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Alabama Medicaid UpdateTina G Pippin
Dental Program DirectorAlabama Dental Association Annual Session
June 16, 2006
Medicaid Overview
Medicaid “Rules”
• Medicaid was established in 1965 by federal law to provide medical assistance to low income and resource individuals.
• States may choose to have a Medicaid program, but must comply with all federal Medicaid requirements once a program has been implemented.
• Funded through a federal and state partnership (generally 70/30 in Alabama)
“Rules” continued
• Federal law sets minimum eligibility and benefit levels.
• With few exceptions, Alabama’s program is at the federal minimum level for eligibility.
• Alabama has one of the most conservative benefit packages in the country.
• Medicaid cannot make any more program cuts and still be in compliance with federal regulations.
Don’t be confused…
• Medicaid is a federal and state program and provides medical assistance to low income and resource individuals.
• Medicare is a federal program to provide medical insurance generally to individuals aged 65 and older.
Who Determines Eligibility
• Three Alabama agencies certify individuals for Medicaid.
• Agencies certify certain groups of individuals for Medicaid based on their circumstances.
• These agencies are:
• The Social Security Administration
• The Department of Human Resources
• The Alabama Medicaid Agency
The Face of Medicaid
DemographicsFY 2005
Medicaid covers:
• 20.7% of Alabama’s total population (includes all eligibility categories)
• 46% of all deliveries in Alabama
• 37.9% of Alabama’s children (under 19)
• 19.7% of Alabama’s elderly (65 and above)
• 74% of nursing home days in Alabama
Total Medicaid Eligibles As a Percentage of Alabama’s Population
Note: Includes individuals eligible for Plan First
FY
Medicaid Children Under age 19 as a Percent of Alabama’s Child Population
FY
Children in Working Families As of September 2005
Source: Obtained for MLIF and SOBRA populations based on information from Medicaid applications as filed.
Eligible and Payment Distribution By AgeFY 2005
Medicaid Eligibles by Aid CategoryFY 2005
Eligibles Percent Distribution by Race FY 2005
Cost Per Eligible FY 2005
By Category
By Gender
By Age
Economic Impact
Hospital
Care
Primary
Care
Maternity
Care
Pharmacy
MEDICAID
High Medicaid CountiesFY 2005
These 12 counties have the highest concentration of Medicaid eligibles across the general population (30% or greater).
Bullock 35% Lowndes 33%
Butler 33% Macon 31%
Conecuh 31% Marengo 30%
Dallas 41% Perry 43%
Greene 40% Sumter 39%
Hale 32% Wilcox 46%
These 11 counties have the highest concentration of Medicaid eligibles across the children’s population (50% or greater).
Bullock 66% Lowndes 55%
Butler 56% Macon 50%
Conecuh 56% Perry 63 %
Dallas 65% Sumter 65%
Greene 66% Wilcox 71%
Hale 50%
High Medicaid CountiesFY 2005
• In FY 2004, Medicaid paid approximately $3.7 billion to providers for various health care services rendered; $2.7 billion represents federal funds brought into the State.
• In FY 2005, Medicaid paid approximately $3.9 billion to providers for various health care services rendered; $2.8 billion represents federal funds brought into the State.
Economic Impact
Medicaid expenditures supported more than 84,323 jobs in various industries within the state.1
1 Economic Impact of the Alabama Medicaid Agency on the Economy of the State of Alabama and its Counties, Amy K. Yarbrough, MSHA, MBA, Administrative Fellow, University of Alabama at Birmingham
Economic Impact (continued)
Medicaid payments
5 counties receive in excess of $100 millionJefferson $520 million
Mobile $252 million
Tuscaloosa $144 million
Madison $127 million
Montgomery $315 million
• 8 counties receive payments in excess of $60 million.
• 16 counties receive payments in excess of $40 million.
• 31 counties receive payments in excess of $20 million.
Financial Impact by County
FY 2005
• Without Medicaid revenue, critical components of Alabama’s healthcare infrastructure could not continue to exist.– 52% of the patient days at The Children’s
Hospital of Alabama are paid for by Medicaid.
– 77% of the patient days at USA Children’s and Women’s Hospital are paid for by Medicaid.
Source: Information obtained from Medicare Cost Reports as filed.
Financial Impact by Hospital
Program Funding
Federal Funds70.83%
Benefit Payments98.0%
Administrative Costs 2.0%
State Funds29.17 %
Where It Comes From, Where It Goes
FY 2005
Hospital22.7%
Pharmacy16.4%
Nursing Facilities22.7%
Waivers7.2%
Adminstrative2.2%
Dental1.3%
Physicians7.0%
Health Services2.2%
Insurance4.8%
Mental Health Services
4.5%
Community Services
8.1%
MR/DD0.8%
Distribution of PaymentsExcluding Hospital Disproportionate Share Payments
FY 2005
Dental Care ExpendituresFY 1998-2005
Millions
FY
Medical Care ExpendituresFY 1994-2005
Billions
Excludes DSH payments, enhancements, and pharmacy rebates
FY
• Medicare Modernization Act, 2003
• Health Insurance Portability and Accountability Act
(Currently implementing NPI)
• Pryor Amendment, 1990 (Mandated open drug formulary)
• OBRA 1989 (Mandated the EPSDT program)
• CCA 1988 (Mandated coverage of QMB)
History of Unfunded Mandates
General Fund ContributionsMedicaid as a Percent of the GF
FY
Medical Services Update
Town Hall Presentation to
Provider Support Personnel
Goal
Improve health care outcomes for Medicaid recipients
through creation of a medical home while containing the escalating cost of quality
health care.
Basic Program Concepts
• Providers enroll as a Primary Medical Provider (PMP)
• Patients are assigned to a PMP
• Services must be provided directly or through referral (NO REFERRAL needed for Dental Services)
• PMPs are paid a monthly case management fee based on signed contract
Who Can Be A PMP?
• Pediatricians
• Internists
• Family Practitioners
• General Practitioners
• OB/GYNs
• FQHC
• RHC
• Specialists (ex: special needs child)
Who Is IN Patient 1st?
• SOBRA Children
• MLIF Eligibles
• Infants Of SSI Mothers
• Aged
• Blind
• Disabled
Who is NOT In?
• Foster Children
• SOBRA Adults
• Dual Eligibles
• Institutionalized (nursing homes, group homes, MR facilities, DYS)Lock-Ins
• Enrollees of Private HMO
• Medically Exempt
Real World Numbers
• 1,018 PMPs Enrolled– 944 Physicians– 74 Clinic Based
• 448,708 Total Enrollees– 84,247 Over 21– 364,461 Under 21
* As of 4/20/06
Moving Into the 21st CenturyTools to Help the PMP Manage the Patient
In-Home Monitoring
InfoSolutions
ePrescribing
In-Home Monitoringaka Disease Management
• Partnership with USA Hospital and the Alabama Department of Public Health (ADPH)
• Telemetry concept
• Targets chronic diseases through claims utilization
• Diabetics initial phase
• Can monitor blood sugars, weight and blood pressure
• Coordination with Primary Physician
• Supported with case management
• Web based with real-time reporting available
InfoSolutions
Purpose is to inform providers of prescription activity based on Medicaid paid claims data.
• Desktop or PDA tool for physicians
• Download patient prescription information
e-PrescribingComponent of InfoSolutions
• Download prescription history
• Automatically alerted to potential drug-to-drug interactions
• Prescribe/refill multiple medications
• Print prescriptions up to 30 feet away using Bluetooth technology
• Establish “favorites” list of frequently prescribed medications
• View both Blue Cross/Medicaid formulary
Plan f irst• Different from “regular”
family planning
• Have to use enrolled providers
• Providers dispense birth control pills and the “patch”
• Nuva Ring is not covered
• Women will have to recertify each year
Successful … very
• 95,448 women enrolled (3/06)
• Teen enrollment grew by 21% during 1st five years
• 9,014 births averted in DY 4 (10/03-9/04)
• Approximately 25% of women utilize private providers (in addition or instead of public)
• Enrollees were 42% more likely to use contraceptives and 33% more likely touse effectively
Pharmacy Update
Prescription UtilizationFY 2005
4.052.27
3.68
5.46
8.49
0
1
2
3
4
5
6
7
8
9
10
RX Per Month
Medicaid Total
Pediatric
Non LTC Adult
Adult
Long Term Care
Pharmacy ExpendituresPercent Change from Previous Year Net of Rebates
• The Preferred Drug List (PDL), monthly brand limit, and system edits continue to be important management tools.
• These programs are estimated to save 20% of the pharmacy program expenditures in FY 2007.
Program Update
Projected FY 2007 expenditures with program initiatives - $443.6; without initiatives - $554.5; before rebates.
Medicaid Fiscal Division
Monthly Brand Limit
• July 1, 2004 a monthly brand limit was implemented, allowing 4 brand prescriptions per month with unlimited generic and OTC prescriptions.
• Children and nursing home patients are excluded.
• Anti-psychotic and anti-retroviral drugs are allowed up to total of 10 brand prescriptions.
• Allowances are made for additional brands per month for certain classes if a physician needs to “switch” a patient from one brand to another in the event of adverse or allergic reactions.
PDL Update
• November 1, 2003 a Preferred Drug List (PDL) was implemented, requiring that drug classes be reviewed by our Pharmacy and Therapeutics (P&T) Committee for clinical recommendations for inclusion into the PDL.
• Medicaid is currently re-reviewing implemented classes into our PDL to ensure up-to-date clinical information is taken into consideration for PDL clinical decisions.
Medicare Part D Update
a
Medicare Prescription Drug Coverage
What Do You Need To Know?
Medicare Basics
• Part A– Hospital Insurance
• Part B– Medical Insurance (doctor visits)
• Part C– Medicare Advantage
• Part D– NEW Medicare Prescription Drug Benefit
Eligibility and Enrollment
• Entitled to Part A and/or enrolled in Part B
• Must reside in the plan’s service area
• Program voluntary (for most)
• Must enroll with the drug plan
• Monthly fees apply (for most)
Prescription Drug Benefit
• Available to everyone with Medicare
• Provides coverage for brand-name and generic drugs
• Medicare contracts with private companies
• Benefit started January 1, 2006
• Extra help with drug cost available for many people with limited income and resources
Initial Enrollment Period
• November 15, 2005 through May 15, 2006
• Penalty of 1% per month added to monthly fee if
– Enrollment is delayed and
– Beneficiary is without “creditable coverage”
Coverage Varies by Plan
• Select the Plan that meets your needs
• Plans may not cover all drugs
• Plans must give a 60-day notice if they decide not to cover a drug
• Plans must have Appeals process
What to do if your Prescription Plan will not pay for your medicine?
• Check with your doctor to see if he/she can switch you to a
medicine that the plan will cover
• Change Plans
• If your medicine can not be changed ask your doctor to request an appeal on your behalf
Requesting a Coverage Determination or Appeal
• Beneficiary can request
• Appointed representative
• Prescribing physician can request
• Others can assist with form completion, letter writing, etc.
Need Help With Medicare Part D?
Call 1-800-MEDICARE (1-800-633-4227)
Visit www.medicare.gov
For extra help:
- Social Security Administration
- 1-800-772-1213
- www.socialsecurity.gov
- 1-800-AGELINE (1-800-243-5463)
Questions regarding Medicaid (1-800-362-1504) Visit www.medicaid.state.al.us
Resources
• Enrollment and Appeals Guidance http://www.cms.hhs.gov.gov/PrescriptionDrugCovContra/06_RxContracting_EnrollmentAppeals.asp
• “How to File a Complaint, Coverage Determination, or Appeal” http://www.medicare.gov/Publications/Pubs/pdf/1112.pdf
Dental Program
Premise
Good oral health prevents pain, suffering,
missed days of school or work and
unnecessary costs due to dental treatment.
Why Is Good Oral Health Important?
• Dental related illness causes poor children to “miss” 12 times more school days than children from higher income families
• Poor oral health has been associated with other medical problems including heart disease and premature births
Is There An Oral Health Problem In Alabama?
• Two out of five Alabama schoolchildren are estimated to have untreated tooth decay
• Almost 70% of low-income children in Alabama did not visit a dentist last year
Is There An Oral Health Problem In Alabama?
• Alabama has 30% fewer dentists per capita than the nation and our dentists are not distributed evenly (38 dentists in Alabama versus 54 per 100,000 population nationally)
• One-third of all Alabamians over age 65 have no teeth, the 9th highest percentage in the country
Dental ProgramVision Statement
To ensure every child in Alabama enjoys optimal health by providing equal and timely access to quality, comprehensive oral health care, where prevention is emphasized promoting the total well-being of the child.
Alabama Medicaid Dental Program
• Approximately 450,000 Medicaid eligible children with limited access to dental services
• 8 counties with no Medicaid dentists or one Medicaid dentist
• Limited participation in other counties with most not accepting new Medicaid patients
Currently…..
• Increased dental rates to 100% of BCBS 2001 rates
• More procedure codes covered
• Increased provider assistance
• Made case management services available
• Increased enrolled dentists to over 700
Where to begin?
• Where do I find ______?
Alabama Medicaid Provider Manual
• Updates Quarterly
• Provides All Information on Policy and Billing
• Now Available on CD Rom
• You are responsible for policies listed in the manual.
Chapters you need….
Chapter 1 Introduction
Chapter 2 Enrollment
Chapter 3 Eligibility
Chapter 4 Prior Authorization
Chapter 5 Filing Claims
Chapter 6 Receiving Reimbursement
Chapter 7 Rights and Responsibilities
Chapter 13 Dental
Appendix
• Appendix B Electronic Media Claims (EMC) Guidelines
• Appendix E Medicaid Forms
• Appendix G Non-Emergency Transportation (NET)
• Appendix I Outpatient Hospital and ASC Procedures
• Appendix J Explanation of Benefit Codes
• Appendix K Third Party Carrier Codes
• Appendix L AVRS Quick Reference Guide
• Appendix N Medicaid Contact Information
Come On Board!!!
• How do I become a provider?– For an enrollment application Contact
• EDS provider enrollment unit 1-888-223-3630 • Medicaid’s dental program 1-334-242-5997
– EDS issues a 9 digit provider number (effective the first day of the month the application is received)
– You must receive a provider number for each physical location where you perform services
Provider’s Rights
• Keep records for 3 years plus current
• Provide same services to Medicaid patients as all other patients
• Can bill recipients when services are non-covered or patient exceeded limits
• Can limit number of patients seen, days seen or ages
Chapter Three--EligibilityWho is eligible?
Three important questions to ask…
– Are they eligible?
– Are they under the age of 21?
– Do they have full Medicaid benefits?
Verifying Eligibility
Three Primary Ways
1. Provider Electronic Solutions Free Software provided by EDS. Quick response time – one at time or in batches
2. Automated Voice ResponseToll free Number 1-800-727-7848Available 23 hrs/day, 7 days per week
3. Secure Website: https://almedicalprogram.alabama-medicaid.com/secure/logon.do
Provider Assistance Center
Toll free number 1-800-688-7989 • Speak with a representative
• Verify up to 6 recipients at a time
• NOTE: If you want claims history information, you must ask for a provider representative.
Dental Benefit Information
• Provides last two PAID dates of service for the following codes:• Panoramic X-rays – D0330• Full Series X-rays – D0210• Oral Exams – D0120 or D0150• Prophylaxis/Fluoride – D1110,
D1120, D1201, D1203, D1204, D1205• Space Maintainers – D1510, D1515,
D1520, D1525, D1550
Third Party Liability (TPL)
• Verify at each visit
• Apply all payments received toward services rendered
• If incorrect - update recipient file by calling:
A-G 334-242-5280H-P 334-242-5254Q-Z 334-242-5279
Prior Authorization
• Who…
• What…
• When …
• Where?
How to Obtain a Prior Authorization
• Use the Prior Authorization Dental Request Form (form 343) in provider manual Chapter 4 (can copy)
• Mail to: EDS PO Box 244032 Montgomery, AL 36124-4032
• Note: X-rays must be mailed in a separate sealed envelope
and be of diagnostic quality
Prior Authorization
Some of the services requiring Prior Authorization:– Complete Bony Extractions– Periodontics– Space Maintainers after the first two
Look in Chapter 13 for complete list.
Inpatient and Outpatient Hospitalization
• Required for children ages 5 through 20 when medical criteria is met
• Not required for children under age 5
• Reimbursed for recipients older than 21 when dental problems have exacerbated underlying medical condition
Hospital Care
• Dentists must have all procedures loaded to prior authorization file to get paid
• Use correct place of service
• Hospitals use D9420 for payment for facility fee
• Must receive prior authorization number from dentists for children 5 or greater
Emergency Prior Authorization
• Call the Dental Program at 334-242-5997– Talk with staff or leave a
voice message with the following information:
– Recipient’s name and Medicaid number
– Provider number of dentist– Phone number of dentist– Fill out Prior Authorization
Request Form 343 and mail that day
Chapter 13Dental Program
• Examinations
– D0120 Periodic: Once every six months (not to the date/within the same month)
– D0140 Limited oral: Problem focused, once per recipient per provider per year and cannot be billed in conjunction with periodic or comprehensive. Need to document what done.
– D0150 Comprehensive: Once per recipient per provider, must document!
Prophylaxis and Fluoride Billing
• When billing for prophylaxis and fluoride treatment performed on the same date of service for a recipient, use the appropriate combined code :
• D1201 Topical fluoride with prophylaxis - Child (up to and including age 12)
• D1205 Topical fluoride with prophylaxis – Adult (over 12 years of age)
Radiology
• Full mouth and panoramics
are covered every three years
at age 5 (exceptions by report)
• Posterior bitewing and
single anterior can be taken
every six months
• BW-4 Films limited to age 13
and older
• Must be of diagnostic quality
Space maintainers
• Non-covered for premature loss of primary incisors and placed greater than 180 days after the premature loss of a primary tooth
• Non-covered for permanent tooth
• Limited to one per recipient’s lifetime for a given space to be maintained
• Bill the space where tooth was extracted
• If extraction of tooth is not is Medicaid paid claim history, you must send in for override
Endodontics
• Pulp caps without a protective dressing are non-
covered
• D3120 - Indirect pulp caps covered for deep carious
lesions on permanent teeth only
• D3220 - Therapeutic pulpotomy covered for primary
teeth only; not billable with other endo codes
• Criteria for pulpal therapy and root canals
Incomplete Procedures
• Applies to multiple appointment procedures i.e. root canals and crown
• Effective July 1, 2003, payment is made to the provider that started the procedure
• Must have documentation in record of multiple attempts to complete procedures (letters, phone calls)
• Subsequent provider should know that procedure is considered non-covered
Crowns and Core Buildups
• Covered following root canal therapy ONLY
• Crowns limited to permanent teeth
• Recipients must be 15 years of age
• Cast post and core must beradiographically visible, one-half length of canal
• Must have post-op x-ray after crown inserted
What if the root canal is not in paid claims history?
• Send in for an administrative review with a clean claim and x-ray showing completed root canal therapy and crown inserted (DO NOT send in for a prior authorization.)
• Only send claim with procedures needed for review
• Send to the Medicaid Dental Program
Periodontics
• Only codes covered include D4341 scaling and
root planing, D4355 full mouth debridement and
D4910 periodontal maintenance
• All require prior authorization with periodontal
charting and/or radiographs
• Criteria listed in Chapter 13-22 and 13-23
Oral Surgery
• Primary teeth limited to D7140 unless
by report for valid indications
• Prior authorization required
for D7240 and D7241
(by report)
• Surgical extractions require
documentation listed in
Chapter 13-24
• Extractions due to crowding to
facilitate orthodontics are non-covered
Palliative (Emergency) Treatment D9110
• This must not be billed with definitive treatment or emergency procedures.
• These procedure codes
include:
-D0210 -D0350 -D0470 -D9220 -D9610-D1110 through D7971
Non-Covered Services
• These include, but are not limited to dental implants, prosthetic treatment (bridgework, partials or dentures), all porcelain crowns, esthetic veneers and adult dental care.
• Refer to Provider Manual Chapter 13 for details.
Show me the money!
Reimbursment
Paper Claims
• Only ADA-approved claim forms are acceptableVersion 2002,2004
• OCR Scannable form recommended
• CDT2005 codes must be used (D-codes)
• There will be a release of CDT2007 in January
When it is required to send a paper claim?
• When filing:– Accident Form XIX-TPD-1-76
– Third Party Denial
– Administrative Review/ Override
Why bill electronically?
• Less than two week turn-around on claims
• Immediate claim correction
• Enhanced online adjustment functions
• Improved access to eligibility information
Enhances effectiveness and efficiency
Enhancements
• Can now use LAN, ISP or DSL connection
• View EOP within software
• Claim status
• Send adjustments/reversals electronically
Important Facts to remember…
• Tooth numbers 1-9 must have a “0” in front when billing (example 01)
• Primary teeth - use letters
• Supernumerary teeth – NEW VALUES!
• Place of service codes include:– 11 office– 22 outpatient, requires prior authorization– 21 inpatient, requires prior authorization – 31 nursing facility, requires prior authorization
Oral Cavity Codes
• 00 – Full Mouth
• 01 – Upper Arch
• 02 – Lower Arch
• 10 – Upper Right Quadrant
• 20 – Upper Left Quadrant
• 30 – Lower Left Quadrant
• 40 – Lower Right Quadrant
Filing Limit
• Medicaid requires all claims for Dental providers be filed within one year of date of service.
• Providers should process claims for payment as soon as service is completed.
• 120 days from other insuranceEOP date
• 120 days from adjustment, if past the filing limit
Administrative Review
• Must be received within 60 days of the date the claim became outdated
• Must have documentation showing attempts to get claim paid (see Chapter 7-6)
• Mail to:Alabama Medicaid AgencyDental Program Administrative ReviewPO Box 5624Montgomery, AL 36103-5624
Changes to MMIS - 2007
Introducing interChange,
The New Alabama Medicaid System
Medicaid Modernization
• Improvement/ Focus Areas:
• Create an NPI compliant system
• Improve Technology for AMA
• Improved Provider Access
• Faster Claims Processing
• New Interactive Web Portal
• Interactive Claims Submission
• Immediate claim correction capabilities
• Improved EOP Retention
• Provider Electronic Solutions
• Upgrade Only
• NPI Numbers Utilized
What Will Change With The New System?
Alabama Medicaid
Provider Community
interChange
interChange Highlights
System Features•Real-time claims processing•Interactive claims submission•Browser-based screens•Eligibility verification•Providers can correct and resubmit claims immediately•24x7 Provider access•Claim Status Inquiry
interChange HighlightsEligibility
interChange HighlightsClaims Submission
interChange HighlightsClaims Inquiry
interChange HighlightsExplanation of Payment
interChange HighlightsViewing Submitted Claims
Upcoming Events
• Claims processing will continue in current system as performed today
• Send your NPI information to EDS when requested (ALERT will be sent/read Provider Insider)
• Training Classes for providers will be conducted in Spring 2007
Smile Alabama!
• Primary goals: – Increase number of Medicaid dental
providers– Increase number of children
receiving dental care
• Other goals: – Provider training and support– Patient education– Assistance with claims processing
– Patient education tools/resources
Medicaid’s Dental Outreach Initiative
Targeted Case Management
• Case management by social workers and nurses– available through the EPSDT program
– Assistance with patient education, follow-up on missed appointments, coordination of services, transportation.
– http://www.medicaid.alabama.gov/documents/Program-Pt1st/Care_Coord_ContactList_1-19-06.pdf
Available Tools
• Alabama Medicaid Provider Manual
– Available on CD-Rom
– Policy/procedure information on all Medicaid Programs
• Provider Insider Newsletter
– Published bimonthly
– Policy changes and clarification on existing policy
• Alert Bulletins
– “Urgent” information published as needed
More Tools
Mini Messages– Part of EOP statements– Gives status of system
problems/claims issues– Notice of any recoupments/
re-processing of claims
Medicaid Web site: (www.medicaid.alabama.gov)
– Contains contact information– Forms– Provider Notices– Fee Schedules
Important Numbers To Remember
• Medicaid– Dental Program (Policy Questions) 334-242-5997
Fax 334-353-5027– Recipient Inquiry Unit (Toll-free) 1-800-362-1504– Outreach/Education (Educational Materials)
334-353-5203
• EDS– Provider Assistance Center (Billing Issues)
1-800-688-7989– Provider Enrollment (Enrollment Issues)
1-888-223-3630– EMC (Electronic Claims Submission Issues)
1-800-456-1242
NETNon-Emergency Transportation
• Requires Prior Authorization • Provides transportation vouchers to patients
(like a check)• Vouchers must be signed by dentist• Covers one escort for recipients under 21• Must be done 5 days prior to appointment,
unless urgent• Call 1-800-362-1504, press #3
What’s happened since last year…
Health Watch Technologies (HWT)
• Medicaid is working with Health Watch Technologies (HWT) to further insure payment integrity.
• HWT will provide a cross functional team to include professionals in medicine, law, public policy, hospital administration, nursing, mental health, and data analysis.
Review Algorithms
Examples of review algorithms
• CDT and HCPC coding guidelines to insure appropriate billing of comprehensive codes, mutually exclusive codes, and modifier use
• Regulation and policy based rules to include coverage limitations and non-covered services
• Unbundling review of lab and ER services, surgical procedures and procedures
Review Algorithms
Examples continued:
• Unreasonable volume to indicate excessive units of a service
• Duplicate billings of the same claim or same service by multiple providers
• Recipient utilization of narcotics, or other services that indicate potential drug seeking behavior
National Provider Identifier…NPI
• Covered providers can begin applying for NPIs May 23, 2005
• Compliance date applicable to most entities is May 23, 2007– By this date, covered entities
must use only the NPI to identify providers in standard electronic transactions.
– http://nppes.cms.hhs.gov
– www.ada.org
NPI: The Concept
• Provides the ability to bill all health plans uniformly – no longer necessary to use different identifiers for different health plans, contracts, locations
• Billing will be simplified
• COB payments will come sooner
• If 100% paper, does not apply
Healthy Smiles for
Healthy Children
It’s All About
AND you call who?
Medicaid Dental Program Tina Pippin
Iola Dow334-353-8473
EDSCyndi Crockett
Provider Relations Supervisor 334-215-4170
Questions….
