HP Provider Relations October 2011 Medical Equipment Guidelines

HP Provider RelationsOctober 2011

Medical Equipment

Guidelines

Medical Equipment Guidelines October 20112

Agenda

– Medical Equipment Services• Provider Code Sets

• Fee Schedule

• Date of Service

• Rolling 12-Month Period

• Capped Rental

• Repair and Replacement

• Mail Order Incontinence, Ostomy, and Colostomy Supplies

• Preferred Diabetic Supply List

• Manual Pricing

– Billing the Member• Spend-down

– Claim Attachments

– Prior Authorization

– Denials and Resolutions

– Helpful Tools

– Questions


Objectives

Following this session, providers will:

– Understand medical equipment guidelines

– Understand guidelines for billing the member

– Be familiar with spend-down

– Understand the claim attachment process

– Be familiar with the Prior Authorization form and prior authorization inquiry process

– Understand the top denials and resolutions

DescribeMedical Equipment Services


Provider Code Sets

– The IHCP established provider code sets for DME (Durable Medical Equipment), specialty 250, and HME (Home Medical Equipment) specialty 251

– 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

– 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


Viewing Provider Code Sets












Fee Schedule

Access the fee schedule to determine:

– Reimbursement rates

– Pricing effective dates

– Prior authorization requirements

– Program coverage

• Applies to Traditional Fee-for-Service Medicaid and Care Select


Accessing the Fee Schedule










Understanding Fee Schedule Instructions


Date of Service for Billing

– The date of service is the date the equipment is delivered, not ordered• Date of service for items that are mailed is

the date the item is shipped

– 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)


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


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


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


Capped Rental

– Medicare capped rental policy for DME

• The 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


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


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


Mail Order Incontinence, Ostomy, and Colostomy Supplies

– 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

1-888-217-9610binsons.com

• Healthcare Products Delivery, Inc (HPD)1-800-291-8011hpdinc.net

• J & B Medical1-866-674-5850jandbmedical.com

Contracted vendors

http://www.binsons.com/

http://www.hpdinc.net/

http://www.jandbmedical.com/


Mail Order Incontinence, Ostomy, and Colostomy Supplies– Members must obtain supplies via mail order

• The contracted vendor may make other arrangements in emergency situations

– 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 12-month period

– 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


Mail Order Incontinence, Ostomy, and Colostomy Supplies

– The following programs and claim types are not affected by the contract:• 590 Program

• Medical Review Team (MRT)

• Pre-Admission Screening 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 entity (MCE)


Changes to the Preferred Diabetic Supply List

Effective for claims with dates of service on or after January 1, 2011, all Indiana Medicaid and Healthy Indiana Plan members using a blood glucose monitor were required to convert to one of the preferred blood glucose monitors and corresponding test strips

Preferred Diabetic Supply List

Blood glucose monitor Corresponding test strip

Freestyle Lite System Kit Freestyle Lite Test Strips

Freestyle Freedom Lite System Kit Freestyle Lite Test Strips

Precision Xtra Meter Precision Xtra Test Strips

Accu-chek Aviva Care Kit Accu-chek Aviva


Preferred Diabetic Supply List Billing

Effective for claims with dates of service on or after January 1, 2011:

–Professional claims, including paper CMS-1500, electronic 837P, and Medicare crossover claims for blood glucose monitors and diabetic test strips, must be submitted to the fee-for-service (FFS) medical benefit for all Indiana Medicaid and Healthy Indiana Plan members

–The modifiers NU (indicating a new product) and RR (indicating a rental product) are no longer used

–Claims with a date of service of January 1, 2011, and after which contain either of these modifiers are denied

• For claims with dates of service prior to January 1, 2011, the NU or RR modifier is still required for claims payment



Effective for claims with dates of service on or after January 1, 2011:

–Claims for the following procedure codes require the NDC or NDC and modifier, depending on the vendor of the product being dispensed:

• E0607 – Home blood glucose monitor• A4253 – Blood glucose test or reagent strips for home blood glucose monitor, per 50

strips

–Claims billed for an NDC included on the Preferred Diabetic Supply List (PDSL) do not require the addition of modifier U1

If modifier U1 is included with a preferred blood glucose monitor or diabetic test strip NDC, the claim will be denied for edit 4300 – Invalid NDC-to-procedure code combination

Claims billed for a blood glucose monitor or diabetic test strip not listed on the PDSL require the addition of modifier U1, along with the NDC and appropriate procedure code

• Claims billed for an NDC not on the PDSL are denied with edit 4300 – Invalid NDC-to-procedure code combination when modifier U1 is not included


Preferred Diabetic Supply List BillingEffective for claims with dates of service on or after January 1, 2011:

CMS-1500 Form

– Enter the NDC qualifier of N4

– Enter the NDC 11-digit numeric code

– Enter the drug description

– Enter the NDC Unit qualifier • F2 – International Unit • GR – Gram • ML – Milliliter • UN – Unit

– Enter the NDC Quantity (Administered Amount) in the format 9999.99

• Refer to the IHCP Provider Manual, Chapter 8, Section 4



– Edit 217 – NDC number is missing Verify the NDC and resubmit the claim

– Edit 218 – NDC number is not in a valid format Verify the NDC was submitted in the proper 5-4-2 format

See BT200731 for additional NDC information

– Edit 4004 – This NDC is not on file. Please verify that the NDC was filed correctly Verify the NDC submitted on the claim is the NDC from the product

– Edit 4300 – Invalid NDC-to-procedure code combination NDC submitted on the claim does not belong to the procedure on the claim – verify

and resubmit

– Edit 4360 – Diabetic test strips and monitors are limited to specific products Verify the products billed are included in the PDSL – see BT201055 for additional

information

NDC edits


Manual PricingEffective for dates of service July 1, 2011, and after

– Maximum reimbursement rates for DME and prosthetics procedure codes that are currently manually priced are based on Medicare’s established fee schedule, if available

– If a rate cannot be established based on Medicare’s fee schedule, a rate may be established using acquisition cost information

– If a rate cannot be established, procedure codes that remain manually priced are reimbursed at 75 percent of the manufacturer’s suggested retail price (MSRP)• Providers are required to submit documentation of the MSRP with the claim

• MSRP information may be downloaded from the manufacturer’s website• Providers are still required to submit a manufacturer's cost invoice with their claims for DME and prosthetics procedure codes that remain manually priced

Note: Refer to BT201114

LearnBilling 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 during 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


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

– The waiver must not contain any conditional language; for example, the words “if” or “and”


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


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)


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

DescribeClaim Attachments


Claim Attachment Feature



– Unique number assigned by provider

– Claim and document specific

– Each ACN can 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 emailed attachments are not accepted

Attachment control number (ACN)




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


Claim Attachment Cover Sheet

ExplainPrior Authorization


Prior Authorization

– Verify eligibility to determine where to send the PA request• ADVANTAGE Health Solutions – FFS

Prior Authorization DepartmentP.O. Box 40789Indianapolis, IN 462401-800-269-5720 Fax: 1-800-689-2759

• ADVANTAGE Health Solutions – Care SelectPrior Authorization DepartmentP.O. Box 80068Indianapolis, IN 462801-800-784-3981 Fax: 1-800-689-2759

• MDwise – Care SelectPrior Authorization DepartmentP.O. Box 44214Indianapolis, IN 46244-02141-866-440-2449 Fax: 1-877-822-7186

– Prior authorization for risk-based managed care recipients should be sent to the appropriate entity

Prior authorization by telephone, fax, or mail


Prior AuthorizationPrior authorization by telephone, fax, or mail


Prior Authorization

– 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

278 prior authorization inquiry


Prior Authorization278 Prior Authorization Inquiry

ResolveDenials and Resolutions


Denials and Resolutions

– Cause:

• NDC information is missing

• NDC is not in the proper format

– Resolution:

• Resubmit the claim with the NDC

Denial – Edit 0217 – NDC Missing

Denial – Edit 0218 – NDC is not in a valid format

– Cause:

• Qualifier, unit of measure, or NDC code is not in the correct format

– Resolution:

• Verify the information submitted is accurate

Refer to IHCP Provider Manual, Chapter 8, Section 4



– 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 0593 – Medicare Denied Detail

– 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

Denial – Edit 3001 – Dates of service not on PA master file



– Cause:

• Procedure code billed is restricted to a specific program

– Resolution:

• Verify procedure code is covered for dates of service billed

• Verify procedure code is covered for the member program via the Fee Schedule

Denial – Edit 4021 – Procedure Code vs. Program Indicator

– Cause:

• Modifier used is not compatible with procedure code billed

– Resolution:

• Verify modifier is valid and appropriate for procedure code

Denial – Edit 4033 – Invalid Procedure Code/Modifier Combination



– 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 Web interChange

Denial – Edit 0509 – Net Charge Out Of Balance



– 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 MCE

Denial – Edit 2003 – Recipient Ineligible on Dates of Service



– Cause:

Manual pricing is required

– Resolution: Submit Manual Pricing and MSRP

• 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

Denial – Edit 6000 – Manual Pricing Required



– Resolution: Submit Manual Pricing

DME SUPPLY MANUFACTURING INVOICE1 SUPPLY ROAD 4/27/09ANYWHERE, INDIANA800-123-2345

BILL TO:DME/HME SUPPLIES200 STATE STREETANYWHERE, INDIANA

ITEM NUMBER/DESCRIPTION U/M QTY PRICE TOTALEXTRA SET RT ANGLE HCPCS: B9998 5/BOX 1 59.90 59.90 5 sets in a box - ordered 1 box 59.90/5 = 11.98 each

Member rid# 123456789999 Abe Lincoln

**********COST INVOICE*************





ManufacturerName

HCPC Code and Manufacturer Description

Manufacturer’s Suggested Retail Price

Find HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP website at indianamedicaid.com

– IHCP Provider Manual (Web, CD, or paper)

– Customer Assistance• Local (317) 655-3240

• All others 1-800-577-1278

– Written Correspondence• HP Provider Written CorrespondenceP. O. Box 7263Indianapolis, IN 46207-7263

– Provider field consultant

• View a current territory map and contact information online at indianamedicaid.com

http://www.indianamedicaid.com/

http://www.indianamedicaid.com/

Q&A

Documents

HP Provider Relations October 2011 Medical Equipment Guidelines