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Waiver Billing Presentation

Presented by the EDS Provider Field Consultants

October 2007 Waiver Billing Presentation

AgendaWelcome and Announcements

• Session Objectives

• Definition of Medicaid Waiver

• Provider Enrollment

• Member Eligibility

• Billing

• Claim Form and NPI

• Spend-down

• Paper Claim Filing Hints

• Remittance Advice

• Adjudicated Claim Information

• Claim Voids and Replacements (Adjustments)

• Helpful Tools

• Questions


Session Objectives

At the end of this session, providers will be able to:

• Understand the definition of a Medicaid waiver

• Understand the waiver provider enrollment process

• Understand requirements necessary for a member to qualify for waiver services

• Understand how spend-down impacts claim processing

• Understand how to verify member eligibility

• Understand how to submit and adjust claims


Definition of 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 and Medicaid Services (CMS) to obtain additional funding through the Medicaid program -it allows for the provision and payment of HCBS services 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 five HCBS waivers under two waiver categories:

–Nursing Facility Level of Care Waivers (includes two waivers)

–ICF/MR Level of Care Waivers (includes three waivers)


HCBS Waivers

Nursing Facility Level of Care Waivers

Administered by the Division of Aging

• Aged and Disabled Waiver (AD)

• Traumatic Brain Injury Waiver (TBI)

ICF/MR Level of Care Waivers

Administered by the Division of Disability and Rehabilitative Services

• Developmental Disabilities Waiver (DD)

• Autism Waiver (AU)

• Support Services Waiver (SS)


IFSSA Waiver DivisionsThe following divisions support the administration of the HCBS waivers:

• 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:

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


Provider Enrollment Process

• The prospective waiver provider initiates the waiver enrollment process by contacting one of the two Indiana Family and Social Services Administration (IFSSA) waiver divisions

• The waiver divisions coordinate a thorough certification process with the prospective provider

• A waiver provider must be certified by the appropriate waiver division at the IFSSA before EDS can process a Medicaid waiver enrollment application


Provider EnrollmentProcess

• Download the IHCP Waiver Provider Application:

– Visit www.indianamedicaid.com

– Go to the Provider Services tab

– Choose Provider Enrollment from the drop down list

– Access the link titled Enroll a New Provider in the IHCP

– Print the IHCP Waiver Provider Application and Maintenance Form

• Complete the enrollment application (original signatures are required)

• Avoid having your application returned. Call 1-877-707-5750 if you have questions about the enrollment forms

http://www.indianamedicaid.com/


Provider EnrollmentMailing the Application

• The enrollment packet must include:

–Completed IHCP Waiver Provider Application and Maintenance Form (with all applicable schedules)

–Completed IRS W-9 Form

–Waiver Approval Letter certifying the waiver services that the provider is approved to perform

• Mail to:EDS Provider Enrollment, WaiverP.O. Box 7263Indianapolis, IN 46207-7263


Provider UpdatesIt is the provider’s responsibility to inform the IFSSA waiver divisions

and the IHCP when there are changes to their enrollment profile

• Updates to the following information must be submitted to the Waiver Division at the IFSSA instead of EDS’ Provider Enrollment Department

– Waiver Specialty Change - Tax Identification Changes

– Name Changes - Changes in Ownership (CHOW)

– Service Location Additions

• Updates to the following information must be submitted to the EDS Provider Enrollment department:

– Address changes (home office, mail-to, pay-to, and service location)

– Telephone number changes

– Banking information changes (if enrolled in electronic funds transfer)

• Requests for changes must be submitted using the IHCP BillingProvider Application available at www.indianamedicaid.com


Member EligibilityWhere it Begins

The Division of Family Resources (DFR):

• Enters member application into their 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


Waiver Program Member Eligibility

Members Must Qualify for Waiver Program Eligibility

• Individuals who meet waiver Level of Care status and who 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 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)


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) which is reviewed by the state

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

• Information from the NOA is sent to EDS for placement on the member’s Prior Authorization 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


Member EligibilityEDS Role

•Receives recipient data from (ICES)

•Updates IndianaAIM within 72 hours

•Provides and supports the eligibility verification systems (EVS)

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


Member EligibilityHow to Verify

There are three EVS available:

•The automated voice response (AVR)

–1-800-738-6770, or

–317-692-0819, Indianapolis area

•Omni swipe card terminal device

•Web interChange


Automated Voice-Response SystemEVS Using the Telephone

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


OMNI EVS Card Reading Device

•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 (refer to IHCP provider bulletin BT200711)

See Chapter 3 of the IHCP Provider Manual for more information.


Web interChangeEVS Using the Internet

The following is available through Web interChange:

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

• Spend-down information

• DFR information

• Detailed TPL information

• Online TPL update requests

• Web interChange is accessible via www.indianamedicaid.com



Waiver Billing

• Notice of Action

–Lists the approved service provider

–Lists the approved service codes

–Gives the approved units and dollar amounts

• CMS-1500 claim form

–Use service code approved on the NOA

–Include all modifiers listed with the service code

• Refer to the HCBS Waiver Program Provider Manual for information regarding

–Service Definitions

–Allowable Services

–Service Standards

–Documentation Standards


Authorized Services

You may only bill for authorized services. In order 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 NPI

• Waiver providers use the CMS-1500 claim form when submitting paper claims for services

• The NPI is not needed for waiver providers who do not perform healthcare services

• 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

• Only the member and county are aware of the spend-down amount

• EDS 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


Paper Claim Filing Helpful Hints

• 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 claims to

EDS Waiver Program Claims

P.O. Box 7269

Indianapolis, IN 46207-7269

• Review the remittance advice (RA) closely


Remittance AdviceStatement with claims processing information

• 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

• Most Common Waiver Claim Denials

–2013 – Recipient Ineligible for Level of Care

–3000 – Units exceed PA Master

–3001 – DOS Not on PA Master File

–5000 – Possible Duplicate


Adjudicated Claim InformationInternal Control Number

The Internal Control Number (ICN) is a 13-digit number assigned to each claim

• The region tells how the claim was submitted

– 20 is for electronic with no attachments

– 21 electronic with attachments

– 10 paper with no attachments

– 11 paper with attachments

– 50 voids/replacements – noncheck-related

Region Year Julian Date

Batch Range Sequence

20 07 158 150 000


Claim AdjustmentsVoids and Replacements

• “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.


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

–1-800-577-1278, or

–(317) 655-3240 in the Indianapolis local area

• Written Correspondence

–P.O. Box 7263Indianapolis, IN 46207-7263

• Provider Relations Field Consultant

–View a current territory map and contact information online at www.indianamedicaid.com




Helpful ToolsAdditional Avenues 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

Questions

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