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Rural Health Clinic Division of Medicaid Important Information 2013 Office of the Governor | Mississippi Division of Medicaid.

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Presentation on theme: "Rural Health Clinic Division of Medicaid Important Information 2013 Office of the Governor | Mississippi Division of Medicaid."— Presentation transcript:

1 Rural Health Clinic Division of Medicaid Important Information 2013 Office of the Governor | Mississippi Division of Medicaid

2 RHC BASICS Kimberley Funchess – Facilities and Transportation Programs OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID2

3 Rural Health Clinics Governing Document: Administrative Code Title 23, Part 212 – Found on Division of Medicaids Website: Reimbursement for RHC Services: Funded by Medicare and Medicaid OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID3

4 Rural Health Clinics Provide to Mississippians: Primary healthcare – including specialty practice (OB/GYN, pediatric, etc.) Six specified lab tests required on-site – urine, HGB/HCT, blood glucose, stool, pregnancy, cultures Supportive services not mandated OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID4

5 Hospital Services Services provided in an inpatient or outpatient hospital setting are NOT eligible for reimbursement by an RHC provider – These services must be billed by a qualified, eligible provider using his/her Medicaid provider number – Claims billed by an RHC provider with the following places of service will be denied: POS 21POS 22POS 23 Providers employed by an RHC may render services in an inpatient or outpatient hospital, but the services must be billed by the provider, not the RHC OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID5

6 Service Limits All service limits are applicable – Physician visits – Dental – Vision – Mental Health Additional benefits are available for beneficiaries who qualify for Expanded EPSDT services. COE limits apply – COE 029, 031, 051, 54, 045, 088 OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID6

7 Prior Authorization All prior authorization requirements are applicable: – Dental – Expanded EPSDT – Pharmacy – Vision OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID7

8 Documentation Provider documentation must: – Include complete patient records – Verify appropriate services provided – Include date of service, presenting complaint, findings, treatment rendered, provider signature – Include details such as drug dosages, lab values, radiology reports, etc. Documentation may be audited by DOM or a contracted entity at any time Services not documented may be subject to recoupment or further investigation by Program Integrity Providers referred to a regulatory body may be prosecuted for fraud or suffer monetary penalties OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID8

9 Co-mingling Definition : – Simultaneous operation of an RHC and another physician practice, thereby mixing the two practices (share hours of operation, space, staff, equipment, supplies, and other resources). Physicians and non-physician practitioners may not operate private Medicare and Medicaid practice during RHC hours of operation using clinic resources. OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID9

10 RHC REIMBURSEMENT KEY POINTS Marilyn Dickerson, CPC – Coding Specialist OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID10

11 RHC Reimbursement Paid based upon encounter rates – Encounter rates are set for individual providers – One encounter rate per face-to-face visit allowed – Provider must bill encounter code to receive reimbursement – Codes other than encounter codes will reimburse at a rate of zero OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID11

12 Multiple Encounters Same Day Up to four encounters may be reimbursed for the same date of service – Limited to one encounter for each visit type Medical Dental Vision/Eyeglass Mental Health – Additional medical encounters may be paid on the same date of service by submitting a paper claim with supporting documentation OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID12

13 Encounter Codes Medical – – 99350H – – 99397H – S – 59426S T – 99337T1023 Dental D0000 – D9999 Vision/Eyeglass – OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID13

14 Mental Health Encounter Code Changes Valid for dates of service beginning 1/1/ – – – – No longer valid after 12/31/ – – – – OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID14

15 Obstetrical Billing Antepartum Visits – CPT codes – 99215, and Visit 1, 2, or 3 one per visit in – range Visit 4, 5, or 6 use Visit 7 or more use Postpartum visits When clinic physician is not the delivering physician use Modifiers Include modifier -TH with all antepartum, delivery and postpartum codes OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID15

16 Billing Reminders RHC should not be listed as the servicing provider on the claim Non-covered and invalid procedure or diagnosis codes will deny if billed $3.00 copay applies, unless exempted by policy National Correct Coding Initiative Edits (NCCI) do not apply 5% assessment does not apply OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID16

17 Additional Billing Information Provider Reference Guide Part 212 – Rural Health Clinics OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID17

18 EPSDT PROGRAM Shanda Boarden, RN – EPSDT Program OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID18

19 Mississippi Cool Kids Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Secondary Facility Location Requirements OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID19

20 Enrollment Requirements for Secondary Locations Contact the Bureau of Provider Enrollment at (601) and request to link a secondary location to the primary locations provider facility group number. The Bureau of Provider Enrollment will notify the requestor that the secondary location has been linked. It is the responsibility of the requestor to contact the Bureau of Medical Services at (601) to request the MS Cool Kids Secondary Location Form. After receipt and approval the requestor will be notified. OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID 20

21 EPSDT Servicing Providers The EPSDT Servicing Provider must be one of the following provider types: Physician Nurse Practitioner Physician Assistant OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID21

22 Equipment, Supplies, and Other Requirements Pediatric Scales (Balanced) Adult Scales (Balanced) Equipment to measure height Equipment to measure infant length and head circumference Audioscope or Audiometer, (calibrated annually) Snellen Eye Chart or Titmus Machine Plus Lens Pediatric Blood Pressure Cuff Anemia testing machine (HCT/HGB) HCT/HGB equipment calibration log Ophthalmoscope Otoscope Disposable gloves and Sharps container Urine dipstick for glucose and protein (Expiration Date) Containers for urine specimen collection OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID22

23 Equipment, Supplies, and Other Requirements continued Developmental Assessment Tool (Denver Kit or Alternative Supplies) Gown and Drapes available Supplies available to obtain necessary lab (Lead, RPR) Private Medical Record Filing System (HIPPA complaint) Private Exam Area Waiting room adequate for isolation of well and sick child Bathroom and hand washing facilities Exit doors clearly marked Handicap Ramp or access Fire extinguisher Disaster/Fire plan posted Administrative Policies, procedure manual, job descriptions OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID23


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