Vermont Medicaid Provider Manual VTMedicaid

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Provider Manual
dvha.vermont.gov/
vtmedicaid.com/#/home
5/23/2018 Green Mountain Care Provider Manual 2
Summary of Updates
The Detailed Summary of Provider Manual Changes contains all detailed changes made to this Provider
Manual is maintained and available for review at http://www.vtmedicaid.com/#/manuals
Date
Section Information
05/23/2018
Rental/Loaned
05/23/2018
Rental Reimbursement Policies
05/23/2018
Durable Medical Equipment (DME), Prosthetics,
Orthotics & Medical Supplies
05/03/2018
Payment DVHA Primary/Manual Pricing
05/03/2018
Procedure Codes & Pricing
04/16/2018
Obstetrical Care (Section # change only)
04/16/2018
Midwife Services (Section # change only)
04/16/2018
Timely Filing Reconsideration Requests
04/16/2018
DME Face-to-Face Requirements
04/16/2018
Home Health Face-to-Face Requirements
03/21/2018
Payment DVHA Primary
01/23/2018
Durable Medical Equipment (DME), Prosthetics,
Orthotics & Medical Supplies
12/29/2017
Concurrent Review for Admissions at Vermont
& In-Network Border Hospitals
12/29/2017
Claim Copy Requests
12/08/2017
Refunds
12/08/2017
Audiological Services/Hearing Aids
11/09/2017
Subacute Care
10/26/2017
09/29/2017
Telemedicine Services
Telemedicine Services
08/23/2017
Payment DVHA Primary
Payment Dual Eligible / Medicare Primary
06/22/2017
Anesthesia
06/12//2017
Psychiatry/Psychology
TENS/NMES
Provider Reconsideration Requests
Timely Filing (Section # change only)
Timely Filing Reconsideration Requests
Adjustments (Section # change only)
Prior Authorization of Medical Services
Immunizations
Health Examination of Defined Subpopulation
National Correct Coding Initiative (NCCI) Guidelines
Bilateral Billing Procedures
02/10/2017
Telemedicine Outside a Facility
Supervised Billing
Concurrent Review for Admissions at Vermont and In-
Network Border Hospitals
12/23/2016
Reimbursable Services - Home Health Hospice
Home Health Agency & Hospice Services Billing
Instructions/Field Locators
Hospital Clinical Laboratory Tests
Place of Service (POS) Codes
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12/01/2016
Assistant Surgeon
10/13/2016
Rehabilitative Therapy
Wheelchairs & Seating Systems
08/17/2016
Claims System & Provider Services
Prior Authorization Requirements
07/01/2016
Provider Based Billing
06/02/2016
Choices for Care: ERC/Nursing Facilities/HBW,
Moderate Needs
Hospital Outpatient Billing Instructions/Field Locators
04/18/2016
Long Acting Reversible Contraceptives Provided in an
Inpatient Hospital Post-Partum Setting
04/01/2016
Supervised Billing for Behavioral Health Services
Psychiatry/Psychology
03/01/2016
Provider Based Billing
Place of Service (POS) Codes
Provider Claim Modification Process
Provider Administrative Review Process
Continuous Passive Motion (CPM) Devices
Electronic Health Record Program Reconsideration
Process
Appeal of EHR Incentive Program Reconsideration
02/10/2016
Inpatient Newborn Services
Correct Coding Practices
New, Revised and Deleted Codes
Fee Schedule
01/19/2016
Supervised Billing for Behavioral Health Services
12/18/2015
Payment DVHA Primary
Incident-To Billing For Licensed Physicians
Supervised Billing For Behavioral Health Services
12/01/2015
Provider Enrollment, Licensing & Certification
National Correct Coding Initiative (NCCI) Guidelines
11/01/2015
Inpatient Newborn Services (Physician)
Organ Transplant
Organ Transplant Donor Complication
Important Telephone Numbers, Addresses and
Websites
In-State & Out of State Psychiatric & Detoxification
Inpatient Services
10/15/2015
Obstetrical Care
10/01/2015
ICD-9/ICD-10 References (Throughout Entire Manual)
Abortions
Midwife Services
CMS 1500 Paper Claim Billing Instructions/Field
Locators
09/01/2015
Psychiatry/Psychology
ICD-9/ICD-10 References (Throughout Entire Manual)
08/01/2015
Organ Transplant Donor Complication
Electronic Health Record Incentive Program (EHRIP)
EHR Incentive Program Reconsideration Process
EHR Incentive Program Appeal Process
Medical Necessity
Obstetrical Care
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Midwife Services
Concurrent Review for Admissions at Vermont & In-
Network Hospitals
Timely Filing
Psychiatry/Psychology
07/13/2015
Provider Administrative Review Process
Program Integrity Reconsideration & Appeal Process
07/01/2015
Claims System & Provider Services
Third Party Liability (TPL)/Other Insurance (OI)
CMS 1500 Paper Claim Billing
06/01/2015
Telemonitoring
04/15/2015
Member Information
Medicaid and Medicare Crossover Billing
Rehabilitative Therapy
Bilateral Procedures Physician/Professional Billing
Enteral Nutrition
Inpatient/Outpatient Overlap
Hospital Inpatient Billing Instructions
Hospital Outpatient Billing Instructions
02/01/2015
Individual Consideration/Manual Pricing
Rehabilitative Therapy
Chiropractic Services
Midwife Services
Bilateral Billing Procedures
01/01/2015
Prior Authorization Reviewers
Telemedicine
Hospital Inpatient Billing Instructions/Field Locators
Hospital Outpatient Billing Instructions/Field Locators
Home Health Agency & Hospice Services Billing
Instructions/Field Locators
Short Term Stays
Home Based Waiver (HBW) Billing Instructions/Field
Locators
12/01/2014
Midwife Services
CMS 1500 Paper Claim Billing Instructions/Field
Locators
Home Health Agency & Hospice Services Billing
Instructions
Home Based Waiver (HBW) Billing Instructions/Field
Locators
11/03/2014
Contractual Allowance
Rehabilitative Therapy
Ambulance Services
EPSDT Program Well Child Health Care
CMS 1500 paper Claim Billing Instructions/Field
Locators
Inpatient Claims: Medicare Part A Exhausts or Begins
During the Inpatient Stay
Provider Based Billing
10/01/2014
Claim Submission & Correspondence Mailing
Addresses
Member Bill of Rights
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Contractual Allowance
Out-of-Network Elective Outpatient Referrals
Psychiatric/Psychology
Short Stays
Same/Next Day Readmission Policy
Transfer Cases
Dialysis
08/23/2014
Cardiac Rehabilitation
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Table of Contents
SUMMARY OF UPDATES ........................................................................................................................... 2
TABLE OF CONTENTS ............................................................................................................................... 6
SECTION 1 GENERAL INFORMATION AND ADMINISTRATION ......................................................... 14
Important Telephone Numbers, Addresses and Websites ......................................................... 14
Administration & Responsibilities ................................................................................................ 14
1.2.1 Member Eligibility Determination ....................................................................................................... 14
1.2.2 Administration of Insurance Programs .............................................................................................. 15
1.2.3 Claims System & Provider Services .................................................................................................. 15
1.2.4 Claim Submission & Correspondence Mailing Addresses ................................................................. 16
1.2.5 Claim Copy Requests ........................................................................................................................ 16
1.2.6 Provider Claim Modification Process ................................................................................................. 17
1.2.7 Provider Reconsideration Process .................................................................................................... 17
SECTION 2 GREEN MOUNTAIN CARE .................................................................................................. 18
Medicaid for Adults ..................................................................................................................... 18
Dr. Dynasaur (Children) .............................................................................................................. 18
Prescription Assistance Pharmacy-Only Programs .................................................................... 18
Medicare Savings Programs (MSP) ........................................................................................... 18
Primary Care Plus (PC PLUS) .................................................................................................... 18
2.5.1 Allowed Practitioner Types ................................................................................................................ 19
2.5.2 Application ......................................................................................................................................... 20
2.5.3 Enrollment Minimum/Maximum ......................................................................................................... 20
2.5.4 Monthly Enrollment List ..................................................................................................................... 20
2.5.5 Provider Enrollment Status Change .................................................................................................. 20
2.5.6 Notice of Termination of Participation in PCP Plus............................................................................ 20
2.5.7 Hospital Admitting Privileges ............................................................................................................. 20
2.5.8 Referrals ............................................................................................................................................ 20
2.5.9 Case Management Responsibilities .................................................................................................. 22
2.5.10 Case Management Fee and Treatment Plan .................................................................................. 22
SECTION 3 POLICIES & OTHER INFORMATIONAL RESOURCES ..................................................... 23
Advisory ...................................................................................................................................... 23
Vermont Medicaid Banner .......................................................................................................... 23
Claim Edit Standards .................................................................................................................. 23
3.3.1 Correct Coding Practices .................................................................................................................. 23
3.3.2 New, Revised and Deleted Codes ..................................................................................................... 24
Correct Form Versions ................................................................................................................ 24
Manuals for Providers ................................................................................................................. 24
Medicaid Rule & State Plan Resources ...................................................................................... 24
National Correct Coding Initiative (NCCI) Guidelines ................................................................. 25
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Remittance Advice ...................................................................................................................... 26
3.8.1 The 835 Transaction (Electronic Remittance Advice) ........................................................................ 27
SECTION 4 MEMBER INFORMATION .................................................................................................... 27
Eligibility ...................................................................................................................................... 27
4.1.1 Partial Eligibility ................................................................................................................................. 27
4.1.2 Eligibility Verification .......................................................................................................................... 27
Identification ................................................................................................................................ 29
Member Bill of Rights .................................................................................................................. 29
Member Cost Sharing/Co-pays and Premiums .......................................................................... 30
Qualified Medicaid Member (QMB) ............................................................................................ 31
Notice of Decision ....................................................................................................................... 31
Court Ordered Services .............................................................................................................. 31
Retroactive Eligibility ................................................................................................................... 31
Member Grievance Process ....................................................................................................... 31
Member Appeal Process ............................................................................................................ 31
Fair Hearing ................................................................................................................................ 32
Advanced Directives ................................................................................................................... 32
SECTION 5 PROVIDER ENROLLMENT, LICENSING & CERTIFICATION ........................................... 32
Enrollment & Certification ........................................................................................................... 32
5.1.1 Enrollment Agreement Signatures ..................................................................................................... 33
Payment Conditions .................................................................................................................... 34
Conditions of Participation .......................................................................................................... 34
Documentation of Services ......................................................................................................... 34
Rights & Responsibilities ............................................................................................................ 34
Termination ................................................................................................................................. 35
SECTION 6 COORDINATION OF BENEFITS/MEDICAID PAYMENT LIABILITY/THIRD PARTY
LIABILITY 35
Contractual Allowance ................................................................................................................ 35
Reimbursement of Overpayments .............................................................................................. 35
Who is Responsible for Payment? .............................................................................................. 36
6.3.1 Supplementation ............................................................................................................................... 36
Who Is Primary ........................................................................................................................... 36
Notice That Medicaid Will Not Be Accepted ............................................................................... 37
Medicaid & Medicare Crossover Billing ...................................................................................... 37
Third Party Liability (TPL)/Other Insurance (OI) ......................................................................... 38
6.7.1 Third Party Liability Coverage Codes ................................................................................................ 41
Workers Compensation/Accident Liability Billing ........................................................................ 42
SECTION 7 PRIOR AUTHORIZATION FOR MEDICAL SERVICES ....................................................... 43
Clinical Practice Guidelines ........................................................................................................ 43
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Prior Authorization Requirements ............................................................................................... 43
7.2.1 Required Documentation ................................................................................................................... 43
7.2.2 Immediate Need Exception ............................................................................................................... 44
Determination Time..................................................................................................................... 44
7.3.1 PA Decision Reconsiderations .......................................................................................................... 45
Medical Necessity ....................................................................................................................... 46
7.4.1 Medical Necessity Form (MNF) ......................................................................................................... 46
Utilization Review........................................................................................................................ 46
Prior Authorization Notice Of Decision ....................................................................................... 47
Services Requiring Prior Authorization ....................................................................................... 47
7.7.1 Concurrent Review for Admissions at Vermont & In-Network Border Hospitals ................................ 47
7.7.2 Out of-State Elective Inpatient Hospital Admissions.......................................................................... 47
7.7.3 Out-of-Network Elective Outpatient Referrals.................................................................................... 48
7.7.4 In-State & Out of State Psychiatric & Detoxification Inpatient Services ............................................. 48
7.7.5 Out-of-State Urgent/Emergent Inpatient Hospital Admissions ........................................................... 48
7.7.6 Rehabilitative Therapy ....................................................................................................................... 48
SECTION 8 REIMBURSEMENT, BILLING PROCEDURES AND CLAIM PROCESSING ..................... 50
Adjustments Requests ................................................................................................................ 50
Timely Filing ................................................................................................................................ 51
8.2.1 Timely Filing Reconsideration Requests ........................................................................................... 52
Usual & Customary Rate (UCR) ................................................................................................. 52
Incident-To Billing For Licensed Physicians ............................................................................... 52
Supervised Billing for Behavioral Health Services ...................................................................... 53
Locum Tenens ............................................................................................................................ 56
Time-based Procedure Codes Billing Guidelines .................................................................... 57
Electronic Claim Submission ...................................................................................................... 57
Electronic Funds Transfer (EFT) ................................................................................................ 58
Claim Disposition Information Introduction ................................................................................. 58
Remittance Advice (RA) ............................................................................................................. 58
8.11.1 RA Sections..................................................................................................................................... 58
8.11.2 RA Headings & Descriptions ........................................................................................................... 59
8.11.3 Earnings Data & Message Codes ................................................................................................... 62
Refunds ....................................................................................................................................... 63
SECTION 9 BILLING PROCEDURES CMS1500 & UB04 CLAIM TYPES ............................................. 64
Abortions ..................................................................................................................................... 64
Aids/HIV ...................................................................................................................................... 64
Organ Transplant ........................................................................................................................ 64
9.3.1 Organ Transplant Donor Complication .............................................................................................. 65
CPT Category III Procedure Codes ............................................................................................ 65
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Factor HCPCS Codes ................................................................................................................. 65
Fee Schedule .............................................................................................................................. 65
Health Examination of Defined Subpopulation ........................................................................... 66
Interpreter Services/Limited English Proficiency (LEP) .............................................................. 66
9.8.1 Informed Consent .............................................................................................................................. 66
9.8.2 HIPAA ............................................................................................................................................... 66
9.8.3 Vermont Medicaid Billing ................................................................................................................... 66
9.8.4 Limited English Proficiency (LEP) Resources ................................................................................... 67
9.8.5 Deaf and Hard of Hearing Resources ............................................................................................... 67
9.8.6 Additional Online Information ............................................................................................................ 67
Inpatient Newborn Services ........................................................................................................ 67
Modifier ‘LT’ & ‘RT...................................................................................................................... 68
Place of Service (POS) Codes ................................................................................................... 68
Rehabilitative Therapy see section 7.7.6 .................................................................................... 70
Spend-Down ............................................................................................................................... 70
Long Acting Reversible Contraceptives Provided in an Inpatient Hospital Post-Partum Setting71
SECTION 10 CMS 1500 CLAIM SUBMISSIONS ....................................................................................... 71
Payment DVHA Primary ............................................................................................................. 71
Non-Reimbursable Services ....................................................................................................... 73
CMS 1500 Claim Type Billing Information ............................................................................... 74
10.3.1 Alcohol/Drug Detoxification Treatment ............................................................................................ 74
10.3.2 Ambulance Services ........................................................................................................................ 74
10.3.3 Anesthesia....................................................................................................................................... 76
10.3.4 Antineoplastic Drugs ....................................................................................................................... 78
10.3.5 Assistant Surgeon ........................................................................................................................... 78
10.3.6 Audiological Services/Hearing Aids ................................................................................................. 79
10.3.7 Bilateral Procedures Physician/Professional Billing ......................................................................... 80
10.3.8 Capsule Endoscopy (Esophagus through Ileum) ............................................................................ 80
10.3.9 Children with Special Health Needs Infant Toddler Programs ......................................................... 80
10.3.10 Chiropractic Services .................................................................................................................... 80
10.3.11 Consultation .................................................................................................................................. 80
10.3.12 Detail Processing .......................................................................................................................... 81
10.3.13 Developmental & Autism Screening of Young Children ................................................................ 81
10.3.14 Diabetic Teaching .......................................................................................................................... 82
10.3.15 Drugs Requiring Prior Authorization .............................................................................................. 82
10.3.16 Dual Eligibility ................................................................................................................................ 83
10.3.17 Emergency Indicator ..................................................................................................................... 83
10.3.18 Emergency Room Services ........................................................................................................... 83
10.3.19 EPSDT Program Well Child Health Care ................................................................................... 83
10.3.20 ESRD Related Services ................................................................................................................ 84
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10.3.21 Evaluation & Management Services (Post-Operative Care) .......................................................... 85
10.3.22 Family Planning Services .............................................................................................................. 85
10.3.23 FQHC/RHC ................................................................................................................................... 85
10.3.24 Health Maintenance Organization (HMO) ..................................................................................... 87
10.3.25 Hospital Based Physicians ............................................................................................................ 87
10.3.26 Hysterectomy ................................................................................................................................ 88
10.3.27 Immunization ................................................................................................................................. 88
10.3.28 Independent Laboratory ................................................................................................................ 89
10.3.29 Injections ....................................................................................................................................... 90
10.3.30 Inpatient Services .......................................................................................................................... 91
10.3.31 Lead Screening ............................................................................................................................. 91
10.3.32 Maintenance Drug Prescriptions ................................................................................................... 91
10.3.33 Mastectomy ................................................................................................................................... 91
10.3.34 Medical Nutrition Therapy ............................................................................................................. 91
10.3.35 Multiple Surgery Pricing ................................................................................................................ 91
10.3.36 Naturopathic Physicians ................................................................................................................ 92
10.3.37 NDC (National Drug Code) ............................................................................................................ 92
10.3.38 Non-Emergency Medical Transportation (NEMT) .......................................................................... 93
10.3.39 Obstetrical Care ............................................................................................................................ 93
10.3.40 Midwife Services ........................................................................................................................... 95
10.3.41 Oral Surgery .................................................................................................................................. 97
10.3.42 Over-The-Counter (OTC) Medications .......................................................................................... 97
10.3.43 Oximetry Services ......................................................................................................................... 97
10.3.44 Pharmacologic Management (Psychiatric) .................................................................................... 97
10.3.45 Physician Visit Limits ..................................................................................................................... 97
10.3.46 Post-Operative Follow-up Visits .................................................................................................... 98
10.3.47 Psychiatry/Psychology .................................................................................................................. 98
10.3.48 Radiology .................................................................................................................................... 101
10.3.49 Smoking Cessation Counseling ................................................................................................... 102
10.3.50 Specimen Collection Fee............................................................................................................. 102
10.3.51 Sterilizations ................................................................................................................................ 103
10.3.52 Team Care Program .................................................................................................................... 103
10.3.53 Telemedicine Services ................................................................................................................ 103
10.3.54 Topical Fluoride Varnish .............................................................................................................. 104
10.3.55 Vision Care & Eyeglasses ........................................................................................................... 104
SECTION 11 DURABLE MEDICAL EQUIPMENT (DME), PROSTHETICS, ORTHOTICS & MEDICAL
SUPPLIES ............................................................................................................................................. 106
Rental Reimbursement Policies ................................................................................................ 106
Capped Rentals (CR) ............................................................................................................... 107
Rental/Loaned ........................................................................................................................... 107
Face-to-face Requirements ...................................................................................................... 108
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Reimbursable/Non-Reimbursable Services .............................................................................. 108
Payment DVHA Primary/Manual pricing ................................................................................... 109
Payment-Dual Eligible/Medicare Primary ................................................................................. 109
Prescribing Provider.................................................................................................................. 110
Dates of Service ........................................................................................................................ 110
Procedure Codes & Pricing ...................................................................................................... 111
Repairs ...................................................................................................................................... 111
Supply Returns ......................................................................................................................... 111
Durable Medical Equipment (DME) Recycling ......................................................................... 112
Rehabilitation Equipment Review ............................................................................................. 112
DME Billing Information - Equipment Specific (Alphabetical) ................................................... 112
11.15.1 Adaptive Weighted Eating Utensils ............................................................................................. 112
11.15.2 Apnea Monitors ........................................................................................................................... 112
11.15.3 BICROS/CROS (Contralateral Routing of Sound) ....................................................................... 113
11.15.4 Blood Pressure Monitors ............................................................................................................. 113
11.15.5 Breast Pumps .............................................................................................................................. 113
11.15.6 Continuous Passive Motion (CPM) Devices ................................................................................ 113
11.15.7 CPAP & BIPAP ............................................................................................................................ 114
11.15.8 Crutches ...................................................................................................................................... 114
11.15.9 Enteral Nutrition ........................................................................................................................... 114
11.15.10 Glucometers .............................................................................................................................. 114
11.15.11 Hospital Beds ............................................................................................................................ 114
11.15.12 Incontinence Supplies ............................................................................................................... 115
11.15.13 Medical Supplies ....................................................................................................................... 115
11.15.14 Oxygen ...................................................................................................................................... 115
11.15.15 Peak Flow Meters ...................................................................................................................... 115
11.15.16 Special Needs Feeder Bottles ................................................................................................... 115
11.15.17 Speech Augmentation Devices ................................................................................................. 115
11.15.18 Splints ....................................................................................................................................... 116
11.15.19 TENS/NMES ............................................................................................................................. 116
11.15.20 Tracheostomy Care Kits ............................................................................................................ 116
11.15.21 Ventricular Assist Devices ......................................................................................................... 116
11.15.22 Wheelchairs & Seating Systems ............................................................................................... 116
11.15.23 Wheelchair Repairs ................................................................................................................... 117
CMS 1500 Paper Claim Billing Instructions/Field Locators ...................................................... 117
SECTION 12 UB04 CLAIM SUBMISSIONS ............................................................................................ 121
Reimbursable Services ............................................................................................................. 121
Reimbursement Policy .............................................................................................................. 122
Patient Share (Applied Income) Reporting ............................................................................... 122
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General Hospital Billing Information ......................................................................................... 123
12.4.1 Bilateral Billing Procedures ........................................................................................................... 123
12.4.2 In-Network & Extended Network Hospitals .................................................................................... 123
12.4.3 Inpatient/Outpatient Overlap Examples ......................................................................................... 123
12.4.4 Inpatient Claims: No Medicare Part A; Has Medicare B Coverage ................................................ 124
12.4.5 Inpatient Claims: Medicare Part A Exhausts or Begins During the Inpatient Stay ......................... 124
12.4.6 Inpatient Claims: Medicare Primary but Medicaid Eligibility Termed During Stay.......................... 124
12.4.7 Interim Inpatient Claims ................................................................................................................. 125
12.4.8 Present on Admission (POA) - Inpatient Admissions .................................................................... 125
12.4.9 Short Stays .................................................................................................................................... 125
12.4.10 Same/Next Day Readmission Policy ........................................................................................... 126
12.4.11 Subacute Care ............................................................................................................................ 126
12.4.12 Transfer Cases ............................................................................................................................ 126
12.4.13 Outpatient Services Rendered During an Inpatient Stay ............................................................. 127
Out-Patient/Inpatient Hospital Services .................................................................................... 127
12.5.1 Cardiac Rehabilitation ................................................................................................................... 127
12.5.2 Dialysis .......................................................................................................................................... 127
12.5.3 Inhalation Therapy ......................................................................................................................... 127
12.5.4 Hospital Clinical Laboratory Tests ................................................................................................. 127
12.5.5 Observation Rooms ....................................................................................................................... 128
12.5.6 Private Room................................................................................................................................. 128
12.5.7 Provider Based Billing ................................................................................................................... 128
12.5.8 Hospital Inpatient Billing Instructions/Field Locators ..................................................................... 129
12.5.9 Hospital Outpatient Billing Instructions/Field Locators ................................................................... 132
SECTION 13 HOME HEALTH AGENCY SERVICES .............................................................................. 135
Conditions for Payment ............................................................................................................ 135
Face-to-face requirements ........................................................................................................ 136
Reimbursable Services ............................................................................................................. 136
13.3.1 Visit at Patient’s Place of Residence ............................................................................................. 136
13.3.2 Nursing Care Services .................................................................................................................. 137
13.3.3 Registered Nurse Services ............................................................................................................ 137
13.3.4 Licensed Practical Nurse Services ................................................................................................ 137
13.3.5 Home Health Aide Services........................................................................................................... 138
13.3.6 Personal Duties ............................................................................................................................. 138
13.3.7 Medical Duties ............................................................................................................................... 138
13.3.8 Household Services ...................................................................................................................... 138
13.3.9 Hospice ......................................................................................................................................... 138
13.3.10 Respite Billing .............................................................................................................................. 138
13.3.11 Telemonitoring ............................................................................................................................. 139
Home Health Agency & Hospice Services Billing Instructions/Field Locators.......................... 140
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Adult Day Services Billing Instructions/Field Locators.............................................................. 144
SECTION 14 ASSISTIVE COMMUNITY CARE SERVICES (ACCS) ...................................................... 147
Revenue Code & Date Span Billing .......................................................................................... 147
Assistive Community Care Services (ACCS) Billing Instructions/Field Locators .................... 148
SECTION 15 CHOICES FOR CARE: ENHANCED RESIDENTIAL CARE (ERC)/NURSING FACILITIES
HOME BASED WAIVER (HBW), MODERATE NEEDS .......................................................................... 151
ERC Paper Claim Submission Billing Instructions/Field Locators ............................................ 151
Choices for Care: Nursing Facilities - General Billing Information ........................................... 154
15.2.1 Authorization for Care & Non-Covered Services ........................................................................... 154
15.2.2 Member Placement Levels (RPL) .................................................................................................. 155
15.2.3 DME in Health Care Institutions .................................................................................................... 155
15.2.4 Duration of Coverage .................................................................................................................... 156
15.2.5 Hold Bed ....................................................................................................................................... 156
15.2.6 Leave of Absence .......................................................................................................................... 157
15.2.7 Nursing Home Claims & Patient Hospitalization ............................................................................ 157
15.2.8 Patient Share in a Nursing Facility ................................................................................................ 157
15.2.9 Prior Payments .............................................................................................................................. 157
15.2.10 Choices for Care Short-Term Respite Stays ............................................................................... 158
15.2.11 Services Included in Per Diem Rate ............................................................................................ 158
15.2.12 Short Term Stays ........................................................................................................................ 158
15.2.13 Nursing Facilities Billing Instructions/Field Locators .................................................................... 158
Home Based Waiver (HBW) Billing Instructions/Field Locators ............................................... 162
SECTION 16 PROGRAM INTEGRITY ..................................................................................................... 164
Fraud ......................................................................................................................................... 164
Private Litigation ....................................................................................................................... 165
Sanctions .................................................................................................................................. 165
Program Integrity Reconsideration & Appeal Process ............................................................. 165
16.4.1 Reconsideration of Improper Payment and the Recovery of Overpayments ................................. 165
16.4.2 Program Integrity Appeal of Improper Payment and Overpayment Deficient Practice .................. 166
Violations .................................................................................................................................. 166
SECTION 17 OTHER PROVIDER INFORMATION ................................................................................. 166
Provider Tax .............................................................................................................................. 166
Pharmacy Tax ........................................................................................................................... 167
SECTION 18 ELECTRONIC HEALTH RECORD INCENTIVE PROGRAM ............................................ 167
Electronic Health Record Program Reconsideration Process .................................................. 167
Appeal of EHR Incentive Program Reconsideration ................................................................. 168
APPENDIX 1 170
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Section 1 General Information and Administration
The Department of Vermont Health Access (DVHA) is responsible for the administration of the State of
Vermont’s publicly funded health insurance programs.
Green Mountain Care is the brand name for the family of publicly funded health coverage programs offered
by the State of Vermont. Programs include Medicaid, Dr. Dynasaur and premium assistance pharmacy-only
programs.
IMPORTANT TELEPHONE NUMBERS, ADDRESSES AND WEBSITES
Department of Vermont Health Access
280 State Drive
Waterbury, VT 05671
Telephone: 1.802.879.5900
Fax: 1.802.879.5619
Website: http://dvha.vermont.gov
DXC Technology
312 Hurricane Lane
Suite 101
Williston, VT 05495
Telephone: 1.802.878.7871 (Out-of-State) or 1.800.925.1706 (In-State)
Fax: 1.802.878.3440
Website: http://www.vtmedicaid.com/#/
DXC Technology Provider Call Center
Toll-Free In-State: 1.800.925.1706
Local and Out-Of-State: 1.802.878.7871
DXC Technology Enrollment Unit
1.802.879.4450, option 4
Email: vtproviderenrollment@DXC.com
DXC Technology Checks, Claim Submission and Correspondence Mail
For all Checks: DXC Technology, PO Box 1645, Williston, VT 05495
For all Claims and other correspondences: DXC Technology, PO Box 888, Williston, VT 05495
ADMINISTRATION & RESPONSIBILITIES
1.2.1 Member Eligibility Determination
Application for health benefit eligibility and other public benefit determinations may be made online at
http://dcf.vermont.gov/mybenefits/apply_for_benefits or at a DCF Economic Services Division (ESD) District
Office http://dcf.vermont.gov/esd/contact_us/district_offices. Eligible members are enrolled in the appropriate
health care assistance program by the Department for Children and Families, Economic Services Division
(ESD), Health Access Eligibility Unit (HAEU). Questions about applying and other information queries can be
made at any DCF District Office http://dcf.vermont.gov/ or by calling the Benefits Service Center/District
Office.
Benefits Service Center/District Offices:
Telephone (800) 479-6151
The Benefits Service Center’s call center interactive voice response (IVR) system services providers and
member statewide. Providers should stay on the line after the message for a separate queue, and will be
serviced directly.
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1.2.2 Administration of Insurance Programs
The Department of Vermont Health Access (DVHA) has the primary responsibility for establishing program
policy direction and administration of Vermont’s health insurance programs, determining service coverage,
establishing provider reimbursement rates, and provides funding for provider payments.
Department of Vermont Health Access:
Telephone (802) 879-5900
http://dvha.vermont.gov/
312 Hurricane Lane, Suite 201
Williston, VT 05495
DVHA operates the Green Mountain Care Member Services Unit to provide information to health benefit
applicants and respond to questions and problems from members.
Green Mountain Care Member Services:
Telephone (800) 250-8427
TTY: (888) 834-7898
101 Cherry Street, Suite 320
Burlington, VT 05401-9823
1.2.3 Claims System & Provider Services
The State of Vermont contracts with a fiscal agent DXC Technology (DXC) to process Medicaid claims and
perform other duties as required by the contract. This includes maintenance of the eligibility sub-system,
claims processing billing codes and rates, and electronic fund transfers for reimbursement of services.
The Provider Services Unit of DXC Technology consists of four components: Provider Relations
Representatives, Provider Call Center Agents, Provider Enrollment and the Publications Coordinator. This
unit is available to assist Vermont Medicaid providers and their billing personnel (at no cost), Monday
through Friday from 8:00am to 5:00pm (except for State holidays; see the Holiday Closure Schedule at
http://www.vtmedicaid.com/#/resources
Provider Services/DXC: Toll-free in Vermont (800) 925-1706
Local and Out-of-State (802) 878-7871
*Note: DXC does not assist or take calls from members. Please direct all member questions to Green
Mountain Care Member Services (800) 250-8427.
Provider Enrollment
Provider Enrollment facilitates the enrollment and revalidation of providers requesting to participate in the
Vermont Medicaid Program. Representatives are available during regular business hours to answer written
and verbal inquires; see Section 5 Provider Enrollment, Licensing & Certification.
Provider Call Center
Call Center Agents are available to assist providers with program eligibility questions, provide service
limitation information, assist with claim inquiries and other information not available through the Voice
Response System (VRS) or Vermont Medicaid website http://www.vtmedicaid.com/#/
DXC provides claim and member information only to enrolled Vermont Medicaid providers; therefore,
providers are required to state their provider number at the time of contact. The following information that
will be requested, when applicable:
Member ID Number
Internal Control Number (ICN)
Date of Service
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Date of Remittance Advice (RA)
The Help Desk is not authorized to verify eligibility for dates 9 or more days beyond the date of inquiry.
Provider Relations Representatives
Provider Relations Representatives are available to travel throughout the state for problem solving and
provider education. These representatives work to increase provider participation by speaking at
professional association meetings, scheduling provider visits, and presenting statewide workshops for
Vermont Medicaid. Providers wishing to schedule a visit or identify the representative assigned to their
area are directed to the Provider Representative Map at http://www.vtmedicaid.com/#/manuals
Written Inquiries
To ensure accuracy and consistency, submit written inquiries on the Provider Inquiry Form, available at
http://www.vtmedicaid.com/#/forms. Send completed inquiries to:
DXC Technology
Provider Services Unit
P.O. Box 888
Williston, Vermont 05495-0888
To expedite the handling of your request, complete boxes one through twelve of the Provider Inquiry Form
and attach the appropriate documentation.
Note: Provider Inquiry Forms may not be used to:
Resubmit corrected claims*
Request an adjustment on a paid claim
Check on the status of a claim.
*Corrected claims should be sent directly to DXC with copies of all required attachments, when applicable.
If there are no attachments, claims may be resubmitted electronically, see Section 8.1 Adjustment
Requests.
1.2.4 Claim Submission & Correspondence Mailing Addresses
To ensure your request is processed in a timely manner, use the correct PO Box specific to each
correspondence type mailed to DXC Technology.
PO Box 1645 All Checks
PO Box 888 All Claims, Other Mail & Inquiries
Williston, VT 05495-0888
Health care providers and administrators wishing to send paperwork using a registered or certified carrier
service are to use our physical office address:
DXC Technology 312 Hurricane Lane, Suite 101 Williston, VT 05495
1.2.5 Claim Copy Requests
When a member or an attorney for a member requests a copy of a claim which has been paid, please
inform them that copies should be requested in writing from: DVHA - COB Unit, 280 State Drive,
Waterbury, VT 05671.
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1.2.6 Provider Claim Modification Process
The Department of Vermont Health Access (DVHA) allows claim reviews by DXC Technology for the below
modifications to claims:
Modifiers: Changes (additions and/or removals) to modifiers. Requested modifications must be
submitted on appropriate claim form with supporting documentation to DXC Technology, PO Box 888,
Williston, VT 05495
Units: Changes to previously listed units may be reviewed when sent on appropriate claim form with
any applicable supporting documentation to DXC Technology, PO Box 888, Williston, VT 05495
Place of Service or Diagnosis Codes: Changes to previously listed Place of Service codes or
Diagnosis codes may be sent for review with appropriate claim form and any applicable supporting
documentation to DXC Technology, Attn: Utilization Review, PO Box 888, Williston, VT 05495
Provider Type and Specialty: If a provider would like a review of the services covered under their
specialty scope of practice, please send request and supporting documentation to DXC Technology,
Attn: Utilization Review, PO Box 888, Williston, VT 05495
1.2.7 Provider Reconsideration Process
The Department of Vermont Health Access (DVHA) allows an enrolled provider a process for requesting a
review of certain claims payments. DVHA’s position is that providing a “second look” for certain decisions
may help improve accuracy. DVHA will review a decision for the following:
Timely filing denial (refer to section 8.2.1 on Timely Filing Reconsideration Requests
requirements)
Improper payments or non-payments
Coding errors
A. A request for review must be made no later than 30 calendar days after the DVHA gives notice to
the provider of its decision. Requests after 30 days will be returned with no action taken.
The request for review must be filed on the Reconsideration Request form (located at
http://www.vtmedicaid.com/#/forms)
B. All issues regarding providers’ objection to the findings must be documented. The request should
provide a brief background of the case, and the reasons why the provider believes the DVHA
should have ruled differently.
C. Requests will be reviewed by a qualified member of the DVHA when all information related to the
claim is submitted. Upon receipt of the request and all supporting information, the DVHA will
review all information received. The DVHA may consider additional information, either verbal or
written, from the provider or others, to further clarify the case.
D. The qualified DVHA reviewer will issue a written decision to the provider of its review decision or
notify the provider that an extension is needed within 30 calendar days of receipt of the request
for review.
E. There is no additional review or reconsideration after the written decision on the review. This
decision is final.
All requests for review must be addressed to:
DXC Technology
Administrative Review
PO Box 888
Williston VT 05495
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Section 2 Green Mountain Care
Green Mountain Care is a family of state-sponsored low-cost and free health insurance programs for
uninsured Vermonters.
MEDICAID FOR ADULTS
Medicaid programs for adults provide low-cost or free coverage for Vermonters who are eligible based on
income and resources. Medicaid provides a broad benefit package that may include acute care, long-term
care, dental, pharmacy and, if necessary, transportation to medical services.
Members are enrolled in PC Plus managed care and may be responsible for certain co-payments for
services performed in an inpatient and outpatient hospital setting as well as for pharmacy and dental benefits
(see section 4.4 Member Cost Sharing).
DR. DYNASAUR (CHILDREN)
Dr. Dynasaur encompasses all health care programs available for children up to age 19 Children’s Health
Insurance Program (CHIP) and Underinsured Children Members are enrolled in the PC Plus managed care
program.
PRESCRIPTION ASSISTANCE PHARMACY-ONLY PROGRAMS
Prescription assistance programs help Vermonters pay for prescription medicines based on income, disability
status and age. Pharmacy program requirements apply http://dvha.vermont.gov/for-providers.
There is a monthly premium based on income, and co-pays based on the cost of the prescription; see
Section 4.4 Member Cost Sharing/Co-pays and Premiums.
VPharm - VPharm assists Vermonters enrolled in Medicare Part D with payment for prescription medications.
In general, VPharm covers drug classes that are excluded from the Part D benefit, and may assist with
premiums and cost-sharing.
Healthy Vermonters - Healthy Vermonter’s provides a discount on both long-term and short-term
prescriptions for Vermonters not eligible for other pharmacy assistance programs.
MEDICARE SAVINGS PROGRAMS (MSP)
Qualified Medicare Beneficiary - A Qualified Medicare Beneficiary (QMB) is an aged, blind or disabled
individual with income at or below 100% FPL who is eligible for Medicaid payment of Medicare premiums,
deductibles and co-insurance but not for any other payments
Specified Low-Income Beneficiaries - A Specified Low-Income Medicare Beneficiary (SLMB) is an aged,
blind or disabled individual who is eligible for Medicaid payment of their Medicare Part B premium if the
individual would be eligible for QMB except for income with income above 100% but at or below 120%FPL.
Qualified Individuals A Qualified Individual (QI-1) is an aged, blind or disabled individual with income at or
below 100% FPL who is eligible for Medicaid payment of Medicare Part B premium if the individual would be
eligible for QMB except for income with income above 100% but at or below 135%FPL and does not receive
any other federally-funded medical assistance except for coverage for excluded drug classes under part D
when the individual is enrolled in part D.
PRIMARY CARE PLUS (PC PLUS)
Primary Care Plus (PC Plus) is a primary care case management program developed by the DVHA as part of
Vermont’s Global Commitment. Vermont requires that all Medicaid and Dr. Dynasaur member enroll in PC
Plus. Many services covered under PC Plus need to be authorized by the Primary Care Provider (PCP).
Services rendered to a member enrolled in a primary care case management (PCCM) must follow the
guidelines for the PCCM program.
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The key goals of PC Plus are to:
Enhance the continuity of care through the creation of a “medical home”
Establish a partnership between the Medicaid administration and community providers
Maximize dollars spent for medical services
PCPs coordinate their members’ health care needs by providing the following services:
Primary care medical services, covered by Vermont Medicaid
Referral authorization for needed specialty and other covered medical services
Arrange 24-hour-a-day/seven days-a-week coverage
PCPs receive a monthly case management fee for each member enrolled with the PCP. This fee is for
coordinating members’ health care services. The case management payment structure is based on the
number of patients that are attributed to the practice. Vermont Medicaid will attribute members to the PCP
who has billed for appropriate services and who has seen the member within the last 24 months.
Membership in PC Plus is mandatory for all Medicaid and Dr. Dynasaur members who are not otherwise
exempt from managed care enrollment under the provisions of the 1115 waiver. Under the waiver, individuals
who have third party insurance, in addition to Medicaid/Dr. Dynasaur, and individuals who are on home and
community-based waivers, are exempted from PC Plus enrollment. In addition, individuals enrolled in the
Medicaid High Tech Program and individuals living in long-term care facilities are exempt from PC Plus
enrollment.
Once they are found eligible, members who are not exempt are sent an enrollment package from the Green
Mountain Care Member Services Unit and are asked to select a primary care provider. A primary care
provider is assigned to those members who do not make a selection within 30 days.
Members may change their PCP by contacting the Member Services Unit. Members can be verified as
members of PC Plus using the VRS and the Vermont Medicaid web site http://www.vtmedicaid.com/#/
A PCP enrolled in the PC Plus program must meet all of the following requirements listed in the below
sections.
2.5.1 Allowed Practitioner Types
The PCP must be enrolled and in good standing in the Vermont Medicaid program and be routinely providing
services as a:
Family Practice Physician
General Practice Physician
Internal Medicine Physician (general internists)
Pediatric Physician
Adult, Pediatric or Family Nurse Practitioner
Naturopaths
Physician specialists, with one or more sub-specialties, may enroll as PCPs for members with life-
threatening, degenerative or disabling conditions or disease. They must agree to meet the obligations of a
PCP and have experience in and are willing to provide primary care services.
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2.5.2 Application
Providers who wish to be a PCP in the PC Plus program must be actively enrolled in the Vermont Medicaid
program and are required to complete and return the PCP “Agreement For Participation.
Providers who are enrolling with PC Plus as a group, must complete a single “Application for Participation”,
signed by a representative of the practice group. The PCP Agreement for Participation and the Provider
Enrollment Agreement can be accessed at: http://www.vtmedicaid.com/#/provEnrollDataMaint
2.5.3 Enrollment Minimum/Maximum
PC Plus PCPs can set a limit on the number of PC Plus members to be enrolled in their practice. Maximum
enrollment for a PCP is 1500.
Should a PCP desire to increase or decrease the maximum number of members to be managed, the PCP
must notify DXC in writing at least 60 days prior to the new change. A new Application for Participation will
not be required.
2.5.4 Monthly Enrollment List
PCPs will receive a monthly roster of enrolled members. The roster does not assure continuing eligibility;
therefore, eligibility should be verified for each date of service prior to rendering the service. It is required that
incorrect member information is noted and a revised roster be returned to the DXC Enrollment Unit for
updating. This information may be returned by fax to 802-878-3440, Attn: enrollment or mailed to: DXC
Technology, Attn: Enrollment, PO Box 888, Williston, VT 05495.
2.5.5 Provider Enrollment Status Change
PCPs must notify DXC in writing should any of the changes listed below occur which will affect participation
in the plan. Mail written notification to DXC Technology, PC Plus, and P.O. Box 888, Williston, Vermont
05495-0888 or faxed to (802) 878-3440.
Group Composition
If there is any change in the composition of individual providers in a group that originally agreed to participate
in the Primary Care Plus Plan, the moving PCP is required to complete a new Agreement for Participation
prior to the effective date of change.
In addition, any provider who has not previously participated in the PC Plus plan will need to complete the
Agreement for Participation located at http://www.vtmedicaid.com/#/provEnrollDataMaint
Office Location
Any change in PCP office address, telephone numbers or name of practice, must be communicated in writing
to DXC as soon as possible and prior to the effective date of the change.
2.5.6 Notice of Termination of Participation in PCP Plus
All individually participating or group identified PCPs must notify DXC of their intention to withdraw from
participation, in writing, at least 90 days prior to the termination date. Providers are required to give their
patients 30 day notice prior to termination.
2.5.7 Hospital Admitting Privileges
A PC Plus PCP must have either local hospital admitting privileges or a formal arrangement with a physician
who has local hospital admitting privileges and who agrees to abide by PC Plus requirements.
2.5.8 Referrals
Referral of PC Plus members can be made to any provider currently enrolled in the Vermont Medicaid
program.
The goals of the referral process are to:
Ensure that the PCP is involved in medical decisions affecting members
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Reduce utilization of unnecessary medical services
Reduce duplication of services
Promote continuity of care
The PCP will be responsible for coordinating care between the member and any specialty care that the
member may need through the referral system. A referral takes place when a participating PCP refers their
PC Plus member for medically necessary covered services not normally provided by the PCP. Referrals by
the member’s PCP will be required for payment of claims submitted by specialty providers. Members seeking
specialty care without a referral from their PCP will be responsible for the visit, if they are informed in
advance and in writing that because they have no referral, they will have to accept financial responsibility for
the visit. See Section 6.5 Notice That Medicaid Will Not Be Accepted.
Effective July 1, 2012, non-emergency (elective) out-of-state medical visits will require prior authorization
from the DVHA Clinical Unit. Out-of-State Network Hospitals and Extended Network Hospitals are excluded
from this requirement. In network referring providers must submit requests using the Out-of-
State Elective Office Visit Request Form located at:
http://dvha.vermont.gov/for-providers/forms-1. Fax requests to 802-879-5963.
Referrals may be made orally or in writing. Both the PCP and the referral to specialty provider are required to
keep documentation of the referral in the patient’s medical records. The referral must include the following
information:
Patient identification information
Date
Reason for referral
Requested service (evaluate, evaluate and treat)
Providers who make referrals in writing may do so using their own referral form. Referral forms do not need
to be attached when submitting claims. The referral provider will be reimbursed on a fee-for-service basis for
Vermont Medicaid covered services.
The following services do not require a referral from the PCP:
Chiropractic services
Dental services (Medicaid/Dr. Dynasaur only)
Emergency services
Family planning services, defined as services that prevent or delay pregnancy
Gynecological services
Naturopathic services
Personal care for children
Prenatal and maternity care
Routine eye exams for adults/children and eyeglasses for children
Mental health services
School-based health services
Services rendered by the PCP or those providing back-up coverage for the
PCP
Substance abuse services
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Local Transportation services (Medicaid/Dr. Dynasaur only)
2.5.9 Case Management Responsibilities
In addition to providing primary care services, PCPs must provide a number of case management services.
Responsibilities include:
For referrals, the PCP must use Vermont Medicaid participating providers or providers enrolled to
serve members enrolled in the PC Plus program, unless the required service is not otherwise
available from a currently enrolled Vermont Medicaid provider. If the PCP wants to use a provider
who is not enrolled, DXC should be notified to solicit the enrollment of the provider.
The PCP must have provisions for access to 24-hour/seven days-per-week coverage that will
assure practitioner availability in person or by phone.
The PCP (or PCP’s practice) must maintain office-visiting hours at least four days per week for at
least twenty-five hours per week for member appointments, unless this provision is waived by the
DVHA in order to assure access to services and providers. Participating PCPs who work in a
practice on a part-time basis, must inform the DVHA of the times they are available to see patients.
DVHA may request a corrective action plan from the PCP if timely access responsibilities are not
met.
The PCP must assure that all members have a current medical history and record, and must
maintain medical records for each member.
The PCP must agree to adhere to the appointment waiting times standards set out in the Medicaid
Rule 7101.3 O (1) (b). These appointment standards state that any member should have immediate
access to emergency care and for non-emergent care be seen within: 24 hours for urgent care, 2
weeks for non-urgent care with prompt follow-up and 90 days for preventive and routine physical
examinations and 30 days for routine, laboratory, x-ray, general optometry, and all other routine
services.
PCPs must provide all covered primary care services consistent with their qualifications.
The PCP must assure that every child or adolescent enrolled in the practice is screened according
to the requirements of the Vermont Department of Health’s EPSDT Periodicity Schedule.
The PCP must follow the provisions of the Generic Drug Act where it permits
substitution and will prescribe the lowest cost equivalent available.
After consultation with specialists, the PCP will review and approve medically necessary specialty
services as appropriate, except for services exempted or those approved by the DVHA or the
DVHA’s designated prior authorization agent.
The PCP must participate in quality improvement projects agreed to by participants in the PC Plus
network and the DVHA.
The PCP must cooperate with the DVHA’s accessibility surveyors. The DVHA will provide each
PCP practice site with the results of any accessibility survey conducted.
The PCP must notify the DVHA of any change in his/her office physical plant that might change
physical accessibility to The Department.
2.5.10 Case Management Fee and Treatment Plan
In addition to fee-for-service reimbursement, PCPs will be paid a monthly case management fee for each
member assigned to their practice. The PCP does not need to file a claim for the case management fee.
Claims for the monthly fee will be generated by DXC based on the number of members enrolled in the
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practice and payment will appear on the Remittance Advice (RA). Actual services provided to members will
be reimbursed on a fee-for-service basis in accordance with Vermont Medicaid fee-for-service payment
policies and procedures.
When a PCP develops a treatment plan for a member, the PCP may submit a claim to DXC for
reimbursement for the development of this plan using procedure code G9001. A PCP may submit no more
than one treatment plan claim, per member, per calendar year. A covering practitioner cannot bill for a
treatment plan. Payment will be made in accordance with the Vermont Medicaid fee schedule for this
service. The treatment plan does not have to be submitted with the claim; however, it must be kept in the
member’s medical records. Treatment plans must include, at a minimum, the following information:
Presenting clinical problems
Expected outcomes
Services required, including level of intensity
Provider(s) of services
Section 3 Policies & Other Informational Resources
ADVISORY
The Vermont Health Access Advisory is a bi-monthly publication of DXC and DVHA. This newsletter provides
important information which is necessary for accurate billing to Vermont Medicaid. Providers may retain
copies for the Advisory and consult them whenever a question arises regarding DVHA policy or procedure or
use the Advisory archive http://www.vtmedicaid.com/#/advisory.To request electronic delivery, e-mail vtpubs-
comm@DXC.com.
VERMONT MEDICAID BANNER
The first page of the Remittance Advice (RA), the weekly report listing the status of each claim and any
pertinent financial information, is referred to as the Vermont Medicaid Banner. Messages on the Banner page
keep providers informed of important changes in policy or billing procedures. The Vermont Medicaid Banner
may be the only or first notification of a change in billing procedure. It is the provider’s responsibility to obtain
this information from their RA regarding DVHA policy or procedure. The Vermont Medicaid Banner is posted
online weekly at www.vtmedicaid.com/#/bannerMain and is archived at the same online location.
The Vermont Medicaid Banner can be emailed directly to you when you join our communications email
distribution list. Send your email address to vtpubs-comm@DXC.com to receive this provider resource and
other communications relevant to Vermont Medicaid.
CLAIM EDIT STANDARDS
Vermont Medicaid adheres to the following edit standards:
AMA, CPT, HCPCS and NCCI;
National Specialty Society Edit Standards; or
Proprietary NCPDP-compliant pharmacy adjudication software provided through our Prescription
Benefit Management(PBM) Goold Health Systems ®
Other appropriate nationally-recognized edit standards, guidelines or conventions approved by the
commissioner.
3.3.1 Correct Coding Practices
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Providers are responsible for correct and accurate billing including proper use as defined in the current
manuals: AMA Current Procedural Terminology (CPT), Health Care Procedure Coding System (HCPCS),
Current Dental Terminology (CDT), the most recent International Classification of Diseases clinical
Modification (ICD-10-CM) and International Classification of Diseases Procedure coding system (ICD-10-
PCS).
Please refer to the most current coding manuals for full details on proper coding and complete
documentation. If your practice utilizes a billing agent, it is still the practice’s responsibility to make sure
correct coding of claims is occurring.
3.3.2 New, Revised and Deleted Codes
DVHA’s Fee Schedule is updated on a monthly basis to reflect any code changes. It is the responsibility of
the billing provider to refer to this schedule at: http://dvha.vermont.gov/for-providers/claims-processing-1
(See section 9.6 Fee Schedule.) Codes are a National Standard and may be updated on a quarterly basis.
Correct coding is the sole responsibility of the billing provider. DVHA is not authorized to give code selection
guidance.
CORRECT FORM VERSIONS
The Department of Vermont Health Access and DXC Technology requires the use of current form versions,
this includes but is not limited to: prior authorization requests and patient consent forms. All requests and
patient consent forms received on outdated form versions will be denied.
MANUALS FOR PROVIDERS
The Provider Manual, Dental Supplement and the Applied Behavior Analysis, Mental Health and Substance
Abuse Services Supplement are available at http://www.vtmedicaid.com/#/manuals
The Inpatient Psychiatric & Detoxification Authorization Manual Supplement is available at
http://dvha.vermont.gov/for-providers/mental-health-inpatient-detox
The 340B Medicaid Carve-In Manual and Amendments are located at http://www.vtmedicaid.com/#/forms
The Pharmacy Benefit Management Program Provider Manual is located at http://dvha.vermont.gov/for-
providers under the Pharmacy section. The Pharmacy Benefit Management Program is for prescription drugs
dispensed by retail pharmacies.
DVHA clinical coverage guidelines for Durable Medical Equipment (DME), Laboratory and Radiology,
Therapy, J Codes, Intensive Social Support Services, and other services are located at
http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines.
Check monthly for manual revisions.
MEDICAID RULE & STATE PLAN RESOURCES
Medicaid Rule, along with other DVHA rules, are located online at http://humanservices.vermont.gov/on-line-
rules/dvha.
Note: Per State statute, Vermont’s Secretary of State is charged with publication of a bulletin of rules. As
such, the Secretary of State is the official source for the most current and comprehensive rules for DVHA.
DVHA is not responsible for reliance on regulations posted should rules be different than those posted on the
Secretary of State website. An electronic copy of the rules maintained by the Secretary of State is available
via http://www.lexisnexis.com/hottopics/codeofvtrules/.
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NATIONAL CORRECT CODING INITIATIVE (NCCI) GUIDELINES
The Patient Protection and Affordable Care Act (PPACA) mandates that all claims submitted on or after
October 1st, 2010, must be filed in accordance with the National Correct Coding initiative (NCCI) guidelines.
The NCCI was developed by CMS to promote the correct coding of health-care services by providers and to
prevent improper payment when incorrect coding occurs.
For the Medicaid NCCI Policy Manual that contains the NCCI rules, relationships, and general information,
Medicaid NCCI FAQs, and the complete edit files, please refer to:
https://www.medicaid.gov/medicaid/program-integrity/ncci/index.html. Code combinations are refreshed
quarterly.
In accordance with the National Correct Coding Initiative (NCCI), Vermont Medicaid has implemented pre-
payment edits and applies NCCI guidelines for claims with a date of service on or after 10/01/2010.
The National Correct Coding Initiative (NCCI) contains two types of edits:
NCCI procedure-to-procedure (PTP) edits that define pairs of Healthcare Common Procedure Coding
System (HCPCS) / Current Procedural Terminology (CPT) codes that should not be reported together
for a variety of reasons. The purpose of the PTP edits is to prevent improper payments when incorrect
code combinations are reported.
Medically Unlikely Edits (MUEs) define for each HCPCS / CPT code the maximum units of service (UOS)
that a provider would report under most circumstances for a single beneficiary on a single date of service.
PTP Edits have been implemented apply to all:
Practitioner
Ambulatory surgical center (ASC) services
Outpatient services in hospitals (including emergency department, observation, and hospital laboratory
services)
Provider claims for durable medical equipment (DME)
MUE Edits have been implemented and apply to all:
Practitioner
Ambulatory surgical center (ASC) services
Outpatient services in hospitals (including emergency department, observation, and hospital laboratory
services)
Provider claims for durable medical equipment (DME)
Each NCCI code pair edit is associated with a CMS policy as defined in the National Correct Coding Initiative
Policy Manual. Effective dates apply to code pairs in NCCI and represent the date when CMS added the
code pair combination to the NCCI edits. Code combinations are processed based on the effective date.
Termination dates also apply to code pairs in NCCI. The date represents when CMS removed the code pair
combination from the NCCI edits.
NOTICE: The MUE files have been updated with the addition of a new field on the rationale for each MUE,
effective the third quarter of 2014. Please refer to Appendix B of the Medicaid National Correct Coding
Initiative Edit Design Manual for explanations of the MUE rationales.
NCCI Reconsideration
Claims or procedure codes that have been denied based on NCCI guidelines may be appealed with an
appropriate modifier or documentation of medical necessity. If the submitted procedure code is denied
because NCCI guidelines indicate the code is included in another procedure, the claim may be reconsidered
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with a modifier if applicable. If a modifier does not apply but medical necessity can be proven, the provider
must submit documentation of medical necessity that indicates both services were necessary on the same
date of service.
For reconsideration instructions refer to: 1.2.7 Provider Reconsideration Process for additional
information about claims reconsideration
REMITTANCE ADVICE
The Remittance Advice (RA) is a computer-generated report provided by the fiscal agent. It indicates the
status of all claims that have been submitted for processing and payment information. The RA is posted at
http://www.vtmedicaid.com/#/ under TransactionsLogin on a weekly basis. The banner page of the RA
provides important information about policy and billing.
When a provider submits VT Medicaid claims via electronic claim submission (ECS) directly or
through a clearinghouse or billing service, the Remittance Advice (RA) will be posted to the VT
Medicaid Portal at http://www.vtmedicaid.com/#/
When a provider is not set up for ECS and is only submitting paper claims to
Vermont Medicaid, the RA will be mailed weekly; however, if the provider switches to ECS, the RA
will be posted to the web and the RA mailing will stop.
When a provider is set up for ECS, all RA information will be posted to the Web
Portal regardless of whether the claims were submitted on paper, electronically or any combination
thereof.
Provider payments are made at the end of the week on Friday. The system retains the four most recent
Web RAs. When a fifth RA is posted to the Web Portal, the oldest dated RA will drop off the system. Once
an RA drops off the system, it cannot be reposted; therefore, it is highly recommended that RA copies are
saved/printed for future reference.
The Web RA can be accessed via two different account types a Trading Partner account, and a Provider
Web Services (PWS) account.
Go to http://www.vtmedicaid.com/#/
If you have a Trading Partner Account (User ID starts with 701), navigate to TransactionsLogin or if you
have a Provider Web Services (PWS), navigate to TransactionsLogin-UAT.
If you have a Trading Partner Account (User id starts with 701…) click on
Transaction Services, then Production Logon.
If you have a PWS account, click on Provider Web Services.
Use the Account ID and password to Logon
For either method of access after logging on, click on View RA Files
Pick the Provider Number from the drop down (if you have more than one)
Click Go
Click on the appropriate pdf
Click Open (this should display the RA on the screen)
For questions about an existing account, creating an account, or accessing the Web RA, please contact the
EDI Coordinator at 802-879-4450, select option 3 or email at vtedicoordinator@DXC.com.
Providers with questions about their RA’s content are to contact the DXC Technology Help Desk at 800-
925-1706 in-state or 802-878-7871 out-of-state.
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3.8.1 The 835 Transaction (Electronic Remittance Advice)
Vermont Medicaid posts the 835 weekly, to the web portal http://www.vtmedicaid.com/#/ for Trading
Partners who have elected the 835 transaction. The 835 is a pull from the website (i.e. must be
downloaded). There is no restriction on the number of times the 835 can be downloaded and it is available
until it rolls off the system; at a minimum, it is available for at least one month from the posting date.
Normal processing has financial cycle running on a Friday with the 835 posting late the following Monday
or Tuesday. The requirement for the 835 posting is +/- (plus or minus) 3 days from the EFT effective date
(always the Thursday following a financial cycle). In the event the 835 will be delayed past the required
Sunday posting date, a banner will be placed on the web site referencing the delay, and if known, the
cause and the expected posting time and date.
If your 835 is missing after Sunday (EFT+3), and no banner has been posted stating its release is delayed,
please contact the EDI Coordinator at 802 879-4450 Option 3, or email vtedicoordinator@DXC.com.
Include your Trading Partner ID and the week you are referencing.
Section 4 Member Information
ELIGIBILITY
"Member" is the term used to refer to a person who has been determined eligible for and enrolled in one of
the Vermont health insurance programs. Eligibility is determined at the Health Access Eligibility Unit or a
district office of the Vermont Department for Children and Families, based on a review of the applicant's
needs, income and resources. The various Vermont health insurance programs have differing eligibility
requirements and benefits. Effective January 1, 2014, individuals who are 65 or older, blind or are disabled
and not yet entitled to or don’t have Medicaid must apply for health care benefits through Vermont Health
Connect at http://healthconnect.vermont.gov/ or by calling 1-855-899-9600.
Each member is assigned a unique identification (UID) number and receives a Green Mountain Care
member card imprinted with their name and UID. The UID number will be 1 to 8 digits in length and is to be
entered on the claim exactly as it is shown on the member’s card.
When submitting an electronic claim for member with a one digit Unique ID Number insert a zero in front of
the single digit UID (04, 05, 06 and etc.); to allow the claim to be accepted. This instruction does not apply to
paper claims.
Providers must verify the patient's eligibility and other insurance information using the patient's Medicaid UID
number by accessing either of the automated eligibility verification systems.
4.1.1 Partial Eligibility
Providers are allowed to compliantly bill the correct monthly code that meets the definition of the actual
services provided in a month for members who have partial eligibly in that month. However, providers may
only bill the dates-of-service during the time frame in which the member is actively eligible for Medicaid.
4.1.2 Eligibility Verification
The Green Mountain Care Eligibility Verification System (EVS) provides member information to
participating health care providers. There are two components of the EVS that are described in this manual
and Appendix.
Voice Response System (VRS), 802-878-7871, option 1; or
Go to www.vtmedicaid.com/#/, navigate to the Transactions menu and select the appropriate Login
(Trading Partners use “Login”, Web Services use “Login - UAT”).
If for any reason you are unable to use either method, you may call the DXC Provider Services Help Desk
at (800) 925-1706 or (802) 878-7871.
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The EVS delivers a response that is clear to the user and appropriate for the method of access used in
making the inquiry. The DVHA encourages all providers to take full advantage of this system to verify a
patient’s eligibility status before services are rendered. This system offers the following functionality:
Available 24 hours a day, seven days a week (except for routine maintenance)
Responds with rapid verification information
Substantially minimizes the risk of non-payment for services rendered to ineligible
patients
Decreases the number of claim resubmissions due to inaccurate eligibility information
Providers should complete all VRS or website transactions to be sure that all the pertinent information is
captured. Compare the aid category given on the VRS or http://www.vtmedicaid.com/#/manuals to the aid
category listing (see Appendix to the Provider Manual), in order to determine the program in which the
member is enrolled in. This will assist you in determining covered services and co-payment requirements
where applicable. Providers may verify eligibility for the current date, up to one year in the past and rely on
the accuracy of the response for up to nine days beyond the current date.
Providers should retain the authorization number issued by the system to assure that the information
received can be verified by the system. The number is not a guarantee of payment. The member must be
eligible on the date of service and the services provided must be medically necessary and covered.
In addition to eligibility verification, providers can receive other insurance information and determine if
service limits are approaching or have been reached. Providers can also confirm the amount to be paid in
the next RA or if that amount is zero, the amount and date of the last payment given.
All provider calls to DXC are routed through the VRS. Spoken prompts will direct you on how to access the
service/information you require Contact the DXC Provider Services Unit for information that is not available
through VRS or the http://www.vtmedicaid.com/#/ website.
At the beginning of each call users are asked to enter their Vermont Medicaid provider number followed by
their PIN number. The provider number and PIN number are a security measure to ensure the user is
authorized to access the requested information. If the provider or PIN numbers entered are not valid or
current, access will be blocked.
To expedite the process, please have the following information ready when placing a call to the VRS:
Provider number
Provider PIN number
Member identification number
Dates of service
Transactions are limited to ten (10) per call are (example: five eligibility and five service limits)
Providers using the VRS have access to the following data:
Eligibility Verification
Date-specific eligibility
Third party liability information (up to five segments)
Member lock-in data
Date of birth
Co-pay indication
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Service Limitations when exhausted
Office visits
Visual refractions
Visual glasses
Adult dental benefits (dollars spent)
Last dental oral exam
Chiropractic visits
Current RA check amount
Carrier Codes
Carrier Codes are two or three digit codes that identify other insurance carriers. The complete list can be
accessed on the Vermont Medicaid Portal at http://www.vtmedicaid.com/#/resources
IDENTIFICATION
A Green Mountain Care identification card is issued to each person enrolled in a Vermont Medicaid
program. Members must present their card for any covered service. Because the card is not surrendered
when eligibility stops, providers must verify eligibility each time a medical service is delivered to be certain
that the member is eligible on the date that the service is provided. The system knows of each termination of
benefits nine days prior to the effective date. Verification can be made up to nine days in advance of the
appointment. Note: there are only room for 25 characters on the Green Mountain Care card for the
member’s name so some names will not be completely printed.
MEMBER BILL OF RIGHTS
DVHA is a Managed Care Organization (MCO) and must ensure that its enrolled health care providers are
aware of our Member Bill of Rights and that health care providers take these rights into account when
providing services to members.
The Member Bill of Rights
As a member of a Vermont health care program, an individual member has the right to:
Be treated with respect and courtesy
Be treated with thoughtfulness for his or her dignity and privacy
Choose and change providers
Get facts about program services and providers
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Get complete, current information about his or her health in understandable terms
Be involved in decisions about his or her health care, including having questions answered and
having the right to refuse treatment
Ask for and get a copy of his or her medical records and ask for changes to be made to them when
he or she believes the information is wrong
Get a second opinion from a qualified provider who is enrolled in Vermont Medicaid
Complain about the program or his or her health care
Be free from any form of restraint or isolation used as a means of bullying, discipline, convenience, or
retaliation
Ask for a reconsideration if services are denied that he or she thinks are needed
Members have the right to look at their medical records, and to obtain copies of the records. A reasonable
fee may be charged to cover making copies and postage. An office may not charge for copies of records
needed to support a claim or a reconsideration or Copying of medical records for the purpose of supplying
them to another health care provider.
MEMBER COST SHARING/CO-PAYS AND PREMIUMS
Certain members must participate in the cost of care for services.
Co-payments are never required of Medicaid members who are:
Under age 21;
Pregnant or in a 60-day post-pregnancy period;
Living in a long-term care facility, nursing home or hospice;
Copayments are not required for family planning services and supplies, emergency services (includes: dental
services covered by a GA Voucher), and durable medical equipment (DME) and medical supplies.
Although some members are required to make co-payments under Medicaid, if the member is unable to
make the payment, Medicaid providers may not deny services. Per section 1916(c) of the Social Security
Act, "no provider participating under the State [Medicaid] plan may deny care of services to an individual
eligible for [Medicaid] on account of such individual's inability to pay [the copayment]."
Medicaid Co-Pays
$1.00 - for prescription drugs costing less than $30.00
$2.00 - for prescription drugs costing $30.00 or more but
less than $50.00
$3.00 - for prescription drugs costing $50.00 or more
$3.00 - per dental visit
$3.00 - per day for hospital outpatient services
VPharm Pharmacy
Aid Categories VD, VE, VF, VG, VH, VI, VJ, VK, VL, VM, VN & VO:
$1.00 - Co-pays for prescriptions less than $30.00
$2.00 - Prescriptions $30.00 or more
VPharm covers drug classes that are excluded from the Part D benefit.
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Medicare Crossover Coverage: For members with category codes VG, VH, VI.
Vision Coverage: For members with category codes VG, VD, VJ & VM.
Healthy Vermonter’s Program
Aid Category VP
Offers access to drugs at a discounted price, which is the Vermont Medicaid rate for prescription drugs.
QUALIFIED MEDICAID MEMBER (QMB)
A QMBY’s only benefit is Medicare cost sharing coverage. They are not considered dual eligible.
PQ Pure QMB
VG %150 VPharm and QMB
VH %175 VPharm and QMB
VI %225 VPharm and QMB
NOTICE OF DECISION
The Department for Children and Families (DCF) notifies members in writing of its decisions made regarding
eligibility, retroactive eligibility, spend-down requirements and other determinations of status or program
changes. These letters are called “Notice of Decision” letters and are issued by the district office or HAEU. A
copy of the Notice of Decision is a required attachment for certain claims involving spend-down.
COURT ORDERED SERVICES
If a member is mandated by a court to seek a service, the service may be covered if it meets the medical
necessity and Vermont Medicaid guidelines.
RETROACTIVE ELIGIBILITY
Vermont Medicaid eligibility is occasionally granted retroactively. The provider may bill for services rendered
during the retroactive period. A note indicating the date of retroactive eligibility must accompany the claim to
waive the timely filing limit; see section, 8.1 Timely Filing.
MEMBER GRIEVANCE PROCESS
A member grievance is a complaint about issues other than actions, such as the location or convenience of
their health care provider or the quality of the health care provided. A member may file a Grievance by calling
the Green Mountain Care Member Customer Support Center when the member and provider are unable to
resolve the issue, and it is within 60 days of the problem. DVHA will respond to the grievance within 90 days
with a letter to the member. A member who filed a Grievance and is not satisfied with the results may ask for
a Grievance Review by a neutral person to ensure that the grievance process was handled fairly. Neither
member nor provider shall be subject to retribution or retaliation regarding the grievance. The member may
also call the Office of Health Care Advocate at 1-800-917-7787 for assistance.
MEMBER APPEAL PROCESS
Members may ask for review of certain actions if they disagree with the action. For decisions made by
DVHA, a request for an appeal or fair hearing may be requested through Green Mountain Care Member
Services by calling 1-800-250-8427 or by letter to: Green Mountain Care Member Services, Department of
Vermont Health Access, 101 Cherry Street, Suite 320, Burlington, VT 05401. Requests must be made within
90 days from the decision date and appeals are heard by a qualified person not responsible for the original
decision.
A provider may ask for an appeal on behalf of the member, if requested to do so by the member. In most
instances, a decision will be made within 45 days of the appeal request. In some instances, the process can
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be extended up to an additional 14 days. However, a decision will always be made within 59 days of the
appeal request.
If the need for the denied benefit is an emergency, an expedited appeal may be requested. If after review it is
determined that the appeal is an emergency, a decision will be made within three business days.
The following actions may be appealed:
Denial or limit of a covered service or eligibility for service, including the type, scope or level of
service;
Reduction, suspension or termination of a previously approved covered service or a service plan;
Denial, in whole or in part, of payment for a covered service;
Failure to provide a clinically-indicated covered service, by any provider;
Failure to act in a timely manner when required by State rule;
Denial of a request to obtain covered services from a provider who is not enrolled in Medicaid (note
that the provider who is not enrolled in Medicaid cannot be reimbursed by Medicaid).
Members with an employer sponsored insurance plan may call the customer service number on the back of
their ID card to obtain information on appealing a decision made by that plan.
When a member is told that the benefit has changed because of a change in a federal or state law, the
member may not ask for an appeal but may request a fair hearing. For additional information, refer to the
Health Care Programs Handbook located at http://www.greenmountaincare.org/member_information.html,
Member Handbooks.
FAIR HEARING
A member that disagrees with the appeal decision may request a fair hearing by the department responsible
for the decision. The request must be made within 90 days from the date of the original notice of decision or
action, or 30 days from the date of an appeal decision.
ADVANCED DIRECTIVES
Hospitals, nursing homes, home health agencies, hospices and prepaid health care organizations are
required to provide certain patients with information about their right to formulate advance directives and
maintain written policies and procedures with respect to advance directives. They are also required to
document in patients’ files whether or not an advance directive is in effect, provide education for staff and the
community on issues concerning advance directives, and ensure compliance with State law on advanced
directives at their facilities. Providers are responsible to guard the confidentiality of member information in a
matter consistent with the confidentiality requirements in 45 CFR parts 160 and 164 and as required by state
law. http://www.cms.hhs.gov/securitystandard/downloads/securityfinalrule.pdf.
Providers can obtain Advance Directive (AD) forms and additional information on AD from the Vermont
Ethics Network website: http://www.vtethicsnetwork.org/ or by mailing your request to:
Vermont Ethics Network
61 Elm Street
Montpelier, Vermont 05602
Section 5 Provider Enrollment, Licensing & Certification
ENROLLMENT & CERTIFICATION
In order to participate in and receive reimbursement from Vermont Medicaid Programs, providers must be
enrolled. Licensed or certified health care providers may be enrolled as Vermont Medicaid providers if at least
one service they provide is recognized in the Vermont Medicaid State Plan. Any health care provider who is
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interested in becoming enrolled in the Vermont Medicaid program should contact the DXC Provider Enrollment
Unit. Enrollment requires that the provider submit applicable enrollment forms, a signed General Provider
Agreement and a copy of the applicable license/certification document and meet all federal and state
requirements. When the DVHA accepts an applicant, a Vermont Medicaid provider ID number will be issued
and a confirmation of enrollment letter will be sent. Payments will not be made until a provider number has
been assigned.
Enrollment may include the following:
Full enrollment is for participating providers who are in-state and out-of-state in network as well
providers that are determined by DVHA to contribute to the Green Mountain Care network and see
Vermont Medicaid members on a regular basis
Ordering, Prescribing, Referring and Attending providers and Residents, whether the physician or
practitioner who actually performs the services for the patient or the referring or prescribing provider,
must be enrolled as a participating Vermont Medicaid provider.
Court ordered enrollment is for providers whose services have been ordered by a court, a fair
hearing decision or by a Coverage Exception.
Request (M108/7104) decision of the commissioner. Court ordered providers would only be enrolled
for dates consistent with the order/decision.
Special status is granted for out-of-state and out-of-network providers who have seen a Vermont Medicaid
member in an emergency or urgent situation, or who have been prior approved for out-of-state services. The
DVHA does not deem a provider enrolled in Medicare as enrolled in Vermont Medicaid. DVHA will pay for
emergency and post-emergency stabilizations services delivered by providers who were not enrolled at the
time of the emergency.
Note: Non-participating enrollment is no longer accepted.
The difference between Enrollment, Re-Enrollment and Revalidation:
Enrollment is for providers that have never previously registered with Green Mountain Care
Re-Enrollment is for providers that have previously enrolled and their eligibility has lapsed
Revalidation is for providers that have previously enrolled and who revalidate within the 90-day
notification period
All providers interested in applying for enrollment, or need to Re-Enroll or Revalidate their eligibility, please visit
http://www.vtmedicaid.com/#/provEnrollAppPackets for all application packets.
Enrollment will be rejected if:
Mandatory information is not received
The provider is disbarred or sanctioned from participation in federal programs
The provider is disbarred or sanctioned by the State of Vermont
Clinical Laboratory Improvement Amendments (CLIA)
Providers that provide laboratory services are required to include a current copy of their CLIA certification at
time of enrollment, re-enrollment or revalidation.
5.1.1 Enrollment Agreement Signatures
All signatures must be original and signed in ink. Applications with signatures deemed not original will not
be processed. Stamped, faxed or copied signatures will not be accepted.
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Exception:
Faxed signatures are allowed for certain cases including but not limited to out-of-state special enrollment
for a single member and other special enrollment cases as identified by DVHA. Upon receipt of the faxed
provider enrollment agreement, DXC is directed to telephone the provider to confirm that the provider did in
fact send the fax. DXC may then begin the screening and enrollment process. Enrollment, including the
assignment of a Vermont Medicaid provider number, may be completed with the use of the faxed
agreement only. Original hardcopy signature must be submitted to DXC Technology for file. Signatures
should be in blue ink to denote authenticity.
PAYMENT CONDITIONS
Providers are entitled to payment for diagnostic, therapeutic, rehabilitative or palliative services when all of
the following conditions are met:
The provider is enrolled with Vermont Medicaid
The services are covered by the applicable program
The services are medically necessary
The services are within the scope of the provider’s license
The services are documented in the patient’s medical records
Prior approval, if required, has been obtained
The claim is submitted within the timely filing limits and contains all required
information
The provider complies with the Advance Directives Law
The member is eligible on the date of service
Billing may not be done in advance of any service to be performed or supplied
CONDITIONS OF PARTICIPATION
The Conditions of Participation are stated in the Provider Enrollment/Recertification Agreement and the
General Provider Agreement and the applicable provision by provider type. Please consult your current
agreement for details.
DOCUMENTATION OF SERVICES
Each provider must keep written documentation for all medical services, actual case record notes for any
services performed, or business records that pertain to members for services provided and payments
claimed or received. All documentation must be legible, contain complete and adequate information and
applicable dates. Providers must submit information upon request of the State Agency of Human
Services, Office of the Vermont Attorney General or U.S, Secretary of Health and Human Services and at no
charge to the requester. The documentation for any service that was billed must be kept for seven years.
This information must also be available at any time for on-site audits. Records of any business transactions
between the provider and any wholly owned supplier, or between the provider and any subcontractor, during
the 5 year period ending on the date of the request, must be submitted within 35 days of the request.
RIGHTS & RESPONSIBILITIES
Participation in Vermont Medicaid is voluntary. Participating health care providers:
May not discriminate on the basis of race, color, sexual orientation, or national origin
May not treat a Vermont Medicaid member any differently than a patient with other payer sources
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May not refuse service to a Vermont Medicaid member simply because the member is covered by other
health insurance
Must meet commonly accepted standards of professional practice.
Must submit claims and required documentation in a form acceptable to the State of Vermont
Must ensure that claims are received within the timely filing limits
May not bill Vermont Medicaid or member any fee for missing a scheduled appointment per Federal
Medicaid policy
Adhere to other applicable federal and State of Vermont laws, rules and procedures
TERMINATION
Providers who no longer wish to participate in the Vermont Medicaid Program are required to notify DVHA of
their intent to terminate their enrollment. This may be done at any time by either writing a letter to DXC
Technology or by indicating on the Vermont Medicaid Termination form. If requested, the provider’s
enrollment will be closed on the date specified. Providers are required to give their patients 30 day notice
prior to termination. Primary care providers in PC Plus are required to give 90 day notice before termination
of the PC Plus agreement.
Section 6 Coordination of Benefits/Medicaid Payment Liability/Third Party Liability
CONTRACTUAL ALLOWANCE
Vermont Medicaid is payer of last resort, and as such, will not consider and pay amounts that exceed the
Medicaid rate, even when payment is combined with payments from primary insurance
When another insurance carrier has made a payment, document the total payments received by other
insurance carriers in the appropriate field on your claim form.
When the entire allowed amount is applied to the primary insurance deductible, the claim may be submitted
to Vermont Medicaid but must be accompanied by an EOB. Vermont Medicaid will consider payment based
on the Vermont Medicaid allowed amount after deducting any payment made by a primary insurer.
The provider is prohibited from collecting an amount that exceeds the contractual amount that is agreed upon
in the contract with primary payer.
REIMBURSEMENT OF OVERPAYMENTS
Providers are reminded of the 2009 Fraud Enforcement and Recovery Act (FERA) which amended the False
Claims Act, 31 U.S.C §§3729-3733, by increasing the scope of the false claims liability to include persons
who knowingly conceal the retention of any overpayment of government money and the 2010 Patient
Protections and Affordable Care Act (PPACA) which directly linked the retention of overpayments to false
claims liability. PPACA requires the report and return of all overpayments within 60 days after the date on
which the overpayment was identified or the date the corresponding cost report was due, whichever is later.
Additionally, providers must submit notification in writing as to the reason of the overpayment. DXC will
forward any cases in which the discovered overpayment was not refunded during the timeline mandated by
PPACA to the DVHA Program Integrity Unit for their review.
Hospitals (in addition to the above information) DXC contracts with AIM HealthCare to audit hospitals for
credit balances on accounts. This arrangement does not negate the provider's responsibility to report and
return overpayments timely. DXC will forward any cases in which the discovered overpayment was not
refunded during the timeline mandated by PPACA to the DVHA Program Integrity Unit for their review.
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WHO IS RESPONSIBLE FOR PAYMENT?
Verifying eligibility before service:
Providers are expected to verify eligibility for every member prior to providing the service or item to be clear
about who has financial responsibility for the service. Eligibility can be verified up to nine days in advance
however, this is not a guarantee of payment. Eligibility can be verified through the automated Voice
Response System (VRS/Malcolm), online Transaction Services (http://www.vtmedicaid.com/#/) or by calling
the Provider Services Unit help desk. When an eligible aid category code is given, the provider should
determine that the service to be provided is covered within that aid category. This will also show what other
insurance is on file. To ensure timely processing of your claim, validate other insurance with member or refer
them to the Department for Children and Families.
Billing the Member
If the provider bills Vermont Medicaid for a service or item, the provider may not bill the patient for any
reason except the following:
The amount due is for unpaid Vermont Medicaid co-payments and deductibles
The claim was denied for lack of eligibility and the date of service was greater
than 60 days beyond the loss of eligibility date
The claim was denied because another insurer’s rules were not followed
The claim is submitted to Medicaid by Medicare for a patient enrolled in a
Medicaid pharmacy only plan or
If the DXC system reports that a member has other insurance, the provider
must bill the service or item to the other medical insurance prior to billing
Vermont Medicaid. If the member is no longer enrolled with the other insurer
and the member does not report the insurance change to Vermont Medicaid
within 30 days and after the 30 days have lapsed, the DXC system still reports that the patient has
other insurance, the provider may bill the member.
Under the Provider Enrollment Agreement (Conditions of Participation #9), failure to give advance
notice that a Vermont Medicaid payment will not be accepted prevents the provider from billing the
member. If the member is eligible for Vermont Medicaid and the provider has made the decision not to
bill Vermont Medicaid for the service or item requested, the member must be informed in advance of
providing the service.
Federal Medicaid policy does not permit providers to bill Vermont Medicaid or the member any fee for
missing a scheduled appointment.
6.3.1 Supplementation
Once Vermont Medicaid has been billed for a service or item, the provider may not attempt to collect any
additional reimbursement for that service or item from the member, the member’s family or anyone acting
on behalf of the member, except for:
The applicable conditions described below in section 6.4 Who is Primary
Permitted deductible and co-payment amounts
Specific allowed supplementations authorized in Medicaid Rule 7602
WHO IS PRIMARY
When the DVHA is the primary payer (i.e. the DXC system indicates no other insurer) and Vermont Medicaid
payment is accepted, the provider should submit all bills to the DVHA’s fiscal intermediary and never to the
patient. Under the provider agreement, the provider has agreed to accept the DVHA’s payment or denial
(except as enumerated above) as payment in full.
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When the DXC system shows a source other than the DVHA as the primary payer (such as Medicare or any
other insurance carrier) the DVHA is the payer of last resort. Under the provider agreement, certain
restrictions apply.
When Vermont Medicaid is secondary to a private insurer and a co-payment is required by the primary
insurer at time of service, the provider is to bill the claim to Vermont Medicaid and indicate the amount paid
by the primary insurance. Vermont Medicaid reimburses their allowed amount, minus the amount the other
insurer has paid.
Providers that do not wish to bill Vermont Medicaid for the co-payment are only allowed to bill the member if
they notify the member in writing, prior to rendering the service, that they will not bill Vermont Medicaid for
the co-payment. The member must sign and date this notification; please retain documentation in the
member’s file.
If the third party payment was made directly to the member, the provider may bill the member for the amount
paid by such third parties. In addition, the provider may collect patient liability or spend-down amounts.
NOTICE THAT MEDICAID WILL NOT BE ACCEPTED
If a provider does not intend to bill Vermont Medicaid for specific services, the patient must be fully informed
of the decision and its consequences prior to rendering the service. Patients must understand that they will
be financially responsible for the service(s). To document that proper notice was given; providers are
required to document the agreement/understanding between member and provider on their letterhead.
Comprehensive documentation showing evidence that proper notice was given to the member should include
the following information:
1. Provider’s name and Vermont Medicaid provider ID number
2. Member’s name and signature (or signature of a parent, if the member is a minor)
3. Description of service(s) sought
4. A clear statement that the provider is unwilling to accept Vermont Medicaid payment for the specific
service(s) sought and if the member wants to get this service from this provider, the member or
responsible adult must accept full financial responsibility
5. Date of signing
The provider is to give a copy to the member or responsible adult and retain a copy in the member’s file.
Failure to give advance notice prevents the provider from billing the member. When the member or
responsible adult accepts financial responsibility, the claim cannot be submitted to DXC for processing.
MEDICAID & MEDICARE CROSSOVER BILLING
A Green Mountain Care member may be eligible for both Vermont Medicaid and Medicare. When dual
eligibility exists, Medicare must be billed first on an assigned basis.
After Medicare payment, the DVHA pays deductibles and coinsurance for crossover claims.
Providers must include their NPI and taxonomy code on any claims sent to Medicare in order to assure
proper automatic crossover and subsequent Vermont Medicaid processing of your claims. Vermont Medicaid
is aware that Medicare does not have this same requirement but will include the taxonomy code, as
submitted on the claim, on the crossover file.
DXC Technology does not accept a CMS1500 crossover claim submitted with multiple Medicare Attachment
Summary Forms. When submitting a CMS1500 crossover claim that contains more than 6 details, each 6
details must be submitted as an individual claim with its Medicare Summary Attachment Form; indicate the
number of details and the total. The total must equal only the sum of the detail lines listed on that claim form.
The Department of Vermont Health Access reviews all Medicare crossover claims where the Medicaid
allowed amount (coinsurance / deductible) is over $10,000.00. These claims require DVHA’s review and
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approval prior to payments being made. To facilitate the processing of these claims, please attach the
following information to your claim if the expected coinsurance /deductible payment from Medicaid is over
$10,000.00: the Medicare Attachment Summary Form, the Medicare EOMB and the discharge summary at
the time of submission. Any claims submitted without the required supporting documentation will be denied.
A Medicare Attachment Summary Form should not be attached if an item or service is non-reimbursable by
Medicare. If the service or item is denied by Medicare, a completed claim along with the Medicare EOB
should be submitted within twelve months of the date of service.
The Medicare Attachment Summary Form is only to be used for beneficiaries who are enrolled in both
Medicare and Vermont Medicaid. It is not to be used for reporting actions by any other insurers.
Vermont and New Hampshire Providers:
In order to crossover, Vermont Medicaid eligibility information must be clearly indicated on the Medicare
claim. These claims, as well as any future adjustments to these claims, will crossover automatically to DXC
for payment. If you do not receive the DVHA payment within 30 days of the Medicare paid date, submit the
claim to DXC with the Medicare Attachment Summary Form.
If a service or item is denied by Medicare as non-reimbursable and is reimbursable by the DVHA, submit a
CMS 1500 claim, completed to the DVHA specifications, along with the Medicare denial to DXC within twelve
months of the date of service.
Other Out-of-State Providers (Except New Hampshire):
All out-of-state providers should first bill their regional Medicare carrier for services to dual eligible Vermont
residents. After Medicare payment is received, send a claim to DXC for payment of any coinsurance or
deductible as follows:
Send a claim completed to the DVHA specifications with a copy of the Medicare Attachment
Summary Form. The Medicare payment date must appear on the Medicare Attachment Summary
Form.
If a service or item is denied by Medicare as non-reimbursable and is reimbursable by the DVHA,
submit a CMS 1500 claim with the EOMB, completed to the DVHA specifications to DXC within
twelve months of the date of service; see section 8.1 Timely Filing
THIRD PARTY LIABILITY (TPL)/OTHER INSURANCE (OI)
Vermont Medicaid is the payer of last resort. Providers are required to pursue and apply all third party
payment resources prior to billing Vermont Medicaid. Third party resources include, but are not limited to,
Medicare, private/group health insurance plans, military and veteran’s benefits, Worker’s Compensation and
accident (automobile, homeowners, etc.) insurance. (See Section 6.9 for information specific to Workers
Compensation and Accident Liability Billing)
TPL-Verification
The member’s other insurance information, including the name of the other insurance company, address,
carrier code and type of coverage, is available on the Vermont Medicaid website, Provider Web Services
(http://www.vtmedicaid.com/#/, TransactionsLogin - UAT) and the Voice Response System (VRS) when
the provider checks the member’s eligibility. Providers will review the member’s eligibility information for the
date of service and must bill other insurance carrier(s) before billing Vermont Medicaid. Use of the available
information will guide providers in billing.
Timely Filing of OI Claims
Providers will respect the member’s right to receive all medically necessary services and equipment in a
timely manner and must submit claims to primary insurers promptly to mitigate issues with member primary
insurance benefits exhausting.
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Other Insurance Denial/DVHA Authorization Request
The following procedures are required for DVHA authorization requests when the primary insurer has
reviewed and denied a claim request for an item or service:
OI Denial for Non-Covered or Benefits Exhausted
The provider is required to submit to the DVHA the authorization request form (Medical Necessity Form or
other) with all standard documentation, the notice of denial from the primary insurer that indicates the item or
service is not a covered benefit or that the benefit limit was determined to be exhausted, and all necessary
documentation to support medical necessity. The DVHA will then review.
The provider does not need to appeal to the primary insurer before billing
Medicaid when the item/service is not covered or benefits are exhausted.
If the code/service does not require authorization from Vermont Medicaid, then
the provider can bill Medicaid directly with a copy of the primary insurer’s
denial attached.
OI Denial for Not Medically Necessary
The provider and/or member is required to pursue all levels of reconsideration and appeals with the primary
insurer. If the request remains denied by the primary insurer, the provider and/or member is required to seek
review by the Vermont Department of Financial Regulation if the cost of the item or service exceeds $100. If
the denial stands, then the provider may submit the request to the DVHA with copies of all of the original
documentation, the denials from the primary insurer and the Department of Financial Regulation’s support of
the denial. The provider should not submit any additional documentation than what was reviewed by the
primary insurer.
If the code/service does not require authorization from Vermont Medicaid, then
the provider can bill Medicaid directly, with copies of the primary insurer’s
denials (original and appeals) and the Department of Financial Regulation’s support of the denial
attached.
OI Blanket Denials
Providers are required to submit blanket denials from a primary insurer to DXC every calendar year, for
example: a blanket denial issued on July 7, 2013, will only be valid until December 31, 2013 and a new
denial will be required as of January 1, 2014. Blanket Denials are required each calendar year as health
insurance benefits are reviewed and health care policies are generally, renewed yearly.
Vermont Medicaid will accept a blanket denial for the same calendar year as the date(s) of service of the
claim(s) being submitted for payment.
All Blanket Denials are to include the following:
Name of the insurance company
Member name
Date(s) of service
Rev/Procedure code or description of service
Providers may obtain a “blanket statement” from an insurance company that states that the company never
covers a particular service for the member’s policy and attach it to the claim when billing for that service.
Blanket statement must be less than one year old and must be attached to each claim submitted. Providers
must indicate the member’s name and identification number and the applicable dates of service and the
provider must sign and date the blanket statement.
Medicare Qualified Independent Contractor
For members covered by Medicare, the requirement to go through the Medicare Qualified Independent
Contractor appeal level applies, with the exception of wheelchairs that Medicare denies or downgrades.
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Upon documentation of the Medicare action, Medicaid will review for medical necessity and payment
determination.
The DVHA will reject a request if there is reason to believe that the OI received incorrect or incomplete
information from the provider and based its decision on that incorrect or incomplete information. Providers
must determine OI/Medicare benefits before rendering the service to minimize the risk of non-coverage by
both OI or Medicare and the DVHA.
Other Insurance Attachments
Providers may submit electronically to DXC claims that have been denied by another insurance company
(third party payer/primary payer) when that payer has denied the claim using certain adjustment reason
codes. Providers are required to include the adjustment reason code used by the primary payer when
submitting the claim but will not need to send a copy of the primary insurance attachment. The list of
adjustment reason codes that will be accepted electronically is available at
http://www.vtmedicaid.com/#/resources, select 837 Adjustment Reason Codes. DXC may select your claim
for post payment review and request a copy of the explanation of benefits; if so, providers are required to
supply all supporting documentation in a timely manner. Failure to do so will result in the recoupment of your
paid claim.
When submitting a paper claim, an attachment is needed only when a third party insurance carrier has not
made a payment. Providers must attach documentation from the carrier that verifies the member’s name,
insurer’s name, dates of service, service code or exact description of service, the amount reimbursed and the
payment or denial date. If the carrier does not include this information in the documentation (i.e. the carrier
issues a blanket statement that the particular service is not covered), the provider must write the necessary
information on the attachment, then sign and date the attachment. It must be clear that the attachment
relates to the specific services billed on the Medicaid claim.
If there was a payment made by the third party, providers must indicate the amount paid in the “prior
payments” field. Documentation from the carrier is not required with the claim form if there is a payment
amount, thus allowing the claims to be submitted electronically. In cases where a member has more than
one other insurance, providers must indicate on paper, that payment was received (or denied) from each
insurance company.
If the other insurance amount is less than $3.00, the provider must include the “other insurance attachment
verifying that exact payment amount.
Exceptions: Members are excluded from the third party liability requirements specified above for the
following services:
Prenatal Care Services: This includes routine supervision of normal pregnancy, prenatal screening of
mother or fetus, and care provided in the prenatal period to the mother for complications of pregnancy
Preventive Care Services: This includes immunizations, screening tests for congenital disorders, well-
child visits, preventive medicine visits, preventative dental care, and screening and preventive
treatment for infectious and communicable diseases
Court-enforced Medical Support Members: This is identified by an insurance
coverage type D1 through D9 which indicates “Absent Parent”
Claims exempt from TPL may be submitted directly to DXC. Indicate “not billed” in the “other insurance” field
when submitting paper claims. When submitting electronically, simply indicate “no” in the “other insurance”
field. The provider should only indicate that other insurance has not been billed if that is, in fact, true.
If the provider chooses to first bill the third party in these cases, he or she must wait 30 days from the date of
furnishing the service before billing Vermont Medicaid. Medicaid must be credited with any payments
received from the other third party payer.
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Accidents
Claims billed with a “yes” in the accident field and those with a trauma diagnosis will be tracked in the claims
processing system and monitored for post payment recovery from liable parties. In order to determine liability
information, DXC will send questionnaires to members regarding some trauma cases.
Discrepancy in TLP Information
When a provider believes that the other insurance listed in the eligibility file is incorrect, contact the DCF
district worker for clarification/correction or have the member contact Member Services.
HMOs
Are treated as other health insurance. When a Vermont Medicaid member does not comply with the rules of
their HMO, such as securing prior authorization, the HMO may choose not to cover the service. In such
cases, Vermont Medicaid will not pay for the service either and the member will be responsible for payment.
TPL Cost Avoidance: DXC maintains eligibility files, which contain member health insurance information.
This data is integrated in the claims processing system to coordinate benefits.
6.7.1 Third Party Liability Coverage Codes
The VRS and the Vermont Medicaid website use the following codes to describe the type of services
covered by a patient’s other insurance. The Coverage Codes (below) and the insurance matrix (see
Appendix) will help in understanding how to interpret the information provided about third party liability. For
example, if the VRS reports “07” for a member, the matrix shows that a dental claim for dental services will
fail for reason 408 if the third party information is not provided. Contact DXC if you do not know whether the
coverage code refers to the service you have provided.
Code
Type of Coverage
01
Hospital Inpatient Services
02
Hospital Outpatient Services
03
Hospital Inpatient/Outpatient Services
04
Physician Services
05
Physician Inpatient/Outpatient Services
06
Physician Inpatient/Outpatient Services/Major Medical
07
Dental Coverage
08
Vision Coverage
09
Drug Coverage
10
Physician Inpatient/Outpatient Services/Major Medical/Dental
11
Physician Inpatient/Outpatient Services/Major Medical/Vision
12
Physician Inpatient/Outpatient Services/Major Medical/Drug
13
Medicare Supplement A & B
14
Indemnity Coverage Payment to Client
15
Major Medical
16
Major Medical/Physician
17
Major Medical/Physician/Dental
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18
Major Medical/Physician/Vision
19
Major Medical/Physician/Drug
20
Major Medical/Physician/Dental/Vision/Drug
21
Inpatient/Outpatient/Physician/Dental/Major Medical/Drug/Vision
22
Medicare Supplement Part A
23
Medicare Supplement Part B
24
Specialty Coverage (e.g., cancer)
25
HMO
26
Nursing Home
27
Veterans Home
28
Worker's Compensation
50
Absent Parent (4D)
99
Unknown
A1
Medicare A
B1
Medicare B
WORKERS COMPENSATION/ACCIDENT LIABILITY BILLING
Providers have two choices regarding billing when a member is also covered by worker’s compensation or
accident insurance, such as auto insurance, homeowners, etc.
1. Bill Vermont Medicaid or
2. Bill workers compensation/auto insurance.
If the provider chooses to bill the workers compensation or the accident Insurance (i.e., auto insurance,
homeowners, etc.), the provider cannot bill Vermont Medicaid simultaneously. (Refer to your provider
enrollment/recertification agreement.)
If a provider decides at any point to bill Vermont Medicaid, the provider must withdraw the claim to the
workers compensation/auto insurer. The withdrawn claim is still subject to the 180 days timely filing limit.
Vermont Medicaid will pay the claim and bill the responsible insurance provider. Payments made by the
insurance provider will come directly to Vermont Medicaid. No reimbursement will be made to the provider.
When a provider bills worker's compensation or accident insurance, and the claim is denied by workers
compensation or accident insurance, the provider then has 1 year from the date of service to submit their
claim to Vermont Medicaid for payment.
If a payment is received from a worker’s compensation/accident insurer after the provider has received
payment from Vermont Medicaid, the provider must return or refund the payment to Vermont Medicaid.
In regards to billing the member, 42 USC § 1396a (a)(25)(C) states: “In the case of an individual who is
entitled to medical assistance under the State plan with respect to a service for which a third party is liable for
payment, the person furnishing the service may not seek to collect from the individual (or any financially
responsible relative or representative of that individual) payment of an amount for that service…”
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Section 7 Prior Authorization for Medical Services
Prior authorization (PA) is a process used to assure the appropriate use of health care services. The goal of
PA is to assure that the proposed health service, item or procedure meets the medical necessity criteria; that
all appropriate, less-expensive alternatives have been given consideration; and the proposed service
conforms to generally accepted practice parameters recognized by health care providers in the same or
similar general specialty who typically treat or manage the diagnosis or condition. It involves a request for
approval of each health service that is designated as requiring prior approval before the service is rendered.
Please review the fee scheduled at: http://dvha.vermont.gov/for-providers/claims-processing-1 for services
that require a PA. Authorization will not be granted after the service is rendered.
The DVHA PA criteria and regulations can be found in Medicaid Rule 7102. These rules and procedures
govern PAs performed by the DVHA and its agents. DVHA rules are available online at
http://dvha.vermont.gov/budget-legislative
No retroactive prior authorization will be granted. The DVHA PA requirements apply when the DVHA is
known to be the primary payer for the service or item or the service or item is not a covered benefit by the
member’s primary insurer.
Waiver of Prior Authorization (Exceptions):
Medicaid Rule 7102.3 allows two general exceptions to securing authorization prior to the date of service.
Emergency Services: Services normally requiring PA do not require PA when treating an emergency
condition.
This exception applies to both the emergency care and the post-emergency stabilization. Post-emergency
stabilization care will be provided until the attending emergency physician determines that the patient is
sufficiently stabilized for transfer or discharge.
Retroactive Eligibility: Covered services that normally require PA, which are provided to an individual in
the retroactive period (defined as eligibility start date to eligibility segment update date), do not require
PA.
CLINICAL PRACTICE GUIDELINES
The Department of Vermont Health Access has adopted various Clinical Practice Guidelines that are based
upon evidence based medicine. These guidelines outline the preferred approach for most patients and are
used to support the decision making processes. The guidelines can be found
http://dvha.vermont.gov/forproviders/clinical-coverage-guidelines
PRIOR AUTHORIZATION REQUIREMENTS
The DVHA Clinical Operations Unit (COU) enters prior authorizations with the exact procedure code(s) given
by the requesting provider on the request form. In those instances when the procedure code to be billed does
not exactly match the code requested/authorized, the provider must notify the COU in writing prior to claim
submission. Include the DVHA prior authorization number, the rationale for the code change and signature.
Fax information to (802) 879-5963.
All unlisted procedure codes require authorization from the DVHA COU prior to the service being rendered.
If it is determined during a surgical procedure that an unlisted procedure is appropriate and medically
necessary, prior authorization must be requested prior to claim submission. Fax information to (802) 879-
5963. Surgical procedure notes must be attached with the claim indicating the usual and customary charge
for the service.
7.2.1 Required Documentation
At a minimum, the documentation required to support a PA request must include a completed and legible
copy of a medical necessity form, or other appropriate documentation, with the prescribing provider’s
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signature, and all documents necessary for identification and pricing of the service requested, when
applicable. Providers are required to keep the original legible copy of the medical necessity form in the
patient’s record. It is not necessary to submit a completed claim form with a PA request. If a request for PA is
denied and a provider has questions or needs additional information, contact the DVHA Clinical Unit.at (802)
879-5903.
Notwithstanding any other review, the State reserves the right to review medical records at any time and
without advance notice.
7.2.2 Immediate Need Exception
1. URGENT: Authorization in advance does not have to occur if the service or item is rendered for
urgently needed care as defined below and if the urgent care is required outside of normal DVHA
business hours. If a request for authorization is shown to be for urgently needed care, and if the
request for authorization is made on the next business day, the request will be considered timely.
Payment for such services or items will further depend on a determination that they are medically
necessary. If any such item is not considered medically necessary, the DVHA will provide normal
reimbursement for a reasonable quantity of consumable items actually provided and/or the DVHA
will provide normal reimbursement for the rental of such items in the minimum allowable period for
the service.
2. IMMEDIATE: Authorization in advance does not have to occur if the service or item is rendered for
immediately needed care as defined below. However, the request for PA must be faxed to the
DVHA Clinical Unit by the next business day., The provider should submit documentation of
medical necessity and evidence that the care or item was immediately needed. This may take the
form of an order or a discharge plan. Payment for such services or items will further depend on a
determination that the service(s) are medically necessary. If any such item is not considered
medically necessary, the DVHA will provide normal reimbursement for a reasonable quantity of
consumable items actually provided and/or the DVHA will provide normal reimbursement for the
rental of such items in thirty-day increments.
Definitions:
“Emergency Medical Condition” means the sudden and, at the time, unexpected onset of an illness or
medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the
absence of immediate medical attention could reasonably be expected by the prudent layperson who
possess an average knowledge of health and medicine, to result in:
Placing the member’s physical or mental health in serious jeopardy; -or-
serious impairment to bodily functions; -or-
serious dysfunction of any bodily organ or part.
“Post Emergency Stabilization” is the care required after an emergency to stabilize the patient for transfer or
discharge. The attending emergency physician determines when a patient has been sufficiently stabilized for
transfer or discharge. Post-emergency stabilization care is covered 24 hours per day, 7 days per week as
necessary to stabilize a patient after an emergency.
“Urgently-Needed Care” or “Urgent Care” means those health care services that are necessary to treat a
condition or illness of an individual that if not treated within twenty-four (24) hours presents a serious risk of
harm.
“Immediately Needed” means that action is needed on the same day to avoid delay in discharge or to allow
the member to remain in a community setting.
These definitions are consistent with both Medicaid rules and Department of Financial Regulation
DETERMINATION TIME
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The timeframes now correspond to 42 CFR §438.210. DVHA will continue to issue a notice of decision within
three days of receipt of all the necessary information. However, the longest time to wait for a decision is now
28 days, not 30. A request must be decided within 14 days of receipt of the request, but that time frame may
be extended up to another 14 days if the beneficiary or provider request the extension, or if the extension is
needed to obtain additional information and an extension is in the beneficiary’s interest.
Also, when a provider indicates, or DVHA determines, that following this timeframe could seriously
jeopardize the beneficiary’s life, health, or ability to attain, maintain, or regain maximum function, DVHA must
make an expedited decision and provide notice as expeditiously as the beneficiary’s health condition requires
and no later than three working days after receipt of the request. This may be extended up to 14 days if the
beneficiary so requests, or if the extension is needed to obtain additional information and an extension is in
the beneficiary’s interest. Under federal law, the department is obligated to provide a response within 24
hours of a request for PA of a drug.
7.3.1 PA Decision Reconsiderations
The DVHA will conduct a review of a denied prior authorization (prior to submission of claims) at the
request of a provider. The DVHA will conduct the following review if requested by the provider (prior to
submission of claim):
1. PA denial by the DVHA at the request of a provider
2. Peer to Peer review with DVHA Physician
3. PA denial about the “immediate need” for durable medical equipment;
4. PA denial because documentation was inadequate;
5. Purchase versus rental decisions for durable medical equipment.
The DVHA will not review any decision other than those listed above. All request for the above
reconsiderations must be faxed to (802) 879-5963.
Prior Authorization Contact information:
DVHA Clinical Unit
(802) 879-5903
Fax
(802) 879-5963
Dental
(802) 879-5903
Prescription Drugs are reviewed by the Pharmacy Benefit Manager Change Healthcare
Change Healthcare Call
Center
(844) 679-5363
7:30am - 6:30pm, M-F
(844) 679-5366
after hours on call 24/7 365
day/year
Change Healthcare
Pharmacy Help Desk Phone:
1-844-679-5362
All drugs and supplies requiring prior authorization can be identified on the Preferred Drug List (PDL) which
can be found at http://dvha.vermont.gov/for-providers/pharmacy
Select outpatient elective diagnostic imaging procedures require prior authorization; please see the
Diagnostic Imaging Program Guidelines & list of radiology CPT codes requiring prior authorization located at
http://www.vtmedicaid.com/#/resources
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Elective Diagnostic Outpatient High Tech Imaging:
eviCore Customer Service
(888) 693-3211
eviCore Fax
(888) 693-3210
Web based PA Requests
http://www.medsolutionsonline.com
Fax forms can be obtained at http://www.medsolutionsonline.com or by calling MedSolutions Customer
Service (888) 693-3211, 8a.m. to 9 p.m., Monday through Friday. Diagnostic Imaging Program Guidelines
and a complete list of CPT codes requiring prior authorization can be accessed at
http://dvha.vermont.gov/for-providers/claims-processing-1
MEDICAL NECESSITY
Vermont Medicaid only pays for items that are medically necessary. Per the Medicaid Rule, 7103, medically
necessary is defined as health care services that are appropriate, in terms of type, amount, frequency, level,
setting and duration to the member’s diagnosis or condition. Medically necessary care must be consistent
with generally accepted practice parameters as recognized by health care providers in the same or similar
general specialty as typically treat or manage the diagnosis or condition and
Help restore or maintain the member’s health -OR-
Prevent deterioration or palliate the member’s condition -OR-
Prevent the reasonably likely onset of a health problem or detect an incipient problem
Additionally, for EPSDT-eligible members, medically necessary includes a determination that a service is
needed to achieve proper growth and development or prevent the onset or worsening of a health condition.
7.4.1 Medical Necessity Form (MNF)
A completed DVHA Medical Necessity Form (DVHA 60) is the preferred documentation for Home
Respiratory Therapy programs, DME and certain prescribed medical supply items with a few exceptions. The
ordering physician or nurse practitioner needs to complete the MNF and give a clean copy to the patient or to
the DME supplier.
Submission of the form and any necessary information to clearly document medical need is all that is needed
to make the request for prior authorization.
If the code/service requires prior authorization, the DME supplier will send the MNF and all pertinent
information to the DVHA as a PA request.
Both the ordering providers and the DME vendor are required to keep legible copies of all information in the
patient record.
The signature date on the MNF/order must be within 6 months (before or after) of the dispensing date (billed
DOS) for all items except ostomy and urologic supplies. (The order on these supplies is good for one year).
Medical Necessity and prior authorization forms are available at http://dvha.vermont.gov/for-
providers/forms1.
UTILIZATION REVIEW
The DVHA conducts numerous utilization management and review activities. Reviews are intended to assure
that quality services are provided to members and that providers are using the program properly. The
reviews are generally an examination of records, known as a desk audit, although they may also include an
on-site visit from the utilization review unit.
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DVHA staff utilizes clinical criteria for making Utilization Review (UR) decisions that are objective and based
on sound medical evidence. Approved criteria include the following:
Change Healthcare InterQual® Guidelines
DVHA Clinical Guidelines
Vermont State Medicaid Rules
Hayes and Cochrane New Technology Assessments
Other Nationally Recognized Evidence Based Criteria
Change Healthcare InterQual® Guidelines are now available to providers behind the Vermont Medicaid
secure provider web portal at http://www.vtmedicaid.com/#/, navigate to the Transactions menu and choose
login (Trading Partners use “Login”, Web Services use “Login - UAT).
DVHA Clinical Guidelines and Vermont Medicaid State Rules will continue to be available at the DVHA
website at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines.
PRIOR AUTHORIZATION NOTICE OF DECISION
The Notice of Decision is a system-generated form that the requesting and supplying provider receives as
well as the member from the DVHA in response to a Prior Authorization (PA) request.
The Notice of Decision contains the following information:
Box 2: The value will be either “A” (approved) or “D” (denied) or “I” (awaiting further information)
Box 3: The dates of service
Box 4: The procedure code
Box 5: The number of units and/or occurrences
SERVICES REQUIRING PRIOR AUTHORIZATION
7.7.1 Concurrent Review for Admissions at Vermont & In-Network Border Hospitals
The Inpatient Concurrent Review Procedures are available at http://dvha.vermont.gov/for-providers/clinical-
coverage-guidelines.
All Vermont hospitals, including in-network border hospitals, are not required to submit faxed daily census
sheets to the Department of Vermont Health Access (DVHA) Clinical Operations Unit (COU). Please note:
Continue to use the File Transfer Protocol (FTP) for submitting information as required by other DVHA
programs. This requirement only applies when Medicaid is the primary payer. This requirement does not
apply to Inpatient Rehabilitation stays, psychiatric unit and psychiatric hospital admissions. In addition,
notification of patient discharge is required.
Prior Authorization is required if the patient stay is to exceed 13 days. The admitting facility must fax a
completed Inpatient Concurrent Review Notification Form to the DVHA COU at (802) 879-5963 for all
inpatient admissions that have an expected length of stay exceeding 13 days, including time in the
emergency department and/or observation by day 13, but no earlier than day 10 of the admission. Failure to
get a PA
for an admission that exceeds 13 days will result in a denial of the claim. Forms are available at
http://dvha.vermont.gov/for-providers/forms-1.
Retrospective reviews will not be performed when DVHA is not notified of an admission by day 13, but no
earlier than day 10 of the admission.
7.7.2 Out of-State Elective Inpatient Hospital Admissions
(Excluding Designated Border Hospitals)
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All elective inpatient admissions to out-of-state/out-of-network hospitals require prior authorization from the
DVHA COU prior to admission. The admitting facility must fax a completed Vermont Medicaid Out of State
Preadmission Form located at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines, clinical
documentation and an explanation as to why this care cannot be performed within the State of Vermont to
(802) 879-5963. The prior authorization must be requested as early as possible and no less than 3 business
days prior to the planned admission.
7.7.3 Out-of-Network Elective Outpatient Referrals
Prior authorization is required for referrals to out-of-state/out-of-network medical visits that are
elective/nonemergency, for codes 99201-99215, 99381-99456, and 99341-99360; however, PA is not
required for referrals for office visits to:
Providers affiliated with Extended-network hospitals
Providers affiliated with Out-of-state In-network hospitals
All other PA requirements will apply. A list of Green Mountain Care in-network and extended network
hospitals is available at http://dvha.vermont.gov/for-providers/green-mountain-carenetwork.
Referring providers must submit requests using the OOS Medical Office Request Form located at
http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines. Fax all requests to the DVHA COU: (802)
879-5963.
Note: Only office visit(s) are being approved. Do not proceed with any non-emergent outpatient procedure
until you have first determined and documented that the service cannot be performed by an in-network
provider.
7.7.4 In-State & Out of State Psychiatric & Detoxification Inpatient Services
The Department of Vermont Health Access (DVHA) in collaboration with the Department of Mental Health
(DMH) requires concurrent review for psychiatric and detoxification inpatient admissions. This includes all
children and adults, including those enrolled in CRT. Admitting facilities must complete the Vermont Medicaid
Admission Notification form for Inpatient Psychiatric and Detoxification Services and fax it to the DVHA at 1-
855-275-1212 within 24 hours of an urgent or emergent admission. Elective or planned admissions will
require prior authorization by the DVHA. The admitting facility must fax a completed Vermont Medicaid Prior
Authorization form to 1-855-275-1212. Forms are available at:
http://dvha.vermont.gov/for-providers/clinical-prior-authorization-forms. For additional information please see
the Vermont Medicaid Inpatient Psychiatric & Detoxification Manual available at: http://dvha.vermont.gov/for-
providers/mental-health-inpatient-detox.
7.7.5 Out-of-State Urgent/Emergent Inpatient Hospital Admissions
(Excluding Designated Out-of-State Network Hospitals)
All urgent and emergent inpatient admissions to out-of-state (OOS) hospitals require notification to the DVHA
Clinical Unit of the admission within 24 hours or the next business day. Concurrent review will begin at the
time of notification and throughout the course of the inpatient hospital stay. The admitting hospital must fax a
completed Out-Of-State Urgent and Emergent Hospital Admissions form located at
http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines and clinical documentation to the DVHA at
(802) 879-5963.
The hospital is required to notify the DVHA upon patient discharge.
7.7.6 Rehabilitative Therapy
Speech-Language Pathology (SLP) providers may enroll as private practitioners with Vermont Medicaid.
Coverage of private practice SLP services are limited to those services provided outside of the school or
hospital systems for Medicaid members of any age. The following statements apply to all therapy services:
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Medicaid does not cover any treatments or any portions of a treatment, when the efficacy and/or safety of
that treatment is not sufficiently supported in current, peer reviewed medical literature.
All treatment must demonstrate medical necessity.
Per National Correct Coding regulations, treatment must be billed under the most specific code. Billing a non-
covered service under a less specific code in order to obtain coverage could constitute fraud and could
expose the provider to recoupment and fraud investigation.
Examples of treatment that do not have sufficient support in current medical literature at this time include, but
are not limited to: sensory integration therapy, craniosacral therapy, myofascial release therapy, visceral
manipulation therapy, auditory integration training, and facilitated communication.
Note also, that treatment with goals related to leisure, sports, recreation, and avocation are not covered
benefits because they do not meet the bar of medical necessity. Treatment with goals related to vocation and
education are not covered benefits because there are other resources for coverage, including the
Department of Vocational Rehabilitation and the Department of Education.
Adult Coverage
Physical, Occupational, and Speech Therapy outpatient services for Medicaid eligible adults are limited to 30
combined visits per calendar year.
Prior authorization for therapy visits beyond 30 combined visits in a calendar year may be requested for
members with the following diagnoses: spinal cord injury, traumatic brain injury, stroke, amputation, or
severe burn.
Changing programs or eligibility status within the calendar year does not reset the number of available visits.
See Frequently Asked Questions (FAQ), under Therapy Guidelines at
http://dvha.vermont.gov/forproviders/clinical-coverage-guidelines. Limitations and prior authorization
requirements do not apply when Medicare is the primary payer.
The limit does not apply to services provided in inpatient facilities or by home health agencies; inpatient
facilities and home health agencies should follow the rules and processes currently in place.
Members under age 21
Prior authorization for outpatient therapies (PT, OT, ST) changed for Medicaid members under age 21. The
initial eight visits from the start of the member’s acute care episode/condition are allowed, per therapy
discipline, before prior authorization is required. Providers must request prior authorization in advance of the
8th visit if additional therapy services are necessary. Providers are required to determine the first date of
treatment at any outpatient facility, regardless of coverage source. It is the responsibility of the therapists to
track therapy visit/service history.
For members with a primary insurance, a prior authorization is not required if the primary insurer pays a
portion of the claim. However if the primary insurer denies the claim for being a non-covered service, if the
primary insurance benefit has exhausted, or if the primary insurance applied all to the deductible, prior
authorization is required for over 8 visits.
Subsequent authorizations will be required at 4 month intervals, based on the start of care date.
This requirement does not apply to home health agencies.
Per the Physical, Occupational and Speech Therapy guidelines posted at
http://dvha.vermont.gov/forproviders/clinical-coverage-guidelines, therapy providers can bill a maximum of 4
units of timed therapy procedures codes that state “15 minutes” are allowed per treatment session. The 4-
unit maximum is the combined totaled of timed units, not a per-procedure code limit. Evaluation, re-
evaluation and other non-timed codes are not subject to the limit and may be billed in addition to the 4 timed
codes during a single session. The code for wheelchair management, direct one-on-one patient contact,
each 15 minutes” is an exception and is excluded from the 4-unit limit.
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Providers should refer to Medicaid Rule and Therapy Guidelines for additional information at
http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines
Therapists should use the Medicaid Request for Extension of Rehabilitation Therapy Services form. Be sure
to include the original start of care date by any facility or provider, for the condition listed.
Physical, Occupational and Speech Therapists who choose to submit rehabilitation therapy extension
requests on forms other than the DVHA Therapy Extension Request form are strongly encouraged to use the
new DVHA Cover Sheet, available at http://dvha.vermont.gov/for-providers/forms-1.
Use of this form with your alternative request documentation will ensure that DVHA receives the information
required to process your prior authorization (PA) request. DVHA expects that the use of this form will speed
the PA process.
Outpatient Therapy Modifiers
VT Medicaid follows Medicare’s requirement that speech, occupational and physical therapists bill with
modifier GN, GO or GP to identify the discipline of the plan of care under which the service is delivered.
GN = Services delivered under an outpatient speech-language pathology plan of care
GO = Services delivered under an outpatient occupational therapy plan of care
GP = Services delivered under an outpatient physical therapy plan of care
Medicare provides a link to the list of applicable therapy procedure codes, (this list is updated annually by
CMS). VT Medicaid therapists need only reference the code list itself; do not use the column information.
http://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html.
All therapy services (including codes listed as “Sometimes Therapy”) that are performed by a therapist (and
billed with the therapist as the attending) must be part of an outpatient therapy plan of care and the billing
codes must use one of the above therapy modifiers to bill.
Some codes on this list are “Always Therapy” services regardless of who performs them. These services
must be part of an outpatient therapy plan of care and the Billing codes must use one of the above therapy
modifiers to bill.
Practitioners other than therapists must use these modifiers when performing listed services which are
delivered under an outpatient therapy plan of care.
These modifiers are not to be used with codes that are not specified on the list of applicable therapy codes.
Modifiers may be reported in any order.
Prior Authorization Requests must give the exact codes and modifiers in the same order as they will be billed
on the claim.
Section 8 Reimbursement, Billing Procedures and Claim Processing
DVHA does not arbitrarily deny or reduce the amount, duration or scope of a required covered service solely
because of diagnosis, type of illness or condition of the member
DVHA does not incentivize or provide rewards to employees, providers or contractors for denial of services
or prior authorizations.
ADJUSTMENTS REQUESTS
Adjustment requests may be submitted to DXC when a claim is paid incorrectly. These requests can be
initiated by the provider, DXC or the DVHA. If the error originates with the provider, then the provider must
submit the adjustment. When requesting an adjustment, submit an adjustment form. Give a brief description
of the reason for the adjustment and the action required.
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A new claim form with the correct information is required when changing the pay to, provider number,
member number or funding source. Any request, which does not have the proper attachments, will be
returned. If timely filing also applies, then attach a copy of the RA.
Denied claims cannot be submitted as adjustment requests. A claim that has been denied should be
corrected and resubmitted with all attachments as a new claim.
Adjustments are the preferred method of correction because they eliminate the use of providers’ personal
checks for repayment of incorrectly processed claims. Adjustments also provide an accurate record of how
the claim was processed.
Once a claim has been processed and placed in a PAID status, providers have one year from the original
paid date to adjust claims that would result in a positive financial outcome for the provider.
Providers can request adjustments and recoupments to claims billed incorrectly that result in a negative
financial outcome for the provider within three years of the original date of service; the entire claim will be
recouped. Partial recoupment requests are to be submitted as refunds. If the claim is more than three years
old, the provider must refund the overpayment by completing the refund form and attaching the refund check.
The Medicaid Refund form is available on our website at http://www.vtmedicaid.com/#/forms
Late Charges (Applies to UB-04 Hospital charges)
Late charges to the original paid claims must be submitted as adjustments. These adjustments must be
submitted either using the DXC Technology paper adjustment form or electronically through the DXC
Technology Provider Electronic Solutions (PES) Application. Paper claims with type of bill 117 (adjustment
inpatient) or 137 (adjustment outpatient) will not be accepted.
For instructions on completing adjustments using DXC Technology’s PES software, please visit
http://www.vtmedicaid.com/#/pes
Forms for completing single and multiple adjustments can be downloaded from
http://www.vtmedicaid.com/#/forms
TIMELY FILING
When the system indicates that Vermont Medicaid is the primary payer, the timely filing limit for such claims
is 180 days from the date of service. In no case will a claim be considered if the date of service is greater
than two years prior to the DVHA’s receipt of the claim. If a claim has a date or dates of service past the
timely filing limit, it may be submitted for payment reconsideration directly to DXC if one or more of the
following conditions are met:
DXC denied the claim within the timely filing limit for a reason other than exceeding the time limit. A
copy of the remittance advice showing the denial must be attached to each claim
A member’s eligibility was made retroactive and the date of service is within the
retroactive period. The claim must be submitted within the first twelve months of the date on the Notice
of Decision.
Inpatient claim, the timely filing limit is 180 days from the date of
discharge
When a claim is billed to Medicare with Vermont Medicaid noted as the secondary payer (using the
crossover function), the crossover claim will be considered timely if it is received within two years of the date
of service.
Global bills for maternity and orthodontia, which must be filed within 12 months of the first date of service.
When the system indicates that Vermont Medicaid is not the primary payer, providers can either file all claims
(except Medicare crossover claims) within 180 days, or providers may separate these claims into two groups
each with a different timely filing requirement.
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For claims that are not “pay and chase” (see below), the timely filing limit is 12 months from the date of
service the timely filing limit is 180 days from the date of service for “pay and chase” claims (i.e. where the
system indicates that the member is covered by court ordered insurance D1, D2, D3, D5, D8 and D9) or the
claim is for any of the following procedure and diagnosis codes:
Procedure codes: 99381-99385, 99391-99394 and 99173
Diagnosis codes: Please see Appendix 1 for ICD-10 codes
Members covered by court ordered insurance can be identified by using the Voice Response System that
says “The recipient has other insurance with (name) with coverage type (coverage code D1 or D2, etc.).”
8.2.1 Timely Filing Reconsideration Requests
The Department of Vermont Health Access will review a decision of an untimely claim in unusual
circumstances, if the claim has previously denied for timely filing.
For timely filing reconsideration requests, providers must fully research and document in the request the
extenuating circumstances surrounding the claim (e.g. submission dates, adjusted dates, and denial dates).
Providers should submit all supporting documentation (e.g. account notes, emails, denials or other insurance
correspondence. Do not send Medical records with a timely filing reconsideration request).
Providers submitting a timely filing reconsideration request for a single claim should use the “Timely Filing
Reconsideration Form Single Claim”. For reconsideration requests that contain more than one claim for the
same recipient, providers should use the “Timely Filing Reconsideration Form Single Patient Multiple
Claims”. Both forms are located at http://www.vtmedicaid.com/#/forms. Completion instructions are included
in the form.
If there is no documentation or the documentation is insufficient to validate extenuating circumstances for the
late submission, your request will be denied.
All Timely Filing Reconsideration Requests should be mailed to:
DXC Technology
Attn: Timely Filing
PO Box 888
Williston, VT 05495
For non-timely filing reconsideration requests, please see Section 1.2.7 Provider Reconsideration
Requests.
USUAL & CUSTOMARY RATE (UCR)
Various claim forms (CMS 1500, UB 04 and 837) require the submission of “Charge” or “Total Charges” or
“Charge Amount” to be reported for each service billed. The provider’s “usual and customary charge” or
“uniform charge” is a dollar amount in effect at the time of the specific date of service. This is the amount to
be reported on the claim. This usual and customary charge is the amount that the provider bills to insured
and self-pay persons for the same service. If the provider has more than one charge for a service, the lowest
charge will be reported to Vermont Medicaid, except, if the charge has been reduced on an individual basis.
INCIDENT-TO BILLING FOR LICENSED PHYSICIANS
Incident-to billing is a way of billing for services in an office setting only, provided by a non-physician
practitioner (NPP) whose provider type does not allow them to enroll with Vermont Medicaid. There is no
incident-to billing in a facility. NPPs that are eligible to enroll in Vermont Medicaid must enroll and bill using
their own provider number and cannot bill incident-to.
When NPPs who are not eligible for enrollment in Vermont Medicaid provide services that are incident-to a
physician or other practitioner’s service, they may bill under the physician/practitioner’s Vermont Medicaid
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provider ID (NPI/Taxonomy) if they are employed by the billing provider (part-time, full-time, leased,
contracted) and when the service are:
An integral, although incidental, part of the professional services
Commonly rendered without charge or included in the physician’s bill
Of the type that is commonly furnished in physician offices or clinics
Furnished by the physician or auxiliary personnel under the physician’s direct
supervision
Documentation is critical for patient care and must clearly link the service to the clinically-supervising
provider, including for example, co-signature and credentials of both practicing and clinically supervising
provider and notation within the medical record of the clinically supervising provider’s involvement. Services
billed in this manner may be subject to post payment review.
The billing/clinically supervising provider must:
Be actively enrolled with Vermont Medicaid
Have seen the patient first, made a diagnosis and created a plan of care
Provide formal case oversight (documented one-on-one meetings to review the case)
Be present in the office suite on site or immediately available within 15 minutes commute to provide
assistance and direction throughout the time the service is performed
The service must:
Be within the scope of practice of person providing the service;
Follow the plan of care created by the billing/clinically supervising provider
Be only for the diagnosis in the original plan of care
If the patient requires a service for another diagnosis, the visit does not qualify for “incident-to”
billing
The billing/clinically supervising provider must see the patient to make a new diagnosis and
create a plan of care before s/he can bill incident-to for a different diagnosis.
Incident-to billing is NOT Allowed if:
It is a new patient visit
It is an established patient with a new problem/diagnosis
There is no clinically supervising provider present in the office suite and immediately available
within 15 minutes
SUPERVISED BILLING FOR BEHAVIORAL HEALTH SERVICES
Supervised billing (formerly known as “Incident-To” billing) requirements as described below apply
only to clinical services, and are not applicable to case management, specialized rehabilitation or
Emergency Care and Assessment Services.
These requirements apply to all providers being reimbursed for “supervised billing” under Medicaid.
“Supervised billing” is a way for a supervising provider who is enrolled in Vermont Medicaid to bill for clinical
behavioral health services provided by non-licensed personnel under their direct supervision. Providers who
are eligible to enroll in Vermont Medicaid must enroll and bill using their own provider number; they cannot
bill under another provider’s number.
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Supervision of unlicensed providers is critical for patient care, and the service must clearly link to the clinical
supervisor. Supervision requirements for professional licensure are described in the administrative rules
under the Secretary of State, and must be adhered to for the purpose of “supervised billing”. The supervising
provider must sign off on the treatment plan and demonstrate continuing involvement in supervising patient
care. Services billed in this manner may be subject to post payment review.
1. Supervising Providers
The following Medicaid contracted providers may bill for supervised services:
Licensed physician certified in psychiatry by the American Board of Medical Specialties;
Licensed psychiatric nurse practitioner;
Licensed psychologist;
Licensed marriage and family therapist;
Licensed clinical mental health counselor; and
Licensed clinical social worker
Licensed alcohol and drug abuse counselors
The following conditions apply to the Medicaid-contracted provider in order to bill for unlicensed clinical
services:
1. Supervisors must be licensed and actively enrolled in Vermont Medicaid.
2. All supervising providers must only supervise for services within their scope of practice.
3. Supervisors must adhere to the supervision requirements outlined in the Secretary of State’s
Administrative Rules for their specific provider type. For Licensed Alcohol and Drug Abuse Counselors,
supervisors must meet requirements outlined by the Vermont Alcohol and Drug Addiction Certification
Board.
o Note: For purposes of billing clinical services, any behavioral health provider licensed and
enrolled Medicaid behavioral health providers and supervising within their scope of practice may
provide supervision under this policy. Unlicensed providers who are seeking licensure from the
Office of Professional Regulation (OPR) will need to obtain supervised hours from a supervisor
meeting the requirements outlined by OPR in order to apply for licensure.
4. Supervisors do not need to provide direct services in order to bill for supervised services
5. Supervisors must provide regular, face-to-face ongoing supervision to the unlicensed provider, as
outlined in the Secretary of State’s or Vermont Department of Health’s Administrative Rules for the
specific provider type.
6. Supervisors must sustain an active part in the ongoing care of the patient.
7. A licensed provider qualified for scope of services must be immediately available in person or by phone
within 15 minutes.
2. Non-Licensed Providers
Supervisors may bill Medicaid for clinical services provided by the following non-licensed providers:
Master-level mental health practitioners, including clinical social workers, clinical mental health
counselors, and marriage and family therapists, actively fulfilling 3,000 hours of supervised practice.
Psychiatric Nurse Practitioners actively fulfilling 24 months and 2,400 hours of supervised practice.
Psychologists actively fulfilling 2,000 hours of supervised practice after receiving a doctoral or master’s
degree in psychology.
Addiction counselors who are:
o Actively fulfilling the required number of hours of supervised work experience providing
alcohol/drug counseling services, commensurate with their degree as outlined by the Vermont
licensing entity, -or-
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o Possessing (or will possess within 180 days of hire) a Vermont Addiction Apprentice
Professional certificate, -or-
o Possessing an Alcohol and Drug Counselor Certification.
The following conditions must apply to non-licensed providers in order for the supervisor to bill for non-licensed
services:
Mental health practitioners shall be entered on the roster of non-licensed and noncertified
psychotherapists, and must be actively working towards professional licensure.
Psychologists shall be entered on the roster of non-licensed and noncertified psychotherapists, and
must be actively working towards professional licensure.
Psychiatric Nurse Practitioners shall be a Registered Nurse with a Collaborative Provider Agreement,
and must be actively working towards professional licensure.
Non-certified addiction counselors must be actively working towards professional licensure.
Individuals who have been on the roster that is maintained by the Office of Professional Regulation in
the Office of the Secretary of State for more than five years after January 1, 2016 will no longer be
eligible under Medicaid to provide clinical services. Extensions may be granted on a case-by-case basis.
Designated Agency and Specialized Service Agency Providers only: For individuals seeking a waiver to
the “Five-Year Rule”, please fill out the Supervised Billing Five Year Rule Waiver form found at:
http://www.vtmedicaid.com/#/provEnrollDataMaint. Return all completed forms to: Provider Member Relations
Unit, Department of Vermont Health Access, 312 Hurricane Lane, Suite 201, Williston, VT 05495.
3. Billable services provided by supervised non-licensed providers
Clinical services within the provider’s scope of practice, including:
Diagnosis & Evaluation
Individual Therapy
Group Therapy
Family Therapy
Medical Evaluation/ Management
Medication/ Psychotherapy
The following services are not eligible for reimbursement:
Services rendered by any provider who is eligible to be enrolled as a Vermont Medicaid provider but
has not applied to be a Vermont Medicaid Provider.
Services performed by a non-licensed provider who cannot practice independently and is not actively
working towards licensure.
4. Procedures for Billing
1. Practices/Agencies must maintain documentation on unlicensed master’s level individuals providing
clinical services that includes the following:
a. Name of rostered, unlicensed provider
b. Degree and discipline
c. Name of supervising provider
d. Status of license-eligibility:
i. License-eligible
ii. Rostered non-licensed and noncertified psychotherapists
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iii. Psychiatric Nurse Practitioners fulfilling 24 months and 2,400 hours of supervised
practice.
iv. Addiction counselors fulfilling required hours of supervised work experience.
e. Date when individual was entered on the roster that is maintained by the Office of Professional
Regulation in the Office of the Secretary of State, if applicable.
2. Supervising provider must use their unique provider number for services provided by unlicensed
providers.
a. For claims submitted to Medicaid, the following pricing modifiers must be used:
Modifier
Definition
Information
AH
Licensed Clinical Psychologist
This modifier should not be used when the claim is
for supervised billing.
AJ
Licensed Clinical Social Worker
This modifier should not be used when the claim is
for supervised billing.
HO
Master’s Degree Level
This modifier is required when the claim is for
supervised billing when the non-enrolled provider
that is rendering the service is "Master's Degree
Level."
HN
Bachelor’s Degree Level
This modifier is required when the claim is for
supervised billing when the non-enrolled provider
that is rendering the service is "Bachelor's Degree
Level."
b. For Designated Agencies, Specialized Service Agencies, and ADAP Preferred Providers Only:
For claims submitted to DMH or ADAP fund sources, the modifiers in the above table are not
required.
3. In the event of a supervisor’s short-term absence (e.g. vacation) where another licensed provided is
providing supervision, the documented licensed supervisor should continue to be included on the claim
as the provider using the appropriate modifier indicated above. Length of absence appropriate for this
approach should be defined in provider’s internal policy.
4. For neuropsychological testing, the supervising provider must conduct an initial face-to-face
neurobehavioral status exam to determine the medical necessity for neuropsychological testing and the
extent of such testing. Evaluations, including initial neurobehavioral status exam, administration of all
tests, final report, and feedback session, if held, should be billed to Medicaid at the conclusion of the
process on a single claim. The patient’s record should include documentation of dates and times of
face-to-face ongoing supervision to the unlicensed clinician. For other documentation requirements and
best practice guidelines please see Local Coverage Determination (LCD) Psychological and
Neuropsychological Testing (L31990).
NONCOMPLIANCE WITH POLICY
MEDICAID CONTRACTED PROVIDERS MAY BE AUDITED REGARDING THESE REQUIREMENTS AND
MAY BE REQUESTED TO REIMBURSE DVHA THE MONIES BILLED FOR THE NON-LICENSED
PROFESSIONAL.
LOCUM TENENS
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A Locum Tenens is a physician to “step in” for another provider that is on leave or has permanently left a
practice. The Locum Tenens physician must be licensed in Vermont and be actively enrolled in Vermont
Medicaid.
If a Locum Tenens physician is covering for a physician on leave, they are then allowed to use that
physician’s NPI number for up to 60 days. Modifier Q6 (Service rendered by a Locum Tenens physician)
should be used to show that the service was provided by a Locum Tenens physician. The Billing provider is
100% liable for all locum tenens billing.
TIME-BASED PROCEDURE CODES BILLING GUIDELINES
Please follow the below guidelines when billing time based procedure codes.
Critical care procedure codes that are time-based
The billed units must reflect the actual time spent in face-to-face contact with the member in the home
and/or on the way to the hospital.
The duration of time to be reported by a physician is the actual time spent evaluating, managing and
providing the critically ill or injured patient’s care. Services are not to be provided to any other patient.
Your full attention is limited to the critically ill or injured patient’s care.
In a facility setting, duration of time reflects time spent at the patient’s bedside or elsewhere on the floor
or unit. You must be immediately available to the patient. Only one physician may bill for critical care
services rendered to a patient during any billable period of time. Time counted toward critical care may
be continuous clock time or intermittent aggregated time.
Paper claims will be required if the number of units billed exceeds the allowed number of units. It is
required that clear copies of the provider’s actual records be submitted with each claim. The number of
units billed must be documented.
The total number of minutes and date of service must be clearly written in the documentation and
circled.
Failure to clearly mark the number of minutes will result in claim denial.
All other time-based procedure codes
The billed units must reflect the actual time spent.
Paper claims will be required if the number of units billed exceeds the allowed number of units. It is
required that clear copies of the provider’s actual records be submitted with each claim. The number of
units billed must be documented.
The total number of minutes and date of service must be clearly written in the documentation and
circled.
Failure to clearly mark the number of minutes will result in denial of the claim.
ELECTRONIC CLAIM SUBMISSION
The State of Vermont and DXC encourage the use of Electronic Claim Submission (ECS). ECS allows for
efficient, reliable and economic transfer of claims between the provider’s facility and DXC. The same
standards and conditions applicable to paper claims, with regard to accuracy and completeness also apply to
claims submitted electronically.
ECS is fast, easy to use and eliminates time-extensive paperwork. ECS prevents most errors, allowing
providers to submit “clean” claims the first time. Turn-around time for electronic claims is considerably faster
than for paper claims. For information on available methods of electronic billing, please contact the Electronic
Data Interchange (EDI) Coordinator at DXC.
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ELECTRONIC FUNDS TRANSFER (EFT)
Vermont Medicaid requires health care provider payments to be made through Electronic Funds
Transmission (EFT), as stated in the Conditions of Participation of the Provider Enrollment
Agreement/Recertification Agreement. Failure to do so may result in the suspension of payments.
EFT allows payment for “clean” claims within five business days. Funds are electronically deposited into a
specified bank account, avoiding stop payments and reissues due to damaged or misplaced checks.
EFT has no effect on billing procedures but does apply to all claim types submitted. Providers are not
required to submit claims electronically to receive direct deposits.
At time of enrollment, complete the Electronic Funds Transfer Request Form located on the Vermont
Medicaid Portal at http://www.vtmedicaid.com/#/provEnrollDataMaint. This form is also used to facilitate a
change or cancelation of EFT enrollment.
Select the above link to open the forms page of the Vermont Medicaid Web Portal; scroll down to Enrollment,
click the Electronic Funds Transfer Request Form. Once opened, select “save as” from the file drop down
menu and rename the document to save a copy to your PC. Open the saved Electronic Funds Transfer
Request Form from your PC. Light blue fields indicate where text can be entered. Please remember to save
the form whenever changes are made, complete all required sections and obtain the authorized signature.
One of the following documents must be attached to both new EFT enrollment and change enrollment
requests for verification of account owner and account number: (1) voided check or (2) a signed letter from
your bank that lists the account holder’s name, and the appropriate financial institution’s account and routing
numbers.
Return your completed Electronic Funds Transfer Request Form by mail to: DXC Technology, P.O. Box 888,
Williston, VT 05495 or fax to 802-878-3440. Please direct all questions and EFT status requests to the DXC
Enrollment Unit at 802-879-4450 (option 4).
CLAIM DISPOSITION INFORMATION INTRODUCTION
This section will assist providers in reviewing the status of each of their claims on the Remittance Advice
(RA). It will also explain steps providers must follow to make adjustments or refunds on paid claims. A strong
knowledge of these available resources and procedures will assist providers in maintaining accurate
payment records.
REMITTANCE ADVICE (RA)
The Remittance Advice (RA) is a computer-generated report provided by the fiscal agent. It indicates the
status of all claims that have been submitted for processing. The RA is posted at
http://www.vtmedicaid.com/#/ a weekly basis, with your four most current RAs available. The banner page of
the RA provides important information about policy and billing. See Appendix for RA example.
The Explanation of Benefits (EOB) codes printed on the RA explain the reason(s) why Vermont Medicaid
claims are paid or denied. Full descriptions for each code are printed at the end of the RA.
EOB codes for denials that pertain to the entire claim are printed directly under the patient’s name and the
ICN on the RA. Detail denials are printed under each billing detail on the RA. Please review all areas of the
claim before resubmitting directly to claims processing. If the reason for your denial is unclear, please contact
the DXC Provider Services Unit.
Providers that bill electronically will only receive electronic RAs. Please contact the DXC EDI Department at
DXC if you are interested in submitting and receiving this information electronically.
8.11.1 RA Sections
The RA is divided into the following sections:
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Paid Claims - All claims paid in the current cycle. EOB codes under the claim header and details indicate the
reason(s) for the payment amount. There may be as many as ten EOB codes per header and per denial.
Denied Claims - All claims denied in the current cycle. EOB codes under the claim header and details
indicate the reason(s) for the denial. There may be as many as ten EOBs per header and per detail.
Suspended Claims - Claims requiring manual review by either DXC or the DVHA will be identified in this
section prior to disposition. The purpose of this section is to inform the provider that DXC has received the
claim, and payment or denial will be forthcoming.
Adjusted Claims - Claims for which adjustments have been processed to correct information, overpayment,
underpayment or payment to the wrong provider.
Financial Items - Financial transactions such as recoupments, manual payouts and TPL recoveries.
TPL & Medicare Information - Other insurance and Medicare information for members with related denials on
the RA.
Earnings Data - This “Earnings Data” section of the RA is provided to show the current RA totals as well as
cumulative year-to-date details.
Message Codes - Definitions of the EOB codes listed on the RA.
8.11.2 RA Headings & Descriptions
Recipient Name - Member name is listed in alphabetical order. The name appears in last name, first name
format.
MID - The member’s Medicaid Identification Number also known as the UID.
ICN - Each claim and any attachments received by DXC are assigned a unique identifying number called the
Internal Control Number (ICN). This number is displayed in the third column on the RA. The fifteen digit
number aids in identifying, locating or researching the claim, either during or after processing.
The following summary describes what each number represents:
Digit
Description
1-2
Valid region code values for paper claims are: 10-Paper Claim without
attachments. 11- Paper claim with attachments Valid region code values for
ECS claims are: 40 - ECS
The valid region code values for financial items are listed in the description of
the financial items section
3-6
The year the claim was received at DXC
7-9
Three digits indicating the Julian Date on which DXC received the claim.
These numbers correspond with the calendar dates; see the Appendix
document. For example, 001 corresponds with January 1 and 365
correspond with December 31
10-15
The last six digits following the date are designed for DXC control purposes.
These numbers uniquely identify the claim and allow personnel to access the
claim both manually and through the computer
HVER - The version number of the claim. The original claim paid for the services rendered is version 00. The
first adjustment to any payment is version 01, etc.
PT ACCT/RX# - The patient account or medical record number is reported as it appeared on the claim.
BILLED AMT - The amount charged for the service.
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ALLOWED AMT -The Vermont Medicaid allowed reimbursement.
OI AMT - The amount paid by another insurance for this claim or detail.
LIAB AMT - The amount for which the patient is responsible, excluding co-pay.
COPAY AMT - The co-payment amount related to the claim.
PAID AMT - The amount included in the payment for this claim.
HEADER MESSAGES - These numbers relate to the EOB codes printed under the header information.
These numbers, which are referred to as EOB codes, indicate the reasons for payment or denial for the claim
on the header level (top portion of the claim).
DNUM - The detail number.
DVER - The version of the detail. The original detail paid is version 00. The first adjustment to any payment
is version 01, etc.
FDOS - The beginning date of service as it appears on the claim.
TDOS - The ending date of service as it appears on the claim.
PROC+MODS - The procedure code and corresponding modifiers as they appear on the claim.
QTY BLD - The number of units of service as it appears on the claim.
DETAIL MESSAGES - The numbers relate to the EOB codes printed under the detail information. These
numbers indicate the reasons for payment or denial on the detail level of the claim.
ADJUSTED CLAIMS - This section of the RA includes detailed information on both the original and the
adjusted claim. The original claim data is displayed first, followed b the adjusted claim data and an
explanation of the effect the adjustment had on the original claim.
RECIPIENT NAME - Member name on the adjusted claim is listed in alphabetical order. The name appears
in last name, first name format.
MID - The member’s Medicaid identification number on the adjusted claim.
ICN - The internal control number of the adjusted claim.
HVER - The version number of the adjusted claim. The original claim paid for the services rendered is
version 00. The first adjustment to any payment is version 01 etc.
PT ACCT/RX # -The patient account or medical record number is reported as it appeared on the adjusted
claim.
BILLED AMT - The amount charged for the service on the adjusted claim.
ALLOWED AMT - The Medicaid allowed reimbursement on the adjusted claim.
OI AMT - The amount paid by another insurance for this claim or detail on the adjusted claim.
LIAB AMT - The amount for which the patient is responsible, excluding co-pay on the adjusted claim.
COPAY AMT - The co-payment amount related to the adjusted claim.
PAID AMT - The amount included in the payment for this adjusted claim.
HEADER MESSAGES - These numbers relate to the message codes printed under the header information.
These numbers, which are referred to as EOBs, indicate the reasons for payment or denial for the claim on
the header level (top portion of the claim).
DNUM - The detail number on the adjusted claim.
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DVER - The version of the detail on the adjusted claim. The original detail paid is version 00. The first
adjustment to any payment is version 01, etc.
FDOS - The beginning date-of-service as it appears on the adjusted claim.
TDOS - The ending date-of-service as it appears on the adjusted claim.
PROC+MODS - The procedure code and corresponding modifiers as they appear on the adjusted claim.
QTY BLD - The number of units of service as it appears on the adjusted claim.
DETAIL MESSAGES - These numbers relate to the message codes printed under the detail information.
These numbers indicate the reasons for payment or denial on the detail level of the adjusted claim.
ADJUSTMENT REASON - A text field that explains why the adjustment took place.
NET ADJUSTMENT AMOUNT - This field indicates the net effect the adjustment had on the claim. The value
is equal to the difference between the Original Claim Paid Amount and the Adjusted Paid Amount.
FINANCIAL ITEMS: The “Financial Items” section of the RA is printed only when a financial activity other
than claims adjudication takes place. Please refer to the sample “Financial Items” section of the RA in this
section - Sample Remittance Advice. The following summary describes the information in the “Financial
Items” section:
CCN - The Cash Control Number of the financial transaction. The first two digits of the number indicate the
type of financial transaction (i.e., system payout, recoupment, refund).
A/L NUMBER - The number assigned to the provider's ledger to account for the transaction.
MID - The member's ID number is shown if the financial transaction is related to a specific claim. When the
transaction does not relate to a specific claim, this space is blank.
ICN - The Internal Control Number of the claim is shown if the financial transaction is related to a specific
claim. When the transaction does not relate to a specific claim, this space is blank.
HVER - The version number of the related claim, if applicable.
DNUM - The detail number on the related claim, if applicable.
DVER - The detail version number of the claim, if applicable.
TXN DATE - This field indicates the date the transaction was entered and logged in the provider's account
ledger.
ORIG AMT - The original amount to be exhausted by financial transactions.
TXN AMT - The dollar amount corresponding to the transaction. This is the actual amount of money included
or withheld from the payment and applied to the original amount.
BAL AMT - The remaining balance to be exhausted by future financial cash transactions (amount still owed
against the receivable or payable). This value is equal to the Original Amount less the Transaction Amount.
RSN CD - This field describes why the transaction was performed.
FINANCIAL ITEMS REASON CODE The financial reason codes and their descriptions listed with any
financial transactions on the RA.
TPL & MEDICARE INFORMATION - The TPL AND MEDICARE INFORMATION REPORT displays the
members for who claims denied for other insurance during the week. It is generated only when such
transactions occur. The report lists only the insurance carrier that caused the claim to fail.
RECIPIENT NAME - The name of the member who had other insurance coverage for the denied claim.
ICN - The Internal Control Number assigned to each denied claim.
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HVER - The header version number corresponds to the ICN and indicates the version of the claim. The
original header has a version number of '00'. Subsequent version numbers (01, 02, etc.) are the result of
adjustments made to the header.
DVER - The detail version number corresponds to the detail and indicates the version of the detail. The
original detail has a version number of '00'. Subsequent version numbers (01, 02, etc.) are the result of
adjustments made to the detail.
DNUM - The detail number corresponds to the ICN and indicates the detail of the claim.
OTHER INSURANCE - The name and address of the insurance carrier with whom the member has other
insurance coverage.
CARRIER CODE - The carrier code of the insurance carrier listed above.
POLICY NAME - The name of the person who holds the insurance policy.
RELATIONSHIP DESCRIPTION - The relationship between the member and the policy holder.
POLICY - The policy number of the insurance policy that the member holds with the insurance carrier.
GROUP - The group number that the insurance policy falls under. This field is only populated if the member's
insurance policy is a group policy.
MEDICARE - This field indicates the Medicare type. Possible values are 'PART A' and 'PART B'.
MEDICARE ID - The Medicare ID of the member if applicable.
8.11.3 Earnings Data & Message Codes
The EARNINGS DATA AND MESSAGES CODES - displays the financial data for the current RA and year-
to-date as well as the message codes that were listed with any claims (EOB codes) on the RA.
NUMBER OF CLAIMS PROCESSED (CURRENT) - The total number of claims processed during the past
week. This figure includes all paid, denied, suspended, and adjusted claims appearing on the RA.
NUMBER OF CLAIMS PROCESSED (YTD) - The total number of claims processed this calendar year. This
figure includes all paid, denied, suspended, and adjusted claims appearing on the RA; it is equal to the sum
of the “Number of Claims Processed” fields on each RA year-to-date.
DOLLAR AMOUNT PROCESSED (CURRENT) - The dollar amount paid for claims processed during the
past week.
DOLLAR AMOUNT PROCESSED (YTD) - The dollar amount paid for claims processed this calendar year.
This figure is equal to the sum of the “Dollar Amount Processed” fields on each RA year-to-date.
SYSTEM PAYOUT AMOUNT (CURRENT) - The dollar amount paid out as a result of system generated
financial transactions during the past week.
SYSTEM PAYOUT AMOUNT (YTD) - The dollar amount paid out as a result of system generated financial
transactions for this calendar year. This figure is equal to the sum of the “System Payout Amount” fields on
each RA year-to-date.
MANUAL PAYMENT AMOUNT (CURRENT) - The dollar amount paid out through manual checks during the
past week.
MANUAL PAYMENT AMOUNT (YTD) - The total dollar amount paid out through manual checks for this
calendar year. This figure is equal to the sum of the “Manual Payout Amount” fields on each RA year-to-date.
RECOUP AMOUNT WITHHELD (CURRENT) - The dollar amount withheld as a result of recoupment
financial transactions during the past week.
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RECOUP AMOUNT WITHHELD (YTD) - The dollar amount withheld as a result of recoupment financial
transactions for this calendar year. This figure is equal to the sum of the “Recoup Amount Withheld” fields on
each RA year-to-date.
PAYMENT AMOUNT (CURRENT) - The total dollar amount paid for paid claims, system or manual payouts,
minus recoup amounts.
PAYMENT AMOUNT (YTD) - The total dollar amount paid for claims submitted and financial transactions
incurred for the calendar year. This figure is equal to the sum of the “Payment Amount” fields on each RA
year-to-date.
CREDIT ITEMS (CURRENT) - The dollar amount relating to any credit items for the past week. Credit items
are all Medicaid void transactions, State void transactions, and refund transactions.
CREDIT ITEMS (YTD) - The total dollar amount relating to any credit items for the calendar year. Credit
items are all Medicaid void transactions, State void transactions, and refund transactions.
NET ADJUSTMENT AMOUNT (CURRENT) - The total net adjustment amount from adjusted claims
processing during the past week. This figure is equal to the sum of the “Net Adjustment Amount fields
located in the “Adjustments” section of the RA for each adjusted claim.
NET ADJUSTMENT AMOUNT (YTD) - The total net adjustment from adjusted claims processing for the
calendar year. This figure is equal to the sum of the “Net Adjustment” fields for each RA year-to-date.
NET 1099 ADJUSTMENT (CURRENT) - The net 1099 adjustment incurred from financial transactions during
the past week. This figure is equal to the net sum of all positive and negative 1099 transactions during the
past week.
NET 1099 ADJUSTMENT (YTD) - The total net 1099 adjustment incurred from financial transactions for the
calendar year. This figure is equal to the net sum of the “NET 1099 Adjustment” fields on each RA year-to-
date.
COVERED DAYS INCLUDING NURSERY (CURRENT) - This field only applies to hospital claims. It
indicates the total number of covered days (including nursery care) billed during the past week.
COVERED DAYS INCLUDING NURSERY (YTD) - This field only applies to hospital claims. It indicates the
total number of covered days (including nursery care) billed during the calendar year.
NET EARNINGS (CURRENT) - The net earnings for the past week. This figure is calculated as follows:
Claims Paid Amount
+ System Payout Amount
+ Manual Payout Amount
- Recoup Amount Withheld
- Credit Items
+/- Net 1099 Adjustment (may be positive or negative)
= Net Earnings
NET EARNINGS (YTD) - The total net earnings for the calendar year. This figure is equal to the sum of all
the Net Earnings fields on each RA year-to-date.
ELECTRONIC FUNDS TRANSFER STATEMENT The dollar amount deposited electronically. This
statement includes the account number into which the money was deposited as well as the date the deposit
was sent to the provider’s bank.
MESSAGE CODES - The (EOB) codes displayed in other sections of the RA and a written explanation for
each.
REFUNDS
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In the event of a Medicaid overpayment, a refund check may be attached to a Medicaid “Refund Form”
(http://www.vtmedicaid.com/#/forms) and sent to DXC. The Refund Form requires providers to state the
reason for the refund and to designate the claim or account against which it should be applied. Refunds will
be reflected on the Financial Items page of the RA. The refund amounts will be deducted automatically from
the YEAR-TO-DATE total.
When other health insurance payments are received after Medicaid payment has been made, the provider
should refund to DXC the lesser of the amount paid by the insurer or the Medicaid payment. Failure to do so
may be criminally punishable as Medicaid fraud.
Check mailing address: DXC Technology, P.O. Box 1645 Williston, VT 05495
Section 9 Billing Procedures CMS1500 & UB04 Claim Types
ABORTIONS
Induced abortions are billable only when the Abortion Certification Form has been submitted and approved
by the appropriate funding source prior to the procedure being rendered. Forms can be found by clicking on
the applicable Abortion Certification link at http://ovha.vermont.gov/for-providers/forms-1. The two funding
source forms are described below.
1. Vermont Medicaid
Completion of form DVHA 219A is required for abortions performed if the pregnancy is a result of rape
or incest, or when the mother’s life is endangered by carrying the fetus to term. This consent form and
the medical documentation of the situation must be sent to DXC with each claim.
2. State Funds
Abortions considered medically necessary require the completion of Physician Certification form DVHA
219B, and are paid by the Department for Children and Families (DCF) funding.
The form must be completed, signed and attached to the claim when submitted for processing.
Spontaneous and missed abortions completed surgically are billable under Vermont Medicaid with use of the
appropriate procedure and diagnosis codes. A certification form is not required.
Vermont Medicaid does reimburse for abortions performed by Certified Nurse Midwives.
Abortion Diagnosis Codes
Unspecified abortion diagnosis codes will not be accepted by Vermont Medicaid. When billing, use a more
specific abortion diagnosis code. Providers should refer to a current ICD-10-CM manual for the correct code.
AIDS/HIV
Vermonters living with HIV infection who meet certain income guidelines may be eligible for help with
Medicaid co-payments for treatment drugs through the Vermont Medication Assistance Program (VMAP)
http://healthvermont.gov/prevent/aids/aids_index.aspx#Anchor-Th-57625.
Vermont residents not covered by the Medicaid may be eligible for coverage of HIV medications, and/or for
benefits. Application for this benefit may be obtained by writing to: VMAP Coordinator, Department of Health-
Vermont Medication Assistance Program (VMAP), P.O. Box 70, Burlington, VT 05402.
ORGAN TRANSPLANT
Vermont Medicaid covers organ transplantation services once the procedure is no longer considered
experimental or investigational. Reimbursement will be made for medically necessary health care services
provided to an eligible beneficiary or a live donor and for the harvesting, preservation, and transportation of
cadaver organs. Post-transplant services for live organ donors are covered under the recipients Medicaid
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benefit and should be billed under the recipient’s Medicaid ID as both the patient and the insured and include
the date of birth.
9.3.1 Organ Transplant Donor Complication
The instructions below are only for billing donor complications related to the transplant surgery.
Institutional Electronic Claims for organ donor complications:
Enter patient relationship code 18 in Form Locator 59 (Patient’s Relation to Insured)
Enter the Medicaid beneficiary’s (organ recipient) information in Form Locators: 08 (Patient
Name/Identifier), 09 (Patient Address), 10 (Patient Birth Date), and 11 (Patient Sex)
Add a value of 39 along with the Donor’s name to the 837I Loop 2300 , Billing Note Segment NTE02
(NTE01 = ADD)
Include Occurrence Code 36 (Date of Inpatient Hospital Discharge for covered transplant patients)
Paper UB-04 claims:
Enter patient relationship code 39 in Form Locator 59 (Patient’s Relation to Insured)
Enter the Medicaid beneficiary (organ recipient) information in Form Locators: 08 (Patient
Name/Identifier), 09 (Patient Address), 10 (Patient Birth Date), and 11 (Patient Sex)
Enter the Donor’s name Form Locator 80 (remarks)
Include Occurrence Code 36 (Date of Inpatient Hospital Discharge for covered transplant patients);
Electronic Professional Claims:
Enter the recipient’s Medicaid number 2010BA Loop. Subscriber Name, NMI1 Segment, Element 9
Enter the recipient’s name 2010BA Loop- Subscriber Name, NM1 Segment, Element 3-5
Enter 39 and the Donor’s Name and address 2300 Loop- Claim Note, NTE segment or 2400 Loop-Line
Note, NTE segment
For Paper CMS 1500 claims:
Enter the recipient’s Medicaid number on Item 1A- Insured’s I.D. Number
Enter the recipient’s name on Item 2- Patient’s Name
Enter 39 and the Donor’s Name and Address on Item 19- Reserved for Local Use
CPT CATEGORY III PROCEDURE CODES
Category III codes are non-covered because they represent “emerging technology, services and
procedures”. These services are universally considered experimental or investigational and therefore not
covered by Vermont Medicaid. Should a service/procedure represented by a Category III code become
accepted medical practice, providers may send written documentation to the DVHA Clinical Operations Unit
(fax: 802-879-5963) requesting a coverage review.
FACTOR HCPCS CODES
Factor HCPCS Codes are typically submitted through the pharmacy benefit (except in cases of emergency).
Claims for services billed through the medical benefit require notes be included. All claims submitted for
emergency room services are exempt from this requirement.
FEE SCHEDULE
The Fee Schedule is published at http://dvha.vermont.gov/for-providers/claims-processing-1 for providers to
access current reimbursement rates on file for all procedure codes accepted by Vermont Medicaid. Other
pertinent information includes pricing effective dates, whether the code requires a prior authorization and
allowable provider types and specialties.
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Services that are non-reimbursed by Vermont Medicaid are also identified. The PAC 8 (invalid codes) & 9
(non-covered) lists include all codes which are on file as “Do not pay”. It is imperative that providers
reference this list prior to rendering services to ensure validity of specific procedure codes. When a
procedure code is updated to a PAC 9 status, providers are notified 30 days prior to the change via banner.
HEALTH EXAMINATION OF DEFINED SUBPOPULATION
DVHA will only accept diagnosis code V70.5 (ICD-9) or Z02.89 (ICD-10) (Health examination of defined
subpopulations) when it is billed as the primary diagnosis for the subpopulation “Refugees”. All other claims
containing diagnosis code V70.5 or Z02.89 will be denied. Diagnosis code V70.5 or Z02.89 is acceptable
billing for new refugees, but only when used for their first domestic health examination and related diagnostic
tests; and when medically necessary for a follow-up visit. Each claim must indicate V70.5 or Z02.89 as the
primary diagnosis and must contain the notation “Refugee – Initial Exam” or “Refugee – Second Visit”. All
subsequent care must be billed with an appropriate medical diagnosis per standard billing practice.
INTERPRETER SERVICES/LIMITED ENGLISH PROFICIENCY (LEP)
Providers are required under federal and State laws to provide interpreters for patients with limited English
proficiency (LEP) and for those who are deaf or hard of hearing.
Title VI of the Civil Rights Act of 1964
Title VI regulations, prohibiting discrimination based on national origin
Executive Order 13166 issued in 2000
Vermont’s Patients’ Bill of Rights (18 VSA 1852)
Vermont Public Accommodations (9 VSA 4502)
9.8.1 Informed Consent
The Vermont Patients’ Bill of Rights provides that “the patient has the right to receive from the patients’
physician information necessary to give informed consent prior to the start of any procedure or treatment.”
Additionally, failing to obtain informed consent may be a factor in medical malpractice litigation, although
there are some exceptions. For the purposes of medical malpractice actions, “lack of informed consent” is
defined as a failure to disclose to the patient reasonably foreseeable risks, benefits, and alternatives to the
proposed treatment, in a manner permitting the patient to make a knowledgeable evaluation. In addition,
patients are entitled to reasonable answers to specific questions about foreseeable risks and benefits. [12
V.S.A. § 1909] Using interpreters, translations services or other communication aids and services may be
necessary to ensure that patients with LEP, who are deaf or hard-of-hearing receive appropriate information
about the proposed treatment to enable them to give informed consent to treatment.
9.8.2 HIPAA
An interpreter or bilingual employee is covered under the health care operations exception for purposes of
HIPAA, and the patient’s written authorization to disclose protected health information is not required.
Providers who utilize a private company for interpretation on an ongoing contractual basis should ensure that
their contract conforms to the HIPAA Privacy Rule business associate agreement requirements. In other
situations, with disclosures to family members, friends, or other persons identified by an individual as
involved in his or her care, when the individual is present, the health care professional or facility may obtain
the individual’s agreement or reasonably infer, based on the exercise of professional judgment, that the
individual does not object to the disclosure of protected health information to the interpreter.
9.8.3 Vermont Medicaid Billing
A provider who pays for interpreter services for Vermont Medicaid members may bill procedure code T1013
for each 15 minutes of paid interpreter services provided, on-site or via telephone. This may include
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interpreter service outside of the actual healthcare provider encounter in order to fill out forms or review
information/instructions.
The provider may not bill Vermont Medicaid or the member for a missed appointment per federal policy.
Claims are submitted using the CMS 1500 claim form with HCPCS code T1013, with the exception that
Home Health Agencies use the UB04 claim form with revenue code 940 with the HCPCS code T1013.
FQHC/RHC providers must bill T1013 for interpreter services using their non-FQHC/RHC provider numbers.
When a member receives services that are not eligible for reimbursement, the interpreter services are
ineligible for reimbursement.
9.8.4 Limited English Proficiency (LEP) Resources
Organization: AT&T On Demand Interpreter (PHONE)
Web: www.att.com/interpreter
Organization: Voiance (PHONE)
Phone/Web: 1-866-743-9010 www.voiance.com
Organization: Language Line Services (PHONE)
Phone/Web: 1-877-866-3885 www.languageline.com
Organization: Vermont Refugee Resettlement Program (IN-PERSON)
Phone/Email: 1-802-655-1963 vrrp@uscrivt.org
9.8.5 Deaf and Hard of Hearing Resources
Organization: Language Services Associates (IN-PERSON)
Phone/Web: 1-800-305-9573 www.lsaweb.com
Organization: Vermont Interpreter Referral Service (IN-PERSON)
Phone/Web: 1-802-254-3920 www.virs.org
Organization: Registry of Interpreters for the Deaf
Phone/Web: 1-703-838-0030 www.rid.org
Vermont Agency of Human Services: In-house contract for interpretation services.
9.8.6 Additional Online Information
http://www.vtmd.org/interpreter-issues-and-resources
http://www.aot.state.vt.us/civilrights/Documents/VermontTranslationServices-GeneralPublic.pdf
INPATIENT NEWBORN SERVICES
Members may apply for a newborn ID for their child at the time of delivery using forms available at the facility
or by application, at the Department for Children and Families (DCF) office. It is recommended providers wait
for the child’s ID number to be issued before billing Medicaid.
If the baby’s MID is not yet available when the provider needs to bill, the mother’s ID can be used only if the
baby and mother are inpatient together for the duration of the stay, up to 7 consecutive days. The mother’s
inpatient delivery charge must be paid or claim will deny. This information (of payment) can be verified
through the Provider Services help desk at 800-925-1706 or 802-878-7871.
Example: Mother leaves hospital