Transcript Slide 1

Medical Equipment Guidelines
Claim Attachments and
Denial Resolution
Presented by EDS Provider Field
Consultants
October 2009
Agenda
Welcome and Announcements
• Date of Service
• Provider Code Sets
• Capped Rental
• Repair and Replacement
• Billing the Member
• Rolling 12 Month Period
• Mail Order Incontinence, Ostomy, and
Colostomy Supplies
• Claim Attachments
• Denials and Resolutions
• Helpful Tools
• Questions
MEDICAL EQUIPMENT UPDATES
2
/ OCTOBER 2009
Session Objectives
• Following this session, providers will be able to
understand:
– Medical Equipment Guidelines
– Claim Attachment Process
– Top Denials and Resolutions
MEDICAL EQUIPMENT UPDATES
3
/ OCTOBER 2009
Medical Equipment
Guidelines
MEDICAL EQUIPMENT UPDATES
4
/ OCTOBER 2009
Date of Service
• The date of service is the date the
equipment is delivered, not ordered
• For the IHCP to reimburse for medical
equipment, the member must be
eligible on the date of service (date of
delivery)
MEDICAL EQUIPMENT UPDATES
5
/ OCTOBER 2009
Provider Code Sets
• The IHCP established code sets to
ensure appropriate reimbursement for
medical equipment codes
• Providers must ensure that they are
enrolled as the correct provider type
and specialty
–Type and specialty can be verified
using the Provider Profile option on
the Web interChange
MEDICAL EQUIPMENT UPDATES
6
/ OCTOBER 2009
Provider Code Sets
• The durable medical equipment (DME)
provider type is 25 and the following
are provider specialties:
– 251 – Home medical equipment provider
– 250 – DME/Medical supply dealer
– Enrolling in the 251 specialty does not
cover services in the 250 specialty, and
enrolling in the 250 specialty does not
cover services in the 251 specialty
Page 5 of the paper Provider Enrollment
form lists the primary specialty in box 39,
the additional specialty can be hand
written in the unassigned box to the right
MEDICAL EQUIPMENT UPDATES
7
/ OCTOBER 2009
Capped Rental
• Certain procedure codes are limited to 15
months of continuous rental
• The IHCP evaluates requests from providers
for approval of capped rental items
– In long-term need situations, a decision
may be made to classify the item as
“purchase” instead of “rental”
• Continuous rental is defined as rental
without interruption for a period of more
than 60 days
– A change in provider does not cause an
interruption in the rental period
• A complete list of procedure codes for
capped rental can be found in the Indiana
Health Coverage Programs Provider Manual,
Chapter 8, Section 4
• The provider must service the item at no
cost to the IHCP
MEDICAL EQUIPMENT UPDATES
8
/ OCTOBER 2009
Capped Rental
• Centers for Medicare and Medicaid Services (CMS)
changed the capped rental policy for DME
• The new policy states that the capped rental period is 13
months
– After 13 months, the member owns the DME
• Medicare will pay for reasonable and necessary
maintenance and service of the DME item
– This policy change applies to DME items in which the
first month of rental is on or after January 1, 2006
• At this time, Medical Policy has not been directed to
make changes to the IHCP’s capped rental policy
MEDICAL EQUIPMENT UPDATES
9
/ OCTOBER 2009
Capped Rental
Claims Submitted for Capped Rental Items
The allowed charge is the lower of the 1993 Medicare rental
fee schedule amount or the actual submitted charge
• The IHCP pays claims until the number of rental payments
made reaches the capped rental number of 15 months
• When the 15 month rental period has been exhausted, the
DME/HME equipment is considered purchased and becomes
the property of OMPP
• Providers should base their decisions to rent or purchase
DME or HME on the least expensive option available for the
anticipated period of need
MEDICAL EQUIPMENT UPDATES
10
/ OCTOBER 2009
Repair and Replacement
• Repair of purchased equipment may
require prior authorization based on the
Healthcare Common Procedure Coding
System (HCPCS) codes
• The IHCP does not pay for repair of
equipment still under warranty
• The IHCP does not authorize payment
for repair necessitated by member
misuse or abuse, whether intentional or
unintentional
• The rental provider is responsible for
repairs to rental equipment
MEDICAL EQUIPMENT UPDATES
11
/ OCTOBER 2009
Repair and Replacement
• The IHCP does not cover payment for
maintenance charges of properly
functioning equipment
• The IHCP does not authorize replacement
of medical equipment more than once
every five years per member
– More frequent replacement is allowed
only if there is a change in the
member’s medical needs that is
documented in writing and significant
enough to warrant a different type of
equipment. Such requests require PA
• A long-term care (LTC) facility’s per diem
rate includes repair costs for equipment
MEDICAL EQUIPMENT UPDATES
12
/ OCTOBER 2009
Billing the Member
• The following circumstances are the only situations in
which an IHCP provider may bill a member:
–The service rendered is non-covered by the IHCP
–The member has exceeded the program limitations for a
particular service; for example, the services were denied
prior authorization (PA)
–Before receiving the service, the member must
understand that the service is not covered under the
IHCP, and the member is responsible for the charges
associated with the service
–A signed waiver must be maintained in the member’s
record that the member voluntarily chose to receive a
service that was not covered by IHCP
MEDICAL EQUIPMENT UPDATES
13
/ OCTOBER 2009
Billing the Member
• “Medicaid-pending” individuals are responsible to pay the
provider
• It is the patient’s responsibility to notify the provider of
Medicaid approved status within 12 months of the date of
service
• Providers may bill the patient if there is no notification of
Medicaid eligibility within this time period
• Providers may also bill the member when the spend-down or a
copay applies to the claim
• Spend-down – Look for ARC Code 178 on the remittance
advice
• Copay – Look for ARC Code 3 on the remittance advice
MEDICAL EQUIPMENT UPDATES
14
/ OCTOBER 2009
Rolling 12 Month Period
• Is not:
– Based on a 12-month calendar year
– Based on a fiscal year
– Renewable on January 1 of each year
• Is:
– Based on the first date that services are
rendered by a particular provider
– Renewable one unit at a time beginning
365 days after the date that services are
rendered by a particular provider
MEDICAL EQUIPMENT UPDATES
15
/ OCTOBER 2009
Mail Order Incontinence, Ostomy, and
Colostomy Supplies
Contracted Vendors
• Effective February 1, 2008, the OMPP contracted with
three vendors to provide incontinence, ostomy, and
urological supplies to fee-for-service members
• The three contracted vendors are:
– Binson’s Home Health Care Center
1-888-217-9610
www.binsons.com
– Healthcare Products Delivery, Inc (HPD)
1-800-291-8011
www.hpdinc.net
– J & B Medical
1-866-674-5850
www.jandbmedical.com
MEDICAL EQUIPMENT UPDATES
16
/ OCTOBER 2009
Mail Order Incontinence, Ostomy, and
Colostomy Supplies
• Members must obtain supplies via mail order
– The contracted vendor may make other
arrangements in emergency situations
• The contracted vendors began providing
services February 1, 2008, with full
implementation completed on June 1, 2008
• A full listing of codes affected by this change is
available in BT200823
• The annual maximum allowable reimbursement
is $1,950 per member per rolling calendar
year.
MEDICAL EQUIPMENT UPDATES
17
/ OCTOBER 2009
Mail Order Incontinence, Ostomy, and
Colostomy Supplies
Program Guidelines
• The contracted vendor service applies to the Fee for
Service and Care Select Programs
• Only paid Crossovers and TPL claims are excluded from
the program
– If Medicare or the TPL denies the claim, the services are
limited to the 3 contracted vendors
• The following programs and claim types are not affected
by the contract:
– 590 Program
– Medical Review Team (MRT)
– Pre-Admission Screening and Resident Review (PASRR)
– Long Term Care (LTC)
– Waiver
• Risk-based managed care (RBMC) members are excluded
– Supplies for these members are billed to the appropriate
managed care organization (MCO)
MEDICAL EQUIPMENT UPDATES
18
/ OCTOBER 2009
Mail Order Incontinence, Ostomy and
Colostomy Supplies
Nursing Assessment
• A needs assessment is part of the initial
enrollment process
• Members receive a telephone call from a
staff nurse or a questionnaire by mail
• The questionnaire gives the vendor
additional information regarding the
member’s supply needs
MEDICAL EQUIPMENT UPDATES
19
/ OCTOBER 2009
Claim Attachments
MEDICAL EQUIPMENT UPDATES
20
/ OCTOBER 2009
Claim Attachments
MEDICAL EQUIPMENT UPDATES
21
/ OCTOBER 2009
Claim Attachments
MEDICAL EQUIPMENT UPDATES
22
/ OCTOBER 2009
Claim Attachments
Attachment Control Number (ACN)
• Unique number assigned by provider
• Claim and document specific
• Each ACN may only be used one time
• Write “ACN #” and the assigned ACN on each
page of documentation corresponding to that
number
MEDICAL EQUIPMENT UPDATES
23
/ OCTOBER 2009
Claim Attachments
Report Type and Transmission Code
• Select the appropriate Report Type
–Report Type describes the document being
sent
• Transmission Code defaults to “BM” – by mail
–Electronic and e-mailed attachments are not
accepted
MEDICAL EQUIPMENT UPDATES
24
/ OCTOBER 2009
Claim Attachments
Attachment Control Cover Sheet
MEDICAL EQUIPMENT UPDATES
25
/ OCTOBER 2009
Claim Attachments
Attachment Control Cover Sheet
• Available on IHCP home page, under Forms
• Complete cover sheet for each claim
• Include provider information
• Provide member ID
• List each ACN pertaining to specific attachment
• Indicate the number of pages of documentation
submitted per attachment (not including the
cover sheet)
• Mail cover sheet and supporting documentation
to the appropriate P.O. Box (P.O. Box 7259)
MEDICAL EQUIPMENT UPDATES
26
/ OCTOBER 2009
Denials and Resolutions
MEDICAL EQUIPMENT UPDATES
27
/ OCTOBER 2009
Denials and Resolution
Denial: Edit 0593 – Medicare Denied Detail
Cause:
At least one detail submitted contains Medicare COB
data resulting in a review of all detail COB data
Resolution:
• Review to ensure COB data for detail in question does
not contain all zeros or is missing
• Crossover claim that has Medicare denied detail along
with covered detail should be adjusted to only include
the covered detail.
• Submit non-covered detail on separate claim with
Medicare EOB – this is not a crossover claim
MEDICAL EQUIPMENT UPDATES
28
/ OCTOBER 2009
Denials and Resolution
Denial: Edit 0558 – Co-Insurance and Deductible Missing
Cause:
Claim submitted has no coinsurance and deductible amount indicating
that this is not a crossover claim.
Resolution:
• Compare the detail line(s) to the Medicare EOB and complete crossover
information
• Medicare crossover claims can be submitted electronically using Web
interChange
The following header information is required for the claim to process:
– Payer ID and Payer Name
– TPL/Medicare Paid Amount
– Subscriber Name, Primary ID, Relationship Code, Gender, DOB, and Claim
Filing Code
– If the Payer ID is a Medicare payer and the Claim Filing Code is MA or MB,
the claim is considered to have crossover information
Note: Obtain COB information, including Payer IDs from the HELP tab, Reference
Materials on Web interChange
MEDICAL EQUIPMENT UPDATES
29
/ OCTOBER 2009
Denials and Resolution
Denial: Edit 4209 – Procedure Code/Modifier Combination
Cause:
No matching pricing segment for the procedure/modifier
combination billed on the HCFA 1500 Claim form
Resolution:
• Refer to the Provider Procedures Manual for the
appropriate use of the modifiers TC, 26, RR, and NU.
- Effective December 31, 2008, the Centers for
Medicare & Medicaid Services (CMS) end-dated
modifier RP – replacement and repair, as announced
in provider bulletin BT200843, dated December 30,
2008.
• Verify the procedure code/modifier combination on the
Fee Schedule on the IHCP home page
MEDICAL EQUIPMENT UPDATES
30
/ OCTOBER 2009
Denials and Resolution
Denial Edit 4021 – Procedure Code Vs Program Indicator
Cause:
Procedure code is not covered for the dates of service for the
program billed
Resolution:
Verify the procedure code and program coverage on the Fee
Schedule on the IHCP home page
MEDICAL EQUIPMENT UPDATES
31
/ OCTOBER 2009
Denials and Resolution
Denial: Edit 4033
Combination
-
Invalid Procedure Code Modifier
Cause:
The modifier used is not compatible with the procedure
code billed
Resolution:
• Verify procedure code and modifier combination on
the Fee Schedule on the IHCP home page
• Consult the IHCP Provider Manual
MEDICAL EQUIPMENT UPDATES
32
/ OCTOBER 2009
Denials and Resolution
Denial: Edit 6000 – Manual Pricing Required
Resolution: Submit Manual Pricing
– Invoice requirements
•
Date
•
Billed amount per unit (for example, box, case,
and so forth)
•
Calories (enteral feeding)
•
Procedure code
•
Member name
•
Member ID number
•
Itemization of repairs
– Bulk Invoices – illustrate calculations specific to
the member
MEDICAL EQUIPMENT UPDATES
33
/ OCTOBER 2009
Denials and Resolution
Denial: Edit 6000 – Manual Pricing Required
Resolution: Submit Manual Pricing
MEDICAL EQUIPMENT UPDATES
34
/ OCTOBER 2009
Denials and Resolution
Denial: Edit 6000 – Manual Pricing Required
Resolution: Submit Manual Pricing
DME SUPPLY MANUFACTURING
1 SUPPLY ROAD
ANYWHERE, INDIANA
800-123-2345
INVOICE
4/27/09
BILL TO:
DME/HME SUPPLIES
200 STATE STREET
ANYWHERE, INDIANA
ITEM NUMBER/DESCRIPTION
EXTRA SET RT ANGLE HCPCS: B9998
U/M
5/BOX
QTY
1
5 sets in a box - ordered 1 box
59.90/5 = 11.98 each
Member rid# 123456789999
Abe Lincoln
**********CUSTOMER INVOICE – ORIGINAL*************
MEDICAL EQUIPMENT UPDATES
35
/ OCTOBER 2009
PRICE
59.90
TOTAL
59.90
Denials and Resolution
Denial: Edit 3001 - Dates of service not on P.A.
master file.
Cause:
No Prior Authorization in IndianaAim
Resolution:
• Verify the date of service and procedure code
billed are correct on the requested P.A.
• Obtain amended/corrected P.A. if necessary
MEDICAL EQUIPMENT UPDATES
36
/ OCTOBER 2009
Denials and Resolution
Denial: Edit 0509 – Net Charge Out of Balance
Cause:
• Claim totals do not balance to the net charge
entered on the claim
Resolution:
• TPL claims: the net charge on a paper claim
form in field 30, should equal the total charge,
field 28, less the TPL paid amount, field 29
• Medicare Crossover claims: the total charge,
field 28, and the net charge, field 30, should be
the same
MEDICAL EQUIPMENT UPDATES
37
/ OCTOBER 2009
Denials and Resolution
Denial: Edit 2003 – Recipient Ineligible on Dates
of Service
Cause:
• Member is not eligible for IHCP services being
billed
Resolution:
• Verify member eligibility using Web
interChange, AVR or Omni
• Verify the claim was sent to the appropriate
billing entity
– Fee for Service and Care Select to EDS
– RBMC to the appropriate MCO
MEDICAL EQUIPMENT UPDATES
38
/ OCTOBER 2009
Helpful Tools
Avenues of Resolution
• IHCP Web site at
www.indianamedicaid.com
• IHCP Provider Manual (Web, CD-ROM, or
paper)
• Customer Assistance
– 1-800-577-1278, or
– (317) 655-3240 in the Indianapolis local
area
• Written Correspondence
– P.O. Box 7263
Indianapolis, IN 46207-7263
• Provider Relations Field Consultant
– View a current territory map and contact
information online at HCP Web site at
www.indianamedicaid.com
MEDICAL EQUIPMENT UPDATES
39
/ OCTOBER 2009
Questions
MEDICAL EQUIPMENT UPDATES
40
/ OCTOBER 2009
EDS
950 N. Meridian St., Suite 1150
Indianapolis, IN 46204
EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal
opportunity employer and values the diversity of its people. ©2008 Hewlett-Packard Development Company, LP.
MEDICAL EQUIPMENT UPDATES
41
/ OCTOBER 2009