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May 15, 2015
Informational
Presentation for
Elderly Wavier
Providers
Agenda
Part I - Authorization for EW Services
Part II – Billing Reminders
Part III – ICD-10
Part IV – Fraud Waste & Abuse
Part V – Reminders
Part VI - Resources
Authorization for EW Services: Presented by: Esther Versalles-Hester
Elderly Waiver Services
The Elderly Waiver funds Home and Community Based Services for people age 65 and older who are eligible for Medical Assistance (MA) and require the level of medical care provided in a nursing facility, but choose to reside in the community.
May be provided to persons living in:
Own home
Relatives home
Adult Foster Care
Customized Living/Assisted Living
Residential Care
How members qualify for EW?
Waiver Services may be requested by:
Member.
Member’s representative.
Primary Care Physician or Attending Health Care
Provider.
Care Coordinator/Case Manager.
Eligibility is determined by the results of a Long
Term Care Consultation (LTCC) Assessment
which completed by the Care Coordinator/ Case
Manager.
Eligibility for EW: After the LTCC is conducted, a care plan is developed
that documents the need for waiver services.
Services must meet the EW eligibility:
Member must be financial eligible.
DHS - 3543 form (Payment of Long-Term Care Services) filled
out by member.
DHS - 5181 form (Managed Care Organization/County/
Tribal Agency Communication Form-Authorization of
Home Care Services) sent to county financial worker.
No services may begin until financial eligibility is verified.
EW Services that support
members living in home:
http://mn.gov/dhs/people-we-
serve/seniors/services/home-community-
services/programs-and-services/elderly-waiver.jsp
Services Available in Qualified
Residential Settings:
Customized Living
24- Hour Customized Living
Residential Care Settings
Adult Foster Care
Services that support relocation
from Nursing Homes or
Institutions Transitional Supports
• Example would be Moving Home Minnesota
program
• Case Management
Non-covered EW Supplies and
Equipment(not all inclusive)
Items available through state plan- see DHS
Provider Manual Equipment and Supplies
Chapter.
Covered by third party payer including Medicare
or state educational or vocational agencies.
That is diversionary or recreational.
That is for comfort or convenience.
An item or support normally furnished by
members parents, family or spouse.
Does not meet an identified need.
Non-covered EW Supplies and
Equipment cont’d
Not approved in the Care Plan.
All prescription, and over the counter,
medications, compounds and solutions and
related fees and co-payments.
Costs related to internet access.
Animals, including service animals and their
related costs.
Exercise equipment.
Experimental or investigational equipment.
Authorization Process for EW
Services: Upon completion of the LTCC ( face to face)
assessment by the case manager/care coordinator:
1. The WSAF ( Waiver Service Approval Form) is sent
by the UCare delegated care coordinator/case
manager to UCare Clinical Services Intake, via fax
or secured e-mail.
2. Intake reviews the approval, ensures the form is
complete and aligns with DHS EW related policy.
Authorization Process for EW
Services cont’d:
3. An authorization is entered in the UCare system
and a letter is generated to the member and
provider of service.
4. Please note that UCare Internal care coordinator/
case manager staff, work with their care
management support team who enter
approvals directly into the UCare approval system.
Authorization Reminders:
Before providing EW services to a UCare member,
you must obtain written authorization through the
Case Manager/Care Coordinator or County Care
Coordinator.
As of March 1st 2015, Homemaking and EW
Transportation require an authorization for claims
payment purposes.
Please contact UCare Clinical Services Intake at:
612 676-6705 if you are in need of a copy of
the EW service approval letter.
Billing Reminders Presented by: Rebecca Walsh
Submitting claims to UCare Bill all EW services to
UCare electronically using
the 837P Professional
claim transaction. (This
corresponds to the paper
form called HCFA 1500.
The Rendering and Billing
segments are required –
how you complete them
varies, depending on your
provider setup, and there
are a couple submission
options.
Billing continued
Providers must enter a diagnosis code when
submitting claims.
Providers are required to use the most current,
most specific diagnosis code when submitting their
claims.
You need the UCare Member ID on the claim.
Use date spans only when you have provided
services for all dates in the span.
Date of Service / Submit As:
Line 1= 1/1/20YY – 1/1/20YY
Line 2= 1/3/20YY – 1/3/20YY
Line 3 = 1/5/20YY – 1/5/20YY
Line 1 = 1/1/20YY – 1/5/20YY
Line 1 = 1/1/20YY – 1/2/20YY
Line 2 = 1/5/20YY – 1/5/20YY
Monday 1/1/20YY
Wednesday 1/3/20YY
Friday 1/5/20YY
Monday 1/1/20YY
Tuesday 1/2/20YY
Wednesday 1/3/20YY
Thursday 1/4/20YY
Friday 1/5/20YY
Monday 1/1/20YY
Tuesday 1/2/20YY
Friday 1/5/20YY
Resource for EW Providers:
http://www.dhs.state.mn.us/main/idcplg?IdcService
=GET_DYNAMIC_CONVERSION&RevisionSelectionM
ethod=LatestReleased&dDocName=id_056766#P2
19_11562
Claim Example:
Date of
Service
from
Date of
Service to
Place of
Service
HCPC D
X
Fee Units
03/30/2015 03/30/2015 12 S5130 A 18.24 4 Pay
03/30/2015 03/30/2015 12 S0215 2.24 4 Deny
03/30/2015 03/30/2015 12 S5130 A 18.24 4 Pay
03/30/2015 03/30/2015 12 T2003 A 40.02 2 Pay
Billing Recipient Absences
Providers may not bill for days the recipient is
away from the home for the entire day and did
not receive any services.
Providers are required to bill only for days they
provide service and payment for these absent
days is not allowed.
Submission of Claim
When you submit claims for waiver program
services:
Use the Professional (837P) claim.
Bill only for services already provided.
Bill only for services approved on the
authorization.
EW Tiered Services
Tier 1 - Mandatory Enrollment through DHS as of
01/01/2014. UCare only uses DHS enrolled
providers for Tier 1 services.
Tier 2 and 3 –Strongly encouraged to enroll with
DHS.
How Does UCare Identify EW
Providers: NPI
National Provider
Identifier
1234567890
UMPI
Unique Minnesota
Provider Identifier
Q123456789
UCare Legacy Number
Group Practice Number
123456
A0123
If you have an:
NPI
Put the NPI in loop 2010AA
Leave the rendering loop blank
UMPI
Put the UMPI in loop 2010BB and 2310B /
segment REF02 with a G2 qualifier.
Providers Not Using NPI or UMPI
Put your UCare Group Practice Number in loop 2010BB
segment REF02 with qualifier G2 in Ref 01
Your UCare Legacy Number in loop 2310B / segment REF02
with a G2 qualifier.
Who do I contact with questions?
Provider Assistance Center
612-676-3300 or 1-888-531-1493 (toll free).
- Available Monday – Friday, 7 am to 5 pm.
Serves as a resource on your questions .
Presented by: Tim Nix
ICD-10 Is Coming Soon!
On October 1, 2015, the United States will
transition from ICD-9-CM to ICD-10-CM/PCS.
Everyone covered by the Health Insurance
Portability and Accountability Act (HIPAA) must
implement ICD-10 for medical coding, including:
Physicians.
Hospitals.
Ambulatory surgery centers.
Health plans and…
Elderly Waiver providers.
MHCP Rules for Providers
“MHCP requires agencies to enter the most
current, most specific primary diagnosis code
when submitting claims for most waiver and AC
services…”
“Use ICD-10 codes for services provided
October 1, 2015, or later.”
Be sure you are ready…
In addition to the appropriate HCPCS codes, your
claims must include an accurate ICD-10 diagnosis
code to be accepted for processing and payment.
Even though you may receive the diagnosis code
from a Care Coordinator, it is your responsibility
to ensure your claims are properly coded.
As of 10/1/2015, Payers Must…
National Drug Code – Claims Data Submission
Since October 2013, the Minnesota Department Action
Claims
coded in If...
ACCEPT ICD-9 Date of service or discharge on or before
9/30/15
REJECT ICD-9 Date of service or discharge after 9/30/15
ACCEPT ICD-10 Date of service or discharge on or after
10/1/15
REJECT ICD-10 Date of service or discharge before 10/1/15
REJECT Both Claim contains both ICD-9 and ICD-10 codes
Tips for ICD-10 Success?
Learn the differences between ICD-9 and ICD-10
diagnosis codes.
Be sure the diagnosis code on the claim is the
right one for the date you are providing services:
ICD-9 for dates BEFORE 10/1/15.
ICD-10 for dates AFTER 10/1/15.
If it is not, your claim will be rejected.
Contact the Care Coordinator for the correct
code before submitting your claim.
Submit current claims promptly to eliminate
backlogs.
When in doubt…
If you have questions for UCare about ICD-10, send
them to [email protected]. We welcome your input.
An additional resource on ICD-10 can be found at:
http://www.health.state.mn.us/auc/icd10/icd10inde
x.html
Fraud Waste & Abuse – Presented by: Julia Twaddle
Fraud, Waste & Abuse Special Investigations Unit (SIU)
-Detects possible cases.
-Investigates cases.
-Recovers overpayments.
-Prevents future issues.
-Post-payment review.
Fraud, Waste, Abuse:
•Billing for services that didn’t
occur.
•Altering documentation/claims.
•Duplicate claims.
•Services not authorized.
It is a federal crime to provide false
information on day services or transportation billings for
Medical Assistance (UCare) payment.
What are the rules? Federal Regulations
State Statute and Rules 9505.2175
Provider Contract (county or UCare)
Provider Manual
• Include member’s name on each page
• Date of chart entry and date service rendered
• Length of time, if a time-based code
• Signature and title of person who rendered
• Legible
• Each individual service
Records:
Do NOT: Do not bill for services when the member did not
attend
Do not bill 6 hours if the member wasn’t there all
6 hours (time based code)
Do not bill transportation if the member was not
picked up and/or dropped off by you
Do not bill more than authorized or without an
authorization (i.e., transportation)
Do not bill services you know should be denied
Do not bill based on the authorization
DO: Bill based upon records of service actually
rendered
Examples:
The member is out of the country visiting family
from February 1 through March 31. ADC provider is
authorized 6 hours per day 4 days per week and
billing company knows they are supposed to bill the
same every week. So the claims are submitted even
though the member did not attend.
This is fraud.
The care manager authorized the member to attend
6 hours per day, but the member actually comes for
only 4 hours because he leaves early every day to be
home for the family meal. ADC provider bills 6
hours anyway, because it was authorized.
This is fraud.
Kickbacks:
Compensation, bribe or rebate
Felony:$25,000 fine and/or 5 yrs. in prison
PROHIBITED:
coupons providing discounts
cash
merchandise
or other goods or services of value (gift cards)
in exchange for utilizing services from a particular
provider.
Avoid: Influence
What can you do?
Follow the rules.
Tell us when you make a mistake and fix it.
Cooperate with SIU when we come onsite or
contact you.
Report Suspected Fraud/Abuse: UCare Special Investigations Unit
P.O. Box 52 Minneapolis, MN 55440-0052
Anonymous reports can be made by calling
612-676-6525
Who Do I Contact?
Provider Assistance Center
612-676-3300 or 1-888-531-1493 (toll free).
- Available Monday – Friday, 7 am to 5 pm.
Serves as a resource if you have claim payment concerns that are trends, or have a significant impact on our accounts receivables.
Resources
Find other key resources on the UCare website
www.ucare.org/providers
Additional Reminders
EW Requirement.
Verify members eligibility monthly.
Bill appropriate codes.
Reimbursement based upon the DHS Fee Schedule.
Brief Overview of Presentation:
Authorization for EW Services
- Authorization process reviewed.
- New Auth Requirements effective 3/01/15.
Billing Reminders
- Bill Appropriate code for appropriate service.
ICD-10
- Effective 10/01/15.
Fraud Waste & Abuse
- Explained and examples provided.
Reminders
Resources
Questions & Answers
We look forward to working with you!
Спасибо Merci شكرا Gracias
Ua Tsaug Mahadsanid آپ کا شکریہ
Thank you
