollment forms are in electronic format on the Web by using www.indianamedicaid.com
•All forms may be filled out online and the information submitted electronically
•All pages requiring original signatures and tax information (W-9s) must be mailed to EDS Provider Enrollment after completing the online application
•Enrolling online provides the following advantages:
– Quicker provider enrollment
– Complete and accurate information
– Easier enrollment
PRENATAL CARE COORDINATION BILLING5 / April 2009
Provider EnrollmentStep 1: Begin at indianamedicaid.com
PRENATAL CARE COORDINATION BILLING6 / April 2009
• Indiana Health Coverage Programs (IHCP) Web site at
www.indianamedicaid.com
• Provider Enrollment helpline at 1-877-707-5750
Provider Enrollment ApplicationProvider Enrollment
PRENATAL CARE COORDINATION BILLING8 / April 2009
• Download the Provider Enrollment Application:
– Visit www.indianamedicaid.com
– Go to the Provider Services tab
– Choose Provider Enrollment from the drop-down list
– Access the link titled Enroll a New Provider in the IHCP
– Print the Provider Enrollment Application and an IRS W-9 Form
• Complete the enrollment application (original signatures are required)
• Avoid having your application returned
– Call 1-877-707-5750 if you have questions about the enrollment forms
ProcessProvider Enrollment
PRENATAL CARE COORDINATION BILLING9 / April 2009
• IHCP reimbursement is available for the following practitioners who provide care coordination services to eligible pregnant women in the IHCP:
– State-licensed physician
– State-licensed registered nurse
– State-certified social worker or a social worker with a baccalaureate or master’s degree from a school accredited by the Council on Social Work Education
– Dietician registered with the Commission on Dietetic Registration of the American Dietetic Association
– Community health worker working under the supervision of one of the professionals listed above
Provider Enrollment RequirementsProvider Enrollment
PRENATAL CARE COORDINATION BILLING10 / April 2009
•The enrollment packet must include:
– Completed Provider Enrollment Application (with all applicable schedules)
– Completed IRS W-9 Form
– Waiver Approval Letter certifying the waiver services that the provider is approved to perform
•Mail to: EDS Provider Enrollment
P.O. Box 7263Indianapolis, IN 46207-7263
Mailing the ApplicationProvider Enrollment
PRENATAL CARE COORDINATION BILLING11 / April 2009
Provider Updates
•Updates to the following information must be submitted to the EDS Provider Enrollment Unit:
– Address changes (home office, mail-to, pay-to, and service location)
– Telephone number changes
– Banking information changes (if enrolled in electronic funds transfer)
•Requests for changes must be submitted using the EDS Provider Update Form available at www.indianamedicaid.com
PRENATAL CARE COORDINATION BILLING12 / April 2009
•Members must be enrolled in the IHCP and have pregnancies that are at risk for low birth weight or poor pregnancy outcome to be eligible for the IHCP to pay for care coordination services
•Each member has a Hoosier Health Card used for identification
•Viewing a Hoosier Health Card alone does not verify eligibility
Who is Eligible?
Member Eligibility
PRENATAL CARE COORDINATION BILLING13 / April 2009
• Providers must verify eligibility on the date of service
• Providers who fail to verify eligibility are at risk of their claims being denied due to member ineligibility or coverage limitations
Verifying EligibilityMember Eligibility
PRENATAL CARE COORDINATION BILLING14 / April 2009
Three Eligibility Verification Systems (EVS) are available:
•Automated Voice Response (AVR)
– 1-800-738-6770, or
– (317) 692-0819, Indianapolis area
•Omni swipe card terminal device
•Web interChange
How to VerifyMember Eligibility
PRENATAL CARE COORDINATION BILLING15 / April 2009
AVR provides the following:
•Member eligibility verification
•Benefit limits
•Prior authorization
•Claim status
•Check write
Contact AVR at (317) 692-0819 in the Indianapolis local area or 1-800-738-6770
EVS Using the TelephoneAutomated Voice Response System
PRENATAL CARE COORDINATION BILLING16 / April 2009
• Is cost-effective for high-volume providers
•Uses plastic Hoosier Health card
•Allows manual entry
•Prints two-ply forms
•Requires upgrade for benefit limit information (refer to IHCP provider bulletin BT200711)
See Chapter 3 of the IHCP Provider Manual for more information
EVS Card Reading DeviceOmni
PRENATAL CARE COORDINATION BILLING17 / April 2009
The following is available through Web interChange:
•Member information available by member ID, Social Security number (SSN), Medicare number, or name and DOB
•Division of Family Resources (DFR) information
•Detailed third-party liability (TPL) information
•Online TPL update requests
•Web interChange is accessible via www.indianamedicaid.com
EVS Using the InternetWeb interChange
PRENATAL CARE COORDINATION BILLING19 / April 2009
Benefit Packages
Benefit Package
Coverage
Package A – Standard Plan
Encompasses the full array of Indiana Health Coverage Programs (IHCP) benefits for children, low-income families, and some pregnant women enrolled in the Hoosier Healthwise Program.
Package B Coverage is limited to pregnancy-related and urgent care services for some pregnant women.
Package C Limited coverage (including preventive, primary, and acute care services) for children under 19 years old enrolled in the Children’s Health Insurance Plan (CHIP).
PRENATAL CARE COORDINATION BILLING20 / April 2009
Diagnosis Code:
• V68.9
Procedure Codes:
• H1000 – Initial Assessment (One per pregnancy)
• H1004 – Reassessment (One per trimester)
• 99502 – Home visit for newborn care and assessment
Diagnosis and Procedure CodesCare Coordination Services
PRENATAL CARE COORDINATION BILLING21 / April 2009
•A0160 U1 – Two round trips per initial assessment
•A0160 U2 – Two round trips per assessment
•A0160 – One round trip per postpartum assessment
Procedure Codes for MileageCare Coordination Services
PRENATAL CARE COORDINATION BILLING22 / April 2009
Prenatal Care Coordination Forms
• Risk Assessment Form:– Must be kept in the member’s record to substantiate
services beyond the initial assessment
• Combined Assessment Form
– Used for one initial assessment and follow-up
– One reassessment and follow-up per trimester occurring after the initial assessment
– One postpartum assessment
• Care Coordination Outcome Report– Send the Outcome Report to the Indiana State
Department of Health (ISDH) regardless of when the patient has finished care
PRENATAL CARE COORDINATION BILLING23 / April 2009
•Following up to verify or reschedule appointments
•Locating services sources
•Making appointments
•Arranging transportation
•Making home visits (including the postpartum home visit)
•Referring member to the Social Security agency
•Performing follow-up activities to ensure services were received
Prenatal Care Coordination Services
Care Coordination Services
PRENATAL CARE COORDINATION BILLING24 / April 2009
Case management services for pregnant women:
•Active, ongoing process of assisting the member to identify, access, and use community resources and coordinate services to meet individual needs
•Third Party Liability edit overrides for care coordination services
•Providers not required to file for reimbursement from other insurers
Care Coordination ServicesPrenatal Care Coordination
Services
PRENATAL CARE COORDINATION BILLING25 / April 2009
Notice of Pregnancy – Effective July 1, 2009
The Office of Medicaid Policy and Planning (OMPP), managed care organizations (MCOs), the Indiana State Department of Health (ISDH) and other Medicaid stakeholders worked jointly to develop a universal assessment for pregnant women to capture:
• Maternal Obstetrical History• History of Prior Births (Still birth, Pre-term, Low Birth Weight)• Diagnosis of Pregnancy Risk• Maternal Medical History (including conditions that require
management during pregnancy - HTN, Diabetes)• Current Medications• Mental Health History and Current Conditions• Substance Abuse/Use History • Tobacco Use History • Social Risk Factors• Needed Referrals
PRENATAL CARE COORDINATION BILLING26 / April 2009
•Reimbursement of $60 to the physician/clinic per Notice of Pregnancy (NOP) submitted within five calendar days of the prenatal visit
•Other details:– Provider must submit a claim to be reimbursed for NOP
form submission
– NOP form submission may be billed one time per member, per pregnancy
– Providers submit the NOP form via Web interChange
– Providers bill for submission of the NOP form using procedure code 99354 with modifier TH
Note: Procedure code and reimbursement available July 1, 2009
ReimbursementNotification of Pregnancy
PRENATAL CARE COORDINATION BILLING27 / April 2009
•Print a hard copy and complete during the exam
• Enter information electronically from hard copy or
•Enter the information electronically during the exam
•To qualify for payment, provider must:– Submit NOP within five calendar days from Date of
Service, and
– Complete NOP prior to 30 weeks gestation
Completing the NOPNotification of Pregnancy
PRENATAL CARE COORDINATION BILLING28 / April 2009
Notification of Pregnancy
Click on the
appropriate
responses.
Then
click “Next”
Completing the NOP
PRENATAL CARE COORDINATION BILLING29 / April 2009
Notification of Pregnancy
•Data is sent to the member’s MCO
•MCOs provide additional support services (for example, nurse case management, home visits) depending on needs of member
•MCO can also help with coordination between the physician’s office and member
•MCO will also coordinate with the prenatal care coordinator
•The OMPP will use the data to monitor outcomes of births and to develop programming that better meets the needs of pregnant women in Medicaid
PRENATAL CARE COORDINATION BILLING30 / April 2009
Presumptive Eligibility – Effective July 1, 2009
•What is presumptive eligibility?
– A period of time during which a pregnant woman, who has been determined by a qualified provider to be “presumptively eligible,” may receive ambulatory prenatal services while her Hoosier Healthwise application is being processed
– Inpatient care, hospice, long-term care, delivery services, postpartum and services unrelated to the pregnancy or birth outcome are not covered
PRENATAL CARE COORDINATION BILLING31 / April 2009
•To be eligible for Presumptive Eligibility (PE), a pregnant woman must:
– Be pregnant, as verified by a professionally administered pregnancy test
– Not be a current Medicaid member
– Be an Indiana resident
– Be a U.S. citizen or a qualified non-citizen
– Not be currently incarcerated
– Have gross family income less than 200 percent of the federal poverty level
Who is Eligible?Presumptive Eligibility
PRENATAL CARE COORDINATION BILLING32 / April 2009
Many of the requirements for qualified providers are mandated by Federal Medicaid regulations:
1. Must be enrolled in Medicaid
2. Must provide outpatient hospital, rural health clinic, or clinic services as defined in sections 1905 (a)(2)(A) or (B), 1905(a)(9), and 1905(l)(1) of the Social Security Act
3. Must be trained and certified by the State (or designee) to perform PE functions
State-specific requirements include:
1. Must be able to verify pregnancy via a professionally administered pregnancy test
2. Must have Internet, telephone, printer, and fax access that is available to facilitate the PE and Medicaid application process
3. Must have Administrator access to Web interChange• Complete the Administrator Request Form to set up an
administrator
Presumptive EligibilityWho Can Be a Qualified Provider?
PRENATAL CARE COORDINATION BILLING33 / April 2009
Qualified providers (QPs) may include the following provider types/specialties:– Family or general practitioner– Pediatrician– Internist– Obstetrician or gynecologist– Certified nurse midwife– Advanced practice nurse practitioner– Federally qualified healthcare center– Medical clinic– Rural health clinic– Outpatient hospital– Local health department– Family planning clinic
Who Can Be a Qualified Provider?Presumptive Eligibility
PRENATAL CARE COORDINATION BILLING34 / April 2009
How the PE Process Works
• Check for any existing Medicaid coverage using the Eligibility Inquiry feature of Web interChange
• QP professionally administers a pregnancy test or accepts pregnancy test administered by another professional to determine if the patient is pregnant– Over-the-counter pregnancy tests cannot be used to
determine pregnancy for PE• If the patient is not covered by Medicaid, a QP-trained
staff member accesses the PE Application by clicking the “PE Application for Pregnant Women” button (Step 1)– The PE Application window is available during the
following business hours:• Monday-Friday – 8 a.m. to 6 p.m. (Eastern time)• Saturday – 8 a.m. to Noon (Eastern time)
Note: If applicable, the non-QP refers the patient to a QP to complete the PE application process
PRENATAL CARE COORDINATION BILLING35 / April 2009
How the PE Process Works
•QP enters the following information based on responses from the patient:– Applicant name, Social Security number, date of birth, home
address, mailing address, contact telephone, gender, marital status, gross income, family size, and race
•QP also answers “yes” or “no” to the following:– Indiana residency, incarceration status, verification of
pregnancy, U.S. citizenship, and whether or not an application for Medicaid/Hoosier Healthwise is pending
•Applicant responses are to be accepted by the QP without asking for verification documents– If presented, verification documents may be faxed with the
Hoosier Healthwise application
PRENATAL CARE COORDINATION BILLING36 / April 2009
How the PE Process Works
•QP provides the woman with access to a telephone to contact the enrollment broker (MAXIMUS)
•MAXIMUS explains the selection process to the woman and assists her to select a primary medical provider (PMP) and MCO
•QP ensures the woman’s PMP and MCO choices are written on her PE determination notice for reference
•MAXIMUS activates the patient’s PE number
If, on that day, the woman fails to contact MAXIMUS to make her PMP and MCO selections, her PE eligibility will terminate that day and the QP will receive no reimbursement for prenatal services
PRENATAL CARE COORDINATION BILLING37 / April 2009
How the PE Process Works
• Applicant is responsible for reviewing the printed Hoosier Healthwise application and providing additional responses as appropriate
• QP ensures the patient signs the Hoosier Healthwise application and faxes it to the Division of Family Resources (DFR). QP also faxes a statement signed by the physician or nurse indicating the woman is pregnant and the date the pregnancy began
• Modernized counties:– Direct questions about the Hoosier Healthwise application to the DFR
Document Center at 1-800-403-0864– Fax is sent to the DFR Document Center at 1-800-403-0864– Direct questions about the Hoosier Healthwise application to the
local DFR office– At http://www.in.gov/fssa/dfr/2999.htm, click “Where Do I Apply,”
then click on woman’s county of residence to locate county DFR telephone and fax information
– Fax is sent to the county DFR office
PRENATAL CARE COORDINATION BILLING38 / April 2009
How the PE Process Works
•PE Considerations:
– The above functions occur on the same day
– There is no PE coverage if the woman, who has been determined to be presumptively eligible does not select a PMP and MCO with the Enrollment Broker
– Women are eligible for PE only one time per pregnancy
– QP enrollment activities are performed on a voluntary basis
– QPs should allow approximately 15 minutes to complete PE functions
PRENATAL CARE COORDINATION BILLING39 / April 2009
•Prenatal care coordinators can:
– Encourage clinics to become qualified providers
– Perform outreach to physicians to accept women with Presumptive Eligibility
– Refer pregnant women to qualified providers for eligibility determination
– Assist women with follow-up of Medicaid Application process
Presumptive Eligibility ProcessHow You Can Help
PRENATAL CARE COORDINATION BILLING40 / April 2009
Helpful Tools – PE and NOP
•Bulletin about PE is scheduled for late April 2009
•Training of qualified providers is scheduled to begin in mid-May 2009
•Bulletin about NOP is scheduled for mid-May 2009
Both programs are scheduled to begin
July 1, 2009
Questions about PE and NOP can be directed to the Office of Medicaid Policy and Planning:
PRENATAL CARE COORDINATION BILLING41 / April 2009
MCOs contracted in Hoosier Healthwise risk-based managed care (RBMC):
•Anthem
1-866-408-6132
•Managed Health Services (MHS)
1-877-647-4848
•MDwise
1-800-356-1204
•ADVANTAGE administers PrimeStep primary care case management (PCCM) and Care Select
1-800-889-9949, Option 3
Managed Care in the IHCPManaged Care
PRENATAL CARE COORDINATION BILLING42 / April 2009
Care Management Organizations
•Two health plans were selected to function as care management organizations (CMOs) for the Care Select program
– ADVANTAGE Health SolutionsSM
www.advantageplan.com
1-866-504-6708
– MDwisewww.mdwise.org1-866-440-2449MDwise also serves as one of Indiana’s three Hoosier Healthwise MCOs
PRENATAL CARE COORDINATION BILLING43 / April 2009
•Providers may not collect from a member or family member any portion of the covered service that is not reimbursed by the IHCP, except for copayments on transportation and pharmacy services and any member liability payment authorized by law
•Participating providers must accept the Medicaid determination of payment in full
Billing the IHCP Member for Noncovered ServicesBilling
PRENATAL CARE COORDINATION BILLING44 / April 2009
You may only bill for authorized services. For services to be authorized they must:
•Meet the needs of the member
•Be a noncovered service by the IHCP or a covered service, which the member has exceeded the program limitations
•The member must understand, before receiving services, that they will be financially responsible
•Provider must maintain documentation showing the member accepted responsibility for the charges
Billing the IHCP Member, ExceptionsBilling
PRENATAL CARE COORDINATION BILLING45 / April 2009
•Remittance Advices (RAs) provide information about claims processing and financial activity related to reimbursement
– RAs contain internal control numbers (ICNs) with detail-level information
– RAs give detail status (paid or denied)
– RAs give payment amount
See the IHCP Provider Manual, Chapter 12, for more details
Statement with Claims Processing InformationRemittance Advice
PRENATAL CARE COORDINATION BILLING46 / April 2009
The ICN is a 13-digit number assigned to each claim
•The region tells how the claim was submitted
– 20 – electronic with no attachments
– 21 – electronic with attachments
– 10 – paper with no attachments
– 11 – paper with attachments
– 50 – voids/replacements – noncheck-related
Region Year Julian Date
Batch Range Sequence
20 07 158 150 000
Internal Control NumberAdjudicated Claim Information
PRENATAL CARE COORDINATION BILLING47 / April 2009
• “Replacement” is a HIPAA-approved term used to describe the correction of a claim that has already been submitted
• Replacements can be performed on paid and denied claims
• Denied details can be replaced or billed as a new claim
• To avoid unintentional recoupments, submit paper adjustments for claims finalized more than one year
• “Void” is the term used to describe the deletion of an entire claim
• Voids can be performed on paid claims only• Voids and replacements can be performed to correct
incorrect or partial payment, including zero dollar amount
Note: Paper replacements can only be processed on paid claims
Voids and ReplacementsClaim Adjustments
PRENATAL CARE COORDINATION BILLING48 / April 2009
•Use the approved version of the CMS-1500 claim form
•Do not use staples or paper clips
•Verify that the claim form is signed, or complete the Attestation for Signature on File
•Review the RA closely
Helpful Hints
Paper Claim Filing
PRENATAL CARE COORDINATION BILLING49 / April 2009
Top Five Denials for Care Coordination Services
1008 – Rendering provider must have an individual number
2006 – Members are eligible for emergency services only
2017 – Recipient ineligible on date(s) of service
0512 – Claim past filing limit
9018 – No payment made spend-down is > than IHCP allowed
PRENATAL CARE COORDINATION BILLING50 / April 2009
• IHCP Web site at www.indianamedicaid.com
• IHCP Provider Manual (Web, CD-ROM, or paper)
• Customer Assistance
– 1-800-577-1278, or
– (317) 655-3240 in the Indianapolis local area
• Written Correspondence
– P.O. Box 7263Indianapolis, IN 46207-7263
• Provider Relations Field Consultant
– View a current territory map and contact information online at www.indianamedicaid.com
• Indiana State Department of Health
– (317) 233-1344
Avenues of ResolutionHelpful Tools
PRENATAL CARE COORDINATION BILLING52 / April 2009
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