Connecticut Medical Assistance Program Refresher for Home … · 2011. 8. 10. · version. Claims submitted via the Web prior to March 9, 2011 display 4010. Any and all future adjustments

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Connecticut Medical Assistance Program Refresher for Home Health ProvidersPresented by

The Department of Social Services

& HP for Billing Providers

2CT interChange MMIS

Training Topics

Home Health Agenda

•HIPAA 5010•Prior Authorization Request Process•New Connecticut Behavioral Health Partnership

•Common Claim Denials/Resolution•Program Resource Update•Questions


HIPAA 5010

The Department of Social Services (DSS) is implementing the new 5010 version of the HIPAA Transaction and Code Set Standards.

• HIPAA rules mandate that by January 1, 2012, all covered entities must submit transactions in the 5010 version. DSS will be mandating an earlier implementation date of November 15, 2011 for institutional claims.

• The new 5010 version impacts all electronic transactions, including client eligibility verification, and Web and paper claim submissions.

• DSS is staggering the cutover of the new 5010 transactions.

• HIPAA 5010 version updates can be accessed from the www.ctdssmap.com, information page, under HIPAA.

http://www.ctdssmap.com/�


Implementation Schedule

Transactions Implementation Dates

X12 270/271 Eligibility Verification - Batch 1/26/2011

X12 999 Acknowledgement 1/26/2011

Web Claim Submission and Web Eligibility Verification 3/9/2011

Provider Electronic Solutions (PES) TBD

Paper Claims Changes - Professional 4/27/2011

X12 837 Professional 4/27/2011

X12 837 Institutional 4/27/2011

X12 837 Dental 4/27/2011

X12 835 Remittance Advice 4/27/2011

X12 276/277 Claim Status 4/27/2011

Paper Claim Changes – Institutional 6/29/2011

Paper Claim Changes - Dental 7/27/2011


X12 999 Acknowledgement

The Centers for Medicare and Medicaid Services (CMS) has mandated a transition to the new 5010 version of the ASC X12 HIPAA Transaction and Code Set Standards effective January 1, 2012. As a result of the Department of Social Services 5010 implementation, the 999 Acknowledgement will replace the 997 Functional Acknowledgement.

• The new HIPAA 5010 Version of the 999 Acknowledgement can be accessed from the www.ctdssmap.com, information page, under HIPAA and clicking on the link “ASC X12N 999 Acknowledgement for Health Care Insurance Transactions.”

• The IK5 in the 999 replaces the AK5 reported in the 997. The 999 also reports an AK9. If both display an A in the first position, the file is accepted. If both display an R the file is rejected.



Web Claim Submission

A new field titled 837 Version indicates the claim’s HIPAA version. Claims submitted via the Web prior to March 9, 2011 display 4010. Any and all future adjustments to these claims will retain this 4010 version. Claims submitted via the Web on or after March 9, 2011 display 5010.

• All diagnosis panels will display version ICD-9 until the implementation of ICD-10 scheduled for 2013.

• Medical Record Number has been expanded to 50 characters.

• Referring Provider has been added at the header.

• Rendering Provider has been added at the header.


Web Claim Submission (Cont.)


Web Claim Submission (Cont.)

Medicare Allowed Amount field is removed.


HP Provider Electronic Solutions

• Upgrade your HP Provider Electronic Solutions software now to the current 3.76 version to ensure a smooth transition to the upcoming 3.77 5010 version of the software.

• Read the HIPAA 5010 Implementation of Provider Electronic Solutions – Provider Bulletin PB 2011-60

• Keep alert to notifications on the Provider Electronic Solution software implementation date and future training workshops.


ASC X12N 835 Health Care Payment/Advice Transaction

The new HIPAA 5010 Version of the X12N 835 Health Care Payment/Advice updates can be accessed from the www.ctdssmap.com, information page, under HIPAA and clicking on the link “ASC X12N 835 Health Care Payment/Advice.”

• This references the most significant changes to the 835 transactions.

– Client’s first and last name will be expanded to 35 and 60 characters respectively.

– The received date of the claim will be included in the 835.

– The corrected client name will be included when the name submitted on the 837 is different than the name in the client eligibility file.

• Both provider and trading partners must identify the complete scope of changes reported in the implementation guide.



HIPAA 5010 837 Institutional Electronic Claim Transaction

Effective April 27, 2011, DSS began accepting HIPAA 5010 X12N 837 Institutional Electronic Claim Transaction

• Existing formats (4010) will continue to be supported until a cutover date is announced, it is strongly recommended that you upgrade prior to that time.

• Important Changes

–5010 version identifier code is 005010X223A2

–Taxonomy qualifier of “PXC” will replace “ZZ”.

–The Service Location Address for all providers must be a street address, not P.O. Box. A nine digit zip code will be required.


Client Eligibility Verification

Web and 270/271 Eligibility Verification.

• The client’s address will be added to the eligibility response.

• The following data will no longer be provided in the eligibility response:

– Medicare coverage effective date and end date

– HIC

– PDP name

– PDP Plan ID

– Third Party Liability (TPL) Policy Number

– Policy Holder name

– TPL Coverage Type

– TPL Effective date and TPL End date


Client Eligibility Verification (Cont.)

• The eligibility response will include the program in which the individual has coverage in the Connecticut Medical Assistance Program along with the following service type codes if they are covered services for the client’s benefit plan.

• 1 - Medical 86 - Emergency Services• 4 - DX X-Ray 88 - Pharmacy• 5 - DX Lab 93 - Podiatry• 33 - Chiropractic 98 - Professional (Physician) Visit-Office• 35 - Dental AD - Occupational Therapy• 42 - Home Health Care AF - Speech Therapy• 45 - Hospice AL - Vision (Optometry)• 47 - Hospital DM - Durable Medical Equipment• 54 - Long Term Care MH - Mental Health• 56 - Medically Related PT - Physical Therapy

Transportation • 75 - Prosthetic Device RT - Residential Psychiatric Treatment• 82 - Family Planning UC - Urgent Care









The Automated Voice Response System (AVRS) will continue to return TPL information in the client eligibility verification response.

• Providers can access AVRS by dialing 1-800-842-8440 or locally to Farmington, CT at (860) 269-2028.

– Select option 1 for Self Service Options, enter the AVRS ID and PIN,

– Select option 1 for Eligibility Verification.

• The provider may also contact the insurer to obtain policy related information.


Web Account Maintenance

Clerk Account - AVRS ID and PIN



Primary Account Holder – Clerk Maintenance

• Add AVRS ID and PIN to clerk’s account

• If they cannot add it to the clerk’s account they would need to delete their clerk ID and set-up a new user ID.



Updating Provider’s address

• Sign into the secure Web portal as the Primary Account Holder

• Click on Demographic maintenance

• Click on the Location Name Address link beneath the Provider information panel.



Updating Provider’s address



Updating Provider’s address cont.

• Click on the Service Location row then click on maintain address.

• Change the service location address. A PO Box cannot be within Address 1 or 2 and a full 9 digit zip code is required.

• Click save in the bottom right corner of the panel.

• "Save was Successful" message should appear confirming the address change.



• Cont. Provider Account Holder - Updating Provider’s address


Prior Authorization

• Prior Authorization (PA) means the approval from the Department of Social Services (DSS), or a contracted agent of the Department of Social Services, for the provision of a service or the delivery of goods from the department before the provider actually performs the service or delivers the goods

• Obtaining PA does not guarantee payment or ensure client eligibility. It is the responsibility of the provider to verify client eligibility for the appropriate date (s) of service.


Prior Authorization – Medical Policy

Current Medical Policy requires Prior Authorization if:

• >2 nurse visits per week (Sun.-Sat.) for any combination of Skilled Nursing Services (S9123, S9123TT, S9124, S9124TT, T1502, T1502TT, T1503, T1503 TT).

• >14 hours per week (Sun.-Sat.) for Home Health Aide Services (T1004).

• >2 therapy services (PT/ST), per week, excluding initial evaluation (RCC 421/441).

• >1 therapy service (OT), per week, excluding initial evaluation (RCC 431).


Prior Authorization Request Process

Current Service Authorization

• Home Health services requested by a Home Health Agency or Connecticut Home Care (CHC) Services requested by an Access Agency (CCCI, SCCAA, SWCAA) are authorized based on the total plan of care for each procedure code within the span dates of service for which PA is requested.

• Providers, should request PA for all units of the procedure (s) to be serviced within the time frame requested.

Example: Client requires 3 units of S9123 per week for 6 weeks = 18 units of service. PA request should = 18 units.


Prior Authorization Request Process cont.Effective for dates of service June 1, 2010, providers can now request prior authorization for service combinations via a “procedure list” code as indicated:

Skilled Nursing

List code “SN”

Complex Nursing

List Code “CN”

Obstetrics Nursing

List Code “ON”

Medication Admin.

List Code “MA”

S9123 S9123 TG S9123 TH T1502

S9124 S9124 TG TE S9124 TH T1502 TT

S9123 TT S9123 TG TT S9123 TH TT T1503

S9124 TT S9124 TG TE TT S9124 TH TT T1503 TT


Prior Authorization Request Process (cont.)

• Benefits of requesting Prior Authorization via a “list code”

–Providers can submit claims for services in any combination on the “list code” up to the units authorized

• Note: an RN must assess the Plan of Care every 60 days

–Less frequent change requests• RN to LPN

• Oral or injection vs other

• Primary vs subsequent

–Reduce claim denials due to no service authorization

–Reduce rebilling after change of authorization has been completed


Prior Authorization -Request Process cont.Prior to submitting a Prior Authorization request to DSS Home Health Providers should:

•Verify client eligibility to determine the source of authorization (Managed Care Organization or DSS).

•Verify the primary reason for the visit does not fall in the CTBHP 291-316 diagnosis code range.

•Verify if there is an overlap in an existing PA for your agency to service the client

–If there is an overlap, determine if the existing or the new request is the primary reason for the visit.

»If new request is not the primary reason for the visit, contact the source of the existing PA for additional service authorization.


Prior Authorization –Request Process cont.

•If DSS is the source for authorization, complete the most current version of the PA form located on the www.ctdssmap.com Web site.

From the home page > Publications > Forms >Authorization/Certification Forms > Prior Authorization Request Form

–Providers may complete the PA form on line, print and fax or mail to HP

• Form completed on line cannot be saved

–Printed PA forms may also be handwritten

• Hand written forms should be prepared in a legible manner




Note:

Incomplete or illegible requests or those submitted on outdated forms will be returned.

• Forms returned by the provider should be resubmitted with the Return to Provider (RTP) letter indicating why the PA form was returned



•Fax your PA requests to HP:

•Initial PA request – Fax # (860)269-2138

•Reauthorization – Fax # (860)269-2137

•Changes to an existing service authorization due to an increase in service or change in the plan of care contact DSS at:

– Home Health PA changes - (860)424-5192

– CHC PA changes - (860)424-4906


Prior Authorization – Preparing the PA Form










New Connecticut Behavioral Health Partnership (CTBHP)

Effective April 1, 2011 Home Health Agencies are now required to authorize Home Health Services with the CT BHP Administrative Services Organization (ASO) Value Options (VO) when:

–the client is HUSKY A, HUSKY B, Charter Oak, Medicaid, or Medicaid Low Income Adults (LIA) and those with a Waiver benefit or covered under Money Follows the Person (MFP)

• Access Agency Care Managers will Contact CTBHP when the client is covered under Connecticut Home Care

–the plan of care exceeds the unit limit

–the primary reason for the visit is related to a behavioral health diagnosis in the range of 291-316

–medical services performed in conjunction with these primary behavioral health services that exceed the unit limit in the 291-316 range will also be authorized by CTBHP


New Connecticut Behavioral Health Partnership

Contact CTBHP at 1-877-552-8247 when the primary reason for the visit is between behavioral health diagnosis codes 291-316 and the plan of care will exceed these unit limits:

Note: Charter Oak clients are limited to a combination of thirty (30) nursing and therapy visits per client benefit year.


New Connecticut Behavioral Health Partnership cont.

Existing authorizations prior to April 1, 2011

•Will remain in effect until the units of service are exhausted

•Providers must contact VO for modifications to an existing PA, when the primary reason for the visit is related to diagnosis 291-316, for service such as:–Resumption of care

–Change in condition

–Conversion from a primary to subsequent patient

Note: Existing PAs will be end dated by VO to prevent authorization overlaps, causing the VO PA to “error off” resulting in possible future claim denials.


New Connecticut Behavioral Partnership cont.

Prior to requesting Prior Authorization providers should:

•check client eligibility to determine benefit limitations– Charter Oak benefits are limited

•determine if a PA already exists for the service authorization being requested– overlaps in PA may cause future claim denials

•request service authorization via a code list to avoid future modifications due to:

– RN/LPN

– Oral/injectables or other medication administration

– Primary or subsequent



CT BHP Claims Processing Guidelines

•Home Health Providers have:

–120 days to submit their CTBHP claims to HP for HUSKY A, HUSKY B and Charter Oak clients.

–One year to submit their CTBHP claims for Fee for Service and Medicaid LIA clients



•CTBHP claims processing follows Connecticut Medical Assistance Program Home Health PA audit guidelines as previously noted.

• PA requirements can be viewed on the CT BHP Web site at www.ctbhp.com, select For Provider, then click on covered services and under the authorization schedule select Home Health Care Agencies

•All other appropriate rules will be applied in processing these claims for payment.

http://www.ctbhp.com/�


Prior Authorization – Current Claims Processing – cont.

• Effective for dates of service June 1, 2010 and forward, if a PA exists for a procedure code or RCC within the span dates of service on a Home Health claim, all units paid will decrease the PA on file, up to the number of units authorized.

• Effective for dates of service July 1, 2010 and forward, if a PA exists for a procedure code within the span dates of service on a CHC or CHC Waiver claim, all units paid will decrease the PA on file, up to the number of units authorized.


Claim Resolution Guide

Provider Manual Chapter 12 – Claim Resolution Guide

• This guide lists commonly posted Explanation of Benefit (EOB) codes and provides a brief explanation of the reason why claims were either suspended or denied.

• This guide provides a detailed description of the cause of each EOB and more importantly, the necessary correction to the claim, if appropriate, in order to resolve the error condition.

• This guide also provides tips to assist providers to where they need to go to find additional information to help on correcting their claims.


Common Home Health Claim Denials

Edit 2522 – Bill Medicare first or provide appropriate adjustment reason code and date of HHABN or NMNOC.

• Cause

• Medicaid is payer of last resort. The client’s eligibility file indicates that the client has Medicare coverage and the Home Health claim was submitted without reference to a Medicare payment, Medicare denial or the reason a Home Health Advanced Beneficiary Notice (HHABN) or MCO Notice of Medicare Non-Coverage (NOMNC) was issued.

• Resolution

• The claim must either be billed to Medicare, or the HHABN or NOMNC must be issued to the client indicating the reason the client’s care does not meet Medicare coverage criteria.

• The claim must then be resubmitted to HP indicating either Medicare made a payment or denied the claim.


Common Home Health Claim Denials cont.

Edit 2522 cont.

• If the denial is due to a HHABN or NOMNC, the appropriate claim adjustment reason code must be entered to identify the reason the HHABN or NOMNC was issued.

• Detailed billing instructions for each of these examples are located in Chapter 11 of the Provider Manual, the Institutional Other Insurance/Medicare Billing Guide found on www.ctdssmap.com.

• Tip: Refer to Provider Bulletin PB10-06 found on www.ctdssmap.com for more information regarding Medicare Cost Avoidance of Home Health claims.



Edit 2522 cont.

Effective for dates of Service April 1, 2010 and forward, this Edit/EOB will set if client has Medicare A, B or A & B and:

• Adjustment reason code associated with MPA or MPB is other than 150, 151 or 152

• Date of HHABN or NOMNC is missing from the claim

• Claim filing indicator associated with MPA or MPB is MC.

(loop 2320 Other subscriber information –SBR 09 based on payer in 2330B)



• Edit 6230 – Plan of Care exceeded or PA required for greater than two nursing visits per week

–Applicable to Home Health claims with dates of service on or after June 1, 2010. (This code is currently not in the Claims Resolution Guide)

–Reasons for Denial:

• Original PA request was approved with modifications

Solution: Verify PA approved as requested on your secure web account – external notes on the PA/status confirm any modifications.

• PA authorized for a partial week and provider submits unauthorized and authorized units on the same claim

Solution: Recoup the claim and resubmit claims outside of the PA span date within the week first, then submit the services within the week with PA.



Reasons for Denial-Edit 6230 cont:

• PA units authorized have been used

Solution: Review paid claims for units of service used/authorized on your secure web account. Request additional units as needed.

Note: Units prior to request will not be authorized.

• Provider already paid for two nursing visits within the week (Sun. – Sat.) Codes in any combination include S9123, S9124, T1502, T1503 with or without the TT modifier.

Solution: Submit a PA request to DSS. Note: PA will not be granted for dates of service prior to request.

Note: It is important to reconcile processed claims as soon as possible.


Common Home Health Claim Denials cont.Reasons for Denial-Edit 6230 cont:

• A PA exists with overlapping dates of service and same procedure/list code with benefits exhausted due to a plan of care change (i.e. daily med admin changed to weekly pre-pour) or

• A PA exists with overlapping dates of service and same procedure /list code for another reason for service (i.e. PA for wound care and new service for med admin weekly pre-pour)

Solution: Perform PA inquiry on secure web account to determine PA overlaps in service. PA may need to be end dated or modified.Note: When a PA is in place for a specific procedure code/list

code within a specific date range, all claims billed for the same code and span dates of service will take PA, until the PA is exhausted. Once exhausted all claims for the same service within the span dates on the PA will deny.


Other News

•Increased CT BHP HUSKY Rates (PB 2011-40)

–Retroactive to July 1, 2008

•Increased CT BHP Charter Oak Rates (PB 2011-51)

–Retroactive to August 1, 2008

•Presumptive Eligibility Revised Form W-538 (PB 2011-57)

–Used for children under age of nineteen and pregnant women who have been determined to be presumptively eligible for HUSKY A or HUSKY B.


Resource Updates

•Connecticut Medical Assistance Program Web site

www.ctdssmap.com

–HIPAA 5010 • Quick access to all 5010 Connecticut Medical Assistance Program Publications

• From the home page under Important Messages >Welcome to the HIPAA 5010 Implementation Page

–HIPAA 5010 Transaction updates• From the home page > Information > HIPAA



Resource Updates

–New Connecticut Behavioral Partnership –CTBHP

• From the home page > Information > Publications > Bulletin Search > »PB 2011-15 »PB 2011-21

• Access the CTBHP Web site from the home page > Information > Links > CT Behavioral Health Partnership (CT BHP)

• Access the CTBHP Web site directly > www.ctbhp.com

http://www.ctbhp.com/�


Resource Updates cont.

–Home Health Prior Authorization changes• From the home page > Information > Publications > Bulletin Search > »PB 2010-41 »PB 2010-44

• From the home page > Information > Publications > Chapter 9 (Prior Authorization)

–Claim Resolution Guide• From the home page > Information > Publications > Chapter 13 > Claim Resolution Guide



–Institutional Other Insurance/Medicare Billing Guide• From the home page > Publications > Provider Manuals > Chapter 11 Institutional Other Insurance/Medicare Billing Guide

–Home Health Paper Claim (UB-04) Instructions • From the home page > Publications > Provider Manuals > Chapter 8 > select Home Health > view chapter 8 > Home Health Services Claim Submission Instructions



–Medicare Cost Avoidance Claims Processing

• From the home page > Information > Publications > Bulletin Search > »PB 2010-06

• From the home page > Provider > Provider Services > Provider Training > Medicare Cost Avoidance Claim Submission Requirements > Presentation



•HP Provider Assistance Center (PAC):–Monday through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays

–1-800-842-8440 (in-state toll free)–(860) 269-2028 (local to Farmington, CT)

•EDI Help Desk–Monday through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays

–1-800-688-0503 (in-state toll free)–(860) 269-2026 (local to Farmington, CT)


Connecticut Medical Assistance Program Refresher Workshop for Home Health Providers

Time for Home Health Questions

Documents

Connecticut Medical Assistance Program Refresher for Home … · 2011. 8. 10. · version. Claims submitted via the Web prior to March 9, 2011 display 4010. Any and all future adjustments