Medicare administrative contractor
A.J. Hanna, director of Provider Outreach and Education, discussed the transition to the Medicare Administrative Contractor (MAC). National Government Services (NGS) was awarded Jurisdiction 8 (Indiana and Michigan). Due to a protest, the transition will be delayed until possibly May 2009.

Medicare University
The NGS Web site has introduced Medicare University (MU) that features computer-based training, face-to-face seminars, Webinars and teleconferences. You have the ability to self-report training you have completed by creating an account online. For further information, visit the NGS Web site and click on the Medicare University logo.
 
Overpayment request
Nathan Kennedy, Provider Outreach and Education, Midwest Medicare A/B team lead, reported that a listserv was sent regarding second overpayment request letters. When Medicare pursues an overpayment, an initial letter is sent to the provider. If the overpayment is not satisfied, the contractor sends a second follow-up letter and also sends a copy of the first letter. 

Currently, the Centers for Medicare & Medicaid Services (CMS) is working on an issue with the Medicare carrier system (MCS) that is causing generation of a letter that is sometimes inappropriate and may not pertain to the overpayment. When providers submit appeals prior to a refund request, they are receiving appeal letters with a second refund letter – instead of a first refund letter.

Be aware that the refund letter is still valid and the refund will still be pursued; however, you may receive an incorrect letter along with a refund letter. Please follow the directions on the second refund letter. 

Private fee for service (PFFS)
MLN Matters article SE0902 states effective Jan. 1, 2009, when a dispute is denied, providers have the right to request the decision be reviewed by an independent contractor under CMS. First Coast Service Options, Inc., is the independent review entity. For more detail, please see here.

PECOS
PECOS is an acronym for Internet-based Provider Enrollment, Chain and Ownership System, which now reduces the time required to enroll or make changes in your Medicare information. Essentially, PECOS streamlines the enrollment process and allows review of enrollment information.

There are now three ways to enroll as a Medicare provider:

• Internet-based PECOS
• NGS form assist
• Paper enrollment application

For more information, visit here.

ASCA reminder
The Administrative Simplification Compliance Act (ASCA) prohibits payment of initial health care claims that were not sent electronically as of Oct. 16, 2003, except in limited situations. Those are as follows:

• Small Provider Claims-- Providers having fewer than 25 full-time equivalent employees (FTEs) that are required to bill a Medicare intermediary are considered small. Physicians and suppliers with fewer than 10 FTEs who are required to bill a Medicare carrier or durable medical equipment regional carrier are classified as small. See section 90.1 of Chapter 24 of the Medicare Claims Processing Manual (Pub. 100-04) for more detailed information on calculation of FTE employees and this ASCA requirement in general.
• Roster billing of inoculations covered by Medicare, except for those companies that agreed to submit these claims electronically as a condition for submission of flu shots administered in multiple states to a single carrier.
• Claims for payment under a Medicare demonstration project that specifies claims must be submitted on paper.
• Medicare Secondary Payer Claims when there is more than one primary payer and one or more of those payers made an "Obligated to accept as payment in full" adjustment.
• Claims submitted by Medicare beneficiaries or Medicare managed care plans
• Dental claims
• Claims for services or supplies furnished outside of the U.S. by non-U.S. providers
• Disruption in electricity or communication connections outside of a provider's control expected to last more than two business days.
• Claims from providers submitting fewer than 10 claims per month on average during a calendar year

Providers should determine if they meet one or more of these situations, and if they do, they should not submit a waiver request. Some situations are temporary or apply only to certain claims. In these cases – or when billing other types of claims – submit claims electronically and according to HIPAA standards. See Sections 90 - 90.6 of Chapter 24 of the Medicare Claims Processing Manual (Pub.100-04) for further information. Providers should submit a waiver when NGS sends a letter requesting information.

Provider enrollment clarifications
Medicare does not require a physician to be board certified in order to enroll under a specialty.

Also, regarding provider enrollment, change request 6097 has information, effective Jan. 20, 2009, regarding the following enrollment verification and program integrity activities and details:

• Change in practice location
• Change in correspondence – special payment address
• Change in electronic funds transfer
• Reactivation and revalidations

Find detailed information here.

Enrollment revalidation
CMS has not issued instructions on another revalidation process at this time.

Customer Care new provider authentication
Change request 6139 (MM6139 revised) stated effective April 6, 2009, telephone or written inquiries to Medicare contractor provider contact centers, including calls to interactive voice response (IVR) system, will require the following three data elements:

• National Provider Identifier (NPI)
• Provider Transaction Access Number (PTAN)
• Last 5 digits of the tax identification number (TIN)

This change is intended to better safeguard providers’ information.

Find more information here.

EDS Updates
The Hoosier Healthwise program implemented open enrollment March 1, 2009. Members can change health plans only at the following times:

• During their first 90 days enrolled with a new health plan
• During their annual open enrollment period
• Anytime there is “just cause” (for example, quality of care concerns)

Using Web interchange, providers can make the following profile updates:

• Ownership information
• Changes in members of a board of directors
• Name of office manager or other management personnel
• Ownership in subcontractor entities
• Enrollment or disenrollment in electronic funds transfer (Note that EFT deposits occur 18 days after submitting an enrollment via Web interchange.)
• Address changes
• Changes to the home office address (Require submission of the IHCP Name and Address Maintenance Form along with the W-9, which must be mailed to EDS Provider Enrollment.)
• Addition or removal of specialty designations
• Completion of the Indiana Health Coverage Program (IHCP) Termination Form

Online provider enrollment
Providers can now enroll in the IHCP using the Internet rather than completing paper forms and mailing them. However, only newly enrolled providers may use the online enrollment tool at this time.

Medical Review Team outreach
In accordance with 405 IAC 5-20-8 Outpatient Mental Health, the following documents the plan to reach out to psychiatrists, licensed physicians and health service provider in psychology.

The role of the Medical Review Team (MRT) is to determine an applicant’s categorical eligibility for Medicaid under the disability category. The MRT consists of physicians and consultants who specialize in Medicaid disability eligibility determinations.

These professionals review information to determine whether new applicants meet the criteria for disability and establish medical reviews for current Medicaid members. The MRT issues favorable or unfavorable eligibility decisions based on medical evidence that supports whether the applicant has a significant impairment.

When a medical provider completes an assessment of an applicant and submits the required determination forms to the Division of Family Resources, the provider may submit a claim to EDS for payment of certain examinations and reports. If the MRT authorizes an applicant to obtain additional tests, a provider may also submit claims for those services. However, such services should not be performed unless the applicant presents the Additional Information Request form. 

The provider should submit these claims using the MRT member identification that begins with 850 and the member’s Social Security number.

EPSDT program
The Indiana HealthWatch Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a preventive health care program for members under age 21. Its purpose is to facilitate the introduction of young IHCP members to early and complete evaluations for detection of abnormalities before they become chronic or debilitating.

EPSDT medical screenings are conducted at regular intervals during the years of a child’s life up to the 21st birthday for Medicaid-eligible children and up to the 19th birthday for a child in Package C. If the member is in a Hoosier Healthwise risk-based managed care network, the member’s managed care organization can provide information.

Notice of pregnancy
Beginning July 1, 2009, providers who deliver prenatal services to pregnant women are to submit a report of the woman’s pregnancy on Web interchange. Notice of pregnancy (NOP) enables providers to identify early signs of potential health risks that contribute to poor birth outcomes.

Providers should bill for NOP using procedure code 99354 with a TH modifier for a reimbursement rate of $60.

Presumptive eligibility
Beginning July 1, 2009, qualified providers who administer a urine pregnancy test can determine that a pregnant woman is presumptively eligible for reimbursement of needed ambulatory prenatal services. This will be discussed in great detail during the second-quarter workshops. A bulletin will also be published.

Care Select updates
The Office of Medicaid Policy and Planning (OMPP) announced the completion of the auto-assignment of wards of the court and foster children into Indiana Care Select, effective Jan. 15, 2009. Each new enrollee in the IHCP has 30 days from the date of initial eligibility to select a PMP or be auto-assigned to a Care Select PMP. A Care Select member’s guardian or caregiver can contact the member’s assigned care management organization (CMO) to select a different Care Select PMP at any time.

Continuity of care
Care Select PMPs are reminded that new Care Select members may already be receiving care form IHCP-enrolled specialists, hospitals, ancillary providers or their previous PMPs. A PMP who ordered services prior to the Jan. 15, 2009, auto-assignment effective date may not be the same PMP a member is assigned to after Jan. 15, 2009. 

The OMPP and the CMOs request that newly assigned PMPs work with a member’s previous PMP and other providers to ensure continuity of care. If care has already been initiated for a member, review the member’s medical record and authorize the continuation of that care until the member can become an established patient with your practice. Authorize care by releasing your quarterly two-character certification code and NPI to these providers, so they may receive reimbursement for their services.  

Prior authorization
Specialists, hospitals and ancillary providers who deliver services that require prior authorization (PA) in the Traditional Medicaid and Care Select programs are reminded they must contact the member’s CMO to request PA. Advantage Health Solutions, INC processes all PA requests for members in Traditional Medicaid and members in the Advantage Care Select network. MDwise processes all PA requests for members in the MDwise Care Select network.

There is an exception to this rule if the member switches CMO networks during the time a requested PA has been suspended. If the member’s previous CMO has suspended a provider’s PA request, the provider must submit the requested additional information to the member’s previous CMO, even if the member has selected a new PMP and new CMO. Additional information submitted to the new CMO will be rejected, and you will need to submit that information to the member’s previous CMO.

If the provider has received PA from a Hoosier Healthwise managed care organization (MCO), a copy of the MCO’s written authorization must be submitted to the member’s CMO. Authorizations are valid for 30 days from the date of the member’s initial eligibility in Care Select or for the remainder of the PA dates of service, whichever comes first. 

Providers are encouraged to fax PA requests to members’ assigned CMOs for more efficient processing of PAs.

Care coordination conferences
The CMOs will coordinate with their Care Select PMPs to perform care coordination conferences to review a member’s plan of care and the process with that plan of care.

Care coordination conferences are a covered benefit for IHCP members assigned PMPs. The conferences can occur up to twice per member, per rolling calendar year and will be scheduled on a semiannual basis. Conferences can be held in person at the PMP’s office or via phone conference.

This is a billable service as a 99211 with an SC modifier. The primary diagnosis providers should use when billing for care coordination conferences is either the member’s last known diagnosis related to the member’s disease state or V70.9. This service can be provided by the PMP, a NP or PA with no reduction in the benefit.

The CMO will compensate the provider $40 for each member twice a year. A Bulletin was issued in March describing this service in greater detail. 

Anthem Healthy Indiana Plan (HIP)
The ISMA welcomed Anthem HIP to the Medicaid Coalition. Covered benefits in the plan include physician care, preventative care services, specialized services, pharmacy, mental health and substance abuse.

Non Covered benefits include chiropractic services, vision, dental, custodial care, pregnancy-related services and out-of-network services. The Anthem member identification card has an alpha prefix YRK with unique ID# from the Anthem ID Card.

Follow Anthem commercial filing/billing requirements. A 180-day claim filing time limit applies to both professional and institutional claims. This is the same as Anthem commercial.

HIP claims are included on commercial vouchers/remittance advice. The new HIP ID card has an emblem in the top right hand corner of the card. Applicable emergency room co-pays are $3, $6 or $25 for parents based on Federal Poverty Level (FPL).