User ID recertification
All current online users will need to recertify. The deadline for recertification for Part B PPTN, Claim Status Inquiry and Durable Medical Equipment is July 5, 2010. Processing time will be 30 business days. E-mail questions to Wellpoint.

Fee schedule update
At the time of this report, no permanent fix to the Sustainable Growth Rate (SGR) formula or the physician fee schedule has occurred.

Timely filing
Centers for Medicare &Medicaid Services (CMS) is updating edit criteria related to timely filing limits for Medicare fee-for-service claims, as a result of the Patient Protection and Affordable Care Act (PPACA), section 6404. The filing limit has been changed to one year.

• Claims with dates of service prior to Oct. 1, 2009, will be subject to pre-PPACA timely filing rules and associated edits.
• Claims with dates of service Oct. 1 through Dec. 31, 2009, received after Dec. 31, 2010, will be denied as past the timely filing deadline.
• Claims with dates of service Jan. 1, 2020, and later that are received one calendar year beyond the date of service will be denied.

Imaging services
The PPACA reduces payment for the technical component of certain diagnostic imaging for second and subsequent procedures. This reduction is from 75 to 50 percent of the Medicare Physician Fee Schedule amount with an effective date of July 1, 2010.

Again this is on the technical component only.

E-prescribing
The e-prescribing program is separate from the Physician Quality Reporting Initiative (PQRI). At this time you may participate in either or both programs. For a practical guide to e-prescribing, visit www.cms.gov/partnerships/downloads/11399-P.pdf.

PQRI education
PQRI, a voluntary reporting program, provides incentive payments to practices. Find educational material about PQRI on this site.

Also, see a getting started with PQRI tip sheet here.

Health Professional Shortage Area (HPSA)
Effective for claims with dates of service on or after Jan. 1, 2009, only services furnished in areas designated as geographic HPSAs as of Dec. 31 of the prior year are eligible for HPSA bonus payment.

If you are providing services in a HPSA area not on the eligible zip code list for automated HPSA bonus, you must use the AQ modifier to receive the payment.

For more information, visit the CMS website.

ABN of non-coverage and modifiers
Changes were recently made to the Advanced Beneficiary Notice (ABN). Modifier GA was redefined to mean “waiver of liability statement issued as required by payer policy.” The GA modifier should be used only when a valid ABN is on file. The GA modifier can also be used on assigned claims when the beneficiary refuses to sign the ABN.

GX is a new modifier defined as “notice of liability issued voluntarily under payer policy.” It can be used on the same line with other modifiers that indicate patient liability.

This GX modifier replaces the NEMB and can be used to inform a patient that a service will be denied for reasons other than medical necessity. GX should never be used for a covered service.

For further ABN modifier details, please visit the CMS website. Or see the Claims Processing Manual, Chapter 30, section 40.3.6, pages 100-4, and chapter 1.

Signature guidelines
The recently released MM6698 article offers six-pages of detailed information on signature guidelines for medical review purposes. It is important to review these guidelines located here.

Page 4 includes information on signature logs. Also find the guidelines in table format on the National Government Services (NGS) website.

Benign skin lesions
On Nov. 15, 2008, NGS made changes to the policy on removal of benign skin lesions (LCD – L27361 and SIA – A47397). It is important to note that a primary ICD-9-CM code AND a secondary ICD-9-CM code representing a complication are required for certain conditions.

Medicare Convention
Please check the convention website for information on the Medicare Convention and watch for listservs providing more details, as well as registration information.

HP
Mona Green, Provider Relations field consultant for HP Enterprise Services, demonstrated the revised IHCP Provider website; the planned implementation date is July 1. The site will appear similar to the member site recently released. No information will be eliminated, and the current information has been rearranged into a more logical structure.

Find the new member website here.

Second-quarter IHCP Provider Workshops will include CMS-1500 billing, paper and electronic; IHCP updates; Medicare-related institutional claim filing, paper and electronic; IHCP 101; managed care and HIP updates; Care Select care management organization updates; a live demonstration of the attachment process; details on billing Medicare crossovers; and third-party liability.

See the April IHCP Provider Newsletter NL201004 for workshop dates, registration deadlines and locations.

OMPP
Welcome to John McCullough, new Provider Relations manager for Office of Medicaid Policy and Planning (OMPP).

For an update on the status of modernization issues, McCullough advised interested ISMA members to see here.

Hoosier Healthwise - Anthem
Sandy Koons, Network Education representative, advised that Anthem participates in the Right Choices Program (formerly the Restricted Card Program). For additional information, please refer to the IHCP Provider Manual, Chapter 13.

Effective for claims with dates of service beginning Dec. 31, 2009, OMPP assumed responsibility for pharmacy benefits for the Hoosier Healthwise and Healthy Indiana Plan (HIP). Hoosier Healthwise and HIP pharmacy claims previously processed by Anthem are now processed by HP Enterprise Services.

Anthem will continue to handle Hoosier Healthwise and HIP medical benefits.

For more information, please visit the state’s website on the Indiana Medicaid website or call (866) 879-0106.

Hoosier Healthwise MDwise
Marc Baker, Provider Relations representative for MDWise, advised of a mass claims adjustment for Presumptive Eligibility (PE) claims paid by HP that should have been paid by the PE member’s MCO. More information will be coming via HP and the various MCOs.

MDwise has developed a new 2010 HEDIS Performance Measures poster available shortly on its website. The poster will also be distributed at the upcoming second quarter HP workshops.

Hoosier Healthwise - MHS
Holly Cram, Provider Relations specialist for Managed Health Services, advised that MHS participates in the Right Choices Program.

Healthy Indiana Plan - MDwise
Marc Baker noted members will be receiving updated MDwise HIP cards that will reflect new pharmacy contact information.

Services denied for 278-C01 have been reprocessed and adjusted (unless prior authorization was required).

For 2010 office consults, MDwise will continue to pay the 2009 consult codes until further notice.

Care Select - Advantage
Kelvin Orr, director of Network Development and Contracting, explained that effective July 1, the Medicaid Rehabilitation Option (MRO) program will undergo a transformation. OMPP, in conjunction with the Division of Mental Health and Addiction (DMHA), has developed a benefit plan structure for Medicaid members receiving MRO services.

Currently, there are no prior authorization requirements and no benefit limitations imposed for members receiving MRO services during the benefit period. While members can continue to access MRO providers based on self-referral, members who have a qualifying MRO diagnosis will be assigned a service package based on individual level of need. See Bulletin BT201013.

Care Select - MDwise
Marc Baker noted Care Select-MDwise follows OMPP-approved guidelines when releasing a provider’s two-digit certification code.

Provider Relations performs education and outreach to providers who are unfamiliar or have questions about the certification code process.

The new 2010 HEDIS Performance Measures poster also includes MDwise Care Select, as well as MDwise Healthy Indiana Plan information. The poster will allow providers to find this information in one place, in one document.

MDwise continues to recruit primary medical providers into the Care Select programs that cover HCBS Waiver members.