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HP Provider Relations July 2013 Transportation.. the right way.

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Presentation on theme: "HP Provider Relations July 2013 Transportation.. the right way."— Presentation transcript:

1 HP Provider Relations July 2013 Transportation.. the right way

2 Transportation GuidelinesJuly Agenda –Session objectives –Transportation services –Provider enrollment –Member eligibility –Billing guidelines –Copayment amounts and exemptions –Prior authorization –Common denials –Frequently asked questions –Helpful tools –Q&A

3 Transportation GuidelinesJuly Session Objectives At the end of this session, providers will understand:  Enrollment, recertification and revalidation  Understand Eligibility Verification  Correct billing practices  Copayments and copayment exemptions  Prior authorization  Common claim denials  Helpful tools

4 HP Provider Relations July 2013 Transportation Services

5 Transportation GuidelinesJuly Types of Transportation Services –Advanced Life Support – ALS Care given at the scene of an accident, act of terrorism, or illness; care given during transport; care given at the hospital by a paramedic or emergency medical technician- intermediate; and care that is more advanced than the care usually provided by an emergency medical technician or an emergency medical technician-basic advanced –Basic Life Support – BLS BLS services do not include invasive medical care techniques or advanced life support –Commercial or Common Ambulatory Service – CAS Transporting ambulatory members to or from an IHCP covered service –Non-Ambulatory Service – NAS Transporting non-ambulatory services (member must travel in a wheelchair) to or from an IHCP-covered service –Taxi Taxi providers transport members to or from an IHCP covered service −may operate under authority from a local governing body (city taxi or livery license)

6 HP Provider Relations July 2013 Enrollment

7 Transportation GuidelinesJuly Enrollment – Meet the requirements Reference the IHCP Provider Type and Specialty Matrix to determine documentation requirements 

8 Transportation GuidelinesJuly Enrollment – ALWAYS use the most recent forms

9 Transportation GuidelinesJuly Enrollment – ALWAYS use the most recent forms

10 Transportation GuidelinesJuly Enrollment - Reminders Review the matrix:  Choose the correct provider specialty  Prepare the required documents Motor Carrier Certificate Proof of auto insurance Copy of driver’s license for all drivers Fingerprint and background checks; Surety bond  BT and BT Application fee  IHCP Affordable Care Act requirements IHCP Bill Pay site ** additional documentation may be required Download the most recent version of the Provider Enrollment form ****Enrollment with Traditional Medicaid does not automatically enroll a provider with the Managed Care Entities

11 Transportation GuidelinesJuly Enrollment – Recertification

12 Transportation GuidelinesJuly Enrollment – Recertification When a provider is required to recertify, a notification is sent to the provider 60 business days prior to the end date of a provider's eligibility to participate  Expiring license  Motor carrier certificate  Proof of insurance If a provider fails to recertify before their eligibility end date, the provider must re-enroll with the IHCP by submitting a new IHCP Provider Packet in its entirety.re-enroll with the IHCP

13 Transportation GuidelinesJuly Enrollment – Revalidation Under the Affordable Care Act (ACA), the Indiana Health Coverage Programs (IHCP) is required to revalidate all provider enrollments. The ACA screening criteria apply during revalidation.  Providers will receive notification letters with instructions for revalidating 90 and 60 days before their revalidation deadline.  Providers should not take any steps to revalidate until they receive their notification letters.  Providers that fail to submit revalidation paperwork in a timely manner may be deactivated from participation in the IHCP as of the deadline date.

14 HP Provider Relations July 2013 Eligibility

15 Transportation GuidelinesJuly Verify Eligibility – WebinterChange, AVR, Omni swipe

16 Transportation GuidelinesJuly Verify Eligibility – Key areas  Member is eligible  Member has a NF (nursing facility) level of care  Member is QMB  ALSO – have all Medicaid benefits  ONLY – only have coverage for Medicare co-insurance and deductible  Spend down  NEVER collect spend down in advance  Enrolled in Hoosier Healthwise Risk Based Managed Care(RBMC)  Follow guidelines for the appropriate managed care entity  Third Party Liability (TPL) Insurance  Medicare and TPL are primary  Benefit limits exhausted  Prior authorization may be required

17 HP Provider Relations July 2013 Billing Guidelines

18 Transportation GuidelinesJuly Billing Guidelines – What is a trip? –For billing purposes, a trip is defined as transporting a member from the initial point of pickup to the drop-off point at the final destination  Cancelled transportation appointments or no show by the member is NOT a billable fee to the IHCP and the member can NOT be billed –Transportation must be the least expensive type of transportation available that meets the medical needs of the member –Trips must be billed according to the level of service rendered and not according to the vehicle type

19 Transportation GuidelinesJuly Billing Guidelines – What is a trip? –If the provider transports a member on the same date of service, but different trip levels (for example the “to” trip was a CAS trip, and the “return” trip was a NAS trip, with mileage for each base), these base trips must be billed on two different claim forms with the corresponding mileage for each base –If the provider makes a round trip, or two one-way trips for the same member, same date of service, and same level of base code, both runs should be submitted on the same detail with two units of service –All mileage for the trip must be billed on the one detail with the total number of miles associated for the roundtrip to include the first 10 miles

20 Transportation GuidelinesJuly Billing Guidelines – Mileage Mileage does not start until the member is in the vehicle (loaded mileage)  Transportation providers are expected to transport members along the shortest, most efficient route to and from a destination  Mileage must be documented on the trip sheet using odometer readings or mapping software programs  Mileage is reimbursed, in addition to the base rate, under the following circumstances: Ambulance providers are reimbursed for loaded mileage of the trip regardless of the type or level of service being billed Taxi providers are not reimbursed for mileage and are not required to submit mileage with their claim; however, the mileage must be documented

21 Transportation GuidelinesJuly Billing Guidelines – Mileage Mileage does not start until the member is in the vehicle (loaded mileage The first 10 miles of a CAS or NAS trip are billed into the base rate with no separate reimbursement for mileage  For trips less than 10 miles, the IHCP does not require the provider to bill mileage; however, if the provider does bill mileage, the IHCP processes the mileage as a denied line item  CAS and NAS providers must bill for all mileage when travel exceeds 10 miles one way  Total mileage should be billed – including the first 10  Fractional miles are not allowed  If the provider transports the member between 15.0 and 15.4 miles, the provider should bill 15 miles; if the trip is between 15.5 miles and 16.0 miles, the provider should bill 16 miles

22 Transportation GuidelinesJuly Billing Guidelines – Multiple passengers –When two or more members are transported simultaneously from the same county to the same vicinity for medical services, the second and subsequent member transported in a single CAS or NAS vehicle is reimbursed at one-half the base rate For example, no mileage should be billed in conjunction with T Nonemergency transport; commercial carrier, multi-pass, individualized service provided to more than one patient in the same setting –The full base code, mileage, and waiting time are reimbursed for the first member only –The IHCP does not provide reimbursement for multiple passengers in ambulances or family member vehicles – Additional reimbursement is not available for multiple passengers when the billing provider does not bill non-IHCP customers for these services

23 Transportation GuidelinesJuly Billing Guidelines – Multiple destinations Member is transported to multiple points in succession, the provider may not bill for a trip between each point of the destination –The following examples offer explanations of this concept: Example 1: A vehicle picks up a member at home and transports the member to the physician’s office. This is a one-way trip. Example 2: A vehicle picks up a member from home and transports the member to the physician’s office. The provider leaves, and later the same vehicle picks the member up from the physician’s office and transports the member back to the member’s home. This is considered two one-way trips. Example 3: A vehicle picks up the member from the physician’s office and transports the member to the laboratory for a blood draw, waits outside the laboratory for the member, and then transports the member home. This is a one-way trip, even though there was a stop along the way. A stop along the way is not considered a separate trip.

24 Transportation GuidelinesJuly – Ambulance CodeDescription A0427Advanced life support (ALS) emergency transport, level 1, one or more interventions A0426ALS nonemergency transport, level 1, one or more interventions A0428Basic life support (BLS), nonemergency transport A0429BLS, emergency transport A0225Neonatal transport, ambulance service, base rate one way CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Billing Guidelines - Codes

25 Transportation GuidelinesJuly – Ambulance Billing Guidelines - Codes CodeDescription T2003ALS nonemergency transport; level 1 (common carrier ambulatory) A0130ALS nonemergency transport; level 1 (common carrier nonambulatory) T2003BLS nonemergency transport; (common carrier ambulatory) A0130BLS nonemergency transport; (nonambulatory) A0425 U1 A0425 U2 Ground mileage, per statute mile Level 1 (ALS) Level 2 (BLS) A0420 U1 Ambulance service − Waiting time ALS one-half (1/2) hour increments A0420 U1 Ambulance service − Waiting time BLS one-half (1/2) hour increments

26 Transportation GuidelinesJuly – Air ambulance Billing Guidelines - Codes CodeDescription A0431Ambulance service, conventional air service, transport, one way (rotary wing) A0430Ambulance service, conventional air service transport, one way (fixed wing) A0436Rotary wing air mileage, per statute mile A0431 QL Ambulance service, conventional air service, transport, one way (rotary wing); if the member is pronounced dead after takeoff to point of pickup

27 Transportation GuidelinesJuly – Bus Billing Guidelines - Codes CodeDescription A0110Nonemergency transportation and bus, intrastate, or interstate carrier

28 Transportation GuidelinesJuly – Taxi Billing Guidelines - Codes CodeDescription A0100 U4Nonemergency transportation – Taxi, suburban A0100 UATaxi – 0-5 miles A0100 UBTaxi – 6-10 miles A0100 UCTaxi – 11 miles and up A0100 TT UATaxi – 0 to 5 miles, multi-passenger A0100 TT UBTaxi – 6 to 10 miles, multi-passenger A0100 TT UCTaxi – Nonregulated, multi-passenger, 11 miles or more A0100 TK UATaxi – 0 to 5 miles, accompanying parent or assistant A0100 TK UBTaxi – 6 to 10 miles, accompanying parent or assistant A0100 TK UCTaxi – Nonregulated, accompanying parent or assistant, 11 miles or more

29 Transportation GuidelinesJuly – Common carrier ambulatory service (CAS) Billing Guidelines - Codes CodeDescription T2003Common carrier ambulatory service – Base rate T2004Common carrier ambulatory service – Multiple passenger T2001Common carrier ambulatory service – Accompanying parent or assistant, base rate A0425 U3CAS mileage T2007 U3Level 3 CAS waiting time in one-half (1/2) hour increments

30 Transportation GuidelinesJuly – Common carrier non-ambulatory services (NAS) Billing Guidelines - Codes CodeDescription A0130Wheelchair – Common carrier nonambulatory, base rate A0130 TTWheelchair – Common carrier nonambulatory, multiple passenger, base rate A0130 TKWheelchair – Common carrier nonambulatory, accompanying parent or attendant, base rate A0425 U5NAS Mileage T2007 U5Waiting time in one-half (1/2) hour increments

31 Transportation GuidelinesJuly – Family member Billing Guidelines - Codes CodeDescription A0090Mileage for family member automobile transportation Note: Transportation providers may be reimbursed for transporting a family member ONLY if the 266 specialty is part of the provider profile

32 Transportation GuidelinesJuly Billing Guidelines – Rotary wing air ambulance –Requires a prior authorization –Providers are required to bill for both the base rate and mileage codes –Claims no longer require an attachment for a cost invoice  Can be submitted electronically –Each code is reimbursed at a specific rate per the IHCP Fee ScheduleIHCP Fee Schedule –Refer to IHCP Provider Manual, Chapter 8, Section 4

33 Transportation GuidelinesJuly Billing Guidelines - Taxi –Taxi providers cannot transport outside the jurisdiction designated by their city taxi license –To transport outside the jurisdiction, the taxi provider must be enrolled as a common carrier –If a taxi transports across county borders, the Indiana Department of Revenue’s Motor Carrier Services Division must certify taxi transport as a common carrier

34 Transportation GuidelinesJuly Billing Guidelines - Modifiers –Providers must include the origin and destination modifiers with the base rate procedure codes –The first character of the two-digit modifier indicates the transport’s place of origin –The second character indicates the destination –When a member is transported by more than one transportation company on the same date of service, use of the modifiers helps to prevent one of the claims from denying as a duplicate of the other provider’s claim –A list of appropriate modifiers can be found in the IHCP Provider Manual in Chapter 8, Section 4IHCP Provider Manual in Chapter 8

35 Transportation GuidelinesJuly Billing Guidelines - Modifiers ModifierDescription DDiagnostic or therapeutic site, other than P or H EResidential, domiciliary, or custodial facility (nursing home, not SNF) GHospital-based dialysis facility (hospital or hospital-related) HHospital ISite of transfer between types of ambulance JNonhospital-based dialysis facility NSkilled nursing facility (SNF) PPhysician office RResidence SScene of accident or acute event

36 Transportation GuidelinesJuly Billing Guidelines - Diagnosis DialysisNursing HomeGeneral V560 V561 V568 V Required to bypass 20 one-way trip limitation Required on all dialysis claims Required to bypass 20 one-way trip limitation Required on all nursing home Will not bypass 20 one- way trip limitation Required on all claims except dialysis and nursing home

37 Transportation GuidelinesJuly Billing Guidelines - Attendant An additional attendant may be needed in situations where the driver cannot load the member without help, such as when wheelchair-bound member lives upstairs and the residence has no wheelchair ramp. In this situation:  The additional attendant who assists must be an employee of the billing provider and is not required to remain for the trip  Providers must document the need for an additional attendant on the driver’s ticket  Claims must include the appropriate procedure codes and modifiers

38 Transportation GuidelinesJuly Billing Guidelines – Accompanying parent/attendant –Accompanying parent  members younger than 18 years of age need an adult to accompany them to a medical service, the provider should bill the appropriate accompanying parent or attendant code –Accompanying attendant  when adult members need an attendant to travel with them for a medical service, the provider should bill the appropriate accompanying parent or attendant code –The following are guidelines for billing the accompanying parent or attendant codes:  The procedure code for the base rate and the accompanying parent or attendant is billed under the IHCP member identification number (RID)  Additional reimbursement is not available for accompanying parent or attendant when the billing provider does not bill non-IHCP customers for like services  The provider must maintain documentation on the driver’s ticket to support that the accompanying parent or attendant was transported with the IHCP member −This documentation must include the name, signature, and relation of the accompanying parent or attendant

39 Transportation GuidelinesJuly Billing Guidelines – Wait time Wait time in excess of 30 minutes is reimbursable when:  the vehicle is parked outside the medical service provider, awaiting the return of the member to the vehicle and if the member is transported 50 miles or more one-way  PA is obtained for all codes associated with trips of 50 miles or more one-way, including waiting time  the first 30 minutes of wait time is not covered; however, the total wait time must be included on the claim, or the claim will not be paid appropriately One unit of service is billed for each 30 minutes of wait time (round to nearest unit)  Documentation, including start and stop times, must be maintained on the driver’s ticket to support the wait time billed

40 HP Provider Relations July 2013 Member Copayment

41 Transportation GuidelinesJuly Member Copayment - Amounts CopaymentDescription $0.50Services for which the IHCP pays $10.00 or less $1.00Services for which the IHCP pays $10.01 to $50.00 $2.00Services for which the IHCP pays $50.01 or more IHCP requires a copayment for transportation services  The copayment shall be made by the recipient and collected by the provider at the time the service is rendered  Medicaid reimbursement to the provider shall be adjusted to reflect the copayment amount for which the recipient is liable  Members cannot be denied services for inability to pay copay at the time of service – the member may be billed

42 Transportation GuidelinesJuly Copayment - Exemptions Copayments are not required for:  Members younger than 18 years old  An assistant or accompanying adult traveling with a member younger than age 18 years old  Pregnancy (indicated by checking yes or no radio button or entering Y in field 24H on a paper claim)  Services furnished to individuals who are inpatient hospital, nursing facilities, Intermediate care facility for the intellectually disabled

43 HP Provider Relations July 2013 Prior Authorization

44 Transportation GuidelinesJuly Prior Authorization Requirements –Trips exceeding 20 one-way trips per rolling 12-month period require prior authorization (PA) –Other services that require PA: Air ambulance transportation Bus transportation –Interstate transportation or transportation services rendered by a provider located out-of-state in a nondesignated area

45 Transportation GuidelinesJuly PA Requirements - Exceptions –Emergency ambulance services –Hospital admission or discharge Transportation to a hospital for admission or from a hospital to home after discharge is exempt from 20 one-way trip limitation –Members on renal dialysis V56.0, V56.1, or V56.8 (required to bypass PA) –Members in nursing homes V70.5 (required to bypass PA)

46 Transportation GuidelinesJuly PA Requirements  When requesting PA providers should include codes for all services: Base rate Mileage Wait time Accompanying parent or attendant or additional attendant Trips of 50 miles or more one way require PA  Signature stamps Providers may use signature stamps on the PA request form; refer to IHCP Provider Manual, Chapter 6, Section 1

47 Transportation GuidelinesJuly Traditional Medicaid fee-for-service PA Contacts –Traditional Medicaid fee-for-service PA requests are processed by ADVANTAGE Health Solutions P.O. Box Indianapolis, IN (Fax)  PA submission available on Web interChange

48 Transportation GuidelinesJuly Care Select PA Contacts Each care management entity (CME) is responsible for processing PA requests for its respective Care Select members: –MDwise Care Select P.O. Box Indianapolis, IN (Fax) –ADVANTAGE Health Solutions P.O. Box Indianapolis, IN (Fax)

49 HP Provider Relations July 2013 Common Denials

50 Transportation GuidelinesJuly Mileage is not reimbursable unless the recipient is transported 11 miles or more one way – please verify and resubmit Edit 4080 –Cause System is deducting first 10 miles from the claim –Resolution The initial 10 miles are included in the base rate; mileage is only reimbursed for 11 miles or more Providers should bill the total miles traveled for each trip IndianaAIM will automatically calculate the appropriate mileage reimbursement

51 Transportation GuidelinesJuly Prior authorization required for one-way trips in excess of 20 Edit 6803 –Cause Claims have been paid for 20 one way trips –Resolution check for benefit limits reached on eligibility prior to transporting member Submit a PA request for more trips resubmit claim after approved PA is received

52 Transportation GuidelinesJuly Possible duplicate Edit 5000 –Cause Two round trips made in one day; the second trip denies as a duplicate –Resolution Indicate four units on one line Combine total mileage on one line Maintain documentation for the two separate round trips

53 Transportation GuidelinesJuly QMB recipient Edit 2007 –Cause Member enrolled in Medicare –Resolution Verify eligibility review QMB status for ONLY versus ALSO

54 HP Provider Relations July 2013 FAQ Frequently Asked Questions

55 Transportation GuidelinesJuly Frequently Asked Questions –Why is the copayment deducted from my claim twice? Do not deduct copayment amount when submitting claims The IHCP systematically deducts the copayment from the claim payment –Why is a copayment deducted when the patient is pregnant? To bypass the copayment edit, indicate yes in pregnancy field on paper claim field 24H and on an electronic claim pregnancy button –Why is a copayment deducted when I transport a patient to the hospital for admission? Indicate the appropriate two-digit place of service code

56 Transportation GuidelinesJuly Frequently Asked Questions –Why do I receive denials for the 20-trip limit when I transport a nursing facility patient? To bypass the 20-trip limit denial, you must use diagnosis code V70.5 when transporting a nursing facility patient –If I make two round trips in one day, why does the second round trip deny as a duplicate? The IHCP will pay claims for both trips if you bill them on one detail line indicating 4 units of service Maintain documentation for the two separate trips –Why are 10 miles of each one-way trip deducted from my mileage? The initial 10 miles are built into the base rate Mileage is only reimbursed for 11 miles or more

57 HP Provider Relations July 2013 Resources

58 Transportation GuidelinesJuly Helpful Tools –IHCP Provider website at indianamedicaid.com indianamedicaid.com –IHCP Provider Manual (web, CD, or paper) –IHCP Provider Manual, Chapter 8, Section 4 –Customer Assistance –Written Correspondence HP Written Correspondence P.O. Box 7263 Indianapolis, IN –Provider field consultant Locate area consultant map on: indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or Web interChange > Help > Contact Us

59 Q&A


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