UTAH MEDICAID OUTPATIENT CONVERSION 2011

1. UTAH MEDICAID OUTPATIENT CONVERSION 2011 May 19, 2011 PRESENTED BY DARIN DENNIS

2. Introductions

3. Purpose of Meeting • To provide details regarding outpatient billing changes • To solicit feedback and questions

4. Areas NOT affected • Changes do NOT include: • LTAC • Ambulatory Surgical Centers • Physician • Ambulance • Inpatient

5. Go Live Date • Utah Medicaid is currently on target to be ready by July 1, 2011. • UHA has requested go live currently scheduled for August 1, 2011. Testing results will be monitored in weekly meetings.

6. Medicaid Outpatient Methodology Current Future Coverage is procedure-code based Pay is APC or fee-schedule based No Urban/Rural differential No emergency differential Use Medicare’s Outpatient Code Editor Use CMS’ outpatient pricer If not covered by Medicare, use Medicaid fee schedule • Coverage is generally revenue-code based • Reimbursement is percent-of-charge or fee-schedule • Urban vs. Rural differential • Emergent use of the E.D. results in higher reimbursement

7. Medicare Methodology • Hospitals identified as Critical Access Hospital or OPPS facility • Line item procedure code receives Status Indicator (A-Z) indicating coverage and payment

8. Medicaid Changes • Important to bill all codes & charges (determines outlier payments) • All lines require a procedure code for payment • Most (~90%) of the procedure codes that Medicare covers (9,300 codes) for outpatient will be covered by Medicaid (8,400 codes).

9. Medicaid Plans Affected • Traditional & Non-Traditional plans will have similar coverage (see procedure code list) • Primary Care Network plan coverage will only include Revenue code 045X with an emergency diagnosis (no change).

10. Medicaid vs. Medicare • Outpatient definition (Medicaid=24 hour limit) • Always include NDC on pharmaceuticals (needed for rebates) • As a general rule for Medicaid: Experimental, investigational, cosmetic and fertility-related procedures are not covered • Medicaid copayments are still utilized

11. Medicaid – Additional changes Recently approved to use: • Modifiers • Condition codes • Revenue Codes (90% of codes opened) • Occupational Therapy and Physical Therapy will keep submission differences • Post-Payment audits will occur (like Medicare)

12. Contact info Darin Dennis ddennis@utah.gov 801-538-9189

13. Other questions • Prior Authorization • Payment dispute and over/under payment resolution instructions • 835 processing: Delays or suspensions plan • Crossover claims: when to bill as regular fee-for-service