Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical...

Indiana Health Coverage ProgramsDXC Technology

Durable & Home Medical Equipment (DME & HME)

Fee-for-Service

October 2017

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Session Objectives

• Reference Materials• Provider Healthcare Portal• Service Descriptions• Manual Pricing• Updates• Helpful tools• Questions

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Reference MaterialsReference material, code tables, fee schedules

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Reference Materials

• Providers can stay abreast of current developments and research issues:– Banners and bulletins– News and announcements– Provider Reference Materials

• Medical Policy Manual• DME & HME Reference Module

– Code Tables– Subscribe to email notices– Fee schedules

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Reference Materials

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New Look for Subscribers!

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DME & HME Reference Module

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DME & HME Code Tables

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Procedure Codes Requiring Attachments

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Professional Fee Schedule

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Provider Healthcare PortalPortal overview, web-based training, benefit limit details,

Written Correspondence, billing members

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Provider Healthcare Portal

• What can you do in the Provider Healthcare Portal?– Submit, copy, edit, void claims– Check on status of claims– Verify eligibility– View, print remittance advices– Request prior authorization– Provider enrollment and revalidation– Secure correspondence– And more…..

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Provider Healthcare Portal Login Page

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Provider Healthcare Portal User Access

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Search Payment History

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Portal – Benefit Limits Details

Example• Benefit limit details listed in Portal eligibility screen:*

– 6113 DME Limited to $2,000 per Recipient per Calendar year– 6114 DME Limited to $5,000 per Recipient per Lifetime– 6085 Incontinence supplies limited to $1950/Rolling Year

*If the limitation does not appear on the eligibility screen, the service is available (based on fee-for-service claim data only)

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Portal – Benefit Limits Details

Benefit limits are found on the Eligibility page

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Provider Healthcare Portal

• Web-based training

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DME, HME, SuppliesProvider Type, Description of Services, Classifications

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Provider Type

Provider Type 25 Specialty 250 – DME Specialty 251 – HME Must have HME license

Each specialty has it’s own code set

Revalidation required every 3 years: Application fee & Background check FingerprintingRefer to www.indianamedicaid.com > IHCP Provider Type and Specialty Matrix for additional requirements

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Description of Service

• Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and generally is not useful to a recipient in absence of illness or injury

• Must be ordered in writing by a physician

• Written order must be kept on file by physician and rendering provider

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Description of Service

• Items include but are not limited to the following:

• Capped rental items • Inexpensive or other routinely

purchased items• Items requiring frequent or

substantial servicing • Customized items • Prosthetic and orthotic devices • Oxygen and oxygen equipment

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Capped Rental Items

Capped rental items are procedure codes limited to 15 months of continuous rental• Continuous rental: rental without interruption for a

period of more than 60 days• If rental period exceeds 60 days, and the

interruption reasons are justified, a new PA request must be submitted to begin a new 15-month rental period

• Justification could change in medical necessity, hospitalization, or nursing facility stay

• A change in provider does not cause an interruption in rental period

• Capped rental items are subject to prior authorization

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Items Requiring Frequent or Substantial Servicing

For items requiring frequent or substantial servicing, IHCP reimburses providers for rental payments only, as long as equipment is deemed medically necessary

• Claims for the purchase of these items are denied• Repair of rental items is responsibility of rental provider

• Table 4 – Procedure Codes for Equipment and Supplies Classified by the IHCP as Needing Frequent and Substantial Servicing

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Customized Items

Custom equipment: equipment uniquely constructed or substantially modified to meet specific needs of an individual patient, according to description and orders of member’s treating physician• Due to their unique aspects, these

items cannot be grouped with similar items for purposes of payment

• Suppliers must submit documentation of cost of item, including cost of labor and types of materials used in customizing item

• Customized items must be billed using HCPCS code E1399 requires PA

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Prosthetic and Orthotic Devices

All prosthetic and orthotic devices billed under HCPCS L codes are paid in lump sum amounts and may not be rented• Prosthetic and orthotic devices

billed with HCPCS L codes • Requires PA

All PA reviews based upon medical necessity

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Oxygen and Oxygen Equipment

IHCP reimburses liquid and gaseous oxygen systems as rental-only items, subject to PA Reimbursement for oxygen contents is

included in reimbursement of oxygen system and is not separately reimbursable for rented systems Oxygen contents are separately reimbursable

when a third party has purchased an oxygen system, or IHCP or third party has rented or purchased a portable oxygen system

Accessories, including but not limited to cannulas, masks, and tubing, are also included in allowance for rented systems and are not separately reimbursable Accessories are separately reimbursable with a

purchased system

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Manual Pricing

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Manually Priced Items

Reimbursement for many DME services and supplies, including those that are billed with a non-specific HCPCS code with a description such as unspecified, unclassified, or miscellaneous are based on manual pricing• Manually priced HCPCS codes are

reimbursed at 75% of manufacturer’s suggested retail price (MSRP)

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Manually Priced Items

• Documentation submitted with each claim may be monitored or subject to a post-payment review

• Manually priced DME, medical supply, and hearing aid procedure codes will continue to be reimbursed at 75% of MSRP

• Codes without an MSRP will be reimbursed at provider’s cost plus 20%

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Manually Priced Items

• Manufacturer’s retail invoice or suggested retail price (MSRP) is required as acceptable documentation:o Manufacturer’s invoice showing MSRP,

suggested retail price, or retail price o Quote from manufacturer showing MSRP,

suggested retail price, or retail price o Manufacturer’s catalog page showing MSRP,

suggested retail price, or retail price (publication date of catalog must clearly show on documentation)

o MSRP pricing from manufacturer’s website (manufacturer’s web address must be visible on printed documentation from its website)

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Manufacturer’s Suggested Retail Price

MSRP documentation must include:• Manufacturer’s name clearly visible on header of documentation• MSRP pricing (for example, MSRP/Retail) typed from manufacturer o No handwritten notes or pricing will be accepted

• Description of item• Specific HCPCS code

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Approved MSRP Documentation

Date Descriptions

Manufacturer’s suggested retail price

Manufacturer’s LogoManufacturer’s Name

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Approved MSRP Documentation − Quote

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Approved MSRP Doc. Catalog Page

Catalog page must have publication date

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Approved MSRP Documentation − Website

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Updates

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DME Codes No Longer Billed with NU

• Effective April 28, 2017, the IHCP revised billing guidelines for DME codes billed with NU modifier

• Claims billed with NU will be denied with EOB code 4033-Invalid procedure code modifier combination

• Refer to banner BR201713 for a list of affected codes (most are Q codes)

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DME & Supplies Covered as Home Health Service

Effective May 1, 2017, the IHCP revised coverage policy for home health services• For coverage of certain DME & supplies as a home health service,

documentation of face-to-face encounter must occur no more than six months before start of service.

• Examples: – Decubitus care equipment– Oxygen and related respiratory equipment– Monitoring devices– Compression devices

Refer to bulletin BT201723 for complete list

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Red-and-White Claim Form

• Effective January 1, 2018 the IHCP will require the below claim types to be submitting for processing on the appropriate red and white forms.

– CMS-1500 (02-12) – professional claims – UB-04 (CMS-1450) – institutional claims

• The IHCP will no longer accept copied (black and white) claim forms on or after January 1, 2018.

• Claims not received on the red-and-white claim form on or after January 1, 2018, will be returned to the provider.

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Helpful Tools

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Helpful Tools

• IHCP website at indianamedicaid.com– IHCP Provider Reference Modules– Medical Policy Manual

• Customer Assistance available 8am-6pm EST Monday –Friday

– 1-800-457-4584• IHCP Provider Relations Field Consultants– See the Provider Relations Field Consultants page at

indianamedicaid.com • Secure Correspondence via the Provider Healthcare

Portal • Written Correspondence

– DXC Technology Provider Written CorrespondenceP.O. Box 7263Indianapolis, In 46207-7263

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QuestionsFollowing this session please review your schedule for the next session you

are registered to attend