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Medicare/Medicaid Coaltion Report
Medicare/Medicaid Coaltion Report
March 4, 2011 meeting
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Medicare Medicaid

Enhancements to the IVR
Effective Jan. 14, 2011, the Provider Interactive Voice Response System (IVR) has new features that allow Part B providers to obtain additional information regarding pending Medicare Part B claims.

These enhancements are intended to improve your experience when contacting the National Government Services (NGS) Customer Care Department.

When calling for pending claim status, the IVR will now provide you with the following:

  • Part B payment floor - The IVR will read back the total pending dollar amount for claims still within the payment floor (14 days for electronically submitted claims and 29 days for paper claims). The system will tell you the number of claims “approved to pay” and the dollar amount of those claims.
  • Part B ADS letter - For claims for which NGS Medicare needs additional information, a request is made in the form of an Automated Development System (ADS) letter. The IVR Claims Information option will be updated to read back a status message associated with the ADS letter for pending claims. If a claim is pending and you received an ADS letter, you will hear: “We sent a letter to you on (date sent) requesting additional information. The message associated with the ADS letter is (information and the code description). Once we have that information, we'll finish processing your claim.
  • Part B pending claims - For claims in which an additional information ADS letter was sent, the Part B Claims Status option of the IVR will provide a message regarding current status in the Medicare claims processing system.
    • If you provided the requested information and the claim is pending, you will hear: “We did receive the additional information you provided. Your claim is currently in medical review. Please check the system periodically and watch for your remittance advice in the mail.”
    • If NGS is still awaiting your response to the ADS letter, the claim is still pending and you will hear: “While we await further processing instructions, your claims are on hold.”

As a reminder, the IVR now allows Part B providers to obtain the status of their provider enrollment applications. When calling for provider enrollment application status, please have the following information ready:

  • Your case number (assigned to your Provider Enrollment Chain and Ownership System [PECOS] enrollment submission), or
  • Your National Provider Identifier (NPI) and Tax ID Number (TIN) or Social Security number associated with the NPI

At the command prompt, say “provider enrollment” or enter option 6 on the telephone keypad. You will be prompted to provide your case number (assigned to your PECOS enrollment submission) or your NPI and TIN.

For the Customer Care Department's direct telephone lines for provider enrollment inquiries, use (866) 389-1375, toll-free in Indiana.

For the IVR numbers and hours of operation, visit the NGS website; click on the quick link for Customer Service (IVR and telephone).

2011 electronic prescribing (eRx) incentive
In November, the Centers for Medicare & Medicaid Services (CMS) announced that, beginning in 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between Jan. 1, 2011, and June 30, 2011, may be subject to payment adjustments on their Medicare Part B Physician Fee Schedule (PFS) covered professional services.
From 2012 through 2014, payment adjustments will increase each calendar year.

  • 2012 – 1 percent decrease
  • 2013 – 1.5 percent decrease
  • 2014 – 2 percent decrease

The payment adjustment does not apply if less than 10 percent of an eligible professional's (or group practice's) allowed charges for the Jan. 1 through June 30, 2011, reporting period are comprised of codes in the denominator of the 2011 eRx measure.

How to avoid the 2012 eRx payment adjustment
An eligible professional (EP) can avoid the 2012 eRx payment adjustment if the EP:

Is not a physician (MD, DO or podiatrist), nurse practitioner or physician assistant as of June 30, 2011, based on primary taxonomy code in NPPES (Make sure primary taxonomy code in NPPES is accurate.)

  • Does not have prescribing privileges (Note: The EP must report G8644 at least one time on an eligible claim prior to June 30, 2011.)
  • Does not have at least 100 cases containing an encounter code in the measure denominator
  • Becomes a successful e-prescriber
  • Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure
  • Claims a hardship exemption
    • EP practices in rural areas with limited high-speed Internet access, use code G8642 at least one time on an eligible claim
    • EP practices in areas with limited available pharmacies for electronic prescribing, use code G8643 at least one time on an eligible claim

A group practice participating in eRx GPRO I or GPRO II during 2011 must become a successful e-prescriber. Depending on the group's size, the practice must report the eRx measure for 75 to 2,500 unique eRx events for patients in the denominator of the measure.\

For additional information, please visit the “Getting Started” webpage here.

EHR eligibility requirements
Incentive payments for eligible professionals (EPs) are based on individual practitioners.

If you are part of a practice, each EP may qualify for an incentive payment if each EP successfully demonstrates meaningful use of certified EHR technology. However, each EP is eligible for only one incentive payment per year, regardless of how many practices or locations the EP serves.

Who is an EP under the Medicare EHR Incentive Program?
EPs are required to have an active NPI and must be a:

  • Doctor of medicine or osteopathy
  • Doctor of dental surgery or dental medicine
  • Doctor of podiatry
  • Doctor of optometry
  • Chiropractor

Who is an EP under the Medicaid EHR Incentive Program?
Under Medicaid, EPs must be a:

  • Physician (primarily doctors of medicine and doctors of osteopathy)
  • Nurse practitioner
  • Certified nurse-midwife
  • Dentist
  • Physician assistant who furnishes services in a Federally Qualified Health Center or Rural Health Clinic led by a physician assistant

Professionals eligible for both the Medicare and Medicaid EHR Incentive Programs must choose which incentive program they wish to participate in when they register. Before 2015, an EP may switch programs only once after, the first incentive payment is initiated. Most EPs will maximize their incentive payments by participating in the Medicaid EHR Incentive Program.

Annual wellness visit and prevention
The Affordable Care Act (ACA) of 2010 expanded coverage that allows payment for an annual wellness visit (AWV), including personalized prevention plan services (PPPS) for individuals no longer within the 12 months of the effective date of their first Medicare Part B coverage period. The patients must not have received either an initial preventive physical examination (IPPE) or an AWV within the past 12 months. Medicare co-insurance and Part B deductibles do not apply.

The AWV will include establishment of, or update to, an individual's medical and family history, measurement of height, weight, body-mass index or waist circumference, and blood pressure – with the goal of health promotion and disease detection. The AWV is intended to foster coordination of screening and preventive services that may already be covered and paid for under Medicare Part B.

Who can provide the AWV with PPPS?
The AWV with PPPS can be provided by a physician who is a doctor of medicine or osteopathy (as defined in section 1861(r)(1) of the Social Security Act), or a physician assistant, nurse practitioner or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act), or a medical/health professional. That includes a health educator, registered dietitian or nutrition professional, or other licensed practitioner, or a team of such medical professionals working under the direct supervision (as defined in CFR 410.32(b)(3)(ii)) of a physician, as defined in the first bullet point of this section.

GZ Modifier automatic denial
For the GZ Modifier (item or service expected to be denied as not reasonable and necessary, used when an Advance Beneficiary Notice is not on file), all carriers – Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT), Recovery Audit Contractors (RACS), Program Safeguard Contractors (PSCs) and Zone Program Integrity Contractors (ZPICs) – shall automatically deny claim line(s) items submitted with a GZ Modifier. Contractors shall not perform complex medical review on claim line(s) items submitted with a GZ Modifier. This will be a contract obligation.
The automatic denial for the GZ Modifier has an implementation date of July 5, 2011, for dates of service July 1, 2011.

Enhancements to NGS Connex
The National Government Services (NGS) Connex online inquiry application offers providers and suppliers the ability to:

  • Learn claim status
  • Obtain beneficiary eligibility information
  • Access provider demographics
  • View financial data
  • Order duplicate remittances

To use Connex, you must have Internet access and an email address.
For more information, review the Connex Quick Steps Job Aid and Training Materials links here.

New enhancements to Connex include:

  • Medicare Advantage section of the Entitlement Screen - Medicare Advantage plan name and plan numbers are now displayed. This information will be displayed in the Medicare Advantage section of the Entitlement Screen when applicable.
  • Part A and Part B termination dates - Current and prior year Part A and Part B termination dates for Medicare beneficiaries are now indicated. This information will be displayed in the beneficiary eligibility information section of the Entitlement Screen.
  • DME claim finalized date - Durable medical equipment (DME) claim finalized dates are now displayed within the claim header details information located on the My Claims screen.
  • Provider search options - When you perform a query from the Provider list section on the My Provider Profile, My Claims, Entitlement and My Financials screens and a match is found, the system will position the selection arrow on the first provider found within the list. If no match is found, the system will display an error message.
  • Reason/rejection descriptions - The Connex application now allows providers to obtain reason/rejection descriptions for individual claim lines submitted for payment. Access this information through the My Claims screen.

Important Note from NGS
NGS is working to add Certificate of Medical Necessity (CMN) status and same/similar information to the Connex online inquiry system for DME suppliers. Notification will be sent as soon as this option becomes available.

As additional enhancements are made to Connex, messages will be sent through the NGS email updates program.

As you experience this feature, please let NGS know how they are doing by completing the website satisfaction survey if presented. NGS officials are interested to know what they are doing well and what they can continue to improve upon. This survey will be offered through FORSEE while on the NGSMedicare.com website.


This month's coalition meeting was held at the Indiana Government Center. Kim Forrest, RHIA SUR manager, and Jina Hughes, Office of Medicaid Policy and Planning (OMPP) program integrity manager, provided information on the Patient Protection and Affordable Care Act (PPACA).

Audits and coding
Included in this presentation was an announcement that the Recovery Audit Contracts (RAC) begin April 1, 2011. OMPP will coordinate audits through its arrangement with Thompson Reuters. More information will be provided at future coalition meetings.

Mona Green, provider relations field consultant, advised members present that Indiana Health Coverage Programs (IHCP) began applying correct coding methodology to claims with dates of service on or after Oct. 1, 2010, as directed by the Centers of Medicare & Medicaid Services (CMS).

Beginning March 14, 2011, and continuing through the week of April 15, 2011, the IHCP will initiate mass adjustments for CMS-1500 claims with dates of service on or after Oct. 1, 2010. For full details, see Provider bulletin BT201036.

HP's testing for software vendors, billing services and clearinghouses began in January 2011 for upgrades to Health Insurance Portability and Accountability Act ANSI version 5010 and National Council for Prescription Drug Programs Development Organization, both of which become effective Jan. 1, 2012. Find an IHCP 5010 Companion Guide on the Indiana Medicaid website.

Testing surveys were submitted to all software vendors and clearinghouses that exchange data with IHCP, and HP is working with trading partners that are participating in the first phase of testing. Now is the time to verify that your software vendor, billing service or clearinghouse has returned the HIPAA 5010 testing readiness survey and has scheduled a testing time.

Claims returned
The Claims and Encounters Unit mailed return to provider (RTP) letters associated with 2227 claims in January 2011. Of these claims, 19 percent were returned for invalid NPI or Taxonomy Code and 37 percent were returned for Member ID missing or invalid.

You are encouraged to submit claims electronically, through a vendor, clearinghouse or by utilizing the Web interChange. If claims require an attachment, those claims can also be submitted electronically using the attachment feature.

Third-party payer fails to respond
When a third-party insurance carrier fails to respond within 90 days of the billing date, you can submit the claim to IHCP for payment consideration. However, to substantiate attempts to bill the third party, the following must be documented in the claim note segment of the 837P transaction:

  • Date of filing attempt
  • The phrase “no response after 90 days”
  • Member's identification (RID) number
  • Your IHCP provider number

Find additional information in NL201010 dated October 2010.

Virtual room education
HP will conduct virtual room training for providers in April. This education will be centered on how to use the tools available on the Web interChange and the IHCP website. The presentation will be a walk through the Web interChange functions.

Anthem and ED specialists
Lisa Lant, manager of Southwest Indiana Field Operations, and Maribel Solano-Mullen, senior network relations consultant, represented Anthem at the meeting. They fielded questions associated with the flat rate that will be paid to specialists who bill the emergency room E&M codes of 99281-99285. The specialist will be paid upon submission of the claim without a PLP review of the codes.

Anthem advised attendees that the flat rate will be paid to specialists who bill the emergency room E&M codes 99281-99285. The specialist will be paid upon submission of the claim without a prudent lay person (PLP) review of the codes. Physicians received this information in the contract mailing that went out on Nov. 14, 2010, where all groups were required to sign a certified receipt.

This was created based on discussions with the ER physician association last fall. In those discussions, physician representatives requested Anthem consider payment for their services without the medical record requirement that delayed payment and/or reduced their payments and – from Anthem discussions with the ER providers – caused significant administrative issues.

The advantage to physicians is that they are paid upon submission of their claims for the ER E&M code without the administrative costs and burden related to PLP review. All participating specialists, including participating midlevel providers, are paid the flat rate.

Please direct any questions to your Anthem contracting representative regarding participation under the standard rate methodology.

Enrollment and eligibility concerns
Chris Kern, provider relations manager for MDwise Care Select, responded to questions regarding issues associated with the new enrollment data processes implemented Jan. 1.

Chris announced that a work-around was put in place to correct the issues physicians were experiencing. MDwise is providing updated PMP assignment information to Web interChange for dates of service March 1, 2011, and after. See BR201110 for further details.

Nancy Robinson, regional network manager for MHS, provided information on eligibility concerns. MHS will honor claims affected by eligibility discrepancies. This is part of MHS's normal protocol, which also includes allowing 365 filing limit for newborns (first 30 days of life) and third-party liability.

MHS is honoring the 90 third-party liability override for non response. MHS requests providers submit proof of primary submission. Robinson discussed web enhancements including professional and institutional billing availability, a code editing tool and care gap alerts.





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