Texas Workers’ Compensation Paper Medical Billing Form Changes

Effective April 1, 2014

Texas Department of Insurance, Division of Workers’ Compensation

Objectives

Part 1• Amended 28 Texas Administrative Code (TAC)

§133.10 Required Billing Forms/Formats

• New 1500 Health Insurance Claim Form Version 02/12 (CMS-1500) - professional services

• International Classification of Diseases (ICD)-9 and ICD-10 transition

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Objectives

Part 2• Medical Billing Process

Part 3• Centers for Medicare and Medicaid Services (CMS)

and Division of Workers’ Compensation (DWC) Resources

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PART 1

28 TAC §133.10 Required Billing Forms/Formats

28 TAC §133.10 Required Billing Forms/Formats

§133.10(a) requires electronic medical billing inaccordance with §133.500 and §133.501 unlessthe health care provider or insurance carrier isexempt from the electronic billing process inaccordance with §133.501.

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28 TAC §133.10 Required Billing Forms/Formats

• The purpose of the amendments is to reflect the changes in the newly updated CMS-1500 adopted by CMS.

• Changes were made to other paper billing form requirements for the purpose of aligning §133.10 to other DWC rules.

• Amendment changes are applicable to certified network, political subdivision, and non-network claims – see § 133.10(a).

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28 TAC Chapter 134 Benefits--Guidelines for Medical Services, Charges, and Payments

The DWC medical reimbursement rules addresswhen the most current reimbursementmethodologies, models, values, and weightsused by CMS are applicable with anymodifications addressed in those rules.

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• The updated CMS-1500 was approved by Medicare in June 2013.

• The updated CMS-1500 accommodates ICD-9 and ICD-10.

New CMS-1500

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28 TAC §133.10 Required Billing Forms/Formats

Requirements before April 1, 2014

CMS-1500 v08/05Field 1a - “999999999” if no

SS#Field 11 - “unknown” if the

claim number is not knownField 14 - no qualifier

requiredField 17 - no qualifier

requiredField 21 - no indicator

required

Requirements beginning April 1, 2014

CMS-1500 v02/12Field 1a - leave blank if no

SS#Field 11 - leave blank if the

claim number is not knownField 14 - qualifier 431

requiredField 17 - no qualifier

required (clarification)Field 21 - ICD-9 or ICD-10

indicator required 9

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CMS-1500 v02/12- Field 1a - leave blank if no SS#- Field 11 - leave blank if the claim number is not known

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CMS -1500 v02/12- Field 14 - qualifier 431 required- Field 17 - no qualifier required (clarification)

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CMS-1500 v02/12- Field 21 - ICD-9 or ICD-10 indicator required

(depending on date of service)- Field 24 - changed from numeric to alpha

Dates of service before October 1, 2014 *

Indicator “9” (field 21) 3-5 characters in length Approximately 13,000

codes Lacks detail

ICD-10 Diagnosis Codes

Dates of service on or after October 1, 2014 *

Indicator “0” (field 21) 3-7 characters in length Approximately 68,000

codes More specific

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ICD-9 Diagnosis Codes

* Transition currently set for October 1, 2014

28 TAC §133.10. Required Billing Forms/Formats (paper billing form instructions)

Professional medical bills submitted before April 1, 2014:

CMS-1500 Version 08/05

Professional medical bills submitted on or after April 1, 2014:

CMS-1500 Version 02/12

Note: §133.10 generally applies to health care providers submitting paper medical bills. 14

28 TAC §133.10. Required Billing Forms/Formats (paper billing form instructions)

Use the new CMS-1500 on or after April 1,2014 for both:

• Professional medical bills submitted for the first time; and

• All requests for reconsideration.

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Requirements before April 1, 2014

UB-04 (Institutional) Field 62 enter “unknown” if the claim number is not known

Requirements beginning April 1, 2014

UB-04 (Institutional) Field 62 leave blank if the claim number is not known

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DWC Form-066 (Pharmacy) Field 15 enter “unknown” if the claim number is not known

DWC Form-066 (Pharmacy) Field 15 leave blank if the claim number is not known

Dental form Field 15 enter “unknown” if the claim number is not known

Dental form Field 15 leave blank if the claim number is not known

28 TAC §133.10 Required Billing Forms/Formats

PART 2

Medical Billing Process

28 TAC §133.20. Medical Bill Submission by Health Care Provider

• A complete medical bill must be submitted within 95 days from the date of service, with some exceptions found in §133.20(b).

• Health care providers may correct and resubmit as a new bill an incomplete bill that has been returned by the insurance carrier in accordance with other billing requirements.

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28 TAC §133.250 Reconsideration for Payment of Medical Bills

If the health care provider is dissatisfied withthe insurance carrier's final action on amedical bill, the health care provider mayrequest that the insurance carrier reconsiderits action.

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28 TAC §133.250 Reconsideration for Payment of Medical Bills

The request for reconsideration must besubmitted: • not later than 10 months from the date of service

for retrospective denial

Insurance carrier shall take final action on areconsideration request: • not later than 30 days of receiving a request

reconsideration of a retrospective denial

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Dispute versus Complaint

Dispute Disagreement between system participants involving the entitlement to workers’ compensation benefits and the amount to be paid.

ComplaintGrievance in the course of a workers’ compensation claim about something that did not happen in accordance with the workers’ compensation laws or rules.

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28 TAC §180.1 Filing a Complaint

Complaint must be submitted in writing:• On-line:

http://www.tdi.texas.gov/consumer/complfrm.html

• By fax: 512-490-1030

• By e-mail: DWC-CRCSIntakeUnit@tdi.texas.gov

• By mail: DWC7551 Metro Center Dr., Suite 100MS-603Austin, Texas 78744

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Types of Disputes

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How do I know which dispute process to pursue?

The reason(s) for denial of payment directs the dispute resolution process. CEL

IROMFDR

Dispute Process?

Explanation of Benefits (EOB)28 TAC §133.240 Medical Payments and Denials

The paper form of an EOB must include:

• Claim adjustment reason code(s) that conforms to the standards described in §133.500 and §133.501 of this title if total amount paid does not equal total amount charged, and

•An explanation of the reason for reduction/denial

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American National Standards Institute (ANSI) Claim Adjustment Reason Codes Washington Publishing Company

http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/

Medical Fee Disputes and Resolution Process

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EOB claim adjustment code examples (not an exhaustive list)

Type of dispute

Form to use

Resolved by

Where to send

Link to Resources and Requirements

P12 - Workers’ Compensation jurisdictional fee schedule adjustment.

198 - Precertification/authorization exceeded.

Medical Fee Dispute

DWC Form -060 Medical Fee Dispute Resolution Request (MFDR)

Medical Fee Dispute Resolution (MFDR)

DWC –MFDR in Austin

http://www.tdi.texas.gov/

wc/mfdr/index.html

28 TAC §133.307 MDR of Fee DisputesNon-network claims

A request MDR of a fee dispute may be filed:

• Not later than one year after the date(s) of service in dispute.

• Not later than 60 days after the date the requestor receives the final decision, inclusive of all appeals, on a related compensability, extent of injury, or liability.

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28 TAC §133.307 MDR of Fee DisputesNon-network claims

A request MDR of a fee dispute may be filed:

• Not later than 60 days after the date the requestor received the final decision on medical necessity, inclusive of all appeals, related to the health care in dispute and for which the insurance carrier previously denied payment based on medical necessity.

• Not later than 60 days after the date of the receipt of a refund notice pursuant to a DWC audit or review.

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PART 3

CMS and DWC Resources

Resources

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Stay Current with CMS

• Staying current with changes in CMS policy is essential for health care providers and insurance carriers.

• It is easier to keep up with changes in Medicare if the health care provider focuses on the specific services that it provides, i.e. Physical Therapists look for Physical Therapy resources & changes, Hospitals look for Hospital resources & changes.

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Medicare BillerWorkers’

Compensation Biller

A good resource for the workers’ compensation biller is the person who bills for Medicare.

How would you bill Medicare?

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Medicare Learning Network (MLN) catalog ofproducts – A comprehensive listing of health care

provider/service specific fact sheets

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MLNCatalog.pdf

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Medicare Learning Network (MLN) catalog of products

CMS Home Page– Medicare home page for health care providers

which includes links to the “home” pages by subject matter or by health care provider type.

http://www.cms.gov/Medicare/Medicare.html

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CMS Home Page

CMS MLN Web-Based training– Includes how to sign-up for electronic mailing lists

to keep up with changes

http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNProducts/WebBasedTraining.html

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CMS MLN Web-Based training

Novitas Outreach & Education Page– Includes webinars– Organized by Part A or Part B

http://www.novitas-solutions.com

1. Select Jurisdiction H

2. Select Outreach and Education

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Novitas Outreach & Education Page

Medicare Claims Processing Manuals 100-04– Detailed payment polices related to coding, billing

and reimbursement by health care provider type.

http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMsItems/CMS018912.html?DLPage=1&DLSort=0&DLSortDir=asceding

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Medicare Claims Processing Manuals 100-04

CMS Transmittals and Corresponding MLN articles

– Contains Transmittals intended for Medicare Administrative Contractors or policy experts for implementation of policies/changes applicable in Medicare. They also contain detailed changes to 100-04 Medicare Claims Processing Manuals if needed for implementation (this is not always needed to implement a policy).

– Contains any corresponding MLN articles which are intended for health care provider education/implementation of policies/changes applicable to Medicare

http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/2013-Transmittals.html

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CMS Transmittals and Corresponding MLN articles

CMS TransmittalTransmittal R2842CP

Form CMS-1500 Instructions: Revised forForm Version 02/12

http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/2013-TransmittalsItems/R2842CP.html

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CMS Transmittal

CMS MLN Article MLN MM8509

CMS 1500 Claim Form Instructions: Revised for Form Version 02/12

http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/Downloads/MM8509.pdf

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CMS Information about ICD-10 - ICD-10 Introduction fact sheet and FAQs - Sign up for CMS ICD-10 Industry E-mail Updates

http://www.cms.gov/Medicare/Coding/ICD10/Index.html

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CMS Information about ICD-10

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National Uniform Claim Committee02/12 1500 Claim Form

http://www.nucc.org/index.php?option=com_content&viw=article&id=186&Itemid=138

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National Uniform Claim Committee02/12 1500 Claim Form

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DWC

Customer Service

Call DWC Comp Connection

800-372-7713 opt. 3

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DWC Health Care Provider Resources

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DWC eNews

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DWC eNews

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DWC Resources

Visit the DWC Health Care Provider Web Pagehttp://www.tdi.texas.gov/wc/hcprovider/compconnection.html

Subscribe to eNews to receive news about various Texas Department of Insurance issues

http://www.tdi.texas.gov/alert/emailnews.html

Send question by e-mail MedBen@tdi.texas.gov

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Learned ObjectivesPart I

Amended 28 TAC §133.10 Required Billing Forms/Formats

New CMS-1500 (professional services)

ICD-9 and ICD-10 transition

Part IIMedical Billing Process

Part IIICMS and DWC Resources

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Any Questions

?