LA Medicaid HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION PRESENTATION

1. LA MedicaidHEALTHCARE FINANCIAL MANAGEMENT ASSOCIATIONPRESENTATION January 30, 2009

2. NATIONAL DRUG CODE (NDC) IMPLEMENTATION • January 2008 Federal Statute Requires the Use of NCD on Claims for Physician Administered Drugs • Most Providers Billing Physician Administered Drugs MUST Enter the Drug NDC and Other Required Information on Claims • Required: Physicians/Physician Groups, APRNs, PAs, Hospital Outpatient, Hemodialysis Ctrs • Excluded: RHC, FQHC, MHC – Providers paid an all-inclusive/encounter rate for services

3. PHYSICIAN ADMINISTERED DRUGS Physician-Administered Drugs Include Any Drugs Ordered by a Doctor (or APRN With Prescriptive Authority) Regardless of Which Clinical Professional Actually Administers the Drug

4. RECORDS REQUIREMENTS AND RETENTION Drugs Will Be Invoiced to Drug Manufacturers for Medicaid Rebates Medicaid Will Audit Claims Upon Manufacturer Request or if Outlier Billing Detected May Request Drug/NDC Invoices or Packaging Labels; Documentation of Drug Administered – Name, Strength, Amount, and Date Providers Must Retain All Records for 5 Years From DOS OR Until Conclusion of All Audit Questions, Disputes, & Review Issues

5. IMPLEMENTATION SCHEDULE FOR EDUCATIONAL EDITS PROFESSIONAL: (Physicians, Physician Groups, APRNs, Physician Assistants) - Effective Dates of Service 03/01/08 & After - Effective with Processing Date 03/01/08 OUTPATIENT HOSPITAL & HEMODIALYSIS - Effective Dates of Service 03/01/08 & After - Effective with Processing Date 05/23/08 Billing Instructions Posted on Web Site

6. INITIAL DELAY OF CLAIM DENIALS The initial plan to deny claims on July 1, 2008 was postponed Educational Edits have continued to appear on RAs

7. IMPLEMENTATION OF CLAIM DENIALS • Effective April 1, 2009, claims will deny if NDC data is missing or invalid • Effective for Physician, Outpatient Hospital, and Licensed Hemodialysis Centers. NDC TRAINING WEBINARS SCHEDULED FOR FEBRUARY 3-6, 2009

8. Claim Edits for NDC Edit 120 Quantity Invalid/Missing Edit 231 NDC Code Not on File Edit 127 NDC Code Missing or Incorrect

9. REQUIRED NDC DATA Required Data Must Be Entered EXACTLY As Indicated In Billing Instructions To Prevent Denials REMINDER: Both EDI and Hard Copy/Paper Claims Must Enter NDC Data AND HCPCS Code

10. BILLING OF REVENUE CODE 450 Policy Stated in 2007 Hospital Services Training Packet @ www.lamedicaid.com, link Training Only 1 Revenue Code 450 Per Visit Bill with Appropriate ER CPT Code (99281-99285)

11. BILLING OF REVENUE CODE 450 HR450 Visit Includes ALL Services Related to ER Visit Services Provided by Physician, Nurse, Etc., Are Included In The Single HR450 Code (i.e., Suturing, Splinting, Casting, Injections, etc.) Providers May Not Bill Additional Charges For Such Services Providers May Bill Separately for Other Services Provided (i.e., lab, supplies, pharmacy, etc.)

12. BILLING OF REVENUE CODE 450 LA Medicaid’s Reimbursement Methodology is Unlike Medicare or Private Payers (CCR and Cost Settlement at End of Year) Claims Should Be Billed to LA Medicaid as Instructed This Policy Will Be Clarified Through Provider Web Notice

13. BILLING OF REVENUE CODE 450 Denial Edits Implemented in October 2008 Edit 093 – Revenue Code Missing/Invalid Edit 113 – Only 1 ER Code Per Visit All Multiple Claim Lines Will Deny w/These Edits Including the Correctly Billed 450 w/99281-99285 Provider Must Re-Submit Claim Correctly

14. IMPLEMENTATION OF HCPCS AS REQUIRED BY NUBC FOR OUTPATIENT SERVICES • Effective For Dates of Service June 1, 2008 & After • HCPCS Required for Outpatient Hospital Services • Claim Lines Not Correctly Billed Will Deny 513 (HCPCS Required) • Applies to EDI and Paper Claims • Reimbursement Methodology Won’t Change

15. REVENUE CODES REQUIRING HCPCS • 251-269 • 279 • 300-359 • 370-444 • 450-636 • 730-761 • 790 • 820-929

16. 24-HOUR RULE Current Policy - The documented time of an admission whether it is inpatient or outpatient is the time the patient registers - The 24-hour “clock” starts at that time This policy is currently under review by DHH - A change may occur in the future

17. New TPL Payment Procedures EDI Claims - Hospital Inpatient and Outpatient may submit electronic TPL claims (Physicians, Home Health, RHC/FQHC Also) - If billing EDI, no EOBs required - Must enter appropriate/accurate data from EOB into electronic specs - Details for 837 transactions @ www.lamedicaid.com - Post-payment review of claims to ensure accuracy - Questions? Unisys EDI Department – 225/216-6303

18. OUTPATIENT UPDATES Ambulatory Surgeries (HR490) Medicaid Recipients: - HR 490 Claim Lines Denied for 539 (Claim Requires Detail Billing) - Dates of Service April 1, 2007 through April 14, 2008 - Claims Recycled11/18/08 TAKE CHARGE FPW Recipients: - HR 490 Claims Paid Billed Charges - Claims Recycled 09/16/08 and 09/23/08 - Only Codes 58301, 58600, 58615, 58670, 58671

19. Contact Information Unisys Provider Relations Department Phone: (800) 473-2783 (225) 924-5040 Unisys EDI Department Phone: (225) 216-6303 Unisys Web Technical Support Help Desk Phone: (877) 598-8753

20. Questions & Answers