IHCP Rural Health Clinic Billing HP Provider Relations/June
2014
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IRHA Annual Conference June 10, 2014 2 Agenda RHC Basics Claim
Inquiry Common Claim Denials Where to bill claims Third Party
Liability Helpful Tools
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IRHA Annual Conference June 10, 2014 3 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
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RHC Basics
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IRHA Annual Conference June 10, 2014 5 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
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IRHA Annual Conference June 10, 2014 6 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
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IRHA Annual Conference June 10, 2014 7 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
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IRHA Annual Conference June 10, 2014 8 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
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IRHA Annual Conference June 10, 2014 9 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
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IRHA Annual Conference June 10, 2014 10 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
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IRHA Annual Conference June 10, 2014 11 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
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IRHA Annual Conference June 10, 2014 12 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
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IRHA Annual Conference June 10, 2014 13 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
26Military Treatment Facility Dental services are billed with
Current Dental Terminology (CDT) codes on dental claim forms
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Claim Inquiry
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IRHA Annual Conference June 10, 2014 15 Claim Inquiry
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IRHA Annual Conference June 10, 2014 16 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.
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IRHA Annual Conference June 10, 2014 17 Claim Inquiry
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IRHA Annual Conference June 10, 2014 18 Claim Inquiry
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IRHA Annual Conference June 10, 2014 19 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
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IRHA Annual Conference June 10, 2014 20 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
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Common claim denials
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IRHA Annual Conference June 10, 2014 22 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
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IRHA Annual Conference June 10, 2014 23 Common Denials 2017 -
Recipient ineligible on date of service
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IRHA Annual Conference June 10, 2014 24 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.
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IRHA Annual Conference June 10, 2014 25 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
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IRHA Annual Conference June 10, 2014 26 Medicare and
Replacement Plans
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IRHA Annual Conference June 10, 2014 27 Medicare and
Replacement Plans
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IRHA Annual Conference June 10, 2014 28 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
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IRHA Annual Conference June 10, 2014 29 Common Denials
Information required in Field 22 Coinsurance/Deductible Information
Medicare Payment Information
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Third Party Considerations
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IRHA Annual Conference June 10, 2014 31 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
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Who pays my claim?
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IRHA Annual Conference June 10, 2014 33 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
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IRHA Annual Conference June 10, 2014 34 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 MCEs can be found on the
Quick Reference Guide at www.indianamedicaid.com
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Helpful Tools
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IRHA Annual Conference June 10, 2014 36 Helpful Tools IHCP
website at indianamedicaid.comindianamedicaid.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) indianamedicaid.com or Web
interChange > Help > Contact Us Web interChange Written
Correspondence HP Provider Written Correspondence P. O. Box 7263
Indianapolis, IN 46207-7263 Avenues of resolution