April 2009 Prenatal Care Coordination Billing Presented by the EDS Provider Relations Field Consultants

April 2009

Prenatal Care Coordination BillingPresented by the EDS Provider Relations Field Consultants

PRENATAL CARE COORDINATION BILLING2 / April 2009

• IHCP

• Provider Enrollment

• Provider Updates

• Member Eligibility

• Benefit Packages

• Care Coordination Services

• Notice of Pregnancy

• Presumptive Eligibility

• Managed Care

Welcome and Announcements

Agenda

•Care Management Organizations

•Billing

•Remittance Advice

•Adjustments

•Paper Claim Filing

•Top Five Denials

•Helpful Tools

•Questions


Indiana Health Coverage Programs

•Traditional Medicaid

•590

•Fee-for-Service


New Provider Enrollment

•Enrollment forms are in electronic format on the Web by using www.indianamedicaid.com

•All forms may be filled out online and the information submitted electronically

•All pages requiring original signatures and tax information (W-9s) must be mailed to EDS Provider Enrollment after completing the online application

•Enrolling online provides the following advantages:

– Quicker provider enrollment

– Complete and accurate information

– Easier enrollment


Provider EnrollmentStep 1: Begin at indianamedicaid.com


• Indiana Health Coverage Programs (IHCP) Web site at

www.indianamedicaid.com

• Provider Enrollment helpline at 1-877-707-5750

Provider Enrollment ApplicationProvider Enrollment


Online Enrollment


• Download the Provider Enrollment Application:

– Visit www.indianamedicaid.com

– Go to the Provider Services tab

– Choose Provider Enrollment from the drop-down list

– Access the link titled Enroll a New Provider in the IHCP

– Print the Provider Enrollment Application and an IRS W-9 Form

• Complete the enrollment application (original signatures are required)

• Avoid having your application returned

– Call 1-877-707-5750 if you have questions about the enrollment forms

ProcessProvider Enrollment


• IHCP reimbursement is available for the following practitioners who provide care coordination services to eligible pregnant women in the IHCP:

– State-licensed physician

– State-licensed registered nurse

– State-certified social worker or a social worker with a baccalaureate or master’s degree from a school accredited by the Council on Social Work Education

– Dietician registered with the Commission on Dietetic Registration of the American Dietetic Association

– Community health worker working under the supervision of one of the professionals listed above

Provider Enrollment RequirementsProvider Enrollment


•The enrollment packet must include:

– Completed Provider Enrollment Application (with all applicable schedules)

– Completed IRS W-9 Form

– Waiver Approval Letter certifying the waiver services that the provider is approved to perform

•Mail to: EDS Provider Enrollment

P.O. Box 7263Indianapolis, IN 46207-7263

Mailing the ApplicationProvider Enrollment


Provider Updates

•Updates to the following information must be submitted to the EDS Provider Enrollment Unit:

– Address changes (home office, mail-to, pay-to, and service location)

– Telephone number changes

– Banking information changes (if enrolled in electronic funds transfer)

•Requests for changes must be submitted using the EDS Provider Update Form available at www.indianamedicaid.com


•Members must be enrolled in the IHCP and have pregnancies that are at risk for low birth weight or poor pregnancy outcome to be eligible for the IHCP to pay for care coordination services

•Each member has a Hoosier Health Card used for identification

•Viewing a Hoosier Health Card alone does not verify eligibility

Who is Eligible?

Member Eligibility


• Providers must verify eligibility on the date of service

• Providers who fail to verify eligibility are at risk of their claims being denied due to member ineligibility or coverage limitations

Verifying EligibilityMember Eligibility


Three Eligibility Verification Systems (EVS) are available:

•Automated Voice Response (AVR)

– 1-800-738-6770, or

– (317) 692-0819, Indianapolis area

•Omni swipe card terminal device

•Web interChange

How to VerifyMember Eligibility


AVR provides the following:

•Member eligibility verification

•Benefit limits

•Prior authorization

•Claim status

•Check write

Contact AVR at (317) 692-0819 in the Indianapolis local area or 1-800-738-6770

EVS Using the TelephoneAutomated Voice Response System


• Is cost-effective for high-volume providers

•Uses plastic Hoosier Health card

•Allows manual entry

•Prints two-ply forms

•Requires upgrade for benefit limit information (refer to IHCP provider bulletin BT200711)

See Chapter 3 of the IHCP Provider Manual for more information

EVS Card Reading DeviceOmni


The following is available through Web interChange:

•Member information available by member ID, Social Security number (SSN), Medicare number, or name and DOB

•Division of Family Resources (DFR) information

•Detailed third-party liability (TPL) information

•Online TPL update requests

•Web interChange is accessible via www.indianamedicaid.com

EVS Using the InternetWeb interChange


Web interChangeEligibility


Benefit Packages

Benefit Package

Coverage

Package A – Standard Plan

Encompasses the full array of Indiana Health Coverage Programs (IHCP) benefits for children, low-income families, and some pregnant women enrolled in the Hoosier Healthwise Program.

Package B Coverage is limited to pregnancy-related and urgent care services for some pregnant women.

Package C Limited coverage (including preventive, primary, and acute care services) for children under 19 years old enrolled in the Children’s Health Insurance Plan (CHIP).


Diagnosis Code:

• V68.9

Procedure Codes:

• H1000 – Initial Assessment (One per pregnancy)

• H1004 – Reassessment (One per trimester)

• 99502 – Home visit for newborn care and assessment

Diagnosis and Procedure CodesCare Coordination Services


•A0160 U1 – Two round trips per initial assessment

•A0160 U2 – Two round trips per assessment

•A0160 – One round trip per postpartum assessment

Procedure Codes for MileageCare Coordination Services


Prenatal Care Coordination Forms

• Risk Assessment Form:– Must be kept in the member’s record to substantiate

services beyond the initial assessment

• Combined Assessment Form

– Used for one initial assessment and follow-up

– One reassessment and follow-up per trimester occurring after the initial assessment

– One postpartum assessment

• Care Coordination Outcome Report– Send the Outcome Report to the Indiana State

Department of Health (ISDH) regardless of when the patient has finished care


•Following up to verify or reschedule appointments

•Locating services sources

•Making appointments

•Arranging transportation

•Making home visits (including the postpartum home visit)

•Referring member to the Social Security agency

•Performing follow-up activities to ensure services were received

Prenatal Care Coordination Services

Care Coordination Services


Case management services for pregnant women:

•Active, ongoing process of assisting the member to identify, access, and use community resources and coordinate services to meet individual needs

•Third Party Liability edit overrides for care coordination services

•Providers not required to file for reimbursement from other insurers

Care Coordination ServicesPrenatal Care Coordination

Services


Notice of Pregnancy – Effective July 1, 2009

The Office of Medicaid Policy and Planning (OMPP), managed care organizations (MCOs), the Indiana State Department of Health (ISDH) and other Medicaid stakeholders worked jointly to develop a universal assessment for pregnant women to capture:

• Maternal Obstetrical History• History of Prior Births (Still birth, Pre-term, Low Birth Weight)• Diagnosis of Pregnancy Risk• Maternal Medical History (including conditions that require

management during pregnancy - HTN, Diabetes)• Current Medications• Mental Health History and Current Conditions• Substance Abuse/Use History • Tobacco Use History • Social Risk Factors• Needed Referrals


•Reimbursement of $60 to the physician/clinic per Notice of Pregnancy (NOP) submitted within five calendar days of the prenatal visit

•Other details:– Provider must submit a claim to be reimbursed for NOP

form submission

– NOP form submission may be billed one time per member, per pregnancy

– Providers submit the NOP form via Web interChange

– Providers bill for submission of the NOP form using procedure code 99354 with modifier TH

Note: Procedure code and reimbursement available July 1, 2009

ReimbursementNotification of Pregnancy


•Print a hard copy and complete during the exam

• Enter information electronically from hard copy or

•Enter the information electronically during the exam

•To qualify for payment, provider must:– Submit NOP within five calendar days from Date of

Service, and

– Complete NOP prior to 30 weeks gestation

Completing the NOPNotification of Pregnancy


Notification of Pregnancy

Click on the

appropriate

responses.

Then

click “Next”

Completing the NOP


Notification of Pregnancy

•Data is sent to the member’s MCO

•MCOs provide additional support services (for example, nurse case management, home visits) depending on needs of member

•MCO can also help with coordination between the physician’s office and member

•MCO will also coordinate with the prenatal care coordinator

•The OMPP will use the data to monitor outcomes of births and to develop programming that better meets the needs of pregnant women in Medicaid


Presumptive Eligibility – Effective July 1, 2009

•What is presumptive eligibility?

– A period of time during which a pregnant woman, who has been determined by a qualified provider to be “presumptively eligible,” may receive ambulatory prenatal services while her Hoosier Healthwise application is being processed

– Inpatient care, hospice, long-term care, delivery services, postpartum and services unrelated to the pregnancy or birth outcome are not covered


•To be eligible for Presumptive Eligibility (PE), a pregnant woman must:

– Be pregnant, as verified by a professionally administered pregnancy test

– Not be a current Medicaid member

– Be an Indiana resident

– Be a U.S. citizen or a qualified non-citizen

– Not be currently incarcerated

– Have gross family income less than 200 percent of the federal poverty level

Who is Eligible?Presumptive Eligibility


Many of the requirements for qualified providers are mandated by Federal Medicaid regulations:

1. Must be enrolled in Medicaid

2. Must provide outpatient hospital, rural health clinic, or clinic services as defined in sections 1905 (a)(2)(A) or (B), 1905(a)(9), and 1905(l)(1) of the Social Security Act

3. Must be trained and certified by the State (or designee) to perform PE functions

State-specific requirements include:

1. Must be able to verify pregnancy via a professionally administered pregnancy test

2. Must have Internet, telephone, printer, and fax access that is available to facilitate the PE and Medicaid application process

3. Must have Administrator access to Web interChange• Complete the Administrator Request Form to set up an

administrator

Presumptive EligibilityWho Can Be a Qualified Provider?


Qualified providers (QPs) may include the following provider types/specialties:– Family or general practitioner– Pediatrician– Internist– Obstetrician or gynecologist– Certified nurse midwife– Advanced practice nurse practitioner– Federally qualified healthcare center– Medical clinic– Rural health clinic– Outpatient hospital– Local health department– Family planning clinic

Who Can Be a Qualified Provider?Presumptive Eligibility


How the PE Process Works

• Check for any existing Medicaid coverage using the Eligibility Inquiry feature of Web interChange

• QP professionally administers a pregnancy test or accepts pregnancy test administered by another professional to determine if the patient is pregnant– Over-the-counter pregnancy tests cannot be used to

determine pregnancy for PE• If the patient is not covered by Medicaid, a QP-trained

staff member accesses the PE Application by clicking the “PE Application for Pregnant Women” button (Step 1)– The PE Application window is available during the

following business hours:• Monday-Friday – 8 a.m. to 6 p.m. (Eastern time)• Saturday – 8 a.m. to Noon (Eastern time)

Note: If applicable, the non-QP refers the patient to a QP to complete the PE application process



•QP enters the following information based on responses from the patient:– Applicant name, Social Security number, date of birth, home

address, mailing address, contact telephone, gender, marital status, gross income, family size, and race

•QP also answers “yes” or “no” to the following:– Indiana residency, incarceration status, verification of

pregnancy, U.S. citizenship, and whether or not an application for Medicaid/Hoosier Healthwise is pending

•Applicant responses are to be accepted by the QP without asking for verification documents– If presented, verification documents may be faxed with the

Hoosier Healthwise application



•QP provides the woman with access to a telephone to contact the enrollment broker (MAXIMUS)

•MAXIMUS explains the selection process to the woman and assists her to select a primary medical provider (PMP) and MCO

•QP ensures the woman’s PMP and MCO choices are written on her PE determination notice for reference

•MAXIMUS activates the patient’s PE number

If, on that day, the woman fails to contact MAXIMUS to make her PMP and MCO selections, her PE eligibility will terminate that day and the QP will receive no reimbursement for prenatal services



• Applicant is responsible for reviewing the printed Hoosier Healthwise application and providing additional responses as appropriate

• QP ensures the patient signs the Hoosier Healthwise application and faxes it to the Division of Family Resources (DFR). QP also faxes a statement signed by the physician or nurse indicating the woman is pregnant and the date the pregnancy began

• Modernized counties:– Direct questions about the Hoosier Healthwise application to the DFR

Document Center at 1-800-403-0864– Fax is sent to the DFR Document Center at 1-800-403-0864– Direct questions about the Hoosier Healthwise application to the

local DFR office– At http://www.in.gov/fssa/dfr/2999.htm, click “Where Do I Apply,”

then click on woman’s county of residence to locate county DFR telephone and fax information

– Fax is sent to the county DFR office



•PE Considerations:

– The above functions occur on the same day

– There is no PE coverage if the woman, who has been determined to be presumptively eligible does not select a PMP and MCO with the Enrollment Broker

– Women are eligible for PE only one time per pregnancy

– QP enrollment activities are performed on a voluntary basis

– QPs should allow approximately 15 minutes to complete PE functions


•Prenatal care coordinators can:

– Encourage clinics to become qualified providers

– Perform outreach to physicians to accept women with Presumptive Eligibility

– Refer pregnant women to qualified providers for eligibility determination

– Assist women with follow-up of Medicaid Application process

Presumptive Eligibility ProcessHow You Can Help


Helpful Tools – PE and NOP

•Bulletin about PE is scheduled for late April 2009

•Training of qualified providers is scheduled to begin in mid-May 2009

•Bulletin about NOP is scheduled for mid-May 2009

Both programs are scheduled to begin

July 1, 2009

Questions about PE and NOP can be directed to the Office of Medicaid Policy and Planning:

[email protected]


MCOs contracted in Hoosier Healthwise risk-based managed care (RBMC):

•Anthem

1-866-408-6132

•Managed Health Services (MHS)

1-877-647-4848

•MDwise

1-800-356-1204

•ADVANTAGE administers PrimeStep primary care case management (PCCM) and Care Select

1-800-889-9949, Option 3

Managed Care in the IHCPManaged Care


Care Management Organizations

•Two health plans were selected to function as care management organizations (CMOs) for the Care Select program

– ADVANTAGE Health SolutionsSM

www.advantageplan.com

1-866-504-6708

– MDwisewww.mdwise.org1-866-440-2449MDwise also serves as one of Indiana’s three Hoosier Healthwise MCOs


•Providers may not collect from a member or family member any portion of the covered service that is not reimbursed by the IHCP, except for copayments on transportation and pharmacy services and any member liability payment authorized by law

•Participating providers must accept the Medicaid determination of payment in full

Billing the IHCP Member for Noncovered ServicesBilling


You may only bill for authorized services. For services to be authorized they must:

•Meet the needs of the member

•Be a noncovered service by the IHCP or a covered service, which the member has exceeded the program limitations

•The member must understand, before receiving services, that they will be financially responsible

•Provider must maintain documentation showing the member accepted responsibility for the charges

Billing the IHCP Member, ExceptionsBilling


•Remittance Advices (RAs) provide information about claims processing and financial activity related to reimbursement

– RAs contain internal control numbers (ICNs) with detail-level information

– RAs give detail status (paid or denied)

– RAs give payment amount

See the IHCP Provider Manual, Chapter 12, for more details

Statement with Claims Processing InformationRemittance Advice


The ICN is a 13-digit number assigned to each claim

•The region tells how the claim was submitted

– 20 – electronic with no attachments

– 21 – electronic with attachments

– 10 – paper with no attachments

– 11 – paper with attachments

– 50 – voids/replacements – noncheck-related

Region Year Julian Date

Batch Range Sequence

20 07 158 150 000

Internal Control NumberAdjudicated Claim Information


• “Replacement” is a HIPAA-approved term used to describe the correction of a claim that has already been submitted

• Replacements can be performed on paid and denied claims

• Denied details can be replaced or billed as a new claim

• To avoid unintentional recoupments, submit paper adjustments for claims finalized more than one year

• “Void” is the term used to describe the deletion of an entire claim

• Voids can be performed on paid claims only• Voids and replacements can be performed to correct

incorrect or partial payment, including zero dollar amount

Note: Paper replacements can only be processed on paid claims

Voids and ReplacementsClaim Adjustments


•Use the approved version of the CMS-1500 claim form

•Do not use staples or paper clips

•Verify that the claim form is signed, or complete the Attestation for Signature on File

•Review the RA closely

Helpful Hints

Paper Claim Filing


Top Five Denials for Care Coordination Services

1008 – Rendering provider must have an individual number

2006 – Members are eligible for emergency services only

2017 – Recipient ineligible on date(s) of service

0512 – Claim past filing limit

9018 – No payment made spend-down is > than IHCP allowed


• IHCP Web site at www.indianamedicaid.com

• IHCP Provider Manual (Web, CD-ROM, or paper)

• Customer Assistance

– 1-800-577-1278, or

– (317) 655-3240 in the Indianapolis local area

• Written Correspondence

– P.O. Box 7263Indianapolis, IN 46207-7263

• Provider Relations Field Consultant

– View a current territory map and contact information online at www.indianamedicaid.com

• Indiana State Department of Health

– (317) 233-1344

Avenues of ResolutionHelpful Tools


Questions


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Documents

April 2009 Prenatal Care Coordination Billing Presented by the EDS Provider Relations Field Consultants