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Billing for Tribal Long Term Care

Billing for Tribal Long Term Care. Accurate Billing and Coding Are the Keys to Reimbursement. ICD – Internal Classification of Disease CPT – Current Procedural Terminology HCPCS – Healthcare Common Procedure Coding System DX – Diagnosis TX – Treatment HX – History

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Billing for Tribal Long Term Care

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  1. Billing for Tribal Long Term Care

  2. Accurate Billing and Coding Are the Keys to Reimbursement

  3. ICD – Internal Classification of Disease • CPT – Current Procedural Terminology • HCPCS – Healthcare Common Procedure Coding System • DX –Diagnosis • TX –Treatment • HX –History • Modifiers • NPI – National Provider Identifier • CMS 1500 – Professional and Fee for Service • CMS 1450 – Facility and LTC CLAIMS TERMINOLOGY: Words to Know

  4. DOS – Date of Service • POS – Place of Service • EMG – Emergency Indicator • EDI – Electronic Data Interchange • RA – Remittance Advice • EOB – Explanation of Benefits • RC – Reason or Remark Codes • Pending • Crossover Claims • Dupe - Duplicate CLAIMS TERMINOLOGY: Words to Know

  5. Each character has a purpose Each place is a degree of specificity WHY CODES ARE SO IMPORTANT Modifiers give details of the code Codes can change and End Dated Submissions will be Denied

  6. INCORRECT CODES = DENIED CLAIMS This Photo by Unknown Author is licensed under CC BY

  7. Where Do You Get The Right Codes? This Photo by Unknown Author is licensed under CC BY-SA This Photo by Unknown Author is licensed under CC BY

  8. Coding Books • Your State Medicaid Office/Website • CMS Website • CMS Online Manuals Getting the Right Codes

  9. Who makes the claim?Inter-Departmental Billing

  10. Clinic & Community Health Aging/Elders Services Tribal LTSS Services Housing Human/Social Services Transportation

  11. Aging and LTSS Medicaid Provider Number vs. Tribal FQHC

  12. CLAIMS MUST HAVES: WHO, WHAT, WHEN,HOW MUCH, and WHERE WHO: INSURED INFORMATION WHAT: SERVICE DESCRIPTION WHEN: Date From and To WHERE: DEPARTMENT HOW MUCH: COST OF SERVICE

  13. SampleInternal Process Transportation Ride Bank/Store Housing Builds a Ramp Aging Sends a Chore Worker Sends Invoices to LTSS Coordinator For Payment LTSS Coordinator Collects and Creates Medicaid Claims Medicaid Payment Received, LTSS Coordinator Resolves to Each Department

  14. {Hidden} SAMPLE Long Term Services Program Invoice Date: __________ ___________________________________ Member Name (Last, First) Department: € Aging € Community Health € Housing € Transportation € Social Services ______________________________________________________________________________________________________ Long Term Care Service Record _______________________________ ______________________________ Provider Signature Title

  15. Accurate Records Timely Filing* SuccessfulBilling Operations HIPAA & PHI Compliance Accounts Receivable Follow-Up & Appeals Reimbursement Reconcilliation

  16. Things to Know About Working Within a State & MCO System Tribal Providers and Medicaid Managed Care This Photo by Unknown Author is licensed under CC BY-SA

  17. Case Management & Prior Auth Tribes as Providers in Local System Rates and Payment Contracting w/ Counties Tribal Medicaid Provisions

  18. Case Management & Prior Auth Tribes as Providers in MCO System Rates and Payment Contracting vs. MOU ARRA Sect. 5006 Provisions

  19. SampleServiceProcess Elder Wants Services from Tribe Elder Enrolled in Waiver Program Case Planning for Elder with County/MCO LTSS Coordinator Gets Service Authorization Tribal Department Provides Services and Creates LTSS Invoice for Claiming

  20. IMPORTANT NOTE: Annual Funding Agreement Update You will need to add a statement to your AFA contract with IHS stating you are providing Long-Term Care Services and Supports to your community.

  21. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.htmlhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html • https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/form_cms-1500_fact_sheet.pdf • https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/837I-FormCMS-1450-ICN006926.pdf • https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html • Tribal Medicare DME https://med.noridianmedicare.com/web/jddme/claims-appeals/billing-situations/ihs CMS RESOURCES

  22. {Hidden} Aniwahya Consulting Services Website: www.Aniwahya.com Office Number: 608.301.5197 Staff Elaina Seep, CEO and Project Management Lead Email: Elaina.Seep@Aniwahya.com Benjamin Gonzales, Director of Project Planning & Marketing Email: Benjamin.Gonzales@Aniwahya.com 

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