Home Health & HP Provider Relations

Transcription

1 Home Health & Hospice HP Provider Relations October 2010

2 Agenda Session Objectives Home Health Benefit Coverage Billing Overhead Multiple Visits Most Common Denials Hospice Benefit Coverage Election/Revocation/Discharge Billing Most Common Denials Helpful Tools Questions 2

3 Session Objectives Home Health providers will: Understand basic coverage requirements Identify the revenue codes and procedure codes to use for billing Understand how to report units and overhead Understand when a prior authorization is not needed Learn how to resolve the top reasons for home health claim denials Hospice providers will: Learn what is involved in the election, revocation, and discharge processes for hospice members Learn what is required for a member to change hospice providers Identify appropriate revenue codes for billing Learn how to resolve the top reasons for hospice claim denials 3

4 Learn Home Health

5 Home Health Coverage Home health services are available when: Members are medically confined to the home Services are ordered d in writing by a physician Services align with a written plan of care Note: Home health services require prior authorization 5

6 Home Health Home health versus HCBS Waiver Homebound Defined: IHCP members, who, because of illness or injury, are unable to leave home without assistance of another person or an assistive device such as a wheelchair or walker, or for whom leaving the home is contrary to medical advice Home health services are appropriate for care and treatment of acute or chronic conditions, rehabilitation, education regarding care, coordination of community services, or to avoid prolonged or repeated hospitalization and/or higher and more costly levels of care Certain home health services duplicate services provided by Home and Community-Based Service (HCBS) Waiver providers BT201022, dated July 6, 2010, assists case managers and providers in determining the appropriate services (Waiver vs. Medicaid) needed for members eligible under the HCBS Waiver program 6

7 Bill Electronic Claims

8 Home Health Web interchange Claims Processing Menu 8

9 Institutional Claim 9

10 Institutional Claim 10

11 Bill Paper Claims

12 Home Health Paper Claims Mail UB-04 paper claims to the following address: HP Home Health Claims P.O. Box 7271 Indianapolis, IN Claims for members assigned to a managed care entity (MCE) must be mailed to the appropriate MCE Anthem Managed Health Services MDwise 12

13 Home Health Revenue Codes and HCPCS/CPT Codes Home health providers bill services according to the following codes Direct prior authorization inquiries to ADVANTAGE or MDwise HCPCS/ Revenue HCPCS/ CPT Code Code CPT Code Revenue Code Revenue Code HCPCS Code 420 G G G G G G G G G G G G G G G TE TD 559 S , CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 13

14 Home Health Units and Partial Units Therapy services One unit equals 15 minutes Requires treatment lasting 8 minutes or more to bill for one unit Providers cannot bill when the service lasts fewer than 8 minutes Home Health Aides, LPN, and RN Services One unit equals one hour Visits for less than one hour are billed as one unit if a service is performed Visits longer than one hour are billed as a partial unit Partial Unit Round partial units of service to the nearest whole unit For nursing services, round up to the nearest whole unit when services last 30 minutes or more 14

15 Home Health Overhead Providers receive a state-wide flat overhead rate for administrative costs and a staffing reimbursement component The IHCP allows one overhead rate per provider per member per day Report occurrence code 61 on claims to report the overhead 61 indicates that one encounter with the member occurred on the date of service For consecutive dates of service, report occurrence code 61 and the date range in the Span Date field When billing for multiple members at the same location on the same date, report occurrence code 61 to only one of the members claim 15

16 Home Health Hospital Discharge Certain services are reimbursable without a prior authorization following a hospital discharge as follows: Therapy services Any combination of therapy services up to 30 units in 30 days following the discharge Use occurrence code 53 on the claim Occurrence code 53 indicates HHA billing for initial therapy evaluations Nursing services May not exceed 120 units within 30 days following the discharge Use occurrence code 50 on the claim Occurrence code 50 indicates previous hospital discharge Services must be ordered in writing by a physician prior to the hospital discharge Member must be homebound 16

17 Home Health Reimbursement Rates BT201018, dated June 1, 2010, provides the rates for home health services for state fiscal year 2011 Home health services are subject to a 5% rate reduction through June 30, 2011, as follows: Service Overhead SFY 2011 Rate Registered nurse (RN) TD $ per hour Licensed practical nurse (LPN) TE $34.30 per provider, per recipient, per day $25.01 per hour Home health aide $19.31 per hour Physical therapy G0151 Occupational therapy G0152 Speech therapy G0153 $14.39 per 15-minute increments $13.65 per 15-minute increments $14.91 per 15-minute increments 17

18 Deny Common Denials

19 Most Common Denial Codes Home Health Edit 4021 Procedure code is not covered for the dates of service for the program billed. Cause The procedure code billed is restricted to a specific program for the dates of service billed and there is no prior authorization ti Resolution Electronic Resubmit the claim and correct the procedure code. See the table on Slide #13 for the list of valid procedure codes. Paper Resubmit the claim and correct the procedure code. See the table on Slide #13 for the list of valid procedure codes. 19

20 Most Common Denial Codes Home Health Edit 0558 Coinsurance and deductible amount is missing indicating that this is not a crossover claim Cause The claim is missing the Medicare coinsurance amount Resolution Electronic Click the Benefits Information button to include the Medicare coinsurance reason code (2) and amount Paper Enter the Medicare coinsurance value code (A2) and amount in field locator 39 of the UB-04 claim form 20

21 Most Common Denial Codes Home Health Edit 3001 Dates of service not on the PA master file Cause The dates of service billed on the claim have not been prior authorized Resolution Electronic and Paper If no prior authorization was requested, complete the Prior Authorization Request Form and fax it to ADVANTAGE Health Solutions or MDwise If a PA was requested but was not approved, contact ADVANTAGE or MDwise for assistance If a PA was requested and was approved, resubmit the claim and ensure that all the dates of service on the claim were approved on the PA 21

22 Most Common Denial Codes Home Health Edit 5001 This is a duplicate of another claim Cause The exact same claim was submitted more than once and the claim has already been paid Resolution Electronic and Paper Look up the claim in Web interchange using the Member ID and Date of Service. The results will identify the date that the claim paid. 22

23 Most Common Denial Codes Home Health Edit 0516 The occurrence code dates do not match the claim detail dates Cause The occurrence code date in the header portion of the claim does not match any of the service dates on the detail lines on the claim Resolution Electronic Resubmit the claim ensuring the occurrence code date (for overhead) matches each date of service in the detail portion of the claim Paper Resubmit the claim ensuring that the occurrence code date (for overhead) in field locators 31a-34b match each date of service in the detail portion of the claim in field locator 45 23

24 Learn Hospice

25 Hospice Benefit Periods The hospice benefit applies to those who are certified as terminally ill Note: A member is considered terminally ill if, given that the illness runs its normal course, the medical prognosis suggests a life expectancy of six months or less Hospice eligibility is available in three consecutive benefit periods: Period 1: 90 days Period 2: 90 days (expected maximum length of illness to run its course) Period 3: Unlimited 60-day period For Medicaid-only members, each benefit period requires prior authorization based on medical necessity 25

26 Hospice Levels of Care Hospice services are reimbursed at one of four levels of care: Routine home hospice care Continuous home hospice care Inpatient respite hospice care General inpatient hospice care 26

27 Hospice Election A member must elect the hospice benefit by completing a Medicaid Hospice Election State Form (R/11-04)/OMPP 0005 When completing the election form, the member or representative specifies an effective date for the hospice benefit and the name of the hospice provider that will render care Note: All hospice forms are available under the Forms link at 27

28 Hospice Election Members who elect the hospice benefit agree to waive the following: Other forms of healthcare for treatment of the terminal illness for which hospice care was elected or for treatment of a condition related to the terminal illness Services provided by another provider equivalent to the care provided by the elected hospice provider Hospice services other than those provided by the elected hospice provider or its contractors 28

29 Hospice Election The hospice provider has responsibility for the management of the member s care If the member resides in a nursing facility, the hospice provider should provide a copy of the Medicaid Hospice Election State Form to the facility for inclusion i in the member s clinical i l record This ensures that the nursing facility staff knows that the member has elected the IHCP hospice benefit The hospice provider should develop coordination procedures with the nursing facility to avoid reimbursement problems between the hospice provider and nursing facility The nursing facility must be aware when the member elects, revokes, or is discharged from hospice care 29

30 Hospice Election Care Select and risk-based managed care members who elect the hospice benefit must be disenrolled from these programs and transitioned to Traditional Medicaid To disenroll the member from managed care programs, the hospice provider faxes the member election forms to ADVANTAGE Health Solutions at Provider should contact ADVANTAGE the same day to ensure receipt of the fax and dtimely disenrollment tfrom the managed care programs ADVANTAGE contacts the enrollment broker (MAXIMUS) to facilitate the disenrollment Hospice provider may bill for services beginning the day after the member is disenrolled from the managed care programs 30

31 Hospice Revocation The member has the right to revoke hospice services at any time Revocation is a patient-initiated initiated process To revoke services, the member or representative must complete the Medicaid Hospice Revocation State Form (4/98)/OMPP 0007, and specify the effective date of the revocation The hospice provider faxes the Medicaid Hospice Revocation State Form to ADVANTAGE Health Solutions at

32 Hospice Revocation A member can elect to receive hospice care intermittently, rather than consecutively, over the three benefit periods If a member later re-elects the hospice benefit, the member returns as a re-enrollment to the next eligible hospice benefit period Upon re-election the hospice provider submits the following forms to ADVANTAGE Health Solutions: Medicaid Hospice Election State Form (R/11-04)/OMPP 0005 Medicaid Hospice Physician Certification State Form (R/12-02)/OMPP 0006 Updated plan of care Documentation must prove medical necessity 32

33 Hospice Discharge The discharge process is initiated by the hospice provider A hospice provider may discharge a member when: The patient moves out of the hospice s service area or transfers to another hospice The hospice determines that the patient is no longer terminally ill; or The hospice determines that the patient s behavior (or other persons in the patient s home) is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired Death of the member Before discharging i a member, the hospice provider must: Advise the patient that a discharge for cause is being considered Make a serious effort to resolve the problem(s) presented by the patient s behavior or situation Ascertain that the patient s proposed discharge is not due to the patient s use of necessary hospice services Document the problem(s) and efforts made to resolve the problem(s) into the medical record 33

34 Hospice Change Hospice Provider The member may change to another hospice provider by filing a Hospice Provider Change Request Between Indiana Hospice Providers State Form (R/12-02) OMPP 0009 The new hospice provider may fax the form to ADVANTAGE Health Solutions at

35 Bill Hospice

36 Hospice Revenue Codes 651 Routine home care delivered in a private home 652 Continuous home care delivered in a private home 653 Routine home care delivered in a nursing facility 654 Continuous home care delivered in a nursing facility 655 Inpatient respite care 656 General inpatient hospice care 657 Hospice direct care physician services 659 Medicare/IHCP dually eligible nursing facility room & board 183 Nursing facility bed hold for hospice therapeutic leave days 185 Nursing facility bed hold policy for hospitalization for services unrelated to the terminal illness of the hospice member Note: Request all prior authorizations using revenue code

37 Deny Common Denials

38 Most Common Denial Codes Hospice Edit 0558 Coinsurance and deductible amount is missing indicating that this is not a crossover claim Cause The claim is missing the Medicare coinsurance amount Resolution Electronic Click the Benefit Information button to include the Medicare coinsurance reason code (2) and amount Paper Enter the Medicare coinsurance value code (A2) and amount in field locator 39 of the UB-04 claim form 38

39 Most Common Denial Codes Hospice Edit 0594 Type of bill not covered by IHCP Cause The claim reported a Type of Bill other than 822 Resolution Electronic Resubmit the claim and report 822 in the Type of Bill field Paper Resubmit the claim and report 822 in field locator 4 of the UB-04 claim form Note: Hospice claims must always report Type of Bill 822 on claims 39

40 Most Common Denial Codes Hospice Edit 4021 Procedure code is not covered for the dates of service for the program billed Cause The procedure code billed is restricted to a specific program for the dates of service billed and there is no prior authorization ti Resolution Electronic and Paper Do not report procedure codes to report hospice services 40

41 Most Common Denial Codes Hospice Edit 2505 This recipient is covered by private insurance which must be billed prior to Medicaid Cause The third party liability (TPL) file at HP indicates the member has other insurance and the claim does not indicate any activity ty by the primary payer Resolution Electronic Resubmit the claim. Click the Benefit Information button in Web interchange and indicate the primary payment information. If the TPL denied the claim, complete the Benefit Information window indicating the denial and mail the EOB using the Attachments process Paper Include the TPL payment information in field locators 50-55a (Medicare), or locators 50-55b (TPL) If the TPL denied the claim, attached the EOB to the UB-04, in addition to completing field locators a or b on the UB-04 claim form 41

42 Most Common Denial Codes Hospice Edit 2024 Recipient not eligible for this hospice level of care for the dates of service Cause The member is not approved for a hospice level of care Resolution There is no hospice authorization on file for the dates of service billed on the claim. Delay submitting claims to HP until ADVANTAGE has completed the authorization process. Members without an IHCP Nursing Facility level of care The nursing facility must complete the Pre Admission Screening or Pre Admission Screening and Resident Review in order to establish a Nursing Facility level of care. This process must be completed before ADVANTAGE can process the hospice authorization 42

43 Find Help Resources Available

44 Helpful Tools Avenues of resolution IHCP Web site at Hospice Provider Manual ADVANTAGE FFS ADVANTAGE Care Select ADVANTAGE Hospice Member Disenrollment Fax: MDwise Care Select

45 Helpful Tools Avenues of resolution Customer Assistance , or (317) in the Indianapolis local area Written Correspondence P.O. Box 7263 Indianapolis, IN Provider Relations Field Consultant 45

46 Q&A