Emergency Medical Services for Aliens (EMSA)

1. Emergency Medical Services for Aliens (EMSA) Presented by: Xerox State Healthcare, LLC Provider Relations

2. Resources • When online use: Ask Service Representative • HIPAA.Desk.NM@xerox.com • NMPRSupport@xerox.com • Call Center 505-246-0710 or 800-299-7304 • New Mexico Web Portal • Provider Information section • Links and FAQ section • Provider Login section

3. Important State Websites STATE WEBSITE: PROGRAM POLICY MANUAL • http://www.hsd.state.nm.us/mad/policymanual.html BILLING INSTRUCTIONS • http://www.hsd.state.nm.us/mad/billinginstructions.html REGISTERS AND SUPPLEMENTS: • http://www.hsd.state.nm.us/mad/registers/2012.html

4. Emergency Medical Services for Aliens • The New Mexico Medicaid program is required to pay for emergency services furnished to individuals who are undocumented aliens, reside in New Mexico and meet the requirements for Medicaid eligibility.

5. Emergency Medical Services for Aliens Medicaid Policy • The Policy Manual for Emergency Services for Undocumented Aliens can be found at the following State website: • http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov832510.pdf • The Billing Instructions for Emergency Services for Undocumented Aliens can be found at the following State website: • http://www.hsd.state.nm.us/mad/pdf_files/BillingInstructions/832510.pdf

6. Emergency Medical Services for Aliens General Eligibility Policy • Who is covered? • Individuals who are undocumented, and non-immigrant aliens and who meet the eligibility criteria for: • JUL Medicaid (category 072) • Children meeting applicable age requirements (category 032) • Medicaid for pregnant women (category 030 or 035) • Supplemental Security Income (SSI), except for citizenship or legal alien status, are eligible to receive emergency services

7. Emergency Medical Services for Aliens General Eligibility Policy (continued) • Undocumented individuals must: • Fill out an application for benefits; • Be residents of New Mexico; and • Furnish proof of residence to the local county ISD office.

8. Emergency Medical Services for Aliens General Eligibility Policy (continued) • Eligibility determinations are made by local county Income Support Division (ISD) offices. • After the receipt of emergency services, the patient or responsible party is responsible for completing an application at the local county ISD office, and • For providing all necessary verifications no later then the last day of the third month following the month in which the emergency services were received.

9. Emergency Medical Services for Aliens General Eligibility Policy (continued) • If an application is denied or an application for Medicaid coverage is not filed by the last day of the third month following the month in which the emergency services were received, the individual is responsible for payment of the provider bill. The provider can bill the patient. • Individuals are responsible for notifying providers of the approval or denial of an EMSA Medicaid application.

10. EMSA Definition of Emergency • “Emergency” as defined for EMSA includes labor and delivery including inductions and cesarean sections, as well as any other medical condition, manifesting itself with acute symptoms of sufficient severity such that the absence of immediate emergency medical attention could reasonably be expected to result in one of the following: • (1) the alien recipient’s death; • (2) placement of the alien recipient’s health in serious jeopardy; • (3) serious impairment of bodily functions; or • (4) serious dysfunction of any bodily organ or part.

11. EMSA Definition of Emergency (Continued) • Only medical services that are necessary to treat and/or evaluate a condition that meets the definition of emergency are covered for the duration of the emergency. • A medical condition, including labor and delivery services. • Labor and delivery services include inductions, scheduled and unscheduled cesarean sections, and routine deliveries. • After delivery, a child can have legally documented or citizenship status because of his/her birth in the United States and, therefore, is not eligible for emergency services for undocumented aliens.

12. New Born Medicaid Coverage • After the mother is approved for EMSA and ISD is notified of the birth, the ISD worker may open a Category of Eligibility 31. • The newborn may be “deemed eligible” under the mother’s Medicaid status for the first year. • If the mother fails to report the birth in a timely manner to the Income Support Division office (ISD), payment to the provider rendering services may be delayed.

13. New Born Medicaid Eligibility Policy Recertification • After one year, the child’s own eligibility must be established pursuant to the requirements for proof of citizenship and identity. • For continued eligibility after the first year, the parent must submit an application or reverification notice for the child to continue Medicaid eligibility.

14. EMSA Services do not include: • Long term care • Organ transplants • Rehabilitation services • Surgical procedures, other than unscheduled emergency procedures • Psychiatric or psychological services • Durable medical equipment or supplies • Eyeglasses • Hearing aids • Outpatient prescriptions

15. EMSA Services do not include:(Continued) • Podiatry services • Prenatal care • Well child care • Routine dental care • Routine dialysis services • Any medical service furnished by a border or out-of-state provider • Non-emergency transportation, and • Preventive care

16. Were to submit claims • All EMSA claims are to be filed directly to Xerox along with a copy of the MAD 310, which is supplied by ISD, plus all medical documentation to support the medical emergency. Please include a cover letter with contact information with the submissions. • Mail to the following address: Xerox P.O. Box 26500 Albuquerque, NM 87125-6500

17. Medicaid Billing Policy • Medicaid billing policies must be followed. For example: • Diagnosis codes must be used and are obtained in the International Classification of Diseases, Clinical Modifications, 9th edition, Vol. 1 and 2 or its successor. • Procedure codes to be used are contained in the Physician’s Current Procedural Terminology (CPT) manual and the Healthcare Common Procedure Coding System (HCPCS) Level II codebook. • Detailed policy and billing instructions can be found at: PROGRAM POLICY MANUAL http://www.hsd.state.nm.us/mad/policymanual.html BILLING INSTRUCTIONS http://www.hsd.state.nm.us/mad/billinginstructions.html

18. Troubleshooting EMSA Claims • How long should a provider wait before following-up on an EMSA claim? • Allow 4 weeks from the date the claim(s) were submitted to Xerox to appear on the Web Portal. • Claims suspended for a manual review and authorization can be viewed on the Web Portal and on the Remittance Advice. • If there is no claim in the Web Portal at that time, resubmit the claim for processing.

19. Troubleshooting EMSA Claims (continued) • Can an EMSA claim be adjusted? • No! Each specific claim is authorized individually.

20. Troubleshooting EMSA Claims (continued) When to resubmit a denied claim… If the denial code 1300 is on the EOB, please refer to the letter sent by Molina TPA/UR regarding denial of the services based on the medical record review. For questions regarding this denial of emergency services contact Molina TPA/UR. Call Molina TPA/UR (505) 348-0311 (in Albuquerque) (866) 916-3250, (toll free)

21. Troubleshooting EMSA Claims (continued) • When an EMSA claim denies for billing reasons, the corrected claim containing the Prior Authorization (PA) number must be resubmitted with the MAD 310 and proof of timely filing to Xerox. If you do not have the PA notice that contains the number, you can contact Molina TPA/UR for the number. Call Molina TPA/UR (505) 348-0311 (in Albuquerque) or (866) 916-3250, (toll free) For all other billing denials related to claims in which you’re unsure how to correct the problem, please call Xerox (Provider Relations), and a representative will assist you. Call Xerox (505)246-0710 (in Albuquerque) or (800) 299-7304, (toll free)

22. Troubleshooting EMSA Claims (continued) • An EMSA claim has paid and now there are charges that need to be added to that claim, how should the rebilling of this claim be handled? • Request that the original claim be voided by using the Adjustment/Void Form • Send to Xerox: - All medical records - A new claim with Proof of timely filing with the PA number - The MAD 310 - A cover letter, with contact information of the submitter, explaining that this is a resubmission and the first claim was incorrect.

23. Resources • When online use: Ask Service Representative • HIPAA.Desk.NM@xerox.com • NMPRSupport@xerox.com • Call Center 505-246-0710 or 800-299-7304 • New Mexico Web Portal • Provider Information section • Links and FAQ section • Provider Login section