IHCP Rural Health Clinic Billing HP Provider Relations/June 2014

Agenda RHC Basics Claim Inquiry Common Claim Denials Where to bill claims Third Party Liability Helpful Tools

Objectives Participants will understand: The basics of RHC How to bill for services How to read and resolve claim issues Who to bill for services

RHC Basics

The Beginning RHC programs were established to address underserved rural communities and to reduce patient load on hospital emergency rooms Any area that is not in a U.S. Census-designated “urbanized area” (50,000 population) A FQHC may be in an urban area Must be in a designated shortage area Federally designated Health Professional Shortage Area (HPSA) Federally designated Medically Underserved Area (MUA) State governor designated underserved area

Enrollment Basics Providers should forward the Centers for Medicare & Medicaid Services (CMS) letter with enrollment application This letter grants RHC status Submit proper financial documents to Myers and Stauffer (rate- setting contractor) to establish rate Indiana State Department of Health sends Certification and Transmittal (C&T) to HP Providers are enrolled as a group, with rendering providers linked Provider Type 08 Specialty Type 081-RHC

Service Coverage According to 405 IAC 5-16-5, IHCP reimbursement is available to RHCs and FQHCs for services provided by the following providers: • Physician • Physician assistant • Nurse practitioner • Clinical psychologist • Clinical social worker • Dentist • Dental hygienist • Podiatrist • Optometrist

Service Definition A visit is a face-to-face encounter between the patient and provider Multiple services performed during the same visit for the same or related diagnosis are considered a single encounter Multiple visits that occur within the same 24-hour period for the same diagnosis are considered a single encounter

Eligibility Verification Verification of eligibility before every service is strongly encourage The best way to verify eligibility is Web interChange Other ways to verify eligibility Automated Voice Response ( AVR ) system 1-800-738-6770

Reimbursement AIM processing for PPS methodology began April 1, 2003 Must use Healthcare Common Procedure Coding System (HCPCS) Level III codes, including T1015 – clinic, visit/encounter, all-inclusive, and Level I and II codes Provider receives a facility-specific PPS rate determined by Myers and Stauffer

Place of Service Submit claims with place of service codes: 11 – office 12 – home 31 – skilled nursing facility 32 – nursing facility 72 – RHC Submit claims with T1015 and the applicable HCPCS/Current Procedural Terminology (CPT) code The HCPCS/CPT code will deny with error code 6096 –Code not payable according to PPS methodology The encounter rate T1015 is reimbursed according to the rate established by Myers and Stauffer

Service Allowance The IHCP only allows one encounter per IHCP member, per provider, per day, unless the diagnosis code differs Providers can submit valid encounters with differing diagnosis codes to HP for manual processing Documentation should be submitted through Written Correspondence Documentation requirements are: Documentation in writing from the medical record that supports the medical reasons for the additional visit - This documentation includes presenting symptoms or reasons for the visit, onset of symptoms, and treatment rendered. Documentation that the diagnosis for each encounter is different

T1015 Exempt Place of Service Codes Hospital services (place of service 20-26) are not considered RHC, and the T1015 encounter code is not required 20 Urgent Care Facility 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility Dental services are billed with Current Dental Terminology (CDT) codes on dental claim forms

Claim Inquiry

Claim Inquiry

Claim Inquiry National Provider Identifier (NPI) or LPI will automatically populate For multiple locations – choose appropriate service location Member recipient identification number (RID) From and through date of service of specific claim Search by date of service (DOS) Why not search by internal control number (ICN)? ICN will only give information on one specific claim Review all claim submissions and denial reasons Use paid claim (if applicable) for corrections Adjust the paid claim or void and start over Note: Documentation submitted with original claim must also be submitted with current claim. This applies to paper and electronic claims.

Claim Inquiry

Claim Inquiry

Claim Inquiry Claim submission information is displayed Choose the appropriate claim to work with i.e. most recent ICN or paid claim Click on the ICN Choose Scroll to the bottom of the claim Adjustment reason codes (ARCS) Health Insurance Portability and Accountability Act of 1996 (HIPAA) required fields – not the reason detail denied REMARKS HIPAA required fields – not the reason detail denied Provide spend down information

Claim Inquiry CLAIM STATUS INFORMATION Provides detailed information disposition of each EOB (explanation of benefits) code – LOOK FOR THE “D” H/D – the header or detail level WHY DID THE CLAIM/DETAIL LINE DENY description

Common claim denials

Common Denials 2017 - Recipient ineligible on date of service – due to enrollment in a Managed Care Entity Resolution: VERIFY MEMBER ELIGIBILITY Understand the eligibility information Submit claim to the appropriate entity

Common Denials 2017 - Recipient ineligible on date of service

Common Denials 4121 – T1015 must be billed with procedure code Resolution: Copy the claim in Web interChange Add T1015 detail line Save detail Submit claim.

Common Denials 0558 - Coinsurance and deductible amount missing Claim submitted has no coinsurance and deductible amount indicating that this is not a crossover claim Resolution: Verify claim is a crossover claim Submit claim with appropriate crossover information Primary explanation of benefits (EOB) is not required if payment has been made If claim is not crossover Submit as Medicaid primary Include supporting EOB documentation if applicable

Medicare and Replacement Plans

Medicare and Replacement Plans

Common Denials Crossover Claim Information Payer ID = REPLACEMENT PLAN OR MEDICARE PAYER ID Payer Name = Wisconsin Physician Services (Traditional Medicare) or Replacement Plan name in the Payer Name Field Medicare Paid Amount = The total amount paid by Medicare for the claim Subscriber Name = Name of policy holder for primary insurance Primary ID = ID number of the primary insurance (Medicare or Replacement Plan) Relationship Code = 18 (self) Claim Filing Code = 16 (Replacement Plan) or MB (Traditional Medicare) Click Save Benefits at the bottom of the screen Click Save and Close at the top of the screen Note: Obtain coordination of benefits (COB) information from the HELP tab, Reference Materials on Web interChange

Common Denials Information required in Field 22 Coinsurance/Deductible Information Medicare Payment Information

Third Party Considerations

Third-Party Liability Considerations All third-party liability (TPL), patient liability, and copayments continue to apply as appropriate Allowable Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and pregnancy services provided during an encounter continue to bypass TPL edits Medicare crossover reimbursement methodology is excluded from PPS logic T1015 not necessary on crossover claims Medicaid reimburses deductible and coinsurance, even if Medicare payment greater than PPS rate TPL payment information for paper claims: CMS-1500 – Block 29 Dental Claim – Block 35 UB-04 – Block 54 B

Who pays my claim?

Care Select Claims submitted for members in Care Select no longer require primary medical provider (PMP) authorization if the service was not provided by the PMP Self-referral services provided at the RHC do not require PMP authorization In the Care Select network, RHC provider specialties are not entitled to receive the monthly administrative fee payment

Risk-Based Managed Care Submit claims to the applicable risk-based managed care (RBMC) managed care entity with the HCPCS/CPT code Do not include T1015 encounter code Myers and Stauffer reconciles managed care claims to the provider-specific PPS rate and makes annual settlements Providers may submit requests for supplemental payments to Myers and Stauffer Contact information for the MCE’s can be found on the Quick Reference Guide at www.indianamedicaid.com

Helpful Tools

Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual Customer Assistance 1-800-577-1278 Locate area consultant map on: indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or Web interChange > Help > Contact Us Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN 46207-7263

Q&A