Transcript Medicare Home Care Services

Navigating Minnesota’s Health Care Plans
June 28, 2012
Blue Cross and Blue Shield of MN and Blue Plus
Melody Bialke, LISW, MHP
Gov Prog Manager of Business Partnerships
Kathy Moline, RN, PHN
Manager, Integrated Health Management, Gov Prog
© 2011 Blue Cross and Blue Shield of Minnesota. All rights reserved.
Overview
• Blue Plus Public Programs Products
• Medicare Criteria and Blue Plus Authorization Process
• Medicaid (State Plan) Home Care Authorization Process
• Retro Review for Medical Necessity
• Life of a Claim, Late Charges, Claim Attachments
• Timely Filing
• Contact Information for Claims and Authorizations
• Provider Appeals
• EW Claims Processing for Extended Home Care
• Provider Resources
• What is New in 2012
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Blue Plus Public Programs Products
• Blue Plus serves:
• PMAP (Blue Advantage) members in 57 Counties
• MnCare members in 82 Counties
• MSHO (SecureBlue) members in 62 Counties
• MSC+ (Blue Advantage) members in 60 Counties
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Home Care Order of Payer
1. Private Insurance or Medicare
2. Medicaid State Plan
3. EW, CADI, CAC, BI, DD Waivers for “extended” home
care
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Medicare Home Care Services
• Blue Plus does not prior authorize Medicare eligible home care
services
• Agencies bill Blue Plus with Medicare PPS rates
• Determination of eligibility for Medicare services is made by the home
care agency; Blue Plus does not determine if services are eligible
under Medicare
• Medicare covers the following home care services:
• Skilled Nursing services
• Home Health Aide Services
• Physical therapy, Speech Therapy, Occupational Therapy
• Medical social services
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Medicare Home Care, continued
• Medical supplies are included in the PPS rate of payment; these are not
separately billable
• DME continues to be paid to the DME company
Coverage Guidelines:
1. Patients must be confined to their home
2. Under the care of a physician
3. Receiving services under a plan of care established and reviewed
periodically by a physician
4. Require skilled nursing care on an intermittent basis or physical therapy or
speech-language therapy, or
5. Have a continued need for occupational therapy
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Medicare Home Care, continued
• Confinement to home: A member does not have to be
bedridden to be considered home bound. However, the
member’s condition should be one that there exists a
normal inability to leave home and leaving home requires a
considerable and taxing effort.
• Intermittent means provided or needed on fewer than 7
days each week or less than 8 hours per day for periods of
21 days or less
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Medicare Home Care, continued
• Skilled nursing care:
• Observation and assessment of the patient’s condition when
only the specialized skills of a medical professional can
determine the patient’s status
• There must be a reasonable potential for change in a patient’s
condition that requires skilled nursing to identify and evaluate the
patient need for additional treatment or services
• Management and Evaluation of a Patient Care Plan:
Skilled nursing for the management and evaluation are covered when
underlying medical conditions or complications require that only a RN
can ensure the essential non-skilled care is achieving its purpose.
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Medicare Home Care, continued
• Teaching and Training:
• Teaching and training that require skilled personnel are covered if
the skill to train the member or care giver requires the skills of an
nurse
• When it becomes apparent that the patient, family or caregiver will
not be able to be trained or is trained, care is no longer reasonable
and necessary for teaching
• Medication administration:
• Injections: IV, IM or SQ injections may require the skills of a nurse
to administer or to train the member
• Insulin injections are normally self injected and skilled nursing
visits are generally not necessary
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Medicare Home Care, continued
• Oral Medications
• The administration of oral medications is not reasonable and necessary
skilled care in general
• Eye Drops / Topical Ointments
• Administration of eye drops and topical ointments does not require the
skills of a nurse and therefore are not considered reasonable and
necessary
• Tube Feedings
Adjustment, replacement, stabilization and suctioning of the tubes are
skilled nursing services; Feedings are not considered skilled care
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Medicare Home Care, continued
• Nasopharyngeal and tracheotomy aspiration are
considered skilled if needed
• Catheters
• Insertion and sterile irrigation and replacement of catheters is
considered skilled
• Wound Care
• Wound care visits are considered skilled when the services
require a nurse to evaluate and treat the wound
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Medicare Home Care, continued
• Ostomy Care
• Ostomy care during the post-operative period and in the presence of
associated complications may be considered skilled
• Other care
Heat treatment when observation of a nurse is required
Medical gases - during the initial phase of new treatments to provide
education and assessment
Rehabilitation Nursing – such as bowel and bladder training programs
Venipuncture – Visits for venipuncture can no longer be the sole reason for
Medicare home care services
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Medicare Home Care, continued
• Home Health Aide
• The reason for home health aide visits must be to provide
hands on personal care of the patient
• Included are bathing, dressing, grooming, oral hygiene,
feeding, toileting, transfers, bed mobility and ambulation.
• A HHA may be trained to perform wound care that does not
require the skills of a nurse
• Assistance with medication that are ordinarily self
administered
• Therapeutic exercises which support therapy goals
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MA/Medicaid (State Plan) Home Care
• Most State Plan MA Skilled Nurse Visits and Home Health Aide home
care services do require a Blue Plus prior authorization
• This authorization process is different for seniors age 65+ in MSC+
and MSHO than it is for families and children in PMAP and MnCare,
due to the involvement of a Care Coordinator with seniors
• The MSHO/MSC+ Care Coordinator’s role is to coordinate the
provision of all Medicare and Medicaid health and long-term care
services for MHSO and MSC+ enrollees among different health and
social service professionals and across settings of care
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Medicaid MA Home Care Guidelines
Covered Services
• Intermittent home visits to initiate and complete nursing
tasks
• Must be provided by a Medicare Certified home health
agency
• Observation, assessment and evaluation of a member's
physical or mental health status
• Completion of a procedure requiring substantial and
specialized nursing skill such as administration of IV
therapy, intra-muscular injections and sterile procedures
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Medicaid Home Care Guidelines, continued
Covered Services
• Teaching and education / training requiring the skills of a
professional nurse
• Post partum visits to new mothers and their newborns
upon discharge from the hospital
• Up to 2 visits per day if necessary
• Home tele-home care visits if the member’s health status
can be accurately measured and assessed without a need
for a face-to-face hands-on encounter
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Medicaid Home Care Guidelines, continued
Non-covered services
• Telehomecare skilled nurses services that is a communication
between the home care nurse and recipient that consists
solely of a telephone conversation, fax, electronic mail or a
consultation between two health care providers.
• Nurse visits solely for the purpose of monitoring medication
compliance with an established medication program
• Nurse visits to set up or administer medications when the
need can be met by a pharmacy or the member or family can
perform this function
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Medicaid Home Care Guidelines, continued
Non covered services
• Nurse visits to train other home care agency employees
• Services performed for the sole purpose of supervision of the
home health aide or personal care assistant.
• Visits for the sole purpose of blood samples when the
recipient is able to access these services outside the home
• Administrative visits required by Medicare but not qualifying
as a skilled nurse visit
• Nurse visits provided by an RN that is employed by a PCA
organization, or non-Medicare certified private duty nursing
agency
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MA Home Care Auth MSHO/MSC+ Seniors
• MSHO/MSC+ Care Coordinator faxes recommendation to Blue Plus
• Recommendation for Auth of MA Home Care (DHS-5841) for
persons on CADI, CAC, BI, or DD Waivers, OR
• MA Home Care Services Recommendation/Non-disability (Blue
Plus form 6.04.03), AND
• Customized Living tool, if applicable
• Blue Plus obtains necessary medical documentation from home care
agency
• Current CMS-485 form
• Home care records
• Blue Plus may contact Care Coordinator or home care agency for
additional information if needed
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MA Home Care Auth MSHO/MSC+ Seniors, cont.
• Blue Plus reviews MA State Plan requests and determines number of
visits based upon medical necessity and state plan guidelines
• Guidelines referenced for these reviews include DHS guidelines for
Home Care and applicable State Statutes:
https://www.revisor.mn.gov/statutes/?id=256B.0653
• Determinations are based upon the individual member needs, other
services the member has in place or available to them, state statue,
applicable guidelines and the request of the care coordinator,
physician and home care agency
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MA Home Care Auth MSHO/MSC+ Seniors cont.
• Within 10 business days of the request (or 14 calendar days), Blue Plus
sends:
• an authorization determination letter to the member, and
• home care provider, and
• faxes the determination to the Care Coordinator
• Transitions of care:
• To assure that members have access to home care services to
meet their needs upon an acute condition change, Blue Plus will
approve up to 2 weeks of 10 home care visits without review for
members being discharged from an acute in-patient stay. The
Care Coordinator must fax in the home care recommendation
form to begin the services.
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Extended EW Home Care MSHO/MSC+ Seniors
• Elderly Waiver (EW) Extended HHA and PDN authorization
is done by the local Care Coordinator, based on the needs
identified in the Long Term Care Consultation (LTCC)
Assessment
• Services do not need to meet medical necessity criteria, BUT
there must be a corresponding unmet need identified in the
LTCC that is not being met with state plan or Medicare
covered home care
• Must exhaust state plan home care first
• Extended HHA must be authorized in the same day as the State
Plan service
• Care Coordinator puts authorization in Bridgeview EW
Service Agreement; authorization letter is sent to the provider
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Families and Children MA Home Care Auth
(under age 65 PMAP and MnCare)
• Most home care services require authorization:
• Exceptions:
• Nursing evaluation visits (not including PCA assessments)
• Post Partum visits and family health protocols visits
MA Home Care Provider faxes a “Home Health Pre-Service Request”
to Blue plus along with supporting information
•Initial evaluation (for initial services only)
•Current CMS-485 form
•Home care records
• Within 10 business days of request BluePlus will review for medical
necessity and send determination to member and home care provider
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Families and Children Authorization cont.
MA Home Care Provider faxes a “Home Health PreService Request” to Blue plus along with supporting
information:
• Initial evaluation (for initial services only)
• Current CMS-485 form
• Home care records
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Families and Children Authorization cont.
• Blue Plus reviews MA State Plan requests and determines
number of visits based upon medical necessity and state
plan guidelines. Guidelines referenced for these reviews
include DHS Guidelines for Home Care and applicable
State Statutes:
• https://www.revisor.mn.gov/statutes/?id=256B.0659
• Services are reviewed using the individual member
circumstances, services available to the member besides home
care, state statute, MHCP manual guidelines and the
recommendation of the home care agency.
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Retro Review for Medical Necessity
• If a home care claim comes in and there is not an
authorization on file, claim will pend for medical
review
• Blue Plus will contact the home care provider for the
necessary information
• If, after review, it is determined that the visit/service
does not meet medical necessity, the claim will be
denied
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Life of a claim at Blue Cross
• Blue Cross uses Availity for exchanging HIPAA mandated electronic
data interchange (EDI) transactions. You can get information on how to
register and conduct electronic transactions through availity.com
(1-800-Availity)
• Web-based Claim Submission, Eligibility & Remittance Tool
• One-stop shop with no-cost to providers
• Once registered, may sign up for live training webinars
• Pre-system edits align with Uniform Claims Companion Guides Health.state.mn.us/auc
• Effective November 14, 2011, provider remittances generated on this
date and forward are no longer available through providerhub.com
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Electronic Transactions
Blue Cross accepts the submission and/or generates the
following HIPAA compliant transactions:
• Health Care Claim (837 P and D)
• Health Care Claim Payment/Advice (835)
• Health Care Eligibility Benefit Inquiry and Response
(270/271)
• Health Care Claim Status Request and Response
(276/277)
• Health Care Services Review- Request for Review and
Response (278)
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Claims Payments
• Time-frame for processing clean claims
• Per DHS contract, within 30 days of receipt
• Provider Remittance is available every week and
at month end
• Must register through Availity to receive
electronic 835 - Health Care Claim
Payment/Advice
• Payments are sent weekly to participating
providers
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Claim Attachments
• Electronic attachment detailed instructions can be found
on Blue Cross website as well as frequently asked
questions and answers
• Blue Plus does accepts claims with attachments
electronically
• The claim must adhere to the electronic rules found in the
Uniform Companion Guides
• Related attachment should be faxed to Blue Plus at
1-800-793-6928
• Attachment cover sheet can be found on the AUC website
& must be used as the first page on each claim attachment
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Claim Attachments
• If the attachment is too large for a fax then you
can mail the attachment directly to Blue Cross
Blue Shield of MN at:
Blue Cross Blue Shield of Minnesota
P.O. Box 64338
St Paul. MN 55164-0338
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Timely Filing Deadlines
• Participating providers are required to submit original
claims within six (6) months after the date of service
• Replacement claims timely filing
• Six calendar months from the process date of the
predecessor claim
• Cancel claims
• No timely filing limit
• Provider-submitted appeals
• 90 days from the process date of the claim
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Integrated Health Management Government Programs
Intake
PMAP, MNCARE, MN Senior Care Plus, MSHO
• (651) 662-5540 or 1-800-711-9868
• FAX: (651) 662-4022 or 1-866-800-1665
• This number may also be utilized to obtain
information about who the member’s care
coordinator is
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Provider Services
Listen for the current phone options when
you call
• (651) 662-5200 or 1-800-262-0820 (toll free)
• Fax number is (651) 662-2745
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Provider Appeals
• MN Blue Cross participating providers have the
right to appeal any claim denial by completing
the appropriate appeal form listed on the AUC
website
• We allow a 60 day time frame for completing a
provider appeal once it is submitted to us
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Elderly Waiver Claims – Extended Home Care
• As of July 1, 2010 all Elderly Waiver claims are processed
and paid by Bridgeview Company (formerly FirstSolutions)
on Blue Plus’ behalf
• This includes Extended HHA, Extended PCA, Extended PDN
• Bridgeview Company’s website for EW claims
• www.bridgeviewcompany.com
• Changes are posted on their website and are
communicated via remittance advices and mailings
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Provider Resources
• www.bluecrossmn.com
• Bottom left corner under Access Your Secure Site, click
providers.bluecrossmn.com for access to:
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Blue Cross Provider Policy and Procedure Manual
Medical Policy
Provider Bulletins
Provider Quick Points
Provider Press Newsletter
“How-to” documents
Forms
Provider Web Self-service
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What Is New In 2012
• Maintenance therapies no longer covered for ages 21 and
above
• No longer any Medicaid coverage for services delivered or
items supplied outside of the US. (Canada has been
removed from the allowable list of countries to receive
services)
• Providers may now seek payments from a member for
non-covered services not otherwise eligible for payment
(Signed waiver required)
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Blue Cross® and Blue Shield® of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association.