Enrollment
Here are the most common reasons for returning, developing and rejecting of Medicare enrollment applications.
Reasons for return:
- No signature
- Wrong application
- Not an original signature
- Wrong carrier
Copied signature
Reasons for development:
- EFT (CMSD 588) and documentation missing
- No authorized official/delegated official
- Sections of form not completed
- Documentation missing
- Effective dates missing
Reasons for rejection:
- Requested information not received in 30 days
- Specialty not recognized by CMS
- No medical license in the state or suspension
- Disbarred from Medicare
PECOS changes
Physicians and non-physician practitioners seeking enrollment in the Medicare program can now complete the process online themselves over the Internet, or they may allow a third-party, such as a staff member or an external enrollment agency, to handle enrollment. This represents a change from a previous statement indicating only physicians and non-physician practitioners could use the Provider Enrollment Chain/Ownership System (PECOS).
Remember to hit “Submit’ when using the PECOS Web process or the application will not be received. When submitting the PECOS application, print, sign and date the certification statement and mail it to the Medicare enrollment contractor. This must be done within seven days of the electronic submission.
Find PECOS here.
Recovery Audit Contractor (RAC)
The Recovery Audit Contractor for Indiana, which is in Region B, is expected to be up and running by 2010. The RAC’s main task is to discover payment errors and underpayment on a post-payment basis. Currently, in the demonstration project there have been $371.5 million identified in improper payments; 96 percent are overpayments and
4 percent are underpayments.
RACs are bound by Medicare policy, national coverage determinations, local coverage determinations and manual instructions. They conduct two types of reviews: automated (no medical record needed) and complex (medical record required). RAC audits are not random, but details about how a physician is selected are not shared.
RACs will review adherence to Medicare policies, billing and coding, and medical necessity. RACs may not look at:
- Any service under another payment program
- Cost reporting settlements
- Claims greater than three years since initial determination
- Claims paid before Oct. 1, 2007
- Beneficiary liable claims
- Demonstration claims
- Pre-payment review claims by the contractor
- Randomly chosen claims
Here is how the process unfolds. The RAC contractor:
- Requests claims from contractors
- Requests records based on data-mining (process of extracting patterns) from providers
- Reviews documentation and makes determination
- Sends claim adjusted over/underpayment notice
Two major areas where RACs found improper payments were billing for services medically unnecessary and incorrectly coding services. Prepare for the RAC audits by:
- Knowing where improper payments have already occured
- Checking Office of Inspector General (OIG) and CERT reports
- Watching ALL data markers
- Conducting internal audits
- Identifying corrective actions
Respond to RAC medical record requests fully and promptly (within 55 calendar days). Give the RAC the provider’s address and a contact person. Keep track of the number of medical records requested and the date requested. Check the status of your claims on the RAC Web site, which will be available by Jan. 1.
Also, note the ISMA is offering a free educational session on RAC audits during the annual convention. Find details about the RAC session, scheduled for Friday, Sept. 25, here.
Keep copies of what you send to the RAC and appeal if you don’t think your audit is correct. The appeals process for RAC denials is the same as the appeal process for Carrier/FI/MAC denials.
RAC Contractor –
CGI Technologies and Solutions, Inc.
11325 Random Hills Road
Fairfax, VA 22030
Contacts:
CMS RAC Web site
E-mail
Continue to monitor the CMS Web site for updates on the MAC.
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EDS phase-out of paper
Effective Sept.1, 2009, EDS will no longer print and mail the following:
- Paper Remittance Advice
- Banner pages
- Bulletins
- Newsletters
- Claim Correction Forms (CCFs)
- Paper communications
Providers not enrolled to receive payments via electronic funds transfer (EFT) will continue to receive paper checks by mail. However, all are encouraged to enroll to receive EFT payments. EFT enrollment may be performed online via Web interChange using the Provider Profile menu option. This eliminates lost checks and providers receive payments more quickly.
Banner pages, bulletins, and newsletters are available at the Indiana Health Coverage Programs (IHCP) Web site here. These publications will no longer be printed and mailed on and after Sept. 1. Sign up to receive automated e-mail notifications when these notices are published to the Web site.
To receive e-mail notifications, access the IHCP Web site and click “IHCP Email Notifications.” Each user in a medical practice must enroll separately for the individual to receive e-mail notifications.
NPI Stage Three
Stage Three of the National Provider Identifier (NPI) will complete full implementation of NPI by approximately September 2009. Stage Three also will change the current logic in the system to eliminate the use of Legacy Provider Identifiers (LPIs) for typical health care providers. Several technical processes involving paper claims, financial information and electronic data interchange (EDI) will be updated to fully implement Stage Three.
Web interChange maintenance
Using Web interChange, you can make the following profile updates:
- Ownership information
- Changes in members of a board of directors
- Names of office manager or other management personnel
- Ownership in subcontractor entities
- Enrollment or disenrollment in EFT
- EFT deposits occur 18 days after submitting an enrollment.
- 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.
- Adding or removing specialty designations
- MRT physician outreach
In accordance with state law on outpatient mental health, there is a documented plan to reach out to psychiatrists, licensed physicians, and health service providers in psychology (HSPPs) as follows.
The Medical Review Team (MRT) determines 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 initiate 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.
Pregnancy form
Beginning July 1, 2009, those who provide prenatal services to pregnant women will submit a report of the woman’s pregnancy on Web interChange. Notification of Pregnancy (NOP) enables providers to identify early signs of potential health risks that contribute to poor birth outcomes.
Bill for NOP using procedure code 99354 with a TH modifier for a reimbursement rate of $60. Watch for more information in an upcoming bulletin.
Presumptive eligibility for pregnancy
Beginning July 1, 2009, certain provider types who administer a pregnancy test can determine that a pregnant woman is presumptively eligible for Medicaid and be reimbursed for needed ambulatory prenatal services.
Provider types who make this determination are called “qualified providers,” and that includes primary care specialties, rural health clinics (RHCs), clinics and outpatient hospital departments.
When the qualified provider determines a positive pregnancy test, the provider accesses Web interChange to submit pregnancy information online.
On that same day, the provider helps the patient contact MAXIMUS, the enrollment broker, so she can select a primary medical provider and managed care organization. The qualified provider also faxes the patient’s Hoosier Healthwise application to the Division of Family Resources.
Coverage of ER services
For Hoosier Healthwise - An MCO may conduct a prudent layperson review to determine if a member presenting at an emergency room had an emergency medical condition. Per state law, an emergency medical condition is one manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in the following:
- Placing the health of the individual (or with a pregnant woman, the health of the woman or unborn child) in serious jeopardy
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
- Regardless of the outcome of the prudent layperson review, both the facility and physician must receive reimbursement for the screening services. Specifically, for physician services billed on a CMS-1500 claim, if a prudent layperson review determines the service was not an emergency, the MCO must reimburse, at minimum, for Current Procedural Terminology (CPT®1)* code 99281 – Emergency department visit – Level 1 screening fee. For facility charges billed on a UB-04, if a prudent layperson review determines the service was not an emergency, the MCO must reimburse for revenue code 451.
With the exception of the physician screening fee and facility fee, the MCO is not required to reimburse providers for services rendered in an emergency room for treatment of conditions that do not meet the prudent layperson standard as an emergency medical condition, unless the MCO authorized this treatment.
The MCOs are to reimburse according to this methodology for dates of service beginning July 1, 2009. For questions regarding specific billing guidelines, please contact the appropriate MCO Provider Services Line:
- Anthem Hoosier Healthwise:
1-866-408-6132
- MDwise Hoosier Healthwise:
1-800-356-1204
- Managed Health Services:
1-877-MHS-4U4U or 1-877-647-4848
Care Select and Traditional Medicaid - The IHCP covers services for a member presenting to an emergency room with an emergency medical condition, as determined by the screening physician. Per state law, an emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:
- Placing the health of the individual (or with a pregnant woman, the health of the woman or unborn child) in serious jeopardy
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
- For members presenting to an emergency room with or without an emergency condition outlined above, the IHCP has adopted the following guidelines:
- Facility Billing
If the screening identifies a member has a non-emergent medical condition, the facility may bill only Revenue Code 451 – EMTALA-emergency medical screening service and will be reimbursed the lesser of the provider’s submitted charge (usual and customary) or the emergency screening fee of $25. If the screen determines the member has an emergency condition, the hospital would bill for medically necessary emergency services using the appropriate revenue and Healthcare Common Procedure Coding System (HCPCS) codes. The screening revenue code may not be billed in conjunction with emergency room treatment services.
- Physician Billing
If the physician determines that the member has a non-emergent medical condition, the physician may bill only one of the three CPT codes – 99281, 99282 or 99283 – and will be reimbursed the lesser of the provider’s submitted charge (usual and customary) or the rate on file. If the screen determines the member has an emergency condition, the physician may bill the screening code, as well as medically necessary services.
1 CPT® is a registered trademark of the American Medical Association.
The next Medicare/Medicaid coalition meeting is scheduled for July 17, 2009. |
