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Medical Equipment
Guidelines
HP Provider Relations
October 2010
Agenda
– Indiana Medicaid Web site
– Billing the Member
– Updates
– Spend-down
– Date of Service
– Claim Attachments
– Provider Code Sets
– Prior Authorization
– Capped Rental
– Denials and Resolutions
– Repair and Replacement
– Helpful Tools
– Rolling 12-Month Period
– Questions
– Mail Order Incontinence,
Ostomy, and Colostomy
Supplies
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Medical Equipment Guidelines
October 2010
Objectives
Following this session, providers will:
– Be familiar with the Indiana Medicaid Web site
– Understand medical equipment guidelines
– Understand guidelines for billing the member
– Be familiar with spend-down
– Understand the claim attachment process
– Be familiar with prior authorization inquiry and Prior
Authorization Form
– Understand the top denials and resolutions
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Medical Equipment Guidelines
October 2010
Introduce
Indiana Medicaid Web site
Indiana Medicaid Member Web Site
http://member.indianamedicaid.com/
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Medical Equipment Guidelines
October 2010
Indiana Medicaid Member Web Site
Member tab
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Medical Equipment Guidelines
October 2010
Indiana Medicaid
Member tab
– Qualification Guidelines
– Medicaid Programs
– Apply for Medicaid Benefits
– Check Application Status
– Search for a Provider
– Choose a Health Plan
– Presumptive Eligibility
– Pharmacy Information
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Medical Equipment Guidelines
October 2010
Indiana Medicaid Provider Web Site
http://provider.indianamedicaid.com/
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Medical Equipment Guidelines
October 2010
Indiana Medicaid Provider Web Site
Provider tab
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Medical Equipment Guidelines
October 2010
Indiana Medicaid Provider Web Site
Provider tab
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Medical Equipment Guidelines
October 2010
Provider Tab
– Link to the Web interChange
– Provider Enrollment
– Banners – Bulletins –
Newsletters
– Workshop Information
– Provider Education and
Assistance
– News and Announcements
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Medical Equipment Guidelines
October 2010
Describe
Medical equipment services
Updates
Procedure Code A4253 - Blood glucose test or reagent strips for home
glucose monitor, per 50 strips
– Effective for claims with dates of service on or after January 1, 2010:
• Providers
are permitted to bill up to four units, or 200 strips, per beneficiary per 30
days
• Additional
units of A4253 deny unless prior authorization (PA) is obtained
Procedure Code A4259 – Lancets, per box of 100
– Effective for claims with dates of service on or after January 1, 2010:
•
Providers are permitted to bill two units, or 200 lancets, per beneficiary per 30 days
• Additional units of A4259 deny unless PA is obtained
CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American
Medical Association.
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Medical Equipment Guidelines
October 2010
Updates
Procedure Code K0739 – Repair or nonroutine service for durable
medical equipment other than oxygen equipment requiring the skill of a
technician, labor component, per 15 minutes
– Effective January 1, 2010, K0739 is a covered code
– Replacement for code E1340
– Claims denied with edit 4021 – Procedure Code vs. Program Indicator
should be re-filed
Procedure Code E2609 – custom wheelchair cushion, any size
– Effective May 14, 2010, E2609 is no longer included in the long-term
care durable medical equipment (DME) per diem procedure list
– Requires prior authorization
– May be billed separately to Medicaid
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Medical Equipment Guidelines
October 2010
Updates
– Manually Priced Supplies – Effective September 24, 2010, Healthcare
Common Procedure Coding System (HCPCS) codes for DME,
supplies, and hearing aids that are currently manually priced will
require a cost invoice with the claim in conjunction with the retail
invoice for claim adjudication
• A cost invoice is an itemized bill issued directly from the seller of the supply to the
provider listing the goods supplied and stating the sum of money due to the supplier
• Claims will continue to be reimbursed using the retail invoice, unless no invoice is
submitted by the provider. The cost invoice will aid OMPP to establish rates for
HCPCS
– Invoices custom-generated by the provider that include the price of the
goods plus the provider’s margin will no longer be accepted for
HCPCS codes identified in Bulletin 201037
– Claims with a “from” date of service on or after September 24, 2010,
submitted with HCPCS procedure codes listed in the table in
BT201037, along with only a retail invoice, or a provider customgenerated invoice, will be denied with:
• Explanation of Benefit Code 9024 – Inappropriate invoice attached to the claim, please
resubmit with the proper attachment
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Medical Equipment Guidelines
October 2010
Date of Service
– The date of service is the date the
equipment is delivered, not ordered
– For the Indiana Health Coverage
Programs (IHCP) to reimburse for
medical equipment, the member
must be eligible on the date of
service (date of delivery)
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Medical Equipment Guidelines
October 2010
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
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Medical Equipment Guidelines
October 2010
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 handwritten in the unassigned space to the
right
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Medical Equipment Guidelines
October 2010
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
– The provider must service the item at no cost to the IHCP during the
rental period
• Once the equipment is considered purchased, any nonwarranty repairs are billable
– A complete list of procedure codes for capped rental can be found in
the Indiana Health Coverage Programs Provider Manual, Chapter 8,
Section 4
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Medical Equipment Guidelines
October 2010
Capped Rental
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/home medical equipment (HME) is considered purchased and
becomes the property of the Office of Medicaid Policy and Planning
(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
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Medical Equipment Guidelines
October 2010
Capped Rental
– Medicare 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
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Medical Equipment Guidelines
October 2010
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
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Medical Equipment Guidelines
October 2010
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 change in equipment; such requests
require PA
– A long-term care (LTC) facility’s per diem
rate includes repair costs for equipment
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Medical Equipment Guidelines
October 2010
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
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Medical Equipment Guidelines
October 2010
Mail Order Incontinence, Ostomy, and
Colostomy Supplies
Contracted vendors
– OMPP contracted with three vendors to provide incontinence,
ostomy, and urological supplies to fee-for-service members
– The three contracted vendors are:
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•
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 Guidelines
October 2010
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 the IHCP
Provider manual, Chapter 6, Section 5.
– The annual maximum allowable reimbursement is $1,950 per
member per rolling calendar period
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Medical Equipment Guidelines
October 2010
Mail Order Incontinence, Ostomy, and
Colostomy Supplies
– 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 three
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)
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Medical Equipment Guidelines
October 2010
Learn
Billing the member
Billing the member
The following circumstances are the only situations in which an
IHCP provider may bill a member:
–
The service rendered is noncovered 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
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Medical Equipment Guidelines
October 2010
Billing the Member
–
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 the IHCP
–
The waiver should state:
• Member’s name
• Reason for noncoverage
• Service requested
• Estimated charge
–
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The waiver must not contain any conditional language; for
example, the words “if” or “and”
Medical Equipment Guidelines
October 2010
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 a spend-down is
applied to their claim
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Medical Equipment Guidelines
October 2010
Spend-down
– Member is eligible on the first of the month
– Providers may not refuse service to a member pending verification of
the status of spend-down for the month
– A provider may bill a member for the dollar amount identified beside
ARC 178 on the Remittance Advice (RA) statement
– The member is not obligated to pay the provider until the member
receives the Medicaid Spend-down Summary Notice listing the
amount applied to spend-down
• Notices are sent on the second business day following the end of the month
– Members cannot be billed for more than their spend-down amount
– Providers must bill their usual and customary charge to the Indiana
Health Coverage Programs (IHCP)
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Medical Equipment Guidelines
October 2010
Spend-down
– Providers may discharge a member from their care if a
member does not adhere to established payment
arrangements of outstanding copayments or spend-down
– Providers cannot be more restrictive with spend-down
members than with other patients
– The first claim processed by the IHCP applies to spend-down,
regardless of the date of service within the month
– The system uses the billed amount to credit spend-down
– Third Party Liability (TPL) amounts are deducted from billed
amount prior to crediting spend-down
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Medical Equipment Guidelines
October 2010
Describe
Claim attachments
Claim Attachment Feature
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Medical Equipment Guidelines
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Claim Attachment Feature
Attachment Control Number (ACN)
– Unique number assigned by provider
– Claim- and document-specific
– Each ACN may only be used one time
– 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
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Medical Equipment Guidelines
October 2010
Claim Attachment Feature
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Medical Equipment Guidelines
October 2010
Claim Attachment 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)
– Write “ACN #” and the assigned ACN on each page of
documentation corresponding to that number
– Mail cover sheet and supporting documentation to the address
at the bottom of the cover sheet, HP, P.O. Box 7259,
Indianapolis, IN, 46207
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Medical Equipment Guidelines
October 2010
Claim Attachment Cover Sheet
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Medical Equipment Guidelines
October 2010
Explain
Prior Authorization
Prior Authorization
Prior authorization by telephone, fax, or mail
– Verify eligibility to determine where to send the PA request
• ADVANTAGE Health Solutions – FFS
Prior Authorization Department
P.O. Box 40789
Indianapolis, IN 46240
1-800-269-5720 Fax: 1-800-689-2759
• ADVANTAGE Health Solutions – Care Select
Prior Authorization Department
P.O. Box 80068
Indianapolis, IN 46280
1-800-784-3981 Fax: 1-800-689-2759
• MDwise – Care Select
Prior Authorization Department
P.O. Box 44214
Indianapolis, IN 46244-0214
1-866-440-2449 Fax: 1-877-822-7186
– Prior authorization for risk-based managed care recipients should
be sent to the appropriate entity
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Medical Equipment Guidelines
October 2010
Prior Authorization
278 prior authorization inquiry
– Allows the requesting provider to
inquire about all nonpharmacy prior
authorizations via the Web
• It does not matter if the PA was submitted via
paper, telephone, fax, or Web
– The requesting provider and the
named service provider may view a
PA without the PA number
– All other providers must have the PA
number to view a PA
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Medical Equipment Guidelines
October 2010
Prior Authorization
278 Prior Authorization Inquiry
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Medical Equipment Guidelines
October 2010
Resolve
Denials and resolutions
Denials and Resolutions
Denial – Edit 593 – Medicare Denied Detail
– Cause:
• At least one detail is a Medicare-denied detail
• At least one detail contains Medicare coordination of benefits (COB) information
– Resolution:
• Submit separate claims for Medicare-denied details and Medicare-covered
details
Denial – Edit 3001 – Dates of service not on PA master file
– Cause:
• No prior authorization in IndianaAIM
– Resolution:
• Verify the date of service and procedure code billed are correct on the requested
PA
• Obtain amended/corrected PA if necessary
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Medical Equipment Guidelines
October 2010
Denials and Resolutions
Denial – Edit 4021 – Procedure Code vs. Program Indicator
– Cause:
• Procedure code billed is restricted to a specific program
– Resolution:
• Verify procedure code is covered for dates of service billed
• Verify recipient is eligible for program indicated
Denial – Edit 4033 – Invalid Procedure Code/Modifier Combination
– Cause:
• Modifier used is not compatible with procedure code billed
– Resolution:
• Verify modifier is valid and appropriate for procedure code
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Medical Equipment Guidelines
October 2010
Denials and Resolutions
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
 Field 22 should be blank
• Medicare Crossover claims:
 The total charge, field 28, and the net charge, field 30, should be the same
 Complete field 22 with paid amount and coinsurance and deductible
Note: These claims may be filed on the Web interChange
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Medical Equipment Guidelines
October 2010
Denials and Resolutions
Denial – Edit 2003 – Recipient Ineligible on Dates of Service
– Cause:
• Member is not eligible for IHCP services being billed
– Resolution:
• Verify the claim was sent to the appropriate billing entity
 Fee-for-Service and Care Select to HP
 RBMC to the appropriate MCO
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Medical Equipment Guidelines
October 2010
Denials and Resolutions
Denial: Edit 6000 – Manual Pricing Required
– Cause:
Manual pricing is 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
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Medical Equipment Guidelines
October 2010
Denials and Resolutions
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
5 sets in a box - ordered 1 box
59.90/5 = 11.98 each
Member rid# 123456789999 Abe Lincoln
**********COST INVOICE*************
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Medical Equipment Guidelines
October 2010
U/M
5/BOX
QTY
1
PRICE
59.90
TOTAL
59.90
Find Help
Resources Available
Helpful Tools
Avenues of resolution
– IHCP Web site at www.indianamedicaid.com
– IHCP Provider Manual (Web, CD-ROM, or
paper)
– Customer Assistance
• Local
• All
(317) 655-3240
others 1-800-577-1278
– Written Correspondence
• HP
Provider Written Correspondence
P. O. Box 7263
Indianapolis, IN 46207-7263
– Provider field consultant
• View a current territory map and contact
information online at www.indianamedicaid.com
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Medical Equipment Guidelines
October 2010
Q&A