WYOMING MEDICAID PROVIDER MANUAL. Medical Services HCFA-1500

Transcription

1 WYOMING MEDICAID PROVIDER MANUAL Medical Services HCFA-1500

2 Medical Services March 01,1999 Table of Contents AUTHORITY Chapter One General Information How the Billing Manual is organized Updating the Billing Manual State Agency Responsibilities Fiscal Agent Responsibilities Quick Address and Telephone Reference Chapter Two Verifying Recipient Eligibility Recipients with Cards Regular Medicaid Recipients - Green Card Qualified Medicare Beneficiaries (QMBs) - Buff Card Presumptive Eligibility - White Card Other Types of Eligibility Identification How to Read the Recipient Identification Card Recipients Without Cards2-23 DFS 611 Foster Care Authorization Form Minimum Medical Program (MMP) Recipients Notice of Award Aliens eligible for Emergency Services Emergency Medical Services Approval Notice History Using Eligibility Verification Systems (EVS) Chapter Three Third Party Liability What is Third Party Liability (TPL) How to Identify TPL How to Bill Third Party Payers What are the exceptions to Third Party Billing When the services are for Preventive Pediatric Care i

3 Medical Services March 01,1999 When the services are related to Prenatal Care When the policy holder of the other insurance is an absent parent When legal liability has not been established Questions about TPL Why should I care about TPL Who pays the bill when a recipient has other insurance Can I refuse to accept Medicaid patients with other insurance if my office doesn't bill other insurance When can I bill a recipient Wyoming Health Insurance Premium Payment Program What is WHIPP Benefits to recipients Benefits for all Wyoming residents What will Medicaid cover under the WHIPP program What recipients must do to enroll in WHIPP Chapter Four Billing Instructions Choosing the Correct Claim Form Coding Requirements (HCPCS, ICD-9-CM, E & M) Evaluation and Management Services Diagnosis Procedures: Modifiers: How to Complete the HCFA Basic Rules Before You Begin Instructions for Completing the HCFA Place of Service Codes (POS) Prior Authorization Instruction for Completion of the Prior Authorization Form How to Bill for Newborns Required Attachments and How to Complete Attachments Sterilization Consent Form Hysterectomy Acknowledgment of Consent Abortion Certification Medical Necessity Sample Claims and Forms ii

4 Medical Services March 01,1999 Where to Send Your Claim How to Resubmit a Denied Claim Medicare Crossovers General Information How to File a Claim for a Dually Eligible Recipient The Remittance Advice When Your Patient Has Other Insurance Sample Remittance Advice How to Read Your Remittance Advice Adjustments and Refunds RefundingMoney to Wyoming Medicaid Incorrectly Billed or Keyed Claims Third Party Recovery After Medicaid's Payment How to File a Void or Adjustment Request How to Complete the Adjustment Request Form Where to Send the Adjustment Request Chapter Five Electronic Media Claims What is Electronic Media Claims Submission (EMC) Benefits Types of Electronic Media Claims Transmissions Getting Started in EMC The Future in Medicaid Claims Processing Training Equipment Cost Chapter Six Getting Help When You Need It Provider Services Available How to Call for Help How to Write for Help How to Get On-Site Help Ordering Claim Forms Order Form Training Workshops iii

5 Medical Services March 01,1999 Chapter Seven Recipient Eligibility Policy Eligibility Determination Responsible Agency Eligible Individuals Qualified Medicare Beneficiaries Special Low Income Medicare Beneficiary Presumptive Eligibility Newborns Aliens eligible for Emergency Services Definition of Emergency Service Verification of Recipient Data Verification of Recipient Eligibility Recipient Identification Verification of Recipient Age Recipients Without Cards Responsibility for Provider Payment Assistance to Potential Eligibles Timely Claims Filing Requirements in Conjunction with Retroactive Eligibility Medicare Eligibility Description of Medicare Benefits Services Provided in Wyoming Recipient Lock-In Freedom of Choice Chapter Eight Provider Responsibilities Enrollment Changes in Enrollment Recertification Termination. 8-3 Accepting Medicaid Patients Compliance Requirements Provider-Patient Relationship Medical Necessity 8-5 Forms Policy Medicaid Payment is Payment in Full Out-of-State Service Limitations WMSA Border Cities iv

6 Medical Services March 1, 1999 Medicare Covered Services Usual and Customary Charges No Show Appointments Authorized Signatures Timely Filing Timely Filing Criteria Exceptionsto the Twelve Month Limit Important Information Regarding Retroactive Eligibility Decisions Failure of Eligible Recipient to Notify Provider of Medicaid Eligibility Billing Tips to Avoid Timely Filing Denials Filing Deadlines for Adjustments Record Keeping, Retention, and Access Requirement Retention of Records Access to Records Audits and On-Site Visits Chapter Nine Overview of Service Coverage and Limitations Covered Services Service Limitations Payment Reimbursement Copayment Incentive Payment Program Ambulance Services Covered Services Service Levels Limitations Reimbursement Guidelines Ambulatory Surgical Centers Covered Procedures Facility Services Professional Services Limitations Reimbursement Guidelines Children s Health Services Codes for pediatric evaluations and follow up of Complex Disorder CHS Local Procedure Codes Third Party Billing Community Mental Health Center and Substance Abuse Center Services Program Requirements Covered Services Covered Services for recipients Under Age v

7 Medical Services March 1, 1999 Psychiatrist Services Reimbursement Guidelines Limitations Developmental Centers Covered Services Treatment and Documentation Reimbursement Guidelines Family Planning Clinics Covered Clinic Services Limitations Reimbursement Guidelines Federally Qualified Health Care Centers (FQHC) Reimbursement Guidelines Health Check- EPSDT Components of a HEALTH CHECK Physical HEALTH CHECK Periodicity Schedules Treatment and Referral Services Expanded HEALTH CHECK Services Hearing Services Hearing Aid Examination Hearing Aid Services Covered Services Reimbursement Guidelines Indian Health Services Reimbursement Guidelines under Wyoming s Medicaid Program Laboratory Services Covered Services Limitations Reimbursement Guidelines Medical Supplies - Durable Medical Equipment Limitations Documentation Certification of Medical Necessity Medical Records Nurse Midwife/Nurse Practitioner Nutritional Services Covered Services Pharmaceutical Services Coverage Limitations Provider Guidelines Physical Therapy Covered Services Limitations Physician Services vi

8 Medical Services March 1, 1999 Abortion Allergy and Clinical Immunotherapy Anesthesia Services Consultation Services Dermatology Home Visits Hospital Services Hysterectomies Injections Locum Tenens Maternity Care Medical Supplies Furnished by a Physician/Practitioner's Office Nursing Facility Visits Office and Outpatient Services Organ Transplants Preventive Medicine Psychiatric Services Sterilizations Surgery Radiology Services Coverage Supervision and Interpretation Limitations Reimbursement Guidelines Rural Health Clinics Covered Services Physician Direction Requirements Reimbursement Guidelines Inpatient Services Vision Services Coverage Reimbursement Guidelines Waiver Programs Developmentally Disabled Adult Developmentally Disabled Children Long-Term Care (LTC)/Home and Community-Based Waiver Services Chapter Ten Utilization Review Utilization Review Complaint Referral Release of Medical Records Lock-in Recipients Fraud and Abuse vii

9 Medical Services March 1, 1999 Definition of Fraud Definition of Abuse Provider Responsibility Referral of Suspected Fraud and Abuse Sanctions Adverse Action Report of Suspected Abuse of the Medicaid Health Care System Appendix A Social Security Administration District Offices... A-1 Appendix B County DFS Offices... B-1 -B-2 Appendix D Injection Codes...D-1 - D-22 Appendix E Wyoming Medicaid Local Codes...E-1 - E-6 viii

10 Medical Services March 1, 1999 AUTHORITY The Wyoming Department of Health is the single State agency appointed pursuant to the Social Security Act to administer the Medicaid program in Wyoming. The Division of Health Care Financing directly administers the Wyoming Medicaid program in accordance with the Social Security Act, the Wyoming Medical Assistance and Services Act, the W.S et seq.) This manual is intended to be a guide for the provider when filing medical claims with the Wyoming Medicaid program. The manual is to be read and interpreted in conjunction with Federal regulations, State statutes, administrative procedures and federally approved State Plan amendments. This manual does not take precedence over Federal regulation, State statutes or administrative procedures.