2012 Archives Hot Tip of the Week

Filing a Secondary (TPL) Claim to MO HealthNet

May 14, 2012

You have a patient who has private commercial insurance in addition to MO HealthNet. The commercial insurance company has processed and either paid or denied your claim. Now you need to submit your claim to the MO HealthNet Program to determine if any of the balance will be paid by the program. How do I file this claim to MO HealthNet?

Note–if the commercial insurance has paid the provider more than the MO HealthNet allowable for the service(s), no additional payment will be made when the claim is submitted.

The claim should be billed through the MO HealthNet Web portal, emomed.com using the following guidelines:

• Log on to the Web site and choose ‘Claim Management’. Be sure the correct NPI is displayed.
• Select the appropriate claim type under ‘New Claim’ and complete the required fields in the Claim Header Information section. Be sure to click on ‘Save Claim Header’ to save the data to the claim.
• Complete all the newly opened and required detail line fields. Make sure you save each detail line to the claim.
• After you have entered all the information and saved, scroll to the first orange divider line titled ‘Other Payers’ and click on the title. Complete the Header Summary fields and then click on ‘Save Other Payer Data and Manage Codes’. This opens the ‘Other Payer Detail Summary’ fields.
• Under ‘Associated Line Items’, click on the appropriate numbered box for the line of the claim that you are entering information. From the information on the commercial EOB, select the correct ‘Claim Group Code’ (such as PR-Patient Responsibility and/or CO-Contractual Obligation) from the drop down box, enter the appropriate Claim Adjustment Reason Code (such as 1-deductible, 2-co-insurance, 3-copayment and/or 45 for the contractual) and the Adjustment Amount ( amount of patient responsibility and/or contractual). Once the information has been entered for this line of the claim, click on ‘Save Codes to Other Payer‘. If appropriate, complete any additional detail lines.
• After completing information for each detail line of the claim, click on ‘Save Other Payer to Claim’.
• Finally, click on the ‘Submit’ button at the bottom of the page for submission of your completed claim.

Insurance Fields on a Paper CMS-1500 Claim Form

May 7, 2012

Sometimes it is necessary to file a paper CMS-1500 claim form, such as when there are multiple surgeries or when submission of other claim documentation is necessary to receive reimbursement.

When you do file a claim by paper, and the patient has no third party resource for payment, remember to leave fields 4, 7, 9-9d, 11-11d, and 29 blank. When information is entered in these fields, the claim will deny asking you to bill the third party resource before submitting the claim to MO HealthNet. Many providers are entering Medicaid information in these fields which results in claim denial.

Field-by-field claim filing instructions can be referenced in Section 15 of the provider manuals

CMS Hosting Provider Education Webinar/Conference Calls

April 30, 2012

The Centers for Medicare & Medicaid Services (CMS) is hosting six Payment Error Rate Measurement (PERM) program provider education Webinar/conferences calls during PERM Cycle 1 (2012) of which Missouri is included. The purpose is to provide an opportunity for the providers of the Medicaid and Children's Health Insurance Program (CHIP) communities to enhance your understanding of specific provider responsibilities during PERM.

The PERM program is designed to measure improper payments in the Medicaid and CHIP programs as required by the Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act (IPERA).

Webinar/Conference call participants will learn from presentations that feature:

• The PERM process and provider responsibilities during a PERM review
• Frequent mistakes and best practices
• The Electronic Submission of Medical Documentation (esMD) program

Participant call in information will be posted on the Provider Education Calls page, approximately 10 days prior to the calls. The PERM Cycle 1 (2012) Provider Education Webinar/Conference calls Webinar are being presented on a Connect Pro platform.

Prior to attending a webinar, a Adobe Acrobat Connect Pro Connection Test is recommended. This test will verify that your computer meets the minimum system requirements needed to attend this meeting and suggest actions to take if it does not. The test will also ensure that your system is configured to provide you with the best Connect meeting experience.

The webinar dates are:

Date	Time	Join the webinar
May 23, 2012	1:00 to 2:00	PERM Cycle 1-2012-Web1
June 21, 2012	1:00 to 2:00	PERM Cycle 1-2012-Web2
July 24, 2012	1:00 to 2:00	PERM Cycle 1-2012-Web3
August 23, 2012	1:00 to 2:00	PERM Cycle 1-2012-Web4
September 25, 2012	1:00 to 2:00	PERM Cycle 1-2012-Web5
October 24, 2012	1:00 to 2:00	PERM Cycle 1-2012-Web6

There will be time available for questions and answers at the end of the presentations however; CMS encourages all participants to submit questions in advance to PERMProviders@cms.hhs.gov or you may also contact your State PERM representative, Carissa Duewell at MMAC, Carissa.duewell@dss.mo.gov or 573/751-3399 with any questions and for education and training in your state.

Please check the CMS website and PERM Provider's page regularly for helpful education materials, FAQS, and updates.

Time Limit to File Adjusted Crossover Claims

April 23, 2012

Adjustments to MO HealthNet payments are only accepted if filed within 24 months from the date of the Remittance Advice (RA) on which payment was made OR within 6 months from the date of the Medicare reprocessing date. Only the adjustments that are the results of lawsuits or settlements are accepted beyond 24 months.

If the above guidelines are met and processing of an adjustment necessitates filing a new claim, the timely limits for resubmitting the corrected claim is limited to 90 days from the date of the MO HealthNet RA indicating recoupment, 12 months from the date of service, or 6 months from the Medicare reprocessing paid date, whichever is longer.

If the above guidelines are NOT met and higher reimbursement is being sought, DO NOT adjust the claim as there will be no additional reimbursement above the original payment.

If the above guidelines are NOT met and a lower reimbursement amount is due, providers should not void the claims; instead submit the Provider Initiated Self Disclosure Report Form (PISDR) or submit a spread sheet as long as the spread sheet includes all the information that is required on the PISDR form. The provider should include:

• The date MO HealthNet made payment on the claim(s) that Medicare adjusted.
• A letter explaining why the claim(s) were adjusted.
• A check in the amount to be refunded.

The provider should send all documentation to the address indicated on the form.

Please reference Hot Tip "Sending Claims for Special Handling" dated July 5, 2011, which explains the guidelines to follow when submitting paper crossover claims that require special handling.

Injections and Immunizations Given in a Rural Health Clinic

April 9, 2012

Provider-based Rural Health Clinics (RHCs) may not bill for administration fees for injections or Vaccine of Children (VFC) immunizations. Provider-based RHCs may bill an appropriate level Evaluation and Management (E & M) code if a medically necessary E&M service is provided in addition to an injection or VFC immunization. If an injection or non-VFC immunization is given, the provider must bill using the National Drug Code (NDC) on a pharmacy claim form. Injections or non-VFC immunizations for MO HealthNet managed care participants must be billed to MO HealthNet through the fee-for-service program as pharmacy is carved-out of managed care.

Independent RHCs may not bill an administration fee for injections or VFC immunizations. The administration fee is included in the all-inclusive encounter rate for the visit. If the injection or immunization is the only service provided then an encounter may not be billed. The costs associated with the injection or non-VFC immunization would be included on the RHC cost report.

Note: MO HealthNet requires providers who administer immunizations to qualified MO HealthNet eligible children to enroll in the Vaccines for Children (VFC) Program through the MO Department of Health and Senior Services. Details are given in Section 13.4 of the Rural Health Clinic Manuals.

Hospitalization at the Time of Managed Care Enrollment or Disenrollment

April 2, 2012

If a MO HealthNet participant is in the MO HealthNet fee-for-service program at the time of acute inpatient hospitalization on the effective date they are to enter a MO HealthNet managed care health plan, the participant shall remain in the fee-for-service program until an appropriate acute inpatient hospital discharge.

Participants, including newborns, who are in a managed care health plan at the time of acute inpatient hospitalization on the effective date of entering a different health plan, shall remain with that health plan until an appropriate acute inpatient hospital discharge.

Participants, including newborns, who are hospitalized in an acute setting, shall not be disenrolled from a health plan until an appropriate acute inpatient hospital discharge, unless the member is no longer MO HealthNet fee-for-service or MO HealthNet Managed Care eligible or opts out.

Providers should notify the Provider Communications Unit at 573/751-2896 when any of the above situations occur so changes can be made to the participant’s file and the provider is reimbursed from the proper payor.

How to Submit Claims When MO HealthNet is Tertiary Payer

March 26, 2012

There are times when you must file a Medicare Crossover claim for a participant that has a supplemental insurance policy. To enter your claim, do the following:

• Log onto the MO HealthNet Web Portal at emomed.com and enter your user ID and Password.
• Choose the appropriate crossover claim form.
• Complete the claim header Information and save claim header.
• Complete each line detail saving after each entry.
• Complete the other payers header summary using the information on the Medicare EOMB and "save other payer data and manage codes".
• Complete the associated line items fields based on the information on the Medicare EOMB (show PR-Patient Responsibility and CO-Contractual Obligation) and “save codes to other payers” after completing the required fields for each line on the claim.
• Save other payer to claim.
• Complete the other payers header summary for the supplement policy and "save other payer data and manage codes".
• Complete the associated line items fields. Under claim group code, you must choose OA-Other Adjustments. The claim adjustment reason code is 023 (payment and/or adjustments from other payer). The adjustment amount is the amount Medicare paid on the line. In the next claim group code field, you must choose PR-Patient Responsibility. The claim adjustment reason code is 001-Deductible or 002-Co-insurance. The adjustment amount is the amount of deductible/co-insurance due minus what the supplemental policy paid on the line. In the next claim group code field, you should choose CO-Contractual Obligation. The claim adjustment reason code is typically 045. The adjustment amount is the amount of the contractual or write-off on the line. You must complete an associated line item for each line on the claim.

Note: If billing for inpatient services on the MedicareUB-04 Part A Institutional Crossover Claim, complete your claim header information and enter each revenue code and days/units billed to Medicare. Be sure to save after each entry. Then you must complete the other payer header summary for both Medicare and the supplemental insurance policy. Part A claims are processed at the header. Therefore, the Payer at Header Level box must be checked.

Delivery and Placement Dates Versus Date of Service

March 19, 2012

Reminder — The date of service for items such as dentures, hearing aids, eyeglasses or durable medical equipment, should be the date of delivery or placement of the device or item. The date of service is not the date the device or item is ordered or fabricated. Providers should reference Missouri State Regulation 13 CSR 70-3.100(7)(D)(7).

5010 Compliant?

March 12, 2012

By now, most of you may be aware that if you are not 5010 compliant by April 1, 2012, you cannot be reimbursed by MO HealthNet for service claims you submit for MO HealthNet participants.

What we are referring to is being compliant with the Accredited Standards Committee (ASC) X12 version 5010 and NCPDP Telecom D.0 standards for electronic health care transactions under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you continue to submit claims through v4010 or v5.1transactions, they will be rejected and you will have a disruption in payment.

Please reference Provider Bulletin dated December 12, 2011 for complete information.

Participant Administrative Lock–In

March 5, 2012

Some MO HealthNet participants are restricted (or locked-in) to a provider or providers, such as a certain physician, hospital and pharmacy where they can receive treatment or services. This is to help the participant use the MO HealthNet program properly. A provider checking patient eligibility is given the names and phone numbers of the lock-in providers. Payment of services for a locked-in participant cannot be made to other providers except for emergency services or authorized referral services.

Claims for emergency services must be submitted on a paper claim form with an attached Certificate of Medical Necessity and/or medical records documenting the emergency circumstances.

When a physician is the designated/authorized provider, they are responsible for the participant's primary care and for making necessary referrals to other providers as medically indicated. When a referral is necessary to other providers, the lock-in provider must complete a Medical Referral Form of Restricted Recipient (PI-118) and send it to each provider to whom the participant is referred.

The referral form must contain the NPI (and taxonomy code if appropriate) for the provider to whom the patient was restricted on the date of service. For example, if the participant is locked into a clinic, you must use the clinic's NPI (and taxonomy code if appropriate) on either the paper form or the electronic form. Do not put the physician's individual NPI on the referral form as the information will not match the MO HealthNet lock-in file. The NPI on the claim from the provider who received the referral must match the NPI on the referral form.

The information from the form can then be submitted by the treating provider(s) via the Internet at emomed.com or the form can be mailed to Wipro Infocrossing Healthcare Services, P.O. Box 5900, Jefferson City, MO 65102.

The referral form is good for 30 days from the date of service or appointment. A new referral form must be submitted if additional care is required after the 30 days.

We Need Your Suggestions!

February 27, 2012

The Provider Education Unit of the MO HealthNet Division (MHD) wants to provide weekly hot tips that are beneficial to you, the provider. Hot tips are often developed when MHD observations and reports indicate trends in billing errors or areas of misunderstandings regarding program policies and procedures.

Provider Education encourages and welcomes your input to the topics you would like to see as hot tips you believe would benefit the provider community. If you have suggestions, please send them by E-mail to: MHD.provtrain@dss.mo.gov.

Denture Coverage Reminders

February 21, 2012

Dentures are a covered benefit for the following MO HealthNet participants:

• members eligible in one of the assistance categories for pregnant women, ME (Medical Eligibility) codes 18, 43, 44, 45 and 61 (the MO HealthNet Managed Care health plans are responsible for coverage of dentures for pregnant members with these same ME codes);
• individuals eligible through one of the assistance categories for the blind, ME codes 02, 03, 12 and 15;
• individuals residing in a nursing home regardless of their ME code – verification of vendor care/nursing home eligibility is determined by checking for “Nursing Home Information” when verifying participant eligibility; and
• participants under the age of 21.

Dentures are not covered for MO HealthNet participants with a limited benefit package. For those participants receiving dental care meeting the criteria established for individuals with a limited benefit package even when that care may include full mouth extractions, dentures are still a non-covered service. A complete list of ME codes for participants receiving limited benefits can be found in the MO HealthNet Guide–Puzzled by the Terminology.

When submitting claims for dentures to MO HealthNet, the date of service is the date of placement. Dentures, full or partial, do not require prior authorization.

History and Physical Prior to Outpatient Surgery

February 14, 2012

As a reminder, Procedure code 99218, 99219 or 99220 may be used in the outpatient setting (POS 22) for the initial history and physical workup prior to outpatient surgery.

NOTE: These procedure codes are not to be used for any other service provided in the outpatient setting.

Information regarding billing a history and physical prior to outpatient surgery can be found in Section 13.21.B of the MO HealthNet Physician Manual.

Split Claims

February 6, 2012

Claims submitted to MO HealthNet may, due to the adjudication system requirements, have service lines separated from the original claim. This is commonly referred to as a split claim. Each portion of a claim that has been split is assigned a separate internal control number and the sum of the service line(s) charge submitted on each split claim becomes the split claim total charge. Currently, a maximum of 28 service lines per claim are processed. All detail lines that exceed the size allowed are split into a separate claim. If a claim denies for more than 25 edits, the claim must be split into multiple claims.

Timely filing, duplicate claim submission, third party liability and spenddown all post an edit for each line and can cause a claim to deny for more edits than the system can process. Providers can avoid this type of claim denial by submitting smaller claims with fewer line details.

MO HealthNet applies editing to Medicare/MO HealthNet crossover claims very similar to that used to process MO HealthNet only claims. The system can only process 25 edits or less on one claim. If the claim denies for more than 25 edits, the crossover claim must be split into multiple claims. When splitting the claim into multiple claims, the claim header charge will be different than the one sent to Medicare because the claim header charge must reflect the total charge of the service lines on the smaller split claim.

Providers can also bill smaller claims to Medicare so that the claim can crossover correctly without being manually split to address more than 25 edits.

Additional information regarding split claims can be found in Section 17.6 of the provider manual. Information regarding Medicare/MO HealthNet crossover claims can be found in the Crossover Claim Editing Bulletin, Volume 29, Number 8 dated August 21, 2006.

Temporary MO HealthNet During Pregnancy (TEMP)

January 30, 2012

As a reminder, TEMP services for pregnant women (Medical Eligibility codes 58 or 59) are limited to ambulatory prenatal services. Services other than ambulatory prenatal may be reimbursed if a Certificate of Medical Necessity is submitted with the claim and it affirms that the pregnancy would have been adversely affected without the service.

The diagnosis on the claim form must be a pregnancy/prenatal diagnosis (V22.0 through V23.9 or V28 through V28.9). Nurse midwives must use diagnosis codes V22.0 through V22.2 or V28 through V28.9.

If the TEMP participant is provided illness care, the illness diagnosis code must appear as the primary diagnosis code on the claim. However, a pregnancy/prenatal diagnosis code must also appear on the claim form.

Inpatient hospital services and deliveries performed either inpatient or outpatient are not covered under the TEMP program. Other non-covered services include: postpartum care; contraceptive management; D & C; treatment of spontaneous, missed abortions or other abortions.

Infants born to mothers who are eligible under the TEMP Program are not automatically MO HealthNet eligible under the TEMP program.

For more information on the TEMP Program, please reference Section 13.3 of the MO HealthNet Physician Manual.

Timely Filing Guidelines

January 23, 2012

MO HealthNet timely filing guidelines for claims and adjustments can be found in Section 4 of Provider Manuals and are outlined below:

• Original claims must be filed by the provider and received by the state agency within twelve (12) months from the date of service. Any claims that originally were submitted and received within twelve (12) months from the date of service, but were denied or returned to the provider, must be resubmitted and received within twenty-four (24) months of the date of service.

• Medicare/MO HealthNet crossover claims that have been filed within the Medicare timely filing requirement must be received by the state agency within twelve (12) months from the date of service or six (6) months from the date on the Medicare provider's notice of the allowed claim. Claims denied by Medicare must be filed by the provider and received by the state agency within twelve (12) months from the date of service.

  NOTE: A non-QMB Medicare Part C claim must be filed by the provider and received by the state agency within twelve (12) months from the date of service. Any claims that originally were submitted and received within twelve (12) months from the date of service, but were denied or returned to the provider, must be resubmitted and received within twenty-four (24) months of the date of service.

• MO HealthNet claims with third party liability must first be submitted to the insurance company in most instances. However, the claim to MO HealthNet must still meet the timely filing guidelines outlined above. Claim disposition by the insurance company after one (1) year from the date of service does not serve to extend the filing requirement. However, the twelve (12) month filing rule may be extended if a third-party payer, later reverses the payment determination sometime after twelve (12) months from the date of service has elapsed and requests the provider return the payment. In this case, the provider may file a claim with MO HealthNet later than twelve (12) months from the date of service by submitting the claim to the Third Party Liability Unit, P.O. Box 6500, Jefferson City, MO 65102 for special handling.
• Adjustments to a paid claim must be filed within twenty-four (24) months from the date of the remittance advice on which payment was made. If the processing of an adjustment necessitates filing a new claim, the time limit for resubmitting the new, corrected claim is ninety (90) days from the date of the remittance advice indicating recoupment or twelve (12) months from the date of service, whichever is longer.

MO HealthNet provider manuals can be referenced through the following link: http://manuals.momed.com/manuals/.

Consultations

January 17, 2012

As a reminder, MO HealthNet still recognizes the consultation codes, 99241-99245 and 99251-99255. While many payors have changed the way consultations are billed, MO HealthNet still requires the use of the codes shown above for reimbursement.

If you have billed consultations incorrectly, please file an online adjustment to correct.

Please reference the Physician Manual, Section 13.28 for the guidelines to bill consultations.

Nursing Home Room & Board Claim Filing Reminders

January 9, 2012

The following are claim filing reminders for nursing homes when submitting claims for their room and board charges:

• The FA–465 is the facility’s authorization to submit claims to MO HealthNet;
• With the exception of days a resident is locked in to a hospice, all days are to be billed to MO HealthNet with the appropriate revenue codes;
• Each month should be billed chronologically. For example, if a resident had an inpatient hospital stay 11/29/11 – 12/02/11,
  was discharged 12/03/11 and in a Medicaid only bed for the remainder of the month,
  the inpatient hospital days for 12/01/11 – 12/02/11 must be billed before the Medicaid only days;
• Facilities are not restricted to once monthly billing, room and board charges may be submitted at anytime during the month.

For more information on MO HealthNet’s nursing home program, providers can reference Section 13 of the MO HealthNet nursing home manual.

Contacting Provider Education

January 3, 2012

Requests for provider training can be made by email to mhd.provtrain@dss.mo.gov or by telephone at (573) 751-6683. All information, including the provider NPI number, must be readily available.

When calling the Provider Education Training Unit, ask for the appropriate representative (shown below). If you need to leave a message be sure to include your name, the provider name, provider NPI, telephone number, extension number if necessary and the type of training needed. It is not possible to list all the MO HealthNet programs below, but by providing the pertinent information above, your request for assistance can easily be directed to the appropriate staff.

The names of the Provider Education representatives and some of their training programs are listed below:

Becky – personal care/homemaker-chore, home health, private duty nursing, psychology/counseling, speech/occupational/physical therapy, including these providers within a group or clinic;

Dawn – durable medical equipment, ambulance, adult day health care, nursing homes, dental, hospice, optical (optometrists), including these providers within a group or clinic;

Renee – nurse practitioners, podiatrists, hospitals, physician/clinics, professional medical billing concerning Federally Qualified Health Centers and Rural Health Clinics; NOTE: Responsible for providers East of MO Hwy. 63 including Columbia.

Carol – nurse practitioners, podiatrists, hospitals, physician/clinics, professional medical billing concerning Federally Qualified Health Centers and Rural Health Clinics; NOTE: Responsible for providers West of MO Hwy. 63 including Jefferson City.

General claim billing, claim denials, Remittance Advices and participant eligibility questions should be directed to the Provider Communications Unit at (573) 751-2896. The Provider Education Unit should be contacted only for program training or questions regarding policy clarification.