Wyoming Medicaid- Provider Services Updates Provider Workshops Summer 2017
Facilities Update TITLE 25- Involuntary Hospitalization Effective August 1, 2016- Wyoming Medicaid began processing Title 25 claims through the Medicaid claims payment systeminstead of submitting these to the Wyoming State Hospital, they should now be submitted to Conduent. Effective April 1, 2017- Wyoming Medicaid can pay on medically appropriate services delivered to clients under a Title 25 hold.
T25 Required Documentation Required T25 attachments: Title 25 Certification Form Copy of the Clinician/Medical Examiner documentation supporting involuntary hold (Form 3-81) Copy of the Order for Continuing Emergency Detention and/or the Order for Involuntary Hospitalization Copy of the Order of Dismissal- required if the patient is being discharged (Form 14-81) Copy of any Explanation of Benefits, if applicable WYhealth PA Letter- for inpatient services only, approved or denied (for Medicaid clients only)
T25 Policy Changes Effective April 1, 2017- several major policy changes for billing T25 services For Wyoming Medicaid eligible clients: Inpatient services- Must be submitted on paper Must be prior authorized through WYhealth (for admissions after April 1) Must be billed according to all Medicaid policies and guidelines *Title 25 claims must be billed upon discharge. Interim billing is not allowed.
T25 Policy Changes- Medicaid clients, cont. Outpatient/ER/Observation services- Must be submitted on paper Must be billed according to all Medicaid policies and guidelines Professional services- Must be submitted on paper Must be billed according to all Medicaid policies and guidelines *UB and 1500 claims can be submitted together for the same client with ONE set of T25 documentation included
T25 Policy Changes For Non-Wyoming Medicaid eligible clients: Inpatient services- Must be submitted on paper Must be billed using 0919 revenue code for each eligible inpatient day Outpatient/ER/Observation services- Must be submitted on paper Must be billed according to all Medicaid policies and guidelines Professional services- Must be submitted on paper Must be billed according to all Medicaid policies and guidelines * NO PA submission to WYhealth requirement for non-medicaid clients
Title 25 Reimbursement Methodology Medicaid eligible clients: Inpatient- paid per discharge Level of Care payment based on primary diagnosis Outpatient/ER/Observation- paid per Medicaid s OPPS reimbursement methodology Professional services- paid per Medicaid fee schedule
Title 25 Reimbursement Methodology Non-Medicaid eligible clients, or Medicaid eligible T25 clients with a denied PA from WYhealth (does not meet medical necessity, e.g.): Inpatient- per diem, $677/day Outpatient/ER/Observation- paid per Medicaid s OPPS reimbursement methodology Professional services- paid per Medicaid fee schedule
72 Hour Rule Reminder: No payment can be made by the State within the first 72 hours of the emergency detention- weekends and holidays are not included in the 72 hours. Services provided within the first 72 hours of the emergency detention must be billed to the County, unless the client is not a Wyoming resident- in this case, the entire stay should be billed to the State.
72 Hour Rule Example: Jane Doe was detained via a 3-81 order on Monday, February 13, 2017, at 11:45 am and admitted the same day. The first date payable by the State or Medicaid will be Thursday, February 16 th at 11:45 am, 72 hours after the detained date/time.
PA Process Initial admission PA request to WYhealth will remain the same Complete form titled Acute Inpatient Psychiatric Admission Authorization Form within one business day of the admission Indicate involuntary status on the form The initial 72 hours will continue to be administratively denied as county responsibility (if required for your records)
PA Process Following the expiration of the initial 72 hours, providers will submit: Form titled Continued Stay Review Acute Care Psychiatric Services with all supporting clinical documentation Must be submitted to WYhealth within 1 business day of the expiration of the initial 72 hours If medical necessity is met, a PA will be created and an authorization letter sent to the provider Approved PA letter must be submitted as part of the Title 25 documentation sent to Conduent
PA Process If medical necessity is not met, a denial will be issued If Medicaid (WYhealth) denies the PA request, the Wyoming State Hospital is obligated to make payment on the claim Include a copy of the denied PA as part of the Title 25 documentation sent to Conduent
Important Title 25 Information Please visit https://wyequalitycare.acsinc.com/institutional.html for the following: Title 25 Billing Manual Title 25 Certification Form Visit wyhealth.net for Medicaid Behavioral Health prior authorization forms or call 1-888-545-1710 for prior authorization questions.
Nursing Home Information Who to call for what? Nursing home claim issues/questions/status- Conduent Provider Relations- 1-800-251-1268 PASRR Level I submission issues/questions through the web portal/password resets- Conduent EDI Services- 1-800-672-4959, option 3 PASRR Level II requirements/submission questions- Optum WYhealth- 1-888-545-1710
Nursing Home Reserve Bed Days Reminder: As of October 1, 2016- reserve bed days are no longer a covered Medicaid service; for example, when a nursing home or swing bed client is admitted to the hospital, has a visit home, etc. Reserve bed days may be billed to the client as long as they are informed in writing before the leave occurs of their financial responsibility. Any leave days that have been billed and paid by Medicaid after October 1, 2016 will be recovered.
Home Health Changes Changes effective 3/1/17 Each date of service must be billed on a separate line item no span billing on lines (the claim can be for a span, but each date of service must have a separate line item) Home Health Exemption Letter retired PA from Qualis will confirm client is not Medicare eligible. Encounter Definition all services that COULD be performed in a single visit to the client, regardless of whether the provider left and came back before completing the services due to scheduling or reasons of client or provider convenience. A separate encounter cannot be billed unless there is a medical need for services to be separated (i.e. dressing changes, medication timing, frequency of need).
Home Health Prior Authorizations Prior authorizations conducted through Qualis Health http://www.qualishealth.org/healthcareprofessionals/wyoming-medicaid 800-783-8606 Requests are reviewed using InterQual criteria and Wyoming Medicaid Home Health policy (Rule Chapter 12 and Provider Manual) If services do not meet InterQual Criteria, request is reviewed by staff physician at Qualis Provider can ask for a reconsideration through Qualis Health if they feel a denial to be inappropriate If reconsideration is also denied, provider can appeal to Home Health Program Manager Amy Buxton
Home Health Prior Authorization State Appeal To appeal to the state after Qualis has denied the reconsideration request: Send an email to Amy Buxton (amy.buxton@wyo.gov) with Qualis Health s reference numbers. Do not need to send any documentation submitted to Qualis again Include in your email the services you feel the client needs and why you feel they meet the state s policy under the Rules and policy in the Provider Manual Information will be clinically reviewed by state staff and a determination will be returned
Home Health State Appeal Results State reconsideration will have one of four results: Qualis denial will be upheld Qualis denial will be temporarily overturned with a transition plan to move client s services to a more appropriate source (Example: Waiver services) Qualis denial will be partially overturned Qualis denial will be overturned and appropriate services will be prior authorized.
Home Health Services Not Covered Services that are not covered under Home Health: Respite care Medication reminders Medication administration for stable, daily medications Exceptions injections, drugs that are being titrated, drugs with frequent dosage changes, drugs that have a need for dosage calculations that change when the client is demonstrated to be unable to be educated to handle these processes by themselves or with a caregiver s assistance Home Health Aid services where the client does not have a Skilled Nursing need Home Health Aid services where the client does not meet at least a minimum level of need (stand by assistance is not covered)
Home Health Services Not Covered Services expected to be provided by any parent or caregiver (bathing, dressing, feeding) where there is not a medically complex reason the parent or caregiver cannot provide the service Duplication of services being provided under another program Services that are not medically necessary Services that are not ordered by a physician
Physical, Occupational, and Speech Therapy Physical, Occupational, and Speech Therapy services are automatically approved for the first 20 dates of service for each client, each calendar year (PT, OT, and ST each have 20 visits allowed, they are not combined) Providers are expected to review policy and determine if the services meet coverage criteria for the first 20 visits. Beginning with visit 21, services will require a medical review and authorization Current process: Submit a Cap Limit Waiver Request form and required documentation Future process (tentatively 10/1/17): Prior Authorization for services Providers will need to bill with a prior authorization number on their claims once this process is implemented
Physical, Occupational, and Speech Therapy Clients age 21 and older are limited to rehabilitative care Acute care following an injury, accident, illness, or surgery Exacerbation of a chronic condition with intent to create or modify a home exercise program and discharge client after a period of therapeutic treatment Maintenance, exercise, weight loss and general conditioning are not covered services Clients age 20 and younger are covered for medically necessary care Acute care following an injury, accident, illness, or surgery Exacerbation of a chronic condition with intent to create or modify a home exercise program and discharge client after a period of therapeutic treatment Medically necessary care for long term conditions as prescribed by a physician (habilitative care)
Rehabilitation vs. Habilitation Rehabilitative Services Services that help patients keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the client was sick, hurt, or suddenly disabled. Habilitative Services Services that help patients keep, learn, or improve skills and functioning for daily living. Examples would include therapy for a child who isn t walking or talking at the expected age.
Physical, Occupational, and Speech Therapy Practitioner s Prescription requirements: Not valid for more than 180 days Cannot be written ahead of time (i.e. prescription for the next 180 day period cannot be written at the beginning of the current 180 period September prescription cannot be written in June). Must include specific frequency and duration cannot say up to 4x/week or 1 4x/week Approvals of services after the initial 20 visits will be based on the practitioner s prescription if the prescription says 2x/week for 4 weeks, only a 4 week approval can be authorized and a new authorization will need to be obtained when the 4 week prescription is expired
Medicare Crossover Claims Effective January 1, 2017, Wyoming Medicaid implemented a new payment methodology for Medicare Crossover claims processing Prior to this date, Wyoming Medicaid 100% of co-insurance and deductible The current methodology is a lesser of methodology Wyoming Medicaid will compare the amount Wyoming Medicaid would have paid with the amount Medicare has already paid, and pay the lesser of the co-insurance and deductible or the difference between what Wyoming Medicaid would have paid and the Medicare paid amount.
Medicare Crossover Examples Procedure code 97110 billed with 4 units Wyoming Medicaid allowed amount - $29.11 per unit ($116.44) Medicare paid - $84.66 Medicare co-insurance: $21.60 A = Medicaid allowed amount Medicare paid amount $116.44 84.66 = $31.78 B = Medicare co-insurance $21.60 Which is less, A or B? ($31.78 or $21.60) B Medicare co-insurance - $21.60 claim will pay $21.60
Medicare Crossover Examples Procedure code 97112 billed with 1 unit Wyoming Medicaid allowed amount - $29.85 Medicare paid - $27.04 Medicare co-insurance: $6.90 A = Medicaid allowed amount Medicare paid amount $29.85 $27.04 = $2.81 B = Medicare co-insurance $6.90 Which is less, A or B? ($2.81 or $6.90) A Medicaid allowable less Medicare paid - $2.81 claim will pay $2.81
Medicare Crossover Claims If Medicare has already paid more than the Medicaid allowable amount, the claim will pay at $0 Certain denial edits will cause the claim to deny, even if Medicare paid the claim Client eligibility Provider eligibility Some denial edits will be ignored if Medicare has already paid the claim Modifier edits NCCI edits Medicare specific coding requirements
Medicare Crossover Claims When Wyoming Medicaid does not cover a code, there is no amount to calculate the A fee from Wyoming Medicaid will default an allowed amount for the purpose of the calculation This fee is 50% of the Medicare allowed amount Institutional claims do not contain a Medicare allowed amount, and as such, the co-insurance and deductible total is used for the Medicare allowed amount for this calculation Professional and Outpatient claims are calculated on a line by line basis Inpatient claims are calculated as a whole claim
Provider Enrollment Retroactive enrollments will not be allowed Per the Affordable Care Act, Section 6401(a) and the Medicaid Provider Enrollment Compendium (MPEC) Providers will be responsible for keeping their Medicaid enrollment current Reenrollments will need to begin early enough that they are completed before there is a gap in active enrollment status Policy is tentatively schedule to begin July 1, 2017 Emergency Retroactive Enrollment Criteria The provider is out of state The services are furnished by an institutional provider, individual practitioner, or pharmacy at an out-of-state practice location The furnishing/treating provider is enrolled in an approved status in Medicare or in another state s Medicaid plan on the date of service The claim represents either a single instance of care furnished over 180 day period, or multiple instances of care furnished to a single participant, over a 180 day period
Health Check - EPSDT What is the Early and Periodic, Screening, Diagnosis and Treatment Program? Comprehensive healthcare to children from birth up to and including 20-years of age who are eligible for Medicaid. Preventive health philosophy of discovering and treating health problems before they become disabling and far more costly to treat in terms of both human and financial resources. Examines all aspects of a child s well-being and corrects any problems that are discovered.
Health Check - EPSDT Coding Diagnosis Codes to be used when Billing for EPTSD Well Child Checks Diagnosis Code Description Z76.1 Health Supervision of Foundling. Z76.2 Other Healthy Infant or Child Receiving Care. Z00.121, Z00.129 Routine Infant or Child Health Check. Topical Fluoride Procedure Code Modifier Description 99188 32 Topical Fluoride Varnish. Preventative Medicine Services Procedure Code Modifier Description 99381/99391 32 Comprehensive Preventative Medicine Age 0 through 11 Months. 99382/99392 32 Early Childhood Age 1-4 Years. 99383/99393 32 Late Childhood Age 5-11 Years. 99384/99394 32 Adolescent Age 12-17 Years. 99385/99395 32 Age 18-20 Years. Modifier 32 Mandated Services Referral.
Health Check - EPSDT Includes At a minimum, these screenings must include, but are not limited to: Comprehensive health and developmental history Comprehensive unclothed physical examination Dental screening Appropriate vision testing Appropriate hearing testing Appropriate laboratory test (Blood Lead Level testing is required at twelve (12) and twenty four (24) months for all children). The most current copy of the immunization schedule may be found at http://www.cdc.gov/vaccines/schedules/index.html
Health Check - EPSDT & Office Visit If an abnormality(ies) is encountered or a pre-existing problem is addressed in the process of performing preventative medicine E&M service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem oriented E&M service, then the appropriate office/outpatient code 99201-99215 should also be reported. Modifier 25 must be added to the office/outpatient code to indicate that a significant, separate identifiable E&M service was provided by the same physician on the same day as the preventative service. The appropriate preventative medicine service is additionally reported.
Immunizations The immunization status of each child should be reviewed at each Well Child Screen. Reviewing the immunization status of a child includes interviewing parents/caretakers, reviewing immunization history/records, and reviewing known high risk factors to which the child may be exposed. Immunizations needed by children at their Well Child Screen should be given on-site, provided there are not existing contradictions. Immunizations are to be given according to the Advisory Committee on Immunization Practices (ACIP).
Immunizations Arrangements should be made with the parents/responsible adult for the completion of immunizations. If immunizations have not been completed at the recommended age, the healthcare professional should set up a schedule to ensure the child becomes current. The Recommended Immunization Schedule can be found at http://www.cdc.gov/vaccines/schedules/index.html.
NDC/JCODE Billing Effective March 1, 2017, Wyoming Medicaid will be standardizing its methodology for the reimbursement of physician administered drugs. Rates will be established by using the drug's Average Sales Price (ASP) rate as published by Center for Medicare and Medicaid Services (CMS). Rates will be reviewed at least annually. For drugs that are not listed on the ASP file published by CMS, Wyoming Medicaid will first reimburse the Wholesale Acquisition Cost (WAC), and if no WAC is available, will default to the Average Wholesale Price (AWP) for the drug based on the CPT/HCPCS submitted on the claim form. Rates are available for viewing on the Wyoming Medicaid fee schedule. https://wyequalitycare.acs-inc.com/fee_schedule.html
NDC/JCODE Billing Continued As an important reminder for providers billing physician administered drugs, the units billed MUST be the CPT/HCPCS units appropriate for the dose administered. The units reported on the claim should NOT be the NDC-based units. The applicable NDC for the drug administered must also be included on each claim. All NDC s are 11 digits long, if your NDC is not 11 digits your claim will deny.
Continuity of Care Document CCD Viewer Would it be helpful to know that your patient was seen in the ER last month? Would you like to know what previous services have been provided to your patient? Would knowing the past diagnosis be helpful and pertinent to your patient s care today and the course of treatment? Would your treatment be the same if you knew what medications your patient is receiving from another practitioner? Would you like to know what immunizations your patient has received? Would you like to know what lab or radiology tests have been conducted?
Continuity of Care Document CCD Viewer The CCD viewer allows authorized users to search for and retrieve a Patient Summary Continuity of Care Document (CCD) for current Medicaid recipients. The CCD document is used to supplement the patient s clinical health record. The CCD is a HITSP standard patient summary document that contains all of the following information from the THR Gateway: Problems Family History Immunizations Vital Signs Social History Test Results Medications Procedures Alerts Allergies/Adverse Reactions And more
CCD Viewer Putting All The Pieces Together! To request THR CCD Viewer access, please send an e-mail containing: Clinic Name Address Phone Number Provider Names Provider Email Addresses Primary Contact To Andrea Bailey at: andrea.bailey@wyo.gov Visit the website at: http://wyomingthr.wyo.gov/ccd-viewer
State Contact Information Sara Rogers, Facilities Manager- General hospital, critical access hospital, psychiatric hospital, rehab hospital, nursing home, swing bed, PRTF, ESRD- sara.rogers@wyo.gov Sheree Nall, Provider Services Manager- Physician, nurse practitioner, FQHC, RHC, podiatry, ASC, Family Planning Waiver, family planning clinics, PHNs- sheree.nall@wyo.gov Amy Buxton, Provider Services Manager- DME, prosthetics/orthotics, home health, therapies, audiology, lab/radiology, ambulance, CORF, dieticians, chiropractors, client travel- amy.buxton@wyo.gov