Fee schedule
Until congress takes action, the current Medicare physician fee schedule will expire April 1. Please monitor your listserves for up-to-date information.

Deletion of consultation codes
The Centers for Medicare & Medicaid Services (CMS) has released MLN Matters article SE1010 that includes questions and answers on reporting evaluation and management (E/M) services after Jan. 4, 2010. Find the article here.

Rescinded instructions
The Place of Service (POS) and Date of Service (DOS) instructions for interpretation of the professional component and technical component of diagnostic tests (MM 6375) was rescinded Feb. 5, 2010.

The compliance standards for consignment closets and stock and bill arrangements (MM 6528) were rescinded
Feb. 4, 2010.

ICD-10 looms ahead
CMS is beginning some basic introduction to ICD-10 through national provider conference calls. The first call was March 23, 2010. Please check your CMS listserves for details about future calls. Visit here to learn more.

RAC audits
Find information on Recovery Audit Contractors Fraud Referrals from the Office of Inspector General here.

Annual Medicare conference
National Government Services (NGS) has announced an upcoming Medicare educational conference, The 2010 Conference Ignite. Information on location and courses is still pending. NGS will send listserves containing conference details in the upcoming weeks.

Advance Beneficiary Notice (ABN)
Effective April 1, 2010, two HCPCs level 2 modifiers were updated to distinguish between voluntary and required uses of the ABN. Note that:

• GA has been designated as required.
• GX (new modifier) has been designated as voluntary and claims line items submitted with the GX modifier for non-covered charges will assign beneficiary liability to the claim line item.

For greater detail, see here.

Medicare enrollment
CMS has issued new regulations for foreign-born physicians and non-physician practitioners (NPP).

In summary, if a new enrollee indicates in Section 2 of the CMS855-I or in PECOS that he or she was born in a foreign country, the Medicare contractor shall verify that the physician or NPP is:

1. A United States citizen 
2. A legal resident of the United States, or
3. Otherwise legally authorized to work in the United States

This verification helps ensure all physicians and practit-ioners enrolling in the Medicare program are legally authorized to perform Medicare services. Find the regulation here. 

Revalidation of PPTN user ID
Preferred Provider Telecommunication Network (PPTN) is a computer inquiry system that gives you easy and immediate access to claims processing and beneficiary eligibility information. You can monitor the processing of all claims as they appear in the Medicare Part B processing system for a specific provider number, using a beneficiary’s Health Insurance Claim number (HICN), through either a specific date or dates of service.

This will include paid, denied and pended claims for electronically transmitted claims, paper claims, assigned and non-assigned claims. PPTN also provides you with access to beneficiary eligibility information.

Save time and money by accessing PPTN to obtain:

• Detailed claims information on pending and paid claims
• Electronic claims batch inquiries
• Beneficiary eligibility information

If you currently have a PPTN ID, you will need to recertify your user ID for PPTN. This process will begin on or after March 29, 2010. At that time, you can access information regarding recertification through an icon on the NGS Web page.

Recertification must be completed within 45 days of the announced start date or your user ID will be suspended until recertification is complete.

OMPP
Glenna Asmus, manager, Quality and Outcomes from Office of Medicaid Policy and Planning (OMPP), announced that between July 1, 2009, and Feb. 23, 2010, a total 6,961 women enrolled in Presumptive Eligibility for Pregnant Women (PE). An average 200 women per week enroll in the PE program. They are required to submit a Hoosier Healthwise Medicaid application at the time of enrollment.

PE provides coverage for outpatient prenatal care. Coverage begins on the date of Web-based approval and selection of primary medical provider or managed care organization. PE is closed when one of the following conditions is met:

1. If a pending application is on file, PE closes the day following receipt of the Medicaid determination at HP (formerly EDS). 
2. If no pending application is on file by the last day of the month following PE approval, HP will close the PE segment on the last day of the month following PE approval. 

According to OMPP, 81 percent of women applying for PE are approved for Medicaid. Women are most often denied for missing documentation and/or no interview.
For women with a Medicaid decision, 93.7 percent are approved for Medicaid within 45 days of filing an application. This means most women are staying on PE for only four to six weeks; however, this is time that previously would have been an uncertain coverage period. 

You will be reimbursed for pregnancy-related outpatient services during the PE period, even if Medicaid is denied. A review of initial data for the Notification of Pregnancy (NOP), a risk assessment, shows that 60 percent of PE-eligible women with an NOP are entering prenatal care during weeks one to 12 of pregnancy. 

Noncovered Services
Attendees expressed concerns about the requirement to notify women of non-covered services, especially miscarriage and delivery services. OMPP advised that the issue would be presented to FSSA legal staff for review. 

UPDATE: After review, FSSA legal staff advised you must provide notice of the non-covered service to bill the member. Other significant legal notes indicated the Emergency Medical Treatment and Active Labor Act would require treatment of most – if not all – conditions physicians would want women to pay for when treated in an emergency department (ED). If treatment is not provided in an ED, you would not be able to bill the woman if she was already a Medicaid recipient. You must provide notice of the non-covered service in order to bill the member.

To ensure payment for services, you must inform the woman that the service is non-covered. If the woman is determined eligible for Medicaid at the time the non-covered service was provided under PE, Medicaid coverage will retroactively cover the service. Therefore, it is very important for the patient to follow-up on her Medicaid application. 

Observation stays
Coalition attendees also asked if observation stays were considered covered under PE. OMPP researched the issue and provided an update after the meeting. 

UPDATE: Observation stays are considered a covered outpatient service under PE. The PE FAQ document will be updated to reflect this clarification.

One attendee noted an inability to use the PE Web application since Jan. 1. Relia Manns, HP field consultant for PE and NOP, will schedule an onsite visit with this office since remote troubleshooting has not yet been effective.

OMPP was asked to provide a checklist of items required for the Hoosier Healthwise Application to PE Qualified Providers. MDwise representatives said they already have a checklist approved by OMPP. Manns will determine if the MDwise checklist can be posted on the HP PE Web page.

A laboratory provider noted difficulty in obtaining reimbursement from MDwise for common prenatal lab services. A couple others noted Anthem was requiring submission of a paper copy of the Notification of Pregnancy (NOP) for NOP claims.

An issue regarding Package A (low-income families) women remaining on an OB’s panel after delivery/postpartum was discussed. The issue will be discussed. However, the best way to make sure these women are moved from the OB’s panel after post-partum is for the woman to contact MAXIMUS, the enrollment broker, at 1-800-889-9949. 

Pharmacy issues
Attendees advised pharmacies are sometimes attempting to charge pregnant women for prescriptions, even though the policy indicates pregnant women do not have a co-pay.
UPDATE: Pharmacies must enter the correct code, a pregnancy indicator of 2, for pregnant members when submitting claims to ensure the member is not charged a co-pay. This information was communicated shortly after the pharmacy consolidation in early January via a mass fax to pharmacy providers.

Coalition members expressed difficulty finding pharmacies that will provide Rhogam (injectable) to Medicaid members. 

UPDATE: To be covered by Medicaid, the drug must be from a rebating labeler and Rhogam is not. A few choices from rebating labelers are: HyperRHO, WinRHO and Rhophylac. The rebating labeler status would apply to both pharmacy and medical claims; these drugs are currently covered.

The cost for the Mirena IUD is a concern since it is increasing $100 per unit, and the Medicaid rate will not cover the cost of the device. Glenna Asmus, OMPP Quality and Outcomes manager, is taking this issue to the coverage/benefits group at OMPP for review.

If you are having issues with Presumptive Eligiblity or Notification of Pregnancy that are not being resolved with the MCO or HP, contact Asmus at OMPP at
Glenna.Asmus@fssa.IN.gov.

MDwise Advantage
Kelvin Orr, director of Network Development and Contracting, wants to query ISMA members to determine how his organization is doing. Please e-mail any comments, questions or complaints about ADVANTAGE’s prior authorization processing to Orr at korr@advantageplan.com.

ADVANTAGE Care Select has successfully received 774 new members through the Feb. 1 auto-assignment of HCBS waiver members. ADVANTAGE is working with OMPP and the state’s enrollment broker to recruit the waiver members’ “provider of choice”. Advantage is making calls to physicians, who previously treated or cared for waiver members to encourage them to enroll in Care Select and become the member’s assigned PMP.

Anthem-Hoosier Healthwise
Sandy Koons, Network Education representative, reminded members about Hedis measures. As part of the mandatory National Committee for Quality Assurance (NCQA) accreditation process, Anthem is required to collect data annually from providers for HEDIS. Since January, Anthem has been making calls to establish key contacts. Once confirmed, Anthem will fax a medical records request identifying records they need.

Anthem-HIP
Maribel Mullen, Network Relations consultant, announced that ISMA members are invited to attend one of Anthem’s Availity and E-business provider workshops. Register online here. The Event title is 2010 Availity & E-Business Workshop.

Event description:  Availity is a Health Information Network providing administrative, financial and clinical services to users ranging from health care providers to health plans and technology partners.

MDwise Care Select
MDwise would like all primary medical providers (PMPs) enrolled in the MDwise Care Select network to sign up for a free service online called CareConnectNX (CCNX). PMPs may sign up on the MDwise Web site by accessing the Care Select product, then Online Services and then downloading the CCNX acknowledgement form. Complete the acknowledgement form and return it to MDwise.

MDwise will grant access and send the PMPs logon information via e-mail. CCNX provides important information about a PMP’s member (on their PMP roster) such as case notes, care plans, care goals and pharmacy information.

The online service is free to PMPs and the information can be used during care conferences with the member’s assigned MDwise care manager.

Care Conferences
MDwise is conducting care conferences with PMPs regarding its Care Select members. PMPs may receive notification of the care conference request via mail along with the member’s care plans. PMPs may view the member’s care plan using CCNX.

Once this information is received, PMPs may select members they wish to discuss with the MDwise care manager assigned to them. The care manager will follow-up with the PMP’s office to schedule the care conference at a time convenient to the office.

Upcoming events
The IHCP and HP Enterprise Services welcomes ISMA members to the All Association Meeting held biannually at HP. Attendees will hear about recent changes and anticipated enhancements to the Medicaid program. The next meeting will be held April 14, 2010, from 1:30-4:30 p.m., at the HP offices at 950 N. Meridian Street, Indianapolis, IN 46204.

To confirm your attendance contact Jenny Atkins at (317) 488-5340.