Transcript Hospital Responsibilities with Regard to Act 269 of the

Louisiana Medicaid
National Drug Code (NDC)
Transitional Requirements for Claims Submission
On-Line Webinar
February 3-6, 2009
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NATIONAL DRUG CODE (NDC)
IMPLEMENTATION
• Federal Statute Enacted in January 2008 Requires
the Use of NDC on Claims for Physician
Administered Drugs
http://www.cms.hhs.gov/DeficitReductionAct/Downloads/Section6001,6002and6003oftheDRA.pdf
• Most Providers Billing for Physician Administered
Drugs MUST Enter the Drug NDC and Other
Required Information on Claims
► Physician
► Outpatient Hospital
► Licensed Hemodialysis Centers
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PROVIDERS EXCLUDED FROM THIS
NDC IMPLEMENTATION
• Rural Health Clinics
• Federally Qualified Health Centers
• Mental Health Clinics
Providers that bill all-inclusive services and are
paid encounter rates
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PHYSICIAN ADMINISTERED DRUGS
• Physician-Administered Drugs Include Any Drugs
Ordered by a Doctor (APRN or PA With Prescriptive
Authority) Regardless of Which Clinical
Professional Actually Administers the Drug
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RECORDS
REQUIREMENTS AND RETENTION
• Drugs Will Be Invoiced to Drug Manufacturers for
Medicaid Rebates
• LA Medicaid Will Audit/Review These Claims Upon
Manufacturer Request or if Outlier Billing
Detected
• Providers Must Retain All Records for 5 Years From
Date of Service OR Until Conclusion of
All Audit Questions/Disputes/Review Issues
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RECORDS
REQUIREMENTS AND RETENTION
• May Request Copies of Office Records Including
Documents Pertaining to Billed HCPCS/NDC Codes
• May Include Drug/NDC Invoices for Purchase of
Drugs; Documentation of Drug Administered
Including Name/Strength/Amount/Date and
Copies of Labels from Drug Packages*
* These are examples of what the provider may present as proof of the NDC used.
If the provider has invoice records, copies of labels are not necessary but may be
requested if available from drugs on hand.
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DELAY IN IMPLEMENTATION
OF CLAIM DENIALS
• INITIALLY, Claim Denials Were To Be Effective
With Processing Date July 1, 2008
• Denial Edits Were Postponed to Assist
Providers with Preparing for the Transition
• Educational Edits were Implemented Effective
With Date of Service March 1, 2008 and
Continue to be Educational
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NEW NDC IMPLEMENTATION DATE
FOR PHYSICIAN, OUTPATIENT HOSPITAL &
HEMODIALYSIS CENTER CLAIMS
• EFFECTIVE WITH PROCESSING DATE
April 1, 2009, CLAIMS WILL DENY IF NDC
INFORMATION IS NOT PRESENT
• APPLIES TO BOTH EDI & HARD COPY/PAPER
CLAIMS
- Must have both NDC Data &
Procedure/HCPCS Code
- Must be correctly entered on the claim
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REQUIRED NDC DATA
• Required Data Must Be Entered EXACTLY As
Indicated In Billing Instructions To Prevent Denials
• REMINDER: Both EDI and Hard Copy/Paper Claims
To view the CMS 1500 Professional Billing Instructions, click on the link below:
http://www.lamedicaid.com/provweb1/billing_information/CMS_1500_Professional_NDCs.pdf
To view the UB04 Hospitals Billing Instructions, click on the link below:
http://www.lamedicaid.com/provweb1/billing_information/UB04_Hospitals_NDC_052108.pdf
To view the UB04 Hemodialysis Billing Instructions, click on the link below:
http://www.lamedicaid.com/provweb1/billing_information/Hemo_Billing_NDCs.pdf
To view the 837 Professional EDI Companion Guide, click on the link below:
http://www.lamedicaid.com/provweb1/HIPAABilling/837P_Companion_Guide_02-2008.pdf
To view the 837 Institutional EDI Companion Guide, click on the link below:
http://www.lamedicaid.com/provweb1/HIPAABilling/837I_Companion%20Guide_static.pdf
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REQUIRED NDC DATA
EDI Claim Data
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REQUIRED NDC DATA
Paper Claim Instructions
• NDC Data
- Qualifier N4 Followed by the NDC
- Do Not Enter a Space Between Qualifier & NDC
- Do Not Enter Hyphens or Spaces Within NDC
- Leave 1 Space
- Enter Appropriate Unit Qualifier and Actual Units Given
- Leave 3 Spaces
- Enter Brand Name As Written Description In Remaining
Spaces (Not applicable for UB-04)
• HCPCS Code Applicable for NDC Data
• Claim Form Examples Presented on Slides 15, 16, & 17 11
IMPLEMENTATION FOR
OUTPATIENT HOSPITAL BILLING
- Duplicate Edit Logic Lifted to Accommodate Multiple
Entries of Revenue Codes 250 & 636 Without
Denying as a Duplicate
Examples (Paper Claim Sample):
When 2 or more Drugs or 2 or more NDCs are reported with revenue code
250 or 636, enter individual claim lines with revenue code 250 or 636 and
the corresponding NDC and Procedure Code:
Ex #1:
250
N412345678901UN1234.567
J1000
250
N498765432101UN4321.765
L2000
N412345678901UN1234.567
J1000
N498765432101UN4321.765
L2000
Ex #2:
636
636
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ELECTRONIC CLAIMS TRANSMISSION
• Electronic (EDI) Transmission of Claims is the
Preferred Method for Submitting Claims
• Medicaid Encourages this Method which
Eliminates Data Entry of Claims and Expedites
Processing and Payment of Claims
• Acceptable EDI Vendors, Billing Agents, and
Clearinghouses are found in the VBC List Located
on the LA Medicaid Web Site link below. The List
is Updated Monthly.
http://www.lamedicaid.com/provweb1/HIPAA/VBC_monthly.pdf
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Claim Edits for NDC
Edit 120
Edit 127
Quantity Invalid/Missing
NDC Code Missing or
Incorrect
Edit 231
NDC Code Not on File
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CMS 1500 CLAIM EXAMPLE
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UB-04 CLAIM EXAMPLE FOR
OUTPATIENT HOSPITAL SERVICES
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UB-04 CLAIM EXAMPLE FOR
HEMODIALYSIS CENTER SERVICES
SAMPLE ONLY.
FOR EXAMPLE.
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MEDICARE REQUIREMENTS
In order to capture the
information needed to fulfill
the rebate requirements for
State Medicaid Agencies,
CMS issued Change Request
(CR) 5950 for Medicaid drug
rebate information to be
entered on paper claims for
submission to Medicare for
beneficiaries dually eligible
for Medicare and Medicaid.
• Providers should refer to
the CMS web site and other
sites below for information
concerning Medicare
requirements.
•
•
•
•
http://www.cms.hhs.gov/default.asp
http://www.trispan.com/
http://www.cms.hhs.gov/ContractorLearn
ingResources/downloads/JA5835.pdf
http://www.cms.hhs.gov/MLNMattersArti
cles/downloads/MM5950.pdf
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PAYMENT REMINDERS
For All Claims Reporting
Physician Administered Drugs
– Processing Date for Implementation of Claim Denials =
April 1, 2009
– Must Report All Required Information
– Must Be Entered EXACTLY As Indicated
– Applies To Both EDI and Paper Claims
– Records Related to Services Must Be Kept for 5 Years
From Date of Service or Until Audit Conclusion
– Must Supply Records When Requested by DHH
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GENERAL REMINDERS
– Frequently Asked Questions (FAQ) Posted on Web
– Provider Notices Posted on Web
www.lamedicaid.com
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CONTACT INFORMATION
Unisys Provider Relations Department
Phone: (800) 473-2783
(225) 924-5040
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Questions
&
Answers
As you exit from the presentation, please
wait to take the short survey before
disconnecting from the web site.
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