Clinical Medical Policy Department Clinical Affairs Division DESCRIPTION
|
|
- Jade Charles
- 6 years ago
- Views:
Transcription
1 Inpatient Rehabilitation Facilities (IRFs) [For the list of services and procedures that need preauthorization, please refer to Go to Comunicados a Proveedores, and click Cartas Circulares.] Medical Policy: MP-ME Original Effective Date: February 18, 2009 Reviewed: January 29, 2013 Revised: This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and, provider s contract; unless specific contract limitations, exclusions or exceptions apply. Please refer to the member s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions. DESCRIPTION Inpatient rehabilitation facilities (IRFs) are licensed and certified hospitals or units specialized in comprehensive rehabilitative health care. Rehabilitation is defined as the re-establishment of a disabled person to self-capacity. Inpatient rehabilitation program offer services like physical therapy, occupational therapy, speech pathology, social or psychological services, orthotics and prosthesis services to help improve functioning of patients caused by conditions such as stroke, neurological disorders, spinal cord injury, head injury, arthritis, serious fractures and loss of limb among other conditions. (MCS) will require the following criteria, which are the same, required by the Centers of Medicare and Medicaid Services (CMS) for Inpatient Rehabilitation Facilities: 1. Close Medical Supervision by a Physician with specialized training or experience in This need should be verifiable by entries in medical record that reflect frequent and direct, and medically necessary physician involvement in the patient s care; at least every 2 or 3 days during hospital stay and is an indicator of a patient s need for services generally available in hospital setting, 2. Twenty-four hour rehabilitation nursing. The patient requires 24hr availability of a registered nurse with specialized training or experience in 3. Intense level of rehabilitation services. The general threshold is that the patient must require and receive at least three hours a day of physical and/or occupational therapy. The furnishing of services no less than five days a week satisfies the requirement for daily services. In some instances, patients who require, in-patient hospital rehabilitation services may need, on a priority basis, other skilled rehabilitative modalities such as speech-language pathology services, or prosthetic-orthotic services and their stage of recovery makes the concurrent receipt of intensive physical or occupational therapy services inappropriate. 1
2 4. Multi-Disciplinary Team Approach to delivery of program. Includes a physician, rehabilitation nurse, social worker and/or psychologist, and those therapist involved in the patient s care. At a minimum, a team must include a physician, rehabilitation nurse, and one therapist. 5. Coordinated program of care. Patient records must reflect evidence of a coordinated program with documentation on records of periodic team conferences held at least weekly to: a) Assess the individual progress or problems impending progress; b) Consider resolutions to such problems; and c) Reassess the validity of the rehabilitation goals initially established. The decisions made during such conferences, such as those concerning discharge planning and the need for any adjustment in goals or in the prescribed treatment program, must be recorded in the clinical record. 6. Significant Practical improvement. Hospitalization is covered in those cases where the rehabilitation team concludes that a significant practical improvement can be expected in a reasonable period of time. It is not necessary that there be an expectation of complete independence in the activities of daily living, but there must be a reasonable expectation of improvement that is of practical value to the patient, measured against the patient s condition at the start of the rehabilitation program. 7. Realistic goals. The most realistic rehabilitation goal is self-care or independence in the activities of daily living as self-sufficiency in bathing, ambulation, eating, dressing, homemaking, etc, or sufficient improvement to allow a patient to live at home with family assistance rather than in an institution. The goal of treatment is achieving the maximum level of function possible. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, medical procedures, and drug formulary coverage. 2
3 INDICATIONS (MCS) will consider Inpatient Rehabilitation Facility (IRF) medically necessary, when the following criteria are met at the time of admission to IRF: 1. The patient must require the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy. 2. The patient must generally require an intensive rehabilitation therapy program. 3. The patient must reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program. 4. The patient must require physician supervision by a rehabilitation physician. 5. The patient must require an intensive and coordinated interdisciplinary approach to providing Note 1 : Under current industry standards, the intensive rehabilitation therapy program generally consists of at least 3 hours of therapy per day at least 5 days per week. In certain well-documented cases, this intensive rehabilitation therapy program might instead consist of at least 15 hours of intensive rehabilitation therapy within a 7 consecutive day period, beginning with the date of admission to the IRF. Rehabilitation physician is a licensed physician with specialized training and experience in inpatient The requirement for medical supervision means, that the rehabilitation physician must conduct face to face visits with the patient at least 3 days per week, throughout the patients stay in the IRF to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patients capacity to benefit from the rehabilitation process. 3
4 MCS will consider the following as qualifying medical conditions for treatment in an IRF. Other clinical scenarios will be considered in a case-by-case basis. All scenarios must meet criteria under Indications section of this policy. Medical Condition Stroke Spinal cord injury Congenital deformity Major Limb Amputation Major multiple trauma Femur fracture (hip fracture) Brain injury Neurological disorders Burns Active, polyarticular rheumatoid, psoriatic arthritis, and seronegative arthropathies Systemic vasculitides with joint inflammation Severe advanced osteoarthritis Additional comments and requirements pertaining to the condition Including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson s disease. Must result in significant functional impairment of ambulation and other activities of daily living that: Have not improved after an appropriate, aggressive, and sustained course of outpatient therapy services or; Services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission; or Result from systemic disease activation immediately before admission, but have the potential to improve with more intensive Must result in significant functional impairment of ambulation and other activities of daily living that: Have not improved after an appropriate, aggressive, and sustained course of outpatient therapy services; or Services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission; or Result from systemic disease activation immediately before admission, but have the potential to improve with more intensive Osteoarthritis or degenerative joint disease involving two or more major weight bearing joints (elbow, shoulders, hips or knees but not counting a joint with prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint. Must result in significant functional impairment of ambulation and other activities of daily living that: Have not improved after an appropriate, aggressive, and sustained 4
5 course of outpatient therapy services; or Services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission; or Result from systemic disease activation immediately before admission, but have the potential to improve with more intensive Please note, a joint replaced by prosthesis is no longer considered to have osteoarthritis, or other arthritis, even through this condition was the reason for the joint replacement. Knee or hip joint replacement, or both, during an acute hospitalization immediately preceding the inpatient rehabilitation stay The condition must meet one or more of the following specific criteria; the patient: Underwent bilateral knee or bilateral hip joint replacement surgery during the acute hospital admission immediately preceding the IRF admission; Is extremely obese with a Body Mass Index of at least 50 at the time of admission to the IRF; Is age 85 or older at the time of the admission to the IRF REFERENCES 1. American Academy of Physical Medicine and Rehabilitation. Standards for Assessing Medical Appropriateness Criteria for Admitting Patients to Rehabilitation Hospitals or Units. Prepared by: Medical Inpatient Rehabilitation Criteria Task Force; John L. Melvin, MD, MMSc, Chairman. Accessed January 29, Available at URL address: 2. Centers for Medicare & Medicaid Services (CMS). Article for Inpatient Rehabilitation Care Facility (IRF) Requirements (A18651). Article Retired and Archived. Original Effective Date: 1/29/2004. Article Revision Ending Date: 7/31/2008. Accessed January 29, Available at URL address: show=all 3. Centers for Medicare & Medicaid Services (CMS). Inpatient Rehabilitation Facility Federal Regulation Number CMS-1433-N. Prospective Payment System for Federal Fiscal Year Accessed January 29, Available at URL address: Payment/InpatientRehabFacPPS/List-of-IRF-Federal-Regulations-Items/CMS-1433-N-New.html 4. Centers for Medicare & Medicaid Services (CMS). Local Coverage Article for AIRF: Inpatient Rehabilitation facilities revision to the LCD (A49650). Original Article Effective Date: 12/17/2009. Accessed January 29, Available at URL address: 5
6 details.aspx?articleid=49650&ver=2&contrid=196&contrver=1&cntrctrselected=196*1&search Type=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cT A%7cMCD&ArticleType=Ed%7cKey%7cSAD%7cFAQ&PolicyType=Final&s=46&CntrctrType=8&Ke yword=inpatient+rehabilitation&keywordlookup=doc&keywordsearchtype=exact&kq=true& bc=iaaaabaaaaaa& 5. Centers for Medicare & Medicaid Services (CMS) Manual System. Pub Medicare Benefit Policy. Transmittal 119. Subject: Coverage of Inpatient Rehabilitation Services. Change Request Date: January 15, Accessed January 29, Available at URL address: 6. Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual Chapter 1, Section Inpatient Hospital Stays for Rehabilitation Care. Last revision 01/15/2010. Accessed January 29, Available at URL address: 7. Centers for Medicare & Medicaid Services (CMS). Medicare Inpatient Rehabilitation Facility Classification Criteria. Last updated April 12, Accessed January 29, Available at URL address: 8. Centers for Medicare & Medicaid Services (CMS). Medicare Inpatient Rehabilitation Facility Classification requirements. Medicare Learning Network (MLN) Matters Number: MM3334. Effective Date: 7/1/2004. Implementation Date: 7/1/2004. Accessed January 29, Available at URL address: 9. Centers for Medicare & Medicaid Services (CMS). Retired Local Coverage Determination (LCD) for Inpatient Rehabilitation Facilities (L28913). Original Determination Ending Date: 01/01/2010. Accessed January 29, Available at URL address: actor_id= Centers for Medicare & Medicaid Services (CMS). U.S. Department of Health and Human Services. Medicare Learning Network: Inpatient Rehabilitation Facility Prospective Payment System. ICN / September Accessed January 29, Available at URL address: Centers for Medicare & Medicaid Services (CMS). U.S. Department of Health and Human Services. List of IRF Federal Regulations. Regulation No. CMS-1349-P. Title of document: Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient Rehabilitation Units and Inpatient Psychiatric Units. Publication Date: April 29, Accessed January 29, Available at URL address: Payment/InpatientRehabFacPPS/List-of-IRF-Federal-Regulations-Items/CMS html 12. U.S. Government Accountability Office. Medicare: More Specific Criteria Needed to Classify Inpatient Rehabilitation Facilities GAO April 22, Accessed January 29, Available at URL address: & 6
7 POLICY HISTORY DATE ACTION COMMENT February 18, 2009 Origination of Policy April 22, 2010 Revised CMS LCD retired; information was revised using Medicare Benefit Policy Manual April 22, 2011 Yearly Review April 27, 2012 Yearly Review References updated. Under Indications: The term Only, was deleted right before the phrase: the following as qualifying medical conditions. In addition, the following was added Other clinical scenarios will be considered in a case by case basis. All scenarios must meet criteria under Indications section of this policy January 29, 2013 Yearly Review References updated. New references were added: numbers 2-4, & 9. This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member s plan in effect as of the date services are rendered., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion, (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide. 7
MLN Matters Number: MM6699 Related Change Request (CR) #: 6699
News Flash Medicare will cover immunizations for H1N1 influenza also called the "swine flu." There will be no coinsurance or copayment applied to this benefit, and beneficiaries will not have to meet their
More informationInpatient Rehabilitation Program Information
Inpatient Rehabilitation Program Information The Inpatient Rehabilitation Program at TIRR Memorial Hermann-Greater Heights has a team of physicians, therapists, nurses, a case manager, neuropsychologist,
More informationHospital Discharge Planning: Advocating for Seniors Medicare Rehabilitation Benefits
Chapter 22 Hospital Discharge Planning: Advocating for Seniors Medicare Rehabilitation Benefits Michele M. Lawonn, Esq., P.T., C.A.P.S. Medical-Legal Advocates, LLC SYNOPSIS 22-1. Discharge Planning 22-2.
More informationEVALUATION OF THE POST-ACUTE CARE PATIENT
EVALUATION OF THE POST-ACUTE CARE PATIENT Taylor Bailey, NP-C Jessica Reed, NP-C AGENDA What is Post-Acute Care? Why Post-Acute Care? Post-Acute Care: Who Belongs Where? Overview of Post-Acute Care inpatient
More informationBrain Injury Fact Sheet
TIRR Memorial Hermann is a nationally recognized rehabilitation hospital that returns lives interrupted by neurological illness, trauma or other debilitating conditions back to independence. Some of the
More informationFLORIDA CENTER FOR HEALTH INFORMATION AND TRANSPARENCY
FLORIDA CENTER FOR HEALTH INFORMATION AND TRANSPARENCY DATA CATALOG Rick Scott, Governor Justin M. Senior, Secretary Visit AHCA online at: www.floridahealthfinder.gov Revised 2017 TABLE OF CONTENTS PAGE
More informationCoding, Reporting and Documentation Guidance for Postacute Facilities
Coding, Reporting and Documentation Guidance for Postacute Facilities Ingenix is committed to providing our customers with the most current information necessary to meet the challenges of coding, documentation,
More informationINPATIENT ACUTE REHABILITATION HOSPITAL LIMITATIONS, SCOPE AND INTENSITY OF CARE
INPATIENT ACUTE REHABILITATION HOSPITAL LIMITATIONS, SCOPE AND INTENSITY OF CARE Bacharach Institute for Rehabilitation offers a number of in and outpatient rehabilitation programs and services designed
More informationNeurodegenerative diseases Includes multiple sclerosis, Parkinson s disease, postpolio syndrome, rheumatoid arthritis, lupus
TIRR Memorial Hermann is a nationally recognized rehabilitation hospital that returns lives interrupted by neurological illness, trauma or other debilitating conditions back to independence. Some of the
More informationInpatient Rehabilitation Program Information
Inpatient Rehabilitation Program Information The Inpatient Rehabilitation Program at TIRR Memorial Hermann The Woodlands has a team of physicians, therapists, nurses, a case manager, neuropsychologist,
More informationSharing Our 2017 Outcomes. Average Length of Stay (days) Discharge Rate to Home or Community Setting
Sharing Our 2017 Outcomes We are extremely proud of the number of our patients who have increased their independence in our inpatient rehabilitation program. Changes in independence are measured using
More informationPatients per Condition
Inpatient Rehabilitation Program Outcomes 2015 The Inpatient Rehabilitation Program at Euromedica-Arogi includes nurses, therapists who have special training and expertise in treating individuals with
More information2019 Medicare Advantage and Part D Advance Notice Parts I and II and Draft Call Letter: Ensuring Access to Medical Rehabilitation Services
DRAFT March 5, 2018 VIA ELECTRONIC MAIL Seema Verma Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244 Re:
More informationRegulatory Compliance Risks. September 2009
Rehabilitation Regulatory Compliance Risks September 2009 1 Agenda - Rehabilitation Compliance Risks Understand the basic requirements for Inpatient Rehabilitation Facilities (IRFs) and Outpatient Rehabilitation
More informationKindred, Centerre and RehabCare
Kindred, Centerre and RehabCare Creating the Nation s Premier Inpatient Rehabilitation Provider November 2014 Forward Looking Statements Certain statements contained herein contain forwardlooking statements
More informationMedicare Part C Medical Coverage Policy
Skilled Care Services Medicare Part C Medical Coverage Policy Origination: June 30, 1988 Review Date: February 21, 2018 Next Review: February, 2020 DESCRIPTION OF PROCEDURE OR SERVICE Skilled Care Services
More informationRFS-7-62 ATTACHMENT E INDIANA CARE SELECT PROGRAM DESCRIPTION AND COVERED BENEFITS
The following services are covered by the Indiana Care Select Program. Dual-eligible members, those members eligible for both IHCP and Medicare, will not receive any benefits under Indiana Care Select,
More informationSTROKE REHAB PROGRAM
STROKE REHAB PROGRAM Allied Rehab Hospital is part of Allied Services Integrated Health System, the premier post-acute health-care system in Northeast Pennsylvania, and is the region s leading provider
More informationCURRENT OIG ENFORCEMENT INITIATIVES: A ROAD MAP FOR HIGH RISK COMPLIANCE AREAS
10 th Annual HCCA Compliance Institute Session Las Vegas, NV April 25, 2006 CURRENT OIG ENFORCEMENT INITIATIVES: A ROAD MAP FOR HIGH RISK COMPLIANCE AREAS MARK HARDIMAN HOOPER, LUNDY & BOOKMAN, INC. 1875
More informationNCD for Routine Costs in Clinical Trials (310.1)
NCD for Routine Costs in Clinical Trials (310.1) Publication Number 100-3 Manual Section Number 310.1 Version Number 2 Effective Date of this Version 7/9/2007 Implementation Date 10/9/2007 Benefit Category
More informationBrain Injury Scope of Services
Brain Injury Scope of Services Patricia Neal Rehabilitation Center Fort Sanders Regional Medical Center of Covenant Health The mission of the Brain Injury Program follows within the parameters of the mission
More informationDEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. Discharge Planning
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services ICN 908184 October 2013 This page intentionally left blank. This booklet was current at the time it was published or uploaded
More information10 Ancillary Networks
10 Ancillary Networks This chapter provides information specific to healthcare providers in our contracted ancillary network. Content Section 1: Overview Section 2: Claims and Billing Section 3: Home Based
More informationMedicaid Benefits at a Glance
Medicaid Benefits at a Glance Mountain Health Trust Benefits Children (0 up to 21 years) Ambulatory Surgical Center Services Any distinct entity that operates exclusively for the purpose of providing surgical
More informationFinal Rule LSA Document #14-337(F) DIGEST 405 IAC ; 405 IAC ; 405 IAC ; 405 IAC ; 405 IAC ; 405 IAC
TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES Final Rule LSA Document #14-337(F) DIGEST Amends 405 IAC 5-22-1 to amend the definition of maintenance therapy and add a definition for rehabilitative
More informationMedicare Part A Update
Medicare Part A Update Jennifer Bogenrief, JD Manager, Regulatory Affairs AOTA AOTA Specialty Conference: Effective Documentation Friday, September 12, 2014 1 Topics Medicare Therapy Documentation Requirements
More informationBlue Shield of California
An independent member of the Blue Shield Association City of San Jose Custom ASO PPO 100 90/70 Active Employees Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage
More informationPrograms and Outcomes 2016 DATA
Programs and Outcomes 2016 DATA Table of contents 3 At a Glance 4 Choosing Your Next Level of Care 5 Comprehensive Inpatient Medical Rehabilitation 6 Stroke Rehabilitation 7 Special Diagnosis: Brain Injury
More informationCoding and Payment Guide for Chiropractic Services. A comprehensive coding, billing, and reimbursement resource for chiropractic services
Coding and Payment Guide for Chiropractic Services A comprehensive coding, billing, and reimbursement resource for chiropractic services 2014 Contents Introduction...1 Coding Systems... 1 Claim Forms...
More informationMEDICAL POLICY No R1 TELEMEDICINE
Summary of Changes MEDICAL POLICY TELEMEDICINE Effective Date: March 1, 2016 Review Dates: 12/12, 12/13, 11/14, 11/15 Date Of Origin: December 12, 2012 Status: Current Clarifications: Deletions: Pg. 4,
More informationCoding Guidelines for Certain Respiratory Care Services January 2018 (updates in red)
Coding Guidelines for Certain Respiratory Care Services (updates in red) Overview From time to time the AARC receives inquiries about respiratory-related coding and coverage issues through its Help Line
More informationSeptember 22, 2017 VIA ELECTRONIC SUBMISSION
September 22, 2017 VIA ELECTRONIC SUBMISSION The Honorable Seema Verma Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services 7500 Security Boulevard Baltimore,
More informationTitle 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 07 Medical Day Care Services Authority: Health-General Article, 2-104(b), 15-103, 15-105, and 15-111, Annotated
More informationGender. Age DEMOGRAPHICS POINTS OF DISTINCTION COMISSION FOR ACCREDITATION OF REHABILITATION FACILITIES STATE OF FLORIDA BRAIN AND SPINAL CORD PROGRAM
POINTS OF DISTINCTION 89-bed Acute Adult Inpatient Rehabilitation Unit, All private rooms 4 th largest Rehabilitation provider in the state of Florida Admitted 2157 patients from April 2017 through March
More informationDEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. Discharge Planning
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services ICN 908184 October 2014 This booklet was current at the time it was published or uploaded onto the web. Medicare policy
More informationSummary of Benefits CCPOA (Basic) Custom Access+ HMO
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits CCPOA (Basic) Custom Access+ HMO CCPOA Effective January 1, 2019 HMO Benefit Plan This Summary of Benefits
More informationT M A V e r s i o n TABLE OF CONTENTS PART DEFINITIONS
(a) General. 1 (b) Specific definitions. 1 Abortion. 1 Absent treatment. 1 Abuse. 1 Abused dependent. 1 Accidental injury. 2 Active duty. 2 Active duty member. 2 Activities of daily living. 2 Acupuncture.
More informationMedicare Home Health Prospective Payment System (HHPPS) Calendar Year (CY) 2013 Final Rule
Last updated 11/13/12 Contact: Advocacy@apta.org Medicare Home Health Prospective Payment System (HHPPS) Calendar Year (CY) 2013 Final Rule Introduction COMPREHENSIVE SUMMARY On November 2, 2012, the Centers
More informationMental Health Certified Family Peer Specialist (CFPS)
Mental Health Certified Family Peer Specialist (CFPS) Policy Number: SC170065A1 Effective Date: May 1, 2018 Last Updated: PAYMENT POLICY HISTORY VERSION DATE ACTION / DESCRIPTION Version 1 5/1/2018 The
More informationExhibit A. Part 1 Statement of Work
Exhibit A Part 1 Statement of Work Contractor shall provide Basic Neurological services as described herein to Medicaid eligible Clients who are authorized to receive services at the Contractor s owned
More informationManaged Care Referrals and Authorizations (Central Region Products)
In this section Page Overview of Referrals and Authorizations 10.1 Referrals 10.1! Referrals: SelectBlue only 10.1! Definition of referrals 10.1! Services not requiring a referral 10.1! Who can issue a
More informationPlace of Service Code Description Conversion
Place of Conversion CMS Place of Code Place of Name The place of service field indicates where the services were performed Possible values include: Code Description Inpatient Outpatient Office Home 5 Independent
More informationToday s educational presentation is provided by. The software that powers HOME HEALTH. THERAPY. PRIVATE DUTY. HOSPICE
Today s educational presentation is provided by The software that powers HOME HEALTH. THERAPY. PRIVATE DUTY. HOSPICE At Kinnser, we believe post-acute care businesses need the right software solution for
More informationCigna Medical Coverage Policy
Cigna Medical Coverage Policy Subject Observation Care Table of Contents Coverage Policy... 1 General Background... 2 Coding/Billing Information... 4 References... 5 Effective Date... 10/15/2014 Next Review
More informationNEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES PROCEDURE CODES & FEE SCHEDULE
NEW YORK STATE MEDICAID PROGRAM REHABILITATION SERVICES PROCEDURE CODES & FEE SCHEDULE Table of Contents General Rules and Information... 3 Occupational Therapist, Physical Therapist and Speech Language
More informationReference materials are provided with the criteria and should be used to assist in the correct interpretation of the criteria.
InterQual Level of Care Criteria Rehabilitation Criteria Review Process Introduction InterQual Level of Care Criteria support determining the appropriateness of admission, continued stay, and discharge
More informationAdministration ~ Education and Training (919)
The Accreditation Council for Graduate Medical Education requires the educational program to provide a curriculum that must contain the following educational components to its Trainees; overall educational
More informationIrvine Unified School District ASO PPO /50
An Independent member of the Blue Shield Association Irvine Unified School District ASO PPO 500 90/50 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) THIS
More information2. This additional imaging modality applied to a base procedure, must meet but, not exceed the patient s medical need; and
3D Interpretation and Reporting of Imaging Studies [For the list of services and procedures that need preauthorization, please refer to www.mcs.com.pr. Go to Comunicados a Proveedores, and click Cartas
More informationState of Connecticut REGULATION of. Department of Social Services. Payment of Behavioral Health Clinic Services
R-39 Rev. 03/2012 (Title page) Page 1 of 17 IMPORTANT: Read instructions on back of last page (Certification Page) before completing this form. Failure to comply with instructions may cause disapproval
More informationPlatinum Local Access+ HMO $25 OffEx
Platinum Local Access+ HMO $25 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED
More informationSkilled Nursing Facility Level of Payment Guidelines for Tufts Health Plan Senior Care Options Members
Skilled Nursing Facility Level of Payment Guidelines for Tufts Health Plan Senior Care Options Members For level of payment guidelines for Tufts Medicare Preferred HMO members, click here. LEVEL 1A - SKILLED
More informationSummary of U.S. Senate Finance Committee Health Reform Bill
Summary of U.S. Senate Finance Committee Health Reform Bill September 2009 The following is a summary of the major hospital and health system provisions included in the Finance Committee bill, the America
More informationThe Pain or the Gain?
The Pain or the Gain? Comprehensive Care Joint Replacement (CJR) Model DRG 469 (Major joint replacement with major complications) DRG 470 (Major joint without major complications or comorbidities) Actual
More informationMedicare General Information, Eligibility, and Entitlement
Medicare General Information, Eligibility, and Entitlement Chapter 4 - Physician Certification and Recertification of Services Transmittals for Chapter 4 Table of Contents (Rev. 50, 12-21-07) 10 - Certification
More informationMEDICAL POLICY No R2 TELEMEDICINE
Summary of Changes Clarifications: Page 1, Section I. A 6, additional language added for clarification. Deletions: Additions Page 4, Section IV, Description, additional language added in regards to telemedicine.
More informationRural Health Clinic Overview
TrailBlazer Health Enterprises Rural Health Clinic Overview Steven W. Mildward Published March 2012 108724 2012 TrailBlazer Health Enterprises /TrailBlazer. All rights reserved. Important The information
More informationDean Health Plan Physical Medicine Overview
Dean Health Plan Physical Medicine Overview Provider Training / Presented by: Leta Genasci Above and throughout this document, NIA Magellan refers to National Imaging Associates, Inc. Dean Health Plan
More informationKaiser Permanente Washington - Pre-Authorization requirements:
Kaiser Permanente Washington - Pre-Authorization requirements: Kaiser Permanente Washington requires pre-authorization for most services to be covered. The information below outlines pre-authorization
More informationClinical Utilization Management Guideline
Clinical Utilization Management Guideline Subject: Therapeutic Behavioral On-Site Services for Recipients Under the Age of 21 Years Status: New Current Effective Date: January 2018 Description Last Review
More information10 Ancillary Networks
10 Ancillary Networks This chapter discusses information specific to healthcare providers in our contracted ancillary network. Content Section 1: Overview Section 2: Claims and Billing Section 3: Home
More information8/6/2013. More than a Century of Legal Experience. Agenda
Swing Bed Services: 3 Day Qualifying Stays, Medically Necessary Admissions, and Observation Services Oh My!!! August 13, 2013 Presented by: Jennifer McManis More than a Century of Legal Experience This
More informationGold Access+ HMO $30 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix)
Gold Access+ HMO $30 OffEx Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED
More informationINPATIENT REHABILITATION UNIT Outcomes Report
INPATIENT REHABILITATION UNIT 017 Outcomes Report Welcome to the unit CARF accredited We re proud to share that the Commission on the Accreditation of Rehabilitation Facilities (CARF) has accredited St.
More informationBlue Choice PPO SM Provider Manual - Preauthorization
In this Section Blue Choice PPO SM Provider Manual - The following topics are covered in this section. Topic Page Overview E 3 What Requires E 3 evicore Program E 3 Responsibility for E 3 When to Preauthorize
More informationVANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION
VANTAGE HEALTH PLAN FACILITY CREDENTIALING APPLICATION GENERAL INFORMATION Primary Practice Facility Location The type of application being submitted: Please choose facility type (check all that apply):
More informationInformation for Adults with Physical Disabilities and Long Term Neurological Conditions
Information for Adults with Physical Disabilities and Long Term Neurological Conditions Rehabilitation Medicine Service Community & Therapy Services Directorate of Operations This leaflet has been designed
More informationMedical Policy Definition of Skilled Care
Medical Policy Definition of Skilled Care Document Number: 015 Authorization required for skilled care and shortterm rehab Notification within 24 hours or next business day No notification or authorization
More informationChapter 13 Section 2. Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups
Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC) Chapter 13 Section 2 Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups Issue Date:
More informationBlue Cross provides administrative claims services only. Your employer or plan sponsor is financially responsible for claims.
HOPE COLLEGE - HOURLY ORANGE 007013084/0011/0012/0013/0014/0015/0016/0017 Simply Blue PPO HSA ASC Effective Date: On or after July 2018 Benefits-at-a-glance This is intended as an easy-to-read summary
More informationUNIVERSITY OF MICHIGAN BZK Effective Date: 01/01/2018
UNIVERSITY OF MICHIGAN 68712000 0070051870000-06BZK Effective Date: 01/01/2018 This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional
More informationWakeMed Rehab Spinal Cord Injury Scope of Service
WakeMed Rehab Spinal Cord Injury Scope of Service The WakeMed Rehab Continuum provides an integrated, comprehensive delivery of rehabilitation services utilizing evidence-based practice directed toward
More information# December 29, 2000
#00-53-3 December 29, 2000 Minnesota Department of Human Services 444 Lafayette Rd. St. Paul, MN 55155 OF INTEREST TO! County Social Service Directors/Supervisors! County Designated LMHA for PASRR! County
More informationReview Process. Introduction. InterQual Level of Care Criteria Subacute & SNF Criteria. Reference materials. Informational notes
InterQual Level of Care Criteria Subacute & SNF Criteria Review Process Introduction InterQual Level of Care Criteria support determining the appropriateness of admission, continued stay, and discharge
More informationReview Process. Introduction. InterQual Level of Care Criteria Long-Term Acute Care Criteria
InterQual Level of Care Criteria Long-Term Acute Care Criteria Review Process Introduction InterQual Level of Care Criteria support determining the appropriateness of Long-Term Acute Care (LTAC) admission,
More informationSection 4 - Referrals and Authorizations: UM Department
Section 4 - Referrals and Authorizations: UM Department Primary Care Referral Process 1 Referrals to In-Network Specialists 1 Referrals to Out-Of-Network Specialists 2 Consultation Referral Forms 2 Consultation
More informationSummary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000
Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000 Group Plan PPO Savings Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this
More informationMedicare Preventive Services
Medicare Preventive Services Presented by Part B Provider Outreach & Education December 16, 2015 Event Instructions Today s event is a teleconference Slides will not be advanced during the presentation
More informationAdministration ~ Education and Training (919)
The Accreditation Council for Graduate Medical Education requires the educational program to provide a curriculum that must contain the following educational components to its Trainees; overall educational
More information5101: Home health services: provision requirements, coverage and service specification.
Page 1 of 8 5101:3-12-01 Home health services: provision requirements, coverage and service specification. (A) Home health services includes home health nursing, home health aide and skilled therapies
More informationCMS has finalized its proposal to eliminate Medicare payment for consultations and use the money from
Consultation Services and Transfer of Care CMS has finalized its proposal to eliminate Medicare payment for consultations and use the money from these services to increase payments for visits, including
More informationSubmitting Inpatient Rehabilitation Requests for Authorization
Submitting Inpatient Rehabilitation Requests for Authorization Keys to Success Clinical Webinar for Acute Inpatient Rehabilitation Objectives State the purpose of acute inpatient rehabilitation authorizations
More informationBenefits. Benefits Covered by UnitedHealthcare Community Plan
Benefits Covered by UnitedHealthcare Community Plan As a member of UnitedHealthcare Community Plan, you are covered for the following MO HealthNet Managed Care services. (Remember to always show your current
More informationInpatient Rehabilitation. Scope of Services
Inpatient Rehabilitation Scope of Services Inpatient Rehabilitation is a 12-bed inpatient unit located within Nationwide Children s Hospital. Nationwide Children s is a 451-bed, Level I Trauma Center.
More informationGlobal Surgery Fact Sheet
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Global Surgery Fact Sheet Definition of a Global Surgical Package This fact sheet is designed to provide education on the
More informationMEDICAL POLICY No R5 PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS
PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS Effective Date: September 8, 2014 Review Dates: 10/07, 10/08, 10/09, 6/10, 6/11, 6/12, 6/13, 8/14, 8/15, 8/16, 8/17 Date Of Origin:
More informationAudio Title: Revised and Clarified Place of Service (POS) Coding Instructions Audio Date: 6/3/2015 Run Time: 16:03 Minutes ICN:
Audio Title: Revised and Clarified Place of Service (POS) Coding Instructions Audio Date: 6/3/2015 Run Time: 16:03 Minutes ICN: 909207 Welcome to Medicare Learning Network Podcasts at the Centers for Medicare
More informationChapter 9 Section 1. Ambulatory Surgical Center (ASC) Reimbursement
Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1 Issue Date: August 26, 1985 Authority: 32 CFR 199.14(d) Copyright: CPT only 2006 American Medical Association (or such other date of publication of
More informationQuestions and Answers on the CMS Comprehensive Care for Joint Replacement Model
Questions and Answers on the CMS Comprehensive Care for Joint Replacement Model MEGGAN BUSHEE, ESQ. 704.343.2360 mbushee@mcguirewoods.com 201 North Tryon Street, Suite 3000 Charlotte, North Carolina 28202-2146
More informationNEIGHBORHOOD HEALTH PARTNERSHIP POS SUMMARY OF BENEFITS
XV-2 $30/$60/$200/$1,000/80% R NEIGHBORHOOD HEALTH PARTNERSHIP POS SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to the Point of Service (POS) Plan you have with Neighborhood
More informationSmartSaver. A Medicare Advantage Medical Savings Account Plan. Summary of Benefits and Other-Value Added Services. From Blue Cross of California
SmartSaver From Blue Cross of California A Medicare Advantage Medical Savings Account Plan Service Area C Summary of Benefits and Other-Value Added Services H5769 2007 CO 415 09/22/06 Introduction to the
More informationSummary of Benefits Advantra Freedom PEBTF
Advantra Freedom is a Medicare Advantage Private Fee-For-Service (PFFS) Plan. This Summary of Benefits tells you some features of our Plan. It doesn't list every service that we cover or list every limitation
More informationPassport Advantage Provider Manual Section 5.0 Utilization Management
Passport Advantage Provider Manual Section 5.0 Utilization Management Table of Contents 5.1 Utilization Management 5.2 Review Criteria 5.3 Prior Authorization Requirements 5.4 Organization Determinations
More informationLong-Term Care Glossary
Long-Term Care Glossary Adjudicated Claim Activities of Daily Living (ADL) A claim that has reached final disposition such that it is either paid or denied. Basic tasks individuals perform in the course
More informationReviewing Short Stay Hospital Claims for Patient Status: Admissions On or After October 1, 2015 (Last Updated: 11/09/2015)
7 Reviewing Short Stay Hospital Claims for Patient Status: Admissions On or After October 1, 2015 (Last Updated: 11/09/2015) Medical Review of Inpatient Hospital Claims Starting on October 1, 2015, the
More information2017 Summary of Benefits
H5209 004_DSB9 23 16 File & Use 10/14/2016 DHS Approved 10 7 2016 This is a summary of drug and health services covered by Care Wisconsin Medicare Dual Advantage Plan (HMO SNP) January 1, 2017 to December
More informationOutpatient Observation Services
Outpatient Observation Services Presented by: Gina Hobert, MBA, CHC, CPC-I, CPMA, CEMC, CRC Sr. Manager, Baker Newman Noyes Definition MCR Benefit Policy Manual, CMS 100-02, Chapter 6, 20.6 A. Outpatient
More informationhospic Hospice Care 1 Hospice care is a medical multidisciplinary care designed to meet the unique needs of terminally ill individuals.
Hospice Care 1 Hospice care is a medical multidisciplinary care designed to meet the unique needs of terminally ill individuals. Hospice care is used to alleviate pain and suffering, and treat symptoms
More informationFlorida Medicaid. Outpatient Hospital Services Coverage Policy. Agency for Health Care Administration. Draft Rule
Florida Medicaid Agency for Health Care Administration Draft Rule Table of Contents Florida Medicaid 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority... 1 1.3 Definitions... 1 2.0 Eligible
More informationChoice PPO Retired Employees Health Program Non-Medicare Eligible Retired Members
Choice PPO Retired Employees Health Program Non-Medicare Eligible Retired Members DEDUCTIBLE (per calendar year) Annual in-network deductible must be paid first for the following services: Imaging, hospital
More information