hp provider relations october 2010 waiver billing

HP Provider RelationsOctober 2010

Waiver Billing

Waiver Billing October 20102

Agenda– Session Objectives

– Definition of Medicaid Waiver

– Member Eligibility

– Billing

– Claim Form and NPI

– Electronic Claim Filing

– Paper Claim Filing Hints

– Remittance Advice

– Adjudicated Claim Information

– Claim Voids and Replacements

– Helpful Tools


Objectives

At the end of this session, providers will understand:

– Definition of a Medicaid waiver

– Indiana’s two new demonstration grants

– Waiver provider enrollment process

– Requirements necessary for a member to qualify for waiver services

– How spend-down impacts claim processing

– How to verify member eligibility

– How to submit and adjust claims

DefineMedicaid waivers


Definition of a Medicaid Waiver

– In 1981 the federal government created Title XIX Home and Community-Based Services Program

– This act, referred to as the waiver program, created exceptions to, or “waived,” traditional Medicaid requirements

– A waiver is what the State government requested from the Centers for Medicare & Medicaid Services (CMS) to obtain additional funding through the Medicaid program• It allows for the provision and payment of Home and Community-Based Services (HCBS) that are not provided through the Medicaid State plan

– Medicaid waiver programs are funded with both State and federal dollars

– All Indiana waiver programs have been initiated by the Indiana General Assembly and approved by CMS


What Is the HCBS Waiver Program?

– Traditionally, Medicaid paid for institutional-based services only; however, the HCBS waiver programs allowed services to be “waived” from Traditional Medicaid payment methodology

– The Medicaid HCBS waivers fund supportive services to individuals in their own homes or in community settings, rather than in a long-term care facility setting

– The Medicaid HCBS waivers fund services to individuals who:• Meet the level of care specific to a waiver

• Meet the financial limitations established by the waiver


What Is the HCBS Waiver Program?

– In addition to waiver services, waiver members receive all Medicaid services under the State Plan (Traditional Medicaid), for which they are eligible

– The State administers seven HCBS waivers and grants under three categories:• Nursing Facility Level of Care Waivers (includes three waivers/grants)

• Intermediate care facility for the mentally retarded (ICF/MR) Level of Care Waivers (includes three waivers)

• Psychiatric Residential Treatment Facilities Level of Care Grant


HCBS Waivers

Nursing Facility Level of Care Waivers and Grant

Administered by the Division of Aging (DA)

– Aged and Disabled Waiver (AD)

– Traumatic Brain Injury Waiver (TBI)

– Money Follows the Person Demonstration Grant (MFP)

ICF/MR Level of Care Waivers

Administered by the Division of Disability and Rehabilitative Services (DDRS)

– Developmental Disabilities Waiver (DD)

– Autism Waiver (AU)

– Support Services Waiver (SS)


HCBS Waivers

Psychiatric Residential Treatment Facilities Level of Care Grant

Administered by the Division of Mental Health and Addiction (DMHA)

– Community Alternatives to Psychiatric Residential Treatment Facilities Demonstration Grant (CA-PRTF)


Community Alternatives to Psychiatric Residential Treatment Facilities

– Demonstration project through CMS

– Goal is to demonstrate that cost-effective, intensive community-based services can serve as alternative to treatment in a psychiatric residential treatment facility (PRTF) or assist in a child/youth’s transition back to the community from a PRTF

– More than 41 million federal dollars for five-year duration

– Seven services are offered: Wraparound Facilitation, Wraparound Technician, Respite Care, Non-Medical Transportation, Habilitation, Clinical and Consultative Clinical and Therapeutic Services, and Training and Support for Unpaid Caregivers

– More information about services offered and rates: www.in.gov/fssa/dmha/6643.htm

http://www.in.gov/fssa/dmha/6643.htm


Community Alternatives to Psychiatric Residential Treatment Facilities

– 56 Indiana counties serve as access sites for grant services

– DMHA is seeking more counties to serve as access sites to allow for statewide access

– Additional counties may participate as an access site if:• The county can document that it meets the requirements; or,

• A DMHA-approved access site in another county agrees to provide services on behalf of the interested county


Money Follows the Person Grant

– Demonstration program through CMS

– Helps interested individuals transition out of a nursing facility and into a community-based setting

– ADVANTAGE Health Solutions case managers help facilitate transition

– Participants may receive waiver services plus additional program services:• Additional transportation

• Personal Emergency Response System

– After 365 days, participants transfer seamlessly to one of the waivers


IFSSA Waiver Divisions

The following divisions support the administration of the HCBS waivers and grants:

–Developmentally Disabled, Support Services, and Autism Waivers:

Division of Disability and Rehabilitative Services402 W. Washington St., Room W453Indianapolis, IN 46207

–Aged and Disabled and Traumatic Brain Injury Waivers and Money Follows the Person Demonstration Grant:

Division of Aging402 W. Washington St., Room W454Indianapolis, IN 46207

–Community Alternatives to PRTF Demonstration GrantDivision of Mental Health and Addiction

402 W. Washington St., Room W353Indianapolis, IN 46204

DescribeMember eligibility


Member Eligibility

Medicaid enrollment process starts with the Division of Family Resources (DFR):

–Enters member application into the eligibility tracking system known as the Indiana Client Eligibility System (ICES)

–Determines member eligibility status

–Makes spend-down determinations

–Maintains member information and eligibility files

Where it begins


Member Eligibility

– If an individual is found to meet waiver Level of Care requirements but is not Medicaid-eligible, the individual may become Medicaid-eligible under special waiver eligibility rules

Where it begins


Waiver Program Member Eligibility

Members must qualify for waiver program eligibility

– Individuals who meet waiver Level of Care status and are Medicaid eligible may be approved to receive waiver services

– A limited number of slots are available for each waiver and the waiver slot number is approved by the CMS

– A Medicaid-eligible individual cannot receive waiver services until:

• A funded slot is available

• A waiver Level of Care is established for the member

• A cost-comparison budget is approved (demonstrates cost-effectiveness of waiver services when compared to institutional costs)


Waiver Program Member Eligibility

Once eligibility requirements are met:

– A case manager, along with the client and/or client’s representative, as well as other service providers, develop a Plan of Care (POC), and/or an Individualized Support Plan, which is reviewed by the State

– The Notice of Action (NOA) lists the approved services the client may receive, along with the approved date span, units, and charge per unit

– Information from the NOA is sent to HP for placement on the member’s Prior Authorization (PA) record for appropriate claims payment

– Claims pay only if PA dollars, units, and services are available for the dates of service submitted on the claim

– An approved Notice of Action is not a guarantee of claims payment– Providers must verify member eligibility to ensure Medicaid eligibility has not

been lost


Member Eligibility

– Receives member data from ICES

– Updates IndianaAIM within 72 hours

– Provides and supports the Eligibility Verification System (EVS)

– Makes EVS available 24 hours a day, seven days a week

HP role


Member Eligibility

Three EVS options are available:

– Automated Voice Response (AVR)

• 1-800-738-6770, or

• (317) 692-0819, Indianapolis area

– Omni swipe card terminal device

– Web interChange

How to verify


Automated Voice Response

AVR provides the following:

– Member eligibility verification

– Benefit limits

– Prior authorization

– Claim status

– Check write

Contact AVR at (317) 692-0819 in the Indianapolis local area or 1-800-738-6770

EVS using the telephone


Omni

– Is cost effective for high-volume providers

– Uses plastic Hoosier Health card

– Allows manual entry

– Prints two-ply forms

– Requires upgrade for benefit limit information

See Chapter 3 of the IHCP Provider Manual for more information or also available at ww.indianamedicaid.com

EVS card-reading device


Web interChange

The following is available throughWeb interChange:

–Member information available by Member ID, SSN, Medicare Number, or Name and DOB

–Spend-down information

–DFR information

–Detailed third-party liability (TPL) information

–Online TPL update requests

–Web interChange is accessible via http://provider.indianamedicaid.com

EVS using the Internet

http://provider.indianamedicaid.com/

LearnWaiver billing information


Waiver Billing

– Notice of Action• Lists the approved service provider

• Lists the approved service codes

• Gives the approved number of units and dollar amounts

– CMS-1500 claim form• Use service code approved on the NOA

• Include all modifiers listed with the service code – U7 will identify this is a waiver service

– Refer to the HCBS Waiver Provider Manual for information regarding:• Service definitions

• Allowable services

• Service standards

• Documentation standards


Authorized Services

You may only bill for authorized services. For services to be authorized they must:

–Meet the needs of the member

–Be addressed in the member’s Plan of Care (POC) and/or Individualized Support Plan (ISP)

–Be provided in accordance with the definition and parameters of the service, as established by the waiver


Claim Form and National Provider Identifier– Waiver providers should submit their claims electronically via the

837P transaction or on Web interChange

– The CMS-1500 claim form is used when submitting paper claims

– Electronic submission may be used on the CMS-1500 professional tab

– Waiver providers are considered atypical and are not required to report a National Provider Identifier (NPI) on their claim

– Waiver providers may submit claims using their Legacy Provider Identifier (LPI) as they have in the past

– Waiver providers do not report or use a taxonomy code

Note: Targeted case managers who provide traditional Medicaid services for determining the waiver Level of Care should report and use their NPI


Spend-down

– Spend-down is assigned by the Division of Family Resources at the time of the eligibility determination

– The member is aware of the spend-down amount and responsible for fulfilling that obligation

– HP credits the member’s spend-down based on the usual and customary charge billed on the claim

– Spend-down is credited on claims based on the order they are processed

– ARC 178 appears on the Remittance Advice when spend-down is credited on claims

– Providers may bill the member for the amount listed beside ARC 178

– Member is responsible to pay upon receipt of the Spend-down Summary Notice


Web interChangeProfessional Claims – Medical


Claim Completion


Adjudicated Claim Information

The internal control number (ICN) is a 13-digit number assigned to each claim

–The region tells how the claim was submitted•20 – electronic with no attachments

•21 – electronic with attachments

•10 – paper with no attachments

•11 – paper with attachments

•50 – voids/replacements – noncheck-related

Internal control number


Paper Claim Filing

– Use the approved version of the CMS-1500 claim form

– Do not use staples or paper clips

– Verify that the claim form is signed, or complete the Attestation for Signature on File

– Send paper claims to:

HP Waiver Program ClaimsP.O. Box 7269Indianapolis, IN 46207-7269

– Review the Remittance Advice (RA) closely

Helpful hints


Remittance Advice

– RAs provide information about claims processing and financial activity related to reimbursement

• RAs contain internal control numbers (ICNs) with detail-level information

• RAs give detail status (paid or denied)

• RAs give payment amount

See the IHCP Provider Manual Chapter 12 for more details

– Paper RAs no longer mailed to providers

• RAs available on Web interChange

• Check/RA Inquiry function

• Effective September 1, 2009

Statement with claims processing information


Claim Adjustments

– “Replacement” is a HIPAA-approved term used to describe the correction of a claim that has already been submitted

– Replacements can be performed on paid, suspended, and denied claims

– Denied details can be replaced or billed as a new claim

– To avoid unintentional recoupments, submit paper adjustments for claims finalized more than one year from the date of service

– “Void” is the term used to describe the deletion of an entire claim

– Voids can be performed on paid claims only

– Voids and replacements can be performed to correct incorrect or partial payment, including zero dollar amount

Note: Paper replacements can only be processed on paid claims

Voids and replacements

ResolveMost common denials


Most Common Denials

– Cause• The claim is an exact duplicate of a previously paid claim

– Resolution• No action required, as the claim has already been paid

Edit 5001 – Exact Duplicate


Most Common Denials

– Cause• Waiver provider has billed for a recipient who does not have a waiver Level of

Care for the date of service

– Resolution• Contact the waiver case manager to verify the LOC information is accurate

• Verify the correct date of service has been billed

• If code billed is incorrect, correct the code and rebill

Edit 2013 – Recipient Ineligible for Level of Care


Most Common Denials

– Cause• Provider has billed a procedure code that is invalid for the waiver program

– Resolution• Verify the correct procedure code has been billed

• Verify the procedure code billed is present on the Notice of Action

• Correct the procedure code and rebill your claim

Edit 4216 – Procedure Code not Eligible for Recipient Waiver Program


Most Common Denials

– Cause• The date of service billed is not on the prior authorization file

– Resolution• Verify the correct date of service has been billed

• Verify the date of service billed is on the Notice of Action

• If the incorrect code is billed, correct the code and rebill

Edit 3001 – Date of Service Not on PA Database

Find HelpResources Available


Helpful ToolsAvenues of resolution

– IHCP Web site at www.indianamedicaid.com

– IHCP Provider Manual (Web, CD-ROM, or paper)

– HCBS Waiver Provider Manual

– Customer Assistance• Local (317) 655-3240

• All others 1-800-577-1278

– Written Correspondence• HP Provider Written CorrespondenceP. O. Box 7263Indianapolis, IN 46207-7263

– Provider field consultant

http://www.indianamedicaid.com/


Helpful ToolsAvenues of resolution

– Division of Disability and Rehabilitative Services402 W. Washington St., Room W453Indianapolis, IN 46207

– Division of Aging402 W. Washington St., Room W454Indianapolis, IN 46207

– Division of Mental Health and Addiction402 W. Washington St., Room W353Indianapolis, IN 46204

hp provider relations october 2010 waiver billing

Documents

waiver services

waiver slide

waiver billingoctober

waiver members

medicaid waiver indianas

hcbs waiver programs

waiver billing slide

medicaid waivers