MLTC Provider Billing Manual. For Independence Care System s Managed Long-term Care Plan

Transcription

1 MLTC Provider Billing Manual For Independence Care System s Managed Long-term Care Plan May 2017

2 TABLE OF CONTENTS Section 1: Introduction 1.1 Welcome to Independence Care System 1.2 How To Use This Manual 1.3 Our Care System Section 2: ICS Operating Procedure 2.1 Coordination of Benefits 2.2 Referrals for Services Section 3: Claims Processing 3.1 Paper Claims Submissions 3.2 Electronic Claims Submissions & Payer ID 3.3 Claim Appeals 3.4 Payments 3.5 Helpful Hints for Claims Processing 3.6 Common Causes of Delayed Payments Section 4: Specialty Services Authorization and Billing Guidelines 4.1 Adult Day Health Care 4.2 Audiology 4.3 Dental 4.4 Durable Medical Equipment 4.5 Home Care Aide Services 4.6 Home Delivery of Meals 4.7 Medical Supplies 4.8 Skilled Nursing Facility 4.9 Nutrition Services 4.10 Optometry Services 4.11 Personal Emergency Response System (PERS) 4.12 Podiatry 4.13 Rehabilitation Services 4.14 Respiratory Services 4.15 Skilled Home Health Care Services 4.16 Social Day Care 4.17 Transportation Section 5: Standard Form Instructions and Samples 5.1 UB-04 Sample Claim Form 5.2 CMS 1500 Sample Claim Form 5.3 Dental Sample Claim Form

3 Section 1: Introduction 1.1 Welcome to Independence Care System Welcome to Independence Care System! We are happy to have you as part of our Provider Network. Independence Care System is a nonprofit organization committed to assisting senior adults and people with disabilities to live independently in their communities. ICS operates a Medicaid managed long-term care plan (MLTC) called Community Care and a fully capitated Medicaid and Medicare Plan called Community Care PLUS FIDA-MMP Our role in our members lives is to coordinate a comprehensive range of health and long-term care services. ICS Community Care serves Medicaid-eligible individuals 18 years of age and above who have physical disabilities or chronic illness and who reside in the Bronx, Brooklyn, Manhattan and Queens. ICS Community Care PLUS serves adults 21 years of age and above who reside in the Bronx, Brooklyn, Manhattan and Queens. This Manual is for Community Care/MLTC providers. For a copy of the Provider Manual for Community Care PLUS providers, providerrelations@icsny.org, call Provider Relations at , or go to our website at You can learn more about ICS on our website. 1.2 How To Use This Manual This Manual will serve as your guide to working with ICS. It contains information to help you understand how the ICS referral for services and billing procedures work. The Manual is organized in sections that reflect our service categories. We hope this guide is helpful to you and we welcome feedback on how to improve the guide or our working relationship. We encourage you to review this material carefully and refer to it when you have a question. You may also any questions to our Provider Relations Department at providerrelations@icsny.org. 1.3 Our Care System At Independence Care System, we pride ourselves on member-centered care. Our care system demonstrates our passion and commitment to our members. Responsive: What s important to our members and our member s family is important to us. We work with our members or with our member s family to assess their needs for home care, health care and social services, and to develop their personalized care plan. We ensure that the plan reflects what they see as their needs, as well as the services that are most crucial to their health, safety and well-being. Instructions for Provider Billing ICS Page 1

4 Coordinated: We work with members to get them the health care and social services they need. The ICS team coordinates all of the home care, personal assistance, housekeeping, health care and social services members need, working with the member s primary care doctor, physician specialists, home care agency, and a wide array of community-based providers. Expert: A highly skilled, dedicated, diverse staff, advocating for the member and with the member to be as independent as they can be. Members work with a team of ICS professionals, backed by the resources of our full time staff, including: social workers, registered nurses, Multiple Sclerosis-certified and wound-certified nurses, Medicare and Medicaid eligibility specialists, rehabilitation therapists, wheelchair repair technicians, transportation managers, and organizers of artistic, educational and social programs especially for ICS members. Empowering: Giving the member the knowledge and skills they need to make informed decisions. Members are at the center of all of the decision-making about their care; they have the final say. Respectful: A culture of listening and understanding, where members feel they belong. ICS is at its core a community, made up of our members, their families and caregivers, providers, and our staff. In coordinating the services our members need, we are committed to nurturing that sense of community, to ensuring that everyone is treated with respect and that their voices are heard. Flexible: When the member s life changes, so do our services. The services our members need when they join ICS may not be the same services they need six weeks, six months, or six years later. Maybe they fell, were hospitalized, landed in a nursing home, and were terrified that they would never get out. At times like that, ICS is there, making the changes they need, shepherding them through the transitions they face, getting them back home. Instructions for Provider Billing ICS Page 2

5 Section 2: ICS Operating Procedures 2.1 Coordination of Benefits As a Medicaid managed long-term care plan, ICS is the payor of last resort for coveredauthorized services. If a service that has been ordered is provided to a Member who has other coverage for that benefit from Medicare and/or other Third Party Health Insurance (TPHI), an Explanation of Benefit (EOB) or Explanation of Payment (EOP) from that insurer must be submitted to ICS in order for a Provider to receive payments from ICS. Medicare deductibles are paid in full by ICS. If another insurer has made a payment for service, we will pay co-pays for covered services according to the rules below: For most services ICS will pay the difference between the payments from other insurers and the ICS allowed charge. If payments from other payors equal or exceed the ICS allowed charge, no payment will be made. For medical supplies, nursing homes, respirators (i.e., ventilators), eyeglasses and onsite rehabilitation services, ICS will pay the amount of the Medicare co-pay. For certified home health agency (CHHA) services there is no co-pay. The provider is required to maintain, and make available to ICS upon request, records of coordination of benefits proceeds collected by the provider and amounts paid by third parties directly to members. By law, providers are not allowed to charge ICS members for services covered by ICS Medicaid or Medicare. For ICS members who are covered by Medicare part B, Medicare is the primary insurer and ICS is the secondary insurer. For these members, ICS will consider payment for services that Medicare denies, at the ICS contracted rate, as well as for co-payments and fees due because Medicare benefits have been exhausted. For ICS to consider payment under these circumstances, an explanation of benefits (EOB) from Medicare must be submitted with the claim. In addition, all services must have received prior authorization from ICS. These rules apply to the following service groups: durable medical equipment; disposable medical supplies; complex rehabilitation devices; podiatry services; orthotics & prosthetics; adult day care; and social day care. Providers should include the Medicare EOB with their claim to ICS. The Medicare EOB documents ICS s responsibility for copayments and/or other payments for non-medicare-covered items authorized by ICS. ICS will reject claims that do not include the Medicare EOB other than in a very limited number of circumstances that have been established during the authorization process. In these limited Instructions for Provider Billing ICS Page 2

6 circumstances the special instructions section of the services authorization will state ICS to cover in full at the contracted rate. No EOB required. 2.2 Referrals for Services All covered services require a written authorization from an ICS Care Manager, except for urgent, non-emergency services, which may be provided upon receipt of a verbal referral from the care manager. Referrals may be for limited duration or may be standing referrals for ongoing care from a specialist provider. If services are provided without an authorization, payment may be denied. No member will be referred for services unless he/she is eligible for ICS covered services. The referral will serve as validation of membership, as well as authorization to provide services. The Care Manager is either a Nurse or a Social Worker who is primarily responsible for coordinating the health and long-term care services of a Member. Each Care Manager works as part of a larger unit that includes Member Services Associates, who provide support to both the Members and the Care Managers. Authorization is not a guarantee of payment. Providers who believe that an individual Member may need additional or different non-covered or specialty services from what they are currently receiving should discuss their concerns with the Care Management Staff. The staff is responsible for assisting Members to obtain needed services even if those services are not covered by ICS. Providers who are unable to accept a referral must notify the ICS Care Manager within 48 hours of receiving the referral, or within 24 hours for skilled nursing home care services. Instructions for Provider Billing ICS Page 3

7 Section 3: Claims Processing Independence Care System has contracted with Productive Processing Inc. (PPI) to provide claims processing and administrative services. When submitting claims to PPI, you may submit paper or electronic claims. Submitting electronically will allow us to process your claims faster and more efficiently. 3.1 Paper Claims Submissions Mail to: Independence Care System c/o Productive Processing Inc. P.O. Box 608 Black Earth, WI Phone: / (toll-free) 3.2 Electronic Claims Submissions & Payer ID The ICS Payer ID is: ICS works with two clearinghouses: MD Online (preferred) Phone: (Option 1) Providers can also call the PPI toll free customer service number at: for assistance setting up the submission of EDI claims. 3.3 Claim Appeals Mail to: Independence Care System Attention: Provider Claim Appeals 257 Park Avenue South, 2nd Floor New York, NY Appeals must be filed within 30 days of the date of the denial letter. - Determination will be completed within 45 days of the appeal submission. Instructions for Provider Billing ICS Page 4

8 3.4 Payments Claims and Invoices will be paid within 30 days of receipt for EDI claims and 45 days of receipt for paper claims, if they meet the following criteria: Received within 120 days of the date of service, and properly and accurately completed; Matches the ICS authorization for services and has the appropriate modifiers; and Requests the appropriate payment. All claims received more than 120 days after the date of service will be automatically denied for untimely filing unless accompanied by an EOB or EOP from another payor. If ICS requires additional information or documentation, ICS will pay any undisputed portion of the claim within 45 days and notify the provider of the need for additional information within 30 days of receiving the claim. Payment rates are based on negotiated rates reflected in the specific ICS/provider contract. In the event that the service provided is not covered in the contract and was not negotiated prior to provision of services, claims should be submitted using Medicaid fee-for-service rates. 3.5 Helpful Hints for Quick Claims Processing Providers should bill electronically, if possible. Claims must include Member Medicaid ID / ICS Member ID. Providers must include the appropriate CPT/HCPCS codes and modifier on all submitted claims. Providers must use the Organization name (not individual provider) with the corresponding Tax ID in Box 33 on the HCFA form and Box 1 on the UB-04 form. ICS will only pay claims where the Tax ID on the form matches the contracted tax ID. 3.6 Common Causes of Delayed Payments HCPCS code and modifier not matching exactly with the authorization Member Medicaid ID and/or ICS Member ID not included on the form Untimely submission of claims (after 120 days of DOS) Individual provider and tax ID used, as opposed to name and tax ID of contracted organization In addition, please note that EDI claims are generally processed faster than paper claims. Instructions for Provider Billing ICS Page 5

9 Section 4: Specialty Services Authorization and Billing Guidelines 4.1 Adult Day Health Care What Is Covered? Adult day health care (ADHC) provides skilled services such as nursing, physical, speech, and occupational therapies in a day program setting offered by a residential health care facility or approved extension site. Other services available in ADHC are: nutritional counseling, socialization activities, dentistry, podiatry, and administration of medications. Transportation to and from the facility may be included in the daily rate Exclusions ADHC should not be used for socialization reasons only (please see New York State Office of the Aging Social Adult Day Care Regulations [9NYCRR Social Adult Day Care Programs]) Approval Needed Billing MD order required ICS authorization required Type of claim form: UB-04 (See page 23) Fee schedule Please refer to your ICS contract. 4.2 Audiology What Is Covered? Hearing exam Hearing aid evaluation Selecting, fitting, dispensing of hearing aids Hearing aid repair Replacement of accessories (batteries) when necessary to maintain the hearing aid in functional order Exclusions In-the-canal (ITC) hearing aides that are digital or programmable are not covered. Instructions for Provider Billing ICS Page 6

10 4.2.3 Approval Needed Members can directly access a hearing exam through a network provider. Care managers can authorize hearing aids and items under $500 in cost that meet the ordering guideline criteria referenced above and, if a care manager is unsure of the item, it should be reviewed by the care management supervisor or clinical peer reviewer. Items costing more than $500 require supervisory review to determine cost effectiveness and medical necessity. Supervisors will consult with the clinical peer reviewer before a determination is made. ICS authorization required MD order not required Billing Type of claim form: CMS 1500 (See page 24) For Procedure Codes, Billing Guidelines, and Fee Schedule, please visit: Dental ICS provides dental benefits through the third-party benefit management organization Liberty Dental Plan. The provider should contact the benefit administrator to obtain the authorization. That contact number is What is Covered? Exclusions Routine, preventive dental examination and treatment once every six months such as examinations / cleaning / gum scaling / x-rays Restorative care such as fillings / bridgework / dentures Dentures lost or damaged due to loss, fire, or theft can be replaced with appropriate documentation. Dental implants Approval Needed Instructions for Provider Billing ICS Page 7

11 Member can self-refer to a network provider for routine bi-annual examination and emergent care. Provider will request authorization for payment of any treatment (routine or non-routine) to be provided resulting from the examination. Care Managers can authorize the cost of the treatment plan when it is less than $2,000 following the Medicaid fee-for-service coverage guidelines. If the treatment plan cost is greater than $2,000, the plan must be reviewed by a licensed dental consultant (prospective peer review) prior to authorization. The dental consultant will use his/her professional clinical judgment and base his/her decision on generally accepted professional guidelines. Liberty Dental Plan authorization required MD order not required Billing Type of claim form: ADA Dental Claim Form (See page 25) or CMS For Procedure Codes, Billing Guidelines, and Fee Schedule, please visit: Durable Medical Equipment What is Covered? Devices and equipment needed in the treatment of a specific medical condition or used to support functioning in activities of daily living. These include, but are not limited to: Mobility devices including wheelchairs, walkers, canes, and scooters Hospital beds Bathroom equipment Adaptive aids such as reachers Repair of the above equipment Coverage Criteria Hospital Beds ICS will cover the lease (rental) or purchase of a hospital bed to be used in a member s home. The decision to lease or purchase will be based on other insurance coverage policy, such as Medicare, and any maintenance agreements with the supplier/manufacturer. The standard hospital bed covered under the ICS policy is a semi-electric style bed. A semielectric bed has power operated controls for adjusting the head position and the foot position. The height of the bed from the floor is manually adjusted via a hand crank, located at the foot of the bed. Hospital beds are 36 wide x 80 long (similar in size to a twin/single bed). Bed extensions are available to increase the length to 86 long for members who are more than six feet tall. Instructions for Provider Billing ICS Page 8

12 A fully electric hospital bed has the added feature of power-operated control to adjust the overall height of the bed off the floor and is covered only if the member meets at least one of the following criteria: Requires adjustment of the height of the bed from the floor to safely complete independent transfers; Member weighs over 350 lbs.;** Member has a caregiver who is elderly or frail; or Member has tried to use a standard, semi-electric bed and has functional limitations due to the bed height feature being manually adjustable. ** NOTE: A member who weighs over 350 lbs. will require the use of a bariatric bed. Bariatric beds are 42 wide (6 wider than standard hospital beds). Because of the increased weight capacity, the mattress on the bariatric bed is significantly firmer than a standard hospital bed. Specialty Mattress and Support Surfaces ICS will cover payment of specialty mattresses and support surfaces for persons who have or are at risk for the development of pressure sores. ICS follows the Medicare coverage criteria to determine the type of support surface to be provided. Mobility Devices Ambulatory Aids and Wheelchairs Mobility aids covered under the Medicare Competitive Bid Program walkers and standard manual and power wheelchairs and scooters may be provided under Medicare guidelines if the member is dually eligible with Part B Medicare coverage. Claims should be processed via coordination of benefits. ICS will provide authorization for an evaluation by a qualified health care provider an occupational or physical therapist to determine the features and function of the mobility device to best meet the member s functional need. ICS coverage policy of all mobility devices follows Medicare guidelines for mobility assistive equipment (MAE), with the exception of the in the home use, only limitation. ICS will cover a needed mobility device for both/either in home use and/or for community use. If the need for a wheeled mobility device is only for community use, the claim can be submitted with a GY modifier (known Medicare denial), along with documentation of a clinical assessment conducted by a qualified health care provider (i.e., OT, PT). For a member with complex rehab needs, the provider is encouraged to refer the member back to ICS for a full seating and mobility assessment by a certified assistive technology professional (ATP) to generate a recommendation as the result of a clinical assessment of both functional and environmental needs. Patient Lifts Instructions for Provider Billing ICS Page 9

13 ICS will cover payment for the use of a mechanical lift for members who are unable to be safely transferred using either a stand-pivot method or assisted use of a transfer board. Lifts are either leased (rented) or purchased depending on primary insurance coverage policy, length of need or maintenance agreements with the supplier and/or manufacturer. Members who are unable to safely perform a stand-pivot transfer with the assistance of personal care assistant (PCA) or a sliding board transfer will need to use a mechanical lift when being transferred by a PCA. The standard mechanical lift as defined by ICS coverage policy is a manually operated, hydraulic lift with sling. All sling styles and attachment methods available on manually operated lifts will be covered. A fully electric lift (power-operated lifting arm) will be covered if the member meets one of the following criteria: Member weighs over 300 lbs.; Caregiver is frail or elderly; or A standard lift has been tried and the member has functional limitations due to the lack of a power-operated lifting arm. For members who have never used a mechanical lift, an in home physical therapy (PT) evaluation will be needed to evaluate the member and the environment for the safe use of the lift. If a lift is recommended, the PT will provide instruction to the PCA and family members on safe and effective use of the lift. A one-month rental of a patient lift will be authorized to have a lift available to the PT as part of the evaluation Approval Needed For dually eligible members with Part B coverage, no additional authorization is required from ICS for a claim demonstrating coordination of benefits with Medicare Part B, requesting payment of the Medicare 20% co-pay only. For ICS payment the following is needed: MD order is required ICS authorization required Authorization will be provided following submission of: o Supplier quote (including pricing following Medicaid fee structure). o Supporting documentation and justification by a qualified health care professional that outlines the Member s need for the requested item if the item is not the least costly alternative item to meet the need Billing Instructions for Provider Billing ICS Page 10

14 Type of claim form: CMS 1500 For Procedure Codes, Billing Guidelines, and Fee Schedule, please visit: Home Care Aide Services What is Covered? Exclusions Home health aides (HHAs) provided as part of a treatment plan administered by a certified home health agency Personal care aides (PCAs) Home care aide hours should not be approved for time a member spends in an adult day health program or dialysis treatment Approval Needed Care Manager includes the need for home care aide services on care plan and authorizes the type and number of hours. MD order required. Physician certifies the need for service, but does not determine the number of hours, but may make a recommendation. No MD orders are needed for housekeeping services. ICS authorization required. The ICS authorization of hours and days of the week must exactly match the hours and dates of service rendered by the service provider. Note Regarding billing authorization for home care services All PCA services must receive prior authorization from ICS. If we have not authorized PCA services prior to receipt of a claim, the claim will be denied. At the same time, we recognize that some situations require an aide to provide services or remain with a member beyond what is standardly authorized. These situations should be pre-authorized by ICS whenever possible. In the event you are unable to request the change prior to the services being provided, they must be requested within 48 hours. The ICS Home Care Aide Services staff will then review the request with the member s care manager to determine whether the additional hours are warranted. ICS will not approve requests for the following reasons: A member /client is not informed that a replacement worker is being assigned and refuses the worker upon arrival at the member s home. A PCA arrives late; the member/client was not informed and refuses the worker upon arrival. ICS discontinues or suspends home care services and the aide reports to the member/client s home after 24 hours advance notice of the suspension was provided to the agency. Instructions for Provider Billing ICS Page 11

15 In addition, if a change in shift occurs, resulting in additional hours, you may only submit a claim for the hours of service reflected on the PCA authorization. ICS must be notified of the shift change within 48 hours for retroactive adjustment to the authorization. ICS will not make adjustments to hours on the PCA authorization if prior approval of the change was not requested from an ICS staff member within 48 hours of the change. If you have questions please contact Jeanie Harper, Director of Home Care Quality and Home Care Services, at Billing Type of claim form: UB-04 For Procedure Codes, please refer to the table on the following page: Instructions for Provider Billing ICS Page 12

16 HOME CARE PROCEDURE CODES TABLE MODIFIER 1 ICS SERVICE PROVIDED HCPCS HOME HEALTH AIDE S5125 HOUSEKEEPER - HOURLY T1019 1A HOUSEKEEPER - ONE TIME ONLY MODIFIER 2 MODIFIER 3 T1019 1A 1D 1D Modifier used to distinguish one time cleaning HOUSEKEEPER - ONE TIME ONLY T1019 1A 1D 1J 1D Modifier used to distinguish one time cleaning 1J Modifier used to distinguish heavy duty cleaning PERSONAL ASSISTANT T1019 1B 1B modifier used to PERSONAL ASSISTANT - MUTUAL PERSONAL ASSISTANT - SLEEP IN DAILY PERSONAL ASSISTANT SLEEP IN DAILY MUTUAL PERSONAL CARE AIDE PERSONAL CARE AIDE - MUTUAL PERSONAL CARE AIDE - SLEEP IN DAILY PERSONAL CARE AIDE - SLEEP IN DAILY MUTUAL support PA rate T1019 1B 1B modifier used to support PA rate T1020 1B 1B modifier used to support PA rate T1020 1B 1M 1B modifier used to support PA rate 1M Modifier used to support reduced (half) daily rate T1019 T1019 T1020 T1020 1M 1M Modifier used to support reduced (half) daily rate Please use hourly rate; please convert all 15 minute increments into hourly rate ( i.e., if you are billing one unit, we will process it as one hour, not as a 15 minute increment) 1. All mutual cases shall be billed at the hourly rate multiplied by the number of hours spend caring for each member 2. All sleep in daily cases rates should be the hourly rate multiplied by 13 hours. The total amount should be billed as one unit. 3. All sleep in daily mutual cases rates should be the hourly rate multiplied by 6 hours. The total amount should be billed as one unit Instructions for Provider Billing ICS Page 13

17 4.5.1 Home Care Modifier Definitions HOUSEKEEPING PERSONAL ASSISTANT ONE TIME ONLY SLEEP IN DAILY MUTUAL HEAVY DUTY 1A 1B 1D 1M 1J Fee Schedule Please refer to your ICS contract. 4.6 Home Delivery of Meals What is Covered? Exclusions Home delivered meals are provided when the need is indicated in a member s plan of care. Members who need assistance with meal preparation (i.e., cannot cook, are not safe cooking, have no cooking facilities) and who have less than four hours per day of home care service are eligible for one meal per day to be delivered. Under special circumstances (e.g., PCA is unable to prepare special dietary requirements to address nutritional changes), a member may receive two (2) meals daily for a limited time. None Approval Needed Billing ICS authorization required MD order not required Type of claim form: Please use CPT code S5170 on a CMS 1500 Form. Side orders should be billed with modifier (SO) Fee Schedule Please refer to your ICS contract. Instructions for Provider Billing ICS Page 14

18 4.7 Medical Supplies What is Covered? Medical supplies and items for health use other than medications, prosthetic and orthotic devices and durable medical equipment that are used in the treatment of a specific medical condition and which are consumable, non-reusable, disposable. These include but are not limited to: Diabetic supplies, if not provided by a pharmacy plan Dressing and other wound care supplies Urinary catheters Incontinence supplies (e.g., disposable underwear/briefs/underpads) Nutritional supplements such as Ensure Approval Needed As long as there is a medical necessity for ordering the supplies referenced they will be ordered. MD order required ICS authorization required Billing Type of claim form: CMS 1500 For Procedure Codes and Billing Guidelines, please visit: Skilled Nursing Facility What is Covered? Post-acute care, short-term rehabilitation, respite care, and long-term custodial care in a skilled nursing facility, licensed by the New York State Department of Health. Nursing Home per diem rates cover: Semi-private room and board Nursing and personal care services, including assistance with all activities of daily living Rehabilitation services Recreational and socialization activities Maintenance of the member s room Other facility related services Instructions for Provider Billing ICS Page 15

19 Facilities are expected to hold beds if the resident is expected to return within 15 days. The reimbursement for bed hold or leave of absence due to therapeutic leave is 95% of the Medicaid FFS daily rate Exclusions Members who express a preference to be placed in a non-network nursing facility for a long-term care placement with no intent to return to community living Approval Needed Billing MD order required (The nursing home will usually get the MD order directly). ICS authorization required For Procedure Codes, Billing Guidelines, please visit: Guidelines_UB04.pdf ICS does not require an authorization for provision of Skilled Nursing Services co-payments under the skilled nursing facilities where Medicare is the primary insurer. ICS will reimburse the co-insurance and/or co-payment without a prior authorization, provided that an explanation of benefits from the Medicare carrier is submitted with the claim. ISC will not reimburse any services that Medicare denies without authorization and will not provide an authorization for Medicare denials after the services are rendered Fee Schedule Please refer to your ICS contract. The benchmark rate is the existing Medicaid fee-for-service rate (established by the Department of Health) received by the nursing homes, which includes the cash assessment. For further information on benchmark rates please refer to the letter that was forwarded on June 18, 2015 by the Department of Health or follow the link below. _benchmark_letter.htm Instructions for Provider Billing ICS Page 16

20 Attached is the revenue code crosswalk Service Description Revenue Revenue code Crosswalk code SNF - Bed Hold Therapeutic 0183 Bed Hold Therapeutic (up to 10 days per year) SNF - Bed Hold Therapeutic 0189 Bed Hold Therapeutic (up to 10 days per year) SNF -Bed Hold Temporary Hospitalization 0185 Bed Hold Temporary Hospitalization (up to 14 days per year) SNF Respite 0663 Respite (up to 30 days per year) SNF - Residential Hospice 0658 Residential Hospice SNF - Sub-acute Non Skilled 0199 non skilled custodial care (up to 30 days) Custodial Care SNF - Sub-acute HIV/AIDS 0160 Sub-Acute HIV/AIDS SNF - Sub-acute TBI 0121 Sub-Acute TBI (Traumatic Brain Injury) (Traumatic Brain Injury) SNF - Sub-acute Psychiatric 0124 Sub-Acute Neuro (Short-Term Rehab) SNF - Sub-acute Vent 0194 Sub-Acute Ventilator (Short-Term/Rehab) SNF- Permanent Placement 0120 Permanent Placement (Long Term) SNF- Permanent Placement HIV/AIDS SNF- Permanent Placement Psychiatric SNF- Permanent Placement TBI (Traumatic Brain Injury) SNF - Permanent Placement (Vent) SNF - Sub-acute Short Term Rehab Additional MMP Codes SNF - Sub-acute Short Term Rehab SNF - Sub-acute (Level 1-4 fall under umbrella SNF - Sub-acute (Level 1-4 fall under umbrella SNF - Sub-acute (Level 1-4 fall under umbrella 0160 Permanent Placement HIV/AIDS (Long Term) 0124 Permanent Placement Neuro (Long Term) 0121 Permanent Placement TBI (Traumatic Brain Injury) 0169 Permanent Placement (Vent) 0190 Sub-Acute (Short-Term Rehab) 0191 Sub-Acute (Short-Term Rehab) 0192 Sub-Acute (Short-Term Rehab) 0193 Sub-Acute (Short-Term Rehab) 0194 Sub-Acute (Short-Term Rehab) Instructions for Provider Billing ICS Page 17

21 Skilled Nursing facility shall be responsible for collecting the Net Available Monthly Income (NAMI) and indicate the amount on the claim form: Enter the NAMI amount approved by Social Services agency as the patient s monthly budget In cases where the patient s budget has increased, the new amount shall be entered and submitted to ICS If billing occurs more than once a month, provider shall enter the full NAMI amount on the first claim submitted for the month ICS shall reimburse provider the contracted rate for authorized covered services less the NAMI amount indicated by the provider 4.9 Nutrition Services What is Covered? Exclusions None Assessment by a qualified nutritionist of the nutritional status, food preferences, and need for therapeutic diets Nutritional education as part of a treatment plan Approval Needed Members can self-refer for one wellness evaluation per year within the provider network. Recommended treatment plans submitted by the qualified nutritionist will be authorized by the care manager for members meeting clinical and diagnostic criteria referenced above. ICS authorization required MD order not required Billing Type of claim form: UB-04 or CMS Fee Schedule Please refer to your ICS contract. Instructions for Provider Billing ICS Page 18

22 4.10 Optometry Services ICS provides vision benefits though the third-party benefit management organization Davis Vision. The provider should contact the benefit administrator to obtain the authorization at What is Covered? Optometry services (eye exams, eyeglasses, contacts) are covered. This includes: Annual eye exams to detect visual defects and eye disease Prescription lenses ($50 per lens) and up to $100 for eyeglass frames every two (2) years Replacement of lost, stolen or damaged glasses with documentation Low vision aids Low vision services Exclusions Members with neurological problems, acute vision loss, elevated IOP, suspicious optic nerves, diabetic retinopathy or cataracts, should be referred to an ophthalmologist. Contact lenses and tinted lenses are not covered when prescribed for cosmetic reasons only Approval Needed Members can self-refer for exam from a network provider. Items and services under $500 are authorized following Medicaid fee-for-service guidelines. Items greater than $500 require supervisor s review and any recommendation to deny is reviewed by a clinical peer reviewer utilizing professional clinical judgment and low vision standards of care. ICS authorization required MD order not required Billing Type of claim form: CMS 1500 For Procedure Codes and Billing Guidelines, please visit: Personal Emergency Response System (PERS) What is Covered? Instructions for Provider Billing ICS Page 19

23 An electronic device worn by a member to secure help in the event of a physical, emotional, or environmental emergency. This includes: Installation of equipment Monitoring of equipment Console unit, two personal care activators, and a smoke detector Exclusions Member is no longer living at home (e.g., nursing home, transitional housing) Members that receive 24-hour care or have a reliable caregiver present in home Members who have shown significant improvement in condition and no longer need PERS Approval Needed MD order required ICS authorization required PERS services should be billed with the following modifiers 1U 2U 3U 4U Wireless PERS Fall Detection PERS Wireless PERS Plus Fall Detection Second User PERS Billing Type of claim form: UB-04 or CMS 1500 For Procedure Codes, Billing Guidelines, and Fee Schedule, please visit: Fee Schedule Please refer to your ICS contract Podiatry What is Covered? Routine foot care, such as treatment of corns and calluses, trimming of nails, hygienic care such as soaking or cleaning feet Instructions for Provider Billing ICS Page 20

24 Non-routine care such as: 1. Diagnosis and treatment of any illness or injury in the foot, such as infection or fungus 2. Incisions 3. Excisions 4. Removal of foreign objects 5. Repair or suture of tendons, foot, flexor 6. Treatment of dislocations Exclusions None Approval Needed MD order not required ICS authorization required Billing Type of claim form: CMS 1500 For Procedure Codes, Billing Guidelines, please visit: Rehabilitation Services What is Covered? Rehabilitation services include physical, occupational, and speech therapies provided in a licensed rehabilitation facility or through a certified home health agency. Physical therapy services include examination, diagnosis, and treatment of musculoskeletal and neuromuscular impairments resulting in functional limitations. Occupational therapy includes evaluation of performance, skills assessment, and treatment customized to improve ability to perform activities of daily living. Speech therapy includes evaluation and treatment of slurred speech, breath control, voice issues, aphasia, stuttering, swallowing difficulties and augmentative communication needs Approval Needed Network therapists will submit recommended treatment plans for peer review and approval for the authorization. The Member s Care Management Coordinator (CMC), who supports the member s assigned team, will forward any recommendation for approval for authorization to a Instructions for Provider Billing ICS Page 21

25 clinical peer reviewer for a decision based on professional clinical judgment and professional standards of care. MD order required ICS authorization required ICS does not require the authorization for Physical Therapy, Occupational Therapy and Speech Therapy services co-payment where Medicare is the primary insurer. ICS will reimburse the coinsurance and/or co-pay without a prior authorization, provided that an explanation of benefits from Medicare carrier is submitted with the claim. ICS will not reimburse any services that Medicare denies without an authorization and will not provide an authorization for Medicare denials after the services have been rendered. NOTE: Network Providers are encouraged to call ICS ICS ( ) and request to speak to the CMC supporting the member s assigned team to determine if the member has recently received services from another provider within the calendar year, prior to drafting a treatment plan that may not be authorized Billing Type of claim form: CMS 1500 For Procedure Codes, Billing Guidelines, please visit: Fee Schedule Please refer to your ICS contract. NOTE: Changes for PT/OT services in 2017 Physical Therapy codes to replace Physical Therapy Evaluation - Low Physical Therapy Evaluation - Moderate Physical Therapy Evaluation High Re-evaluation codes to replace PT- Re-eval Physical therapy - Re-Evaluation Occupational Therapy codes to replace Occupational Therapy Evaluation - Low Occupational Therapy Evaluation - Moderate Occupational Therapy Evaluation High Re-evaluation codes to replace OT- Re-eval Occupational Therapy- Re Evaluation Instructions for Provider Billing ICS Page 22

26 4.14 Respiratory Services What is Covered? The performance of preventive, maintenance and rehabilitative airway-related techniques and procedures. Includes: Application of medical gases Humidity and aerosols Intermittent positive pressure Continuous artificial ventilation Administration of drugs through inhalation and related airway management Patient care Patient teaching Exclusions None Approval Needed All MD orders for respiratory services are followed and implemented. Care Manager authorization of equipment as part of care plan; service component is part of contractual agreement with equipment provider. ICS authorization required MD order required Billing Type of claim form: CMS Fee Schedule Please refer to your ICS contract Skilled Home Health Care Services (Skilled RN, LPN, MSW Services) What is Covered? Instructions for Provider Billing ICS Page 23

27 Home health care includes skilled services that are of a preventive, therapeutic, and health teaching nature. This includes: Skilled nursing services Medical social services Home infusion (chemotherapy, intravenous feedings) Skilled nursing includes both registered (RN) and licensed practical nursing (LPN) care arranged (by contract) through certified home health agencies, licensed agencies, or nursing registries. Medical social services describe the psychosocial assessment and treatment planning offered by qualified social workers and social work assistants Exclusions None Approval Needed MD order required (Certified home health agency will obtain MD orders separately.) ICS authorization required Billing Type of claim form: UB-04 or CMS Fee Schedule Please refer to your ICS contract Social Day Care What is Covered? Social Day programs provide special recreational and therapeutic activities designed to provide socialization. Service highlights include: Arts and crafts Physical activities Music and singing Cooking Discussion groups Parties and holiday events Diverse cultural programs Snacks and lunch Exclusions None Instructions for Provider Billing ICS Page 24

28 Approval Needed ICS authorization required MD order not required Billing Type of claim form: UB-04 or CMS Fee Schedule Please refer to your ICS contract Transportation What is Covered? Non-emergency transportation (e.g., public transportation, Access-A-Ride, car service, ambulette, or ambulance) to medical appointments or adult or social day program activities that are part of the Member s care plan Exclusions Transportation to non-medical appointments that are not authorized by care management as part of the care plan Approval Needed Once level of transportation is authorized by Care Manager, Members can arrange transportation to medical or day program appointments, directly or via the Member Services Center. MD order not required Billing Type of claim form: CMS 1500 only For procedure codes and billing guidelines please visit For Transportation Codes with HCPCS/Modifiers, please refer to the table on the following page Fee Schedule Please refer to your ICS contract. Instructions for Provider Billing ICS Page 25

29 Transportation Codes with HCPCS / Modifiers Service Code: Ambulette HCPCS Code HCPCS Code HCPCS Code T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 T2003 Service Code: Ambulance with Basic Life Support HCPCS Code HCPCS Code HCPCS Code A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 A0428 Service Code: Ambulance with Advanced Life Support HCPCS Code HCPCS Code HCPCS Code A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 A0426 Service Code: Livery HCPCS Code HCPCS Code HCPCS Code A0100 A0100 A0100 A0100 A0100 A0100 A0100 A0100 A0100 For detailed instructions, please refer to nes.pdf. Instructions for Provider Billing ICS Page 26

30 Section 5: Standard Form Samples 5.1 UB-04 Sample Claim Form Instructions for Provider Billing ICS Page 27

31 5.2 CMS 1500 Sample Claim Form Instructions for Provider Billing ICS Page 28

32 5.3 Dental Sample Claim Form Instructions for Provider Billing ICS Page 29