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CA AAHAM Conference Provider Outreach & Education
December 2013
DISCLAIMER
This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.
The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.
All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov
The identification of an organization or product in this information does not imply any form of endorsement.
CPT codes, descriptors, and other data only are copyright 2013 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.
December 2013 2
Agenda
• Noridian & CMS Updates • 2 Mid-Night Provision • A/B Rebilling • Dual Eligibility-Crossover Claims • CERT
December 2013 3
Noridian & CMS Updates
Did You Hear?
December 2013 5
Subscribe to Email list for updates from CMS and Noridian, including announcement of events for providers
•No cost •No limit per facility •Tailored to type of Provider
• Noridian would love your website feedback! – Complete Foresee Results Survey
• Provide constructive and complimentary feedback – Help continue growth in webinar customer service
Website Survey
December 2013 6
Noridian Workshops – Part A
December 2013 7
Noridian Workshops – Part B
December 2013 8
Check the Noridian Website
December 2013 9
PECOS Ordering/Referring Providers
• CMS instructed contractors to implement Phase II denial edits January 6, 2014
• Refer to Special Edition (SE)1305 – http://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf
December 2013 10
Update on Incarceration Claim Denials
• Issue corrected • Payments made • Letters to be sent out by end of December • Contact the PCC at 1-855-609-9960 if you do
not receive the letter • For more information see:
• https://med.noridianmedicare.com/web/jea/topics/claim-submission/incarceration-claim-denials
December 2013 11
New Patient E/M Resolution
• CR8165 - Common Working File (CWF) Informational Unsolicited Reports (IUR) or Reject for A New Patient Visit Billed by the Same Physician or Physician Group within the Past Three Years – Part B claims hitting CWF Error Codes 33x4,
33x5, 7579 and 7580
December 2013 12
New Patient E/M Resolution2
• Noridian Provider Alert Update: – 12/04/13: Providers should see the mass
adjusted corrected claims on their remits within the next 5 to 7 business days. If a provider believes a clerical correction is needed to change the new patient evaluation and management (E&M) services to an established E&M, please follow these guidelines:
• If the initial paid date of the claim is less than one year ago, providers may do a Phone Reopening or a Written Reopening
• If the initial paid date of the claim is over one year, providers may only do a Written Reopening
December 2013 13
Non-Medical ADR Requests
December 2013 14
• SB6001 – Edit 32105 • Avoid claim rejections by setting up either: • 1:1 NPI to PTAN match or • Set up the 5 or 9 digit Zip Codes with each PTAN for
your Facility
Correct Provider Billing of Admission Date and Statement Covers Period
• Effective for inpatient hospital claims submitted on or after October 1, 2011 and claims with a discharge date of July 1, 2011 forward: – Admission Date (UB04 Form Locator 12) = date the patient was
admitted as an inpatient to the facility. – Statement Covers Period (UB04 Form Locator 6) = span of
service dates; "From" date is the earliest date of service on the bill.
• On the inpatient claim a valid "from" date could be up to and including 3-days (or 1 day) prior to the actual inpatient admission based on the pre-admission bundling rule.
• Sources: IOM Medicare Claims Processing Manual,
Publication 100-04, Chapter 3, Section 40.3; CMS MLN Article SE1117.
December 2013 15
CR/MM 8248
• Termination of the Common Working File ELGA, ELGH, HIQA, HIQH, and HUQA Part A Provider Queries – Effective 4/7/14 – Providers will need to use HIPAA Eligibility
Transaction System (HETS)
December 2013 16
CR/MM 8465
• ICD-10 Testing with Providers through the Common Edits and Enhancements Module (CEM) and Common Electronic Data Interchange (CEDI) – Effective March 2014 – Announces plans for front-end ICD-10 testing
between MACs and their trading partners – The testing week will be March 3 through
March 7, 2014 December 2013 17
2 Mid-Night Provision
2 Mid-Night Provision
• CMS Rule 1599-F: Inpatient Hospital Admission and Medical Review Criteria (2-Midnight Provision) and Part B Inpatient Billing in Hospitals – Final Rule:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2014-IPPS-Final-Rule-Home-Page.html
– Provider Information & FAQs: http://go.cms.gov/InpatientHospitalReview
December 2013 19
2 Mid-Night Provision2
• CMS Education – CMS ODF calls held – FAQs available on the CMS website – Hospital Inpatient Admission Order and
Certification – Reviewing Hospital Claims for Patient Status:
Admissions On or After October 1, 2013 • Feedback & Questions to CMS at:
mailto:[email protected]
December 2013 20
2 Mid-Night Provision3
• Noridian – Probe & Education Probram – Probe reviews of 10 – 25 claims to be done
• Edit 504IP • Types of facilities included in review
– Acute care Inpatient Prospective Payment System (IPPS) facilities
– Long Term Care Hospitals (LTCHs) – Inpatient Psychiatric Facilities (IPFs)
• Dates of Admission under review: October 1, 2013 through March 31, 2014
• Length of stay: 0-1 midnights
December 2013 21
2 Mid-Night Provision4
• Noridian – Probe reviews
• Records due within 30 days • Reviews to be done within 30 days of receipt • Results of the review will be provided • Denials may result in future complex reviews
– See article posted to web 12/5/13 • https://med.noridianmedicare.com/web/jea/article-
detail/-/view/10521/notification-of-initiation-of-probe-reviews-in-relation-to-final-rule-cms-1599-f
December 2013 22
2 Mid-Night Provision5
• Resources – Inpatient Hospital Reviews: http://www.cms.gov/Research-Statistics-
Data-and-Systems/Monitoring-Programs/Medical-Review/InpatientHospitalReviews.html
– Selecting Hospital Claims for Patient Statues Reviews: Admissions On or After October 1, 2013: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/SelectingHospitalClaimsforAdmissionsonorafterOctober1st2013forReviewForWebPostingCLEAN.pdf
– Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/ReviewingHospitalClaimsforAdmissionFINAL.pdf
– Final Rule CMS-1599-F: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/InpatientHospitalReviews.html
December 2013 23
A/B Rebillings
Reference: SE1333
A/B Rebilling
• CMS Instructions – For Self Audit Claims - Provider Liable – Inpatient claim must be submitted as follows:
• Type of Bill (TOB) 110 in Form Locator (FL) 4 • Non-covered Days • The services from admission through discharge • The appropriate patient status • Occurrence Span Code “M1” and dates of service • Non-covered charges for all services rendered
December 2013 25
A/B Rebilling2
– Self audit claim requirements - Continued • All diagnosis codes • All procedure codes
– After the inpatient claim processes and remittance advice issued
• Submit inpatient Part B claims; TOB 12X
• For Part A Inpatient admissions denied as not reasonable and necessary
December 2013 26
A/B Rebilling3
• For Part A Inpatient admissions denied as not reasonable and necessary – Submit inpatient Part B claims; TOB 12X
• A treatment authorization code of A/B Rebilling submitted by a provider.
• NOTE: Providers billing an 837I shall place the appropriate Prior Authorization code above into Loop 2300 REF02 (REF01 = G1) as follows:
– REF*G1*A/B Rebilling • Condition code "W2" attesting that this is a rebilling and no
appeal is in process; and • The original, denied inpatient claim (CCN/DCN/ICN) number • NOTE: Providers billing an 837I shall place DCN in the Billing
Notes loop 2300/NTE in the format: – NTE*ADD*ABREBILL12345678901234
December 2013 27
A/B Rebilling4
• For DDE or paper Claims – Enter "ABREBILL" plus the denied inpatient
DCN/CCN/ICN in the Remarks Field (form locator #80) on the claim using the following format: "ABREBILL12345678901234".
• Claim Editing Issues – RC 39011: Resolved – RC 31796: Reviewed & determined to be
correct editing – RC 39015: Researching
December 2013 28
Dual Eligibility Crossover Claims
Dual Eligibility
• Crossover claims – Medicare contractors coordinate with the
Coordination of Benefits Contractor (COBC) – Automatically crossover claims payment
information for their policyholders – Eligibility file furnished by the supplemental
insurer is used to drive the process rather than information found on the claim
– Eligibility files are matched, based on the Health Insurance Claim (HIC) number, against Medicare’s internal eligibility file
December 2013 30
Dual Eligibility2
• Crossover Claims – Continued – If a match occurs, the beneficiary’s record is
flagged indicating to which company we will cross claim payment information.
– Noridian than sends the file of claims to the COBC who consolidates the claims for all contractors and forwards it on to the trading partner/supplemental insurer.
– If no match occurs, the claim is not flagged for crossover.
December 2013 31
Dual Eligibility3
• Crossover Claims – Continued – Each trading partner/supplemental insurer is
given the opportunity to specify criteria related to the claims the insurer wants or does not want Medicare to crossover.
– Trading partner/supplemental insurer can choose from list of conditions to allow or refuse a claim crossover from Medicare.
• Automated process – Normally no issues
December 2013 32
Dual Eligibility4
• Reference COBC-Crossover Claims – Part A
https://med.noridianmedicare.com/web/jea/topics/msp/cobc
– Part B https://med.noridianmedicare.com/web/jeb/topics/msp/cobc
December 2013 33
Comprehensive Error Rate Testing (CERT)
CERT
• Issues and Updates – Itemized Statements Omitted When
Requested by CERT • Results in increased errors • Providers are reminded to ensure all necessary
records are submitted to support the services rendered
• Missing itemized statement will result in a CERT error finding whether or not there is any effect on reimbursement
December 2013 35
CERT2
• Issues and Updates – CERT Documentation Submission Timeliness
Update • Effective for reviews on or after 1/1/14 • Change the response time for CERT requests for
Initial Documentation to 60 days, down from 75 days
December 2013 36
CERT3
– CERT Documentation Submission Timeliness Update – Continued
• Follow-up call and letter time frame from CERT will change as well
– Day 0: Contact and/or send letter 1 via fax or mail – Day 30: Contact and/or send letter 2 via fax or mail – Day 45: Contact and/or send letter 3 via fax or mail – Day 60: If no records were received, full claim denial
• Response time for Additional Documentation requests remains 15 days
• Noridian follow-up calls – Day 35 for Initial Documentation requests – Day 7 for Additional Documentation requests
December 2013 37
Questions?
Thank you.