IHCP Rural Health Clinic Billing

1. IHCP Rural Health Clinic Billing HP Provider Relations/June 2014

2. Agenda • RHC Basics • Claim Inquiry • Common Claim Denials • Where to bill claims • Third Party Liability • Helpful Tools

3. Objectives Participants will understand: • The basics of RHC • How to bill for services • How to read and resolve claim issues • Who to bill for services

4. RHC Basics

5. The Beginning • RHC programs were established to address underserved rural communities and to reduce patient load on hospital emergency rooms • Any area that is not in a U.S. Census-designated “urbanized area” (50,000 population) • A FQHC may be in an urban area • Must be in a designated shortage area • Federally designated Health Professional Shortage Area (HPSA) • Federally designated Medically Underserved Area (MUA) • State governor designated underserved area

6. Enrollment Basics • Providers should forward the Centers for Medicare & Medicaid Services (CMS) letter with enrollment application • This letter grants RHC status • Submit proper financial documents to Myers and Stauffer (rate-setting contractor) to establish rate • Indiana State Department of Health sends Certification and Transmittal (C&T) to HP • Providers are enrolled as a group, with rendering providers linked • Provider Type 08 • Specialty Type 081-RHC

7. Service Coverage • According to 405 IAC 5-16-5, IHCP reimbursement is available to RHCs and FQHCs for services provided by the following providers: • • Physician • • Physician assistant • • Nurse practitioner • • Clinical psychologist • • Clinical social worker • • Dentist • • Dental hygienist • • Podiatrist • • Optometrist

8. Service Definition • A visit is a face-to-face encounter between the patient and provider • Multiple services performed during the same visit for the same or related diagnosis are considered a single encounter • Multiple visits that occur within the same 24-hour period for the same diagnosis are considered a single encounter

9. Eligibility Verification • Verification of eligibility before every service is strongly encourage • The best way to verify eligibility is Web interChange • Other ways to verify eligibility • Automated Voice Response ( AVR ) system • 1-800-738-6770

10. Reimbursement • AIM processing for PPS methodology began April 1, 2003 • Must use Healthcare Common Procedure Coding System (HCPCS) Level III codes, including T1015 – clinic, visit/encounter, all-inclusive, and Level I and II codes • Provider receives a facility-specific PPS rate determined by Myers and Stauffer

11. Place of Service • Submit claims with place of service codes: • 11 – office • 12 – home • 31 – skilled nursing facility • 32 – nursing facility • 72 – RHC • Submit claims with T1015 and the applicable HCPCS/Current Procedural Terminology (CPT) code • The HCPCS/CPT code will deny with error code 6096 –Code not payable according to PPS methodology • The encounter rate T1015 is reimbursed according to the rate established by Myers and Stauffer

12. Service Allowance • The IHCP only allows one encounter per IHCP member, per provider, per day, unless the diagnosis code differs • Providers can submit valid encounters with differing diagnosis codes to HP for manual processing • Documentation should be submitted through Written Correspondence • Documentation requirements are: • Documentation in writing from the medical record that supports the medical reasons for the additional visit • - This documentation includes presenting symptoms or reasons for the visit, onset of symptoms, and treatment rendered. • Documentation that the diagnosis for each encounter is different

13. T1015 Exempt Place of Service Codes • Hospital services (place of service 20-26) are not considered RHC, and the T1015 encounter code is not required • 20 Urgent Care Facility • 21 Inpatient Hospital • 22 Outpatient Hospital • 23 Emergency Room • 24 Ambulatory Surgical Center • 25 Birthing Center • 26 Military Treatment Facility • Dental services are billed with Current Dental Terminology (CDT) codes on dental claim forms

14. Claim Inquiry

15. Claim Inquiry

16. Claim Inquiry Note: Documentation submitted with original claim must also be submitted with current claim. This applies to paper and electronic claims. • National Provider Identifier (NPI) or LPI will automatically populate • For multiple locations – choose appropriate service location • Member recipient identification number (RID) • From and through date of service of specific claim • Search by date of service (DOS) • Why not search by internal control number (ICN)? • ICN will only give information on one specific claim • Review all claim submissions and denial reasons • Use paid claim (if applicable) for corrections • Adjust the paid claim or void and start over

17. Claim Inquiry

18. Claim Inquiry

19. Claim Inquiry • Claim submission information is displayed • Choose the appropriate claim to work with i.e. most recent ICN or paid claim • Click on the ICN • Choose • Scroll to the bottom of the claim • Adjustment reason codes (ARCS) • Health Insurance Portability and Accountability Act of 1996 (HIPAA) required fields – not the reason detail denied • REMARKS • HIPAA required fields – not the reason detail denied • Provide spend down information

20. Claim Inquiry • CLAIM STATUS INFORMATION • Provides detailed information • disposition of each EOB (explanation of benefits) code – LOOK FOR THE “D” • H/D – the header or detail level • WHY DID THE CLAIM/DETAIL LINE DENY • description

21. Common claim denials

22. Common Denials • 2017 - Recipient ineligible on date of service – due to enrollment in a Managed Care Entity • Resolution: • VERIFY MEMBER ELIGIBILITY • Understand the eligibility information • Submit claim to the appropriate entity

23. Common Denials 2017 - Recipient ineligible on date of service

24. Common Denials • 4121 – T1015 must be billed with procedure code • Resolution: • Copy the claim in Web interChange • Add T1015 detail line • Save detail • Submit claim.

25. Common Denials • 0558 - Coinsurance and deductible amount missing • Claim submitted has no coinsurance and deductible amount indicating that this is not a crossover claim • Resolution: • Verifyclaim isa crossover claim • Submit claim with appropriate crossover information • Primary explanation of benefits (EOB) is not required if payment has been made • If claim is not crossover • Submit as Medicaid primary • Include supporting EOB documentation if applicable

26. Medicare and Replacement Plans

27. Medicare and Replacement Plans

28. Common Denials Crossover Claim Information • Payer ID = REPLACEMENT PLAN OR MEDICARE PAYER ID • Payer Name = Wisconsin Physician Services (Traditional Medicare) or • Replacement Plan name in the Payer Name Field • Medicare Paid Amount = The total amount paid by Medicare for the claim • Subscriber Name = Name of policy holder for primary insurance • Primary ID = ID number of the primary insurance (Medicare or Replacement Plan) • Relationship Code = 18 (self) • Claim Filing Code = 16 (Replacement Plan) or MB (Traditional Medicare) • Click Save Benefits at the bottom of the screen • Click Save and Close at the top of the screen Note: Obtain coordination of benefits (COB) information from the HELP tab, Reference Materials on Web interChange

29. Common Denials Information required in Field 22 Coinsurance/Deductible Information Medicare Payment Information

30. Third Party Considerations

31. Third-Party Liability Considerations • All third-party liability (TPL), patient liability, and copayments continue to apply as appropriate • Allowable Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and pregnancy services provided during an encounter continue to bypass TPL edits • Medicare crossover reimbursement methodology is excluded from PPS logic • T1015 not necessary on crossover claims • Medicaid reimburses deductible and coinsurance, even if Medicare payment greater than PPS rate • TPL payment information for paper claims: • CMS-1500 – Block 29 • Dental Claim – Block 35 • UB-04 – Block 54 B

32. Who pays my claim?

33. Care Select • Claims submitted for members in Care Select no longer require primary medical provider (PMP) authorization if the service was not provided by the PMP • Self-referral services provided at the RHC do not require PMP authorization • In the Care Select network, RHC provider specialties are not entitled to receive the monthly administrative fee payment

34. Risk-Based Managed Care • Submit claims to the applicable risk-based managed care (RBMC) managed care entity with the HCPCS/CPT code • Do not include T1015 encounter code • Myers and Stauffer reconciles managed care claims to the provider-specific PPS rate and makes annual settlements • Providers may submit requests for supplemental payments to Myers and Stauffer • Contact information for the MCE’s can be found on the Quick Reference Guide at www.indianamedicaid.com

35. Helpful Tools

36. Helpful Tools Avenues of resolution • IHCP website at indianamedicaid.com • IHCP Provider Manual • Customer Assistance • 1-800-577-1278 • Locate area consultant map on: • indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or • Web interChange > Help > Contact Us • Written Correspondence • HP Provider Written CorrespondenceP. O. Box 7263Indianapolis, IN 46207-7263

37. Q&A