Home Health Care April 2019

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Overview

• Provider Enrollment

• Member Eligibility

• Covered Services

• Billing

• Additional Information

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Provider Enrollment

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Enrollment Requirements

• Providers must be certified as a home health agency for Medicare purposes in the

jurisdiction where they are providing services

• Enroll as a home health care provider with AK Medicaid

• If providing home health care out of state, must be enrolled in the Medicaid program in

the jurisdiction where they are providing services

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Enrollment Requirements (cont.)

Provider types the department will pay for home health services:

• Public or private organization may provide comprehensive services

• RHC/FQHC may provide limited home health services

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Update Provider Information

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Recordkeeping

• Recordkeeping requirements are documented in the Individual Provider Agreement and

Tax Certification and Group Provider Agreement and Tax Certification

• Although most recordkeeping requirements are consistent for all providers, some

requirements are provider-type specific

• Providers must maintain complete and accurate clinical, financial, and other relevant

records to support the care and services for which they bill Alaska Medical Assistance for a

minimum of 7 years from the date of service

• Providers are subject to audits, reviews and investigations

Providers must ensure their staff, billing agents, and any other entities responsible for any

aspect of records maintenance meet the same requirements.

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Member Eligibility

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Member Eligibility

Always verify member eligibility by using one of the following options:

• Request to see the member's eligibility coupon or card that shows the current month of

eligibility; photocopy for your records

• Call Automated Voice Response System (AVR):

– 855.329.8986 (toll-free)

• Verify via Alaska Medicaid Health Enterprise website

– http://medicaidalaska.com

• Fax complete Recipient Eligibility Inquiry Form - General

– 907.644.8126

• Submit a HIPAA compliant 270/271 electronic Eligibility Inquiry transaction

• Call Provider Inquiry

– 907.644.6800, option 1 or 800.770.5650, option 1, 1 (toll-free)

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Member Eligibility

Code Category FQHC RHC

11 Medicaid for Pregnant women X X

20 Family Medicaid or APA related Medicaid X X

24 Institutional Long Term Care Medicaid X

30/31 Waiver for adults with physical and developmental disabilities X X

34 Waiver APA/QMB X X

40/41 Older or disabled adult with waiver and Medicaid X X

44 Older or disabled adult with waiver Medicaid, APA and QMB X X

50 Medicaid for children under 21 who are not in state custody X X

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Member Eligibility

Code Category FQHC RHC

51 Medicaid for children under 21 who are in state custody,

including Title IV-E foster care

X X

52 4 months of Medicaid for members otherwise ineligible due to

earned income

X X

54 Medicaid-only for disabled child receiving SSI X X

69 APA/QMB – full Medicaid and QMB X X

70/71 IDD Waiver X X

74 IDD waiver, APA and Medicare X X

80/81 Medically complex children-waiver X X

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Covered Services

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Service Authorization

• Initial visit for evaluation is covered without service authorization

• All other services require SA

• SA must be requested on department form and include a written statement by the

attending physician that:

– Explains the need for home health services, including the reason services cannot be

performed in a clinic, outpatient setting, or physician’s office

– Includes medical recommendations for a plan of care provided on an ongoing basis or

after acute care

• SA will not be for longer than 60 days

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Face-to-Face Encounter

• For initiation of home health services, the patient must have a face-to-face encounter with an appropriate

practitioner, including:

– Physician

– Nurse Practitioner or Clinical Nurse Specialist

– Physician Assistant, under supervision of a physician

– For members admitted to home health immediately after an acute or post-acute stay, the attending

acute or post-acute physician

• Face-to-face encounter must be related to the primary reason the member requires home health

services, and must occur within 90 days before or 30 days after the start of services

• When the face-to-face encounter is provided by a non-physician provider, the clinical findings must be

communicated to the ordering physician

• Clinical findings must be incorporated into a written or electronic document included in the member’s

medical record

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Plan of Care

Plan of care must include:

• Pertinent diagnosis including mental status

• Types of services and equipment required

• Frequency of visits

• Prognosis for the recipient

• Analysis of the recipient’s rehabilitation potential

• Description of the member’s functional limitations

• Activities permitted to the member

• The member’s nutritional requirements

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Plan of Care (cont.)

• Plan of care must include:

– Member’s medication and treatments

– Any safety measures to protect the recipient against injury

– Instructions for a timely discharge and referral

• If plan of care cannot be completed until after evaluation, physician shall make additions or

modifications to the original POC as necessary to reflect the outcome of the evaluation

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Plan of Care Review

• The attending physician shall review the POC and initial and comprehensive assessments:

– At least once during the SA period

– More frequently if member’s condition has a significant change

– If member is discharged from home health agency and returns within the SA period

• Physician shall review need for supplies at least annually or more frequently for certain

items

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Initial Assessment

• To determine immediate care and support of the member

• Must be completed by an RN

• Must be completed by no more than:

– 48 hours after referral

– 48 hours after member’s return to place of residence

– Or by physician-ordered start of care date

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Comprehensive Assessment

• Must be completed by an RN

• Consistent with member’s immediate care and support needs

• No later than 5 days after the date care starts

• Must include a review of each medication the member currently uses in order to

determine:

– Significant side effects

– Ineffective drug therapy

– Duplicate drug therapy

– Member’s noncompliance with drug therapy

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Therapy Assessment

• If speech-language pathology or physical or occupational therapy is the only service

ordered by the physician, a speech-language pathologist or physical or occupation

therapist, as appropriate, may complete the initial and comprehensive assessments

• In this case, the medication review is not required as part of the comprehensive

assessment

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Home Health Services

• Alaska Medicaid covers home health services provided to a member in their place of

residence which may include an assisted living home licensed under AS 47.32

• All Home Health Services must be prescribed by a licensed physician as part of an

approved plan of care

• Services may include:

– Intermittent or part-time skilled nursing services provided by an RN or an LPN

– Home health aides services provided under RN supervision

– Physical or occupational therapies, speech-language pathology, and audiology services

provided by or under the supervision of a qualified practitioner

– Suitable home medical supplies

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Covered Revenue Codes

Subject to a provider’s scope of certification, license, or accreditation, AK Medicaid covers

these revenue codes for home health agencies:

• 0001

• 0270

• 0421

• 0431

• 0441

• 0551

• 0571

• 0572

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Rural Health Clinic Services

• Skilled nursing services provided by an RN

• According to written orders from the member’s physician

• Within scope of the provider’s license

• Provided by an enrolled rural health clinic

• When the location of the member’s place of residence is not served by any public or

private home health agency

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Place of Residence

• Services must be provided to the member in their place of residence

• May include an assisted living home

• Does not include a hospital, skilled nursing facility or intermediate care facility

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Billing

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Claims Submission Methods

There are several billing options for Alaska Medical Assistance providers.

• Alaska Medicaid Health Enterprise

• 837I Transaction (electronic claim using billing software)

– Companion Guide: http://medicaidalaska.com

– Implementation Guide (referred to as TR3): http://www.wpc-edi.com

• Payerpath (electronic claim)

• UB-04, Insitutional Health Insurance Claim Form (paper claim)

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NDC Pricing

• Payment for physician-administered drugs will be based on NDC and NDC quantity

• Exception- Payments currently based on per diem rates or a percentage of provider

charges

• Bill the NDC for the actual drug that is administered

• Record the NDC into the patient record

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NDC Claims

• Identified on 837I and UB-04 claims by revenue codes

• Identified on 837P and CMS-1500 claims by HCPCS codes

– Usually “J” codes

• Include on your claims:

– NDC number

– NDC units of measurement

– Numeric quantity

– Corresponding HCPCS values and units

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NDC Structure

NDC consists of 11 digits in three sections

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NDC Structure (cont.)

• Product label indicates: 54225-1798-29

• Submit on claim as: 54225179829

• Product label indicates: 452-72-89

• Submit on claim as: 00452007289

• Product label indicates: 45-6-9

• How would you submit this on a claim?

• The correct answer is 00045000609

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NDC Units

NDC billing unit standard:

• UN = unit

• ML = milliliter

• GR = gram

• F2 = International Unit

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Timely Filing

• All claims must be filed within 12 months of the date you provided services to the member

• The 12-month timely filing limit applies to all claims, including those that must first be filed

with a third-party carrier

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Additional Information

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Additional Resources

Alaska Medicaid Health Enterprise website at http://medicaidalaska.com

• Information necessary for successful billing

• Includes provider-specific Medicaid billing manuals and fee schedules

You may also call:

• Provider Inquiry

– Eligibility only – 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2

– Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650 (toll-free),

option 1,1,1

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