UTAH MEDICAID OUTPATIENT CONVERSION 2011 May 19, 2011 PRESENTED BY DARIN DENNIS

Introductions

Purpose of Meeting To provide details regarding outpatient billing changes To solicit feedback and questions

Areas NOT affected Changes do NOT include: – LTAC – Ambulatory Surgical Centers – Physician – Ambulance – Inpatient

Go Live Date Utah Medicaid is currently on target to be ready by July 1, UHA has requested go live currently scheduled for August 1, Testing results will be monitored in weekly meetings.

Medicaid Outpatient Methodology Current Coverage is generally revenue-code based Reimbursement is percent- of-charge or fee-schedule Urban vs. Rural differential Emergent use of the E.D. results in higher reimbursement Future Coverage is procedure-code based Pay is APC or fee-schedule based No Urban/Rural differential No emergency differential Use Medicare’s Outpatient Code Editor Use CMS’ outpatient pricer If not covered by Medicare, use Medicaid fee schedule

Medicare Methodology Hospitals identified as Critical Access Hospital or OPPS facility Line item procedure code receives Status Indicator (A-Z) indicating coverage and payment

Medicaid Changes Important to bill all codes & charges (determines outlier payments) All lines require a procedure code for payment Most (~90%) of the procedure codes that Medicare covers (9,300 codes) for outpatient will be covered by Medicaid (8,400 codes).

Medicaid Plans Affected Traditional & Non-Traditional plans will have similar coverage (see procedure code list) Primary Care Network plan coverage will only include Revenue code 045X with an emergency diagnosis (no change).

Medicaid vs. Medicare Outpatient definition (Medicaid=24 hour limit) Always include NDC on pharmaceuticals (needed for rebates) As a general rule for Medicaid: Experimental, investigational, cosmetic and fertility-related procedures are not covered Medicaid copayments are still utilized

Medicaid – Additional changes Recently approved to use: Modifiers Condition codes Revenue Codes (90% of codes opened) Occupational Therapy and Physical Therapy will keep submission differences Post-Payment audits will occur (like Medicare)

Contact info Darin Dennis

Other questions Prior Authorization Payment dispute and over/under payment resolution instructions 835 processing: Delays or suspensions plan Crossover claims: when to bill as regular fee- for-service