Upload
others
View
7
Download
0
Embed Size (px)
Citation preview
Indiana Health Coverage ProgramsDXC Technology
Durable & Home Medical Equipment (DME & HME)
Fee-for-Service
October 2017
2
Session Objectives
• Reference Materials• Provider Healthcare Portal• Service Descriptions• Manual Pricing• Updates• Helpful tools• Questions
3
Reference MaterialsReference material, code tables, fee schedules
4
Reference Materials
• Providers can stay abreast of current developments and research issues:– Banners and bulletins– News and announcements– Provider Reference Materials
• Medical Policy Manual• DME & HME Reference Module
– Code Tables– Subscribe to email notices– Fee schedules
5
Reference Materials
6
New Look for Subscribers!
7
8
DME & HME Reference Module
9
DME & HME Code Tables
10
Procedure Codes Requiring Attachments
11
Professional Fee Schedule
12
Provider Healthcare PortalPortal overview, web-based training, benefit limit details,
Written Correspondence, billing members
13
Provider Healthcare Portal
• What can you do in the Provider Healthcare Portal?– Submit, copy, edit, void claims– Check on status of claims– Verify eligibility– View, print remittance advices– Request prior authorization– Provider enrollment and revalidation– Secure correspondence– And more…..
14
Provider Healthcare Portal Login Page
15
Provider Healthcare Portal User Access
16
Search Payment History
17
Portal – Benefit Limits Details
Example• Benefit limit details listed in Portal eligibility screen:*
– 6113 DME Limited to $2,000 per Recipient per Calendar year– 6114 DME Limited to $5,000 per Recipient per Lifetime– 6085 Incontinence supplies limited to $1950/Rolling Year
*If the limitation does not appear on the eligibility screen, the service is available (based on fee-for-service claim data only)
18
Portal – Benefit Limits Details
Benefit limits are found on the Eligibility page
19
Provider Healthcare Portal
• Web-based training
20
DME, HME, SuppliesProvider Type, Description of Services, Classifications
21
Provider Type
Provider Type 25 Specialty 250 – DME Specialty 251 – HME Must have HME license
Each specialty has it’s own code set
Revalidation required every 3 years: Application fee & Background check FingerprintingRefer to www.indianamedicaid.com > IHCP Provider Type and Specialty Matrix for additional requirements
22
Description of Service
• Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and generally is not useful to a recipient in absence of illness or injury
• Must be ordered in writing by a physician
• Written order must be kept on file by physician and rendering provider
23
Description of Service
• Items include but are not limited to the following:
• Capped rental items • Inexpensive or other routinely
purchased items• Items requiring frequent or
substantial servicing • Customized items • Prosthetic and orthotic devices • Oxygen and oxygen equipment
24
Capped Rental Items
Capped rental items are procedure codes limited to 15 months of continuous rental• Continuous rental: rental without interruption for a
period of more than 60 days• If rental period exceeds 60 days, and the
interruption reasons are justified, a new PA request must be submitted to begin a new 15-month rental period
• Justification could change in medical necessity, hospitalization, or nursing facility stay
• A change in provider does not cause an interruption in rental period
• Capped rental items are subject to prior authorization
25
Items Requiring Frequent or Substantial Servicing
For items requiring frequent or substantial servicing, IHCP reimburses providers for rental payments only, as long as equipment is deemed medically necessary
• Claims for the purchase of these items are denied• Repair of rental items is responsibility of rental provider
• Table 4 – Procedure Codes for Equipment and Supplies Classified by the IHCP as Needing Frequent and Substantial Servicing
26
Customized Items
Custom equipment: equipment uniquely constructed or substantially modified to meet specific needs of an individual patient, according to description and orders of member’s treating physician• Due to their unique aspects, these
items cannot be grouped with similar items for purposes of payment
• Suppliers must submit documentation of cost of item, including cost of labor and types of materials used in customizing item
• Customized items must be billed using HCPCS code E1399 requires PA
27
Prosthetic and Orthotic Devices
All prosthetic and orthotic devices billed under HCPCS L codes are paid in lump sum amounts and may not be rented• Prosthetic and orthotic devices
billed with HCPCS L codes • Requires PA
All PA reviews based upon medical necessity
28
Oxygen and Oxygen Equipment
IHCP reimburses liquid and gaseous oxygen systems as rental-only items, subject to PA Reimbursement for oxygen contents is
included in reimbursement of oxygen system and is not separately reimbursable for rented systems Oxygen contents are separately reimbursable
when a third party has purchased an oxygen system, or IHCP or third party has rented or purchased a portable oxygen system
Accessories, including but not limited to cannulas, masks, and tubing, are also included in allowance for rented systems and are not separately reimbursable Accessories are separately reimbursable with a
purchased system
29
Manual Pricing
30
Manually Priced Items
Reimbursement for many DME services and supplies, including those that are billed with a non-specific HCPCS code with a description such as unspecified, unclassified, or miscellaneous are based on manual pricing• Manually priced HCPCS codes are
reimbursed at 75% of manufacturer’s suggested retail price (MSRP)
31
Manually Priced Items
• Documentation submitted with each claim may be monitored or subject to a post-payment review
• Manually priced DME, medical supply, and hearing aid procedure codes will continue to be reimbursed at 75% of MSRP
• Codes without an MSRP will be reimbursed at provider’s cost plus 20%
32
Manually Priced Items
• Manufacturer’s retail invoice or suggested retail price (MSRP) is required as acceptable documentation:o Manufacturer’s invoice showing MSRP,
suggested retail price, or retail price o Quote from manufacturer showing MSRP,
suggested retail price, or retail price o Manufacturer’s catalog page showing MSRP,
suggested retail price, or retail price (publication date of catalog must clearly show on documentation)
o MSRP pricing from manufacturer’s website (manufacturer’s web address must be visible on printed documentation from its website)
33
Manufacturer’s Suggested Retail Price
MSRP documentation must include:• Manufacturer’s name clearly visible on header of documentation• MSRP pricing (for example, MSRP/Retail) typed from manufacturer o No handwritten notes or pricing will be accepted
• Description of item• Specific HCPCS code
34
Approved MSRP Documentation
Date Descriptions
Manufacturer’s suggested retail price
Manufacturer’s LogoManufacturer’s Name
35
Approved MSRP Documentation − Quote
36
Approved MSRP Doc. Catalog Page
Catalog page must have publication date
37
Approved MSRP Documentation − Website
38
Updates
39
DME Codes No Longer Billed with NU
• Effective April 28, 2017, the IHCP revised billing guidelines for DME codes billed with NU modifier
• Claims billed with NU will be denied with EOB code 4033-Invalid procedure code modifier combination
• Refer to banner BR201713 for a list of affected codes (most are Q codes)
40
DME & Supplies Covered as Home Health Service
Effective May 1, 2017, the IHCP revised coverage policy for home health services• For coverage of certain DME & supplies as a home health service,
documentation of face-to-face encounter must occur no more than six months before start of service.
• Examples: – Decubitus care equipment– Oxygen and related respiratory equipment– Monitoring devices– Compression devices
Refer to bulletin BT201723 for complete list
41
Red-and-White Claim Form
• Effective January 1, 2018 the IHCP will require the below claim types to be submitting for processing on the appropriate red and white forms.
– CMS-1500 (02-12) – professional claims – UB-04 (CMS-1450) – institutional claims
• The IHCP will no longer accept copied (black and white) claim forms on or after January 1, 2018.
• Claims not received on the red-and-white claim form on or after January 1, 2018, will be returned to the provider.
42
Helpful Tools
43
Helpful Tools
• IHCP website at indianamedicaid.com– IHCP Provider Reference Modules– Medical Policy Manual
• Customer Assistance available 8am-6pm EST Monday –Friday
– 1-800-457-4584• IHCP Provider Relations Field Consultants– See the Provider Relations Field Consultants page at
indianamedicaid.com • Secure Correspondence via the Provider Healthcare
Portal • Written Correspondence
– DXC Technology Provider Written CorrespondenceP.O. Box 7263Indianapolis, In 46207-7263
44
QuestionsFollowing this session please review your schedule for the next session you
are registered to attend