CMS-1500 Billing and Reimbursement. HP Provider Relations/October 2013

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1 CMS-1500 Billing and Reimbursement HP Provider Relations/October 2013

2 Agenda Common Denials for CMS-1500 CMS-1500 Claims Billing Types of CMS-1500 Claims Paper Claim Billing Fee Schedule Crossover Claims Billing Third Party Liability Claims Billing Claim Billing Guidelines Resolution Resources Available 2

3 Common Denials for CMS-1500

Edit 2502 Recipient covered by Medicare Part B Cause Medical claims for Medicare Part B coverage for a member have Part B on the eligibility screen but there is no Medicare Remittance Notice (MRN)

4 Edit 2502 Recipient covered by Medicare Part B Cause Medical claims for Medicare Part B coverage for a member have Part B on the eligibility screen but there is no Medicare Remittance Notice (MRN) with the claim showing Medicare denial Resolution Submit the Medicare payment on the right side of field 22 and the coinsurance, deductible, or psych reduction on the left side Resolution Submit the coordination of benefits information 4

Edit 558 Coinsurance and deductible amount missing Cause Fail this edit if there are not crossover payment field amounts present on the claim form Resolution Submit

5 Edit 558 Coinsurance and deductible amount missing Cause Fail this edit if there are not crossover payment field amounts present on the claim form Resolution Submit the Medicare payment on the right side of field 22 and the coinsurance, deductible, or psych reduction on the left side Submit the coordination of benefits information 5

Edit 2505 Recipient covered by private insurance Cause This member has private insurance, which must be billed prior to Medicaid Resolution Add the other insurance payment to the claim Add other

6 Edit 2505 Recipient covered by private insurance Cause This member has private insurance, which must be billed prior to Medicaid Resolution Add the other insurance payment to the claim Add other insurance payment excluding Medicare payments to field 29 on the CMS-1500 claim form If the primary insurance denies, the explanation of benefits (EOB) must be sent with the claim, either on paper with a paper claim, or as an attachment if claim is sent on Web interchange 6

7 CMS-1500 Claims Billing

8 Types of CMS-1500 Claims 837P Electronic transaction Companion Guide available on indianamedicaid.com Web interchange Paper claim Replacement/Adjustment request (for a previously paid claim) 8

9 Providers Types Billing on CMS 1500 or 837P Advanced practice nurses Midwife services, nurse practitioner services, nurse anesthetist services, and clinical nurse specialists Audiologists Audiology services Case managers Care coordination services Certified registered nurse anesthetists (CRNAs) Chiropractors Chiropractic services Clinics Federally Qualified Health Center (FQHC) rural health center (RHC) Comprehensive outpatient rehabilitation facility Dentists Oral surgery Diabetes self-management services Durable medical equipment (DME), home medical equipment (HME), and supply dealers DME, medical supplies, and oxygen 9

10 Providers Types Billing on CMS 1500 or 837P Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service providers Freestanding radiology facilities Radiological services, professional component or global Hearing aid dealers Hearing aids Independent diagnostic testing facility Laboratories Lab services, professional component Mental health providers Medicaid Rehabilitation Option (MRO) services, outpatient mental health services Mid-level practitioners Anesthesiology assistant services, physician assistant services, independent practice school psychologists, and advanced practice nurses under Indiana Code (IC) (b)(3), credentialed in psychiatric or mental health nursing by the American Nurses Credentialing Center Billing under the supervising physician rendering National Provider Identifier (NPI) 10

11 Providers Types Billing on CMS 1500 or 837P Opticians Optical services Optometrists Optometric services Pharmacies Supplies Physicians, medical doctors, and doctors of osteopathy Anesthesiology services, lab services, professional component, medical services, mental health services, radiology services, renal dialysis services, surgical services Podiatrists Podiatric services Public health agencies Medical services School corporations Therapy services: physical, occupational, speech, mental health Therapists Therapy services: physical, occupational, speech, audiology Transportation provider Transportation services, including hospital-based ambulance services Waiver providers Waiver services 11

12 CMS-1500 Paper Claim Billing 12

13 Paper Claim Form Locators 13

14 Paper Claim Form Locators CMS-1500 Fields Description 1 INSURANCE CARRIER SELECTION Enter X for Traditional Medicaid. Required. 1a INSURED S I.D. NUMBER (FOR PROGRAM IN ITEM 1) Enter the IHCP member identification number (RID). Must be 12 digits. Required. 2 PATIENT S NAME (Last Name, First Name, Middle Initial) Provide the member s last name, first name, and middle initial obtained from the Automated Voice Response (AVR) system, electronic claim submission (ECS), Omni, or Web interchange verification. Required. 14

15 Paper Claim Form Locators Field Description 17a Enter the qualifier in the first shaded box of 17a, indicating what the number reported in the second shaded box of 17a represents. Atypical providers should report the IHCP LPI provider number in the second box of 17a. Healthcare providers should report the taxonomy code in the second box of 17a. The qualifier is required when entering the IHCP LPI provider number or taxonomy. Qualifiers to report to IHCP: 1D or G2 are the qualifiers that apply to the IHCP provider number (LPI) for atypical nonhealthcare providers. The LPI includes nine numeric characters. Atypical providers (for example, certain transportation and waiver service providers) are required to submit their LPIs. ZZ or PXC are the qualifiers that apply to the provider taxonomy code. The taxonomy code includes 10 alphanumeric characters. The taxonomy code may be required for a one-to-one match. 15

16 Paper Claim Form Locators CMS-1500 Fields 17b Description NPI Enter the 10-digit numeric NPI of the referring provider, ordering provider, or other source. Required when applicable and for Care Select PMPs for dates of service prior to January 1,

17 Paper Claim Form Locators CMS-1500 Fields Description 19 RESERVED FOR LOCAL USE Enter the Care Select primary medical provider (PMP) two-digit alphanumeric certification code. Required for Care Select members when the physician rendering care is not the PMP or a physician in the PMP s group or a clinic for dates of service prior to January 1, to Note: Report the PMP qualifier and ID number in 17a. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Complete fields 21.1, 21.2, 21.3, and/or 21.4 to field 24E by detail line. Enter the ICD-9-CM diagnosis codes in priority order. A total of four codes can be entered. Required. 17

18 Paper Claim Form Locators CMS-1500 Fields Description 22 MEDICAID RESUBMISSION CODE, ORIGINAL REF. NO. Applicable for Medicare Part B crossover claims and Medicare Replacement Plan. For crossover claims, the combined total of the Medicare coinsurance, deductible, and psych reduction must be reported on the left side of field 22 under the heading Code. The Medicare paid amount (actual dollars received from Medicare) must be submitted in field 22 on the right side under the heading Original Ref No. Required, if applicable. 18

19 Paper Claim Form Locators CMS-1500 Fields Description 24A to 24I Top Half Shaded Area 19 NATIONAL DRUG CODE INFORMATION The shaded portion of fields 24A to 24I is used to report NDC information for physician administer drugs. Required as of August 1, To report this information, begin at field 24A as follows: 1. Enter the NDC qualifier of N4 2. Enter the NDC 11-digit numeric code 3. Enter the drug description 4. Enter the NDC Unit qualifier F2 International Unit GR Gram ML Milliliter UN Unit 5. Enter the NDC Quantity (Administered Amount) in the format

20 Paper Claim Form Locators CMS-1500 Fields 24E 24F 24G 24H Description DIAGNOSIS CODE Enter number 1 4 corresponding to the applicable diagnosis codes in field 21. A minimum of one, and a maximum of four, diagnosis code references can be entered on each line. Required. $ CHARGES Enter the total amount charged for the procedure performed, based on the number of units indicated in field 24G. The charged amount is the sum of the total units multiplied by the single unit charge. Each line is computed independently of other lines. This is a 10-digit field. Required. DAYS OR UNITS Provide the number of units being claimed for the procedure code. Six digits are allowed, and units is the maximum that can be submitted. The procedure code may be submitted in partial units, if applicable. Required. EPSDT Family Plan If the patient is pregnant, indicate with a P in this field on each applicable line or add a Y for EPSDT. Required, if applicable. 20

21 Paper Claim Form Locators CMS-1500 Fields 24I Top Half Shaded Area Description RENDERING ID QUALIFIER Enter the qualifier indicating what the number reported in the shaded area of 24J represents 1D or G2 for IHCP LPI rendering provider number or ZZ or PXC for rendering provider taxonomy code. 1D or G2 are the qualifiers that apply to the IHCP provider number (LPI) for atypical nonhealthcare providers. The LPI includes nine numeric characters. Atypical providers (for example, certain transportation and waiver service providers) are required to submit their LPIs. ZZ or PXC are the qualifiers that apply to the provider taxonomy code. The taxonomy code includes 10 alphanumeric characters. The taxonomy code may be required for a one-to-one match. 21

22 Paper Claim Form Locators CMS-1500 Fields 24J Top Half Shaded Area Description RENDERING PROVIDER ID Enter the LPI if entering the 1D or G2 is the qualifier in 24I for the Rendering Provider ID. Required, if applicable for nonhealthcare providers only. LPI The entire nine-digit LPI must be used. If billing for case management, the case manager s number must be entered here. Taxonomy Enter the taxonomy code of the rendering provider. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the provider has multiple locations. 22

23 Paper Claim Form Locators CMS-1500 Fields Description 24J RENDERING PROVIDER NPI Enter the NPI of the rendering provider. Required if Bottom applicable. Half 28 TOTAL CHARGE Enter the total of all service line charges in column 24F. This is a 10- digit field, such as Required. 29 AMOUNT PAID Enter the payment received from any other source, excluding the Medicare and Medicare replacement plan paid amount. All applicable items are combined and the total entered in this field. This is a 10-digit field. Required, if applicable. Other insurance Enter the amount paid by the other insurer. If the other insurer was billed but paid zero, enter 0 in this field. Attach denials to the claim form when submitting the claim for adjudication. 30 BALANCE DUE TOTAL CHARGE (field 28) AMOUNT PAID (field 29) = BALANCE DUE (field 30). This is a 10-digit field, such as Required. 23

24 Paper Claim Form Locators CMS-1500 Fields Description 31 SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS An authorized person, someone designated by the agency or organization, must sign and date the claim. A signature stamp is acceptable; however, a typed name is not. Providers that have signed the Signature on File certification form will have their claims processed when a signature is omitted from this field. The form is available on the on the Forms page on indianamedicaid.com. Required if applicable. DATE Enter the date the claim was filed. Required. 24

25 Paper Claim Form Locators CMS-1500 Fields Description 33 BILLING PROVIDER INFO & PH # Enter the billing provider service location name, address, and the ZIP Code+4. Required. 33a 33b Note: If the U.S. Postal Service provides an expanded ZIP Code (ZIP Code + 4) for a geographic area, this expanded ZIP Code must be entered on the claim form. BILLING PROVIDER NPI Enter the billing provider NPI. Required. BILLING PROVIDER QUALIFIER AND ID NUMBER Healthcare providers may enter a billing provider qualifier of ZZ or PXC and taxonomy code. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the provider has multiple locations. If the billing provider is an atypical provider, enter the qualifier 1D or G2 and the LPI. Required. 25

26 Paper claim form The IHCP implementation timeline for the revised paper claim form: January 6, 2014: Providers may submit claims on the revised 1500 Health Insurance Claim Form January 6 through March 31, 2014: Claims will be processed on either the current CMS 1500 form or the revised 1500 Health Insurance Claim Form April 1, 2014: Claims will be processed only on the revised 1500 Health Insurance Claim Form Watch for forthcoming publications regarding instructions on how to use the revised 1500 Health Insurance Claim Form 26

27 Third Party Liability Claims Billing

28 Third Party Liability Billing When billing TPL claims Field 28 - Field 29= Field 30 Field 28 Field 29 Field 30 DO NOT COMPLETE ANY INFORMATION IN FIELD 22 28

29 Fee Schedule

30 Fee Schedule Access the fee schedule to determine: Reimbursement rates Pricing effective dates Prior authorization requirements Program coverage Applies to Traditional Fee-for-Service Medicaid and Care Select 30

31 Accessing the Fee Schedule 31

32 Accessing the Fee Schedule 32

33 Accessing the Fee Schedule 33

34 Accessing the Fee Schedule 34

35 Accessing the Fee Schedule 35

36 Understanding Fee Schedule Instructions 36

37 Provider Code Sets

38 Provider Code Sets The following provider types have specific code sets : Chiropractic Durable Medical Equipment Hearing Services HIV Care Coordination Home Medical Equipment Optician Optometrist Transportation Vision 38

39 Viewing Provider Code Sets 39 Medical Equipment Guidelines October 2012

40 Viewing Provider Code Sets 40 Medical Equipment Guidelines October 2012

41 Viewing Provider Code Sets 41 Medical Equipment Guidelines October 2012

42 Viewing Provider Code Sets 42 Medical Equipment Guidelines October 2012

43 Viewing Provider Code Sets 43 Medical Equipment Guidelines October 2012

44 Claim Billing Guidelines

Evaluation and Management Codes Traditional and Care Select Members New patient office visits are limited to one visit per member, per billing provider once every three years Reimbursement is

45 Evaluation and Management Codes Traditional and Care Select Members New patient office visits are limited to one visit per member, per billing provider once every three years Reimbursement is available for office visits to a maximum of 30 per rolling 12-month period, per IHCP member, without prior authorization (PA), and subject to the restrictions in Section 2 of 405 IAC Per 405 IAC 5-9-2, office visits should be appropriate to the diagnosis and treatment given and properly coded 45

46 Chiropractors Traditional and Care Select Members IHCP limits chiropractic services to 50 per member, per calendar year The IHCP reimburses for no more than five office visits out of the 50 total visits Package B reimbursement is available for medically necessary pregnancy-related services. Refer to the IHCP Provider Manual Chapter 8 for a listing of pregnancy diagnosis codes Package C members are allowed five office visits and 14 therapeutic physical medicine treatments per member, per calendar year 46

Chiropractors Traditional and Care Select Members The following are covered codes for office visits: 99201, 99202, 99203, 99211, 99212, 99213 The following are

47 Chiropractors Traditional and Care Select Members The following are covered codes for office visits: 99201, 99202, 99203, 99211, 99212, The following are covered codes for manipulative treatment: Note: Services denied by Medicare must be billed as Medicaid primary claims and be submitted with the MRN 47

Anesthesia Traditional and Care Select Members Use Current Procedural Terminology (CPT ) codes 00100-01999 (refer to IHCP Provider Manual Chapter 8 for more information) One unit = 15 minutes Bill

48 Anesthesia Traditional and Care Select Members Use Current Procedural Terminology (CPT ) codes (refer to IHCP Provider Manual Chapter 8 for more information) One unit = 15 minutes Bill the actual time in minutes and include it in field 24G Additional units are allowed based on a patient s age when billing for emergency services (bill using procedure code 99140) Refer to IHCP Provider Manual Chapter 8 for appropriate billable CRNA codes 48

49 Anesthesia Traditional and Care Select Members Modifiers for medical direction Modifier Description QK QS QX QZ Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals Monitored anesthesia care services CRNA with medical direction by a physician CRNA without medical direction by a physician Note: CRNAs billing with their enrolled individual rendering NPI must not use modifiers listed 49

Anesthesia Traditional and Care Select Members Providers bill postoperative pain management using code 01996 The IHCP does not

50 Anesthesia Traditional and Care Select Members Providers bill postoperative pain management using code The IHCP does not separately reimburse this code on the same day the epidural is placed However, it is reimbursed for subsequent days when an epidural is managed 50

Injections Traditional and Care Select Members The IHCP reimburses for physician office injectable drugs using Healthcare Common Procedure Coding System (HCPCS) J codes and CPT immunization codes

51 Injections Traditional and Care Select Members The IHCP reimburses for physician office injectable drugs using Healthcare Common Procedure Coding System (HCPCS) J codes and CPT immunization codes Claims will be priced based on the Fee Schedule The IHCP reviews pricing for a physician office administered drug each quarter To price appropriately, HCPCS J Codes must be submitted with the appropriate National Drug Code (NDC), name, strength, and quantity 51

52 Injections Traditional and Care Select Members The IHCP Provider Manual contains lists of J codes that require an NDC Chapter 8, Section 4 For paper CMS-1500 claim forms, report NDC information in the shaded area of field 24 The NDC is not used for provider reimbursement 52

53 Diabetes Self-Care Training Services Traditional and Care Select Members Diabetes self-care training is intended to enable the patient or enhance the patient s ability to properly manage a diabetic condition, thereby optimizing the therapeutic regimen 53

54 Diabetes Self-Care Training Services Traditional and Care Select Members The IHCP limits coverage to eight units or a total of four hours per member, per rolling calendar year providers can request prior authorize additional units The following are examples of diabetes self-care management training activities: 54 Accessing community healthcare systems and resources Behavior changes, strategies, and risk factor reduction Blood glucose self-monitoring Instruction regarding the diabetic disease state, nutrition, exercise, and activity Insulin injection Foot, skin, and dental care Medication counseling Preconception care, pregnancy and gestational diabetes

55 Diabetes Self-Care Training Services Traditional and Care Select Members Providers must bill using one of the following procedure codes: 55 G0108 Diabetes outpatient self-management training services, individual per 30 minutes G0109 Diabetes self-management training service, group session (2 or more), 30 minutes Providers should not round up to the next unit; instead, providers should accumulate billable time equivalent to whole units and then bill Limit service to eight units per member, or the equivalent of four hours, per rolling calendar year, applicable under any of the following circumstances: Receipt of a diagnosis of diabetes Receipt of a diagnosis that represents a significant change in the member s symptoms or condition Re-education or refresher training

Surgical Services Traditional and Care Select Members When two or more covered surgeries are performed during the same operative session, multiple surgery reductions apply to the procedure based on

56 Surgical Services Traditional and Care Select Members When two or more covered surgeries are performed during the same operative session, multiple surgery reductions apply to the procedure based on the following adjustments: 100% of the global fee for the most expensive procedure 50% of the global fee for the second most expensive procedure 25% of the global fee for the remaining procedures All surgeries performed on the same day, by the same rendering physician, must be billed on the same claim form; otherwise, the claim will be denied and the original claim may be adjusted 56

57 Surgical Services Traditional and Care Select Members Cosurgeons: Cosurgeons must append modifier 62 to the surgical services Modifier 62 cuts the reimbursement rate to 62.5% of the rate on file Bilateral Procedures: To indicate a bilateral procedure, providers bill with one unit in field 24G, using modifier 50 Use of this modifier ensures that the procedure is priced at 150% of the billed charges or the rate on file Note: If the CPT code specifies the procedure as bilateral, then the provider must not use modifier 50 57

58 Obstetric services Traditional and Care Select Members The IHCP covers the following 14 antepartum visits: Three visits in trimester one Three visits in trimester two Eight visits in trimester three Providers use the following codes to bill for visits: First visit Evaluation and management (E/M) Visits one through six Seventh and subsequent visits Providers use the following modifiers with procedure codes: U1 for trimester one Zero through 14 weeks U2 for trimester two 14 weeks, one day through 28 weeks U3 for trimester three 28 weeks, one day through delivery 58

Obstetric Services Traditional and Care Select Members For pregnancy-related claims, indicate the last menstrual period (LMP) in MM/DD/YY format in field 14 The IHCP will

59 Obstetric Services Traditional and Care Select Members For pregnancy-related claims, indicate the last menstrual period (LMP) in MM/DD/YY format in field 14 The IHCP will deny claims for pregnancy-related services if there is no LMP Indicate a pregnancy-related diagnosis code as the primary diagnosis when billing for pregnancy-related services 59

60 Obstetric Services Traditional and Care Select Members Use normal low-risk pregnancy diagnosis codes: V22.0 V22.1 Use high-risk pregnancy codes: V60.0 through V62.9 For additional information, refer to the IHCP Provider Manual, Chapter 8, Section 4 60

Sterilization and Partial Sterilization Traditional and Care Select Members A sterilization form is not necessary when a patient is rendered sterile as a result of an illness or injury Providers must

61 Sterilization and Partial Sterilization Traditional and Care Select Members A sterilization form is not necessary when a patient is rendered sterile as a result of an illness or injury Providers must note partial sterilization with an attachment to the claim indicating Partial Sterilization and no consent required Partial sterilization can also be submitted on the electronic 837P transaction when Partial Sterilization is indicated in the claim notes 61

62 Sterilization and Partial Sterilization Traditional and Care Select Members Providers must allow at least 30 days, but not more than 180 days, to pass between the date when the member gives the informed consent, and the date when the provider performs the sterilization procedure Members that have retroactive eligibility situation or that patients that failed to inform the provider of IHCP eligibility are still required to have a signed consent form 62

63 Consent for Sterilization Form 63

Family Planning Program Traditional and Care Select Members The Indiana Health Coverage Programs (IHCP) announced implementation of the Family Planning Eligibility Program, effective January 1, 2013

64 Family Planning Program Traditional and Care Select Members The Indiana Health Coverage Programs (IHCP) announced implementation of the Family Planning Eligibility Program, effective January 1, 2013 Family planning coverage is for services provided to individuals of childbearing age to temporarily or permanently prevent or delay pregnancy Members eligible under the Family Planning Aid Category will receive services through the Traditional Medicaid program within the fee-for-service delivery system Please refer to IHCP Provider Manual, Chapter 8, Section 7 for additional information regarding the covered services 64

65 Resolution

Administrative Review/Appeals Providers not satisfied with the determination after the administrative review has been exhausted can send a request

66 Administrative Review/Appeals Providers not satisfied with the determination after the administrative review has been exhausted can send a request for appeal, within 15 business days of receipt of the final administrative review decision Please refer at Chapter 10 of the IHCP provider manual 66

67 Administrative Review Clearly note Healthcare Administrative Review Specialist on the IHCP Inquiry Form or letterhead and send to: Attn: Healthcare Administrative Review Specialist HP Written Correspondence P. O. Box 7263 Indianapolis, IN

68 Resources Available

Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual, Chapter 8 Customer Assistance 1-800-577-1278 Written Correspondence HP Provider Written Correspondence P.

69 Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual, Chapter 8 Customer Assistance Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN Provider Field Consultant Locate area consultant map on: indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or Web interchange > Help > Contact Us 69

70 Q&A

PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEDI-CAL PROVIDER MANUAL CLAIMS DEPARTMENT

PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEDI-CAL PROVIDER MANUAL CLAIMS DEPARTMENT III.A. CMS 1500 Billing Form Effective April 1, 2014, the information listed below are the CMS 1500 fields that must be completed accurately and completely in order to avoid claim suspense or denial. A