Connecticut Medical Assistance Program Refresher for Hospice Providers Presented by The Department of Social Services & HP for Billing Providers 1
Training Topics Hospice Agenda HIPAA 5010 Hospice Form Completion and Future Changes Prior Authorization Request Process Common Claim Denials/Resolution Program Resource Update Questions 2
HIPAA 5010 The Department of Social Services (DSS) is implementing the new 5010 version of the HIPAA Transaction and Code Set Standards. HIPAA rules mandate that by January 1, 2012, all covered entities must submit transactions in the 5010 version. DSS will be mandating an earlier implementation date of November 15, 2011 for institutional claims. The new 5010 version impacts all electronic transactions, including client eligibility verification, and Web and paper claim submissions. DSS is staggering the cutover of the new 5010 transactions. HIPAA 5010 version updates can be accessed from the www.ctdssmap.com, information page, under HIPAA. 3
Implementation Schedule Transactions Implementation Dates X12 270/271 Eligibility Verification - Batch 1/26/2011 X12 999 Acknowledgement 1/26/2011 Web Claim Submission and Web Eligibility Verification Provider Electronic Solutions (PES) 3/9/2011 TBD Paper Claims Changes - Professional 4/27/2011 X12 837 Professional 4/27/2011 X12 837 Institutional 4/27/2011 X12 837 Dental 4/27/2011 X12 835 Remittance Advice 4/27/2011 X12 276/277 Claim Status 4/27/2011 Paper Claim Changes Institutional 6/29/2011 Paper Claim Changes - Dental 7/27/2011 4
X12 999 Acknowledgement The Centers for Medicare and Medicaid Services (CMS) has mandated a transition to the new 5010 version of the ASC X12 HIPAA Transaction and Code Set Standards effective January 1, 2012. As a result of the Department of Social Services 5010 implementation, the 999 Acknowledgement will replace the 997 Functional Acknowledgement. The new HIPAA 5010 Version of the 999 Acknowledgement can be accessed from the www.ctdssmap.com, information page, under HIPAA and clicking on the link ASC X12N 999 Acknowledgement for Health Care Insurance Transactions. The IK5 in the 999 replaces the AK5 reported in the 997. The 999 also reports an AK9. If both display an A in the first position, the file is accepted. If both display an R the file is rejected. 5
Web Claim Submission A new field titled 837 Version indicates the claim s HIPAA version. Claims submitted via the Web prior to March 9, 2011 display 4010. Any and all future adjustments to these claims will retain this 4010 version. Claims submitted via the Web on or after March 9, 2011 display 5010. All diagnosis panels will display version ICD-9 until the implementation of ICD-10 scheduled for 2013. Medical Record Number has been expanded to 50 characters. Referring Provider has been added at the header. Rendering Provider has been added at the header. 6
Web Claim Submission (Cont.) 7
Web Claim Submission (Cont.) Medicare Allowed Amount field was removed. 8
HP Provider Electronic Solutions Upgrade your HP Provider Electronic Solutions software now to the current 3.76 version to ensure a smooth transition to the upcoming 3.77 5010 version of the software. Read the HIPAA 5010 Implementation of Provider Electronic Solutions Provider Bulletin PB 2011-60 Keep alert to notifications on the Provider Electronic Solution software implementation date and future training workshops. 9
ASC X12N 835 Health Care Payment/Advice Transaction The new HIPAA 5010 Version of the X12N 835 Health Care Payment/Advice updates can be accessed from the www.ctdssmap.com, information page, under HIPAA and clicking on the link ASC X12N 835 Health Care Payment/Advice. This references the most significant changes to the 835 transactions. Client s first and last name will be expanded to 35 and 60 characters respectively. The received date of the claim will be included in the 835. The corrected client name will be included when the name submitted on the 837 is different than the name in the client eligibility file. Both provider and trading partners must identify the complete scope of changes reported in the implementation guide. 10
HIPAA 5010 837 Institutional Electronic Claim Transaction Effective April 27, 2011, DSS began accepting HIPAA 5010 X12N 837 Institutional Electronic Claim Transaction Existing formats (4010) will continue to be supported until a cutover date is announced, it is strongly recommended that you upgrade prior to that time. Important Changes 5010 version identifier code is 005010X223A2 Taxonomy qualifier of PXC will replace ZZ. The Service Location Address for all providers must be a street address, not P.O. Box. A nine digit zip code will be required. 11
Client Eligibility Verification Web and 270/271 Eligibility Verification. The client s address will be added to the eligibility response. The following data will no longer be provided in the eligibility response: Medicare coverage effective date and end date HIC PDP name PDP Plan ID Third Party Liability (TPL) Policy Number Policy Holder name TPL Coverage Type TPL Effective date and TPL End date 12
Client Eligibility Verification (Cont.) The eligibility response will include the program in which the individual has coverage in the Connecticut Medical Assistance Program along with the following service type codes if they are covered services for the client s benefit plan. 1 - Medical 4 - DX X-Ray 5 - DX Lab 33 - Chiropractic 35 - Dental 42 - Home Health Care 45 - Hospice 47 - Hospital 54 - Long Term Care 56 - Medically Related Transportation 75 - Prosthetic Device 82 - Family Planning 86 - Emergency Services 88 - Pharmacy 93 - Podiatry 98 - Professional (Physician) Visit-Office AD - Occupational Therapy AF - Speech Therapy AL - Vision (Optometry) DM - Durable Medical Equipment MH - Mental Health PT - Physical Therapy RT - Residential Psychiatric Treatment UC - Urgent Care 13
Client Eligibility Verification (Cont.) 14
Client Eligibility Verification (Cont.) 15
Client Eligibility Verification (Cont.) 16
Client Eligibility Verification (Cont.) The Automated Voice Response System (AVRS) will continue to return TPL information in the client eligibility verification response. Providers can access AVRS by dialing 1-800-842-8440 or locally to Farmington, CT at (860) 269-2028. Select option 1 for Self Service Options, enter the AVRS ID and PIN, Select option 1 for Eligibility Verification. The provider may also contact the insurer to obtain policy related information. 17
Web Account Maintenance Clerk Account - AVRS ID and PIN 18
Web Account Maintenance Primary Account Holder Clerk Maintenance Add AVRS ID and PIN to clerk s account If they cannot add it to the clerk s account they would need to delete their clerk ID and set-up a new user ID. 19
Web Account Maintenance Updating Provider s address Sign into the secure Web portal as the Primary Account Holder Click on Demographic maintenance Click on the Location Name Address link beneath the Provider information panel. 20
Web Account Maintenance Updating Provider s address 21
Web Account Maintenance Updating Provider s address cont. Click on the Service Location row then click on maintain address. Change the service location address. A PO Box cannot be within Address 1 or 2 and a full 9 digit zip code is required. Click save in the bottom right corner of the panel. "Save was Successful" message should appear confirming the address change. 22
Web Account Maintenance Cont. Provider Account Holder - Updating Provider s address 23
Hospice Forms Hospice Election (Rev 7/10) Change Request Between Hospice Providers (Rev 5/10) Medicaid Hospice Discharge (Rev 5/10) Medicaid Hospice Revocation (New 9/09) Forms can be obtained on the www.ctdssmap.com Web site From the Home Page > Publications > Forms > Hospice Forms Review your forms for the latest revisions Providers should review forms for completion and accuracy before faxing All forms should be faxed to: (860)424-5678 (This information is on page two of each form, except revocation.) 24
Hospice Election of the Managed Care (MCO) Client MCO clients are eligible for the Hospice Benefit. Contact the MCO in which the client is enrolled for the correct process and form. Providers should not submit the Election Form to DSS. This form should be submitted directly to the MCO. There will be no hospice benefit election displayed in the eligibility response, if the client has selected a hospice benefit when enrolled in an MCO. 25
Web Based Hospice Forms Design in Process Providers will log in to their secure web account and select the transaction they wish to complete Online Features will include: Required field data prompt Transaction type (includes extension of hospice services) Client ID Date of Hospice Election/Discharge/Transfer Reason for Discharge Contact Name/Telephone Auto Data Field Population Hospice Name/Address per log-in Client Name based on client ID entered Client eligible for (Medicaid or Medicaid and Medicare A) 26
Web Based Hospice Forms Design in Process Online Features cont. Editing: Correct logon ID (Home Health instead of Hospice) Client eligibility Incorrect ID Eligible benefit plan for Hospice» Identify if client MCO Lock-in status Prompt will include action needed if transaction does not match lock-in status Example: Hospice submitting online discharge transaction when client locked into another Hospice provider. Provider will receive message: Cannot discharge client. Client is currently under the care of (hospice name/address/telephone). If the client is being transferred to your agency, select the transfer transaction type. 27
Web Based Hospice Forms Design in Process Date Restrictions for backdating Hospice election Three business days allowed If client eligibility recently added, backdating up to seven days of the eligibility file add date will be allowed 28
Prior Authorization Prior Authorization (PA) means the approval from the Department of Social Services (DSS), or a contracted agent of the Department of Social Services, for the provision of a service or the delivery of goods from the department before the provider actually performs the service or delivers the goods Obtaining PA does not guarantee payment or ensure client eligibility. It is the responsibility of the provider to verify client eligibility for the appropriate date (s) of service. 29
Prior Authorization of Hospice Services A PA form must be completed and submitted to HP for the following Hospice services: RCC 656- General Inpatient Care in a Nursing Facility or Hospital Prior Authorization is required after 5 days of inpatient care Hospice services exceeding a period of twelve months Exception: For dually eligible clients the provider must fax the first page of the original hospice election, Form W-406, to the fax number on the election form, with a strike through of the original effective date. The provider must indicate a new effective date and indicate Extension next to the new date. A PA form is not required. 30
Prior Authorization Request Process When requesting PA, providers must complete the most current version of the PA form located on the www.ctdssmap.com Web site. From the home page > Publications > Forms >Authorization/Certification Forms > Prior Authorization Request Form Providers may complete the PA form on line, print and fax or mail to HP Form completed on line cannot be saved Printed PA forms may also be handwritten Hand written forms should be prepared in a legible manner Incomplete or illegible requests or those submitted on outdated forms will be returned. Forms returned by the provider should be resubmitted with the Return to Provider (RTP) letter indicating why the PA form was returned 31
Prior Authorization Preparing the PA Form 32
Prior Authorization Preparing the PA Form 33
Prior Authorization Preparing the PA Form 34
Prior Authorization Preparing the PA Form 35
Claim Resolution Guide Provider Manual Chapter 12 Claim Resolution Guide This guide lists commonly posted Explanation of Benefit (EOB) codes and provides a brief explanation of the reason why claims were either suspended or denied. This guide provides a detailed description of the cause of each EOB and more importantly, the necessary correction to the claim, if appropriate, in order to resolve the error condition. This guide also provides tips to assist providers to where they need to go to find additional information to help on correcting their claims. 36
Client Eligibility Impacts on Claim Denials Claims will deny: EOB 702 Hospice Room and Board not covered without Nursing Home Authorization. Cause The hospice claim was submitted with Revenue Center Code (RCC) 658 (Hospice Room and Board-Nursing Facility) for a client who has not received authorization by the Department of Social Services to be in the nursing home Client has recently been admitted to the nursing facility and the segment has not yet been added. The process for adding this information to the client s file is a multi-step process contingent on timely submission of admission forms by the facility, Alternate Care, Regional Office and Convalescent review and input. 37
Client Eligibility Impacts on Claim Denials EOB 702 cont. Resolution Once the nursing home authorization has been added to the client s eligibility file, the claim can be resubmitted. Note: Nursing Facilities experience similar denials when submitting claims for clients who have been admitted to their facility within the last few months. 38
Facility Charge Billing RCC 658 Providers are encouraged to: Review their contracts with facilities they reimburse for room and board charges for clients under their hospice care to accommodate the flow of reimbursement to both parties. Providers should keep the following in mind when revising their contracts: Nursing Home room and board will not be paid to the Hospice or Nursing Home provider until:»there is a nursing home authorization segment on the client s eligibility file.» The Convalescent Payment Unit at DSS enters a Pay Start Note: See the DSS Nursing Home Eligibility Process Document Nursing Homes are paid upfront by the client or representative for the client for monthly patient liability due. 39
Facility Charge Billing RCC 658 cont. The full Patient Liability due for the month is taken from the first claim containing at least one detail for Nursing Home room and board received by HP. This practice also applies to Nursing Homes when billing for reserve days for hospice clients receiving an inpatient level of care and for routine room and board for clients not covered under a hospice benefit. Patient Liability in excess of the allowed amount of the claim is set up as an accounts receivable and deducted from the total payment amount on the same Remittance Advice (RA), if funds are available. Nursing Home providers are not allowed to bill for room and board charges in the current month until the first of the following month. 40
Client Eligibility Impacts on Claim Denials EOB 1024 Provider not authorized to bill for client when: Cause No Hospice or Hospice Medicare Lock-in Segment (RCC 658 only) on client s eligibility file Claim dates of service are not within the hospice lock-in segment Hospice lock-in to different Hospice Provider Resolution The claim is not payable until EMS is updated with the client s authorization for the client to be serviced by the billing provider. To determine if EMS has been updated, perform a client eligibility verification transaction. Once EMS has been updated, resubmit the claim. 41
Client Eligibility Impacts on Claim Denials EOB 0710 Revenue not covered for client enrolled in Medicare hospice Cause The hospice claim was submitted for a client who has been authorized for Medicare hospice services and the claim contains a Revenue Center Code (RCC) other than 658. Resolution Only RCC 658 is valid when billing a hospice claim for a client with a Medicare hospice lock-in. Correct the RCC and resubmit the claim, otherwise, the claim is not payable. 42
Client Eligibility Impacts on Claim Denials EOB 0711 Claim denied. Client does not have hospice lockin. Cause The hospice claim is submitted for a client who has not yet been authorized by the Department of Social Services to receive hospice services from the billing provider. Tip: DSS should execute the client s election into the hospice program within 10 business days from date of receipt of the election form. If the lock-in is not in place within 10 days of the submission of the election form to DSS, the hospice provider should contact DSS. DSS will not back date election forms not received within 10 days of election. 43
Client Eligibility Impacts on Claim Denials EOB 0711 cont. Resolution Perform a client eligibility verification transaction to determine if the client has been locked-in to the billing hospice agency. If the lock-in is in place, resubmit the claim to HP. If lock-in is not authorized for the date of service: If services billed are Revenue Center Code (RCC) 658 (Hospice Room and Board-Nursing Facility), the Nursing Home may bill these charges as a routine room and board claim. If services billed are either RCC 651 (Hospice/RTN Home) or 652 (Hospice/CTNS Home), the Hospice may bill comparable Home Health services under their Home Health Agency Provider Number. 44
Client Eligibility Impacts on Claim Denials EOB 0711 cont. If services billed are RCC 656 (Hospice/IP Non-Respite), either the Hospital or Nursing Home may bill charges as a routine Hospital or Nursing Home stay. If services billed are RCC 657 (Hospice/Physician), the professional provider may bill charges as a routine medical claim. 45
Other News Presumptive Eligibility Revised Form W-538 (PB 2011-57) Used for children under age of nineteen and pregnant women who have been determined to be presumptively eligible for HUSKY A or HUSKY B. 46
Resource Updates Connecticut Medical Assistance Program Web site www.ctdssmap.com HIPAA 5010 (Quick access to all 5010 Connecticut Medical Assistance Program Publications) From the home page under Important Messages >Welcome to the HIPAA 5010 Implementation Page HIPAA 5010 Transaction updates From the home page > Information > HIPAA 47
Resource Updates Prior Authorization Information From the home page > Information > Publications > Chapter 9 > Prior Authorization Claim Resolution Guide From the home page > Information > Publications > Chapter 12 > Claim Resolution Guide 48
Resource Updates Hospice Forms From the home page > Publications > Forms > Hospice Forms > Select link to applicable form Hospice Paper Claim (UB-04) Instructions From the home page > Publications > Provider Manuals > Chapter 8 > select Hospice > view chapter 8 > Hospice Claim Submission Instructions 49
Resource Updates cont. HP Provider Assistance Center (PAC): Monday through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays 1-800-842-8440 (in-state toll free) (860) 269-2028 (local to Farmington, CT) EDI Help Desk Monday through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays 1-800-688-0503 (in-state toll free) (860) 269-2026 (local to Farmington, CT) 50
Connecticut Medical Assistance Program Refresher Workshop for Hospice Providers Time for Hospice Questions 51