Transcript Slide 1

Prenatal Care Coordination
Billing
Presented by the EDS Provider
Relations Field Consultants
April 2009
Agenda
Welcome and Announcements
• IHCP
• Provider Enrollment
• Provider Updates
• Member Eligibility
• Benefit Packages
• Care Coordination Services
• Notice of Pregnancy
• Presumptive Eligibility
• Managed Care
• Care Management
Organizations
• Billing
• Remittance Advice
• Adjustments
• Paper Claim Filing
• Top Five Denials
• Helpful Tools
• Questions
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Indiana Health Coverage Programs
• Traditional Medicaid
• 590
• Fee-for-Service
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New Provider Enrollment
• Enrollment forms are in electronic format on
the Web by using www.indianamedicaid.com
• All forms may be filled out online and the
information submitted electronically
• All pages requiring original signatures and tax
information (W-9s) must be mailed to EDS
Provider Enrollment after completing the online
application
• Enrolling online provides the following
advantages:
–Quicker provider enrollment
–Complete and accurate information
–Easier enrollment
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Provider Enrollment
Step 1: Begin at indianamedicaid.com
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Provider Enrollment
Provider Enrollment Application
•
Indiana Health Coverage Programs (IHCP) Web site at
www.indianamedicaid.com
•
Provider Enrollment helpline at 1-877-707-5750
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Online Enrollment
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Provider Enrollment
Process
• Download the Provider Enrollment
Application:
– Visit www.indianamedicaid.com
– Go to the Provider Services tab
– Choose Provider Enrollment from
the drop-down list
– Access the link titled Enroll a New
Provider in the IHCP
– Print the Provider Enrollment
Application and an IRS W-9 Form
• Complete the enrollment application
(original signatures are required)
• Avoid having your application returned
– Call 1-877-707-5750 if you have
questions about the enrollment forms
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Provider Enrollment
Provider Enrollment Requirements
• IHCP reimbursement is available for the following
practitioners who provide care coordination services to
eligible pregnant women in the IHCP:
– State-licensed physician
– State-licensed registered nurse
– State-certified social worker or a social worker with a
baccalaureate or master’s degree from a school accredited
by the Council on Social Work Education
– Dietician registered with the Commission on Dietetic
Registration of the American Dietetic Association
– Community health worker working under the supervision of
one of the professionals listed above
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Provider Enrollment
Mailing the Application
• The enrollment packet must include:
– Completed Provider Enrollment Application (with all
applicable schedules)
– Completed IRS W-9 Form
– Waiver Approval Letter certifying the waiver services that
the provider is approved to perform
• Mail to:
EDS Provider Enrollment
P.O. Box 7263
Indianapolis, IN 46207-7263
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Provider Updates
• Updates to the following information must be submitted to
the EDS Provider Enrollment Unit:
– Address changes (home office, mail-to, pay-to, and service
location)
– Telephone number changes
– Banking information changes (if enrolled in electronic funds
transfer)
• Requests for changes must be submitted using the EDS
Provider Update Form available at www.indianamedicaid.com
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Member Eligibility
Who is Eligible?
• Members must be enrolled in the IHCP and have
pregnancies that are at risk for low birth weight or poor
pregnancy outcome to be eligible for the IHCP to pay for
care coordination services
• Each member has a Hoosier Health Card used for
identification
• Viewing a Hoosier Health Card alone does not verify
eligibility
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Member Eligibility
Verifying Eligibility
• Providers must verify eligibility on the
date of service
• Providers who fail to verify eligibility
are at risk of their claims being
denied due to member ineligibility or
coverage limitations
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Member Eligibility
How to Verify
Three Eligibility Verification Systems (EVS) are available:
• Automated Voice Response (AVR)
–1-800-738-6770, or
–(317) 692-0819, Indianapolis area
• Omni swipe card terminal device
• Web interChange
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Automated Voice Response System
EVS Using the Telephone
AVR provides the following:
• Member eligibility verification
• Benefit limits
• Prior authorization
• Claim status
• Check write
Contact AVR at (317) 692-0819 in the
Indianapolis local area or
1-800-738-6770
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Omni
EVS Card Reading Device
• Is cost-effective for high-volume
providers
• Uses plastic Hoosier Health card
• Allows manual entry
• Prints two-ply forms
• Requires upgrade for benefit limit
information (refer to IHCP provider
bulletin BT200711)
See Chapter 3 of the IHCP Provider Manual
for more information
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Web interChange
EVS Using the Internet
The following is available through Web
interChange:
• Member information available by member
ID, Social Security number (SSN),
Medicare number, or name and DOB
• Division of Family Resources (DFR)
information
• Detailed third-party liability (TPL)
information
• Online TPL update requests
• Web interChange is accessible via
www.indianamedicaid.com
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Web interChange
Eligibility
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Benefit Packages
Benefit Package
Coverage
Package A –
Standard Plan
Encompasses the full array of Indiana
Health Coverage Programs (IHCP) benefits
for children, low-income families, and some
pregnant women enrolled in the Hoosier
Healthwise Program.
Package B
Coverage is limited to pregnancy-related
and urgent care services for some pregnant
women.
Package C
Limited coverage (including preventive,
primary, and acute care services) for
children under 19 years old enrolled in the
Children’s Health Insurance Plan (CHIP).
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Care Coordination Services
Diagnosis and Procedure Codes
Diagnosis Code:
•
V68.9
Procedure Codes:
•
H1000 – Initial Assessment (One per
pregnancy)
•
H1004 – Reassessment (One per
trimester)
•
99502 – Home visit for newborn care
and assessment
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Care Coordination Services
Procedure Codes for Mileage
• A0160 U1 – Two round trips per initial
assessment
• A0160 U2 – Two round trips per assessment
• A0160 – One round trip per postpartum
assessment
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Prenatal Care Coordination Forms
• Risk Assessment Form:
– Must be kept in the member’s record to substantiate
services beyond the initial assessment
• Combined Assessment Form
– Used for one initial assessment and follow-up
– One reassessment and follow-up per trimester
occurring after the initial assessment
– One postpartum assessment
• Care Coordination Outcome Report
– Send the Outcome Report to the Indiana State
Department of Health (ISDH) regardless of when the
patient has finished care
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Care Coordination Services
Prenatal Care Coordination Services
• Following up to verify or reschedule
appointments
• Locating services sources
• Making appointments
• Arranging transportation
• Making home visits (including the
postpartum home visit)
• Referring member to the Social
Security agency
• Performing follow-up activities to
ensure services were received
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Care Coordination Services
Prenatal Care Coordination Services
Case management services for
pregnant women:
• Active, ongoing process of assisting
the member to identify, access, and
use community resources and
coordinate services to meet individual
needs
• Third Party Liability edit overrides for
care coordination services
• Providers not required to file for
reimbursement from other insurers
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Notice of Pregnancy – Effective July 1, 2009
The Office of Medicaid Policy and Planning (OMPP), managed care
organizations (MCOs), the Indiana State Department of Health
(ISDH) and other Medicaid stakeholders worked jointly to develop
a universal assessment for pregnant women to capture:
• Maternal Obstetrical History
• History of Prior Births (Still birth, Pre-term, Low Birth
Weight)
• Diagnosis of Pregnancy Risk
• Maternal Medical History (including conditions that require
management during pregnancy - HTN, Diabetes)
• Current Medications
• Mental Health History and Current Conditions
• Substance Abuse/Use History
• Tobacco Use History
• Social Risk Factors
• Needed Referrals
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Notification of Pregnancy
Reimbursement
• Reimbursement of $60 to the physician/clinic per
Notice of Pregnancy (NOP) submitted within five
calendar days of the prenatal visit
• Other details:
– Provider must submit a claim to be reimbursed for NOP
form submission
– NOP form submission may be billed one time per
member, per pregnancy
– Providers submit the NOP form via Web interChange
– Providers bill for submission of the NOP form using
procedure code 99354 with modifier TH
Note: Procedure code and reimbursement available
July 1, 2009
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Notification of Pregnancy
Completing the NOP
• Print a hard copy and complete during the
exam
• Enter information electronically from hard copy
or
• Enter the information electronically during the
exam
• To qualify for payment, provider must:
– Submit NOP within five calendar days from Date
of Service, and
– Complete NOP prior to 30 weeks gestation
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Notification of Pregnancy
Completing the NOP
Click on the
appropriate
responses.
Then
click “Next”
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Notification of Pregnancy
• Data is sent to the member’s MCO
• MCOs provide additional support services (for
example, nurse case management, home
visits) depending on needs of member
• MCO can also help with coordination between
the physician’s office and member
• MCO will also coordinate with the prenatal care
coordinator
• The OMPP will use the data to monitor
outcomes of births and to develop
programming that better meets the needs of
pregnant women in Medicaid
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Presumptive Eligibility – Effective July 1, 2009
• What is presumptive eligibility?
–A period of time during which a pregnant woman,
who has been determined by a qualified provider to
be “presumptively eligible,” may receive ambulatory
prenatal services while her Hoosier Healthwise
application is being processed
–Inpatient care, hospice, long-term care, delivery
services, postpartum and services unrelated to the
pregnancy or birth outcome are not covered
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Presumptive Eligibility
Who is Eligible?
• To be eligible for Presumptive Eligibility (PE), a
pregnant woman must:
–Be pregnant, as verified by a professionally
administered pregnancy test
–Not be a current Medicaid member
–Be an Indiana resident
–Be a U.S. citizen or a qualified non-citizen
–Not be currently incarcerated
–Have gross family income less than 200
percent of the federal poverty level
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Presumptive Eligibility
Who Can Be a Qualified Provider?
Many of the requirements for qualified providers are mandated
by Federal Medicaid regulations:
1. Must be enrolled in Medicaid
2. Must provide outpatient hospital, rural health clinic, or clinic
services as defined in sections 1905 (a)(2)(A) or (B),
1905(a)(9), and 1905(l)(1) of the Social Security Act
3. Must be trained and certified by the State (or designee) to
perform PE functions
State-specific requirements include:
1. Must be able to verify pregnancy via a professionally
administered pregnancy test
2. Must have Internet, telephone, printer, and fax access that
is available to facilitate the PE and Medicaid application
process
3. Must have Administrator access to Web interChange
•
Complete the Administrator Request Form to set up an
administrator
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Presumptive Eligibility
Who Can Be a Qualified Provider?
Qualified providers (QPs) may include the following
provider types/specialties:
– Family or general practitioner
– Pediatrician
– Internist
– Obstetrician or gynecologist
– Certified nurse midwife
– Advanced practice nurse practitioner
– Federally qualified healthcare center
– Medical clinic
– Rural health clinic
– Outpatient hospital
– Local health department
– Family planning clinic
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How the PE Process Works
• Check for any existing Medicaid coverage using the
Eligibility Inquiry feature of Web interChange
• QP professionally administers a pregnancy test or accepts
pregnancy test administered by another professional to
determine if the patient is pregnant
– Over-the-counter pregnancy tests cannot be used to
determine pregnancy for PE
• If the patient is not covered by Medicaid, a QP-trained
staff member accesses the PE Application by clicking the
“PE Application for Pregnant Women” button (Step 1)
– The PE Application window is available during the
following business hours:
• Monday-Friday – 8 a.m. to 6 p.m. (Eastern time)
• Saturday – 8 a.m. to Noon (Eastern time)
Note: If applicable, the non-QP refers the patient to a QP
to complete the PE application process
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How the PE Process Works
• QP enters the following information based on responses
from the patient:
– Applicant name, Social Security number, date of birth, home
address, mailing address, contact telephone, gender, marital
status, gross income, family size, and race
• QP also answers “yes” or “no” to the following:
– Indiana residency, incarceration status, verification of
pregnancy, U.S. citizenship, and whether or not an application
for Medicaid/Hoosier Healthwise is pending
• Applicant responses are to be accepted by the QP without
asking for verification documents
– If presented, verification documents may be faxed with the
Hoosier Healthwise application
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How the PE Process Works
• QP provides the woman with access to a telephone to
contact the enrollment broker (MAXIMUS)
• MAXIMUS explains the selection process to the woman and
assists her to select a primary medical provider (PMP) and
MCO
• QP ensures the woman’s PMP and MCO choices are written
on her PE determination notice for reference
• MAXIMUS activates the patient’s PE number
If, on that day, the woman fails to contact MAXIMUS
to make her PMP and MCO selections, her PE
eligibility will terminate that day and the QP will
receive no reimbursement for prenatal services
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How the PE Process Works
• Applicant is responsible for reviewing the printed Hoosier Healthwise
application and providing additional responses as appropriate
• QP ensures the patient signs the Hoosier Healthwise application and
faxes it to the Division of Family Resources (DFR). QP also faxes a
statement signed by the physician or nurse indicating the woman is
pregnant and the date the pregnancy began
• Modernized counties:
– Direct questions about the Hoosier Healthwise application to the DFR
Document Center at 1-800-403-0864
– Fax is sent to the DFR Document Center at 1-800-403-0864
– Direct questions about the Hoosier Healthwise application to the
local DFR office
– At http://www.in.gov/fssa/dfr/2999.htm, click “Where Do I Apply,”
then click on woman’s county of residence to locate county DFR
telephone and fax information
– Fax is sent to the county DFR office
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How the PE Process Works
• PE Considerations:
–The above functions occur on the same day
–There is no PE coverage if the woman, who has
been determined to be presumptively eligible
does not select a PMP and MCO with the
Enrollment Broker
–Women are eligible for PE only one time per
pregnancy
–QP enrollment activities are performed on a
voluntary basis
–QPs should allow approximately 15 minutes to
complete PE functions
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Presumptive Eligibility Process
How You Can Help
• Prenatal care coordinators can:
–Encourage clinics to become qualified
providers
–Perform outreach to physicians to accept
women with Presumptive Eligibility
–Refer pregnant women to qualified providers
for eligibility determination
–Assist women with follow-up of Medicaid
Application process
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Helpful Tools – PE and NOP
• Bulletin about PE is scheduled for late April
2009
• Training of qualified providers is scheduled to
begin in mid-May 2009
• Bulletin about NOP is scheduled for mid-May
2009
Both programs are scheduled to begin
July 1, 2009
Questions about PE and NOP can be directed to
the Office of Medicaid Policy and Planning:
[email protected]
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Managed Care
Managed Care in the IHCP
MCOs contracted in Hoosier Healthwise riskbased managed care (RBMC):
• Anthem
1-866-408-6132
• Managed Health Services (MHS)
1-877-647-4848
• MDwise
1-800-356-1204
• ADVANTAGE administers PrimeStep primary
care case management (PCCM) and Care Select
1-800-889-9949, Option 3
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Care Management Organizations
• Two health plans were selected to function as
care management organizations (CMOs) for the
Care Select program
–ADVANTAGE Health SolutionsSM
www.advantageplan.com
1-866-504-6708
–MDwise
www.mdwise.org
1-866-440-2449
MDwise also serves as one of Indiana’s three
Hoosier Healthwise MCOs
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Billing
Billing the IHCP Member for Noncovered Services
• Providers may not collect from a member or family
member any portion of the covered service that is not
reimbursed by the IHCP, except for copayments on
transportation and pharmacy services and any member
liability payment authorized by law
• Participating providers must accept the Medicaid
determination of payment in full
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Billing
Billing the IHCP Member, Exceptions
You may only bill for authorized
services. For services to be authorized
they must:
• Meet the needs of the member
• Be a noncovered service by the IHCP
or a covered service, which the
member has exceeded the program
limitations
• The member must understand, before
receiving services, that they will be
financially responsible
• Provider must maintain documentation
showing the member accepted
responsibility for the charges
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Remittance Advice
Statement with Claims Processing Information
• Remittance Advices (RAs) provide
information about claims processing and
financial activity related to reimbursement
–RAs contain internal control numbers
(ICNs) with detail-level information
–RAs give detail status (paid or denied)
–RAs give payment amount
See the IHCP Provider Manual, Chapter 12,
for more details
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Adjudicated Claim Information
Internal Control Number
The ICN is a 13-digit number assigned to each claim
• The region tells how the claim was submitted
– 20
– electronic with no attachments
– 21
– electronic with attachments
– 10
– paper with no attachments
– 11
– paper with attachments
– 50
– voids/replacements – noncheck-related
Region
Year
Julian
Date
Batch
Range
Sequence
20
07
158
150
000
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Claim Adjustments
Voids and Replacements
• “Replacement” is a HIPAA-approved term used to
describe the correction of a claim that has already been
submitted
• Replacements can be performed on paid and denied
claims
• Denied details can be replaced or billed as a new claim
• To avoid unintentional recoupments, submit paper
adjustments for claims finalized more than one year
• “Void” is the term used to describe the deletion of an
entire claim
• Voids can be performed on paid claims only
• Voids and replacements can be performed to correct
incorrect or partial payment, including zero dollar
amount
Note: Paper replacements can only be processed on paid
claims
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Paper Claim Filing
Helpful Hints
• Use the approved version of the
CMS-1500 claim form
• Do not use staples or paper clips
• Verify that the claim form is signed,
or complete the Attestation for
Signature on File
• Review the RA closely
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Top Five Denials for Care Coordination Services
1008 – Rendering provider must have an individual number
2006 – Members are eligible for emergency services only
2017 – Recipient ineligible on date(s) of service
0512 – Claim past filing limit
9018 – No payment made spend-down is > than IHCP allowed
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Helpful Tools
Avenues of Resolution
• IHCP Web site at www.indianamedicaid.com
• IHCP Provider Manual (Web, CD-ROM, or paper)
• Customer Assistance
– 1-800-577-1278, or
– (317) 655-3240 in the Indianapolis local area
• Written Correspondence
– P.O. Box 7263
Indianapolis, IN 46207-7263
• Provider Relations Field Consultant
– View a current territory map and contact
information online at
www.indianamedicaid.com
• Indiana State Department of Health
– (317) 233-1344
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Questions
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EDS, an HP Company
950 N. Meridian St., Suite 1150
Indianapolis, IN 46204
EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal
opportunity employer and values the diversity of its people. ©2009 Hewlett-Packard Development Company, LP.
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