Transcript HP Enterprise Business Template Angle Light 4:3 Purple

IHCP Updates
HP Provider Relations
February 2011
Agenda
– Objectives
– Changes to Reimbursement
Rates
– Transition and Testing for
American National Standards
Institute (ANSI) Version 5010
– Presumptive Eligibility/Notification
of Pregnancy
– National Correct Coding
Initiative
– Dental Cap
– Diabetic Supply List
– Therapy Service Changes
– Vision Service Changes
– Long Term Care Changes
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IHCP Updates
February 2011
– Prior Authorization for Inpatient
Hospitals
– Universal Prior Authorization
Form
– Software Download for Omni
Users
– Customer Service Inquiries
– Helpful Tools
– Questions
Objectives
– Know about the transition to the Health Insurance Portability and
Accountability Act (HIPAA) version 5010
– Understand NCCI and the impact on claim processing
– Know about the changes/updates related to your provider type
– Understand the Prior Authorization process for inpatient admissions
– Become aware of the universal prior authorization form
– Know about the need to update the Omni system
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IHCP Updates
February 2011
Explain
HIPAA 5010
HIPAA 5010
– The mandatory compliance date for ANSI version 5010 and the
National Council for Prescription Drug Programs (NCPDP) version
D.0 for all covered entities is January 1, 2012
– IHCP 5010 Companion Guides and Upcoming Changes document
are available at www.provider.indianamedicaid.com
• Upcoming Changes document contains only segments that are updated, added,
or deleted
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IHCP Updates
February 2011
HIPAA 5010
– If submitting claims to the IHCP, you need to be aware of the
upgrades to prevent delay in payment
– Transactions affected by this upgrade:
• Institutional claims (837I)
• Dental claims (837D)
• Medical claims (837P)
• Pharmacy claims (NCPDP)
• Eligibility verifications (270/271)
• Claim status inquiry (276/277)
• Electronic Remittance Advices (835)
• Prior authorizations (278)
• Managed Care enrollment (834)
• Capitation payments (820)
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IHCP Updates
February 2011
Testing Information
– All trading partners currently approved to submit 4010 and NCPDP
5.1 versions are required to test and be approved for 5010 and D.0
transaction compliance
• Scheduled testing started in January for software vendors, clearinghouses, and
billing services
– Providers that exchange data with the IHCP using an IHCPapproved software vendor will not need to test
– Providers that submit data via Web interChange do not need to
test
– Each trading partner is required to submit a new Trading
Partner Agreement
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IHCP Updates
February 2011
What You Need To Do
– If you bill IHCP directly
• Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions
– If you are using a billing service or clearinghouse
• Find out if they are preparing for the HIPAA upgrades to ANSI v5010 and NCPDP
vD.0
– Questions should be directed to [email protected]
OR
– Call the EDI Solutions Service Desk
• 1-877-877-5182 or (317) 488-5160
– Watch for additional information in bulletins, banner pages, and
newsletters at www.indianamedicaid.com
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IHCP Updates
February 2011
Define
National Correct Coding Initiative
National Correct Coding Initiative
What is it?
– In the 1990s, the Centers for Medicare &
Medicaid Services (CMS) developed the
National Correct Coding Initiative (NCCI)
to promote national correct coding
methodologies and to control improper
coding leading to inappropriate payment
– NCCI has been in place for many years
and most providers are familiar with the
editing methodologies with Medicare
– Also included in NCCI editing are:
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•
Claims with Third Party Liability (TPL) amounts
•
Claims denied by the primary insurance
IHCP Updates
February 2011
National Correct Coding Initiative
Initial editing encompasses three basic coding concepts
•
Column One
Column Two
•
•
Mutually
Exclusive
Procedures
(ME)
•
Medically
Unlikely
Edits
(MUE)
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IHCP Updates
•
•
This pair of edits represent two codes that normally
should not be reported together.
Column One indicates the correct code, and Column Two
indicates the incorrect or inappropriate code(s) in relation
to the Column One code.
Identifies procedures that cannot be reasonably
performed on the same day because they are mutually
exclusive.
These procedures cannot be performed at the same
anatomic site or same patient encounter.
The maximum units of services that a provider would
report under most circumstances for a single member on
a single date of service.
If the provider bills for more units than the amount of units
established by MUE for that procedure code, that detail line
will be denied when the claim is processed for NCCI editing.
February 2011
National Correct Coding Initiative
Who will be affected?
– NCCI will affect providers submitting the following:
• Institutional outpatient claims
• Professional claims
– Professional claim implementation began January 27, 2011
– Institutional claim implementation begins April 1, 2011
– Watch for more information in your bulletins, banner pages,
and newsletters at www.indianamedicaid.com
– The NCCI policy manual is available at
http://www.cms.gov/NationalCorrectCodInitEd
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IHCP Updates
February 2011
Explain
Dental Cap
Dental Cap Limit
Effective with dates of service January 1, 2011
– $1,000 Cap
• Calendar year cap
• Applies to members 21 and above
 Previous cap was for members 19 and over
• All Indiana Health Coverage Programs (IHCP), including Traditional
Medicaid, Hoosier Healthwise, and Care Select
• Web interChange displays amount of cap met
• Exceptions
 Hospital place of service 21 or 22
• Any service provided in a hospital setting is exempt from the cap
Additional information may be found in BT201059
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IHCP Updates
February 2011
Describe
Diabetic Supply List
Preferred Diabetic Supply List (PDSL)
Changes effective for dates of
service January 1, 2011, and after
– Provider Types
• Durable Medical Equipment (DME)
• Pharmacy
– Preferred Vendors
• Abbott Diabetes Care
• Roche Diagnostics
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IHCP Updates
February 2011
Preferred Diabetic Supply List (PDSL)
Supplies list
Changes effective for dates of service January 1, 2011, and after
– Blood Glucose Monitors
• Freestyle Life System
• Freestyle Freedom Lite System
• Precision Xtra Meter
• Accu-chek Aviva Care
– Diabetic Test Strips
• Freestyle Lite Test Strips
• Precision Xtra Test Strips
• Accu-chek Aviva Care Diabetic Test Strips
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IHCP Updates
February 2011
Preferred Diabetic Supply List (PDSL)
– Members Affected
• All Indiana Medicaid members
• Healthy Indiana Plan members
– Members currently utilizing a blood glucose monitor were required
to convert to the preferred products
• There was no additional cost to the member or provider
– Members continue to have no copayment for blood glucose
monitors and diabetic test strips, regardless of their inclusion on
the PDSL
– Members subject to spend-down are still responsible for any
spend-down liability after the claim adjudicates
– Members were notified by mail of the changes and directions on
how to obtain a new monitor at no cost
• Providers should continue to provide training to members in regard to the
preferred blood glucose monitors and/or refer the members to the manufacturer of
the product
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IHCP Updates
February 2011
Preferred Diabetic Supply List (PDSL)
Billing guidelines
Claims for dates of service on or after January 1, 2011
– Professional Claims Affected
• CMS-1500 Paper Claims
• Web interChange
• Batch (837P Transactions) Claims
– Claim Submission
• Claims must be submitted to the fee-for-service (FFS) medical benefit
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
Includes all Indiana Medicaid Members

Includes all Healthy Indiana Plan members
IHCP Updates
February 2011
Preferred Diabetic Supply List (PDSL)
Billing guidelines
National Drug Code (NDC) Requirement
– N4 qualifier required
– Corresponding 11-digit NDC required
• Utilize the 5-4-2 format
– Unit of measure
• UN
– Required on all claims
• Medicare Crossover claims
• Third Party Liability (TPL) claims
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IHCP Updates
February 2011
Preferred Diabetic Supply List (PDSL)
Billing guidelines
– Procedure Codes Utilized
• E0607 – Home blood glucose monitor
• A4253 – Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
– Modifiers
• NU and RR modifiers are not used for E0607, E0607 U1, A4523 and A4523 U1 for supplies
that are on the PDSL
 Effective with dates of service January 1, 2011, and after
 Exception – Medicare crossover claims require the appropriate modifier
 Exception – TPL claims for non-preferred PDSL require the U1
– Prior Authorization
• Claims for blood glucose monitors and test strips not included in the PDSL will require prior
authorization
• Diabetic test strip quantities exceeding 200 strips per month require prior authorization
Additional information can be found in BT201055
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IHCP Updates
February 2011
Define
Therapy Service Limitations
Therapy Service Limitations
Effective with dates of service January 1, 2011, new
limits for physical, occupational, and speech therapy
were imposed
– Twenty-five visit limit
• Per rolling 12-month period
• Applies to members 21 and older
• Prior authorization (PA) will no longer be required for physical
therapy, occupational therapy, and speech therapy services for
members age 21 or older
− PA is still required for members under 21
• Limit is for each type of therapy
 A “visit” is defined by the type of therapy and date of service. For
example, a member receives physical therapy from a provider during a
one-hour visit. That member receives physical therapy services
defined with procedure codes 97116, 97140, 97530, and 97532 during
the visit. This is counted as one “visit” toward the member’s limitation.
Additional information may be found in BT201058
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IHCP Updates
February 2011
Describe
Vision Services
Vision Services
Effective with dates of service January 1,
2011, new limits for covered eyeglass
benefits
– One pair per year for recipients under 21
• Previously applied to members under 19
– One pair every five years for recipients 21
and over
• Previously applied to members over 19
• Previously one pair every two years
– Affects all IHCP Programs
• Traditional Medicaid
• Hoosier Healthwise
• Care Select
Additional information may be found in
BT201049
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IHCP Updates
February 2011
Note: HIP does not
cover vision services
Explain
Long Term Care
Long Term Care – Facility Leave Days
Effective February 1, 2011, bed hold days are
no longer reimbursed
– Revenue Codes
• 180 – nonpaid
• 183 – therapeutic leave
• 185 – hospital leave
– Impacts all Indiana Health Coverage
Programs Members
• Members in nursing facilities were notified
– Providers should inform members of their
bed hold policy
• Members may be charged for the bed hold if they
choose the service
Additional information may be found in
BT201061
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IHCP Updates
February 2011
Explain
Reimbursement Rates
Five Percent Rate Reduction
Effective with dates of service January 1, 2011, and after
– Attendant Care
• Based on billing provider type 32 – waiver
Additional information may be found in BT201054
– Chiropractors
• Based on rendering provider specialty 150
• Will occur at the claim level detail
Reduction will apply prior to subtracting any third-party liability or spenddown amount
Additional information may be found in BT201051
– Podiatrist
• Based on rendering provider specialty 140
• Will occur at the claim level detail
Reduction will apply prior to subtracting any third-party liability or spenddown amounts
Additional information may be found in BT201050
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IHCP Updates
February 2011
Transportation
New rates effective with dates of service
January 1, 2011, and after
– Five percent reduction
• Ambulance transportation providers
– Ten percent reduction
• Non-ambulance transportation providers
Reduction will apply prior to subtracting any
third-party liability or spend-down amounts
Transportation providers are able to access
the reduced rates on the IHCP fee schedule
at www.indianamedicaid.com
Additional information may be found in
BT201057
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IHCP Updates
February 2011
Explain
Presumptive Eligibility/Notification of Pregnancy
Presumptive Eligibility (PE)
– PE Application
• Review application for accuracy prior to
submission
 Name
 Date of birth
 Address
• Contact HP provider field consultant for
corrections on the application to the
demographic information listed above
• One approved application per pregnancy
 Do not override the warning except for:
– Pre-term delivery
– Abortion
– Miscarriage
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IHCP Updates
February 2011
Presumptive Eligibility (PE)
– Contacting the enrollment broker
• As of January 1, 2011
 Members choose a managed care entity (MCE)
– Previously, members chose a primary care physician (PMP)
 MCE must be chosen the same day application is submitted
 MCE will add the PMP when assigned
 Eligibility may not reflect a PMP immediately
 Claims should be submitted to the MCE listed on the eligibility verification
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IHCP Updates
February 2011
Notification of Pregnancy (NOP)
– Submitting NOP information
• Information cannot be changed once submitted
• Review information for accuracy prior to submitting
– Duplicate NOPs (same woman, same pregnancy) do not qualify
for reimbursement
– Providers will receive an on-screen message if the NOP appears
to be a duplicate
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IHCP Updates
February 2011
Explain
Prior Authorization
Prior Authorization (PA)
Elective inpatient hospital admissions
Effective with admit date of service on January 1, 2011, and after
– Prior authorization is required for all non-emergent inpatient
hospital admissions
• Elective or planned inpatient admissions
• Applies to members of all ages with Traditional Medicaid and Care Select
• Request PA via the telephone
 At least two days in advance
– Outside of normal business hours, weekends and holidays – within 48 hours
of admission
 Contact ADVANTAGE Health Solutions for Care Select members assigned to
ADVANTAGE at 1-800-784-3981
 Contact MDwise for MDwise Care Select members at 1-866-440-2449
 Contact ADVANTAGE Health Solutions for fee-for-service members at 1-800269-5720
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IHCP Updates
February 2011
Prior Authorization (PA)
Elective inpatient hospital admissions
– Excluded from PA requirement
• Emergent admissions
• Routine Vaginal and C-Section deliveries
• Newborn stays
• Medicare/Medicaid dual eligible member
admissions
• Observation
Additional information may be found in
BT201060
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IHCP Updates
February 2011
Define
Prior Authorization
Prior Authorization (PA)
Universal prior authorization form
– Universal form required effective January 1, 2011
– All providers
• All IHCP Programs
 Traditional
 Hoosier Healthwise
 Care Select
 Healthy Indiana Plan (HIP)
– PA form and instructions are available at
www.indianamedicaid.com under the Forms link
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IHCP Updates
February 2011
Prior Authorization (PA)
Universal prior authorization form
– Exception
•
Dental
 Dental PA form available on the IHCP website
•
Pharmacy
 Pharmacy PA form available on the IHCP website
• Behavioral Health
 Traditional Medicaid and Care Select DO use the Universal PA Form
– Indicate "Mental Health" or "MRO" in the upper left hand corner
 Hoosier Healthwise-Risk Based Managed Care and Health Indiana Plan (HIP)
– Use the form authorized by the individual MCE
Additional information may be found in BT201045
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IHCP Updates
February 2011
Prior Authorization (PA)
Universal prior authorization form
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IHCP Updates
February 2011
Define
Omni Download
Omni Download Required
– Required to obtain correct primary care
physician (PMP) information when
checking eligibility
• Omni will show “No PMP assigned" after
upgrade
– Instructions for download
• Refer to BT200711, Table 1.1
• IHCP Provider Manual Chapter 3, Table 3.7
– For assistance contact the Omni help
desk
• (317) 488-5051
• 1-800-284-3548
Additional information may be found in
BR201049
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IHCP Updates
February 2011
Define
Customer Service Inquiries
Customer Service Inquiries
– Claim Status
• Verify claim status on the Web interChange

Claim inquiry
– Procedure Code Coverage
• Verify procedure code coverage, program
coverage, and prior authorization requirements
on the fee schedule
– Spend-down Information
• IHCP Provider Manual Chapter 2, Section 4 and
Chapter 5, Section 5
• Provider Education – Archived Workshop
Presentations
 Spend-down
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IHCP Updates
February 2011
Find Help
Resources Available
Helpful Tools
– IHCP Web site at www.indianamedicaid.com
– IHCP Provider Manual (Web, CD-ROM, or
paper)
– IHCP Fee Schedule
– 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 field consultant
•
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http://www.indianamedicaid.com/ihcp/ProviderServices/
pr_list_frameset.htm
IHCP Updates
February 2011
Q&A