PCU update
Listserv changes coming
Provider enrollment updates
Revalidation updates
EDI: ASCA rules for electronic submitters
Physician Quality Reporting Initiative (PQRI)
CMS announces NPI contingency plan
Provider Outreach Clinical Education
Customer Service Relations

PCU update
Linda Noel, External Affairs, discussed current inventory in the Payment Correction Unit (PCU).

The unit is passing timeliness standards. Attendees had specific questions regarding refunds. A.J. Hanna, Medicare Provider Outreach and Education, said that specific cases would have to be reviewed and parties would be contacted by the appropriate person. Back to top

Listserv changes coming
At this time the archiving feature is not available and it is recommended to print and store any listserv that is important.

Mike Davis, manager, Medicare Provider Outreach and Education, advised providers that enhancement changes are in the works, which will help with listserv concerns and issues. Effective March 26, 2007, there will be changes to the listserv format. Back to top

Provider enrollment updates

Crystal Doan, process improvement coordinator, provided the following information on inventory:

• 2,428 Initial applications
• 406 Changes
• 177 Reassignments
• 4 Initial applications over 180 days

Doan addressed changes to the forms and the proper location of provider information on the CMS 855I and 855B forms. She explained all forms must be completed and applications must be signed, preferably in blue ink, and dated by an authorized delegate.

Providers are being contacted via phone and letters regarding incomplete or incorrect applications. About 70-85 percent of applications are incomplete.

A computer-based training (CBT) disc, currently in a testing phase, will be available soon. The disc will provide a tutorial for enrollment forms. The system will not let providers move forward until all the correct information is placed in the proper fields.

Attendees were advised to send applications via certified mail for tracking purposes and were reminded that CMS requires Electronic Funds Transfer (EFT) when any changes are made to the existing application. Download the 1500 CMS manual. Back to top

Revalidation

On April 21, 2007, CMS will issue a final ruling for new standards governing the enrollment process.

For the first time, this final rule establishes a regul- atory requirement for physicians and suppliers to complete an enrollment form and periodically update and certify the accuracy of the enrollment information in order to retain Medicare billing privileges.

Please note you will be notified by National Government Services when it is time for revalidation. There is no action needed on your part at this time. Back to top

EDI: ASCA enforces rules for electronic submitters

Kellie Templin, Part B EDI consultant, advised electronic submitters have been identified as sending high volumes of paper claims to National Government Services.

Beginning April 5, 2007, paper claims submitted by electronic submitters who do not meet an Administrative Simplification Compliance Act (ASCA) exception or do not have a valid waiver on file will be denied.

The ASCA provision clearly states that effective Oct. 16, 2003, all Medicare claims, with limited exceptions, must be electronic. Waiver form and more details. Back to top

Physician Quality Reporting Initiative (PQRI)
On Dec. 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). TRHCA section 101 authorizes a financial incentive for eligible professionals to participate in a voluntary quality reporting program.

Eligible professionals, who chose to participate and successfully report a designated set of quality measures for services paid under the Medicare Physician Fee Schedule (MPFS) provided July 1 to Dec. 31, 2007, may earn a bonus payment of 1.5 percent of their charges during that period, subject to a cap.

To review the list of eligible professionals, visit the CMS Eligible Professionals PQRI Web page. All Medicare-enrolled professionals in these categories are eligible to participate in the 2007 PQRI regardless of whether the professional has signed a Medicare participation agreement to accept assignment on all claims.

For detailed information on PQRI, go here or use this reference. Back to top

Provider Outreach Clinical Education
Sonja Racke, Provider Outreach Clinical Education, gave an update on current CERT errors and presented recent updates within the Medical Review and Clinical Education Department. Upcoming NGS seminars.

Racke welcomed suggestions regarding educational requests as this helps improve the educational process throughout the provider community. Back to top

Customer Service Relations
Julie Martz, Provider Reference Research specialist, advised that the wait time (queue) in the call center should be shorter since they are receiving help from their East Coast partners. Back to top

Office of Medicaid Policy and Planning (OMPP)
EDS
MHS
MDwise
Anthem

Office of Medicaid Policy and Planning (OMPP)

Katie Holeman-Shipp, Chronic Disease manager for the Office of Medicaid Policy and Planning (OMPP), presented an overview of changes taking place within the current Medicaid Select program.

Physicians enrolled as current Medicaid Select Primary Care Case Management (PCCM) will receive an addendum from the selected vendor to participate in the new program. Although physicians will continue to bill EDS for reimbursement of these services, physicians will work with the new vendor to coordinate care.

The per-member-per-month fee paid by the state to PCCM physicians will increase from $4 to $15. PCCM physicians also will have an opportunity to be reimbursed for a twice annual coordination call at $40 per call.

Please continue to watch EDS Banner Pages and Bulletins for additional information about the Indiana Care Select program. Back to top

EDS

Mona Green, EDS provider consultant, distributed copies of the 2006 IHCP Provider Seminar and outlined the changes involved with billing on the new CMS-1500 (08-05) claim form. Copies of the seminar presentation can be obtained from the IHCP website.

The EDS taxonomy code requirement was discussed at length. Attendees expressed concern about the amount of time and effort this type of requirement would involve. Discussion was later tabled for an opportunity to collectively present the concern to OMPP via the ISMA.

Immediately following the coalition meeting, ISMA Practice Advisor Sandy Distler received notification from an FSSA representative indicating the requirement had not been clear. Taxonomy would NOT be required on each claim, but rather only the ones needing a 1-to-1 match.

Refer to EDS Banner Page BR200714 for the most recent language concerning taxonomy code requirements.

Green mentioned the fields available on the new claim form for the National Drug Code (NDC) information. The implementation date remains July 2007 although no new information is available from EDS. Watch for future Banner Pages and Bulletins for new details as they become available.

To date, the ISMA has learned that the drugs involved will likely include HCPCS codes beginning with a ‘J’ as well as some immunization drug codes residing in the 9xxxx section of the CPT codebook.

Margaret Graves, EDS Third Party Liability, informed attendees that Medicaid will no longer be able to bill Medicare directly for services originally paid by Medicaid when the recipient is discovered to be Medicare-eligible.

HMS, the contractor who oversees this process, will notify physicians that Medicare is the actual primary payer and the Medicaid program should be refunded.

Once notified, physicians will have 60 days to bill Medicare and respond back to HMS with the adjusted amount. If the date of service is past the filing limit, physicians should contact HMS to avoid a 10 percent pentalty. Back to top

MHS

Angela Jackson, Provider Relations manager, presented information on MHS operations. She encouraged use of the Web site to view claims in detail, and announced that prior authorization requests will eventually be accepted via the Web site.

Effective April 1, a new prior authorization list was issued to contracted providers and available also online. The MHS provider directory is available on the Web site and will be updated after the first of each month with the most recent list of network providers.

This directory can be accessed in order to obtain in-network physicians and make in-network referrals. If a specialist cannot be found, please contact the MHS provider relations team for assistance.

MHS is continuing to collect NPI numbers directly from providers and encouraging providers to report NPI directly to them. MHS will follow EDS in terms of delaying the paper claim deadline, as well as NDC requirements. MHS will send detailed claim form completion requirements to contracted providers and make those requirements available online. Back to top

MDwise

Sherry Miles, Provider Relations manager, introduced Jackie Marsalis from CompCare as the contact for any behavioral health questions.

MDwise will follow EDS claim paper deadlines, as well as NPI requirements set by EDS. Miles did confirm that these requirements and guidelines will be standard across all 10 (including CompCare) delivery systems.

However, delivery systems do have separate requirements for other operational processes such as contracting paperwork, prior authorizations requirements, etc.

Physicians are encouraged to contact each delivery system for particular requirements. Concerns were discussed about the difficulty of learning 10 different delivery system requirements and the possibility of standardizing many of the operational requirements. Miles encouraged comments and concerns be sent to her so she can address them at a higher level. Back to top

Anthem

Shelley Evans, Network Education representative, discussed the Community Resource Centers that are being established to better serve physicians and members.

Please bill with the Anthem commercial provider ID number (PIN) on electronic claim submissions for physicians who are contracted commercially with Anthem.

If a physician is not commercially contracted with Anthem, use box 24K to send the physician’s Medicaid ID. Non-contracted providers will not be able to send electronic claims because of the PIN requirement.

Evans noted that Anthem has extended its policy of not requiring authorizations for certain procedures through May 31. Please visit Anthem’s Web site or contact your provider representative for a list of procedures that are included in this temporary policy.

Despite prior communications, Anthem is now offering PO Box 37180 as a claim mailing address in addition to PO Box 37010. Evans confirmed that as long as the prefix ‘YRH’ is attached to the member’s ID number, claims will be accepted at either address. Back to top