Dana Bernier Provider Education MO HealthNet Division (MHD)

Transcription

1 Dana Bernier Provider Education MO HealthNet Division (MHD) 1

2 MO HealthNet policy updates Resources available to providers Navigating Provider Participation webpage Spenddown & Eligibility Electronic Claim Filing Overview 2

3 Provider Manual Webpage: Physician Manual: Hospital Manual: 3

4 Provider Bulletin Webpage: Hot Tips Webpage: 4

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6 For participants to be eligible for asthma education and asthma environmental assessment services the individual must meet the following criteria: Be currently enrolled in MO HealthNet, and Be younger than 21 years of age, and Have a primary diagnosis of asthma, and Have had one of the following events as a result of asthma in the last 12 months: 1 or more Inpatient Hospital stays, or 2 or more Emergency Department (ED) visits, or 3 or more Urgent Care visits, or A high utilization of rescue inhalers (short-acting inhaled beta-2 agonists) defined as 4 or more prescription refills, or underutilization of ICS (inhaled corticosteroids) defined as missing 4 or more refills based on their enrollment months, and at least one ED or Urgent Care visit. 6

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8 Managed Care Provider Toolkit 8

9 Participants must present the new authorization notice to rendering physicians, pharmacies, or other medical service providers enrolled in MO HealthNet fee-for-service program. The temporary or P number on the previous authorization is no longer being used. A photocopy of the notice should be made and maintained in the provider s files for documentation of eligibility. 9

10 The MO HealthNet Division (MHD) may not be billed an amount in excess of the provider s U&C charge for a particular service. The Centers for Medicare and Medicaid Services (CMS) published a final rule on January 1, 2016, pertaining to Medicaid reimbursement for covered outpatient drugs. The purpose of the final rule is to implement changes to the prescription drug reimbursement structure as enacted by the Affordable Care Act (ACA). The professional dispensing fee will only be added to prescriptions filled or refilled by a pharmacy provider. Rural Health Clinics (RHC), Federally Qualified Healthcare Centers (FQHC) and hospital providers will continue to be reimbursed at percent of billed charge. 10

11 MO HealthNet enrolled hospitals may bill for outpatient laboratory services if the services are performed: in their hospital s laboratory by an independent laboratory enrolled as a MO HealthNet provider under an arrangement which documents that the hospital is responsible for billing the services provided by the independent laboratory. by an independent laboratory not enrolled as a MO HealthNet provider under an arrangement which documents that the hospital is responsible for billing the services provided by the independent laboratory. Facility charges cannot be billed if laboratory services are the only provided services during a visit. Clinical diagnostic laboratory services billed by the hospital are paid from the Outpatient Lab Fee Schedule rather than a percentage of the billed charge in order to comply with the Deficit Reduction Act of 1984 (DEFRA). For reporting purposes, services reimbursed on a fee schedule basis shall not be included as allowable MO HealthNet costs in cost settlement. 11

12 The demonstration program will begin on July 1, 2017 and will run through June 30, A complete list of the specific CCBHC services by service code is included in Attachment I of the bulletin. The populations of focus for the demonstration program in Missouri include: Adults with serious mental illness Children and adolescents with serious emotional disorders Children, adolescents and adults with moderate to severe substance use disorders Children and adolescents in state custody who have behavioral health issues Young adults with mental illness or substance use disorders identified as in need of treatment by the courts, law enforcement, or hospital emergency rooms. 12

13 Family planning counseling, education, and birth control Family planning services must be billed with primary diagnosis code of family planning If visit is unrelated to family planning, the visit and any treatment or testing is not covered Department of Health and Human Services approved methods of contraception Diagnosis, testing, including Pap and pelvic exams and treatment of sexually transmitted diseases found during a family planning visit Drugs, supplies, or devices related to women s health services - prescribed by physician or advanced practice nurse Physician Manual Section 10 Family Planning Services 13

14 ME codes 58, 59, & 94 Presumptive Eligibility for pregnant women Limited to Ambulatory Prenatal Care Pregnancy or prenatal diagnosis code required Inpatient hospital services - not Ambulatory Prenatal Services Reference: Hospital Manual, Section 13.3.C and Physician Manual, Section 1.5.G 14

15 TEMP eligibility through end of month following month made eligible Required diagnosis must be pregnancy related Z34.ØØ-Z34.Ø3 Z34.8Ø-Z34.93 OØ9.ØØ-OØ9.Ø3 OØ9.1Ø-OØ9.13 OØ9.211-OØ9.219 OØ9.291-OØ9.299 OØ9.30-OØ9.33 OØ9.40-OØ9.43 OØ9.511-OØ9.519 OØ9.521-OØ9.529 OØ9.611-OØ9.619 OØ9.621-OØ9.629 OØ9.811-OØ9.819 OØ9.821-OØ9.829 OØ9.7Ø-OØ9.73 OØ9.891-OØ9.899 OØ9.9Ø-OØ9.93 Z36 Reference: Hospital Manual, Section 13.3.C 15

16 Children and youth under age 21 ZØØ.121 or ZØØ.129 diagnosis code - HCY screening, well child visit Components for Full Screen, or bill Partial Screen MHD screening guides, signed by screener, keep copy in medical record Complete Lead Assessment electronically using CyberAccess Reference: Physician Manual, Section 9 16

17 Full screen Use age appropriate preventive medicine CPT codes and the EP modifier Partial screen Use age appropriate preventive medicine CPT code with both the EP and 52 modifiers Interperiodic screen Use age appropriate preventive medicine CPT code and NO modifier Lists of these CPT codes are found in Physician Manual, Section 9 17

18 Office visits and full or partial screenings on the same DOS not covered unless medical necessity is clearly documented. First field - Dx for the medical condition stating the interperiodic screening must be entered in the primary dx field Second dx field appropriate screening Use diagnosis code ZØØ.121 or ZØØ.129 Reference: Physician Manual, Section 9.4 Interperiodic Screens 18

19 Use the age appropriate preventive medicine code Use diagnosis code ZØØ.121 or ZØØ.129 Reference Section 9.5 for the appropriate modifiers Reference: Physician Manual, Section C School/Athletic Physicals 19

20 MO HealthNet allows adult physicals once per year Use the age appropriate preventive medicine code ( or ) on claim For a well woman exam, use diagnosis code ZØ1.411 or ZØ1.49 For a work physical, use diagnosis code ZØØ.ØØ or ZØØ.Ø1 Reference: Physician Manual, Section Adult Physicals 20

21 Physician must see resident at least once every 30 days for first 90 days Physician must see resident at least once every 60 days thereafter Physician must examine resident as often as necessary to ensure proper medical care Reference: Physician Manual, Section and Nursing Home Manual, Section I 21

22 All physician/clinic and hospital pharmacy claims (injections and birth control devices) must be filed electronically through either a clearinghouse, billing agent, or The following information is required on a Pharmacy Claim: 11- digit National Drug Code (NDC), metric quantity, and prescription number (unique for that drug), participant information and date of service Reference: Physician Manual, Section Prescription Drugs and Pharmacy Manual, Section 15 22

23 Hospital clinicians may call the NEMT broker at when a participant is being discharged from the emergency room or hospital inpatient stay. Reference: Ambulance Manual, Section 13.3.W and 22 for more NEMT information. 23

24 Report on line detail Surgical revenue code, with additional line for surgical procedure performed Zero charge amount and a quantity of one Multiple surgical procedures, claim will have multiple reporting lines Provider Bulletin: 24

25 Medicare crossover claims that do not crossover automatically from Medicare to MHD have to be filed electronically to MHD Providers are responsible for submitting crossover claims electronically to MHD, if they do not automatically crossover from Medicare for any reason Tip - wait approximately 30 days from the date of the Medicare provider s notice of an allowed claim before filing a crossover claim Reference: Physician Manual, Section 16 25

26 FQHC provider performs services in a hospital setting are billed as non-fqhc services (inpatient, outpatient, and emergency room) Billing and Performing use individual provider's NPI, not FQHC group NPI Claim form: CMS-1500, use applicable electronic claims processing system RHC should bill on UB-04 Payment is made based on the fee-for-service fee schedule 26

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28 MHD Help Desk: (573) Technical support and assistance for issues with emomed.com Establish required electronic claims and RA formats, network communication, HIPAA trading partner agreements 28

29 Providers Initial Contact Providers should contact PCU regarding concerns or questions about proper claim filing, claims resolution and disposition, and participant eligibility questions and verification. Provider Communications Unit PO Box 5500 Jefferson City, MO

30 Questions regarding MHD eligibility benefits and application process Website address: Contact by phone: (855) Family Support Division Info Center FSD- INFO. ( ) 30

31 Pharmacy & Clinical Services (573) or Policy development, benefit design, coverage decisions, provider and program policy inquiries Provider Education (573) or Inquiries regarding education, training assistance and scheduling Register for Training Today! 31

32 MHD Services & Programs For questions regarding programs and policies that cannot be answered by other MHD resources: the above address with following: provider NPI, name and contact information, and complete details regarding the inquiry. 32

33 Medical Pre-Certification Help Desk Medical Pre-Certifications (outpatient, diagnostic, nonemergency MRI, MRA, CT, CTA, PET scans and cardiac imaging) Pre-Certification for certain radiological procedures listed at: 33

34 Account setup or technical questions (888) or (573) CyberAccess web address: CyberAccess helpful Tips: 34

35 MHD participant claim data - procedures, diagnosis codes, and prescription information Pre-Certification for services Radiology, Durable Medical Equipment, Optical, Inpatient Drug Prior Authorization (PA) or Clinical Edit Override (EO) 35

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37 MMAC is responsible for administering and managing Medicaid (Title XIX) audit and compliance initiatives and managing and administering provider enrollment contracts under the Medicaid program. PO Box 6500 Jefferson City, MO Telephone: (573)

38 Inquiries regarding enrollment applications, changes to Provider Master File (addresses, tax identification, ownership, individual's name, practice name, National Provider Identification (NPI) number) 38

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41 Managed Care Toolkit 41

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43 Education and Training 43

44 Puzzled by the Terminology? 44

45 Benefit Matrix Quick benefit reference : Covered services by ME Code Cost sharing or any co-pays 45

46 Audio/Visual Training Series of PowerPoints Available 46

47 MHD Fee Schedule Pricing and coverage information by Procedure Code Excel and on line search options 47

48 MHD Fee Schedule 48

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50 Spenddown Defined Family Support Division (FSD) determines MHD eligibility and sets the coverage effective dates. MHD administers and processes claims for healthcare coverage services Options to Meet Spenddown Patient may submit full payment directly to MHD Auto withdrawal from participant s bank account May submit incurred unpaid and paid medical expenses (bills) to FSD office Partial pay and bill submission options Out of pocket and carryover options that may be utilized Providers may submit Spenddown Provider Form See bulletin for more details 50

51 Verifying Eligibility for Coverage Electronically via emomed at verification via emomed: Provider Communication Management Interactive Voice Response (IVR) system at , option 1 for MHD Participant Eligibility Access Provider Spend down Formhttp://dss.mo.gov/fsd/health-care/mo-healthnet-for-people-with-disabilities.htm Providers may scan and form to sesd@ip.sp.mo.gov Questions or problems, SpendDown.Unit@dss.mo.gov or Fax the form to: Spenddown Office Phone Number: See bulletin for more details 51

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53 If a participant does not pay-in or submit bills, coverage shows inactive Coverage may show inactive during the month Depending on the payment option chosen by participant 53

54 Eligibility verification this is key to properly process claims MHD is the payer of last resort, bill all other insurances as primary Bill claim as soon as possible with diagnosis participant was being seen for on that DOS Obtain all Pre-Certifications before services are provided Limited benefit plans and Non-Covered Services Ensure participants understand and sign appropriate forms, when they are responsible for non-covered services 54

55 MO HealthNet Only MO HealthNet and Commercial Insurance MO HealthNet and Medicare Part A/B MO HealthNet, QMB and Medicare Part C 55

56 CMS(Medical) 1500 form 56

57 Select Claim Form CMS-(Medical)

58 Steps: 1, 2, 3: Enter information as it appears on MHD card 7 Step 4: Enter (optional) Step 5: Required Step 6: Enter ICD10 DX (No Decimals) Step 7: Save Claim Header 58

59 Step 1: Enter Date of Service Step 2: Enter Place of Service Step 3: Enter Procedure Code Step 4: Enter Modifiers Step 9: Save Detail Line To Claim Step 5: Enter DX Code Step 6: Enter Billed Charges Step 7: Enter Days/Units Step 8: Enter Performing 59

60 Click: Submit Claim 60

61 Option 1: Void Option 2: Replacement Option 3: Timely Filing Option 4: Copy Claim Option 5: Printer Friendly 61

62 Claim Adjustments & Resubmissions Provider Manual Section 6 Void Claim - used when the claim paid and should never have been billed, i.e., wrong billing NPI or wrong DCN Choose Void tab to bring up paid claim, scroll to the bottom of the claim and click on the highlighted submit claim button. The claim has now been submitted to be voided or credited in the system Provider Manual Section 6-Adjustments 62

63 Adjustments & Resubmissions (cont.) o Replacement Claim used when a claim paid that has been billed incorrectly o Choose Replacement tab to bring up paid claim, select edit button to make changes, then save the changes. Scroll to the bottom of the claim and click highlighted submit button. The replacement claim has now been submitted Provider Manual Section 6-Adjustments 63

64 Adjustments & Resubmissions (cont.) o Copy Claim - Original used when a claim or any line of a claim denied that needs to be corrected. This will copy a claim just as it was entered o Choose Copy Claim tab to bring up claim, choose original, select edit button to make changes, then save the changes. Scroll to the bottom of the claim and click highlighted submit button. The corrected claim has now been submitted Provider Manual Section 6-Adjustments 64

65 Adjustments & Resubmissions (cont.) o Copy Claim - Advanced used when a claim denied that had been filed using the wrong NPI or wrong claim form o Choose Copy Claim tab to bring up claim, choose advanced, select edit button to edit NPI, then save the changes. Scroll to the bottom of the claim and click highlighted submit button o If claim was filed on wrong form, only DCN and Name will transfer to correct form. Key in claim and click submit button Provider Manual Section 6-Adjustments 65

66 Field 1 and 3: Claim Status Codes Field 2 and 4: Claim Category Codes 66

67 Option : Click corresponding list and find code 67

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69 1 2 3 Search Options Field 1: ICN Field 2: DCN Field 3: Date of Service (DOS) 69

70 1 2 Option 1: Replacement if PAID Option 2: Copy Claim Original if DENIED 70

71 1 2 3 Option 1: Edit Claim Header Option 2: Edit Detail Line Summery Option 3: Delete Line Detail 71

72 1 2 Field 1: New Printer Friendly with corrected information Field 2: New ICN with Updated information 72

73 Select Claim Form CMS-(Medical)

74 Steps: 1, 2, 3: Enter information as it appears on MHD card 7 Step 4: Enter (optional) Step 5: Required Step 6: Enter ICD10 DX (No Decimals) Step 7: Save Claim Header 74

75 Step 1: Enter Date of Service Step 2: Enter Place of Service Step 3: Enter Procedure Code Step 4: Enter Modifiers Step 5: Enter DX Code Step 6: Enter Billed Charges Step 7: Enter Days/Units Step 8: Enter Performing Step 9: Save Detail Line To Claim 75

76 Click: Other Payers 76

77 Step 1: Select Filing Indicator Step 2: Payer Responsibility Step 3: Other Payer ID Step 4: Other Payer Name Step 5: Paid Date Step 6: Paid Amount Step 7: Save Other Payer Data & Manage Codes 77

78 Step 1: Select Line Step 2: Select Claim Group Code Step 3: Enter Claim Adjustment Reason Code Step 4: Enter Adjustment Amount Step 5: Click Save Codes to Other Payer 78

79 Click: Save Other Payer To Claim 79

80 Click: Submit Claim 80

81 Click: Printer Friendly 81

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83 Select- new Xover Claim - Medicare CMS-1500 Part B Professional Claim 83

84 Steps: 1, 2, 3: Enter information as it appears on MHD card 7 8 Step 4: Optional Step 5: Enter Medicare ID (HIC) Step 6: Medicare Provider NPI Step 7: DX Code Step 8: Click Save Claim Header 84

85 Step 1: Enter Date of Service Step 2: Enter Place of Service Step 3: Enter Procedure Code Step 4: Enter Modifiers Step 5: Enter DX Code Step 6: Enter Billed Charges Step 7: Enter Days/Units Step 8: Enter Paid Amount Step 9: Enter Perf. Provider NPI Step 10: Save Detail Line To Claim 85

86 Step 1: Select Filing Indicator Step 2: Payer Responsibility Step 3: Other Payer ID Step 4: Other Payer Name Step 5: Paid Date Step 6: Paid Amount Step 7: Save Other Payer Data & Manage Codes 86

87 Deductible 02-Co-Insurance 03-Co-Payment Step 1: Select Line Step 2: Select Claim Group Code Step 3: Enter Claim Adjustment Reason Code Step 4: Enter Adjustment Amount Step 5: Click Save Codes to Other Payer 87

88 Click: Save Other Payer To Claim 88

89 Click: Submit Claim 89

90 Helpful Hints: Medicare Advantage/Part C plans do NOT forward electronic crossover claims to MHD Part C + QMB= Crossover CMS-1500 Part C Professional Claim (Filing Indicator (16) Medicare Part C) Part C Non-QMB= CMS-1500 (Not a Crossover form ) Filing indicator (16) Health Maintenance Org Medicare Physician Manual Section 16.4 & Section 16.4.A- QMB and NON-QMB 90

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92 Professional Crossover Part C Add Detail Line Amt. Part C Paid 92

93 Professional Crossover Part C Add Group Code, Reason Code, Adjustment Amount for Other Payer from EOB 01-deductible 02-Coinsurance 03-Co-Paymet 93

94 Professional Crossover Part C Save Other Payer to Claim 94

95 Professional Crossover Part C Submit Claim 95

96 Professional Crossover Part C Printer Friendly * Paid Amount + Adjustment Amount= Billed Charges * * * 96

97 Always verify eligibility on the Date of Service prior to delivering services Physician Provider Manual Section 1.6.A Day Specific Eligibility 97

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