2015 Spring Webinar. KY Medicaid. UB04 Packet

Transcription

1 2015 Spring Webinar KY Medicaid UB04 Packet

2 Webinar Expectations PHONE Do not put phones on hold Do not hold conversations or take other calls The leader will mute all lines until the Q/A section remove your phone from mute to ask your question and re-mute your line after asking your question. HP MyRoom Presentation is available in the HP MyRoom for participants attending training. If you cannot access the HP MyRoom, please follow along using a paper copy downloaded at under Provider Relations, Provider Workshops. QUESTIONS Please submit questions through the room Questions or Hands Up Button Please hold all verbal questions until the Q/A section of the presentation Questions submitted during the session that were not reviewed and answered during the session will be added to the FAQ page of the KYMMIS website under Provider Relations/Provider Workshops. If questions should come up after the session please these to KY_Provider_Inquiry@hp.com. 2

3 Agenda How Medicaid Works References Medicaid Websites KYHealth Net Functions Forms/Billing Instructions NCCI/MUE Edits Informational Items ICD-10 Questions and Answers 3

4 How Medicaid Works CMS Department for Medicaid Services Medicaid Policy/Provider Enrollment Department for Medicaid Services (DMS) and Medicaid Policy enforces the rules and regulations that were designed by legislation. Member Enrollment Local DCBS office KYNECT The Local DCBS offices and KYNECT enroll members according to the rules and regulations. HP Enterprise Services HP Enterprise Services, the KYMMIS contractor, can only process claims according to the rules and regulations that Medicaid has designed. Carewise HP Enterprise Services holds the prior authorization contract, but Carewise, who is the subcontractor for HP Enterprise Services, can only issue prior authorizations according to the rules and regulations that Medicaid has designed. 4

5 DEPARTMENT PHONE NUMBER OR WEB ADDRESS ROLES HP Provider Billing Inquiry Claim status, denials, billing questions, member eligibility inquiries and service limitations, PA Inquiries (Providers only) EDI Helpdesk Electronic billing, Electronic RA s, PIN request and password resets Carewise Prior Authorizations, Waiver Eligibility Department for Medicaid Services Member Services Questions or updates to a members file DCBS Contact Center Member eligibility, patient liability (MAP 552), hospice election and termination Department for Medicaid Services Provider Services Department for Medicaid Services Provider Enrollment Questions regarding Medicaid Policy and Member eligibility files (Providers only) Program.integrity@ky.gov Questions or updates to the provider file or enrolling as a new provider. HP Provider Representatives Varies by County Varies by County Provider training, conference calls, association meetings and any escalated issue. (Providers only) 5

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7 Representatives Area Map 7

8 Medicaid Websites Department for Medicaid Services Regulations Fee Schedules Provider Enrollment KYMMIS Billing Instructions Forms Prior Authorization Provider Enrollment Provider Relations KYHealth Net home.kymmis.com Account Management Member Eligibility Claims Billing/Status Prior Authorization Inquiry/Submission Remittance Advice Provider Enrollment Data 8

9 DMS Website Programs and Services- link to your specific regulations Fee and Rate Schedules Access to KYHealth Net System All regulations found here. 9

10 KYMMIS Access to KYHealth Net System Access to DMS Webpage Access to Billing Instructions, Forms, Workshop materials Access to Electronic Guides / KYHealth Net User Manuals 10

11 KYHealth Net Home.kymmis.com The KYHealth Net system is secured by user name and password access. No user name/password sharing is allowed per HIPAA standards. To access KYHealth Net for the first time, find instructions at 11

12 KYHealth Net Applications Change password every thirty days. Electronic Prior Authorization KYHealth Net Important Messages 12

13 KYHealth Net Provider Main Page Provider Status- printable proof of Provider Contract dates and detailed Provider information. 13

14 KYHealth Net Provider Status 14

15 KYHealth Net Provider Status continued 15

16 KYHealth Net Provider Status continued 16

17 KYHealth Net Member Tab Card issuance Eligibility Verification MCO Member Information Pharmacy History Presumptive Eligibility Patient Liability Spend Down From the menu bar, hover over Member for the drop down list shown. 17

18 KYHealth Net Member Eligibility Verification 18

19 KYHealth Net Member Eligibility Verification continued Eligibility Groups that are billable to KY Medicaid include: Medicare Savings Optimum Choices Comprehensive Choices Global Choices MCO (will not reimburse Nursing Facility Providers or Waiver Providers) (IF MAP 552, PA and LOC all show Nursing Facility coverage this will reimburse Nursing Facility Providers) 19

20 KYHealth Net Member Eligibility Verification continued TPL shows any commercial insurance carrier information on file per member. Managed Care will show to which MCO a member is assigned. Click on 5 year history to see the MCO Member ID. *** IF MAP 552, PA, and LOC all show waiver coverage then Waiver claims can process with KY Medicaid. If the MAP 552, PA and LOC all show Nursing Facility coverage, then Nursing Facility claims can process with KY Medicaid. WAIVER and Nursing Facility providers will NEVER bill an MCO for services. Waiver shows the type of Waiver eligibility the member is approved for. NOTE: If panel shows No current coverage for date of service entered, there is simply no data inside that panel. 20

21 KYHealth Net Claims Tab Claims Inquiry Claim Submission Institutional From the menu bar, hover over Claims for the drop down list shown. Find KYHealth Net instruction guides at 21

22 KYHealth Net Claims Submission Institutional 22

23 KYHealth Net Claims Submission Institutional 23

24 KYHealth Net Claims Submission Institutional 24

25 KYHealth Net Claims Submission Institutional 25

26 KYHealth Net PA Tab MMIS Prior Authorization Letter Carewise Prior Authorization Letter Providers are now able to view Confirmation notices, Lack of Information and Denial letters online, via KYHealth Net, through Select PA from the top menu and then select the option titled Carewise Prior Authorization Letter. This will allow you to search for, save or print a copy of the letter. You must be the provider the letter was issued to in order to view and print the letter. Use the MMIS Prior Authorization Letter option to access PA letter copies. 26

27 KYHealth Net RA Viewer Tab 27

28 KYMMIS Provider Relations/Forms Provider Forms All Medicaid Assistance Program (MAP) Agreements and forms are available in the Adobe Acrobat format, and require the Adobe Acrobat Reader 5.0. PRIOR AUTHORIZATION PROVIDER ENROLLMENT PROVIDER RELATIONS 28

29 KYMMIS Provider Relations/Provider Billing Instructions 29

30 NCCI/MUE Edits National Correct Coding Initiatives (NCCI) Edits are hard coded claim edits that during claims processing edit one procedure against others billed the same date of service by the same provider for the same member. Medically Unlikely Edits (MUE) check the number of units billed against the CMS MUE Edit guidelines. Find tables for each edit at -Coding-Edits.html 30

31 Informational Items All Providers Recent update will allow those providers for whom eligibility has enddated to view their Provider Status page on KYHealth Net to know what item requires an update. Centers for Medicare and Medicaid Services (CMS) clarification regarding missed appointments Recently, several providers have requested clarification regarding charging Medicaid recipients for missed appointments. Per clarification from CMS, Medicaid providers are not permitted to bill recipients for missed appointments. Find this policy at 31

32 Informational Items All Providers- continued New Web Portal KY Medicaid will announce a web portal called Partner Portal for Provider Enrollment in the near future. 32

33 Informational Items All Providers- continued MCO claims paid then recouped If an MCO has paid your claim then later recouped the funds due to a retroactive eligibility change, the MCO must void the paid claims in the KY Medicaid history files. If the void is not completed by the MCO, the claim cannot be paid by KY Medicaid. 33

34 Informational Items All Providers Medicaid Eligibility A Medicaid Member is placed in an MCO eligibility group unless a Nursing Facility level of care determination is in place for the requested timeframe. This does not mean the member must reside in a Nursing Facility, merely that the member requires a level of care to that extent. The member s Level of Care (LOC), Prior Authorization, and the MAP 552 must be on file to pay claims for Waiver and Nursing Facility providers. Once these items are in place the member is then moved from MCO coverage to a waiver eligibility coverage such as Comprehensive Choices or Optimum Choices. When the eligibility group is changed to Comprehensive Choices or Optimum Choices, KY Medicaid becomes the payer for all provider types. 34

35 Informational Items EPSDT Providers The EPSDT (Early Periodic Screening, Diagnostic and Treatment) program provides comprehensive and preventative health care to children under age 21 who are enrolled in Medicaid. In the past, providers were enrolled in the EPSDT Special Services program under a separate Provider number. Effective immediately, the EPSDT Special Services provider number is no longer used for the services that are within your scope of practice. You will now bill those services under your traditional Medicaid NPI. All Prior authorization and medical necessity requirements are still in place. All EPSDT Special Services provider numbers will be end dated effective 7/1/15. 35

36 Informational Items Hospital Providers Occupational Therapy, revenue code 430, is a covered service for outpatient hospital billing effective with dates of service 7/4/14. This revenue code requires a CPT to be billed. Revenue code 910, Psychiatric General Service, is also a covered service for outpatient hospital billing effective with dates of service 7/4/14. This revenue code requires a CPT and modifier be billed. The modifier will be entered directly behind the CPT in field 44. The Hospital Billing Instructions are updated with the valid modifiers to be used to identify the Behavioral Health professional who treated the member. 36

37 Hospital, Mental Hospital, PRTF Presumptive Eligibility (P.E.) Overview Check for Medicaid eligibility before calling the Helpdesk. Presumptive Eligibility worksheet and income determinations must be performed before contacting the P.E. Helpdesk for confirmation. Check for new Federal Poverty Level amounts published on the P.E. Presentation at each year. The P.E. worksheet must be filed in the patient record in case of site audits and must have office staff and patient signatures to be valid. P.E. determination must be the PATIENT S choice. If the patient is not interested in the benefit, the P.E. determination cannot move forward. 37

38 Hospital, Mental Hospital, PRTF Presumptive Eligibility (P.E.) Overview Once P.E. determination is complete and confirmation number has been obtained from the helpdesk, enter the confirmation into KYHealth Net immediately. Presumptive Eligibility can be backdated (made retroactive in coverage) if the member comes in on Friday, or over the weekend, and the determination is called on Monday. The only other time retroactive P.E. can be recorded is during a holiday time period when the Helpdesk office is closed. SCENARIO: Friday is a state holiday and the Helpdesk is closed. The member came in after hours on Thursday and the P.E. provider calls the Helpdesk on Monday. That P.E. can be backdated to cover Thursday IF the confirmation is entered by the P.E. provider immediately upon receipt. If the call is not made until Tuesday, the P.E. benefits will only be backdated to Monday. 38

39 Informational Items Intermediate Care Facilities for Individuals with Intellectual Disabilities or Developmental Disabilities The Department for Medicaid Services has replaced the former name of the provider type ICF/MR with Intermediate Care Facilities for Individuals with Intellectual Disabilities or Developmental Disabilities. A new provider type named Intermediate Care Facilities for Individuals with Intellectual Disabilities or Developmental Disabilities Clinic was created for Specialty Clinics constructed on the grounds of state ICF-IDD facilities. Billing Instructions are currently under construction for these clinics. 39

40 Informational Items Nursing Facility Speech Therapy The CPT code (Evaluation of speech, language, voice and communication) was deleted by CMS on January 1, The speech therapy provider must use the most descriptive CPT code for the service being provided to the member. The code has been replaced with the following CPT codes: Evaluation of speech fluency (stuttering, cluttering) Evaluation of speech sound production (articulation, phonological process, apraxia, dysarthria) Evaluation of speech sound production (articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (receptive and expressive language) Behavioral and qualitative analysis of voice and resonance Evaluation for Aphasia Cognitive performance testing. 40

41 Informational Items Waiver Providers The Case Managers and the billing entities must work together to minimize PA issues. Share information so that the billers know when the units increase and work together to ensure the best outcome for the members care. If a modification of a Prior Authorization is required- such as an increase of units needed- the waiver provider should cease billing for that service as of the date of change. If billing continues after the code is requested to be changed, Carewise will not be able to end the existing PA to grant additional units. A void of paid claims will be necessary if the provider continues to bill for the affected code after requesting units to be increased. Providers can give a start date for modified services to start in the future to assist in coordinating the billing. 41

42 Informational Items Home and Community Based Waiver Providers Billing Michelle P. Waiver Services Speech, Physical, and Occupational Therapies are offered to members over the age of 21 in Michelle P. Waiver (MPW). Respite reimbursement is based on a calendar year for Traditional MPW and based on Level of Care (LOC) dates for MPW/CDO. Case Management 590 Occupational Therapy 430 Personal Care 581 Speech Therapy 440 Respite Care 660 Physical Therapy 420 Homemaker 582 Environmental and Minor Home Adaptations Attendant Care 580 Community Living Supports

43 ICD-10 Purpose To communicate KY Medicaid specific changes related to ICD-10 and ICD-10 testing. To understand the changes being made by KY Medicaid for ICD-10 and how they affect you and the transactions you submit. 43

44 ICD-10 KYHealth Net Screen Changes 44

45 ICD-10 KYHealth Net Screen Changes 45

46 ICD-10 KYHealth Net Screen Changes 46

47 ICD I Changes ICD code indicators are added for each claim submitted electronically. Indicator BK signifies the diagnosis sent is an ICD-9 code. The BK is in use at this time. Upon implementation of ICD-10, an ABK indicator will be sent to signify the diagnosis sent is an ICD-10 code. NOTE: Hospital inpatient claims will use the discharge date to determine which version of ICD is to be sent. If the discharge date is on or after 10/1/15, use the ICD-10 diagnosis codes. 47

48 ICD-10 Paper Claim Changes New field requirement on the paper claim submission Field 66 on the UB04 claim form will be a required field once ICD-10 changes are implemented. Field 66 must hold one of the ICD version indicators seen below. 9 = ICD-9 0 = ICD-10 NOTE: A claim cannot hold both an ICD-9 diagnosis and an ICD-10 on the same claim. 48

49 ICD-10 Roadto10.org WHEN is the compliance deadline for ICD-10? On July 31st, 2014, the U.S. Department of Health and Human Services (HHS) issued a rule finalizing Oct. 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. WHO does ICD-10 compliance affect? ICD-10 Compliance is mandatory for all HIPAA-covered entities, including those who do not handle Medicare claims. There are no exceptions to any HIPAAcovered entities. Organizations that are not governed by HIPAA who use ICD-9 codes should be aware that their coding may become obsolete in the transition to ICD-10. For guidelines on what qualifies as a HIPAA-covered entity, please visit index.html. 49

50 ICD-10 Roadto10.org WHAT does ICD-10 compliance mean? ICD-10 compliance means that HIPAA-covered entities must utilize ICD-10 codes for healthcare services rendered on or after the compliance date. Pre-Compliance Compliance Date Post-Compliance CMS and other payers will only accept, recognize, and process ICD-9 codes. Claims billed with ICD-10 codes will be rejected. CMS and other payers will only accept, recognize, and process ICD-10 codes for claims with discharge dates of service 10/1/15 and after. Claims billed with ICD-9 codes will be rejected unless the claim discharge date is 9/30/15 or before. 50

51 ICD-10 Roadto10.org WHERE can you find a list of ICD-10 codes? The ICD-10CM and ICD-10PCS code sets, as well as the official ICD-10CM guidelines, are available free of charge on the 2015 ICD-10-CM and GEMs and 2015 ICD-10-PCS and GEMs pages of the CMS ICD-10 website. HOW do providers prepare for the transition to ICD-10? The best way to get started is to get started! There are five major areas your practice needs to address. Click on the build your action plan button on the home page to begin and track your practice s ICD-10 implementation. 51

52 ICD-10 Roadto10.org DUAL CODING: Does your practice need to use both code sets during and after the transition? Practice management systems must be able to accommodate both ICD-9 and ICD-10 codes until all claims and other transactions for services prior to the compliance date have been processed and completed. Promptly processing ICD-9 transactions as the transition date nears will help limit disruptions and will limit the timeframe when dual code sets need to be used. 52

53 ICD-10 Roadto10.org TRAINING: What type of training does your practice need and where do you find it? Documentation training for physicians, nurse practitioners, physician assistants, and any other staff who document in the patient medical record. Coding training for staff members who work with codes on a regular basis. Overview training for staff members engaged in management and/or administrative functions. There are several online and instructor lead ICD-10 training options available for physician practices. Check with your affiliated hospital systems, medical societies, clearinghouses, and associated professional organizations to see what types of training they have available. You can also find a list of training resources located under Quick References or in the Training and Education Resources section of Your Action Plan on the web page. 53

54 ICD-10 Roadto10.org PAYERS & VENDERS: How should your practice ensure your compliance? It is important to ensure that all payers and technology vendors are ready for the ICD-10 compliance date. Ultimately, it is your responsibility, as a provider, to maintain compliance, regardless of the actions of your payers and vendors. KY Medicaid will conduct CMS Level II compliance testing in adherence with the ICD-10 Final Rule starting in April and continuing through June In addition to the required level II testing, we are conducting end-to-end testing with interested fee-for-service providers starting in March and continuing until September 1, If you are interested in participating, contact the EDI Technical Helpdesk at or ky_edi_helpdesk@hp.com. 54

55 Please use the Question tab on the HP My Room tool bar to type your question. 55