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Presenter Title HHS/ASPR Reimbursement Process for NDMS Definitive Care.

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Presentation on theme: "Presenter Title HHS/ASPR Reimbursement Process for NDMS Definitive Care."— Presentation transcript:

1 Presenter Title HHS/ASPR Reimbursement Process for NDMS Definitive Care

2 1 Definitive Care Definitive Care: Medical treatment or services or beyond emergency medical care, initiated upon inpatient admission to a NDMS hospital and provided for illnesses and injuries resulting directly from a specified public health emergency, or for injury, illnesses, conditions requiring non-deferrable medical treatment or services to maintain health when such medical treatment or services are temporarily not available as a result of the public health emergency. (NDMS MOA, section 803)

3 2 NDMS Coverage NDMS Coverage: NDMS coverage begins when an FCC authorized placement of a patient, who has been evacuated from a disaster area, into an acute care hospital for impatient definitive care. NDMS payment ends when one of the follow occurs, whichever comes first: completion of medically indicated treatment (maximum of 30 days); exhaustion of the DRG payment schedule; voluntary refusal of care; patient returns home or to point of origin/fiscally comparable location or to destination of choice for patient (whichever costs less).

4 3 Hospital Reimbursement Guidelines Inpatient Services: ─Any inpatient care provided within the first 30 days of the patient’s initial placement with a NDMS hospital is covered. ─This could be multiple admissions as long as the dates of service are within the first 30 days (subject to Medicare readmission policies). ─Claims will be adjudicated using Medicare policies.

5 4 Hospital Reimbursement Guidelines Inpatient Services: ─Reimbursement will be made at the lesser of (1) billed charges or (2) 110% of the amount of the Medicare IPPS: Hospitals will receive credit for the IPPS operating payment amount based on DRG and the hospital’s wage index value. Hospitals will receive credit for the IPPS capital payment amount based on DRG and the hospital’s geographic adjustment factor. Credits will be given for disproportionate share and/or indirect GME adjustments. Cost outlier adjustments will be recognized, but direct pass-through components such as direct medical education will not.

6 5 Practitioner Reimbursement Guidelines Practitioner Services: ─Reimburse for medically-necessary professional services furnished to NDMS patients during the course of their NDMS-covered inpatient stay at a NDMS hospital. ─Practitioner must be currently licensed to furnish the care provided and must not have been excluded from participation in federal health care programs. ─Practitioner must provide certified data on the NDMS patient. Medical charts must support the billing of the practitioner.

7 6 Practitioner Reimbursement Guidelines Practitioner Services: ─Reimburse lesser of (1) billed charges or (2) 100% of the amount of the Medicare physicians’ fee schedule. ─Fee schedule allowance will not be adjusted for practitioners based on whether or not he/she is enrolled in the Medicare program and if enrolled whether or not he/she has signed a Medicare participation agreement.

8 7 Coordination of Benefit Guidelines If the Patient is covered by Medicare, TRICARE or the Department of Veterans Affairs – NDMS will not make additional payments and payments from these programs will constitute full reimbursement. If the Patient has private health insurance or non-federal public coverage other than Medicaid – the other insurance should be billed as the primary and NDMS can be billed as the secondary for the difference up to 110% of Medicare for Hospitals and 100% of Medicare for Practitioners. If the Patient only has Medicaid or Section 1011 coverage, NDMS should be billed as the primary.

9 8 Claims Submission Process You can reference: UB-04 and CMS-1500 claim forms should be mailed to TrailBlazer Health Practitioners should submit a pay-to address on the CMS-1500 claim form Hospitals are not required to do so on the UB-04.

10 9 Internal HHS Claims Review Purpose: All denied claims automatically referred for review to determine if the claim should be paid by TrailBlazer Health. Membership ─ASPR Representative ─Emergency Physician ─HHS Contract Technical Representative ─Ad hoc members as needed for questions CMS Representative ─Compliance or Payment ACF Rep Office on Disability Denied claims to be referred to State Medicaid Agency.

11 10 Payment Process Currently, TrailBlazer Health is handling the adjudication of claims and the production of Explanation of Benefits and Remittance Advices. NDMS/ASPR currently must pay providers directly once TrailBlazer Health has determined the amount of reimbursement.

12 11 Payment Process The normal process for Federal Government payments to vendors requires that the vendor register in the Central Contractor Registry (CCR) at A pre-requisite as part of the CCR application process is to obtain a DUNS number from Dun and Bradstreet. Many hospitals already have a CCR registration as this is a pre-requisite for any Federal grant or contracting opportunity.

13 12 Payment Process Issues Most practitioner organizations have struggled with the DUNS/CCR application process. There is an alternative to DUNS/CCR. A provider can fax in an ACH Vendor Enrollment form known as a SF-3881 (a copy can be downloaded here:

14 13 Payment Process Issues This will allow ASPR/NDMS to process a one-time Electronic Funds Transfer to the provider’s bank account. A new form must be faxed in for each payment expected. For example, there have been four rounds of claims payments for Haiti patients. If a provider had submitted a claim in multiple rounds, they would need to fax in an ACH Vendor Enrollment form for each round. The biggest issues seen to date have involved mismatches of Tax ID names.

15 14 The Federal Government has strict policies about not making payments if the Tax ID name on the bank account does not match the name on the claims and remittance advices from TrailBlazer Health. Examples of problems: ─The hospital registered with TrailBlazer under a DBA name: “Hospital X”. However, the bank account Tax ID name registered in CCR or on the ACH Vendor Enrollment form says “Holding Company Y”. This mismatch in names will cause the payment to be suspended and will force TrailBlazer Health to reprint the remittance advices under the name “Holding Company Y” in order for payment to be processed. ─A hospital registered in CCR years ago for a grant opportunity under the name: “Hospital X Mammography Department” which did not match the banking account Tax ID name: “Hospital X”. Payment Process Issues

16 15 Payments and 1099s will come from the Federal Government and not TrailBlazer Health. Provider organizations should register with TrailBlazer Health using the Tax ID name for whatever bank account they ultimately want payment made to. If your organization already has a CCR profile (and thus an ACH Vendor Enrollment form is not necessary), please check your CCR profile to make sure that the information is still current and matches your desired banking information. Payment Process Issues

17 16 Payment Process Notes Please note that if a lien by any branch of the Federal Government has been levied against a provider organization, the Treasury Department will automatically net this amount out of any ACH payment attempted to the provider organization. Unfortunately, remittance advices will be mailed to providers under separate cover by TrailBlazer Health. ASPR/NDMS does not have a mechanism to provide this in conjunction with an Electronic Funds Transfer.

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